Why Not Face Shields Too?

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Last March, I wrote a post suggesting that enough informal evidence was emerging that masks might provide protection against COVID-19 that states might consider enacting mask mandates, requiring at least cloth-type masks. I also suggested that randomized controlled trials (RCTs) of masks could be helpful in helping ascertain the effectiveness of masks. The rest is history. Mask mandates followed. RCTs did not.

This post asks a simple question: Why has there been no movement to require face shields in addition to masks in public places? My instinctive cost-benefit analysis suggests that such a regulation might be worthwhile, but that's not the point of my post. After all, I recognize that there was no causal effect of my first post on the adoption of mask mandates, and I assess the plausibility of shield-plus-mask mandates at close to zero. Rather, I'm interested in the inquiry as a puzzle and as a window into how the public thinks about COVID risk-reduction measures.

Let me start with the affirmative case. Face shields are cheap, less than $1 each for reusable ones. They can be worn concurrently with other personal protective equipment. By themselves, they are not as effective as masks by themselves at protecting wearers from aerosol-sized droplets, and so the CDC does not recommend them "as a substitute for masks." Still face shields at least "block the initial forward motion of the jet" of air from a cough, potentially reducing inhalation of virus particles. A study found that "wearing a face shield reduced the inhalational exposure of the worker by 96% in the period immediately after a cough." A study suggests that a type of shield provides extra protection for ophthalmologists. Perhaps most impressively, after 19% of a group of community health workers in India working with Covid-19 patients themselves tested positive, face shields were added to their existing PPE, and there were no further positive tests.

None of these studies is a gold standard RCT. But the studies of face masks generally aren't RCTs either. One face mask study randomized some people to receiving a recommendation to wear a mask, and it found only statistically insignificant benefits of receiving the recommendation. The medical community has shrugged at the absence of evidence from controlled trials, pointing out that there are other forms of evidence and claiming that randomized controlled trials would be unethical.

The failure to run effective RCTs for both masks and face shields strikes me as a major failure in global efforts against this pandemic. Even if one believes the anecdotal evidence that masks are beneficial is clear, there are many seemingly intelligent people (not just Alex Berenson) who point to anecdotal evidence that mask-making doesn't make a difference. Consider, for example, the comment from "Oleg" that Covid is spreading rapidly in Toronto despite widespread universal mask use. I wouldn't assign much weight to such analysis in comparison to meta-analyses that conclude that masks have some benefit, but some people are genuinely skeptical that masks make much of a difference.

RCTs showing effectiveness wouldn't convince all of them, but it would convince many. Moreover, it's quite possible that many people are overestimating the benefits of masks, viewing them as get-out-of-social-distancing-free cards. Meanwhile, the ethical argument against RCTs does not seem strong. One need not discourage some people from wearing masks to run an effective study. A trial can select some people to receive an intervention encouraging mask wearing. The study giving a recommendation is an example of this, but the intervention could be stronger than a mere recommendation. For example, the treatment group could receive financial incentives, such as a promise that if they answer a video call at some random time quickly while wearing a mask, they will receive some money. Granted, such trials would be expensive, but given the global scale of the pandemic, any improvement in information on an issue so vital is likely to produce benefits greatly in excess of costs.

In principle, RCTs also could provide better information on which type of masks are most successful. There are, of course, many studies assessing masks in the lab, but, so far as I have been able to find, none in the field. Clearly, an RCT could give the control group free cloth masks and the treatment groups some higher quality of mask, such as this Honeywell mask with polypropylene filters, which the Wall Street Journal reported "aimed to combine the comfort of a cloth mask with protection near what an N95 affords."

Even absent RCTs, one could imagine toughening mask mandates to require some of these seemingly higher-quality masks. Yet, I am not aware of any jurisdiction that requires higher levels of protection. There are several easy explanations for this, though. It may be difficult or impossible to determine whether people are wearing compliant masks, and we don't want shoppers fighting with employees about whether their masks meet the relevant standard. Some of the highest quality masks may still be in short supply, and some may still want to reserve them for health care workers. Individuals have spent a lot of money on masks, and they would be frustrated if their purchases were made obsolete.

