One of the lingering questions from the COVID-19 pandemic swirls around the value of wearing face masks, an issue that moved from healthcare to political flashpoint after authorities called for everyone -- both healthy people and those experiencing symptoms -- to wear masks in public.
Where some saw a public health mandate, others saw a political overreach, even a violation of basic American freedoms. The situation became a strange litmus test for party affiliation, with politicians on the right laughing off mask rules or mocking wearers while some on the left were accused of using masks as a virtue signal.
So, who was right?
A dive into the data between the length of mask mandates per state and the number of people who died from COVID shows little connection between the two.
Bluntly, longer mask mandates did not correlate with fewer deaths per capita.
Of course, with uneven compliance and enforcement, easy opt-outs in some states and the near impossibility of tracking the kinds of masks people wore or how many people congregated at one time with or without masks, it's hard to draw definitive conclusions. In the end, most would agree on one thing: It never should have devolved to us vs. them.
Vaccination rates in states -- more than mask-wearing -- changed the trajectory toward life or death. Vaccinations not only help prevent infection, they dramatically reduce the possibility of serious illness or death for those who do get infected. An analysis by Brown University after the U.S hit a grim milestone of 1 million COVID deaths found that more than 300,000 could have been prevented by the vaccine.
“At least every second person who died from COVID-19 since vaccines became available might have been saved by getting the shot,” the study found.
States where the most lives might have been saved by more widespread vaccination include West Virginia, Wyoming, Tennessee, Kentucky and Oklahoma, per the analysis.
MASKS BY THE NUMBERS
If you look only at mask data, the 11 states that did not impose mandates at all have death rates per capita similar to states that did require residents to wear masks. See the map above to track the length of the mandate in your state vs the per-capita rate of COVID death.
One might assume these 11 states with no mandate should all have much higher death rates -- but that's not the case. If you expand the question to whether masks prevent mass infections, the data is also murky. “The incremental benefit of community-level mandates beyond public health guidance has been less certain,” according to a February study in the Journal Health Affairs. See the full report.
To determine deaths per capita for this Audacy Investigation, we utilized data from U.S. News and selected March 26, 2022 -- when the final mask mandate was lifted -- as the cutoff date.
Of the top 10 states with the highest number of COVID-19 deaths per 100,000 people, seven states had mask mandates and three did not.
Mississippi had the highest death rate (410) and the shortest mask mandate (56 days). Arizona, which had no mask mandate, had the second highest death rate (396) and Alabama (268 days with a mask mandate) had the third highest death rate (391). Data from other states reveals long mandates and high death rates.
Rounding out the top 10 states with the highest death rates are:
• Oklahoma - Death Rate: 385, Mandate: 0 Days
• West Virginia - Death Rate: 376, Mandate: 349 Days
• New Jersey - Death Rate: 373, Mandate: 414 Days
• Tennessee - Death Rate: 372, Mandate: 0 Days
• Arkansas - Death Rate: 369, Mandate: 254 Days
• Louisiana - Death Rate: 367, Mandate: 376 Days
• Michigan - Death Rate: 356, Mandate: 423 Days
As for the other states without mask mandates, Georgia had the 12th highest death rate (346), Florida had the 16th highest (340), South Carolina had the 17th highest (339), South Dakota had the 20th highest (325) and Missouri had the 23rd highest (323). The other three states fall into the lower half of the spectrum. Alaska had the 4th lowest death rate (161), Nebraska had the 10th lowest (209) and Idaho had the 17th lowest (272).
The state with the lowest death rate (96) is Hawaii, which actually had the longest mask mandate (704 days). The second lowest death rate (98) was recorded in Vermont (318 days with a mask mandate) and the third lowest death rate (146) was in Utah (153 days with a mask mandate).
MIXED MESSAGES, MIXED RESULTS
Mask guidelines were all over the map when the Centers for Disease Control and Prevention called for all Americans to wear cloth masks to prevent the spread of COVID-19 on July 14, 2020. The White House never issued a nationwide mandate, though it did require masks on public transportation. Instead, then-President Donald Trump delegated mask-wearing policies to state governments.
