This week, the United States surpassed its previous single-day record for new Covid-19 cases. These numbers are climbing as many states ease lockdown restrictions. As hospitals in the South and West become overwhelmed by the virus, governors are rethinking moving forward with reopening plans.
For now, the only options we have for reducing the spread of Covid-19 are social distancing and masks. According to a report released Thursday by the Institute for Health Metrics and Evaluation, by October, cumulative Covid-19 deaths could reach 179,106 people. Their projections show that number dropping to 146,047 people if at least 95 percent of Americans wear masks in public. With “quarantine fatigue” setting in, it seems like masks are our best chance at living a life that resembles pre-pandemic days while protecting others.
But not everyone wants to wear a mask. According to a mid-April Gallup poll, only one-third of Americans said they always wore a mask or face covering when they left home. In some cases, anti-mask sentiments are interspersed with hostility. In Orange County, California, former county health officer Dr. Nichole Quick was threatened with violence and portrayed as Adolf Hitler after she mandated that county residents and visitors wear cloth coverings. In Scottsdale, Arizona, City Councilman Guy Phillips mocked the dying words of George Floyd during an anti-mask protest he organized, declaring, “I can’t breathe.”
“Now that we know that there would be 33,000 fewer Covid-19 deaths if 95 percent of people wear masks, it is hard to understand a choice not to do this,” Carol Taylor, a Kennedy Institute of Ethics senior clinical scholar and a professor of medicine and nursing at Georgetown University, tells me. “I want to live in a world where people do the right things simply because they are the right things to do — not because they fear the penalties of not doing so.”
The question is: How can anti-mask people be convinced that wearing a mask is the right thing to do? And if that’s not possible, how can they be compelled otherwise?
Wearing a mask: An act of patriotism
To answer those questions, we first have to consider the factors that drive anti-mask sentiments. Meghan Halley, a medical anthropologist and a research scholar at Stanford University’s Center for Biomedical Ethics, points out that, unfortunately, there has been confusion due to changing recommendations over time. It’s been unclear to the public why wearing a mask is effective.
“One one hand, people are being told that masks won’t protect you, and on the other hand, they are being told to wear them,” Halley tells me. “In addition, there is a significant emphasis placed on individual autonomy and choice in the public discourse in the United States, and masking recommendations have been interpreted by some as infringing on their individual rights.”
“If I could wave a magic wand, I would a) ensure that the messaging around masks was clear and consistent as to their effectiveness and purpose, and b) promote masking not as an individual responsibility, but as an act of civic responsibility, perhaps even one of patriotism,” she continues. “But, unfortunately, I don't have a magic wand.”
Ultimately, experts tell me, influencing mask choice can come down to either compulsion or requirement.
The first method, compulsion, can be enacted in a variety of ways but is only effective when done carefully.
“I don’t believe scolding, reprimanding, or shaming are useful in this context any more than they are convincing people to embrace other behavioral changes,” Alison Bateman-House, an assistant professor of medical ethics at the NYU Grossman School of Medicine, tells me.
This need to stay away from the negative is echoed by Katherine Fox-Glassman, a psychology lecturer at Columbia University and an expert in decision-making, in her evaluation of how risk choice framing can influence mask-wearing.
She explains that when choosing between a safe option and one that’s uncertain (like “avoid spreading the virus” versus “go maskless and have a small chance of spreading the virus”), people tend to prefer the riskier option when the outcomes are framed in terms of potential losses. Meanwhile, when the same outcomes are presented in terms of their potential gains, people are more likely to select the safe option.
“A lot of Covid-19 messaging has taken advantage of this effect, saying things like ‘stay inside, save lives!’ instead of ‘going outside could cause harm!,’” Fox-Glassman tells me. “So if you want to try to convince someone to wear a mask, a message that focuses on the benefits of doing so is more likely to work than a message that stresses the dangers of failing to cover up.”
Social norms can also play a large role in influencing behavior, Fox-Glassman says. In turn, social norms refer to behaviors that can subsequently be broken down into descriptive norms (what people are doing) and injunctive norms (behaviors society judges as right). Studies indicate that people are more likely to follow a social norm if they see it. Simply seeing others wearing masks is likely to influence others to choose to wear masks who wouldn’t otherwise, she says.
Meanwhile, injunctive norms are powerful when the descriptive norm is bad — like in a community where people are flouting mask-wearing guidelines. Reminding people that wearing a mask is simply the right thing to do can perhaps sway them.
Dr. Kevin Volpp, the director of the University of Pennsylvania’s Center for Health Incentives and Behavioral Economics, agrees that a social norm around wearing masks is a powerful motivator. But he also brings up the method of requirement.
“Given the public health evidence, it would make sense of authorities to require mask-wearing,” Volpp says. “However, requirements won’t necessarily guarantee that people will do this if there are no consequences for not following the regulation. In those cases, fines are likely necessary to ensure that people pay attention to the regulations.”
Bateman-House would like to see local governments, storeowners, and other people in similar positions of power add “masks must be worn here” to the pre-existing rules for public behavior based on public health that have become normalized: not smoking, not spitting, wearing shoes, et cetera.
People who have jurisdiction over someplace, she argues, “have an obligation to protect those within the confines of that space from foreseeable harm.” That should be done through the least liberty-restricting option — “the option that is least intrusive on people’s ability to do as they please should be adopted so long as enough people do it for it to be an effective policy.”
Masks, as of now, are the least liberty-restricting option. But if not enough people wear masks, further freedoms will be taken away — that’s when social distancing is emphasized, and certain lockdowns are resumed.
This is what’s happening now in Texas and Florida, where the respective governors have delayed their next reopening phase amid rising case counts. It is unknown what the scope of the Covid-19 outbreak is, and it is unknown when there will be a vaccine. What is known is that masks can help curb deaths — if people decide to put one on.