Whatever the merits of these arguments against toughening mask requirements, the complete lack of interest in requiring face shields with masks suggests that something else is going on. It's easy to tell if someone is wearing a face shield and face mask. Face shields are not in short supply. And a hypothetical mandate would not mean that anyone could throw away their masks. So why is there absolutely no discussion of whether we should require face shields in addition to masks?

One unsatisfactory answer is that the cost-benefit calculus for adding the requirement of face shields is much worse than the cost-benefit calculus for the initial mask requirement. On the cost side, maybe face shields are much less comfortable. I'm skeptical of this; the added increment of discomfort is fairly low. Similarly, I will readily concede that they look ridiculous (and I felt a little embarrassed wearing one recently to a doctor's appointment). But masks looked equally unflattering when barely anyone was wearing them. The benefit side may be more plausible. Perhaps the marginal benefits of a face shield, for the wearer or for source control, may be considerably lower than the initial benefits of a face mask. But are they so much lower that costs exceed the expected benefits, taking into account society as a whole? That seems doubtful. And so one might expect those who point out that masks aren't so uncomfortable–just wear a mask!–to also highlight that it isn't a big deal to wear a face shield on top of a mask.

So what is the explanation? Perhaps the best answer is that we're all conventional and highly influenced by what people around us are doing. Very few of us are willing to take, let alone urge, steps that no one else is taking. It's easy to paint people who don't wear masks as bad people. But the vast majority of people who don't wear masks are part of groups where non-mask-wearing is the norm. It is personally costly to break a social norm. I wish that everyone would wear masks, at least when associating with people outside their household. But I don't think that their basic decisionmaking calculus is all that different from the approach of people who wear masks but don't wear face shields. People who are willing to be weird for the social good are rare and underappreciated.

One might argue that last year's shift in many social groups to widespread mask-wearing is inconsistent with my claim that concerns about conventionality have inhibited widespread adoption of face shields. Certainly, those shifts demonstrate that in response to an exogenous shock, norms can change quickly. Over a short period of time, for some, wearing a mask went from weird to cool. But once norms are established, they are hard to change. Mask wearing may increase slowly over time. There are some people who have mixed social groups, and so when Covid gets worse, one should expect mask-wearing to increase in a virtuous cycle. But it requires a lot for the norm to change dramatically, especially in the absence of clear new evidence, and in the absence of RCTs, that is unlikely to materialize. And so we should expect face shield use to be common only in certain occupational settings, like emergency rooms and care homes. Even with highly contagious variant Covid-19 strains, it seems unlikely that face shield use will pick up appreciably, let alone that we will see regulatory requirements.

Is there any possibility of some change that would encourage greater face shield use? I can think only of one. President Biden plans to call for 100 days of mask wearing when he becomes President. Can't hurt, but it's hard to see such a request as doing much good. Those who would do it for him are largely already wearing masks, and Trump supporters who don't wear masks are unlikely to change because he says "pretty please." Similarly, general calls to "be careful" won't meaningfully change much behavior at this point, especially given recognition that those making such calls sometimes turn out to be hypocrites. But it is plausible that Biden could induce some of his supporters to take some steps that they are not taking now, especially if he models good behavior for them. If President Biden started wearing a face shield in addition to a mask, maybe ten or twenty percent of the public would do the same. But he'd look kind of silly. I'm not counting on it.

NEXT: A Senatorial Impeachment Two-Step?

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  1. The point of a mask mandate is to provide visual reassurance that something is being done. And some of the studies on masks are at least superficially plausible (others are not). Face shields are a much bigger imposition and there’s no strong evidence that they will provide more reassurance or protection. But if I were a manufacturer of shields I’d be lobbying hard to get my product mandated. Anybody can improvise a face mask. Not everybody can improvise a shield. There’s a multi-billion dollar market awaiting.

    1. Perhaps the tyrants realized (correctly) that the peasants would openly revolt if their arbitrary fiats went this far.

      Don’t overlook the relationship between mask mandates and some of the rage you saw last Wednesday.

    2. ” But if I were a manufacturer of shields I’d be lobbying hard to get my product mandated.”

