Better Masks? More Masks?

It's time to up our protection game.

Two weeks ago, Zeynep Tufecki and Jeremy Howard asked a reasonable question: “Why Aren’t We Wearing Better Masks?

If you’re like most Americans, there’s a good chance you’re going to wear a cloth mask today. Doing so makes sense. It remains the official recommendation in the United States, and it is something we’ve both advocated since the beginning of the pandemic. Both of us wrote articles as far back as March urging people to wear homemade cloth masks. We’re also the authors (along with 17 other experts) of a paper titled “An Evidence Review of Face Masks Against COVID,” which was just published in peer-reviewed form in the Proceedings of the National Academy of Sciences. But it’s past time for better solutions to be available to the public.

We first released the paper as a preprint back in April, and it took nine months to go through peer review. We’re happy that it’s published but, to be honest, we’re also deeply disappointed that it’s still relevant. We’d hoped that by 2021 supply chains would have ramped up enough to ensure that everyone had better masks. Cloth masks, especially homemade ones, were supposed to be a stopgap measure. Why are so many of us still wearing them?

Don’t get us wrong; everything we said about the efficacy of cloth masks stands the test of time. Wearing them is much better than wearing nothing. They definitely help reduce transmission of the coronavirus from the wearer and likely protect the wearer to some degree as well. But we know that not all masks are equal, and early on in the pandemic, there was a dire shortage of higher-grade masks for medical workers. During those emergency conditions, something was much better than nothing. There are better possibilities now, but they require action and guidance by the authorities.

Even all cloth masks are not equal. Construction, materials, and fit matter, and these can’t be tracked or certified with homemade masks. Unlike cloth masks, medical-grade masks (also called respirators) that adhere to standards such as N95 (in the U.S.), FFP2 (in the European Union), and KN95 (in China) do a much better job of protecting the wearer and dampening transmission. Ideally, they should also come with instructions on how to wear them and ensure that they fit properly.

[…]

Worse, the supply situation apparently remains so dire that the CDC still “does not recommend that the general public wear N95 respirators,” because they’re crucial supplies that must continue to be reserved for health-care workers and other first responders.

Not all countries have this problem. Taiwan massively scaled up its manufacturing of masks at the start of 2020, such that by April every citizen received a fresh supply of high-quality masks each week, and the distribution system was regulated by the government. Taiwan’s COVID-19 death rate per capita is more than 1,000 times lower than that in the U.S. Hong Kong has been distributing patented six-layer masks (the efficacy of which has been laboratory tested) to every citizen. Singapore is on at least its fourth round of distributing free, reusable, multilayer masks with filters to everyone—even kids, who get kid-size ones. In Germany, Bavaria has just announced that it will be requiring higher-grade masks. If all of these places can do this, why can’t we?

The authorities are apparently getting on board.

America’s coronavirus guru is advising us to wear two masks.

The nation’s top infectious diseases expert, Anthony Fauci, said in an interview on NBC’s “Today” that wearing two masks “just makes common sense.”

“Today’s” Savannah Guthrie asked Fauci if double-masking was advisable or made a difference, to which he responded “it likely does.”

“I mean, this is a physical covering to prevent droplets and virus to get in. So if you have a physical covering with one layer, and you put another layer on, it just makes common sense that it likely would be more effective,” Fauci said. 

By that logic, seven would be better but, sure.

Our counterparts across the Pond are going the Asian route.

A number of European countries have announced new mask recommendations and requirements, pushing aside fabric masks in favor of surgical masks or medical-grade respirators.

In Germany, the federal and state governments introduced measures last week making medical masks — identified as surgical masks or KN95 or FFP2 masks — mandatory in stores and on public transit. It also issued a recommendation that medical masks be worn whenever there is close or prolonged contact with other people, particularly in enclosed spaces.

FFP2 is a European standard promising filtration similar to that of N95 or KN95 respirators.

The government said that in light of the new coronavirus variants, medical masks “offer greater protection than normal cloth masks, which are not subject to any standards with regard to their effectiveness.”

“We must take the danger posed by this variant very, very seriously, and we must slow the spread of this variant as far as possible,” said Chancellor Angela Merkel.

The German state of Bavaria had already introduced rules requiring FFP2 masks on transit and in shops. The federal government earlier announced it would distribute millions of FFP2 masks to people over 60 and those with chronic conditions.

