Mandatory mask laws are spreading in Canada

Some communities across Canada have started making non-medical face masks mandatory on public transit or even in businesses or indoor spaces to curb the spread of COVID-19.

Some doctors and epidemiologists are calling for such laws to be more widespread. But others warn about the potential negative impacts and say the scientific evidence isn't strong enough to warrant such heavy-handed measures. Here's a closer look at the issue.

What are current public health recommendations around masks for healthy people in public?

The Public Health Agency of Canada recommends wearing a non-medical mask or face covering in public places, especially crowded ones, when physical distancing keeping a distance of two metres from other people isn't possible to do consistently. Such places include stores, shopping areasand public transportation.

The idea is that masks can reduce the spread of respiratory droplets you produce when breathing, talking, coughing or sneezing. The recommendation was put in place because of growing evidence that people can transmit COVID-19 through such droplets before showing symptoms.

Of course, people with symptoms should stay home and not be in public places.

Why do some advocates think voluntaryrecommendationsaren't good enough?

A national group of health-care professionals and epidemiologists called Masks4Canada and a group in Quebec have recently called for more laws making masks mandatory in certain circumstances.

Masks4Canada has written an open letter to federal health officials asking them to recommend such laws to lower levels of governmentfor:

• All indoorspaces outside the home, such as schools, libraries, community centres, stores and restaurants.
• Crowded areas, both indoors and outdoors, including protests and busy parks or trails.
• Public transit.

The letter noted that despite recommendations, a recent poll showed less than half of Canadians are wearing masks when they go out in public. It cited computer simulation studies that showed more than 70 per cent of the population needs to wear masks in public to significantly reduce transmission.

It said that the widespread adoption of other public health measures, such as seat belts and bike helmets, have required laws.

Dr. Amy Tan, an associate professor of family medicine at the University of Calgary and a member of the group, said the goal is to make wearing a mask a universal expectation "the mindset of 'no mask, no boarding' [on transit] or at a store, 'No mask, no service' similar to 'no shirt, no service.'"

Some businesses, such as the Longo's grocery store chain, have already implemented policies barring customers without masks.

Tan saidlaws help increase mask use by giving businesses and transit "cover to say, 'We need to do this.'"

How good is the evidence that mandatory mask laws reduce transmission?

A recent study by a German non-profit economic think-tank compared regions in Germany that implemented mandatory mask laws at different times (before the entire country made masks mandatory in stores and transit on April 27). The study, which was published on the group's website but not in a peer-reviewed journal, suggested mask laws could reduce the daily growth rate of reported infections by 40 per cent.

Other studiesshow that masks do reduce the rate at which sick people shed the virus and the distance droplets travel from your mouth.Mathematical modelling studiesalso suggest that universal mask wearing can be used to control epidemics.

Advocates of universal mask wearing note that countries with widespread or mandated mask use, such as South Korea, Taiwan, China and the Czech Republic, have seen reduced cases and fatalities, although that may be due to other factors.

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Most research on masks so far has involved medical settings or households with a person known to be infected, said Dr. Mark Loeb, a McMaster University professor who studies infectious diseases and recently reviewed the evidence on masks and the spread of respiratory illnesses.

When it comes to mask wearing in the wider community, most studies published in scientific journals don't show a clear impact so far, possibly because of factors such as study size, he said.

He said that the Public Health Agency of Canada's advice on masks is pragmatic and "a wise thing to do." But he questioned whether the evidence on universal mask wearing is strong enough to make it mandatory in all public places, although, he said,mandating it on transit may be reasonable.

Tan saidwe don't have the "luxury of time" to wait for that kind of evidence. "During a pandemic, you need to be looking at the emerging evidence and look at other levels of evidence to say there is more than enough science behind it."

Where in Canada are masks mandatory so far?

Most mandatory mask regulations in Canada so far concern transportation situations where people may have trouble physically distancing.

Transport Canada made masks mandatory for air passengers starting in April.

Some transit agencies in Ontario have announced that masks will be mandatory on buses, streetcars and trains, including Ottawa, Toronto, Hamilton and Guelph.

