Patients & Vulnerable Populations Pandemically Left in the Dark


To be honest, the United States blew it on the mask front. From a public health, caregiver and patient safety, as well as community transmission standpoint, we are at least 3 months late to game. Anytime a brand new virus that humanity does not have any immunity to makes an appearance, is highly contagious, starts rapidly infecting people as well as the doctors and nurses caring for them, hospitalizing, and killing them in concerning numbers across the globe, we should enable every proactive safety measure at our disposal.

The first confirmed case of COVID-19 in the US was on January 20, 2020. The general public and the millions of people who are considered at high-risk for complications from COVID-19 were advised that wearing masks in public was unnecessary. Many individuals were shamed and called out for wearing masks in public, being directly blamed for personal protective equipment (PPE) shortages on the front-lines. Meanwhile, hundreds of millions of masks and PPE are exported out of the country by brokers daily. People out in public have been mocked for a spectrum of reasons, being criticized as to why masks were being worn, used to run errands, and for removing them incorrectly. On April 4, 2020, the Centers for Disease Control (CDC) recommended that the general public wear cloth face masks in public where social distancing may be difficult, such as at the grocery store or pharmacy, especially in areas where cases of the infection are high for active transmission.

There has been extensive media coverage of PPE shortages at hospitals on the front-lines of this pandemic. Protecting our doctors, nurses, and all caregivers and first-responders is of utmost priority as we work to fight against COVID-19. As a patient advocate, patient, and carepartner to 2 disabled adults, with multiple family members in the high-risk population, was the call-to-action for the public to wear masks delayed so as to not risk further depleting PPE needed for those directly caring for patients sick with COVID-19?

As a country, we have lost almost 11 weeks for providing education to bridge gaps in health literacy on proper use of items like masks and gloves. We have lost weeks in giving those isolating at home the opportunity to better protect themselves and reduce, if not prevent, community transmission when they do need to venture out in public for essential means.  We missed the chance to provide purpose to millions who are isolating at home with nothing to do. A sense of purpose during this dark time of pandemic can provide rays of hope and sense of community in the face of uncertainty, grief, loss, and loneliness. This is a national call-to-action for all patients, for all who are considered high-risk, for those isolating at home to actively help make a difference in further flattening this curve and protecting yourself and society by helping make homemade masks.

Why should we wear a mask now?

COVID-19 is extremely contagious. Transmission is happening via droplets and respiration, which includes coughing, laughing, breathing, sneezing.

A significant proportion of people infected with COVID-19 have no symptoms but are active carriers of the disease. You could feel fine yet spread the virus to people you encounter daily as well as contaminate surfaces in public places that can lead to community spread of the disease.

People with mild symptoms may shrug them off as nothing concerning and go about their day. With allergy season upon us, many with mild cases may mistake their symptoms for allergies. Due to limited diagnostic testing, anyone with symptoms is recommended to refer to a telemedicine consult for evaluation, followed by self-quarantine as potentially positive for COVID-19, unless otherwise advised by a physician.

People who are symptomatic, with symptoms such as fevers, coughing, achiness, diarrhea, vomiting, or loss of taste or sense of smell should be wearing a mask to further reduce droplet and respiratory spread of the virus.

Patients and those considered vulnerable to complications of the disease have been lost in the tsunami of information. The majority of the focus, with respect to masks, has been on getting doctors and nurses who are actively caring for patients with the virus PPE. We are missing the entire other side of the coin as we collectively work to further reduce and prevent the spread of COVID-19.

People who are living with chronic illnesses and multiple comorbidities, such as diabetes, cardiac conditions, asthma, cystic fibrosis, cancer, rare disease, or disabilities, are immune-compromised, and/or are elderly are considered at high-risk. These people have more frequent encounters with their doctors and health systems for essential care. It is an endangerment of patient safety for these high-risk populations to continue receiving in-person, essential care, especially in areas that are hotspots for COVID-19, without being provided a mask or advised on how to make a mask, counseled on how to properly wear it, and how to safely dispose of it or sanitize it. It is documented that surgical face masks can reduce the number of flu and common cold viruses that can be detected in the air as microdroplets or aerosols.  The study’s findings are intriguing in support of proactively, universally wearing face masks in public as an added measure and public health strategy to help flatten the COVID-19 curve, especially in hot-spot areas.