Austria put similar rules into effect on Monday, now requiring FFP2 masks or the equivalent in settings including transit, carpooling, businesses open to the public and indoor and outdoor markets. To ensure wide adoption of the new regulations, Austria said it would distribute 1.2 million free masks. Large supermarket chains will also hand out free masks in the first days of the new rules.

France’s High Council for Public Health announced last Thursday that it is now recommending people wear surgical masks in public, on the basis that they offer better protection than fabric masks.

“The recommendation that I make to the French people is to no longer use fabric masks,” said French Health Minister Olivier Véran, according to Reuters.

Véran said industrially made masks are preferable. “Artisanal masks that one makes at home, with the best intentions in the world … do not necessarily offer all the necessary guarantees,” Véran told France Inter last week.

The council now recommends that people wear Category 1 masks in public, rather than those from Category 2, which includes most cloth masks. Category 1 includes FFP2 masks, surgical masks and fabric masks that meet specific standards. Didier Lepelletier, co-president of the COVID-19 working group at the council, discouraged the general public from using FFP2 filter masks, though, warning that they are difficult to wear correctly, according to The Local France.

Honestly, that makes far more sense than having people go out and buy another wave of cloth masks. Or escalate the tensions of store clerks having to now decipher whether people are wearing two masks rather than one.

Of course, an absurd number of people refuse to wear their masks correctly nearly a year into this crisis. So, I’m not sure how much new guidance will help.

UPDATE: I missed Harvard public health professor Joseph G. Allen‘s WaPo op-ed “Everyone should be wearing N95 masks now.”

In the scrambling for information and tools in early days of the pandemic, it was acceptable to just say any cloth mask will do because it’s true. Any face covering is better than none.

But we’ve learned so much since then, and we need to adjust our strategy. A typical cloth mask might capture half of all respiratory aerosols that come out of our mouth when we talk, sing or just breathe. A tightly woven cloth mask might get you to 60 or 70 percent, and a blue surgical mask can get you to 70 or 80 percent.

But there’s no reason any essential worker — and, really, everyone in the country — should go without masks that filter 95 percent.

The masks I’m referring to, of course, are N95s. These are cheap — pre-pandemic they cost about 50 cents — and easy to manufacture. Yet our country has failed to invoke the Defense Production Act to produce enough masks for health-care workers and other essential workers. That needs to change, as my colleagues at Harvard Medical School have written.

FILED UNDER: COVID-19, Health
James Joyner
About James Joyner
James Joyner is Professor and Department Head of Security Studies at Marine Corps University's Command and Staff College and a nonresident senior fellow at the Scowcroft Center for Strategy and Security at the Atlantic Council. He's a former Army officer and Desert Storm vet. Views expressed here are his own. Follow James on Twitter @DrJJoyner.

Comments

  1. MarkedMan says:

    Cloth masks can stop droplets but I haven’t found one that stopped viral sized particles in any meaningful way. On the same equipment used to validate N95 and equivalent masks to 95% efficiency, cloth masks come out in the single digits. A big difference is woven vs. non-woven material. Woven material such as cloth is essentially a screen, and screens have holes. If the wholes are bigger than the particles, they can go straight through. Masks made from non-woven filter material have a random structure that captures particles in several different ways depending on their size, but the most important thing is that there is no straight shot through.

    This isn’t hearsay. I’ve personally tested a half dozen cloth mask materials and my colleagues dozens more, all on the same equipment used to test N95 masks.

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  2. gVOR08 says:

    Masks are our biggest easily prevented failure. The administration originally downplayed masks. And I blame Fauci as much as anyone. On the medical side apparently because N95s were in scarce supply and they didn’t want a run depriving medical personnel of them. On the political side I’d guess they knew if they said to wear masks they’d have caught heat for not having masks available. And as Trump saw COVID purely as a political problem, it was easier to say masks don’t matter.

    Early on transmission mechanisms weren’t obvious, it wasn’t clear that it was almost entirely respiratory. But common sense would have said that until we were sure, masks cost little, might help, and can’t hurt. Would it have been so hard to come out and say, ‘Wear a mask in public. We have to reserve medical grade masks for exposed medical personnel. We’re moving heaven and earth to ramp up supply, including invoking the Defense Production Act. Until we catch up, here’s how to make a decently effective mask for yourself.’

