The scientific debate over the effectiveness of masks in schools has heated up, calling into question whether mask-wearing will help students, as schools across the country open in the midst of the delta variant surge.
Some physicians and scientists have recently claimed that the best evidence shows that masks are not an effective measure against the coronavirus, that the risk of the virus to children is small, and that masks can have a substantial downside for children. Others have countered that universal masking in schools is a necessary measure until vaccines are widespread among young children.
COVID-19 vaccines are highly protective, but at present, only students ages 12 and older are authorized to receive them. But the COVID-19 risk to children is small. Those ages 17 and under account for only .06% of all COVID-19 deaths in the United States, according to data from the Centers for Disease Control and Prevention.
Still, rates of new hospitalizations among minors are 40% higher now than at the previous peak in January, due to the delta variant. Delta is surging in many parts of the country now, just as the school year is set to begin.
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The issue of masks in schools has proved contentious among politicians and parents. While some school districts are mandating masks for the fall, others are making them voluntary. States such as Arizona, Florida, Iowa, Montana, North Dakota, South Dakota, Tennessee, and Texas have banned local schools from imposing mask mandates. Internationally, neither the United Kingdom nor Ireland will require masks for school children this year, while France will only require them for students ages 11 and up.
That may be the right policy, according to Dr. Jay Bhattacharya, a professor of medicine at Stanford University and one of the coauthors of the Great Barrington Declaration, a controversial plan for responding to the pandemic that would focus protection on the most vulnerable, such as the elderly, while avoiding the harmful effects of lockdowns.
“From early in the pandemic, it was very clear that the risk to young people is very small. The number of children who died from COVID in 2020 was less than died from the flu,” said Bhattacharya. He also noted that masks can cause problems for children with learning and emotional development.
Bhattacharya and Neera Sood, a public policy professor at the University of California, Berkeley, recently laid out their case against masks in schools in the Orange County Register, writing that “the onus is on proponents to show that the benefits of masking kids outweigh the costs.”
But Dr. Danny Benjamin, a distinguished professor of pediatrics at Duke University, disagreed.
“Universal masking policy has clearly been shown to interrupt transmission in schools in eight different pee-reviewed publications,” Benjamin said.
Benjamin and his colleague Dr. Kanecia Zimmerman, an associate professor of pediatrics at Duke University, took to the New York Times recently to argue in favor of universal masking in schools. They presented evidence from North Carolina, where staff and students in all public schools were required to wear masks last year. More than 7,000 adults and children attended North Carolina schools while infected with the coronavirus during the last school year, but contract tracing and testing found that only 363 additional children and adults acquired the virus from those infected. Benjamin and Zimmerman credited the mask mandate.
Bhattacharya countered that Benjamin overstated the conclusions from his study, in part because the study had no control group of school districts that either had no mask policy or a policy of voluntary masking. That makes it impossible to know if North Carolina’s mask policy performed better than districts with no mask policy.
Benjamin acknowledged that his study did not have a control group, although he tried to get data from districts without a mask mandate, and those districts refused to provide data.
Of the eight studies that Benjamin stated show the effectiveness of masks in schools, only one had a control group. It did find that schools mandating masks had lower rates of infection. However, all eight of the studies are observational studies, in which researchers cannot control the independent variable — in this context, who wears a mask. This makes them far more prone to bias that can influence the results, unlike randomized controlled trials, in which researchers can control the independent variable.
Bhattacharya said that in the mask studies that do employ randomized controlled trials, it is hard to find evidence that masks work to stop the spread of viruses.
In one such study in Denmark, researchers randomly assigned volunteers to wear masks or not for up to two months. It found no significant difference in COVID-19 infections among those who did not wear masks versus those who did.
“That’s not the type of intervention we are talking about,” countered Benjamin. “We are talking about a voluntary policy of masking for children versus a universal mask policy where it is enforced. If you ask 7-year-olds to voluntarily mask, you can guess how often they will do it.”
Yet, the masking of children could potentially harm their development.
“For children, especially young children, masks can cause problems in basic developmental things, in learning of emotions and language acquisition,” said Bhattacharya.
The ability to recognize smiles and frowns is crucial to children’s emotional development, something that becomes next to impossible when wearing a mask. One recent study found that children under 8 confused the correct emotion with other emotions more often when masks were worn. The confusion was particularly pronounced for those ages 3 to 5.
These concerns inform the World Health Organization’s mask recommendations for minors. The WHO recommends against mask-wearing for children 5 and younger, in part, because of concerns over the possible harm they can do to emotional development. From children ages 6-11, the WHO recommends masking on a case-by-case basis depending on the infection rate in the surrounding community and the effect mask-wearing has on “learning and psychological development.”
But Benjamin said the harm will be relatively small.
“We’re using masks until we get vaccine authorization for all school-age children and we get a high fraction of those kids vaccinated. Masking is a bridge to that goal,” he said. “That should be five to six months from now.”
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The first vaccine maker that will get an emergency use authorization to vaccinate those ages 5-11 appears to be Pfizer. The company says that it will be ready to submit data to the Food and Drug Administration in September.
