June 7, 2020 Dear Madam Mayor, Vice Mayor and Board: Recently we became aware of a campaign to reinstate mandatory masking in Starkville in all public places. Upon learning of this meeting along with some of the data used to support this, we, as local physicians and providers, invested in our patients, this city, our hospital, and our larger community, felt the need to speak up. Each of us gathered here this evening does so because we have the health and well-being of the citizens of Starkville heavily on our mind. We acknowledge that COVID-19 is a real, uninvited virus that has caused sickness, death, fear & confusion in our world, our country, our state, our county and our city. In the sense that this is a “novel” virus that is new to our world, there is no definitive expert. As a group of local providers, we acknowledge that we do not have all of the answers. However, we do believe that our personal experience with COVID and our opinions are important and relevant to the citizens of Starkville. Through four months of tracking this virus here locally, much has been learned. We have a clearer understanding of who is infected by the virus and who is actually sickened by the virus. We have learned that young people are generally not sickened by the virus. We have learned that older people (greater than 80), long term care residents, intellectually disabled people, morbidly overweight people and those with underlying health conditions (chronic lung and heart disease, active cancer, poorly controlled diabetes, and chronic kidney disease) are more adversely affected than those without these conditions. Since the virus does not affect everyone equally, we do not believe that generalized measures to combat the virus should involve everyone equally. Let us be clear, we are not against masks. The issue of mandatory masking is contentious because it is not settled science. It adds additional strain on our patients. It increases anxiety and, in many cases, makes breathing more difficult, as described by many of our patients on a daily basis. In fact, there are some studies that suggest mask usage may have deleterious health effects. Just this past week, the American Society of Cataract and Refractive Surgery issued a statement that mask usage led to complications in some types of laser surgery. Our respected colleagues have cited opinions and research that recommend masks. Studies in support of mask use cite meta-analysis and retrospective reviews of other countries’ experiences. Meta-analyses and retrospective studies are generally viewed as inferior studies in the world of medical science. Notably, some of the studies provided to you in support of mandatory masking acknowledge this. Meta analyses and retrospective studies also do not control for variables such as social distancing or hand washing or isolation of a country. It is not our position to argue the merit of wearing a mask, but rather tell you the data is, at best, inconsistent. We present additional opinions and research that show masks may not be effective. For example, N95 masks, not surgical masks or homemade face coverings, have been shown to be effective when worn properly and for short periods of time. They have not been shown to be effective when wearing them day after day or improperly, which is regularly observed by our group. It is well established that hand to face contact increases one’s risk of infection. Improper mask wear includes adjusting your mask, wearing it below the nose, pulling it down around your neck, or wearing on the head or forehead. In each of our clinics we regularly see masks worn inappropriately through constant hand touching. Mandating their use will certainly exacerbate this. Mandating masks may also provide a false sense of security leading to a decreased conviction to perform the more protective activities such as social distancing and hand hygiene. We do believe that those healthy people who find themselves in a close, intimate encounter with high risk people should wear masks. We do not believe or support the mandate that all citizens should wear masks in all public places. Per the Center of Disease Control’s own statements, social distancing is more effective at decreasing the spread of COVID-19 than wearing a mask. We do not believe that COVID-19 is spread significantly at large establishments (such as grocery stores and big-box stores) where social distancing is already occurring. We do support continued efforts to focus on social distancing and hand-washing. In closing, we believe that this virus is here to stay for the foreseeable future. We must learn to live with it. As providers, we daily note the ever-changing world of medicine. We live in it. We observe it. We practice it. We understand that things change. The absence of data neither endorses nor rejects an idea. As data evolves, we will change with it. We have both professional Hippocratic and moral obligations to do so. Mandatory masking is neither helpful nor scientific. In many cases it may be counterproductive. We urge you to make decisions that will protect the vulnerable but also allow the less vulnerable to live as normal a life as possible. We believe that herd immunity is real and valuable to the population at large. We