    But we didn’t do that. We went to Jared for production. And Etsy became our major mask supplier. Failure to make masks may have been incompetence. But I think it was really that pushing masks would have undercut Daddy-in-Law’s message that it’ll be over by Easter. Other countries as noted in the OP managed to ramp up mask production. There really needs to be investigation to see if Jared was profiteering.

    Now double masking is a thing. Wearing two cloth masks probably helps. I seriously doubt wearing a cloth mask over an N95 really accomplishes much medically. What it does do is color coordinate with an outfit and hide a politician’s N95 so everybody doesn’t ask, “Where’s mine?”

    Trump, and my beloved /s Governor DeSantis, decided to run on not asking anybody to do anything. They made masks another culture war issue. Now even if we had truckloads of N95s at every Walgreens for a nickel apiece a chunk of the base would refuse to use them. I still see conservatives citing cherry picked claims masks are useless, just COVID theatre.

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  3. MarkedMan says:

    @gVOR08:

    Wearing two cloth masks probably helps. I seriously doubt wearing a cloth mask over an N95 really accomplishes much medically.

    I can’t see any mechanism for two cloth masks helping in any meaningful way. When we talk about double masking I assume we are talking about wearing a cloth mask over a surgeons (pleated style) mask. The cloth gives the fit and the surgeons mask does the actual filtering.

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  4. MarkedMan says:

    I should add that if you want to do better than N95 you should concentrate on fit. The next level up is P100 (99.97% efficient) and a good portion of that standard is about fit. Professions that use P100’s typically use cartridge based masks that are adjusted to provide a good fit on each individual.

    But bottom line, a well fitted N95 mask is so much more effective against virus sized particles than a cloth mask I wouldn’t spend too much time worrying about going to a P100. After all, N95 and surgeons masks have kept millions of healthcare providers safe for months even when they are around active spreaders.

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  5. Teve says:

    Jesus, i just saw a guy pull out “if masks work why do we need a vaccine???”. When people started criticizing him he resorted to “i got First Amendment rights!!!” So fucking tedious.

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  6. MarkedMan says:

    A typical cloth mask might capture half of all respiratory aerosols that come out of our mouth when we talk, sing or just breathe. A tightly woven cloth mask might get you to 60 or 70 percent, and a blue surgical mask can get you to 70 or 80 percent.

    How does that “half” (50%) square with my statement above that all the cloth masks tested at my company are in the single digits? We are testing to the standard which limits aerosols from roughly viral sized to ten times that diameter, but that is still orders of magnitude below even tiny droplets. And there is a fair amount of evidence that droplets are the primary mode of transmission. So wearing a mask benefits others if you are a spreader.

    It’s less clear that cloth masks benefit you from getting the disease. If a drop lands on a cloth mask will it seep through? N95 and surgeons masks have a liquid barrier layer. Cloth masks do not. That might be where a cloth plus surgeons mask has greatest efficacy but I have no evidence for that.

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  7. Tyrell says:

    I made a double mask by hot-gluing one mask on top of the other one. The top layer is a Disney theme mask. I have worn this mask since November. Maybe time for a new one. Etsy has some good mask selections at reasonable prices. My next mask will be Maleficent. I know a couple of people who are making some nice masks. They make pro and college sports teams masks. Those styles are usually the highest priced.
    I have problems with my mask causing my glasses to fog up, so I am frequently having to lower it or I will not be able to see. What is the solution for that? And the straps have caused blisters on one ear.

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  8. CSK says:

    @Tyrell:
    Scotch-tape the bottom of the mask to your face. It doesn’t look stupid, and it works. Try it.

    It also works as an additional sealant, obviously.

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  9. CSK says:

    I’ve always worn the two-layered (blue on the outside, white on the inside) disposable surgical masks.

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  10. mattbernius says:

    @Tyrell & @CSK:
    Another option is spit: https://www.leisurepro.com/blog/scuba-guides/spit-work-defogging-scuba-mask-2/

    Yeah, it sounds crazy but it works. And it’s also available as a synthetic spray: https://www.amazon.com/Spit-Shine-Sunglasses-Eyeglasses-Binoculars/dp/B00PUWVMBE

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  11. Cheryl Rofer says:

    Your penultimate paragraph gets it.

