Can’t wear a mask? Why demands for medical proof have experts worried

As one of the key tools in the coronavirus protection kit, face masks have become commonplace in Canadian’s day-to-day.

But should a medical issue prevent you from wearing one, do you need to prove it? Via Rail has decided you do.

As of Nov. 9, passengers with a medical condition or disability “that makes it difficult to wear a mask” must provide an official medical document along with a government-issued photo ID.

It sounds like a simple solution, but it’s a complex problem, said Zain Chagla, an infectious disease physician and McMaster University associate professor.

“It’s easy to say, ‘This person can’t drive because they have a set number of conditions that put them at risk,’ or for someone to fill out paperwork for an (accessible) sticker for a car because they have conditions that make it difficult to ambulate,” he said.

“But this is very different. There are no defined criteria, and that criteria can be very subjective.”

Eligibility tricky

In the early days of the pandemic, there was little evidence showing how beneficial masks could be. Now, and increasingly, studies show they can help save lives in different ways.

Despite this, masks have become an extremely heated point of contention during the pandemic.

A small, but vocal, part of the population, coined “anti-maskers,” are pushing back on the rules. Some groups have even started making fake plastic “face mask medical exemption” cards to avoid having to follow them.

The problem is that there isn’t really a set document to prove exemption, said Chagla.

In Toronto and Ottawa, where health officials have mandated mask use in all indoor public settings, people do not require proof to go mask-free. In Edmonton, city-approved mask-exemption cards were briefly handed out but came under heavy criticism since those who requested a card did not need to provide proof of why they need it.

“People can have a number of reasons to be exempted from masks, but sorting out who is eligible is tricky,” said Chagla.

“Unfortunately, there’s not a good way to distinguish the person who legitimately can’t wear a mask for whatever reason from the person that doesn’t want to wear a mask and says they have a more subjective issue.”

‘Few and far between’

Exemptions for mask use need to be for “a restricted number of indications,” according to the Ontario College of Family Physicians. “There are very few conditions that justify an exemption.”

In Ontario, the exemption applies to children under the age of two, anyone who has trouble breathing and anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

However, the college notes that more clarity is needed on what constitutes a breathing difficulty, since experts in the respiratory field say it’s an uncommon problem.

The Canadian Thoracic Society (CTS), which represents researchers and physicians in respiratory health, states “there is no evidence that wearing a face mask will exacerbate (cause a ‘flare-up’ of) an underlying lung condition.” It recommends that anyone with a lung disease still wear a mask, and if they can’t, the CTS says they should avoid all circumstances where physical distancing is not possible, as this group of people may be at a higher risk of serious illness from the virus.

That’s not to say there aren’t valid reasons, said Sumontra Chakrabarti, an infectious disease physician at Trillium Health Partners.

He pointed to severe forms of asthma or those who require constant oxygen and live with nasal prongs. Chagla acknowledged other issues like facial abnormalities or craniofacial issues, like nasal problems.

“But for the most part, they’re going to be few and far between,” said Chakrabarti, adding that there’s an accessibility and equity aspect to Via Rail’s decision that affects those with true medical issues.

“The concern is that this sort of requirement could trigger a deluge of people going into doctor’s offices and clinics all of a sudden to get these medical exemptions.”

Pressure on health care

Via Rail’s policy requires the exemption document to specify the passenger’s condition or disability and be dated and signed on an official letterhead issued by a health-care provider.

In this case, it only applies to passengers of the rail line, said Chagla, but it’s ultimately “one small piece of a bigger issue.”

If more businesses and services head in this direction, it will inevitably fall to the medical system, “which is already backed up,” he said.

Just like sick notes from doctors — which already put an unnecessary burden on the health-care system — Chagla worries people seeking these notes (whether justifiable or not) will end up clogging walk-in clinics and other providers, creating an “unnecessary need.”

“From a care standpoint, as a physician, if someone came to me and said, ‘I can’t wear a mask because of X,’ I’m not going to sit there and have an hour-long conversation with them to nail down that specific reason as to why. I’m more likely to write a note and say, ‘fine,’” he said.

“It’s hard to prove.”

It gets particularly hard to prove when the reasons are subjective, like anxiety or claustrophobia, he said, or when clinic physicians have no history on hand to back up the claims.

“There’s no test for that,” he said. “It’s going to be extremely difficult to tease out.”

Future regulation possible

Chagla believes Via Rail’s decision stems from liability or risk concerns.

In a statement to Global News, Via Rail said the policy was created to “further protect the health and safety of passengers and employees,” and that any passenger that requires exemption does not need to identify or reveal their medical condition or disability.

While it may come out of good intentions, services like Via Rail need to acknowledge that part of operating during this pandemic will require industries to accept and exclude certain risks rather than “dumping on a group already stressed,” said Chagla. That might mean simply taking someone’s word for it, he said, rather than putting people and practitioners through another process.

Both Chagla and Chakrabarti agree that policymakers might need to start thinking ahead on how to regulate mask exemptions — without encouraging anti-maskers and by continuing to drive home a “greater good” message on why they should be worn.

“Masks are going to be a big part of our lives even in the next couple of years,” said Chakrabarti.

But, Chagla added: “Those mandates need to be sorted out outside of the medical system.”

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