What Masks Reveal: The Materiality of the Face from a Clinical Point of View

Abstract

This essay attempts to discern which lessons the wearing of masks in a time of pandemics can offer to us: in terms of living as a sick or quasi-sick person, in terms of public health policies, and in terms of what faciality means for human life. It tries to do so through a clinical point of view, a view more concrete and materially grounded than a phenomenological one drawn from Levinas's philosophy of the face.

A few months ago, in spring 2021, I passed one of the students from a previous class coming the other way in a hall. In the fall, we wore masks all the time, but in the spring that was not the case anymore. She seemed to ignore me but after a few steps turned back and said, “Sorry Professor Dumont, I didn't recognize you without a mask!”

This was one of many embarrassing, indefinite moments we have experienced under the COVID-19 pandemic.

We didn't recognize each other; we didn't really know what people we had met only while wearing masks looked like. In a surprising way, everybody looked beautiful with masks, yet, at the same time, they were a burden to wear. It was and still is, from time to time—and maybe not forever—a profoundly ambivalent experience. In France, in the first few weeks of the pandemic, everybody was asking for masks: our stock had disappeared without us really noticing it. “Where are the masks?!” was the common cry, accusing the government of incompetence. But when masks became abundantly available, people refused to wear them. The mask, although a long-standing and straightforward tool to prevent the spreading of an infectious disease,¹ seemed necessary, but at the same time there were doubts about its efficiency. Putting on a mask is the simplest of gestures: you only have to loop it around your ears—which reveal here a new function, but an unforeseen irritability—yet it was also a technical gesture that we had to learn. One French minister, in March 2021, became famous by saying that the population, begging for masks, would have no use for them and that they should be reserved for practitioners since even she “wouldn't know how to wear it.”² The mask protects us but at the same time is a gag; it loads social interactions with distance, mistrust, and a latent sense of threat but also lets us maintain them; it is at once supposed to protect us from others and others from us—and we all pretend to believe in this exact symmetry. Sometimes wearing them alone in an empty street is absurd, but we also understand that pretending to be able to scrutinize every rule, even when they are contradictory, would turn us into the “half-smart” described by Blaise Pascal, able to ironize the relativity of human regulations but not to offer more coherent ones.³

Here I'll explore masks in the context of the pandemic not only as objects of controversy but also, through these controversies and in connection with the face and hand transplantations I have discussed elsewhere,⁴ as revealing of some aspects of our lives that would have been undisclosed otherwise. My intention is to reflect on face masks from a clinical perspective: What do they reveal to us of the lives of sick people and of the functions, sometimes hidden, of the human face? As face and hand transplantations help us to grasp dimensions of these body parts that we might not be aware of, here clinics help us grasp aspects of our common life, if we focus on them. Thus while covering our faces, face masks have uncovered unforeseen facial functions and aspects of sickness that might otherwise remain concealed. It is important to seize these anthropological insights that the pandemic has made more visible in a kind of experiment of nature.

Masks and the Life of the Sick

The general adoption of masks prompted insight into some aspects of the everyday life of sick people, particularly those with chronic disease.⁵ Some of those who were chronically sick did not experience a dramatic change to their lifestyles in the acutest phases of the pandemic: being confined at home with few social interactions, living a life frequently monotonous, and being compelled to take health risks in everyday activities like grocery shopping, taking public transportation, or going to work was very familiar to them. Seeing everybody joining in their condition let them feel quite normal for once.⁶

Those without chronic conditions had, conversely, a taste of what everyday life was for patients with chronic illness—not in terms of actual suffering but in some of the burdens of sickness. Indeed, in a pandemic, one of the main challenges of preventing a disease from spreading is identifying infected people and having them removed from ordinary social interactions. But identifying such people is exactly what can't be done: everyone cannot be tested, and the asymptomatic phase of the disease makes people unaware for a time that they are hosting and spreading the virus. This was the case during plagues and the AIDS epidemic, for example: the existence of silent hosts was a major way of spreading the disease. Thus, the only possible answer to this impossibility was to have everybody behave as if they were sick: the universal wearing of masks by what epidemiologists call the “general population” (in contrast to the cohorts of patients). One effect of public health policies in a pandemic is to have everybody identify as quasi-sick, shifting the boundaries between normal and pathological—or making them more permeable.