It is of importance to note that vulnerable populations, people living in poverty, in shelters, in low-income housing complexes, long-term care facilities, such as rehabilitation centers, memory care, and nursing homes, as well as those who are incarcerated at prisons, and those struggling with social determinants of health (SDoH) are at an even higher risk for rapid transmission and infection. With massive influxes of patients exhibiting urgent symptoms, like severe shortness of breath, flooding hospital emergency rooms, we must do even more to better support marginalized and vulnerable communities who are at significant risk for complications from COVID-19. Rampant community spread severely and dangerously impacts us all.

What’s the difference between all these masks?

The general public does not need the same level of protection as a doctor or nurse who is treating patients with COVID-19. Caregivers at the epicenter of this healthcare pandemic are routinely exposed to the coronavirus at significantly higher levels. Patients presenting to the ER often have a higher viral load, or amount of virus circulating in their system. If you are in an environment where you are constantly surrounded by this highly contagious virus at much higher volumes, you must have protection of the highest medical grade in order to protect yourself as well as to safely care for patients.

surgical mask is a loose-fitting, disposable piece of PPE that forms a barrier between the mouth and nose of the wearer and the wearer’s surroundings. A N95 mask is a respiratory mask that filters airborne particles. Unlike surgical masks, N95 masks are designed to fit tightly around the nose and mouth. The FDA regulates PPE, like N95s and surgical masks.

In the same way that there are prescription medications and over-the-counter (OTC) options, handmade masks can be viewed as the OTC option to help further reduce, if not prevent, COVID-19 community transmission. Handmade masks do not guarantee preventing infection with COVID-19. They do not replace the need for social isolation or hand-washing but rather may be viewed as an additional effort to help flatten the curve. Think of seatbelts. Seatbelts do not prevent car accidents but they do reduce, if not entirely prevent, serious risks of injuries and death in the event of a car accident. Seatbelts do not work as a standalone safety measure, but rather, in conjunction with airbag systems and socially responsible drivers.

How do you make a mask?

There are many different patterns and versions of homemade masks. Some health systems caring for large volumes of patients with COVID-19 have provided instructions on making home-made, surgical-type face masks for the general public and for patient use. Cloth masks should be made of fabric that allows for washing and drying without risk of damaging.  Cotton is recommended by the CDC as the fabric of choice. Here are a few options:

  1. Providence Washington had provided a number of publicly available resources from their 100 Million Masks Challenge, including:
    1. Tutorial video on making handmade masks
    1. Step-by-step instructions on how to make handmade masks
    1. A pattern for making handmade masks
    1. Safety tips and consideration when making handmade masks
  2. RJWBarnabas Health in New Jersey has provided simple instructions on how to sew a mask
  3. There are also a number of no-sew mask options:
    1. Option 1: T-shirt quick cut (as per the CDC)
    1. Option 2: Bandana, coffee filter, rubber bands (as per the CDC)
    1. Option 3: paper towel, stapler, & rubber bands
    1. Option 4: paper towel & only rubber bands
  4. Some patients have been making masks out of bras: https://youtu.be/pZkOPwkM_G0

How do you wear a mask correctly?