    If people wear N95 masks the way they wear the masks they have now, there will be no difference because of the stuff that leaks out around them. The fit should be tight, to the skin at all points.

    I am now wearing a paper mask with a cloth mask over it, and a clip to pull the earpieces to the back of my head to keep it tight. It is uncomfortable.

    PPE is uncomfortable. I’ve worn different types of PPE. It’s all uncomfortable. If it’s comfortable, it’s not doing its job.

    And no beards. There’s no way to get a tight fit.

    I see several errors in the comments already posted about what masks do and how they do it. But yes, we’re all experts in masks so go ahead with that. Another reason not to bother with N95 masks.

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  12. Kylopod says:

    @Cheryl Rofer:

    And no beards. There’s no way to get a tight fit.

    Not even a tightly trimmed goatee?

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  13. Cheryl Rofer says:

    @Kylopod: Unless you can get the mask around it so that the edge of the mask touches only skin, no.

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  14. Kathy says:

    I find no shortage online in Mexico for KN95 masks. N95 are as rare as competent trumpers.

    recently I heard about Korean KF94 masks. These look more like cloth masks, but incorporate a filter that claims to stop 94% of viral aprticles.

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  15. Tyrell says:

    @Cheryl Rofer: I had two nose operations years ago to straighten the septum. Since then it is very sensitive to the slightest touch or pressure from masks, glasses, and goggles. I often have to lift the mask to get relief. I try to adjust the straps so they are not real tight. I also have the problem of blisters on my ears.

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  16. Liberal Capitalist says:

    Doesn’t matter. The morons are dooming us.

    Here in the northwestern Florida panhandle (where we are residing in our southern estate), it is solid Trump country, with all the expected cognitive dissidence that would imply. Some of the signs have come down, but many are still up and Trump flags are still flying.

    And of course, they are still not wearing masks. And nothing will change that. And they are anti-vax as well, because if it is only a flu, then why should they be scared of it.

    And … well, just fuck it.

    Too many morons that have had all the benefits of democracy, and no brains.

    Soon, a half million deaths. And they still talk about Bengazi.

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  17. MarkedMan says:

    @Kathy: I think (but am not sure as I’m not familiar with the standard) that KF94’s are roughly equivalent to N95’s.

    N95 and KN95’s adhere to different standards that have basically the same criteria. My experience is that KN95’s meet the standard while N95’s exceed them substantially, but there is no guarantee that remains true. And we aren’t testing random stuff, as my company only gets masks from legitimate manufacturers who want to buy our mask or cartridge testing equipment. I understand from them that there are a lot of fakes on the market.

    The standards bodies are looking at intermediate masks that fit like an N95 but aren’t as effective because they have fewer layers, like a surgical mask. I’ve seen 25%, 50% and 70% suggested but I have no idea what it will turn out to be or even if they will be approved. Their are a few tradeoffs, but the most interesting one is that, given the same material, the higher efficiency the higher the resistance. The less efficient masks would have a lower resistance and therefore should be more comfortable to wear.

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  18. Jen says:

    I’ve been wearing the pleated-type surgical masks, but my problem is fit. I’m tiny, and my face is too big for children’s size surgical masks, but the standard “one size fits all” is so large that there are gaps on either side of my mask–it does not sit flush to my face on my cheeks.

    I’ve solved this by just not going out–seriously. I do grocery shopping online with curbside pickup, and pretty much everything else gets delivered. If I do need to go out and physically go in a store (our local state liquor store doesn’t have curbside pickup, grrr), I put a cloth mask over the surgical one to better seal it, but it’s not a perfect solution. In those situations, I just try and get in and out as quickly as possible.

    We have dozens of cloth masks in the house, along with several boxes of the surgical filter masks. I’m not even sure where I’d find N95, but with my face size I have my doubts as to whether even those would fit properly.

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  19. Cheryl Rofer says:

    @Tyrell: My use of PPE was for protection from plutonium contamination. So my criteria are: Would I like to breathe in plutonium? Would I like to deal with the bureaucratic drama that would accompany being contaminated?

    But masks are for everybody. Some wear them correctly, others less so, and of course we have the anti-maskers. And others, like you, have difficulty wearing them. That variety seems to me to argue against a particularly strict standard of using N95 masks. It probably helps to have some people using them, and it is likely to help their personal safety, but I just don’t see it as a big deal.

