From symbols of illness to signs of solidarity: The other disease that masks curb

Sister Pelisa Dlomo is sitting outside a small clinic on a crisp winter morning in rural Eastern Cape. The queue of patients for the day is growing, rapidly filling the facility’s narrow passages. Some patients are asked to put on masks as staff look over their test results. For many, this will be the moment they realise they have tuberculosis (TB).

“They say the masks stigmatise them. It’s making everyone know that that one is having TB,” Sister Dlomo explains with a sigh. “My patients feel like they’re depersonalised in some way by wearing masks, that it’s a signal for people to run away from them.”

How TB can benefit from measures taken to contain Covid-19

I am a medical doctor and, for the past eight years, I have been studying ways to prevent TB from spreading, interviewing health workers and patients.

Being diagnosed with TB means wearing a mask until you have taken medication for long enough to no longer be infectious. Masks prevent people with TB from expelling infectious germs into the air.

TB — a curable illness — is the leading infectious disease killer globally and South Africa has one of the highest caseloads of the condition. In 2019, it killed 64,000 people in the country.

But, until recently, mask-wearing led to TB patients facing severe stigma — with patients with other diseases mostly not required to wear masks.

This type of stigma has severe consequences. Research has found that the fear of TB-related stigma makes people less likely to undergo TB screening or to take up treatment, which in turn leads to the spread of the disease.

This year’s Covid-19 epidemic, however, dramatically changed the acceptability of one of TB’s most valuable prevention tools. In South Africa, masks have become part of our normal life, embraced as an important method to prevent the spread of Covid-19.

The social meaning of masks has transformed from a symbol of illness to a sign of solidarity amid a common threat.  

Though Covid-19 has had a negative impact on TB services and testing — TB testing with GeneXpert machines in South Africa declined by 48% per week between February and May because of restricted movement during Level 5 lockdown — the country now has the chance to use our new mask prowess to curb the spread of TB as well. But that will only be if we keep masks woven into the fabric of our lives after the Covid pandemic has passed.

Why should we care about TB now, when it has been part of our lives for many years?

Covid-19 is only the latest threat to enter the air we all breathe. In South Africa, crowded spaces such as public transport, schools, hospitals and mines have long posed a threat to our health.

In 2019, TB killed far more people in South Africa than Covid-19 is likely to do in 2020. Eight months since the start of the outbreak in the country, Covid-19 has led to about 19,000 deaths — less than a third of the 64,000 people who died of TB in 2019. 

There is a misperception that TB only affects people with weakened immune systems (as might result from HIV or malnutrition), but the reality is that the TB bacterium spreads through the air and everyone is at risk.

We have been slow in recognising the disease’s impact, because TB progresses slowly. A patient with Covid-19 can develop symptoms days after being in contact with an infectious person, whereas with TB the onset of symptoms can take months or years. After coming into contact with TB, some patients can initially contain the infection, leading to a latent TB infection with no symptoms. Whether a patient develops symptoms immediately or in years depends on how much TB they are exposed to, their immune system, time and luck.

This slow timeline poses a challenge for prevention, but just because the disease presents slowly it does not mean we should be slow in our response.

Masks for patients with TB have been recommended for years to prevent the spread of the disease. This is known as source control. In practice, it means that if someone who is infected, but who is not yet on treatment, wears a mask, it can reduce the spread of multidrug-resistant TB — for which treatment is more expensive and the death rate higher than for ordinary TB — by up to 56%, according to 2012 research published in the American Journal of Respiratory Care and Critical Medicine.

But, because of social norms and stigma, such as those faced by the patients of Sister Dlomo, the use of face masks to prevent the spread of TB has been limited to health facilities and by sick people. Public spaces, such as poorly ventilated offices and taxis can be hotspots for the spread of TB. Yet, before the Covid-19 pandemic, wearing a mask would cause quite a consternation in such spaces.

Just as with Covid-19, knowing who has TB and poses the most risk of infecting other people is difficult.

The old belief was that masks are helpful only for symptomatic TB patients, those who are coughing, as they are likely spreading illness. However, recent research suggests that half of people with TB may have no symptoms at all.  This suggests that for every person asked to wear a mask to prevent the spread of TB another person is spreading it without showing symptoms or feeling ill at all.

Widespread mask-wearing by the public, normalised by the Covid-19 pandemic, offers much promise for TB. By establishing social norms and identifying places where wearing a mask will offer communal protection we may be preventing TB — as well as other diseases such as flu.

Why carry on wearing masks?

But, despite the possibility of communal protection, wearing a mask is not convenient.

Masks have also come to symbolise the Covid-19 pandemic and this poses a challenge. In the near future, it may become tempting to discard masks as we yearn for a post-pandemic life.

But, if we throw away our masks after Covid-19, we will also throw away an opportunity to make a difference in fighting TB.

We should look at implementing low-cost adaptations to improve natural ventilation, using air disinfection like germicidal UV and auditing the safety of shared air using CO2 levels, which will all help to keep Covid-19 and TB at bay.

We have made great progress with the most difficult step — achieving widespread access to reusable cloth masks. It is now part of our routine to grab a mask when leaving the house. We’ve even figured out the details of ear elastics, ties around the head, nose clips for glasses and patterns for different outfits.

But mask guidelines for our post Covid-19 lives can be even smarter. Instead of blanket rules, as used at the start of the pandemic, we should identify high-risk spaces where TB commonly spreads and strongly encourage use of masks there.

This is important for areas with poor ventilation such as taxis, healthcare facilities, schools and shopping centres and should become part of broader airborne disease prevention.

With wider acceptance of mask-wearing, managing the spread of TB at Sister Dlomo’s clinic is starting to look very different. Instead of selecting a couple of people to wear the mask “label”, everyone at the facility wears one, as required by government regulations.

“I think treating people with TB equally with respect and supporting them is so important,” says Sister Dlomo.

She turns a page in her patient register book, opens a new box of masks, and explains: “If we can just fight that stigma and stand together.” DM/MC

Helene-Mari van der Westhuizen is a South African medical doctor and doctoral researcher in the Nuffield Department of Primary Care Health Sciences at Oxford University, studying TB infection control in rural settings in South Africa. Koot Kotze also contributed to this article.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.