      You comment points to one of the many drivers which facilitates government corruption. Mandate a product in some form

  2. It’s pretty simple, really.

    For whatever reason, wearing a mask has become a partisan issue. Wait, who am I kidding. “For whatever reason …” For crying out loud, everything is partisan today. If Biden came out and said that water is wet, than Trumpists would be out demanding powdered water. And if Trump came out and said we should be wearing masks, I have a bad feeling that a lot of Democrats would begin to think that maybe there was some illicit connection to Trump’s finances.

    Ahem. So, it’s hard enough to get people to wear masks. That’s an added, and visible step that people aren’t yet comfortable with. That said, there are several places I have been where employees are either encouraged or required to wear them, given that they have to interact with large numbers of people.

    1. Why aren’t you wearing your face shield? Cause you want to kill my grandma, you jerk!

      1. No. I wanted to SLEEP with your grandmother, not kill her!

        Unfortunately, the rest of the town get their first.

        Maybe next year!

    2. I’m thinking of Dems and Carbon Dioxide.

      But for Carbon Dioxide, we’d all have died in our sleep last night.
      The left tends to forget that — or perhaps never knew it.

  3. Why Not Face Shields Too?

    Hell, why not just slaughter all the infection risks? It’s the only way to be sure.

  4. Professor A,

    Thanks for this thoughtful article. For what it is worth, there have been several randomized controlled trials addressing the utility of masks in mitigating virus transmission via respiratory droplets, reviewed here:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191274

    Granted, these studies mostly looked at flu, but I think the similarities between orthomyxoviruses and coronaviruses outweigh their differences here: similar size (a few hundred nanometers), both RNA genome, similar membrane composition and susceptibility to chemical/thermal perturbations. Combine this with the newer studies looking at SARS-CoV-2 titers in droplets in lab settings (a few with different mask types), and I think the evidence for their effectiveness is clear. Anyone not convinced by this already will likely not be convinced by a RCT as applied specifically to SARS-CoV-2.

    Enforcement of a mask/shield mandate is separate issue, of course. Indeed enforcement appears so fraught as to render the mandates useless, in my opinion. As you point out there is also the “silliness” factor. The sociologists are going to have to figure that one out. The virologists have done all they can, I think.

    LL

    1. The RCTs can be skipped on the basis of thorough laboratory aerodynamic tests.

      Dentists and oral surgeons who work is a hazardous environment use masks, shields and an air evacuator near the patients mouth

  5. I believe it was Jefferson who said that man has a high degree of toleration of rights violations. But even he would say that there is a breaking point. As has been seen over the summer… things that are mandated and put an imposition upon individual choice and freedom (regardless of the offered justifications) face varying levels of tolerance and resistance. Stay at home orders were less rebuffed a year ago than they seem to be now. As mask wearing moved from suggestion to mandate the level of pushback increases. When filling a jar with water there reaches a point where one more drop causes the water to no longer hold its shape as it just barely bulges over the lip of the jar. That one more drop is one too many and the water breaks and goes back to a stable level, with some of it having finally run out of the jar. All these things, masks, lock downs, etc. aren’t happening at once or uniformly in people’s lives. There is no reason to expect an orderly move towards greater, yet incremental, levels of safety especially when each step, when demanded and not voluntarily accepted, creates some degree of pushback.

  6. A face shield deflects something coming at the shield. If the wearer coughs or sneezes a face shield changes the direction of the flow. Most times that is straight up and down. Once droplets are directed upward they tend to come down almost vertically, which pretty much negates any benefit of the shield. There’s no hard science behind masks either. If the wearer coughs or sneezes a mask acts like a diffuser creating the small aerosol droplets that we are trying to avoid. Before anybody asks where I got my medical degree, remember one thing, we are not talking medical here, we are talking fluid dynamics and I make a pretty good chunk of change doing 3D heat and flow modeling.

    1. If you ever wonder, competent folks with advanced medical degrees agree with you. 🙂

    2. Honest question. How does a mask fare for droplets that are expelled through normal exhalation or speech as opposed to coughing or sneezing?

    3. Also… wouldn’t the curve of the shield cause the droplets to move along the curve of the mask rather tha simply up/down? And as most shields are curved around from ear to ear, wouldn’t droplets most likely just zoom past the wearer’s shoulders?

      Not saying that makes them effective or not. Just curious about the physics.