Wearing a mask while asymptomatic is not only to behave as if we were sick but to have actual doubts, all the time, about our status from one second to the next. Wearing a mask reminds us that we may well be sick without knowing it yet. And the most efficient way to wear it properly is perhaps to convince oneself that we are maybe sick at the time being. At that time, we all had a glimpse of what constitutes a major feature of sickness in Georges Canguilhem's view: the loss of lightness.⁷ Being sick is chiefly being anguished about one's health, being worried about it becoming even worse. In the terms of Kurt Goldstein, who inspires much of Canguilhem's analyses, the instinct of survival is not a driving force of the living in general but of the sick individual, who has to carefully avoid catastrophic situations.⁸ Being healthy thus means, on the contrary, being unaware of one's health, not focusing on it, and having the luxury, as Canguilhem says, of taking the risk of falling sick with the assurance that it won't be a major problem and that one will recover.

We all shared in the anxiety of the sick people who have to negotiate all of their activities, or at least most of them, with their environment and have to weigh them beforehand in terms of risks taken. For sick people, even the act of going to medical institutions to seek help is a risk, though such institutions are there to protect them. The other, as I myself am to them, is to me a potential help but also a threat—I know that I need help but also endanger the people helping me: hence a large amount of self-censorship during the acute phase of the pandemic from patients with chronic disease who delayed their hospital appointments. The hospital was the last place where mask wearing has remained mandatory in France (as of February 2023).

We all experienced what life under chronic disease might be: the constant uncertainty about one's health status; the fear of putting it at risk by taking part in the most inoffensive, commonplace, and even compulsory everyday activities; the feeling of being threatened by one’s environment and of being oneself a potential threat to other people; the feeling of isolation connected with sickness and the withdrawal into oneself (which may be an evolutionary tactic of those facing infectious diseases: being sick often entails staying at home, thus reducing the spreading of the disease). We were tempted to relax our health considerations to alleviate our burden, just as people with protracted chronic disease long for periods when they won't need to focus on their condition.⁹ We had the feeling that being (even just potentially) sick could be more of a burden than rearranging our lives to go through the ordeal. We were not certain we'd be recognized by people, or would recognize them also, or would even recognize ourselves—the last of which is intensively the case for sick people fearing catastrophic changes to their identity due to their condition.¹⁰ Thus mutual and self-recognition, which are of course intertwined, appear to play a major role in our sense of identity; disfigured people feel this in their everyday life, and even when they receive an allograft, this aspect can remain problematic. Disfigured people not infrequently wear masks when they appear in public, or they tend to social isolation.

But this set of shared experiences was only temporary: soon we discussed making masks compulsory . . . but only for the most fragile of us—namely, old people and patients with chronic illnesses; thus we would have them intensely identified in the public sphere—and ironically, by the mask, a symbol that had been until then associated with the figure of the caregiver rather than the sick person, especially the surgical mask, which ended up being the type of mask almost exclusively used. This surgical mask was for a long time a symbol of medical modernity—think of the heroization of the surgeon in Western countries after World War II.¹¹ At the same time, the upside of masking was the widespread use of videoconferences, which compelled those suffering from an illness to present a good appearance even from home.