believe that the healthy are able to take the brunt of what is mostly an asymptomatic disease burden for the greater good of the population. In fact, the healthy will have to, as we do not believe Covid-19 will be controlled until herd immunity is reached or an effective vaccine is created, which could take months to years. We do not envy your positions, but we do ask you to please consider our combined 309 years of medical experience when you make your decisions. Thank you for your time. God bless Starkville, Mississippi, and God bless America. Respectfully submitted, James S. Brown, M.D., F.A.C.S. Ophthalmology John L. Turner, M.D., F.A.S.A. Anesthesiology William R. Carter, M.D. Medical Director of Anesthesiology Chief of Staff OCHRMC Henry L. Edmondson, M.D. Family Medicine Everett McKibben, M.D. Family Medicine Daryl P. Guest, M.D., F.A.C.S. General Surgery Paul L. Ruff, M.D. Pediatrics Drew Anthony, M.D., A.B.F.M. F.A.C.O.S. Family Medicine John T. Maples, M.D. Emergency Medicine Medicine Dallas W. Butts, M.D. Emergency Medicine John T. McReynolds, M.D. Anesthesiology Jonathan C. Williams, D.O. Orthopedic Surgery James T. Methvin, D.O., General Surgery Davis Woodard, M.D. Emergency Medicine & Family Glenn Mason, FNP-C, MSN, BSN Orthopedic Surgery Michael D. Shaw, D.O. Emergency Medicine John Cantrell, M.D. Emergency Medicine Medicine Cameron S. Huxford, M.D., F.A.C.P. Pulmonary, Critical Care & Sleep References: MacIntyre CR, Seale H, Dung TC, et al. A cluster randomized trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015; 5:e006577. doi: 10.1136/bmjopen-2014-006577 Effectiveness of Surgical and Cotton Masks in Blocking SARS–CoV-2: A Controlled Comparison in 4 Patients. Seongman Bae, Min-Chul Kim, Ji Yeun Kim, et al. Annals of Internal Medicine. Facemasks and similar barriers to prevent respiratory illness such as COVID-19: A rapid systematic review. Julii Suzanne Brainard, Natalia Jones, Iain Lake, Lee Hooper, Paul Hunter medRxiv 2020.04.01.20049528; doi: https://doi.org/10.1101/2020.04.01.20049528 Jacobs, J. L. et al. (2009) “Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: A randomized controlled trial,” American Journal of Infection Control, Volume 37, Issue 5, 417 – 419. https://www.ncbi.nlm.nih.gov/pubmed/19216002 “N95-masked health-care workers (HCW) were significantly more likely to experience headaches. Face mask use in HCW was not demonstrated to provide benefit in terms of cold symptoms or getting colds.” Cowling, B. et al. (2010) “Face masks to prevent transmission of influenza virus: A systematic review,” Epidemiology and Infection, 138(4), 449-456. https://www.cambridge.org/core/journals/epidemiology-and-infection/article/facemasks-to-prevent-transmission-of-influenza-virus-a-systematicreview/64D368496EBDE0AFCC6639CCC9D8BC05. “None of the studies reviewed showed a benefit from wearing a mask, in either HCW or community members in households (H). See summary Tables 1 and 2 therein.” bin-Reza et al. (2012) “The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence,” Influenza and Other Respiratory Viruses 6(4), 257–267. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1750-2659.2011.00307.x “There were 17 eligible studies. … None of the studies established a conclusive relationship between mask/respirator use and protection against influenza infection.” Smith, J.D. et al. (2016) “Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis,” CMAJ Mar 2016 https://www.cmaj.ca/content/188/8/567 “We identified six clinical studies …. In the meta-analysis of the clinical studies, we found no significant difference between N95 respirators and surgical masks in associated risk of (a) laboratory-confirmed respiratory infection, (b) influenza-like illness, or (c) reported work-place absenteeism.” Offeddu, V. et al. (2017) “Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and MetaAnalysis,” Clinical Infectious Diseases, Volume 65, Issue 11, 1 December 2017, Pages 1934–1942, https://academic.oup.com/cid/article/65/11/1934/4068747 “Self-reported assessment of clinical outcomes was prone to bias. Evidence of a protective effect of masks or respirators against verified respiratory infection (VRI) was not statistically significant” Radonovich, L.J. et al. (2019) “N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial,” JAMA. 2019; 322(9): 824–833. https://jamanetwork.com/journals/jama/fullarticle/2749214 “Among 2862 randomized participants, 2371 completed the study and accounted for 5180 HCW-seasons. ... Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza.” Long, Y. et al. (2020) “Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis,” J Evid Based Med. 2020; 1- 9. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jebm.12381 “A total of six RCTs involving 9,171 participants were included. There were no statistically significant differences in preventing laboratory-confirmed influenza, laboratory-confirmed respiratory viral infections, laboratory-confirmed respiratory infection, and influenza-like illness using N95 respirators and surgical masks. Metaanalysis indicated a protective effect of N95 respirators against laboratoryconfirmed bacterial colonization (RR = 0.58, 95% CI 0.43-0.78). The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza.”