      1. That has been studied at MIT by a specialist is aerodynamics. I’ll look for a publication

      2. You might look at

        Visualizing droplet dispersal for face shields and masks with exhalation valves featured
        Physics of Fluids 32, 091701 (2020); https://doi.org/10.1063/5.0022968

    4. We are talking medical here. It doesn’t matter if the droplets become smaller if they travel a shorter distance, which is the point. Hence social distancing being important. This is easily demonstrated by blowing out candles with a decent mask vs just your mouth.

  7. Because masks are only very indirectly related to Covid any more. They only sort-of work and places with strong mask mandates still have lots of Covid spread.

    They over promised and under delivered on all the Covid countermeasures so far. Anything new won’t be accepted by a public who doesn’t trust public health leaders.

    And face shields wouldn’t change the trends noticeably anyway. Vaccines and warmer weather will.

  8. Does anyone chuckle at an argument which begins with a convincing phrase such as “informal evidence is/was emerging that XX might provide protection”?

    Emerging informal evidence that something might be helpful is the tool of fools: once again, I will cite the 1920’s example of emerging informal evidence of the goodness of eugenics.

    Back in early March, 2020, many data scientists predicted that the CoViD-19 infection would be manageable through August, 2020, without any significant intervention and that thereafter it would basically envelope the entire population available to it before subsiding. To date, those predictions have been accurate in most locations around the world (with exceptions due to stepped-up MMR II vaccinations). Those who track such things note that the reproductive factor Rt diminished below 1.0 in most areas of the US around 10-Dec-2020: for example, in Virginia, a state which due to the incompetence of its Governor has an anemically low CoViD-19 vaccination rate, Rt is now at about 0.8 and still declining. [The University of Utah has a handy graphical Rt /R0 tracking app.]

  9. Wearing a mask is the sign of submission to Democrat douche bag quackery and tyranny. Remember that brave, young, ophthalmologist who warned us of a Chinese Commie biological attack in the form of this COVID? He warned us, and then he died because of the crap Commie Care of China. He caught his in the OR. How more careful can we be than in a Chinese OR? Masks are quackery and mere Democrat douche bag stigmata.

    1. Don’t be too quick to judge. A mask could be worn out of skepticism and uncertainty. I have yet to be fully convinced one way or the other but Pascal’s Wager says… wear the mask for now.

      Also… I wear it to stay employed as the philosophical debate won’t put food on the plate even if I’m right.

      Thirdly… it prevents divorce in some households. That seems as good a reason as any.

      1. I have no objection to your wearing a mask, even without a pandemic. I object to being forced to. Mask mandates have been followed by explosive rates of infection. The best N95 mask has weave 300 nm apart. The diameter of the virus end of the spike to end of spike is 120 nm. That surgeon was likely infected through his eyes (his theory). You need a full hazmat suit with your own oxygen supply to avoid that.

  10. Still no acknowledgement that there are people with medical (respiratory) and mental (claustrophobia) reasons that prevent them from wearing “cloth face coverings” (masks).
    The county where I live issued a proclamation “mandating’ “cloth face coverings” that included an exemption clause for medical issues. I wrote and asked what documentation would be required to have the exemption documented. The reply:
    “As a point of clarification, the Mayor’s Executive Order requiring Face Coverings is not an enforceable mandate. As such, there are not procedural requirements in place for those individuals who cannot tolerate a face covering for medical, sensory or any other condition which makes it difficult from them to utilize a face covering.”
    So the Mandate” is not a “Mandate”; it is a feel good declaration. Yet it provides no protection to disabled individuals from Karens of all sexes hurling invectives.

    1. Suggestions are OK. Orders from neo-Marxists enforced by police thugs are not OK.

  11. Well shit. Before you start mandating face shields, why not actually enforce the mask mandates? Why not prosecute the governors and mayors who opened up huge loopholes for those mostly peaceful arsonists and looters and murderers?

    Inflicting new unenforced laws on the populace makes even less sense than gun- and drug-free zones which are only obeyed by the law abiding.

  12. I think you fail to see how the “mask mandate” strategy will dovetail with the state media push.

    When the mask mandate comes out, the rates are going to start declining largely due to 1) natural immunity gained as a result of higher infections and 2) the vaccine rollout starting to hit. But, all of this will be attributed in the press to the mask mandate. Articles will be written about how when evil Trump was in charge no one wore masks making the pandemic horrible. But, thankfully, now that DC has changed its tune and mask wearing is all the rage the rates are magically plummeting. So that is how it is going to work and the whole purpose.