    What I would like to see is some mathematical modeling of how much difference all that makes. It wouldn’t be that hard to do.

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  20. MarkedMan says:

    @Cheryl Rofer: When I looked into this at the start of this worldwind, there was surprisingly little done on it. The little there was involved real world experimentation and not mathematical modeling, I assume because so many factors involve wild guesses (how tightly they fit, how often people lower them, etc). There were a few studies that examined having medical personnel use surgical masks in more situations while in hospital. And one or two studies that looked at transmission rates of communicable diseases if family members were encouraged to wear medical masks around patients who were home based. That last one showed no effect in encouraging mask use, primarily because it was almost impossible to ascertain whether people were following the protocols or not.

    None of the studies looked at cloth masks because it simply never occurred to anyone that a developed country would be unable to supply medical grade masks to their population for any significant length of time.

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  21. Cheryl Rofer says:

    @MarkedMan: There are more studies available now. I’ve been following rather closely.

    The modeling is quite similar to modeling I’ve done. It’s just more than I care to do now, and I’m sure that others have a setup that could handle it.

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  22. Andy says:

    @Cheryl Rofer:

    If people wear N95 masks the way they wear the masks they have now, there will be no difference because of the stuff that leaks out around them. The fit should be tight, to the skin at all points.

    Yep. I think anyone who wears glasses understands this. And without a tight fit, adding additional layers is just going to restrict airflow through the mask and create more blow-by.

    I have a double-layer cloth mask I’ve been using for months that fits me well and seals adequately. I have never been able to get the N95’s to fit well. I do a bit of woodworking and other activities that require breathing protection and the only thing that fits my face for that is a respirator.

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  23. Mikey says:

    But there’s no reason any essential worker — and, really, everyone in the country — should go without masks that filter 95 percent.

    Way back at the beginning, a PPE manufacturer reached out to the Trump administration with an offer to manufacture N95 masks by the millions.

    They got the proverbial crickets in response.

    And of course Trump could have invoked the Defense Production Act early on, but refused.

    Those are the reasons why we don’t have N95s for everyone. Yet another Trumpian failure.

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  24. inhumans99 says:

    I was watching CNN last week and caught a bit where it was said that if everyone in the U.S. wore the same type of mask they are wearing in the Asian countries referenced in this post that after a month we would actually get control of the virus. The problem is that everyone is left to their own devices to find these masks and purchase them. Notice that the articles James’ references note that they gave the mask out to the general population.

    It still remains one of the great tragedies that if sometime last summer proper masks were handed out to all U.S. Citizens with instructions to wear in public or never be allowed to leave your home that we could have indeed destroyed the curve and got a grip on Covid.

    That to me remains one of Trump’s great failings, more so than even his attempts to steal the election, he could have kept the base that he claims to love safe yet ultimately showed he does not give two flying figs about the base except for their ability to open their wallets and send him money.

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  25. steve says:

    I nearly always wear a surgical mask over my N 95. It keeps it from getting soiled and prolongs its usefulness. We are adequately supplied for 4-5 months at current usage rates, but if we were to have another surge would just as soon have lots on hand.

    As to fit, I think you need to be fit tested to get full advantage if you are going to be working with Covid patients and then you should also be wearing eye protection. If you are talking about less close contacts I dont really know how much you gain from a tight fit. My WAG is that you dont gain a lot in terms of effectiveness but you may lose some in compliance. Wearing an N 95 all day is annoying at best and uncomfortable for many. For routine wear we encourage our staff to wear N 95s. Much more comfortable and pretty decent protection. Since we track every person who tests positive for Covid it looks like we rarely have infections coming from our patients. It is almost all from family and from each other (people eating together, hanging out and ignoring the guidelines.

    Steve

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  26. MarkedMan says:

    @Cheryl Rofer: Can you point to the studies? I’d love to check them out.

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  27. Tyrell says:

    @inhumans99: :Never be allowed to leave your home”. How would that be enforced? I go outside to get some vitamin D by sitting or lying on a beach chair in my own back yard. Are you proposing arresting people for that? I don’t spend my hours and days wandering in stores and outlet malls. I ride my bike, walk, spend a lot of time in the woods, and the river banks fishing. Tell me how that endangers anyone. There is no one around to endanger.