The general use of masks could help the sick appear invisible and normal; it helped people with disfigurement or people suffering from social phobia get out in public. Children who had to undergo facial surgery could be told that the mask would conceal most of their scars during healing. But the mask was also a way of designating the sick to the public. It had the same ambiguity as the dressing that both hides a wound and points to its existence at the same time—the dressing being frequently apt to be concealed under clothes, which was not the case for the masks. In the same way, the theatrical mask conceals the face and signifies a character in the same moment. Thus we might say that wearing a mask is also an experience of the embarrassing visibility of sickness, like the compulsory demonstration of an identity that we do not even recognize as fully ours, which gives birth to insistent looks and not infrequently to intrusive interactions.¹² In the parts of the world where not everybody wears a mask, wearing one may mark you as sick—or overly cautious or having been in contact with a sick person. Disfigured people teach us how important it is not only to be recognized in one's society but also to be invisible, unnoticed when we want to.¹³ Being anonymous is not only a plight; it can also be, in many circumstances, desirable, and part of the definition of being reasonably healthy. There is a type of suffering, that of being too visible, that members of social minorities experience daily: wearing a mask can paradoxically make your face, although covered, more visible to others. You can be isolated by the way people look at you, not just by their not looking at you. Disappearing into the crowd is not only a loss brought on by modern cities; it is sometimes also a desirable feature of everyday life.

In COVID times, medical confidentiality was not infrequently breached: we often knew who was sick or not, and it was too often publicly disclosed. Wearing a mask can play this negative role. Paul Ricoeur famously said that “sickness is private, but health is public.”¹⁴ He thus designated an ideal: sickness should be left private, and health should be a public matter. But in fact, the contrary often happens. As Canguilhem ironically notes, “Public health actually often means publicity of the sickness.”¹⁵ Masks, particularly when not universally worn, reminded us of this duality of public health policies—their Janus faces.

Masks and the Face: What Can Face Masks Teach Us about the Human Face?

Face masks cover the nose and the mouth, not the eyes and the forehead. They are intended to stop the dissemination of viruses through respiration and droplets—though we don't know who is infected, and though the virus is too small to be seen by the naked eye, we have discovered very quickly how it spreads. This kind of mask differs from others. They don't aim at keeping one's identity secret as the mask of a criminal or a superhero would; in that case, the eyes would be the most important parts to cover, and a blindfold would be the best way to conceal one's identity. Nor does the COVID mask aid in assuming someone else's identity—as does the ritual mask, by which an ancestor or a divinity is made present again in the community,¹⁶ the wearer of the mask being erased by this new identity. The same goes for the mask of antique theater, the prosopon by which the actor represents a character—though the modern actor has to mimic this mask by the expert composition of his own natural face, the mask is nevertheless still the allegory of theater. It is the face that the slave in antiquity, aprosopon, was considered lacking. And lastly, the COVID mask is not the carnival mask, which both hides the identity of the wearer and shows it at the same time, replacing it by a grotesque face indicating the fraud, or even highlighting it in a playful way. COVID masks have often been compared to these, leading to unfertile and often excessive analogies based only on homonymy, which overlook the basic, material function of stopping the spread of a disease while leaving the largest possible part of the face free.

COVID face masks do, of course, carry a symbolic meaning—they carry a sense of medical modernity and hygiene, and of uniformity through their homogeneous texture and color—but I would like to give an account of their most immediate and concrete materiality. Through what they deprive us of, and what they aim at avoiding, lessons can be learned about what having a face means, because this pathology, this negativity, has something to teach us about usually unnoticed aspects of common life. In the same way that Kurt Goldstein has endeavored to describe human nature through the lessons gained from the care of neurologically disabled people, particularly soldiers of the First World War,¹⁷ this essay describes how losses help us value and become aware of features of our life and organism that we take for granted in normal times. The negativity of disease and the responses we build to it can positively help build awareness of features of our lives that we could easily miss. Goldstein has shown how, strangely enough, the care of neurologically impaired soldiers creates awareness that conditions of normal health maintain behavior that is not “catastrophic”—that is, not permanently threatened by accidents and potential disasters. These are insights for the progressive constitution of an anthropology that medicine can offer.

