PS: Those ADA "Face Mask Exemption Cards"? Totally fake.

After Amber Lynn Gilles was refused service at a San Diego Starbucks for not wearing a mask, her complaint—via Facebook post—went viral. Gilles shared a picture of the young barista who wouldn’t serve her, and wrote that she was medically exempt from wearing a mask. "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 [sic]."

Gilles’s attempt to shame Lenin the barista has backfired, as people have commented saying that her frustration is “aimed at the wrong people” because Lenin was simply following company policy. Others questioned why she didn’t go through the drive through if she had a medical condition that means she can’t wear a mask. (Incidentally, a GoFundMe campaign entitled "Tips for Lenin Standing Up To A San Diego Karen" has now raised over $20,500 from over 1,800 people from around the world.)

But it's not just Gilles—various videos from across the country have shown multiple men and women claiming to be medically exempt from wearing a mask during the COVID-19 pandemic. And according to The New York Times, certain "Face Mask Exemption Cards"—which are completely fake—are also circulating, claiming to give those in possession of them a pass not to wear a mask due to underlying health conditions. "Wearing a face mask posses a mental and/or physical risk to me. Under the Americans with Disability Act (ADA), I am not required to disclose my condition to you,” reads the card—which not only misspells "poses," but also incorrectly names the Americans with Disabilities Act and references the "Freedom to Breathe Agency," which does not exist.

All of these instances beg the same question: Do medical exemptions for face masks or coverings really exist? Here's what you need to know about when, where, and for whom wearing a face mask is necessary, and whether you can be exempt from wearing one.

Who needs to wear face masks?

The Centers for Disease Control and Prevention (CDC), "recommends that people wear cloth face coverings in public settings when around people outside of their household, especially when other social distancing measures are difficult to maintain." 

The World Health Organization (WHO) takes things a step further with recommendations that differ between who should wear surgical or medical face masks and who should wear cloth face coverings. (Note: Both the CDC and WHO still only recommend N95 respirator masks for "health care personnel (HCP) who need protection from both airborne and fluid hazards."):

Surgical or medical face masks are for:

  • Health care workers
  • People with COVID-19 symptoms
  • People taking care of someone with suspected or confirmed COVID-19
  • People who are 60 years old or older (when social distancing isn't possible in areas with widespread COVID-19)
  • People who have underlying health conditions (when social distancing isn't possible in areas with widespread COVID-19)

Cloth face coverings or fabric masks are for everyone when:

  • COVID-19 is widespread
  • Physical distancing of at least 6 feet isn't possible (including on public transportation, workplaces, stores, and other crowded environments)

Can you be medically exempt from wearing a face mask?

According to the CDC, "cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance."

Beyond that, every state has its own guidelines regarding the wearing of face coverings. In California, the state's Department of Public Health gives mask exemptions to “persons with a medical condition, mental health condition, or disability that prevents wearing a face covering." This includes “persons with a medical condition for whom wearing a face covering could obstruct breathing or who are unconscious, incapacitated, or otherwise unable to remove a face covering without assistance.” In New York City, you don’t have to wear a face covering if you have “a health issue that makes you unable to tolerate [one].”

But here's where it gets tricky: None of the health agencies specify any health conditions that would constitute a mask exemption—and some health professionals don't believe these stated, unspecific exemptions for surgical masks or cloth face coverings are necessary. "There are no known medical conditions aside from a severe skin condition [like a very severe burn that needs medical attention] on your face that would prevent a person from wearing this type of mask,” David Kaufman, MD, pulmonologist and director of the medical ICU at Tisch Hospital, tells Health. “If you can wear a scarf to keep your face warm in the winter, you can wear a mask to prevent the spread of disease.”

According to Dr. Kaufman, there's an important distinction between the types of masks average citizens can and should wear (like surgical masks and cloth face coverings), versus the ones health care professionals should wear in certain settings (like N95 respirator masks). The tight-fitting N95 masks, Dr. Kaufman says, filter the air you breathe and protect you from inhaling small particles like dust or germs that cause disease. Those respirator masks do add some resistance to breathing in and some people with sever lung disease may find breathing more difficult while wearing one, says Dr. Kaufman.

Looser fitting masks, like surgical masks or fabric face masks, however, block some of the air you breathe out. "If you are infected with a contagious disease like COVID-19, a surgical mask limits how much you might spread the disease," says Dr. Kaufman. That also means surgical and fabric masks do not add resistance while inhaling.

Essentially, this means even people with respiratory illnesses—asthma, chronic obstructive pulmonary disease (COPD), and other lung diseases—can safely wear either surgical or fabric masks in public. "Finding a mask that fits well or a face covering with a fabric that is soft will help you stay comfortable while you help keep your family, friends, neighbors, and community safe from COVID-19 and other contagious diseases," says Dr. Kaufman.

Jim Keany, MD, emergency physician, patient safety physician champion, and former chief of staff at Mission Hospital in Orange County, California agrees that there are no medical conditions that would preclude someone from wearing a simple surgical or cloth face mask, because both masks have "no effect on respiratory mechanics." According to Dr. Keany, however, if you are having trouble breathing while wearing a cloth or surgical mask, you may not be wearing it correctly. "If you feel like you're sucking air through the mask, you are wearing the mask too tight," says Dr. Keany. "Simply look for a mask that has some stiffness to it, so that you don't suck it into your mouth [while breathing]."

And if you can't find a face masks that feels comfortable, Dr. Keany suggests a using a face shield that drops down below the level of the chin as an alternative—although he warns that this mode of protection isn't as "tried and true" as face masks. "Theoretically, the shield would also stop the droplets from being dispersed and from landing on the person’s face. The mask is essentially functioning as a shield, not as a filter," he says. "So the two may be almost equivalent. But I am unaware of any head to head comparisons confirming this."

The bottom line: Neither Dr. Kaufman nor Dr. Keany has received any specific, official guidelines on who would be exempt from wearing a face mask—and that it's more important to worry about how to wear a face mask, rather than who may or may not have to. “I believe that most people need education on proper use rather than exemption from such a simple and effective device to keep them and others safe,” Dr. Keany says.

In Dr. Keany’s opinion, if your respiratory status is truly that tenuous that you’re not able to breathe through a cloth face covering, you should stay home and not expose yourself to any risk. “If you are truly that fragile, a COVID-19 infection could be a death sentence,” he says. 

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDCWHO, and their local public health department as resources.

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