In addition, at least two municipalities are implementing mandatory mask laws:

• Cte Saint-Luc, Que., a Montreal suburb that had hundreds of confirmed COVID-19 cases and dozens of deaths by the beginning of June, is making face masks mandatory in indoor public spaces starting July 1.

• Wellington-Dufferin-Guelph Public Health in Ontario made masks or face coverings mandatory at most businesses in the counties of Wellington and Dufferin and the City of Guelph earlier in June.

Most regulations include exceptions for children under twoyears old and people who can't wear a mask because of breathing difficulties or another medical condition or disability.

How are mask laws being enforced?

In Cte Saint-Luc, Que, those who don't follow the bylaw risk fines of up to $500.

Most other authorities, such as the Ottawa and Toronto transit authorities, say they plan to focus more on education than penalties.

That said, both Cte Saint-Luc and Wellington-Dufferin-Guelph are asking businesses to bar people without masks from entering.

Cara Zwibel, director of the fundamental freedoms program at the Canadian Civil Liberties Association, is concerned about that: " I don't know if we want our bus drivers and our grocery cashiers to be interrogating people about their health status to try and decide who can get an exemption and who can't."

Zwibel said she thinks mask rulesputpeople such as transit drivers in "a really difficult position" especially given the confusing language around enforcement.

"If you announce a policy that something is mandatory, it's a bit odd in the same breath to say that you're not going to enforce that I think that kind of announcement confuses people a lot, and it's not really helpful."

Zwibel is also concerned about people with disabilities, such as hearing impairments, who need to see people's faces to read their lips or people on the autism spectrum who may have trouble with masks.

Kate Mulligan, an assistant professor at the Dalla Lana School of Public Health at the University of Toronto who studies health policy and equity, shares those concerns.

She said people with breathing difficulties, such as asthma, may have trouble with masks, and certain groups, such as Black and Indigenous men, may face discrimination when wearing a mask. "They may be perceived as a safety risk, and that could create a safety risk to themselves."

She said exceptions to mandatory mask policies are needed for that reason. "And I think it takes a lot of capacity to do that kind of enforcement."

The lack of enforcement capacity has been cited by officials inQuebec and Ontario as a reasonwhy they're reluctant to make masks mandatory.

Are there other concerns about mandatory mask laws?

Like Loeb, Zwibel questions whether there's enough scientific evidence yet to support mandatory mask laws covering a wide range of public places.

She said there are a lotof indoorspaces where physical distancing is possible. "So, I think we're sort of a long way from seeing a really good justification."

Dr. Isaac Bogoch, an infectious disease specialist at the Toronto General Hospital Research Institute, said if masks are mandated, they need to be provided for free so people aren't barred from businesses or transit for not having access.

"Many people might not have the means to buy a mask or may not have the means to make one," he told CBC News Network Tuesday.

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Tan acknowledged that medical and N95 masks need to be reserved for health-care workers and if non-medical masks are made mandatory, vulnerable people need to be given access. She said other countries with mandatory mask laws have provided masks to their populations. Some transit services such as Toronto's are giving masks out to riders.

Are more jurisdictions likely to make masks mandatoryin the future?

Many seem to be making moves in that direction. For example, health officials in Ontario's Waterloo region are currently talking to business owners about what they would like to see in a mask or face covering policy.

Mulligan, who sits on the Toronto Board of Health but isn't part of any group advocating for masks, said she's been asking about potential mandatory mask policies. So far, she's been told by officials that the evidence doesn't yet support broader mask laws.

"I expect that to change," she said. "Given that we're seeing so much of the city and the province and the country opening up now, I think that we really have no choice but to step up the wearing of masks ... because we do want to reduce the risk."

She thinks governments should have been discussing mask policies as part of their strategy for reopening the economy. She saidthey need to figure out what policies on masks and other ways to reduce transmission have the greatest benefits versus risks.

If there is a future wave of COVID-19, she expects governments to rely more broadly on masking because the economic impact of the main strategy so far lockdowns is so severe.

In the meantime, she suggests people follow public health recommendations to wear masks voluntarily where physical distancing is difficult.

"We do know about the fact that masks reduce the risk to others," she said. "And so therefore, we have a social responsibility to wear them when we can."