Dr. Nicole Saphier: Biden's mask mandate suggestion – Here are 3 questions for the candidate

Dr. Nicole Saphier: Biden's mask mandate suggestion – Here are 3 questions for the candidate

August 14, 2020

Dr. Saphier’s three questions for Biden’s call for national mask mandate

Mask-wearing has become politicized since the coronavirus lockdowns began earlier this year. But here’s the truth: all science, especially public health, is usually messy and our current situation is no exception. This week the debate over where and when to wear a mask became even more politicized.

Thursday, in only his second appearance since announcing Sen. Kamala Harris, D-Calif., as his running mate, presumptive Democratic presidential nominee Joe Biden declared, “Every single American should be wearing a mask when they're outside for the next three months at a minimum.”

Biden himself has said science, not politics should influence decisions regarding COVID-19, yet his statement left a coronavirus weary nation with even more questions.


Given the urgency of the situation, it is important to articulate what an effective universal masking mandate would look like. Unfortunately, no questions were allowed at the event where Biden made his comments but here are three I have for the presidential candidate:

1. What science is backing the decision that masks must be worn outdoors regardless of social distancing measures?

Almost all studies, at least that I’m aware of, have looked at the inside of buildings and little research has compared indoor transmission to what happens outdoors.

An unpublished study of 110 COVID-19 cases in Japan is one exception. It tested individuals then used contact-tracing to follow-up on secondary cases. The results showed that people were much more likely to catch coronavirus indoors. In fact, they suggest indoor transmission was 18.7 times greater compared to the open air.


A team at the Department of Homeland Security Science and Technology Directorate in Washington, D.C. found that environmental conditions play a big part in how long virus particles in aerosols remain viable.

SARS-CoV-2 in mock saliva aerosols lost 90% of its viability in 6 minutes of exposure to sunlight. This was compared to 125 minutes in indoor darkness.

Their overall conclusion was that indoor environments might be especially risky because they lack ultraviolet light and therefore have a greater ability to become more concentrated than if it were in sunlit outdoor spaces.

In fact, there are very few documented outbreaks associated with outdoor transmission.

Instead, the major perpetrators are crowded indoor spaces, poorly ventilated areas and places where people are congregated talking loudly or even singing.

So, I ask you Vice President Biden, what science is guiding the mandatory wearing of masks outdoors when the current recommendations are already to wear masks if one cannot socially distance?

2. If masks are necessary at all times when in public, will this force outdoor dining to close?

The economic consequences of shuttering restaurants to indoor dining have been devastating with many businesses closing their doors forever and leaving millions of Americans unemployed.

When state re-openings allowed outdoor dining to resume, businesses were able to capture some lost revenue and provide jobs back to the American workforce; not to mention also providing a level of normalcy to patrons everywhere.

Indoor dining remains banned in the New York City area and various other places because it has proved far riskier than outdoor dining. While there have been outbreaks linked to indoor dining, especially in bars, I have not heard of a major outbreak being traced to outdoor dining.

So, if outdoor dining has not been proven unsafe, would it be forced to cease regardless if masks are mandated at all times while outdoors?

3. What metrics will you be considering when deciding to end or extend the mandate?

Will it be based on the number of newly confirmed cases, confirmed and presumed positive cases, hospitalization rates or percent positivity?

Or under a Biden administration would the mandate be to “put on a mask until further notice” and keep Americans in the dark about the end date for the plan?

We have already seen the consequences of civil unrest unfolding after stay-at-home orders and rampant unemployment, what else will ensue and how can you guarantee the legitimacy of the metrics you are monitoring?

While I don’t know how Vice President Biden would answer these questions. Here’s my advice: Politics aside, as Americans we should do what we can to follow the science and not get caught up in the political tête-à-tête during an election year.

In the health care setting, universal masking was a key component that turned around transmission in a large hospital, as described in JAMA.

Of course, other confounding interventions both in the hospital as well as in the community were also occurring — such as canceling elective procedures, restricting visitors, and forgoing non-essential business travel so the mask mandate alone is difficult to gauge.

However, many people who become infected can unknowingly spread COVID-19 because they have mild or no symptoms.

So, for the general public, wearing a mask is a way of tipping your hat to show respect for those around you and also contributing to help lessen the spread of the virus.

The CDC has discussed how face coverings decrease the amount of infectious virus exhaled into the environment, reducing the risk an exposed person will become infected.

We know that surgical masks are less effective and cloth face coverings even less however, even a 50% reduction in viral transmission is important in reducing community transmission.

You may remember a few months ago a story about how two hair-stylists working at a Great Clips salon exposed over 100 people to SARS-CoV-2.

A complete investigation published in the CDC’s Morbidity & Mortality Weekly Report found that none of the 139 persons exposed to the two infected stylists developed COVID-19. The most likely reason: both the hair-stylists and 98% of clients wore masks in addition to other safety precautions being adhered to.

A well-crafted message addressing the common good could increase mask use and alter societal norms to improve compliance.  The president himself even said wearing a mask was “patriotic.”

Do we need another “click it or ticket” type mandate as we had for seatbelt safety or can we take individual responsibility while acknowledging this is temporary?

At a minimum, masks should be worn when indoors at public places and when outside and unable to socially distance (greater than 6 feet apart).

We should still be avoiding large gatherings and restricting our circles as much as possible so community transmission is lessened and our children can safely return to school and parents go back to work.

We are still in the middle of a global pandemic with many treatments and preventive innovations under development.

Be patient. Be kind. Continue to do what you can to protect those around you.


Doctors, scientists and the government have jobs to do, but so do all of the people of America.

We will get through this.


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