As the mask mandate debate rages on in Australia, epidemiologists and medical specialists suggest looking to countries where citizens are perfectly happy to wear them to see how powerful the simple infection-control measure can be.
Nearly two and a half years into the COVID-19 pandemic, countries where mask-wearing is a cultural norm are seeing some signs of success as the persistent Omicron sub-variants spread throughout their communities.
University of Otago public health professor and epidemiologist Michael Baker said underlying the widespread acceptance of masks in some countries was a sense of personal responsibility to protect others from COVID-19.
“I’m looking at the countries that appear, on paper, to be keeping their mortality very low … despite having lots of circulating virus, and it’s basically the Asian countries, particularly Japan, South Korea, Singapore,” he said.
Professor Baker said Singapore was a good comparison.
“They did have elimination for a long time, and then they decided that it wasn’t compatible for their economic model so they switched to allowing transmission. And, really, they’re still keeping case numbers and, particularly, deaths down,” he said.
“What’s the fundamental difference? I think a lot of it will be around the cultural norms around not infecting people, which probably means quite high adherence to staying home when sick and with mask use.”
While several infection-control specialists have warned that fatigue around COVID-19 control measures is likely contributing to the spread of Omicron in both Australia and New Zealand, the World Health Organization has urged countries seeing surges in the BA.4 and BA.5 sub-variants to accelerate vaccine uptake and bring back mask-wearing.
New Zealand has a much wider mask mandate than Australia but, even if face coverings are required, there is no established culture of wearing them.
Deakin University epidemiologist and associate professor Hassan Vally said wearing masks was just one example of how cultural differences were contributing to COVID-19 success in some Asian countries.
“Clearly there’s the uptake of masks in those areas, which is a really positive and useful tool in our toolkit, but I think there are a lot of things going on,” Dr Vally said.
“We have a very individualistic culture in the West and it’s the mirror image in the East.
“The emphasis rather, [than] being on freedoms and individuality and independence, is on community and unity and looking at things in a holistic way.
“And, so, I think that’s a really quite important cultural difference that underpins a lot of the success that has happened in Asian countries.”
Mask mandates in Singapore
In Singapore, there is a requirement for masks to be worn in indoor public spaces, including libraries, markets, shopping centres, schools and weddings.
The bride and groom are allowed to switch their mask for a face shield as the ceremony takes place, but the mandate only allows guests to take their face coverings off while eating and drinking.
Associate Professor Ashley St John — from Singapore’s Programme in Emerging Infectious Diseases — said that, largely, there had been acceptance of the rules.
“Mask-wearing is still required indoors [when] outside the home in Singapore, when not actively eating or drinking,” she said.
“From my perspective, most are supportive of maintaining this measure.”
Just as the population is happy to wear masks, Dr St John noted, there were few barriers to the uptake of vaccines.
“Mask-wearing is effective in limiting the spread of COVID-19, but probably the most important aspect of the response to COVID-19 now, that is lowering COVID-associated deaths, is vaccination,” she said.
“Vaccine compliance is high in most Asian countries.”
Dr St John said efforts had been made to communicate the evidence behind Singapore’s mask policy to the public and there was an understanding that masks worked to limit transmission.
Dr Vally said Australians had made a huge shift in their awareness of masks, but there needed to be clear messaging about what their behaviour should be right now as the country sees more than 100 people a day die from the disease and more than 5,000 people admitted to hospital.
“We might not have the level of conformity and social pressure that some Asian countries have, and I think right now there is confusion in the messaging because people seem to think that if the government doesn’t mandate it, they don’t think it’s actually important,” he said.
“If there is a time to sort of dust off mask-wearing, it’s exactly in this situation as part of pulling out all stops to do the right thing for ourselves and our community to try [to] bring transmission down,” he said.
Japanese reminded to take masks off
In Japan, face masks have come to be known as “face pants”.
“It sounds like the throwaway line, but it’s actually really important,” Dr Vally said.
