Will Doug Ford and Kieran Moore change their stance on masking? Why experts say it’s time

The calls are coming quicker and growing stronger: bring back mask mandates to help curtail the triple threat of COVID-19, influenza and respiratory syncytial virus that's sickening Ontarians and putting pressure on an already teetering hospital system.

With cases only expected to spike over the next two months, the growing chorus of medical professionals say the simple step of masking will help stanch the flow of patients flooding into ERs.

Health officials have hinted a return to mask mandates may be necessary if things get bad enough. Some experts are asking in light of pediatric hospitals confronting record-long waits, cancelling surgeries and transferring kids far from home, whether that threshold of severity has already been met.

But so far, the transition to mandatory masking seems to be the province's very last option.

Premier Doug Ford said Wednesday that Ontarians are welcome to wear masks, but there is no recommendation for widespread mandatory masking at this time from Dr. Kieran Moore, the chief medical officer of health.

Moore told the Star in a recent interview that he is strongly recommending" those at risk of severe illness from the three viruses to mask indoors but says he is reluctant to install a mandate.

Instead, he wants people to remember the basic layers of protection" of staying home when sick, masking in indoor settings, wearing a mask while recovering from a respiratory illness. and good hand hygiene.

I'm very loath, after 1,000 days of a pandemic, to put in a mandate," he said. We know what works, and we can trust Ontarians to do the right things in terms of vaccination, treatment, and all these basic layers of protection that we've adhered to so well in the last three years.

Sometimes, the public just needs a reminder."

But experts question whether reminders and recommendations will get enough people to mask to meaningfully curb infections. They worry people have become numb to repeated messaging, and say asking people to mask - even in a worsening health crisis - may not be enough.

Despite weeks of recommendations to mask up, walk into any school, store, movie theatre, arena or mall and masks are seldom to be seen.

Even the spectre of record-long wait times and overcrowding in hospital emergency rooms due to a growing number of people with respiratory illnesses hasn't seemed to scare the public into putting masks back on.

When mask mandates were lifted, people really did interpret this as a signal that the pandemic was over and that they were safe," said Dawn Bowdish, an immunologist at McMaster University who holds a Canada Research Chair in Aging and Immunity. But we are now in a mask-free era with more (COVID) deaths, more hospitalizations for COVID and other respiratory infections, and certainly more pediatric cases than earlier this year when we had mask mandates.

If masks made sense in early 2022, then they make even more sense in late 2022."

There's little doubt that the health system is in a fragile state after years of pandemic stress and is struggling to meet the demands of the current viral surge: overwhelmed pediatric hospitals are moving critically ill teenagers into adult ICUs while cancelling non-urgent surgeries; big Toronto hospitals have repeatedly told staff their ICUs are at capacity in recent weeks; more than a dozen hospitals in primarily rural areas have had to close their emergency departments more than 110 times this year.

New data shows that in September, patients waited an average of 21.3 hours in the emergency room before being admitted - the highest in at least a year. That means only 23 per cent of patients admitted to hospital from emergency departments met the provincial target wait time of eight hours.

And the province has yet to hit peak viral season. Influenza and RSV cases, now spiking early and fast, are expected to keep climbing until December, with COVID still contributing to hospitalizations.

On Wednesday, the head of the Ontario Medical Association said masks can protect against contracting respiratory illnesses and recommended Ontarians wear them indoors.

And last week, Moore warned Ontario had a critical two-week window to vaccinate as many people as possible against influenza to tamp down its spread.

While experts agree that being vaccinated against COVID and influenza is important - there is no RSV vaccine - they say urging more people to take the simple step of masking will also make a difference.

Masking is just like the simplest, lowest-hanging thing that we can do," said Matthew Miller, director of the Michael G. DeGroote Institute for Infectious Disease Research at McMaster, adding that there is no credible data that there's any harm done by masking."

A Public Health Ontario report in August highlighted studies showing that schools that implemented mandatory masking have been associated with lower incidence of COVID compared to schools without mask precautions.

I would have hoped that one of the lessons that we took out of the pandemic is the normalization of masking; there's really no reason why (wearing masks) shouldn't become a habit during times where there is enhanced circulation of respiratory viruses."

During an Aug. 31 press conference - the last one he's done - Moore said a requirement for masking would be introduced if respiratory infections were having severe impacts on the health system.

