Unmasking the rituals of viral epidemics
“You may be able to recover after getting infected of SARS,” a 64-year-old man from Hong Kong said. “But you may kill others if you do not wear a facemask.
“My wife died of SARS because of these irresponsible people.”
The last twenty years witnessed a series of deadly viral outbreaks. Before Covid 19, there was H1N1 in 2009 and SARS in 2003, and in those perilous times the health authorities of Japan, Hong Kong, and elsewhere recommended that citizens wear a mask that covers the mouth and nose. Medical research said then, and it says now, that masking up slows the spread of these airborne viruses.
Not everyone agrees; getting them to wear a mask can be a Herculean labor.
Some agree so much that they don a mask in pollen season.
Why are some reluctant and some enthusiastic about facemasks?
Look to Japan
Social scientists Adam Burgess and Horii Mitsutoshi looked to Japan for the answer. They found that mask wearing in Japan took off around the 1990s as part of national public health campaigns to battle seasonal flu. A popular conception is that Japan is an uber-collective society, but the public health campaigns emphasized that wearing a mask was also about self-protection.
The campaigns worked. But something peculiar happened: when SARS and H1N1 hit, most Japanese wore a mask; when the virus threat receded, about 10 percent of the population still wore one.
To find out why, Burgess and Mitsutoshi wanted to talk to everyday people in Japan. It was January 2011 on the streets of Tokyo, and they stopped 120 people to interview. Now, this is what social scientists would call a “convenience sample,” which is no different than the classic “man-on-the-street” interviews that television shows do. Convenience samples can’t say anything about everybody, but they do show the kind of attitudes that existed at the time.
Many of the interviewees said that they wore a mask during viral epidemics. About half said someone else told them to wear a mask. Only a third of them said that they wear a mask after those epidemics recede.
Most mask-enthusiasts reported that they wore masks, especially in flu and pollen seasons, for self-protection, but their reasons why were not necessarily grounded in science. One person said, “I don’t wear it normally, but I am wearing it because it’s windy today.”
Look to Hong Kong
Japan is not the only country where mask wearing became de rigueur for flu season.
To find out why people wear – or do not wear – a mask, anthropologist Judy Yuen-man Siu went to Hong Kong. Dr. Siu talked to 40 people, 29 of them women, in a health care clinic in January 2015, during the Influenza A outbreak. Interviewees’ age ranged from 22 to 70. Most were middle class, white collar workers – executives, retailers, educators, and the like. Most had a chronic condition of some kind and all of them had some respiratory symptoms.
All donned a mask when SARS was at its worst.
They told Dr. Siu that the government’s public health campaign helped make up their mind to wear a mask. In the media, doctors and other health authorities promoted facemasks as a way to slow and halt the spread of SARS. Mask-enthusiasts saw mask-wearing as a way to support these embattled frontline workers. As a 58-year-old woman put it, “Facemasks were just like a stethoscope and white coat, and it was a symbol of these health care heroes.”
SARS bred fear and uncertainty. “You could never know who the hidden virus carriers were,” a 59-year-old woman said of SARS. “But they could still spread the virus and infect others when they spoke, coughed, or sneezed. Moreover, you could never know if the places you went to had been contaminated by the SARS virus…”
Masking up reduces risk in a risky world. “At the time,” a 59-year-old man said, “I had a very strong feeling that I would definitely get infected sooner or later. It was just a matter of time, and death was near to me. I did not know what I could do. The only thing that I could do at the time was to wear a facemask. With a facemask, I felt much more secure.”
SARS raised a mini-generation of mask-enthusiasts for whom nose and mouth coverings became an annual flu season ritual.
And yet, SARS also raised mask-skeptics.
The skeptics argued that wearing a facemask, especially when sick, is uncomfortable. They thought that wearing one does not speed recovery – it could even slow it. Some said it is bad for your health. Like that of the windy-day masker from Japan, a 32-year-old Hong Kong woman’s reason was not necessarily evidence-based: “I do not use facemasks,” she said, “because I always think that they contain a lot of toxins.”
Damned if You Do…
The reluctant mask-wearer can be ostracized.
And so can the mask-enthusiast.
During viral outbreaks, people pilloried those who did not wear a mask. A 52-year-old man described intense peer pressure: “If you did not wear a facemask, you would be given a dirty look and be discriminated against. No one dared not to wear a facemask at that time.”
