By KAREN JOHNSON and WHITNEY THURMAN
One recent Friday night, we huddled with our colleagues in the pouring rain at a movie theater parking lot– our cars packed with supplies for our mobile vaccine clinic— trying to find someone who wanted an extra dose of Pfizer’s COVID-19 vaccine before it expired. Five months ago, we would have been inundated with people desperate for that extra dose. But that has changed now that the most willing and able segments of the population have largely been vaccinated.
Amidst this backdrop of slowing vaccination rates in the U.S. and many miles to go before reaching all of those willing to be vaccinated, the CDC has released updated recommendations for mask wearing that we believe to be premature and contrary to the ethic and mindset of public health. Buoyed by mounting evidence supporting the effectiveness of vaccines, the CDC— cheered by the Biden administration— gave fully vaccinated Americans the green light to ditch their masks. As fully vaccinated public health nurses who are as excited as anyone about the vaccines’ real-world effectiveness, we nonetheless find ourselves again asking: what are they thinking?
To be clear, we do not question the evidence showing that all COVID-19 vaccines currently approved in the U.S. are safe and effective. We also crave good news, hope, and allowing the bottom half of our faces to see the light of day. We have also appreciated the Biden administration’s commitment to “following the [biomedical] science” in pandemic policymaking. Our concerns lie with the timing of the recommendation; the lack of regard for social science demonstrating the importance of public policy in influencing community norms and human behavior; and the blatant disregard for health equity. That the nation’s preeminent public health institution has fallen prey to the individualistic mindset that typifies American society, as CDC director Dr. Rochelle Walensky stated herself on Sunday regarding this “science-driven individual assessment” of risk, is frustrating, to say the least.
Currently, only one-third of the U.S. has been fully vaccinated. The news media has been full of accounts of many sub-groups who stubbornly defend their right to refuse a COVID vaccine, but the majority of those in the U.S. who remain unvaccinated belong to communities that have been unable to access a vaccine due to difficulty navigating online appointment scheduling, inability to take time off of work, poorly translated informational resources, or being ineligible due to age restrictions or other medical contraindications. Universal mask-wearing has been a critical stopgap measure to protect these at-risk populations until the majority of Americans are vaccinated. The CDC’s recommendation is therefore not only premature: it sends the message to individuals and other governmental entities alike that we don’t need to care about our neighbors.
In addition to slowing the spread of COVID-19, masks are a visible sign of community solidarity and take the burden of worry off unvaccinated individuals and parents of unvaccinated kids. In a nation where basic infection control principles have somehow become political, the CDC’s recommendation to establish a two-tiered approach to public health seems woefully misguided. Encouraging the third of Americans who have been fully vaccinated to go maskless while encouraging those who remain to be vaccinated to mask up will complicate unvaccinated individuals’ efforts to protect themselves while out in public and at work or school— places that everyone has a right to access regardless of their vaccination status. Further, this type of policy recommendation by the CDC is likely to be interpreted as blanket permission for all to discard their masks. In fact, just days after the announcement, the Texas Governor banned schools and governmental entities from mandating masks. He even went as far to implement fines on institutions that attempt to do so, kneecapping any collective action to protect communities, schools, and workplaces. This type of policy decision is the exact reason that we need the CDC to make public health recommendations using a public health framework, not an individualized, biomedical assessment: public health policies must protect the most vulnerable among us who have not yet been vaccinated, or for whom the vaccination may not be as effective.
Even more troubling, this approach centers the good fortune of the predominately white, well-educated, and wealthy communities who have had easiest access to the vaccine thus far. This latest recommendation from the CDC is yet another example of the burden of the pandemic falling disproportionately on communities with the least power to protect themselves. They are now forced to wonder if the unmasked person in their checkout line or dining in their section has been vaccinated with little recourse to protect themselves if they have been unable to be vaccinated before the CDC’s latest recommendation.
Many will say that wearing a mask and getting vaccinated are individual decisions and that we should live and let live. We do not seek to argue with the importance of obtaining individual consent for medical care– this is a basic ethical principle that all healthcare providers understand and honor. But our code of ethics also demands that we think of the greater good. Unlike nurses, infectious diseases do not respect the bounds of individual autonomy. This is why we need public health leaders who use their power to establish norms that emphasize the health and safety of the whole community, with the most vulnerable serving as our common denominator rather than being tossed from the equation entirely. The CDC has the authority, ability, and, in our estimation, responsibility to set a different tone about public health practices: we wear masks to protect and respect each other, not just ourselves.
So where does this leave us? The CDC could rescind the recommendation, thus causing further confusion and frustration. But, as with the proverbial can of worms, this new guidance will not be easily re-bottled. Instead, Americans must choose to continue to mask up until more are vaccinated. We as nurses can use our influence as trusted providers to set an example by masking up and encouraging our patients to do the same. Finally, the Biden administration must conduct an in-depth evaluation of our public health response to the pandemic, including what evidence has been used to make recommendations and how such decisions are being communicated to the public. When considering pandemic policymaking, it is critical that we follow all of the science–not just the science that gives us effective vaccines. This includes the science of individual and collective behavior and the science of risk communication. We must emerge from the pandemic with a robust, fully-funded public health infrastructure capable of performing its essential tasks, including promoting— rather than minimizing— our interconnectedness as the way through a collective crisis.
Karen Johnson, PhD, RN, FSAHM, FAAN and Whitney Thurman, PhD, RN are public health nurses and faculty members at the University of Texas at Austin School of Nursing.