But some wonder if that threshold has been reached.

The thing about public health, which is so unique, is its mission and commitment to prevention," said Maxwell Smith, a bioethicist who specializes in infectious diseases and an assistant professor at Western University.

It's really troubling to think that we need to have a metric of catastrophe - and that apparently we haven't even met it yet with what we're seeing in pediatric hospitals - before we introduce preventative measures, i.e. masking.

The whole point of public health collective measures is to prevent some of these harms to the population."

But is there a collective will to adopt mandatory masking again?

Dr. Marcus Plescia, chief medical officer at Association of State and Territorial Health Officials, a group representing leaders of state public health departments in the U.S., said public health interventions, such as masking, are enforced in part through social pressure.

You have to have people on board enough that it becomes the expectation that people are going to follow a rule," he says. Right now there's a perception (in the U.S.) that we wouldn't really have the public buy-in to have the social enforcement piece work.

I think people are exhausted with the pandemic and infection precautions and they're just not willing to make the kind of changes that we've asked for in the past."

Indeed, bringing back mask mandates in other jurisdictions recently has proved to be an uphill battle. In April, with a spike in COVID cases and hospitalizations, Philadelphia brought back its mandate for masking in all indoor public spaces, such as schools, offices, stores, restaurants and city buildings.

Given how quickly the Omicron wave grew and how many Philadelphians were hospitalized, as well as the large number of deaths in that recent wave, we are in a critical time to slow the spread of COVID-19," the Philadelphia Department of Public Health stated at the time.

It proved futile.

Just four days later, the health department reversed the mandate after strong opposition from both ordinary citizens and businesses who immediately sued, attempting to get the mandate revoked. It seemed the renewed mandate for the city's 1.6 million people, who tend to vote overwhelmingly Democrat, was a line they just wouldn't cross.

In rescinding the mandate, Philadelphia's health commissioner, Dr. Cheryl Bettigole, chalked it up partly to a lack of rise in hospitalizations.

Also in April, the Joe Biden administration's mask mandate for public transportation and commercial flights was struck down by a Florida judge.

Yet here in Ontario, two large municipal public health boards are urging action on masking.

On Monday, Ottawa's health board voted to pen a letter to Ford, Health Minister Sylvia Jones and Moore seeking, among other things, that the province intensify the visibility and reach of a mass health communications campaign" about the benefits of masking and vaccination.

And on Tuesday, Toronto's public health board urged the city's medical officer of health, Dr. Eileen de Villa, to urgently explore" the possibility of reissuing mask mandates, starting with schools, amid rising numbers of children showing up in hospitals with respiratory illnesses.

But any formal mask mandate should come from the province to avoid a patchwork of jurisdictions requiring masks, says Dr. Mustafa Hirji, acting medical officer of health for Niagara Region.

We shouldn't have gotten rid of masks in the first place," said Hirji. It's a simple thing we can do that is actually going to save lives while not restricting our ability to go about our normal activities."

He points out that Canada has recorded more COVID deaths in 2022 than in each of 2020 and 2021.

In addition to helping reduce cases of COVID, RSV and influenza that will require huge hospital resources, masks would also cut down on the high rates of school absenteeism reported by school nurses in the region, he said.

There's a lot of children who had school disrupted over the last two years, which of course has affected their education, affected their social development and now it's being impacted because they're sick and they're away from school again," Hirji said. Masks are a way that we could keep kids in school."

Post-secondary institutions are taking note. In an effort to head off disruption to the coming exam season, the University of Waterloo announced Tuesday it was bringing back mask mandates for any indoor activity that is part of academic course delivery," effective Wednesday. The university said it was taking the step due to data trends pointing to increased levels of COVID and other airborne viruses.

Western University has mask mandates for its learning spaces this fall.

Smith, who works at the university and is a member of the WHO International Working Group on Ethics and COVID-19, says people do wear masks in classrooms, but many remove them in other indoor spaces on campus where masks are encouraged, but not required.

To him, this shows why mandates are sometimes necessary. Right now, he says, there is a massive chasm" between what public health recommends and how the public responds.

After two and a half years," he says, you can't rely on hope for people to act."

With files from The Canadian Press and Rob Ferguson

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie

Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: kwallace@thestar.ca