  13. In a deterministic clinical trial, I have found using a clear polyethylene bag secured around the wearers neck with duct tape greatly reduces the spread of Covid. Unfortunately, the bag is not reusable.

    1. Nor is that human body usable after that clear plastic bag has been on the person head for a few minutes

      1. To be fair, I didn’t claim this was foolproof.

  14. Why not face shields too?

    Why stop there?

    Why not mandate gloves?
    Why not mandate everyone carry hand sanitizer on their person?
    Why not mandate disposable (more sanitary to use a new one every time) N95 masks?

    1. Hell… mandate isolation. Not breathing. Not living!

      That last tactic did solve problems on an individual level incredibly well for other dictatorial places in history. Sure… there were long term systemic problems but if we can lower the curve fast enough maybe we can avoid that!

    2. I strongly support the wearing of the full hazmat suit, with its portable oxygen generator.

  15. Second paragraph second sentence – “My instinctive cost-benefit analysis suggests that such a regulation might be worthwhile, ”

    Cost benefit is the wrong method of analysis
    the correct method is marginal cost vs marginal benefit.
    Social distancing provides the greatest marginal benefit v cost,
    next is reducing time of interaction providing some marginal benefit v cost, but less benefit than social distancing.
    3rd is mask wearing, the incremental benefit of mask wearing after the benefits of social distancing and reduction of time of exposure is relatively small. Unless the person is in a high risk environment, mask wearing provides very little if any benefit.
    Which brings us to use of face shields.
    In summary, the incremental benefit after 1) social distancing , 2) after reduction of time of interaction and 3) after mask wearing, is virtually non existent.

    1. I will add that Michael abramz.. is using examples from high risk environments and like many mask / mitigation proponents is extrapolating the benefits as if the same level of the reduction of the risk of transmission exists in all environments. That simply is not the case. thus the importance of understanding marginal cost v marginal benefit analysis.

    2. Interesting! Do you have support for these judgments?

      1. My comments shouldnt be controversial. Marginal Cost v Marginal benefit, similar to the Law of Diminishing Returns.

        Unfortunately, fear has resulted in an irrational & inflated assessment of the relative reduction in the risk of transmission for the various mitigation techniques

        1. My only dispute with your analysis is where you say social distancing has a huge marginal benefit per cost. I believe you are greatly underestimating the cost, as it makes many jobs completely impossible and discounts the severe harm that social distancing has on emotional health. Your argument also overestimates the benefit, as a substantial fraction of remaining activities do not allow for social distancing at all (routine shopping and practically any form of recreation).

          Partial social distancing has practically no effect at all, merely slowing spread instead of stopping it.

          1. I concur with your comment that social distancing cant be done effectively in many situations. I also concur with your comments regarding the economic limitations.

            My comment was to point out that masking really only provides any reduction in the risk of transmission when social distancing cant be maintain, along with increase in time of interaction.

            the pro maskers are to some extent that wearing a mask by the same amount in a crowded public transportation as in interacting as you pass someone in the parking lot of the grocery store. There is a huge / significant difference in the risk transmission in the two situations.

          2. “Partial social distancing has practically no effect at all, merely slowing spread instead of stopping it.”

            Slowing the spread was the point, duh. Instead of having thousands of people who all needed respiratory support all hitting the hospital at once and fighting over the not-enough equipment there, we get a few people at a time, and the hospital can keep up because people recover from the disease and go home before the next case shows up at the ER door.

  16. There was just one real study done so far, and it suggests masks are not effective.

    Furthermore, studies suggest asymptomatic spread doesn’t even happen in any meaningful amount.

    1. There have been a lot more studies than just ‘one’ performed on the efficacy of masks, and they show that the things people are draping on their faces these days have no effect.

      One of the reasons for that is the same reason that face shields also have no measurable impact: face masks that DO work, like N95 filters, do so by physically preventing the virus-bearing particles from spreading. Most do this through mechanic capture of water droplets. Face shields do not perform any capture of particulate matter; they provide redirection.