Generally speaking, masks prevent us from breathing easily and from eating; we can't be recognized easily (and deaf people can't read lips, hence the use of transparent or inclusive masks); we can't express ourselves, because the mask hinders the flow of our voices and conceals the expressive gestures of the face. All of these are, of course, side effects and not the central aim of these masks, which is to stop the spread of viruses (that's why many viruses other than SARS-CoV-2 have been less virulent while we all wore masks). Among other negative side effects, we can count excessive sweating, condensation on glasses, heat, skin irritation, and the costs, economical and ecological, that come with them.

Away from a Levinasian Understanding of the Face

By offering the list above I want to stress first that masks do not mainly entertain a relationship with “the face” in general, the human face being assimilated too quickly, through a superficial use of Levinas's thought, with a metaphor for Otherness, ethics, and the call for responsibility.¹⁸ An overall abstraction and overinterpretation derive from the use of Levinas's analyses of the face. In the field of face transplantation, it has thus been said that this transplantation “gives humanity” back to patient, since the face is our humanity, implying that disfigured people would be less human or not human at all! Indeed, Levinas highlights how the human face phenomenologically indicates to us how other people shouldn't be reduced to appropriable objects that one can use freely according to one's own egoistic views. For Levinas, the face whispers to us, “You should not kill,” with this interdiction being the first relation that we have with someone else. The face can't be reduced to an object, as the other bodies around us can, and it compels us to act differently toward people than we would toward things. Thus some authors conclude from Levinas that having a population wearing masks is almost comparable to a silent and latent genocide, as if by hindering this face-to-face relation we were “killing” others, reducing them to objects. Face masks, by this interpretation, hinder us from having real human and ethical relations: “If face is a silent call to being met, then a masked face is a no-entry sign [Si un visage est un appel silencieux à se laisser rejoindre, un visage masqué est un sens interdit].”¹⁹

But we don't need to focus too much on the literal, anatomical face in this argument. Let's indeed remember once and for all that Levinas says somehow that the shoulder, in this sense, is also a face: “The whole body can express like the face, a hand or the curve of a shoulder [Et tout le corps peut comme le visage exprimer, une main ou une courbure d’épaule]”: it can also remind us of our duties to the other and break the totality that we form for ourselves.²⁰ “Faciality” is not the exclusive privilege of the anatomical face; other parts of the body can act as silent remembrances of the biblical interdiction to kill. A shoulder can talk to us and look at us in the same way as a face. In Malraux's novel La condition humaine, the Chinese revolutionary activist Tchen is stopped midgesture in stabbing a political enemy in his sleep by the moving sight of his fragile and so human feet. And wearing a mask doesn't totally forbid us from seeing the humanity behind the masks. To summarize, Levinas's analyses of the face as ethical imperative are operative, but they are also excessively metaphorical and open to distortion when used to analyze the mask use during the pandemic. This distortion is contrary to the very spirit of Levinas, though Levinas might also be held accountable for having opened the door to these misuses.

Toward the Materiality of the Face

Face masks do have in my view an ethical and sociopolitical dimension, but mostly through their materiality—and if we avoid overmetaphorization and excessive analogies. The face has functions—or more accurately, in Kurt Goldstein's view, operations—that are important to consider. The metaphysical can derive from these very concrete and experimental analyses. Levinasian analyses sometimes jump too quickly to assign meaning to the face, skipping any biological analysis of the face as a part of a living organism; they even disdain such a perspective as too objective or scientific. And we can also remember that the operations of the face can vicariously be partly assumed by other parts of the body (as with the hands): our face is not the only expressive body part, for example. In this way, being truly faithful to Levinas's seminal intuitions would allow us not only to focus on “the face” as a symbol of our humanity but to accept it as rooted in our organism as a complex and articulated whole in interaction with others and its surroundings.

