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Students on their first day of school after summer vacation at the St. Lawrence Catholic School north of Miami, on Aug. 18, 2021Chandan Khanna/AFP via Getty Images
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The Cult of Masked Schoolchildren

History will not look kindly on our evidence-free decision to make kids suffer most

by
Vinay Prasad
January 20, 2022
Chandan Khanna/AFP via Getty Images
Students on their first day of school after summer vacation at the St. Lawrence Catholic School north of Miami, on Aug. 18, 2021Chandan Khanna/AFP via Getty Images

As we enter the third year of the pandemic, every child age 5 and up is eligible to receive a COVID vaccine in the United States. Oddly, this development has been accompanied by increased pressure on kids to wear masks in school. Some private schools have gone beyond cloth-masking and mandated N95 (or equivalent) masks for children as young as 4. The Berkeley Unified School District in California recently began transitioning students to N95-level masking. This isn’t a matter of protecting children, their teachers, or their grandparents; it’s delusional and dangerous cultlike behavior.

The way to reduce scientific uncertainty when it comes to practices like masking young children is to conduct randomized studies. When it comes to masking kids in schools, the global scientific community has launched no such studies during the pandemic. The U.K. government recently commissioned a report on the efficacy of masks in school settings, which failed to identify any clear evidence in favor of this practice. Moreover, the authors write:

Wearing face coverings may have physical side effects and impair face identification, verbal and non-verbal communication between teacher and learner. This means there are downsides to face coverings for pupils and students, including detrimental impacts on communication in the classroom.

Let’s start with cloth masks, which have been the most common type of facial covering used to cover kids’ faces in school. In the only cluster randomized trial conducted during the pandemic among adults, cloth-masking failed to improve the primary outcome of COVID cases that were confirmed with a blood test. In an umbrella review I conducted with Jonathan Darrow of Harvard and Ian Liu of the University of Colorado, we concluded that cloth-masking simply doesn’t work. A month later, the former health commissioner of Baltimore told CNN the same:

The United States is uniquely aggressive in masking young kids. Contrary to scientific evidence, the Centers for Disease Control and the American Academy of Pediatrics advise that children as young as 2 should wear masks. Europe has always been more relaxed on this issue, and the World Health Organization advises against masks for kids under 6 and only selectively for kids under 11.

Data from Spain on masking kids is sobering. The figure below shows the R value—a measure of how fast the virus spreads—by age. Spain mandated masks at a specific age cutoff. If masks have a visible effect, we should see a step down in the graph at the age kids start to wear them (i.e., the spread should drop at the age masking begins). But as you can see, there is only a slow, deliberate, upward trend with no steps down. Based on the evidence only, it would be impossible to guess which age groups are wearing masks and which are not.

Data from 'Age-dependency of the Propagation Rate of Coronavirus Disease 2019 Inside School Bubble Groups in Catalonia, Spain,' November 2021

Data from ‘Age-dependency of the Propagation Rate of Coronavirus Disease 2019 Inside School Bubble Groups in Catalonia, Spain,’ November 2021The Pediatric Infectious Disease Journal

This simply means that masking was not associated with a large effect in slowing spread. (If you’re curious, kids started to wear masks in this study at age 6.)

Now let’s consider N95 or equivalent masks that are designed to filter a high percentage of particles. To achieve this goal, N95 masks require a snug fit and validation. Notably, there are no approved N95s for kids because these masks have not been subject to validation for young people. All masks sold with this moniker are merely “N95-style” masks thought to be equivalent, possibly. Berkeley and other school districts have mandated them anyway, even though no study suggests the policy can slow the spread of COVID.

What is the goal of masking policy? Does it at least help to “slow” the spread? Pre-vaccine, it made sense to try to delay infection until all those who wished could be vaccinated, the latter being an intervention that does have a demonstrable effect on rates of serious disease and death. While cloth-masking does little if anything to delay infection, universal N95-masking might have indeed been helpful. But does this goal still make sense after vaccines and omicron?

Omicron has shown it is able to infect even vaccinated people relatively easily (even though, yes, vaccines do still appear to protect from severe disease). The fact that omicron is widely spread by vaccinated people, coupled with its rapid rate of spread, means that sooner rather than later we will all be infected—a conclusion shared earlier this month by Anthony Fauci. But if infection is inevitable for everyone, then it no longer makes sense to wear a mask. Even the most effective mask can’t avert infection; it can only delay it while causing inconvenience, discomfort, and difficulty speaking, all of which are detrimental to the educational and emotional well-being of schoolchildren.

Put another way, while we don’t know whether Berkeley’s school masking policy will in fact slow the spread, we do know it’s a bad policy regardless: If it works, it merely delays an inevitable brush with COVID, and is therefore unnecessary; if it doesn’t work (and the impossibility of children maintaining a proper fit and seal for hours on end suggests it can’t), it is simply a piece of public health theater whose side-effects are likely to be severe, and is therefore unnecessary.

