May 13, 2021

On this pivotal day, the Centers for Disease Control and Prevention (CDC) updated its mask guidance, allowing fully vaccinated individuals to go without masks in almost all circumstances. The decision was met by a mixture of plaudits and consternation, from Senate Minority Leader Mitch McConnell celebrating that he was “free at last” to some public health officials criticizing the sudden reversal and confusing recommendation. In the announcement, the CDC emphasized the scientific validity of the decision, but public health, by definition, must employ a broader lens and not be myopically guided by scientific considerations alone. In particular, the CDC’s mask guidance ignores health equity and will disproportionately disadvantage Black communities.

The CDC’s mask guidance will harm the most vulnerable by, in effect, offering Americans a blank check for a return to normalcy. An Economist-YouGov poll found that unvaccinated Americans felt more comfortable socializing without a mask than vaccinated Americans who had received at least one shot.1 As such, the CDC’s guidance will present unvaccinated individuals—about 40% of the population—the scientific cover to discard their masks with impunity, especially given no facile mechanism to verify vaccination status. Previous research has found that people lie about personal health information to avoid being judged, so the unvaccinated may also now perceive masks as a “scarlet letter” and discard them.2 We have already seen immense dishonesty as it relates to social distancing, COVID-19 symptoms, and quarantine practices,3 so the honor system the CDC has put their faith in will inevitably fail. But who will bear the consequences of this failure?

Most likely, it will be Black Americans, who are significantly less likely to have been vaccinated. Indeed, as of May 17, only 28% of Black Americans received at least one dose of the COVID-19 vaccine compared to 42% of White Americans and 52% of Asian Americans.4 This disparity is not unique to the vaccine rollout as, throughout the pandemic, Black Americans have faced disproportionately higher infection, hospitalization, and mortality rates than non-Hispanic White Americans.5 From serving as essential workers in greater numbers to carrying more preexisting conditions to facing ominous difficulties accessing care, Black individuals are undeniable victims of institutionalized racism and health inequities. The CDC’s guidance is in part driven by the US as a whole attempting to resume some normalcy after this prolonged, arduous pandemic, but this endeavor ignores that Black communities are still especially vulnerable to infection due to underlying systemic factors and low vaccination rates. Health equity is premised on a recognition of various levels of privilege and appropriately nuanced responses, not a one-size-fits-all guidance as the CDC endorsed (Fig. 1). Why are we creating policies that have the most potential for harm on communities that need the most protection?

Figure 1
figure 1

The difference between equality and equity. Taken with permission from Interaction Institute for Social Change | Artist: Angus Maguire

Certainly, the CDC hopes the updated mask guidance will provide incentives for Americans to get vaccinated, especially as the rollout shifts from a supply to demand shortage. However, in this calculus too, we overlook Black Americans for whom vaccine hesitancy may be more rooted in historical traumas and everyday racism rather than insufficient masking incentives.6 Permission to discard masks will likely not motivate a Black man to become vaccinated if his trust has been decimated by decades of neglect in healthcare systems and collective memory of the Tuskegee Study. With these considerations compounded by access concerns of finding time off from work and commuting to vaccine clinics, the CDC seems to have missed the mark in this attempt to bolster vaccination rates. Given that the unvaccinated largely believe it is safe to socialize without a mask with other unvaccinated adults indoors (63%) and outdoors (70%), it is also dubious that the new guidance will have meaningful impacts on vaccination rates among any community.1 As such, the CDC may have been better served in this mission by prioritizing racially concordant public health messaging and providing resources to community health centers in minority communities.6 Instead, the CDC issued mask guidance that will burden the vulnerable without providing significant benefits.

Of course, we recognize the mask guidance is in line with the science and must be implemented at some point. The public is restless for a return to normalcy, but we cannot provide that at the cost of Black community health. So how should the CDC have updated the mask guidance? For one, the CDC could have taken a page from its guidelines in May 2020 where they set quantitative benchmarks for states to open up, such as intensive care unit (ICU) beds being less than 80% full for 7 days and the percentage of positive tests being less than 20% for 14 days.7 While states followed this guidance to varying degrees, the framework offered nuances that helped protect the vulnerable. The CDC could similarly propose quantitative benchmarks for vaccination rates by racial/ethnic community in order to loosen mask restrictions on the state level. These gradations would better avoid a one-size-fits-all approach and change masking policy only when it is reasonably safe for those most at risk. More generally, the CDC should establish a digital health pass system to create a standardized national mechanism for verification. While these “vaccine passports” have become quite polarized, with a CDC-sponsored system, private and public entities could more effectively protect their workers if they choose to require vaccination. The CDC’s mask guidance was ultimately inevitable, but it could have been delivered with greater nuance and consideration to health equity.

We are entering a phase of the pandemic where COVID-19 infection rates and mortality have diminished to their lowest levels in nearly a year. However, even as the US seeks to put the pandemic behind us, we have a responsibility to look beneath general trends and rigorously assess the implications of our policies on the most vulnerable. We bear witness to the devastating consequences of ignoring Black communities during the pandemic, and we cannot permit COVID-19 to continue to ravage these communities as the rest of the nation celebrates. In our march towards normalcy, we cannot leave Black communities behind.