One of the main operations of the face that is reduced by masks is indeed its expressivity. It is difficult to communicate with a mask: the voice has trouble going through; the risk of misunderstandings is increased. Interpreting others’ attitudes becomes more difficult since facial expressions and movements are partly hidden by the mask. We then tend to exaggerate them—for example, with our eyebrows. Social tensions seem to have increased during the COVID pandemic, for example, in professional settings—the videoconference also was a source of increasing social tension since part of the usual interactions, but different ones, are also made invisible in this setting. Here also, vicariance is possible, but limited. According to some reports, people who have limited ways of expressing their emotions—for example, disfigured people—tend to have a less rich internal life.²¹ The inability to express emotions tends to incapacitate feelings themselves—which is an argument for theories of emotions postulating that their expressions are not outer translations of them but fully constitutive of them.

From this, one feature of the face is thus highlighted: the fact that it is a major site for expressing ourselves but particularly that this happens through the mobility of the face's features. The “Still Face Experiment”²² shows how much a nonmoving face is a synonym of nonrelation—and, for the child, abandonment. In this experiment, a mother is asked to stay totally still in front of their infant, unexpressive. The child soon expresses astonishment and then anger and despair, trying to “reanimate” the mother and recreate the link. Masks likewise simulate such a nonmoving, impassible face. The importance of mobility in the face has been shown by face transplantations: in these procedures, mobility is of paramount importance for the face's acceptance by patients. Face prostheses do exist and are very accurate; they provide patients with a very precise copy of their former face. But they are unfortunately still nonmoving: the face appears fixed, morbid, like a mortuary mask. It conveys a very disturbing feeling to other people, although it is technically perfectly identical. Patients do prefer having a less identical face, given by a donor, which is more of a “real” face since they can animate it and impregnate it with their own personality. This is not their face, but it is at least really a face, they say. Identity seems here to center more on dynamic identity than on a strict but fixed likeness to a former state. It is the same with pictures: they are exact copies of our face at one instant in time but not necessarily of its proper and unmistakable dynamics. Being photogenic doesn't mean someone's beauty can be exactly captured, either. As Merleau-Ponty stresses, people don't easily recognize pictures of their hands²³ (although they are highly individualized parts of our body), but they never fail to recognize their gait when filmed, though they have never seen it from the outside. They have a better knowledge of their unique behavior in the world, which they know from their internal experience, than of their exterior bodily features. That's why mobility is essential to the face—the fact that we animate our facial features through smiles, eyebrow lifting, and so on; it justifies the idea in face transplantation that it is not the face of someone else that is transplanted, only its facial tissues: the unique animation of the donor will not pass to the receiver, who will not look like them. On top of this, the receiver will have their own animation of these tissues: these facial tissues help them really have a face of their own—even if one not strictly identical to their former face.

As art historian Hans Belting points out, having a face is mainly the capacity to have several expressions, and thus several faces: the face builds its own temporary masks. This is why for Belting any portrait is the meaningful failure to capture a face: what can be captured is the mask that a face has adopted at any given time, but not its ability to switch from one expression to the other.²⁴

The second main operation of the face that we can analyze here through the (dys)function of masks is their ability to modulate our exchange with our environment, not only in human but also very physical ways. Bodily orifices are protected by our ability to close them and by hair, mucous membranes, and saliva. But masks filter what we inhale more than the normal mucous membranes in our body do. Viruses were identified in the nineteenth century by the fact that they could not be filtered by the usual methods of isolating them in a solution, as bacteria could be, since viruses were smaller. Masks are additional filters, which, like the skin itself, constitute barriers, regulating exchanges by keeping some things from entering while letting others pass through. They cover the nose and mouth: in the Platonic classification of the soul, the human face represents externally its tripartition between noûs, the forehead, protecting the brain and thus the intellectual part of the soul; thumos, the nose, connected with the chest and thus the courage and the will; and epithumia, the mouth, connected with the stomach and the appetitive soul. Masks cover the most material parts of this tripartition, those connected with lungs and stomach, key sites of exchange for the body. As biologist Francis Hallé says, in animals the areas of exchange are as extensive as the external surfaces of exchange for plants (their leaves), but these extended areas are internal in the animal.²⁵

