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We have looked closely at the Hawaii Mayor and Governor recommendations, CDC recommendations, the Presidential Coronavirus Guidelines, the World Health Organization, and other published research in regards to wearing a mask in our office. 

It is of utmost importance that our patients ALWAYS feel safe and comfortable in our office.  We do not take this lightly.  We make decisions based on evidence, science, and also common sense, keeping in mind the health of our community.

We believe that the body is strong, capable and resilient.  That we have an immune system and that there are viruses, bacteria, bugs, and germs around us all day, every day.  Could this virus be different?  Possibly, but shouldn’t our body be able to handle it? Of course.  

We choose to do the things that promote greater strength and resilience.  We focus on those.  We trust that our body is self healing, self regulating, and self adapting.  We choose NOT to live in FEAR and have made the decision that the world is not a hostile environment, but a friendly one.

In our last newsletter, we laid out our policy for disinfecting, sanitization, screening practices, and patient flow to best mitigate the possibility of spreading infection.  You can find that newsletter here

With that said, we completely want to respect your comfort level around the situation.  While being compliant with state rules, we thought we would share the science behind it all.  It might surprise you.  


Cloth Mask Research — April 24, 2020 


Mayor Harry Kim’s COVID-19 Emergency Rule #3

Governor Ige State News Release  

CDC recommendations

Presidential Coronavirus Guidelines 


Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis

Clin Infect Dis. 2017 Dec 1; 65(11): 1934–1942. Published online 2017 Aug 7. doi: 10.1093/cid/cix681  


“Our analysis confirms the effectiveness of medical masks and respirators against SARS. Disposable, cotton, or paper masks are not recommended. The confirmed effectiveness of medical masks is crucially important for lower-resource and emergency settings lacking access to N95 respirators. In such cases, single-use medical masks are preferable to cloth masks, for which there is no evidence of protection and which might facilitate transmission of pathogens when used repeatedly without adequate sterilization.


Facemasks for the prevention of infection in healthcare and community settings.

BMJ. 2015 Apr 9;350:h694. doi: 10.1136/bmj.h694.


The use of reusable cloth masks is widespread globally, particularly in Asia, which is an important region for emerging infections, but there is no clinical research to inform their use and most policies offer no guidance on them.


Effectiveness of Surgical and Cotton Masks in Blocking SARS–CoV-2: A Controlled Comparison in 4 Patients

Bae S, Kim M, Kim JY, et al. Effectiveness of Surgical and Cotton Masks in Blocking SARS–CoV-2: A Controlled Comparison in 4 Patients. Ann Intern Med. 2020; [Epub ahead of print 6 April 2020]. doi: https://doi.org/10.7326/M20-1342


Objective: To evaluate the effectiveness of surgical and cotton masks in filtering SARS–CoV-2.

Methods and Findings: The institutional review boards of 2 hospitals in Seoul, South Korea, approved the protocol, and we invited patients with COVID-19 to participate. After providing informed consent, patients were admitted to negative pressure isolation rooms. We compared disposable surgical masks (180 mm × 90 mm, 3 layers [inner surface mixed with polypropylene and polyethylene, polypropylene filter, and polypropylene outer surface], pleated, bulk packaged in cardboard; KM Dental Mask, KM Healthcare Corp) with reusable 100% cotton masks (160 mm × 135 mm, 2 layers, individually packaged in plastic; Seoulsa).

Discussion: Neither surgical nor cotton masks effectively filtered SARS–CoV-2 during coughs by infected patients. Prior evidence that surgical masks effectively filtered influenza virus (1) informed recommendations that patients with confirmed or suspected COVID-19 should wear face masks to prevent transmission (2). However, the size and concentrations of SARS–CoV-2 in aerosols generated during coughing are unknown. Oberg and Brousseau (3) demonstrated that surgical masks did not exhibit adequate filter performance against aerosols measuring 0.9, 2.0, and 3.1 μm in diameter. Lee and colleagues (4) showed that particles 0.04 to 0.2 μm can penetrate surgical masks. The size of the SARS–CoV particle from the 2002–2004 outbreak was estimated as 0.08 to 0.14 μm (5); assuming that SARS-CoV-2 has a similar size, surgical masks are unlikely to effectively filter this virus.


Masks-for-all for COVID-19 not based on sound data


Cloth masks as source control

In sum, given the paucity of information about their performance as source control in real-world settings, along with the extremely low efficiency of cloth masks as filters and their poor fit, there is no evidence to support their use by the public or healthcare workers to control the emission of particles from the wearer.

