'You cannot sustain a red alert': Why more doctors want to stop making kids mask up in school

Fatigue and frustration are setting in two years into the coronavirus outbreak, and a growing chorus of doctors, parents and state officials are calling for an end to school mask mandates.

The issue has long divided Americans across the nation, spurring intense debates and demonstrations at school board meetings, propelling legal battles and emerging as a focal point of state elections.

But a national conversation around an "offramp" to masking in schools has accelerated in recent days. As the omicron wave recedes, multiple states have taken action to phase out statewide school mask mandates, and a number of high-profile medical professionals have changed their tunes on the matter.

One cohort points to increasing access to vaccinations for children and declining COVID-19 cases, hospitalizations and deaths. Another group argues long-term masking puts an outsize burden on kids, with consequences to their mental health and possibly to their development.

"You cannot sustain a red-alert, all-hands-on-deck, emergency kind of response indefinitely," said Dr. Shira Doron, an infectious disease physician and hospital epidemiologist at Tufts Medical Center in Boston. "People just can't be on high alert like that without fatigue, without breaking."

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'Circumstances have changed'

Officials in five Democratic-led states – Connecticut, Delaware, New Jersey, Oregon and Rhode Island – announced plans this week to lift statewide school mask mandates, leaving it up to local school officials to decide whether to keep mandates for students, teachers and staff. Pennsylvania announced an end to its school mask mandate last month.

State officials largely said the policy change was the result of increasing access to vaccinations for children and declining cases. Delaware Gov. John Carney said the state's mandate would expire at the end of March to give "parents time ​to get their school-age children vaccinated."

Officials in California and Massachusetts are reviewing their policies on mask requirements in schools, according to local reports. The governors of Illinois and New York on Wednesday announced plans to end their indoor mask mandates but said masking requirements will continue in schools.

"The equation for schools just looks different right now than it does for the general population. Schools need a little more time for our community infection rates to drop, for our youngest learners to become vaccine-eligible, and for more parents to get their kids vaccinated," Illinois Gov. JB Pritzker said. "In the coming weeks, it is my hope and expectation that we will continue making progress to a place where we can remove school masking requirements and keep kids in schools."

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Multiple familiar faces are also speaking out publicly – on TV news programs and in op-eds – about ending mask requirements. Dr. Scott Gottlieb, a former Food and Drug Administration commissioner who now serves on the board of Pfizer, told CBS' "Face The Nation" on Monday that the U.S. is "at a point where we can safely contemplate" how to move away from mask mandates.

"We can start to lean forward and take a little bit more risk and try to at least make sure students in schools have some semblance of normalcy for this spring term," Gottlieb said. "A lot of kids really haven't known a normal school day for two years now, so we need to try to lean forward aggressively to try to restore that and reclaim that when we can."

Dr. Leana Wen, an emergency physician and public health professor at George Washington University and a Washington Post contributor, wrote an op-ed Feb. 1 calling for "a quick offramp for masking."

"Circumstances have changed. We are in a very different place compared to where we were a year ago or even a month ago," Wen told USA TODAY. "We need a reevaluation of pandemic restrictions starting, most importantly, with our schools."

Other prominent medical professionals – including Dr. Ashish Jha, dean of Brown University's school of public health – have made the same case. Many say it's important to lift some precautions now to preserve public health authority for when it’s needed again.

"The window is opening for this discussion," said Dr. David Rubin, director of the PolicyLab at the Children's Hospital of Philadelphia. "This is not about whether masks are effective. They are effective. This is more about whether that degree of required mitigation is really necessary for this moment in the pandemic."

Are there 'harms of masking'?

Several other medical professionals have voiced concerns that long-term masking could have unintended consequences on children.

Margery Smelkinson, an infectious disease scientist, said there are likely to be costs associated with long-term masking, but the "harms of masking" are harder to quantify than the effects of other measures "because they are more subtle and may take years to manifest."

Smelkinson noted the World Health Organization does not recommend masking for children ages 5 years and under "based on the safety and overall interest of the child and the capacity to appropriately use a mask with minimal assistance." WHO says the decision to use masks for children 6 to 11 depends on a number of considerations, including "potential impact of wearing a mask on learning and psychosocial development."

Doron, the mother of two high school students, told USA TODAY she is worried about how long-term masking contributes to mental health struggles and what she described as a "punitive mask culture" in schools.

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"What I see is a destruction of the relationship between children and their teachers. There is, at least at my children's high school, a nonstop focus on discipline and punishment around mask slippage, so that that relationship has become not about supporting and educating but about enforcement," Doron said.

