1.1 Face covering as infection control tool
Framed as a medical narrative, a face covering can be considered as a piece of personal protective equipment (what a health worker wears when assisting an infectious patient) or as a means of source control to prevent the spread of illness to others (something that a patient with cystic fibrosis wears to prevent the spread of Pseudomonas Aeruginosa when visiting an out-patients clinic) or a combination (the face covering that a dentist uses during dental work). Infection control guidelines are usually developed top-down, for example, guidelines formulated on a global level are adapted nationally, then promoted at local level through facility-based infection control committees. Manufacturing is subject to stringent quality standards (for example in the United States through the National Institute for Occupational Safety and Health in the United States) and procurement is organised on a national level. In countries whose response to COVID-19 was to promote medical masks as face covering for use by the public, production and distribution was coordinated on a national level. For example, South Korea introduced price limits on medical masks, rationed and nationalised distribution through country-wide pharmacy networks, agricultural co-operatives and post offices in rural areas and organised purchase dates based on date of birth.6
When viewing a face covering as medical equipment, filtration efficacy (number of layers and type of material) and optimal fit are key decision criteria. Health workers are trained in standardised infection control techniques, often using simulations with a UV lamp that show how lapses lead to self-contamination or infection risk to patients. Metaphorically, this is akin to placing a protective armour to fight an invisible threat. Donning (putting on) and doffing (taking off) technique when using a face covering is important.
The contribution of infection control as a discipline in creating safe healthcare facilities for patients and health workers have been significant and impactful. However, transposing this medical narrative for public face covering regulations has limitations.7Most randomised controlled trials of the efficacy of face covering have been done in healthcare facilities, where the primary goal of using a face covering is to protect the wearer from infection. Randomised controlled trials on the efficacy of face coverings as source control (i.e. to protect others) are sparse.7 Indeed, WHO interim guidance produced in April 2020 advised that there was “no evidence to suggest” that the intervention would be effective.8 Other authors have argued that for widespread public health interventions, randomized control trial evidence is seldom available or ethical to obtain.7Furthermore, aiming for standardisation in making, using and cleaning of a face covering at population level is challenging when people in different contexts have access to vastly different resources. In such circumstances, making the task of putting on and taking off a face covering feel complicated and risky also makes it more difficult to implement and may add little benefit when a face covering is used as source control rather than personal protective equipment. Applying the medical narrative to the cloth around the face, and sociocultural narrative to the cloth around the rest of the body, makes for a mismatched analytic approach to public apparel.