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  28. Just nutha ignint cracker says:

    @inhumans99: Your mistake is simply that you don’t understand that The Market is omniscient and omnipotent. If everyone needed to have access to supplies of masks, The Market would do what is necessary to meet that need. The fact that The Market hasn’t supplied masks simply shows that they aren’t necessary. The Market also wanted me to note that it resents Dr. Joyner’s implications that it needs the help of the Defense Production Act or other players. The Market has this under control, and Etsy is doing a yeoman’s job of meeting demand. Also, if Jared is profiting from this situation, it’s only because that situation, too, meets the needs of The Market.

    [We return you to your regularly scheduled blog thread.]

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  29. Kathy says:

    @MarkedMan:

    I think (but am not sure as I’m not familiar with the standard) that KF94’s are roughly equivalent to N95’s.

    That’s my understanding as well.

    before we started to get pleated masks at work, I had a cloth mask made by a coworker. It had two layers, plus a square of cloth in a pocket between the layers to act as a filter. It was very effective at filtering my voice, I don’t know how effective it was at filtering droplets.

    The reasons I switched to plated masks was 1) I got tired of washing it by hand every day, and 2) I had to remove it in order to talk (see above). Later I moved on to KN-95 because cases keep increasing, and too many maskholes keep showing up to work.

    BTW, one of these maskholes caught COVID last month. He spent three miserable weeks at home, until he tested negative again. I am glad to say he now wears a mask almost all the time.

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  30. inhumans99 says:

    @Tyrell:

    Tyrell, go to Turkey (where my Aunt lives) and try to violate their quarantine protocols the Turkish government put in place. You might still be able to blog about your rights, freedom, and all that jazz, but only if they let you have access to a computer and the internet from your jail cell.

    Seriously, the folks who tried to take over the Capitol so they could freely frolic in bars without masks because you know…they have “rights,” well, they have no fricking clue what it is like to be quarantined in a country like Turkey, so yes…certain governments might throw your ass in jail if you tried to leave to pick up your Vitamin D instead of having it delivered.

    The United States, Mexico, Brazil…it is all about letting people push back against masks and whining about the infringement on their personal rights, but go to Turkey and if you are of a certain age and out at the time of day when you are told to stay indoors, well…yes, off to jail you go.

    We really are spoiled in America. In other countries if you flout the rules…yes, your ass can be sent to jail.

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  31. CSK says:

    @inhumans99:
    In fairness to Tyrrell, I think he was talking about sitting in his backyard alone getting some sun for Vitamin D. And I don’t see the harm in walking, biking, or fishing maskless as long as you’re isolated. Keep the mask in your pocket and put it on if you see someone approaching.

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  32. Jen says:

    @CSK: That’s what I took from Tyrell’s post too, but inhumans99 is also correct that in some countries, lockdown has meant quite literally “stay inside.” Children in Spain were not allowed outside to play at all during the initial lockdown.

    Americans are unbelievably spoiled in that we never had the true, strict type of “shut it ALL down” that other countries did. We have far more space, quite literally, and that meant we could leave the house, and walk.

    And yet, we still had the whiners.

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  33. CSK says:

    @Jen:
    Oh, I know. We are incredibly lucky to have so much space.

    It amazes me how so many people can be deluded enough to think that taking some simple and relatively painless precautions is part of a communist plot to turn us all into slaves of the state.

    I don’t like wearing a mask, either. But I’ll do it as long as necessary.

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  34. MarkedMan says:

    @Jen: In the past few weeks, Police somewhere (Montreal?) arrested a woman who had taken her pet out for a walk, despite the fact that regulations clearly allowed exceptions for pets. It seems her “pet” was her boyfriend, who was wearing collar and leash. I don’t even want to know if she was carrying the roll of plastic bags…

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  35. Tyrell says:

    @inhumans99: Yes, I am aware of the harsh conditions and corrosive legal system there.
    China is also like that, but on a greater scale.

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  36. Kathy says:

    @Just nutha ignint cracker:

    Cmpletely off topic:

    Hypothesis: the market follows the line of least resistance.

    Consider, people will most often do what’s easy. Go to the nearest gas station, throw things out rather than recycle them, etc. They change habits only on extraordinary circumstances, like high gas prices were even a modest savings justify a longer drive, or when faced with additional resistance, like fines for throwing recyclables away.

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