Doron said she's also wary of how long-term masking affects childhood learning and development. Several other physicians and researchers have sounded the alarm, too.

"Visualization of the entire face is of crucial importance to social, emotional and speech development," Virginia-based internist Jennifer Knips wrote in Time last week. "My first grader has had to learn to read and make friends without ever seeing his teacher’s mouth or other students’ faces."

Doron co-wrote an op-ed last month raising the issue and citing a journal article that suggested mask-wearing could influence language acquisition in children, with a disproportionate impact on children with hearing loss. The article in Otolaryngology–Head and Neck Surgery noted mask-wearing could hinder social development because masks "can also obscure social cues provided through facial expressions."

But Dr. Alexander Chern, a resident physician at NewYork-Presbyterian Hospital who co-wrote the journal article, told USA TODAY "not enough time has elapsed to make definitive conclusions."

Emerging research points to some shorter-term effects. A study published Monday by researchers at York University and Ben-Gurion University in Israel looked at 72 children, ages 6 to 14, and found children are having difficulty recognizing faces that are partially covered by masks.

Numerous physicians and researchers, however, told USA TODAY there is no evidence that mask-wearing harms children’s language and communication skills during their critical development years, and it's too soon to be able to assess potential long-term consequences.

Doron said she acknowledges there is currently no "big study" to back up her views on long-term concerns.

"I'm not a pediatrician, a psychologist, but I am a mother. And I'm a scientist, and I'm a researcher," Doron said. "I feel the downsides. I feel the harms from my children, my friends' children, on a daily basis."

'Take a break from masks'

Public opinion on masking in schools may be changing, but the question remains divisive within the medical community. Several medical professionals who spoke with USA TODAY expressed caution about the growing movement to ease the requirements.

"I'm not happy about it," said Dr. Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health and an adviser for Baltimore City Public Schools. "I just worry that it's going to lead to school closures."

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Gronvall said she sees comments about the adverse effects of masking circulating on social media but has not seen any studies to support the claim.

"While COVID is having certainly a huge impact on children, the masks are not. They seem to be bothering adults more," Gronvall said.

The Centers for Disease Control and Prevention continues to recommend universal indoor masking for all teachers, staff, students and visitors to K-12 schools, regardless of vaccination status. The American Academy of Pediatrics said Monday that it still supports universal masking in schools for everyone ages 2 and older "with rare exception."

Kids have proven they are "quite capable of wearing masks and still learning," said Dr. Nathaniel Beers, a pediatrician at Children's National Hospital and a member of the American Academy of Pediatrics Council on School Health.

"I think we all would love to be able to take our masks off," Beers said. "We are coming close to a place where that can be done safely. But there are several challenges that need to be taken into consideration."

Children under 5 are still ineligible for vaccination, and those who are unvaccinated and immunocompromised remain vulnerable, he said. (About 22% of kids 5 to 11 are fully vaccinated, along with 56% of those 12 to 17, according to CDC data.)

Moreover, many jurisdictions have not achieved substantial vaccination rates or reduced community spread "to levels that would warrant removing masks at this point," Beers said.

Dr. Alin Abraham, a pediatrician with Northwestern Medicine Central DuPage Hospital, said it's important to remember children aren't immune to COVID-19. About 1,000 children have died of the disease in the U.S., and the omicron surge saw more kids being admitted to hospitals with the disease than ever before.

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Some researchers and physicians say they're concerned about how a change in school masking policies could affect children of color, in particular. A May survey by the RAND Corporation found rural and white parents are more likely to want schools to end COVID-19 safety protocols such as masking, and parents of color and urban parents were more likely to want them in place.

"The change in school masking policies is likely going to set us back in our efforts to close the gap in COVID-19 health disparities in communities of color," said Folakemi Odedina, director of the Mayo Clinic's Center for Health Equity and Community Engagement Research.

Dr. Gabriela Maradiaga Panayotti, a pediatrician at Duke Health, said she worries about increased transmission from children to families in historically marginalized groups. She's concerned not just with the impact on health but with the "economic consequences that are really not equally distributed in our society right now."

Meanwhile, medical professionals say the conversation around an "offramp" to masking requires a continued conversation around vaccinations and also raises another question: What would an "onramp" look like?

Several experts told USA TODAY a school mask requirement onramp should come into play if a more deadly variant that evades vaccines begins to circulate.

"I'm open to having that conversation," Doron said. "We need to at least take a break from masks in school over this next period, however long it may be, between waves."

Follow reporter Grace Hauck on Twitter at @grace_hauck.

This article originally appeared on USA TODAY: Is it time to lift COVID mask mandates in schools? What doctors say