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Covid-19 cases are increasing in Santa Barbara County and many parts of the country. Our knowledge about virus transmission and its prevention is also increasing. While all three main prevention strategies — physical-distancing, hand-washing, and face-covering — continue to be recommended, face coverings have emerged as the best among equals. The forcefulness of public health guidance regarding face coverings reflects this, with California now requiring them for virtually everyone in public.
How Is Santa Barbara Doing?
The face-covering requirement on the new car-free zone (promenade) on State Street is now crystal clear.
We counted the number of pedestrians, bicyclists, scooters, and skateboarders using face coverings before and after the requirement was placed. The results are encouraging — but we have a long way to go.
The crowds on the promenade have increased substantially. The percentage of persons using face coverings is edging up but is not keeping pace. More interactions pose risks of transmission.
Interestingly, when wheeled promenaders (bicyclists, scooters, and skateboarders) are excluded, the results are even better. Face-covering use among pedestrians increased more steadily — from 23 percent on May 26 to 55 percent on June 29. The trend is highly significant. The risk of exposures to pedestrians is leveling off due to the use of face coverings, but the risk to people on wheels is not.
The proportion of wheeled promenaders wearing masks has not increased. Young people are riding without face coverings or helmets and doing “wheelies.” For them and their families, now is the time to assure that they do not end up with coronavirus or injuries. Otherwise, the progress we have made toward making the promenade a beautiful place to walk and ride could end.
Why Has Implementation Been So Difficult?
Changing behaviors around our health are notoriously problematic and slow, and motivating the unmotivated is the subject of many studies. The struggle to increase immunization coverage is a perfect example.
Regarding face coverings, official guidance has gone through many changes. In the first statement by the California Department of Health on April 1, the number of exceptions was so large that almost everyone could find an excuse to wiggle out. The first requirement applied to everyone, but there were several exceptions, including those who are exercising, too old, or too infirm (May 26). California’s newest requirements (issued on June 18 and updated on June 29) states that face coverings must be worn in most settings and strongly recommends them for everywhere else. The County of Santa Barbara’s current guidance is not entirely consistent, with several exemptions including people at a restaurant, unable to wear a face covering, or under three years of age.
At the same time, we need to be aware that our ability as humans and society to manage risks to life is deeply flawed. We overreact to some risks and virtually ignore others. This phenomenon helps us understand why some people reject completely face coverings while others are petrified of passing a stranger even when they have one on.
We are safer outdoors, but if that trail, beach, park, or street is crowded with people all around you, that margin of safety is lower. Of course, the combination of outdoors with a face-covering would be best in that circumstance.
How Did Face Coverings Become the Best Among Equals?
We now know that many countries that have been most effective in reducing the spread of COVID-19 have implemented universal face covering. Even without lockdowns, a recent article found, “facemask use by the public approaching 100 percent significantly lowers rates of COVID cases and deaths” when used in combination with physical distancing or periods of lock-down. They were considered “an acceptable way of managing the COVID-19 pandemic and re-opening economic activity.” Masks also decrease the risk of aerosol transmission that some experts believe responsible for spread beyond six feet. They are easy to make, low cost, and effective, and compliance is easier to measure than hand washing and distancing from nonfamily members.
An article in the Journal of the American Medical Association discussed the six-foot social distancing guideline, which is based on research conducted 90 years ago. It’s now known to be oversimplified. It may be more realistic to think of the COVID-19 transmission distance like the concentration of cigarette smoke. A strong smell is equivalent to more risk, but just because you smell it doesn’t mean you will catch it — in other words, it’s less concentrated.
Research on face coverings versus no face coverings reported that transmission was 90 percent at one meter, 80 percent at two meters, and 40 percent at three meters. The use of face coverings alone decreased the risk by 85 percent, according to the June 27 Lancet.
How Can We Do More?
How can we increase the use of face coverings? We need to apply proven strategies known to improve compliance with public health recommendations and regulations. A consistent message from all levels of government would help. “Everywhere” (outside the home) is pretty easy to understand. There is nothing wrong with frequent reminders that both face coverings and social distancing can prevent serious health problems. Interestingly, recent research has shown that fear of disease is an effective motivator.
If we act together when public health recommendations become requirements, enforcement is another proven tool. It should be undertaken equitably and fairly, without imposing undue burdens. We should consider starting now, because, when a COVID-19 vaccine becomes available, we will be faced with similar challenges. Only 50 percent of Americans say they will take a COVID-19 vaccine. The face-mask refusers will become the vaccine-hesitant.
While the State Street promenade may not be representative of the rest of the city or county, it’s a great place to try some new ideas to see if they work.
Daniel B. Fishbein, MD, is an infectious disease and public health physician retired from the Centers for Disease Control and Prevention. Ben Pettit is an attorney in Santa Barbara.