With fears of huge death toll, masks remain key defence in Covid-19 war

An RCT study in Bangladesh's semi-rural and rural areas shows people can be convinced to keep up their masks. The research offers many other takeaways, including huge cost savings

Masks have dropped out of conversations. They were in any case slipping below the nose for a lot of people. There is no doubt the abandoning of mask culture also contributed to the horrible second wave of the Covid pandemic. As people battle acute shortage of beds and of oxygen, a discussion on masks could, however, sound bizarre. 

But according to Mushfiq Mobarak, professor of economics at Yale University, this could be a terrible mistake. “Vaccinations will take a long time to arrive in South Asia to create a wall of immunity. Till then, masks are most essential”.  

Mobarak and his team have done a large RCT (Randomized Controlled Trial) study in Bangladesh on about 350,000 people to study mask usage in semi rural and rural areas. The encouraging news from the study is people can be convinced to keep up their masks. It is a rich study with lots of other takeaways, including huge cost savings. But abstracting from those, his basic conclusion is impressive. Vaccines alone cannot halt even India’s current second wave. Usage of masks has to be consequently given a massive thrust in the interiors. Else even the current misery in cities could soon pale before the onslaught of the disease in the smaller towns and villages.  

Authorities in the states seem to be listening to his arguments. In Bihar, Gujarat and Telangana, the state governments and the local non-governmental organisations have begun to mobilise themselves big time to keep the masks up. A huge advantage with the strategy is its absurdly low cost. 

Self Employed Women’s Association, Sewa was the first off the bloc to adopt the lessons for its 2 million strong fraternity. “Compared to the state governments, Sewa responded the very next week after we made our pitch”, Mobarak told this correspondent. Some of the hiccups at the state government level was also due to the impact of the Covid. A good percentage of the senior officers at the Bihar health department was sick right now. 

Researchers at Yale University, Stanford Medical School, along with those from Innovation for Poverty Action and local partners found masks remained on the bridge of the nose when people were reminded by their peer group to do so. People watch each other, seems to be the refrain from the large study conducted earlier this year. Periodic in-person mask monitoring worked, said Mobarak when he discussed the report at a seminar at NCAER this month. 

To prepare the groundwork, the researchers had distributed effective but cheap surgical masks to the villages covered by the study. The people were also shown videos with popular role models like Bangladesh cricket icons to drive home the message. At the mosques, imams were drafted in to reinforce the message. The villages were divided into control groups where no follow up action was taken versus treatment groups where follow up teams landed to check what percentage of people were still using the masks after the initial burst of publicity. When people in these villages showing up without masks at the local markets were requested to put up one and also offered one on the spot, if they had forgotten to carry one, they remembered the lesson for the future. Mask wearing in these villages shot up. From an average of 13 per cent for the control group villages the jump was nearly three times to 42 per cent. It was the highest in mosques at 49 per cent. But coercive action by the state, like penalties or other threat did not change the behaviour of the people. When chowkidars accompanied the researchers, they hardly made a long term dent. 

The pattern persisted even ten weeks into the trial, well after the eight week long mask promotion exercise had ended. Given the twelve weeks span of a Covid wave, this is a remarkable takeaway. How did they measure if the villagers were maintaining their mask up behaviour. The professor said during the trials and even later researchers would visit the villages to sit unobtrusively at designated public places, tracking on their apps, the pattern of mask behaviour. To ensure that the local people did not recognise them, different sets of researchers conducted the publicity and the follow up. 

Gagandeep Kang, Professor of microbiology at Christian Medical College, Vellore said at the NCAER discussion that the Indian population was far more heterogeneous and so might not respond to the same inducements. Mobarak, however, felt it could be sorted out if the experiments were conducted at neutral venues like markets in the countryside or at malls in the city. Both provided the public stage where a bit of public shaming was  possible to nudge people to change their behaviour, long term. 

“Mounting scientific evidence is pointing to covid-19 primarily transmitting through airborne aerosol transmission.  This suggests that even as governments are working hard to arrange oxygen supplies, increase hospital capacity, and ramp up vaccine availability, communities should deploy effective masking strategies urgently”, he said. 

Echoing him, Shekhar Shah, Director General, NCAER said the think tank plans to extend the learnings with all the health departments of states. “The secretaries are neck deep in handling the current crisis, yet most of them say they all wish to learn how to take this into their states.