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Are there medical reasons to not wear a mask? Yes, but not many

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When Amber Lynn Gilles was refused service by a San Diego Starbucks barista in June, she took her frustrations to Facebook: “Meet lenen from Starbucks who refused to serve me cause I’m not wearing a mask. Next time I will wait for cops and bring a medical exemption.”

After a GoFundMe drive raised over $100,000 for barista Lenin Gutierrez (half of which Gilles now claims belongs to her), she turned over her medical documentation — a pelvic exam from 2015 and a handwritten note from a local chiropractor which noted “underlying breath conditions.”

In what is likely the most high-profile attempt to use a medical condition to sidestep a mask requirement, it is hardly the only one. Similar scenes have unraveled in North Hollywood, Dana Point and San Luis Obispo — and that’s just in grocery stores in California. 

Some airlines have reached a breaking point. American, Southwest, JetBlue and Alaska Airlines, plus Spirit Airlines, no longer allow medical exemptions at all. 

Medical mask exemptions vs. no mask, no service

Viral videos and the proliferation of meaningless exemption cards for sale online have resulted in widespread public skepticism of health-related mask exemptions.

The issue has been further complicated in the U.S. where political partisanship and claims of governmental overreach and personal rights have muddled mask habits during the pandemic. 

Misinformation isn’t helping things either. Some believe that simply citing the existence of a “medical condition” conveys automatic protection under the Americans with Disabilities Act (ADA) — which was designed to prohibit discrimination against individuals with disabilities — and thus allows them to bypass mask requirements.

Disabilities under the ADA, however, are case-specific and require individual assessment.

“The individual would have to establish that she is a person with a disability under the law, which has specific legal standards and is not always an easy or straightforward thing to do,” Professor Jessica Roberts, the director of the Health Law & Policy Institute at the University of Houston Law Center, told USA Today.

Few medical conditions are truly incompatible with all forms of mask wearing.

Mical Raz and Doron Dorfman

JAMA Health Forum

Beyond that, the ADA allows restrictions to stand if an individual poses a “direct threat to the health or safety of others.” In March, the Equal Employment Opportunity Commission determined the Covid-19 pandemic met that threshold.

The Northwest ADA Center, a part of the ADA National Network, asserts businesses should be justified in relying upon guidance from the Centers for Disease Control and Prevention (CDC), as well as state and local governments’ orders, to justify policies that prevent maskless customers from entering their stores.

“In limited circumstances, there could be a situation in which a customer cannot wear a face mask due to a legitimate health reason,” states an article on the center’s website. “In this case … a business may not need to alter their face-mask required policy, but in any event, should attempt to accommodate that customer in an alternative manner … providing curbside pickup; no contact delivery; or assistance via online store services.” 

So what are medical reasons that exempt one from wearing a mask?

While standards set by state and local governments and private businesses vary, the CDC states that masks should not be worn by:  

   ·  children younger than 2 years old

   ·  anyone who has trouble breathing

   ·  anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance

The problem mainly lies in the nebulous middle category — a health issue with a number of possible underlying medical conditions.

It is likely that chronic pulmonary disease in itself is a compelling reason for masking, rather than a category of exemption.

Mical Raz and Doron Dorfman

JAMA Health Forum

Asthma is a common condition that causes breathing issues. According to the CDC, more than 25 million Americans have asthma, or about 1 in 13 people. Still, doctors advise that most asthmatics can safely wear masks.  

“For people with very mild asthma or well-controlled asthma, it’s probably not going to be an issue,” said Dr. David Stukus, member of the Medical Scientific Council for the Asthma and Allergy Foundation of America (AAFA), in an article on the organization’s website. British charity Asthma UK agreed, stating on its website: “Most people with asthma, even if it’s severe, can manage to wear a face mask or covering for a short period of time.”

But what about chronic pulmonary diseases, such as chronic bronchitis and emphysema?

In an article published on July 10, 2020 entitled “Mask Exemptions During the Covid-19 Pandemic—A New Frontier for Clinicians,” authors Dr. Mical Raz and attorney Doron Dorfman argue people with these conditions may have even more reason to mask up. 

“It is likely that chronic pulmonary disease in itself is a compelling reason for masking, rather than a category of exemption,” writes Raz and Dorfman in the JAMA Health Forum. 

The danger is two-fold, they say. Those with a chronic pulmonary illness are at a higher risk for severe disease should they contract Covid-19. They would also likely carry a higher risk of spreading it to others due to chronic coughs associated with their conditions.

Without advising blanket exemptions for these groups, the CDC acknowledges those with sensory sensitivities, intellectual and developmental disabilities and mental health conditions may “have challenges” wearing masks.

Mark Liddell | Moment | Getty Images

The article notes this is true for “pulmonary illnesses without an active exacerbation” and advocates for the issuance of clear guidelines based on objective measures to guide clinicians in making mask exemption determinations.   

In stating that “few medical conditions are truly incompatible with all forms of mask wearing,” the authors acknowledge the existence of conditions beyond the CDC’s recommendations that may make mask-wearing difficult.  

“Some individuals, particularly children, with sensory processing disorders may be unable to tolerate masks. Facial deformities that are incompatible with masking are an additional category of exemption.”

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