“You wouldn’t leave the house without your pants on, so you wouldn’t leave your house without your mask. It speaks to how socially unacceptable it is.”
Such is the social pressure to wear a mask in Japan, residents report being stared at should they venture outside without one.
Japan’s laws do not allow the government to order the population to wear masks nor impose a lockdown, but the country has managed to keep the COVID-19 mortality rate low.
Even as Japan sweltered during a heatwave in May and June, residents did not lose their commitment to outdoor face masks, so much so, the government was forced to issue heat stroke warnings.
Public broadcaster NHK reported that local authorities struggled to convince people to remove their masks during the periods of high heat, with one local governor committing to going mask-free just to set an example.
“Wearing masks has become a daily custom, so people seem resistant to removing them and people also might feel it’s difficult to stop wearing them when many around them continue to do so,” Miyagi Governor, Murai Yoshihiro, said.
A history of ‘mass masking’ in South Korea
When South Korea dropped its mandate on outdoor mask usage in May, Reuters reported many people were reluctant to give up the face coverings, due to ongoing Omicron infections.
From there, South Korea managed to bring the number of daily new COVID-19 deaths down, but it is also now dealing with the stickier BA.4 and BA.5 sub-variants.
According to modelling from its Centres for Disease Control, the country will see 200,000 daily confirmed cases from August to October.
“It is one third of the amount of confirmed cases that we experienced with Omicron last year, when we experienced a peak of confirmed cases in Korea,” Dr Yujin Jeong told a COVID-19 conference in Sydney last week.
“So what is the main strategy with the new surge in Korea? It is still minimising severe illness in high-risk groups and maintaining our lives.”
In recent decades, environmental factors also laid the foundations for the “mass masking” of Koreans, including concerns about pollution and the seasonal Hwangsa phenomenon, which sees dust blow eastward from China, across the Korean Peninsula.
Koreans were quick to turn to masks as an infection-control measure at the outbreak of COVID-19.
Mask-wearing has been “an entrenched feature in the public responses against infectious diseases since the early 20th Century” in South Korea, according to an article published in the East Asian Science, Technology and Society journal in April.
“Now, wearing facial masks was not merely a means for individual protection. It was also an act of social responsibility and solidarity,” the authors argued.
Making mask-wearing a habit
Earlier this year, Canadian psychologists conducted research into mask-wearing, looking specifically at how attitudes and behaviours were split along cultural lines.
Their research — which was published in Frontiers in Psychology journal in March — analysed sentiments towards mask-wearing among East-Asian Canadians and non-East Asian Canadians.
“The frequent use of masks may be reinforced by the relatively favourable attitudes [that] Chinese Canadians held toward public mask-wearing, such as perceiving mask-wearers to be respectful and responsible,” the findings read.
“In contrast, the early mask use hesitancy among non-East Asian Canadians might be associated with their ambivalent attitudes toward public mask use. Specifically, although some non-East Asian Canadians perceived mask-wearers to be socially responsible, others perceived mask-wearers to be ill, strange and overreacting.”
The researchers said cultural and social norms were “a powerful force in shaping health-related behaviours” and recommended policymakers utilise the power of personal connections to bring about long-lasting change.
They said: “Increased use among one’s family, friends, neighbours and colleagues may induce the pressure for one to conform to avoid social disapproval.”
In cultures where masks are widely adopted, there appears to be both an individualistic motivation and a responsibility to the greater good.
And the act of wearing a mask is not political, so much as a logical, infection-control measure.
Dr Vally said as well as getting booster shots, wearing a mask was “one of the easiest things we can do” right now to help prevent transmission and to protect vulnerable people.
“With wearing masks and with mandates, it’s reached this kind of emotionally charged position where it seems to be a symbol of other things,” he said.
“At the end of the day, it’s a piece of fabric that you put over your nose and your mouth to act as a bit of a barrier to help us reduce your likelihood of being exposed to the virus or exposing other people to the virus. That’s all it is.”