Mask mandates are crucial for fighting Covid-19. How should they be enforced?

Mask enforcement won’t work without education.

Though 33 states now have face mask mandates, Gov. Pete Ricketts says his state of Nebraska will not be joining them. On Monday, Ricketts doubled down on his conviction that a statewide mask mandate would be too “heavy-handed.”

“I don’t want to make it a crime,” he said at a press conference.

Ricketts’s resistance comes as his office is challenging mask ordinances in Lincoln and Lancaster County that have already gone into effect. Teachers’ unions have meanwhile called his failure to pass a statewide mask mandate a “dereliction of duty.”

“I would die for my students. Please don’t make me,” read a teacher’s sign at a recent protest across from Ricketts’s office.

Though the science on the effectiveness of masks for reducing the spread of the coronavirus is much better established than it was early in the pandemic, mandatory masking is still a new and contentious idea. Public health experts and unions are calling for a national mask mandate to protect the most vulnerable, but President Donald Trump has said that he opposes it, telling CNN, “No, I want people to have a certain freedom, and I don’t believe in that, no.”

Popular support for mask-wearing is growing: An August 3 Harris/Hill poll found that 82 percent of Americans would support a national face mask mandate. Yet mask-wearing has been correlated with partisan identity, and some Americans still refuse to wear them in indoor public settings like grocery stores, even in states and cities where they’re required. Some are even using fake exemption cards to try to get out of mask-wearing where it is now required.

As consensus grows on the urgency of widespread mask use to slow a raging national health crisis, policymakers are finding that mandates may be helpful but not entirely sufficient. Perhaps unsurprisingly, enforcement — whether it’s by local officials, police, or employees of airlines or retailers — is proving challenging. Meanwhile, lessons from other public health campaigns — including seatbelts, condoms, and texting while driving — suggest that public education is just as important if you actually want people to change their behavior.

The science behind masks and mask mandates keeps getting stronger

People can spread SARS-CoV-2 before they know they are sick, and masks help contain the large droplets that can transmit the virus. This primarily helps prevent an infected person — even if they don’t feel sick — from spreading the virus to others. And it might also afford some level of protection to the mask-wearer as well; there is increasing evidence that masks may help keep their wearer from breathing in aerosols, too.

In July, the Centers for Disease Control and Prevention (CDC) affirmed its guidance that “cloth face coverings are a critical tool in the fight against COVID-19 that could reduce the spread of the disease.” The agency advises that anyone over the age of 2 should wear a face covering that goes over their nose and mouth in public and around anyone not in your household.

A June study published in the journal Health Affairs looked at 15 states and the District of Columbia before and after their mask mandates and found masks reduced new Covid-19 cases, particularly over time. In the first five days after masks were required, new cases slowed by almost 1 percent; at three weeks, it was 2 percent. That may not sound like much, but it adds up. Another study looking at coronavirus deaths in 198 countries found that countries where masks were common had far fewer deaths.

Goldman Sachs has modeled the impact of a national mask mandate and suggests that it would not only reduce the number of people getting sick and dying from Covid-19, but that when used instead of lockdowns, it would save 5 percent of GDP. Many other countries, including the UK, where mask use was initially controversial, have issued a national mask mandate; Germany, for example, has required masks since April.

States are trying to make mask mandates stick with fines and jail time

Many cities and states have decided to issue mask mandates, giving them the legal authority to prosecute people who don’t cover their face.

The first state to introduce a mask mandate was New Jersey, back on April 8, when the state, along with New York, was grappling with a massive wave of cases. It required customers and staff to wear face coverings at essential businesses and on public transit, and said that businesses could deny entry to customers who refused to wear them.

In July, that was extended to wearing masks outside when social distancing wasn’t possible, although the governor has not said how it would be enforced. Initially, the focus was on education, with volunteers in Newark handing out fliers, but in July, the police announced they would hand a summons to anyone who did not comply.

In Colorado, Denver and Boulder counties both adopted mask policies in early May, which were notable both for their early timing and for the steep penalties right off the bat for breaking them. In Boulder County, if you refuse to wear a mask in a public indoor space or outdoors when you can’t stay 6 feet from others, you face up to a $5,000 fine and one year in jail; in Denver, it’s up to $999 or 300 days in jail. (Other countries, like Germany, are levying even heavier fines: Failing to comply with mask use there can lead to a 10,000 euro fine, which is $11,755 US.) Two months after those county-level mandates, Colorado’s governor issued a statewide mask order, which also specifically stated that county or city rules are allowed to be stricter than the statewide order. Denver, for example, requires children over the age of 3 to wear masks; the state only requires children over 11 to do so.