"It's up to the governors. We want to have a certain freedom... we also understand that each state is different and facing unique circumstances," Trump said during a coronavirus news conference on August 13, 2020. "We will continue to urge Americans to wear masks... but we do not need to bring the full weight of the federal government down on law-abiding Americans to accomplish this goal."
By the time the CDC issued its guidance on masks, multiple states had already enacted mandates. Then-CDC Director Dr. Robert Redfield said cloth face coverings were "one of the most powerful weapons we have to slow and stop the spread of the virus – particularly when used universally within a community setting." We now know that N95 respirators are the most effective for protecting against COVID-19. But early on when those were not widely available to the public, health officials pushed the message that covering your nose and mouth with something was better than nothing.
From March 1 through December 31, 2020, state-issued mask mandates applied in 2,313 (73.6%) of the 3,142 U.S. counties, according to the CDC.
New Jersey was the first state to enact a mandatory mask requirement. The order went into effect on April 10, 2020, one month after the World Health Organization declared the coronavirus outbreak a global pandemic. In the months that followed, 38 other states issued similar orders. Wyoming was the final state to enact a mask order on December 9, 2020.
Of the 39 states with mask requirements, 17 had Republican governors and 22 had Democratic governors.
Mississippi was the first state to lift its mask order -- after just 56 days on September 30, 2020. Hawaii was the last state to lift its mask order -- after 704 days on March 26, 2022.
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The mask mandates and their requirements varied widely from state to state, and none were cut and dried. Some made exemptions for people who were fully vaccinated, leaving individuals to the honor system when representing their vaccination status. Others went as far as restricting on-premises dining, leaving many bars and restaurants struggling to stay in business.
One could also assume there are unknown factors like the number of immunocompromised people who stayed home because there were no mask mandates in their area, and the number of people who actually fully covered their nose and mouth with a mask in every area where they were required.
Along with vaccines, you'd be hard-pressed to find a more divisive pandemic-related topic than face masks. In the battle between personal freedoms and government control, some people favored getting arrested over wearing masks at grocery stores, restaurants, schools, council meetings and on public transportation.
Heated debates over masks turned violent and even fatal. In Michigan, a Family Dollar security guard was shot to death after police said he told a customer she needed to wear a mask in the store.
Situations got especially tense on airplanes, where unruly passengers often acted out when confronted over their refusal to wear masks. Incidents of bad behavior in the skies included passengers being duct-taped into seats and restrained with zip ties. There were assaults on flight crew and other passengers, thrown luggage, sexual harassment and more. In 2021, the FAA recorded nearly 6,000 reports of unruly passengers -- more than 70% of which involved mask-related incidents -- and imposed roughly $5 million in fines.
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More than two years later, many are still wondering: Were statewide mask mandates worth the conflict and did they actually save lives? Advocates often point to scientific studies, but the real-world data on COVID mortality doesn't exactly reflect what researchers thought would happen based on projections at the beginning of the pandemic. The early theories didn't necessarily stand the test of time.
According to the CDC Morbidity and Mortality Weekly Report published on March 12, 2021, mask mandates were associated with "statistically significant decreases" in county-level daily COVID-19 case and death growth rates within 20 days of implementation. Statistical significance, by the way, means that a result is likely due to a factor of interest and didn't just happen by chance, according to the Harvard Business Review.
The CDC report looked at changes in daily case and death rates between March 1 and December 31, 2020 compared to data from 20 days before a mandate took effect. It found that mask mandates were associated with a 0.7 percentage point decrease in daily death growth rates in the first 20 days after implementation. Death rates continued to fall by as much as 1.9 percentage points 100 days after masks were required, according to the report.
Another study in the journal PLOS ONE in June 2021 also found that mask mandates were associated with a statistically significant decrease in deaths. The analysis looked at data from 857 counties representing 77% of the U.S. population between February 2 and September 27, 2020. It found that mask mandates were associated with a reduction of 0.13 deaths per 100,000 people up to 40 days after the introduction of mask mandates.