      There are circumstances where redirection is desirable! The examples given, such as dentists, are people who are at risk of being directly spattered by macroparticles. In these special, niche cases, it might be wise for the people at risk to use face shields.

      However, in general, the risk of disease spread is not from macroparticles that quickly fall to the ground – it’s from airborne microparticles. So this is a ‘solution’ that solves nothing.

      If one were to ask about unused protective gear that has actually been shown to have an effect, why is there no push to use goggles? Airtight goggles over the eyes have been shown to have a statistically significant effect in reducing disease spread among coronaviruses – so why is no one pushing for a goggle mandate?

      1. “One of the reasons for that is the same reason that face shields also have no measurable impact: face masks that DO work”

        Your apples appear to be rather orange. the point of a face mask is to limit any virus you might be currently carrying from getting to anyone else, while the point of a face shield is to keep your eyes from being a point of entry for a virus you don’t already have.

  17. One cannot do a randomized controlled trial when mask mandates are ubiquitous – the control group would have to go around demasked.

    The closest thing to a masking RCT in the literature was a Danish study (https://pubmed.ncbi.nlm.nih.gov/33205991/) that, surprisingly enough, found no benefit to the wearer for common masks.

    The next best thing is the Cochrane review [1], which, coincidentally, found that the evidence for universal masking is weak.


    [1] Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, Driel ML, Jones MA, Thorning S, Beller EM, Clark J, Hoffmann TC, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2020, Issue 11. Art. No.: CD006207. DOI: 10.1002/14651858.CD006207.pub5.

    1. The idea of a RCT for determining the efficacy of reducing aerosol dispersal with masks is a false standard. It tells one nothing about the actual physical dispersal of vironions. It says nothing about the range of fits of masks on subjects.

      See The Fluid Dynamics of Disease Transmission Laboratory | Bourouiba Group | Massachusetts Institute of Technology

    2. That’s what I don’t get. The “subjects were encouraged to wear masks” variable is meaningless when there is so much controversy about. Of course there was no effect. There’s no difference between the control and the intervention group.

    3. The real challenge of doing a controlled study of mask effectiveness is determining the cause of a non-event. Did you not get the virus from your interaction because the mask stopped it, or because that person didn’t have the virus in the first place? If they did have it, did it not spread because of the mask, or because you’re swimming in hand sanitizer?

  18. I learned more from the comments than I did form the actual article.

    1. Always true. Lawyers are book worms who know shit. Yet, these know nothing bookworm get to set national policy on complicated technical subjects. It is always a catastrophe.

      1. And you’re a non-bookworm who doesn’t know shit. We keeping putting your type in charge of the government, and it never works out well, whether it’s Trump thinking trade wars are easy to win, or W thinking the regular kind are easy to win.

  19. Face shields are counter productive given the primary benefit of face masks is protecting others from the wearer by dissipating the wearer’s viral load. A piece of plastic covering the face would limit airflow and accelerate the movement of what is exhaled. Like blowing air with a straw.

  20. At the beginning of the pandemic I remember several people joking that we should all wear one of those full-body condoms from the Naked Gun movie.

    Somewhere right now as I type, there is some putz like Michael Abramowicz writing up a position paper.

    Please Jesus, come now. SMOD, save us!

  21. There have been no randomized clinical trials of masks because the politicians know that will show that cloth masks are useless. They’re conditioning us to obey the government so that we’ll accept the vaccine.

    1. I think you’ve been conditioned to be paranoid.

  22. Great security theater. The kind reason used to rail against, now just rolls with.

  23. Good old traditional point, security theater.

    The goal is Burqa, everyone must Burqa.

  24. “Why has there been no movement to require face shields in addition to masks in public places?”

    Simple practicality. People at home have access to materials and can manufacture their own cloth masks, but not so many have the materials to make an effective face shield. Meanwhile, in the early days, the commercially-available face shields were diverted to healthcare workers, where they were most needed. Over time, commercially-manufactured cloth masks found their way into consumers’ hands. In the factories where face shields are made, you need workers and the workers had to come in before they’d made any face shields. They could have diverted some from the warehouse to the factory floor but the story would have been about how they were shorting the healthcare workers. Unpalatable. Instead, you have people making face shields wearing masks, with all the face shields going to the hospitals until the hospitals finally have enough to keep their workers safe.

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