Very few countries walked into 2020 with the confidence, swag, and hopefulness that we did as a country. The Year of Return highlighted the richness, innovation, pride, and optimism we have always had as a nation.

However, after four presidential updates on the Covid-19 pandemic, the World and Ghana are engaged in a battle, unlike any other.

Our global response towards the pandemic will be judged by its decisiveness, comprehensiveness, and extent of inclusion of broad stakeholders and interests. In Ghana, there has been no shortage of eager individuals, professional associations, faith groups and, labour groups offering insights and contributions.

Yet we are in uncharted waters, and the COVID-19 pandemic seems to have an edge despite global and local attempts to mitigate spread. Our Global village is in a long-drawn battle demanding interventions grounded in science, continuous learning,  empathy, [local] context, and inclusive in approach.

A good decision and a fast decision

Our global and national efforts make a difference if implemented a second, a day or a week too early or too late. The weight of each decision keeps the President, the health workforce, the working class the security, the media, and various arms of government up-at-night. The consequences of the lockdown have left some proponents second-guessing the decision. One big lesson we learned was the schism between a "good idea" and its implementation. Our complex adaptive world reminds us that society and nature will react to any change that disturbs the current equilibrium.

Rapid cycle evaluation

Learning during the pandemic is a continuous task for teams advising the President. Yesterday's success or failure should not discourage one from engaging in a rapid cycle analysis of current and future interventions.

Making rounds across academia, civil society and the research community is the value of population-level use of face mask. This debate will soon make its way to social media platforms and ultimately end up as a question to Kojo Oppong Nkrumah, Minister of Information, as has become the practice. But before you do that, I have summarised some of the arguments surrounding the use of a facemask.

Mask for All

Background:  A recent Lancet commentary on the rational use of face masks in the COVID-19 pandemic highlights the "absence of evidence" on the protection gained by a homemade facemask when used by the population. This has been fueled by research findings indicating that it takes 66 minutes for half of the virus in aerosolized droplets to lose its functions.  A YouTube viral video simulating duration and dispersion on droplet from sneezing, coughing and talking has heightened concern around the asymptomatic spread of COVID-19.

Question: Will the mandatory use of homemade face mask help flatten the epidemic curve?

There is a research gap on the effect of the population use of facemask on a community outbreak. However, there are research findings on the protective effect of “surgical mask” among health care workers. The external validity of a scale up to the population should note that the setting-culture, face mask type, technical expertise, and work environment of the subjects of the studies differ.

What do we know? Some regions in China and recently the Czech Republic have implemented mandatory use of face masks. In the Czech Republic, this includes homemade face masks made from tee shirts and apropos spare clothing. Unlike countries with the luxury to distribute surgical or medical facemasks, the homemade face mask sewn by citizens and worn in public.

The World Health Organization (W.H.O.) advised that healthy individuals only need to wear a mask when taking care of a person with COVID-19 infection. The W.H.O.'s advice was timely as the general public at that time was contributing to the shortage of surgical facemask in the world. Since then, the debate on the use of mask keeps intensifying with recent reversal in policy by the Center for Disease Control. In a memo to the White House, the Washington Post report that the C.D.C. referenced increased evidence in COVID-19 spread by individuals who look and appear well. This reversal from the directive that-healthy people do not need a facemask is only an additional community mitigation tool. A homemade face mask or Do It Yourself mask should not replace social distancing and hand washing. There is a genuine concern facemask will undermine messaging related to "stay at home", "wash your hands" or "maintain a distance of 3-6 feet from individuals in public.

In a context like Ghana or African context, there are questions to consider.

1. How is the community responding to existing education on handwashing, social distancing and directives to stay at home?
2. Are the existing messages precise, clear, and contextualized?
3. What is the communication dose on current educational messages? Is it adequate, sustained, relatable? E.g. How often and how diverse are the medium and language used to communicate existing messaging.

If the current messaging on handwashing, social distance is mostly ignored, we ought to re-examine the challenges quickly. Parachuting another community mitigation measure without a quick evaluation will send mixed signals to a section of the population still processing a "lockdown", " a foreign virus in the air", "a loss in livelihood" or "soldiers on the street". Misinformation and viral videos spread just as fast as the virus, with fake videos popping up on social media platforms hourly.

My suggestions after synthesizing some of the data are as follows.

What are the pros:

• The facial mask will reduce spread by asymptomatic cases by trapping droplets from the nose and mouth provided other community mitigated measures are appreciably followed.
• In communities with high transmission, mass use of a locally made mask may improve crowd psychology and willingness to protect each other.
• The face mask use will provide visual reminders of urgency, seriousness, and need for the community to fight pandemic together.
• Evidence so far -(Doing nothing) < (surgical mask) <  (surgical mask + hand hygiene).
• Engaging local artisans to produce a homemade face mask may energize the working class to play an additional vital role in the national response.
• The impact of the face mask may be modest but will complement a contextualized national approach.
• The government may not have to fund this project for the majority of the population.
• A locally made mask may help textile, fashion, and vocational businesses.

Cons: Threats

• Homemade facemasks are not P.P.E.s and should not be the standard for health care workers or frontline staff, except as a last resort.
• Improper use and cleaning will increase the risk of infection to the user and the public. A randomized clinical trial in Vietnam published in the British Medical Journal compared respiratory infection rates among health workers who wore a) medical mask, b) a cloth mask and c) no mask. The Researchers reported higher infection rates in the health care workers who wore cloth mask (D.I.Y. facemask) compared to no facemask. Moisture retention, reuse of the facemask and poor filtration were some of the factors authors cited as likely pathways to infection among cloth masked health care workers.
• Sections of society may reject this intervention for valid social and cultural reasons. Anyone who has used an untarred dusty road will report a common sight of drivers, passengers, “okada drivers" and pedestrians using bandanas, homemade masks, and handkerchiefs to reduce dust inhalation. A keen observer will also note that hygiene around the use of these masks is concerning. 
• The affluent in society may purchase scarce surgical mask meant for health care workers.
• Sections of the public may have a false sense of security if education is inadequate.
• Facemask complements hand washing, social distancing, and is not a silver bullet.

Should we get to that decision node suggested implementation guidelines may include:

• Voluntary use of homemade mask should only be considered as an additional community mitigation measure. Regular evaluations should be done on community adherence to current COVID-19 messaging.
• Homemade masks should be of the right material ( cotton), multilayered, and fit snuggly to an individual’s face.
• Homemade facemasks should be locally made masks made from personal items such as old clean clothing.
• Surgical masks should be reserved for health care workers and sick individuals.
• Guidelines on design, cleaning/washing should be provided by the national response team.
• Individuals should own multiple masks, regularly wash and dry them in the sun.
• Facemasks should not be shared within households or among family and friends.
• Reuse of facemask without adequate cleaning and washing would lead to individual infecting him/herself with both bacterial and non-COVID-19 viral infections.
• Educational videos on handling facemask should be shared using social media platforms.
• Facemask may be useful in high transmission spots with high public interaction.
• Education! Education Education!