Friends and strangers avoided the non-maskers. “My friends and colleagues maintained a great distance from me when I spoke,” a 42-year-old man said about SARS. “Others just ran away when they noticed that I was not wearing a facemask on the streets or during public transportation…”
After viral outbreaks, it is the mask-enthusiasts who feel the sting of the stigma.
“It is unnecessary for normal people to wear a facemask if they just catch a cold or flu,” a 36-year-old woman said. “Because most colds and flus are not serious at all, and will not kill people. Therefore, if a person needs to wear a facemask, I would assume that he or she must have gotten a very serious infection. I will avoid them, because they may make me very sick, or even kill me.”
Folks can get downright hostile, as another 36-year-old woman described: “Even in public transportation, I also wear a facemask if others around me keep coughing or sneezing. However, these selfish people would shoot me a dirty look, and some even cough and sneeze even harder!”
Masculinities come into play, as some equate masking up with weakness. “Wearing a facemask means that I am weak and afraid of bacteria and germs,” said a 31-year-old man. “But I am a man, and I think I am strong, so I do not need to wear a facemask… If I wear a facemask, I will lose face in front of my friends, and they will laugh at me for being so weak.”
Anti-maskers particularly resent the heavy-handed peer pressure. As an employee quoted in a Japanese newspaper put it:
“My company is forcing everyone to wear them all day from the moment one leaves the house to when one gets back home. It feels like I’m suffocating, all the while keeping a microbe-culture adhered to my face and feeding it warmth and moisture with my own breath, so naturally, I hate it. A lot. But when my pay’s on the line, I have no choice but to comply . . .
“At least while the bosses are looking.”
Josh Dubrow wrote this piece based on several articles. One is by Adam Burgess and Mitsutoshi Horii. “Risk, ritual and health responsibilisation: Japan’s ‘safety blanket’ of surgical face mask‐wearing.” Sociology of health & illness 34, no. 8 (2012): 1184-1198. Another is by Po Man Tsang and Audrey Prost. “Boundaries of solidarity: a meta-ethnography of mask use during past epidemics to inform SARS-CoV-2 suppression.” BMJ global health 6, no. 1 (2021). Tsang and Prost conducted a meta-analysis (“meta-ethnography,” they call it) of nine qualitative studies about why people wear masks; five of which were in China, and one was in Japan (the above study). They found that, during public health crises, masks can be a form of social solidarity and a show of support for science. The studies they read seem to indicate that people are more likely to mask-up when they see public officials and members of the media wear masks. Campaign effects wane when the crisis abates. Tsang and Prost led me to the third article I based this piece on, by Judy Yuen-man Siu. “Qualitative study on the shifting sociocultural meanings of the facemask in Hong Kong since the severe acute respiratory syndrome (SARS) outbreak: implications for infection control in the post-SARS era.” International journal for equity in health 15, no. 1 (2016): 1-16.
“You may be able to recover…” (Hong Kong, p. 7)
But something peculiar happened… “Around 12 per cent of 58,000 respondents in a survey that was held after the anxiety had receded in September 2009 reported regular wearing of a mask, while half mentioned handwashing and gargling (Sankei et al. 2009).” (Japan, p. 1188)
In the Tokyo convenience sample, slightly more than half were men.
“I don’t wear it normally…” (Japan, p. 1191).
Dr. Siu conducted the interviews in Canton Chinese. (Hong Kong, p. 2)
“Facemasks were just like a stethoscope …” (Hong Kong, p. 8)
“You could never know who …” (Hong Kong, p. 6)
“At the time I had a very strong feeling…” (Hong Kong, p. 8). A 51-year-old woman echoed that thought: “SARS was so mysterious that I really did not know how it could be transmitted… However, I still had to do something, and wearing a facemask was the only thing that I could do at the time. It gave me a sense that I could at least have some control over my life.” (Hong Kong, p. 8)
“I do not use facemasks…” (Hong Kong, p. 11)
“If you did not wear a facemask…” (Hong Kong, p. 6)
“My friends and colleagues…” (Hong Kong, p. 6)
“It is unnecessary …” (Hong Kong, p. 10)
“Even in public transportation…” (Hong Kong, p. 10)
“Wearing a facemask means ….” (Hong Kong, p. 11)
“My company is forcing everyone…” (Japan, p. 1188)
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