Should kids and parents be afraid of COVID? Parents of kids with immunosuppression and other severe medical problems should seek the guidance and advice of their pediatrician in order to decide what is best for their child. But the majority of parents of healthy kids should put their fears of COVID into perspective. A (pre-vaccine!) analysis from Germany shows that if a child is infected with COVID—with or without preexisting conditions—there is an 8 in 100,000 chance of going to the intensive care unit. According to the same study, the risk of death is 3 in 1 million, with no deaths reported in the over-5 age group. These risks are astonishingly low.

What about the effects of long COVID? The best data we have suggests that between 0% and 2% of kids who are infected will experience symptoms beyond any control measures. But the larger point is that if infection is inevitable—if it is just a matter of time—then considerations of long COVID are moot. No matter how we reach the destination, we will have to help children who develop long COVID. This is true whether we make them wear masks or face shields, or hold their breath every time they go indoors.

When it comes to the downsides of masking kids, I want to be clear that no prior study truly informs the moment: In all of human history we have never masked so many children for so many hours a day for so many years. As such, we have very little data from which to draw lessons. We simply do not know the long-term impacts of this evidence-free intervention.

Yet the preliminary evidence that we do have is illuminating. Fifty-nine percent of U.K. teachers in April 2021 stated that asking pupils to wear masks made understanding them a “lot more difficult.” We know that when someone conceals their lips it’s harder to comprehend what they’re saying. This effect is of course more pronounced among children with hearing and learning disabilities. For this reason, a recent “evidence summary” from the U.K. Department of Education concluded, “Government guidance continues to be that children aged under 11 years old should be exempt from requirements to wear face coverings in all settings including education.”

One justification I often hear for masking kids is some variation of, “My kids are masked and they’re doing just fine.” I hear and see this frequently from professional colleagues—people with doctorate-level training and considerable financial resources to help support the children in question. But is the same true for a child whose mother works long hours and spends prolonged time in day care? Do all kids get the same stimulation outside of school to compensate for the pandemic-era deprivations we subject them to? The answer to these questions is likely no. While the assertion is often made that masking kids is a form of unselfish behavior—and that those who oppose it are the real selfish ones because they put others at risk—the data appears to support the opposite conclusion.

Because U.S. masking policies are largely forms of virtue-signaling and public health performance, it’s not surprising that they are often blatantly self-contradictory and absurd. Recall that the CDC and AAP have both advised masks for kids ages 2 to 5, in contrast to WHO guidelines. To get a sense of this policy in practice, think of the day care centers that made toddlers wear cloth masks except during nap time, when they sleep side-by-side with their peers in the same room. Similarly, schools that mandate masks have little choice but to lift those requirements at lunchtime.

Due to the failures and absurdities of these measures, some doctors, educators, and public health authorities have been working on coming up with offramps to school masking policies. But the difficulty of doing so is a direct byproduct of the lack of evidence to support masking kids in the first place. If you don’t understand the circumstances in which masks actually help or don’t help, it’s hard to know when to stop. The logical moment for a masking reset was the widespread availability of vaccination for kids ages 5 to 11, but that opportunity came and went at the end of last year.

Masking is now little more than an appealing delusion. It arms us with a visible symbol that communicates our commitment to minimizing the pandemic’s damage. It makes some of us feel empowered by giving us something “we can do” in the face of a largely invisible threat. To a certain extent, this is understandable. But most of the masks worn by most kids for most of the pandemic have likely done nothing to change the velocity or trajectory of the virus. The loss to children remains difficult to capture in hard data, but will likely become clear in the years to come.

Less forgivable is the decision we’ve made as a society to shift the anxieties of adults onto the youngest members of society, who count on us to defend their interests before our own. It is thanks to the nature of this particular virus, rather than the foresight of American institutions or adults, that COVID has been relatively impotent against children. The majority of kids who have been infected have recovered without sequelae. And yet we continue to impose the most harmful and onerous restrictions on the youngest among us. While we purportedly do it to protect other age groups, empirical analysis suggests, for instance, that school closures in a given community have done nothing to slow the spread among the elderly in the same community.

When the history books are written, we will not look wise or kind for insisting that kids and toddlers wear masks for hours on end, year after year, without ever testing this policy with controlled trials. We will look ignorant, cruel, fearful, and cowardly. We might even look worse than our primitive ancestors who, when faced with great plagues, engaged in all sorts of bizarre, superstitious behavior—but which rarely included making kids suffer most.

Vinay Prasad is a hematologist-oncologist, associate professor of epidemiology and biostatistics at the University of California, San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People with Cancer.

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