As Colorado’s cases increased through late July, Danica Lee, the director of public health investigations with the Denver Department of Public Health & Environment, says that getting people to wear masks has gotten a little easier as people see the risk of getting infected increase. Lee’s been one of the top health officials in charge of Denver’s Covid-19 response, including finding the balance between public education on the importance of masks and punishing those who refuse to comply.

“So far, we’ve been saving enforcement for truly egregious situations,” she says. But the agency is now switching up its tactics; the Denver Department of Public Health & Environment has its own enforcement teams, and they are now focusing on compliance during nights and weekends. “At first, we focused on trying to encourage people to not be out socializing in public. Over the past few weeks, we’ve had an increased focus on compliance with businesses, as well as individuals,” Lee says. As of July 30, the department had issued 809 mask-related warnings.

In the last week of July, the department went from a total of seven mask citations to 27, the majority of which were issued at bars and restaurants, predominantly to management rather than to patrons. These people have been given a court summons, and the judge will determine the amount of the fine or jail time. The first weekend of August, enforcement teams in Denver issued 20 tickets for violations of public health orders, including not wearing face coverings or exceeding crowd capacities. Inspection teams also closed five businesses that had previously been warned or had particularly egregious violations.

But Lee recognizes that it can be hard for businesses to enforce Denver’s guidelines. The department has been advising business owners to clearly post signs about wearing masks and ensure that their own employees do. “Basically, we’re advising taking all the measures you can short of intervening with individuals because there were quite a few safety concerns over interactions becoming politicized,” she says. “Any time there is a conflict with a patron that looks like it could pose safety hazards, our guidance would be to contact law enforcement.”

Also, laws can be difficult to enforce universally and equably, says Julia Marcus, an infectious disease epidemiologist and an assistant professor at Harvard Medical School.

In one example, during a weekend in May, the New York Police Department handed out masks to white people in affluent neighborhoods while officers punched a Black man and issued tickets to other people of color for not wearing masks. At the beginning of mask orders, some worried that racism would make it unsafe for people of color to cover their faces, like in a viral video of two Black men in surgical masks being tailed around a store by a policeman. Now we are seeing that the opposite problem — being unfairly singled out for not wearing a mask — may also be an issue.

Andrew Caballero-Reynolds/AFP via Getty Images

In the absence of state mandates, corporate mask rules fall on employees to enforce

Many retailers, worried about their high-risk indoor environments, haven’t waited for government orders to require clients to wear masks. Major chains, including CVS, Target, Walmart, McDonald’s, Kroger grocery stores, and Costco, have announced nationwide mask policies, even in places without a statewide order, like Arizona and Florida.

Home Depot, which rolled out a country-wide mask order on July 17, says it has put up signs warning customers and plays announcements over the PA systems. “We also have social distancing captains who will remind customers that they must wear a mask,” a company spokesperson wrote in an email. Home Depot will offer masks to those who arrive without one.

But these mandates also come with limitations. “It’s too dangerous to forcibly or physically deny entry,” the Home Depot spokesperson wrote.

These aren’t idle fears: In San Antonio, a passenger was shot after a man was told he couldn’t ride a public bus without a mask. A Dollar Store employee in Michigan was killed after telling a customer to wear a mask. And employees at a Trader Joe’s in Manhattan were taken to the hospital after a fight with customers who refused to wear masks.

A spokesperson for a major retailer, who asked not to be named because he didn’t have permission from his employer to speak with the media, said businesses just haven’t gotten the support they need from government and law enforcement to enforce mask policies. “There are [customers] who are just being stubborn now, and we’re trying to keep our employees safe,” he told Vox. He says when the company has called law enforcement for help, some stores have gotten the cold shoulder. “They’re like, ‘Don’t call us for a mask policy, it’s a waste of our time. We’re not coming.’ Which is fine, I get it. But if city officials are telling us we have to do it, and there’s no enforcement mechanism … the last thing we want to do is to have our employees physically engage anyone — over any activity.”

Airlines, on the other hand, have had some success in enforcing their mask requirements. A Delta flight was recently forced to return to its gate after two passengers refused to comply with its mask policy. The airline warned that violations of its mask requirement might result in the loss of future travel privileges.