Cloth masks as PPE

A randomized trial comparing the effect of medical and cloth masks on healthcare worker illness found that those wearing cloth masks were 13 times more likely to experience influenza-like illness than those wearing medical masks.

In sum, very poor filter and fit performance of cloth masks described earlier and very low effectiveness for cloth masks in healthcare settings lead us to conclude that cloth masks offer no protection for healthcare workers inhaling infectious particles near an infected or confirmed patient.


Advice on the use of masks the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak


Community setting Individuals without respiratory symptoms should: -avoid agglomerations and frequency of closed crowded spaces; – maintain distance of at least 1 meter from any individual with 2019-nCoV respiratory symptoms (e.g., coughing, sneezing); – perform hand hygiene frequently, using alcohol-based hand rub if hands are not visibly soiled or soap and water when hands are visibly soiled; – if coughing or sneezing cover nose and mouth with flexed elbow or paper tissue, dispose of tissue immediately after use and perform hand hygiene; – refrain from touching mouth and nose; – a medical mask is not required, as no evidence is available on its usefulness to protect non-sick persons. However, masks might be worn in some countries according to local cultural habits. If masks are used, best practices should be followed on how to wear, remove, and dispose of them and on hand hygiene action after removal (see below advice regarding appropriate mask management).

Individuals with respiratory symptoms should:wear a medical mask and seek medical care if experiencing fever, cough and difficulty breathing, as soon as possible or in accordance with to local protocols;


Advice on the use of masks in the context of COVID-19

(👉🏼 UPDATED JUNE 2020)


“At present, there is no direct evidence (from studies on COVID- 19 and in healthy people in the community) on the effectiveness of universal masking of healthy people in the community to prevent infection with respiratory viruses, including COVID-19.”

“There is limited evidence that wearing a medical mask by healthy individuals in households, in particular those who share a house with a sick person, or among attendees of mass gatherings may be beneficial as a measure preventing transmission.(41, 56-61)”

“Many countries have recommended the use of fabric masks/face coverings for the general public. At the present time, the widespread use of masks by healthy people in the community setting is not yet supported by high quality or direct scientific evidence and there are potential benefits and harms to consider”


A cluster randomised trial of cloth masks compared with medical masks in healthcare workers

BMJ Open. 2015; 5(4): e006577. Published online 2015 Apr 22. doi: 10.1136/bmjopen-2014-006577


“The rates of all infection outcomes were highest in the cloth mask arm, with the rate of ILI statistically significantly higher in the cloth mask arm (relative risk (RR)=13.00, 95% CI 1.69 to 100.07) compared with the medical mask arm. Cloth masks also had significantly higher rates of ILI compared with the control arm.”

This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection.

Results of first randomized clinical trial of masks on 1,607 healthcare workers found respiratory infection was much higher in those workers wearing cloth masks (in BMJ Open, 2015).

Masks may actually increase your coronavirus risk if worn improperly, surgeon general warns


US Surgeon General Dr. Jerome Adams 

“Folks who don’t know how to wear them properly tend to touch their faces a lot and actually can increase the spread of coronavirus.”

Based on the research, “there is NO EVIDENCE that masks can prevent someone from infection with respiratory viruses, including COVID-19.”


Covid-19: important potential side effects of wearing face masks that we should bear in mind


“(5) Face masks make breathing more difficult. For people with COPD, face masks are in fact intolerable to wear as they worsen their breathlessness.[5] Moreover, a fraction of carbon dioxide previously exhaled is inhaled at each respiratory cycle. Those two phenomena increase breathing frequency and deepness, and hence they increase the amount of inhaled and exhaled air. This may worsen the burden of covid-19 if infected people wearing masks spread more contaminated air. This may also worsen the clinical condition of infected people if the enhanced breathing pushes the viral load down into their lungs.”


Effectiveness of Cloth Masks for Protection Against Severe Acute Respiratory Syndrome Coronavirus 2


According to the article: “To our knowledge, only 1 randomized controlled trial has been conducted to determine the efficacy of cloth masks (4), and the results do not favor use of cloth masks.”

“In 2015, we conducted a randomized controlled trial to compare the efficacy of cloth masks with that of medical masks and controls (standard practice) among healthcare workers in Vietnam (4). Rates of infection were consistently higher among those in the cloth mask group than in the medical mask and control groups. This finding suggests that risk for infection was higher for those wearing cloth masks. The mask tested was a locally manufactured, double-layered cotton mask. Participants were given 5 cloth masks for a 4-week study period and were asked to wash the masks daily with soap and water (4). The poor performance may have been because the masks were not washed frequently enough or because they became moist and contaminated. Medical and cloth masks were used by some participants in the control group, but the poor performance of cloth masks persisted in post hoc analysis when we compared all participants who used medical masks (from the control and the medical mask groups) with all participants who used only a cloth mask (from the control and the cloth mask groups)(4).”