On the other hand, a study published in the Infectious Disease Modelling journal in April 2020 indicated that masks alone, unless they are highly effective and nearly universal, have a small effect in terms of absolute lives saved. The study looked at hypothetical mask adoption scenarios for Washington and New York state to reach its conclusion.
"I think we've missed the boat on this issue with mask mandates from the beginning," Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told WCCO. "If everyone were to wear an N95 or a KN95 and wear it effectively, we could do a lot to reduce transmission. Instead, we just get bogged down and debate about a mandate about anything you put in front of your face."
Any study dealing with mask mandates has its limitations. Many don't measure compliance and enforcement rates, or how those factors might impact results and conclusions. Moreover, there are many different types of face masks with varying degrees of efficiency. Mask mandates don't specify how effective a face mask must be, only that an individual is wearing one.
Additionally, states create their own public health policies, so there is no uniform process of documenting and reporting COVID deaths. For example, a man with cancer is positive for COVID-19 when he dies. One state could determine the man died of COVID while another state might attribute the death to his pre-existing condition with COVID as a contributing factor. Not every death related to the virus is immediately certified and reported, either.
Researchers also can't predict when a variant might send case and death counts surging, which could impact their hypotheses or expose flaws in previous conclusions.
One study worth noting, published in the American Journal of Preventive Medicine, found an association between mask policies and reduced COVID-19 deaths. The study looked at 44 countries with a combined population of nearly 1 billion people. However, the U.S. was not included in the analysis because it never imposed a nationwide mask mandate. Some would argue that's the foundation for the problem.
The study looked at data between February 15, 2020, the date of the first confirmed COVID-19 death within the targeted countries, to May 31, 2020. It found that over time, the increase in COVID-19 related deaths was significantly slower in countries that imposed mask laws compared to countries that did not.
While a number of studies support the theory that masks cut down on deaths, the data samples used in those studies were all taken during the beginning months of the pandemic. This suggests that masks may have had a larger impact before vaccines were introduced. The knowledge we've gained about the coronavirus since then has dramatically increased as we've experienced waves of sudden increases brought on by the Delta and Omicron variants.
Aside from death data, there's been little investigation so far about masks preventing COVID infection in real-world settings. An early 2022 analysis cited by the CDC found "the real-world effectiveness of face coverings to prevent acquisition of SARS-CoV-2 infection has not been widely studied" although a small sampling of 534 people found that wearing a cloth mask lowered the participants' odds of getting COVID by 56%. Surgical masks lowered the odds of testing positive by 66%, and a respirator by 83%.
Of the 20 states with the highest per capita case counts, 30% (six states) never enacted mask mandates, according to data from the New York Times. On the other hand, Hawaii and Connecticut had two of the longest mask mandates and also some of the lowest per capita case counts of all the states.
The federal mask mandate for public transportation was the last of its kind to exist. It was lifted on April 18, 2022 after it was struck down by a U.S. District judge in Florida who ruled that the policy was implemented in February 2021 in violation of administrative law.
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The U.S. is starting to see another rise in cases, this time fueled by a number of Omicron subvariants. As of May 18, 2022, the 7-day moving average of daily new cases crossed above the 100,000 threshold for the first time since mid-February as many areas are elevated to medium and high community transmission levels, according to the CDC. Meantime, about 78% of people in the U.S. have received at least one dose of a COVID-19 vaccine, and 66.5% are fully vaccinated. Of those who are fully vaccinated, 46.4% have received a booster and are considered up to date.
More than two years into the COVID-19 pandemic, we still have so much to learn about the coronavirus. But at least one thing seems clear: masking has become a personal choice. And both mask advocates and detractors can cite data to justify their positions.
Experts are now warning of an impending summer surge in coronavirus infections, but it remains to be seen if any mask mandates will return.
"I come back to the fact that there are many people in our country today who are at very high risk for serious illness, 7.2 million immunocompromised people, more who have other underlying conditions," said Dr. Osterholm. "I want them to know that masking can be very important in addition to getting vaccinated. If they wear an N95, they can protect themselves substantially."
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