Recommendation or mandate? Thoughts on the CDC's new guidelines

One of the hardest parts of responding to the COVID-19 pandemic has been communication. Trying to give people valid, current and useful information as our understanding of this new virus grows and changes every day. Striking a balance between an abundance of caution and a lack of responsibility. Recognizing that the people on this planet are not lab animals – where we just have to find the right medical treatment to fix the problem – but billions of individuals, each with their own fears, personalities and agendas. Any policy solution has to take into account psychology and sociology as much as it does epidemiology and virology.

So early on, there was a lot of criticism about recommendations that went beyond the science, in an attempt to achieve other policy goals and influence individual behavior. More recently, the reverse happened – the CDC’s new guidelines for indoor mask usage are being criticized because they ONLY consider the science and not the larger public policy implications. Here’s my take on this.

First of all, it’s important to remember that there is a big difference between medical recommendations (your doctor telling you that it’s healthier to eat less starch and fat), and public policy (the FDA banning artificial trans fats from manufactured foods). Both are based on science, but public policy has to take into account all of the consequences and implementation issues of a medical recommendation.

On May 13th, the CDC made a new RECOMMENDATION for people who are fully vaccinated against COVID-19. They had previously said that mask usage wasn’t necessary outdoors for these people in most situations, but the new guidelines said that masks and social distancing aren’t needed indoors either. There are a few exceptions, like public transportation, healthcare settings, prisons and homeless shelters. And they explicitly said that any government regulation or business policy supersedes this recommendation.

The CDC is just saying that if YOU are vaccinated, you are neither at significant risk yourself or a significant risk to others if you unmask indoors. And that’s useful and science-based, but that’s not the only question that governments and businesses need to answer. They need to look at a number of things and decide if lifting mask mandates for vaccinated people is safe for the entire community they serve. They don’t just automatically convert every CDC recommendation into law.

Now in some cases, that IS what happens For example, the FDA extended the Pfizer vaccine’s emergency use authorization to 12 – 15 year olds, the CDC recommended giving it to this age group, and the health departments of the individual states implemented these shots, all within a few days. On the other hand, governments and businesses need to take the May 13th recommendations and look at their individual conditions on the ground to make decisions about masking.

They need to ask questions. For example, what is the local COVID positivity rate? What percentage of our population has been vaccinated? What are the political ramifications of ending or extending a mask mandate? How do we determine if someone has been vaccinated? How does lifting the mandate affect unvaccinated children, when there is no way of being sure that an unmasked person is truly unable to spread the virus? What are the physical characteristics (size and ventilation) of the space involved?

It’s not an easy decision, and at this point, there is no one right answer that I can see for all situations. I think that one of the main reasons why the CDC went so far with these guidelines was to push people to get vaccinated, which is INCREDIBLY important right now. It’s a race between vaccines and variants. Right now, the vaccines seem to cover the variants well, but the more cases we have, the more variants evolve. We have an opportunity to beat this thing, and making people aware of the benefits of vaccination is a great way to make that happen.

So, what's happening now? Since the 13th, about 20 states have revised their mask mandates (New York is to do so this week), and some retailers (e.g. Walmart, Costco, Trader Joes) are allowing vaccinated people to be unmasked inside. Some companies make an effort to confirm vaccination status, others rely on the honor system. And many retailers - large and small - are continuing to require masking indoors for everyone even though their state may have lifted the mandates. These are private companies making business decisions - there is nothing in the CDC guidelines that prohibits a continued policy of indoor masking.

And what should WE do? Well, we should follow local laws, and comply with the policies of public retail establishments - CDC guidelines don’t let us break them. Conversely, if you feel that you aren't ready to unmask yet that's OK, and you shouldn't be shamed for that. Many people with unvaccinated children mask because they are uncomfortable telling their kids that masking is vital for them but unnecessary for their parents, even if there is a good scientific reason for that.

I think that Dr. Ashish Jha (as usual) frames this very well. Outdoor mask mandates aren't currently necessary for anyone - vaccinated or not - except in limited circumstances. While it may be safe for vaccinated people to unmask indoors in public, it would be good for governments and businesses to wait a few weeks longer to lift those mandates, until a greater percentage of the population is immune, because of these other considerations. He estimates that June 15th would be a reasonable target, given the pace and distribution of vaccination in the US. And while the CDC doesn't advise lifting the indoor mask mandates for unvaccinated people, some states have done this as well, which he considers unwise.

Finally, being unmasked indoors, even if it's personally safe for YOU, isn't the whole story. As Dr. Jha tweets:

“That norm says that while folks are still getting vaccinated, infection numbers are high, let’s protect each other in higher risk situations,” he said. “Do I have to? Nope. I’m safe, so what do I care? But I do care about creating an expectation that we protect vulnerable people. We get to choose what kind of community we create. You can think narrowly about your personal interest. Or you can think about your community norms.”

So, please. If you are over 12 and you haven’t been vaccinated yet, do it. Do it for your country, for your city, for your elderly relatives, for people at high risk for complications. Do it for people you will never know - although cases are dropping, almost 600 Americans died yesterday of the virus. Do it to stop the variants. And even if you are young and healthy, do it for yourself. People who “survive” may have long term problems that we won’t know about for years. It’s ALWAYS going to be better to avoid COVID if you can.