Masks remind us that we, as mortal, living beings, are subjected to exchange—and that exchange is both vital for us and dangerous. We are in constant exchange with our environment—whether it is air, nutrition, goods necessary for living, or social exchange with other people, which is not less vital—and as to reconstitute and balance our “inner milieu” (Claude Bernard).²⁶ This exchange is vital in a twofold manner, positive and negative: without it we would die rapidly, but in the course of it, we could inhale or ingest something that puts our survival at risk. Exchange is thus for us a necessity and also a threat. This is why in human societies the encounter with others is often mediated by the exchange of gifts to assert peaceful intentions toward each other—as each encounter is also a potential threat.²⁷ Plato states that gods don't have hands: eternal beings don't corrupt themselves and thus don't need to exchange anything with their surroundings. Perfectly autarchic, self-sufficient, they don't need hands.²⁸

On the contrary, we human beings—and other living beings—live in constant exchange, at the edge of ourselves. Hands and faces are thus parts of our body that are heavily mobilized. They are the only parts often exposed to others; they are the body parts the most exposed to injury as a consequence of their constant use in relation with the outer world. They mobilize a massive part of our brain. As tools of contact with the world, they are naturally major vectors of infection and contagion. It is not by chance that masks and hand-sanitizing gel have become symbols of COVID prophylaxis.

Masks do carry one last lesson at least: as Thomas Nail insists, they help us become more conscious of the biotopic flow in which we live and that each of us leaves behind.²⁹ We are more conscious of the flows of air in our rooms, homes, workplaces, and forms of public transportation. We actively look for them—and maybe for a chance to leave our mask behind in the fresh air outside or in the air of an open window. It encourages us, as Nail says, to adopt an ontology of flow such as the one promoted by Deleuze rather than an ontology of things, solid and static. In a Deleuzian view, the world is not mainly constituted by solid substances, strictly separated one from another; it is rather a coalescence of flows porous to each other and in perpetual dynamic interaction. Our biotopic flow highlights such interactions between the bodies and their complex intertwining rather than strict differentiation.

In Conclusion

These few considerations derived from our experiences with COVID: masks do have sociopolitical and maybe even ontological consequences, as they highlight the not-so-defined boundaries of our bodies. But such conclusions have to be rooted first in the concrete materiality of the care of this disease and in the problems raised by our responses to it, rather than in a fantasized conception of masks and of the human face. Faces cannot be described in terms of a naive phenomenology that pretends to disguise its arbitrariness as a science of essences. Phenomenology often tends, through the method of suspension of the thesis of the existence of the world, to get rid of biological or medical facts, focusing instead on the data of “pure consciousness” too often derived from the thinker’s own singularity. The visible face is not the foundation of our social contract, and masks are neither the exemplification of hell on earth nor the symbol of totalitarianism or of a fully atomized modern society. Masks do provoke suffering though—physiological, social, and political; this suffering needs to be understood. There are lessons to learn about what human faces are and do, as I have tried to bring forth here. We need to identify and alleviate these sufferings. This is a sociopolitical task, but we don't have to dramatize it by an excessive romanticizing of the “face.” In the same way, we must also stress that masks can be analyzed also as positive tools: they help some people to hide from perpetual social intrusion or interaction. It helps balance the “virtues” of having visible faces with the defects of it.

This sanitary crisis can thus be a lesson in humility for sometimes expeditious phenomenology and in favor of a clinical philosophy. Such a philosophy has to be rooted in the medical experience of clinics, where problems that weren't foreseen and solutions that can't be anticipated arise; some of our philosophical prejudices may come to be disproved. Clinics are themselves materially diverse, full of tensions and discordant voices; they must be listened to critically. But they are privileged places to collect useful criticisms for our philosophical habits and to revive the urge for further thought.

Acknowledgments

I would like to thank warmly Frédéric Aubert for his help with editing the English version of this text, and also Hourya Benthouami, Samera Esmeir, and Jessica Ling for their comments on an earlier version.

Notes

Works Cited