Illustration: Shyam G Menon

With COVID-19, the face mask has become part and parcel of our lives. The general feedback from runners who ran wearing a mask is that it is an uncomfortable experience, which you may however get used to. In mid-May 2020, a report appeared in the media (it was circulated on social media as well) of a man in Wuhan, China, who ran wearing a mask and later suffered a collapsed lung. Although health officials believed the culprit was the mask, at least one newspaper reported that a senior doctor at the hospital where the patient was treated had said, the runner was already susceptible to “ spontaneous pneumothorax because of his tall, lanky frame.’’ Aside from speculating, it wasn’t possible to conclude anything from the report. To compound matters, there seems to be no conclusive study available yet on the subject of wearing a mask and running. We spoke to four doctors with strong ties to running, for their take on the subject.

“ There is no real research or study available on the subject yet. It is a new topic,’’ Dr Aashish Contractor, Director, Department of Rehabilitation and Sports Medicine, Sir H. N. Reliance Foundation Hospital, said of the emergent debate around mask and running.

The normal act of running outdoors has to be seen in its full context. It is usually done at an hour before the regular flow of people manifests on roads. There are not many people around and the number of runners among those choosing to be out at that hour is not high. It must also be remembered that runner is neither static nor moving at walking pace. The chances of catching the virus depends on various factors including how crowded an area is, proximity to others, the duration of exposure and the viral load one is exposed to. Against the above outlined outdoor scenario with mask and physical distancing additionally in place, it would appear that the chances of contracting the virus may be further minimized. However it must be borne in mind that exercise – like running – causes heavy breathing. “ I would think you should stay about 20 feet away from another person while running,’’ Dr Contractor – he was Medical Director of the Mumbai Marathon from 2004-2014 – said.

Wearing a mask and running is bound to be difficult. “ Depending on the level of exertion, it will be hard to breathe,’’ he said. One way of overcoming this is to be conscious of how much you are pushing yourself. Rate of Perceived Exertion (RPE) is a good rule of thumb to stay on the safe side. “ If you feel your breathing is becoming hard, slow down. Do that because this is not anyway a time to be proving anything,’’ he said. A simple three ply surgical mask should be adequate for the morning run. Wear it when running and if you are feeling uncomfortable, use your judgement and pull it down a bit for easier breathing. Relief gained; pull it back on. As for the news report about the Wuhan runner who suffered a collapsed lung, Dr Contractor felt available details are inadequate to establish direct link between the condition and use of mask.

Given the number of races held under its banner, the 2019 edition of La Ultra The High was spread over five days in Ladakh. At that elevation oxygen content in the atmosphere is lower than at sea level; it is lower still atop the high mountain passes the ultramarathon’s route touches. “ We encourage runners, support crew and officials to use their bandanas; cover their face to protect themselves from the fumes of passing vehicles. In the case of someone who walked-ran all those five days, at least as many hours as in a half-day would have been spent protected by the bandana and breathing through it,’’ Dr Rajat Chauhan, Race & Medical Director of the event, said. Dr Chauhan specializes in sports & exercise medicine and musculo-skeletal medicine. “ It should be fine,’’ he said when asked about the issue of wearing a mask and running.

However, there were caveats to the observation. A pre-existing medical condition can alter the tolerance someone has for prolonged breathing through protective barrier. Further, you have to get used to breathing so. “ In the last two months of lockdown, I would have gone out of my house just twice. On both those occasions I wore a mask and it wasn’t easy doing the things I had to do while breathing through the mask. My suggestion to those who are in zones where they are allowed to venture out for running is that they first wear the mask indoors for about the same duration as they plan to be out. Get used to it,’’ he said, pointing to the heat of summer as another factor to be aware of.

Illustration: Shyam G Menon

Getting used to the mask gradually also makes sense because in Dr Chauhan’s assessment most amateur runners haven’t learnt to use their lungs efficiently. “ The typical amateur runner in India still has shallow, rapid breathing,’’ he said. Next, your intensity of exercise matters. Intense exercise puts commensurate demand on the respiratory system. “ Do workouts at low intensity. Very long and or high intensity workouts are best avoided,’’ he said. Aside from the fact that high intensity training is a period when risk of cardiac problems is higher (before things improve as product of having exercised), immunity also lowers temporarily in this phase. The present characterized by COVID-19 is not times when immunity should be fiddled with. The N95 mask, which is more effective in keeping the virus at bay, is tough to breathe through. The normal surgical mask is easier to breathe through but not as effective a virus-barrier. “ At the end of the day you are in the realm of informed decision-making,’’ Dr Chauhan said of the challenge in framing best practices for a problem yet to merit in-depth study and research.

“ Right now the ideal approach would be to consider everyone a potential carrier of disease and have everyone stick to safety protocols like using a mask or face cover. This is not a phase to be viewed only through the prism of sport. It is a question of humanity,’’ he said of world battered by COVID-19. His advice to runners was – focus on strength training.   “ I have this saying: if you can’t do something sitting down or standing up, how can you hope to do the same while moving? All those boxes have to be ticked before you get down to running or running with a mask on,’’ Dr Chauhan said.