It is important that masks are worn properly. Tie long hair back off the face. The CDC does have guidance for males on their choice of facial hairstyles however, this is in the context of medical-grade N95 respirator masks that require a tight-fitting for proper seal. Following this guidance during this pandemic in the context of handmade masks certainly can’t hurt until we have data is evidence for otherwise. Wash your hands before putting your mask on. Hold the mask by the ties or edges, avoiding touching the inside part of the mask that will be in direct contact with your face so as to avoid potential cross-contamination. Place the mask over your nose and mouth and secure tightly behind your head. As per the CDC, masks should fit snugly but comfortably, against the side of the face, secured with ties or ear loops, ideally made of multiple layers of fabric. Gaps along the edges of masks can be addressed with double-sided fashion tape. Masks must allow for unrestricted breathing. Do not touch your mask once out in public to prevent cross-contamination. Do not pull it down to speak, eat, drink, have a phone conversation, or smoke a cigarette. Do not wear the mask while only covering your mouth while leaving your nose exposed. Do not remove your mask upon exiting a grocery store, pharmacy, or doctor appointment. Do not remove your mask until you are back home or at the location at which you are socially isolating.

The CDC has recommended that everyone wear a cloth mask when in public, with the exception of children younger than 2 years of age, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the cover without assistance.

How do you remove a mask correctly?

Once you are back home or at your place of social isolation, carefully remove the mask by the ties or ear loops. Do not remove by grabbing the front of the mask and pulling. Do not touch your eyes, nose, or mouth when removing it. Once removed, the mask should be washed and dried or disposed of. Single use masks, such as those made of paper towels, should be disposed of in the garbage. Masks should not be disposed of on the ground, on the sidewalk, in a shopping cart, or left in parking lots. During this pandemic, there is no ban on cleaning up after yourself. Wash your hands immediately after removing and disposing of your mask.

Stop the stigma!

Doctors and nurses have been referred to as the front-line of our fight against COVID-19. That must change.  The combination of social distancing, hand-washing, and mask-wearing are our front-line defense. By the time we need critical medical attention, our doctors and nurses are our last resort and final line of defense.  Our doctors and nurses are like goalies: our last line of defense against the opponent, the coronavirus, which is looking to score wins in the deadly column.

Just like in the game of hockey or soccer, we must do everything to fervently protect our goalies.

Culturally speaking, the US does not view wearing masks in public as a hygienic measure, as is common in Asian countries. Here in the US, we associate wearing masks as something the sick do. It’s no surprise that wearing masks in public in the US is highly stigmatized. Based on the recent CDC guidance recommending that everyone wear a mask in public, in addition to practicing social distancing and good hand-hygiene, getting universal uptake and support of universal masks will require a significant cultural paradigm shift and public education effort.

From public figures of authority, to celebrities, musical artists, athletes, and social media influencers, we must break the stigma associated with wearing masks in public, to give us a competitive advantage against this outbreak. Hospitals and point of care digital content providers must prioritize patient education materials on mask making and use. Google should update its homepage to playfully feature masks in their signature GOOGLE word art. Apple should update their memojis to wear masks.  Doctors can leverage telemedicine to begin encouraging and patients, especially those at high-risk, on the importance of and how to wear masks properly.

We need to leverage the power of social media for disseminating credible information, elevating social responsibility, and promoting wearing homemade masks in public. We need to update our profile pics with selfies with our homemade masks. We need to make TikTok videos and vlog with our handmade masks. We need to take our webinars and zoom calls with our masks to get the conversations started. Children and young adults can be taught about the anatomy of a sneeze, a laugh, cough, a conversation, and a breath and why the mechanics and motions are part of the basis of this pandemic. Children and young adults can be guided as to how to make masks. A few may learn a thing or two about the art of sewing in the process. Masks can be made for one’s self, one’s family, the local communities, for use by the most vulnerable to those in hospitals treating patients. For the time being, there will never be enough masks.

If you go out in public without a mask, not only can you be potentially exposed to the coronavirus, but upon arriving at your home, place of residence, or shelter, you risk potentially exposing those in direct contact with you. Wearing handmade masks needs to be viewed as a public health effort to protect those around us as well as ourselves, especially if we are really going to give it our all to begin going back into our world again.

It’s time to #UnblockHealth by wearing handmade masks.

Grace Cordovano, PhD, BCPA is a board-certified patient advocate specializing in the oncology space, a patient experience enhancer, and information unblocked.