Forest fires and n95 masking

Masking without evidence is an untreated mental illness plaguing public health

Recently forest fires descended upon the east coast. The governor of New York ordered n95 masks to be passed out for free at subways and other locations (no doubt in part motivated by her desire to unload masks the state over purchased) and the NY health authority recommended them.

First, let's agree: Breathing in forest fire smoke is probably best avoided. I tend to forgo long outdoor bike rides when the orange death cloud descends on the Bay Area. Moreover, I once had a trip planned to Portland and skipped it when the city was blanketed in smoke.

But these are voluntary choices, just like I avoid Chicago entirely during the winter months. But when public health makes a recommendation; it should be evidence based. If it spends money to implement a recommendation. It should ask if that is the best use of money.

Consider n95 masking for forest fires. The data is of piss poor quality. Sure, in contrived laboratory studies it filters some smoke, but that isn't the question.

The question is: when you live in a city blanketed with smoke, should you advise citizens to mask when they walk outside, etc? Let's think through that.

First, recognize that some baseline exposure will happen no matter what. Even in your house, you still can smell smoked salmon. The baseline exposure may dwarf any portion remotely modifiable.

Second, recognize that a tiny fraction of people will mask anyway, and others will exercise outdoors without a mask bc they don't care. Ergo, your policy will at best affect a tiny portion of people. Those who will now mask who otherwise wouldn't. This may be a vanishingly small group. Yet, the success of the policy hinges on this!

Now think it through a little more.

How much will they mask? Can they sustain it? Will they have gaps at their nose? Will they alter their behavior (go out more when they otherwise wouldn't?) Aka the Peltzman effect?

When it comes to community n95 masking for forest fires: there is no study showing you should advise citizens to do it. But it could be easily done.. think about it.

Forest fire smoke leads to a number of changes in blood based laboratory values, wbc dynamics and more.

Randomize parts of NYC to free masks or nothing and then come back in 3, 5 and 7 days and measure a preset collection of endpoints in a random cohort. Is there a difference, or no?

Just bc there is a difference doesn't mean your policy improved health, but if there is no difference, then you can rest assured you are spitting in the ocean.

I am confident there will be no difference bc the baseline is nontrivial and the compliance will be piss poor and even a little compensatory behavior change will wash it away.

Most things that 'make sense' do not work in medicine and public health.

Finally, the real motivation for me writing this column is that public health is being led by the dumbest people. They want us to accept that bioplausibility is the basis for costly, recurring policy choices and it simply isn't. You need real world, randomized data.

And PS the same trial I imagine should also have power for, pre-specify and examine harder endpoints like all cause death over 30 days (since smoke is bad for CV events etc).

Let's be honest what is going on: Masking is a mental illness. Some people fell in love with it for political reasons and just won't quit. They wanted to mask kids to prevent monkeypox and want to mask for fires and who knows what is next: masking to prevent droughts.

Finally, If you disagree, I have zero interest in mannequin studies or bioplausibility. I have zero interest in studies that confirm what I concede-- inhaled smoke is bad. Instead, show me any actual epidemiologic data that they policy helps. That's the standard science demands. You won't be able to. I know. I did a lit search.