Can the Public Be Educated to Wear Masks?

The Midwest has been the epicenter of coronavirus since late August, led by North and South Dakota. Masks have the potential to significantly reduce viral transmission, but neither state mandates their use. Will a public health campaign help?

October 5, 2020, 12:00 PM PDT

By Irvin Dawid

Rural Pandemic

Tada Images / Shutterstock

"Now, more than six months into the coronavirus pandemic with per-capita infection rates leading the nation, North Dakota is ready to put some money behind the message that wearing masks is an important step people should take to curb the spread of the virus," reports Patrick Springer for the Grand Forks Herald on Sept. 27 (source article). However, the campaign lacks a vital component, warns a communication professor at North Dakota State University.

Carrie Anne Platt, an associate professor of communication, said research has shown that mandates are effective in getting people to wear masks, especially when accompanied by public education campaigns emphasizing the benefits of wearing masks.

“With COVID-19, you can put other people at risk, but we know from research that it’s not very motivating,” she said. A mandate provides the nudge, reinforced by messaging, Platt said.

The Dakotas lead the nation in per capita infection rates

Planetizen's late August post on the Dakotas, "The Changing Geography of the Pandemic," dealt with the time period where the nation's coronavirus epicenter was leaving the South and West and headed to the Midwest, which was recording the nation's highest rates of increase, if not the highest case incidence.

Harvard's COVID Risk Levels Dashboard indicated on Aug. 25 that North Dakota trailed only Mississippi in having the highest coronavirus case incidence, with 24.2 cases per 100,000 people (seven-day moving average), but that is based on Aug. 23 data.

The dashboard does not include U.S. territories. Guam shows 36 new daily reported cases per 100,000 people, a 176 percent increase in the last week based on Aug. 25 data, according to The Washington Post trackerNorth Dakota had the third-highest daily reported cases per capita, 28 per 100,000, after Guam and Mississippi with 29 per 100,000.

The surge in the Dakotas has not relented since then. The Harvard Global Health Institute/Brown University School of Public Health COVID Risk Levels Dashboard shows that the case incidence has since more than doubled in North Dakota, with 52.7 daily new cases per 100k people (7-day moving average) based on Oct. 2 data, over four times the national average of 13 cases per 100k people. South Dakota and Wisconsin follow, with 48.0 and 43.2 daily cases per 100k, respectively.

Mississippi infections have since plummeted, relatively speaking, to 18.3 daily new cases per 100k people, 16th highest in the nation, dropping it out of the red zone (over 25 daily new cases per 100k) and into the orange zone: "community spread has accelerated and is at dangerous levels," according to color definitions in the Harvard/Brown Key Metrics for COVID Suppression [pdf].

Guam is in fourth place, with 43 daily new cases per 100k, just behind Wisconsin, according to The Washington Post daily tracker as of Oct. 4.

North Dakota also leads the nation in county hot spots, with the small, rural counties of Emmons, Dickey, and Logan claiming the first, second, and fourth highest incidence of new cases, respectively, in the last seven days per 100,000 people, according to The New York Times daily coronavirus tracker on Oct. 4.

Masking resistance

Last May, North Dakota Gov. Doug Burgum, who wears a mask frequently, made an emotional plea to avoid divide over face masks. Yet the first-term Republican governor has refused to issue a mask mandate, similar to his refusal to shut down his state in March and April at the onset of outbreak.

"North Dakota is one of 15 Republican-led states where masks are not mandated statewide, according to the AARP," wrote Jeremy Turley and Michelle Griffith for the Grand Forks Herald on Sept. 9. "Kansas, which has a Democratic governor [Laura Kelly], has mandated masks, but most counties in the state have opted out of the requirement."

Burgum said "masks are essential" in preventing the spread of COVID-19, but he maintained that mandating them statewide is not the best way to tackle the virus.

"We've had a great track record so far of relying on personal responsibility, and I guess I'm still hoping in my heart of hearts that North Dakota can step up and figure out a way to get it done (through) local leadership and local execution," Burgum said. 

Local mandates?

The Associated Press notes on Sept. 10 that the Bismarck–Mandan metropolitan area, composed of Burleigh, Morton, and Oliver counties, is the state's new hot spot, accounting to 25% of new cases.

"State health officials on [Sept. 28] reported 260 new cases of COVID-19 statewide, including 69 in Burleigh County and 19 in Morton County," report Blake Nicholson San Nelson for The Bismarck Tribune. "Burleigh once again led in active cases, with 719 -- one-fifth of the state total of 3,669. Morton has 269 active cases."

On Sept. 11, "the Morton County Commission voted unanimously against creating a public mask mandate Thursday, after nearly a dozen people spoke out against the idea," reported Nelson who captured the sentiment behind the commission's decision to oppose the request by the Burleigh-Morton COVID-19 Task Force that was formed to address the spike in coronavirus cases.

"Liberty and freedom are the foundation of our nation, and liberty and freedom, I believe, in this context, means choice," Commission Chairman Cody Schulz said, adding that he believes the government should instead persuade people to wear a mask.

"I'm a mask wearing advocate but a mask mandate opponent," Schulz said.

Schulz's preference for persuasion over mandating explains the new public education campaign that the state will be launching. It also may indirectly explain the dwindling hospital capacity in the region as Nelson reported on Sept. 25.

South Dakota college town passes mandate

Despite much stronger opposition to a mask-mandate ordinance in Brookings, South Dakota, home to South Dakota State University, the city council voted 5-2 on Sept. 8 to approve a 60-day "mask mandate which requires face coverings at city-sanctioned events and in indoor public and business spaces where 6-foot social distancing is not possible," reported Jodelle Greiner for The Brookings Register.

“If in seven-14 days, any enacted amendments do not assist in reducing COVID growth, staff will have to recommend Phase 2, which closes bars, restaurants, casinos, salons, recreational facilities, gyms, and provides additional regulations in retail, should we reach those triggers,” said City Manager Paul Briseno.

Another sign of rural community spread

A penultimate word on the North Dakota outbreak comes from Jamie Ducharme, who covers health for Time, to help explain why the Midwest epicenter is also greatly impacting rural America, as noted by the aforementioned hot spots.

"It took months for the virus to move from densely populated, urban travel hubs to more sparsely populated rural communities," wrote Ducharme on Sept. 1. "Now, a combination of tourism, reopened businesses and returns to school seem to be allowing the virus to take root in the Midwest."

“We obviously don’t have the population density [of places like New York City], but in the smaller communities…you have a lot of opportunities to interact with people more frequently,” says Victor Huber, a virologist at the University of South Dakota’s Sanford School of Medicine.

As Ashish Jha, the new dean of the Brown University School of Public Health, accurately predicted in an April post"Obviously suburbs and rural areas are less dense, and that doesn't mean that the virus isn't coming; it just means it's going to come a little later, and that it's going to spread a bit more slowly." 

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