When it comes to air quality, Delhi is among the world’s most polluted cities. Colonel Muthukrishnan Jayaraman is a doctor with the Indian Army. He is a regular runner. He first used a mask while running, in 2018, after he was posted to Delhi. “ It was extremely difficult. If you exert yourself, you need more oxygen and getting that in was a challenge,’’ he recalled. The mask was also prone to becoming wet with the moisture of one’s breath. Eventually he stopped using it. Roughly two years later, the mask has become a regular fixture in life due to COVID-19. “ We wear it at work. For that purpose, it is not a problem. But wearing a mask and running is a challenge,’’ the army doctor said. First, it defeats the very idea of a morning run, which is to do something enjoyable. Second, with the more effective masks meant to keep viruses at bay bound to make breathing hard, you end up using simpler models that are not totally competent as virus barrier; it is a compromise. You wear it only because any protection is better than no protection. Consequently, Col Jayaraman is of the view that choosing less crowded stretches of road to run on and maintaining adequate physical distancing is the best option. However, one aspect needs to be borne in mind, he said. During exercise and for a little while afterwards, there is typically a dip in immunity levels. Given this, other precautionary measures to prevent infection, shouldn’t be trivialized, he said.

“ In healthcare, masks have been used for over 100 years now. They are used mainly during an operative intervention, to prevent transmission of infection to the patient,’’ Dr Pravin Gaikwad, pediatrician based in Navi Mumbai, said. A runner and triathlete, he illustrated the equations at work while using precautionary measures like the mask.

For instance, the operation theater scenario of doctor wearing a surgical mask is a case of – I protect you. In the present situation of COVID-19, if 60 per cent of the population wears masks which are even 60 per cent effective in blocking the transmission of virus, the epidemic may be stopped. That would be a case of – I protect you, you protect me. In a highly infectious disease scenario like COVID-19, special N95 respirator is used to protect the healthcare professional and others from him. The equation here is – I protect myself and I protect you. In industry like asbestos, N95 with valve (which is more comfortable) is used to protect the worker but not others. This is a case of – I protect myself but I expose you. “ That would be sinister if used in the present situation,’’ he said.

Masks can cause discomfort. “ The N95 which fits snugly certainly causes a bit of discomfort upon prolonged use. Talking and being heard, is also an issue. Surgical masks are relatively more comfortable. Surgeons use them for a long time – even 9-10 hours – in long supra major surgical procedures,’’ Dr Gaikwad said, adding, “ compared to the surgical mask, homemade cloth masks or bandana, I presume, would be less breathable and therefore less comfortable.’’

Illustration: Shyam G Menon

According to him, running in a face mask would be uncomfortable in any weather. If one really wants to use it, one has to gradually introduce it in one’s regime. It would take a few weeks to months getting used to it. “ As the amount of air inhaled becomes limited, breathing becomes more laborious. Pace would obviously reduce and fatigue would set in faster. Mask becoming damp partly due to water vapor in exhaled air and partly from sweat is another issue making it not only uncomfortable but also less effective,’’ he said. He felt that for running, surgical masks would be more comfortable to use. “ Basically, the mask has to be breathable and effective….a homemade mask which has to be removed time and again will defeat the purpose,’’ Dr Gaikwad said.

Breathable masks don’t pose the risk of inhaling one’s own exhalation to a significant extent so as to cause disturbance in oxygenation. The droplet size of the present Corona virus is 125 microns and that of the CO2 molecule is 0.00023 microns, 1000 times smaller. Still, to check discomfort, the best option would be to keep runs shorter and gentler, striking a balance between getting exercise done and not exerting to levels inviting strain while using a mask. Choose to run after checking what zone (red, orange or green) your area is in and how authorities have relaxed lockdown rules therein. Even if you are using a mask, maintaining physical distancing of at least six feet is a must.  “ There shouldn’t be sudden increase in mileage in even indoor runs or those done on local campuses as this would make a runner prone to injury besides reducing his or her immunity temporarily. We can ill afford both these angles at present. Always listen to your body,’’ Dr Gaikwad said.

Author’s note: On May 18, 2020, the Athletics Federation of India (AFI) – it is the apex body for athletics in the country – issued Standard Operating Procedure (SOP) for its national camps in Patiala and Bengaluru (please click on this link for that report: https://shyamgopan.com/2020/05/20/afi-issues-standard-operating-procedure-for-its-athletes-coaches-and-support-staff/). The on-field protocols followed by elite athletes at these camps have not been gone into in detail in this article because the training ambiance of amateurs and elites is totally different. Amid pandemic, amateurs live and train in a world that includes everyone else; elites live and train in sanitized national camps with access strictly monitored. Nobody goes from the outside into the camps, nobody from within comes out (rejoining requires quarantine). It won’t be fair to compare the two worlds or blindly copy what performance driven-elites do while training against backdrop of pandemic because one ecosystem is controlled and sanitized, the other isn’t. Some general protocols laid down at the national camps make sense as meaningful guidelines for amateurs taking to public spaces for exercise. They include: not going for training if you have any flu-like symptoms such as sneezing, coughing, difficulty in breathing, fatigue etc or if you have been in close contact with someone who showed above-mentioned flu-like symptoms or tested positive for COVID-19 in the preceding 14 days; maintaining a safe and isolated distance of minimum two meters from others while walking to the training ground and during the training, and avoiding exercising / training / walking in groups. For an overview of the AFI’s SOP for its national camps, please follow the link mentioned earlier.

(The author, Shyam G Menon, is a freelance journalist based in Mumbai. The above article is presented in the interest of reading and discussion.)