In the FUTURE RESEARCH DIRECTION paragraph of this study:

“More research on cloth masks is needed to inform their use as an alternative to surgical masks/respirators in the event of shortage or high-demand situations. To our knowledge, only 1 randomized controlled trial (4) has been conducted to examine the efficacy of cloth masks in healthcare settings, and the results do not favor use of cloth masks. More randomized controlled trials should be conducted in community settings to test the efficacy of cloth masks against respiratory infections. According to the US Institute of Medicine, National Academy of Sciences, more research on the engineering design of cloth masks to enhance their filtration and fit is needed (16). Moreover, various methods for decontaminating cloth masks should be tested.”


Swiss Policy Research

Are Face Masks Effective? The Evidence.


Danmask 19 Trial

“The recommendation to wear surgical masks to supplement other public health measures did not reduce the SARS-CoV-2 infection rate among wearers by more than 50% in a community with modest infection rates, some degree of social distancing, and uncommon general mask use. The data were compatible with lesser degrees of self-protection.”



(👉🏼 Update April 2021)

Facemasks in the COVID-19 era: A health hypothesis


CLICK to see effects of masks on normal physiology: physiological effects

“The existing scientific evidences challenge the safety and efficacy of wearing facemask as preventive intervention for COVID-19. The data suggest that both medical and non-medical facemasks are ineffective to block human-to-human transmission of viral and infectious disease such SARS-CoV-2 and COVID-19, supporting against the usage of facemasks. Wearing facemasks has been demonstrated to have substantial adverse physiological and psychological effects. These include hypoxia, hypercapnia, shortness of breath, increased acidity and toxicity, activation of fear and stress response, rise in stress hormones, immunosuppression, fatigue, headaches, decline in cognitive performance, predisposition for viral and infectious illnesses, chronic stress, anxiety and depression. Long-term consequences of wearing facemask can cause health deterioration, developing and progression of chronic diseases and premature death. Governments, policy makers and health organizations should utilize prosper and scientific evidence-based approach with respect to wearing facemasks, when the latter is considered as preventive intervention for public health.


Is a Mask That Covers the Mouth and Nose Free from Undesirable Side Effects in Everyday Use and Free of Potential Hazards?


“Our review of the literature shows that both healthy and sick people can experience Mask-Induced Exhaustion Syndrome (MIES), with typical changes and symptoms that are often observed in combination, such as an increase in breathing dead space volume [22,24,58,59], increase in breathing resistance [31,35,60,61], increase in blood carbon dioxide [13,15,17,19,21,22,23,24,25,26,27,28,29,30,35], decrease in blood oxygen saturation [18,19,21,23,28,29,30,31,32,33,34], increase in heart rate [23,29,30,35], increase in blood pressure [25,35], decrease in cardiopulmonary capacity [31], increase in respiratory rate [15,21,23,34,36], shortness of breath and difficulty breathing [15,17,19,21,23,25,29,31,34,35,60,71,85,101,133], headache [19,27,29,37,66,67,68,71,83], dizziness [23,29], feeling hot and clammy [17,22,29,31,35,44,71,85,133], decreased ability to concentrate [29], decreased ability to think [36,37], drowsiness [19,29,32,36,37], decrease in empathy perception [99], impaired skin barrier function [37,72,73] with itching [31,35,67,71,72,73,91,92,93], acne, skin lesions and irritation [37,72,73], overall perceived fatigue and exhaustion [15,19,21,29,31,32,34,35,69] (Figure 2Figure 3 and Figure 4).”


Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers : A Randomized Controlled Trial


A total of 3030 participants were randomly assigned to the recommendation to wear masks, and 2994 were assigned to control; 4862 completed the study. Infection with SARS-CoV-2 occurred in 42 participants recommended masks (1.8%) and 53 control participants (2.1%).”

“The recommendation to wear surgical masks to supplement other public health measures did not reduce the SARS-CoV-2 infection rate among wearers by more than 50% in a community with modest infection rates, some degree of social distancing, and uncommon general mask use. The data were compatible with lesser degrees of self-protection.”


✅ If you have other research that you would like the doctors at Atlas Specific Spine Center to read regarding this situation, please send it our way.  We appreciate your understanding and concern for the community as a whole. Thank you for taking the time to read this, educate yourself, and to make an informed decision for you and your family.