Alaska Airlines requires during check-in that people agree to wear a mask, and it provides masks on request for people who don’t have one. If passengers refuse to wear one, flight attendants have been given the authority to give passengers a “yellow card” warning, like in soccer, and then ban repeat offenders from future travel. American Airlines recently removed from the plane a woman who refused to wear a mask — and the other passengers clapped.

Other sectors of the travel industry are taking note: The American Hotel & Lodging Association, whose members include Hilton, Hyatt, Marriott, Radisson, and Wyndham, recently started requiring staff and guests to wear face masks regardless of state policy. The specific rules will vary by company, and how this will be enforced hasn’t been made clear. Chip Rogers, president and CEO of the association, said in an emailed statement that many companies have already been instituting mask rules, which helps staff and guests “to make it safer and easier for Americans to travel, while also supporting hotel and tourism employees.”

And as schools reopen, they may become ground zero for mask enforcement fights. In Indiana, for example, Gov. Eric Holcomb recently made a state-wide mandatory mask order for everyone, including all students in third grade and above. “Kids should not be getting mixed messages throughout the day,” Holcomb said in a press conference. “When they leave school grounds, they need to see that everyone is doing what they’re doing — that best practices are best for all.”

To help make this mandate stick, Indiana has purchased 3.1 million masks to distribute to students. Holcomb reportedly wanted to have breaking the mandate punishable as a class B misdemeanor, but after significant pressure, the order says that schools will be responsible for developing and implementing an enforcement plan. States like Nebraska lacking statewide mandates may soon see differing mask rules in schools, depending on their location. That makes it harder for public health officials like Lee in Colorado, who says that in her experience, “it’s really important to have consistent messages between health agencies” at the local and state levels.

Shifting norms around masks to reduce the anger and the shame

Many public health experts say that consistent public health education and effective messaging is the most important tool in getting people to change their behavior. Which means that threatening people with being banned from a business or issuing fines or jail time are not actually the best ways to get more people to wear masks in public.

“As much as we can shift social norms around wearing masks so that there will be fewer angry people who refuse to wear them — that would be best,” Marcus says.

According to Marcus, the AIDS epidemic is an excellent example of the perils of criminalization. There are laws in 26 states around the country that make it illegal to not disclose if you are HIV positive before having sex, but they have only increased stigma and abuse. “The way I see it, it’s all on a spectrum — shaming and fines and arrests, it’s all the same punitive model,” she says.

“Ideally, we would have a model that promotes collective action through rewards and positive reinforcement,” Marcus says. The Surgeon General recently modeled an example of what that would look like, telling the president at an event: “You look badass in a facemask.”

Thus far, the mixed mask messaging from government leaders — and even evolving recommendations from health agencies — hasn’t helped unify people around this effective public health action. It can understandably be hard for residents to embrace this sort of new behavior when even their local officials can’t agree on it.

For example, in Georgia, where Atlanta’s mayor, Keisha Lance Bottom — who herself has tested positive for Covid-19 — tried to create a mask mandate. The governor sued to try to block the mandate in court (“on behalf of the Atlanta business owners and their hardworking employees who are struggling to survive”).

“The main problem with masks now is the lack of a coherent message from the leaders,” says Alex Horenstein, an assistant professor of economics at Miami Herbert Business School at the University of Miami, who studies behavioral economics. He says that this leads to inaccurately assessing the risk of not wearing a mask “since the signal is too noisy,” adding that if more people do not wear masks, the risk aggregates, making those who do less safe too — and possibly leading people to the false conclusion that masks don’t work.

Marcus has found that in conversations with people who are ideologically opposed to masks that they are surprisingly willing “to listen to a scientist when that scientist doesn’t shame them or yell at them for their risky behavior.”

Instead, she tries to acknowledge their concerns — like that masks aren’t effective or that masks infringe on their liberties. From there, they can have a conversation about these issues, talking about how masks are more important in certain settings or about other people’s freedom when distancing isn’t an option. “This is what public health does,” Marcus says. “We try to understand what’s making it hard and then adapt strategies to increase adherence.”

It’s also entirely normal for there to be resistance to a public health intervention, says Horenstein. “People want to have a choice over how much risk they want to face,” he says. “If you make a regulation that constrains people’s choices too much, what happens is they change their behavior so they can still approach their optimal risk.”

Like Marcus, Horenstein says the best answer is public education, tailored to specific audiences’ risks and values. Yet, he adds, risks, at the end of the day, are collective. “So the question we’re facing with masks is: What risk should we let people take when their decisions affect others?”

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