By Derek Kravitz and Rudi Keller
Opening weekend at Busch Stadium last April saw the St. Louis Cardinals start their season in front of socially-distanced seating pods of about 14,500 fans, about a third of the stadium’s capacity.
Masks were required inside the stadium, concessions were cashless and fans couldn’t bring bags with them. The goal: Bring back baseball, but do so without creating daily super-spreader events.
Despite the precautions, the Cardinals’ plan didn’t work.
Using cell-phone data to track fans after they left Busch Stadium and headed to bars and restaurants, increases in COVID-19 case rates were “significantly associated” with the places they ultimately went to, according to a forthcoming Saint Louis University study.
Roughly half of the fans tracked went to a bar or restaurant after one of the Cardinals’ first three home games. Masks weren’t required by St. Louis and St. Louis County at the time, and many bars and restaurants chose not to institute their own mask rules.
A month later, in May, the new delta variant of the virus was already spotted in wastewater samples in Branson. In June, sick patients began overwhelming hospitals in Springfield. By late July, most of the state was in crisis mode, with St. Louis and St. Louis County instituting a new mask mandate.
The baseball study echoes the published work of dozens of other researchers in the U.S. and abroad: Masks, and mask mandates, work to reduce the spread of the COVID-19 virus.
The study goes further than a Department of Health and Senior Services analysis of per-capita COVID-19 case and death rates in masked versus unmasked localities. It not only takes into account cases, deaths and vaccination rates, but also mobility and geography.
“We know there’s greater compliance when there’s a mask order in place,” said Enbal Shacham, a professor of behavioral science and health education at Saint Louis University and one of the study’s co-authors. “We’re human. We don’t always engage in behavior that’s protective to ourselves.”
But mask mandates have become a political touchstone in Missouri and around the country, with clear partisan dividing lines, legal battles and a sense of fatigue that has rendered much of the discussion surrounding mask rules exhausted and moot.
A Cole County Circuit Court ruling that only elected officials have the authority to enact health orders prompted Missouri Attorney General Eric Schmitt to send letters earlier this month to health departments across the state, saying mask mandates were no longer valid.
When a Department of Health and Senior Services study of mask mandates’ effectiveness in Missouri, commissioned by Gov. Mike Parson’s office but not disseminated beyond a small group of government officials, was made public on Dec. 1 by The Missouri Independent and the Documenting COVID-19 project
, it set off a brand new set of political recriminations and competing takes on well-documented science.
The resulting firestorm included Parson lashing out at The Independent in a series of tweets and Missouri’s attorney general calling into question the study’s findings.
A St. Louis County bill to reinstate a mask mandate, citing The Independent and Documenting COVID-19 project’s story, failed to get to a vote after a procedural issue, and the county later abandoned its efforts to maintain one. The city of St. Louis did pass a new mandate last week, in response to a wintertime surge in cases, but is one of the few Missouri jurisdictions to have such a policy.
“It’s become very entrenched and political,” said Lisa Clancy, a Democratic St. Louis County councilwoman who introduced the failed county bill for a new mask mandate.
To those studying the issue, including economists at the International Monetary Fund and academic teams across the country, it’s much more straightforward. Mask mandates, even more than other policy interventions like travel bans, are easy to implement. They typically don’t require much enforcement. And, even when accounting for political leanings and attitudes, they are effective, resulting in at least a 10% reduction in weekly COVID-19 case growth and preventing anywhere between 19% and 47% of deaths.
The unanswered question is: Are mask mandates politically viable in a place like Missouri that is so polarized and worn out after a year of COVID restrictions?
‘Potential lives saved:’ 1,900 in Missouri
This fall, a team of economists from the International Monetary Fund posed a provocative hypothetical scenario:
If Missouri, and other U.S. states, had statewide mask mandates in place for all of 2020, how many lives would have been saved?
They looked at neighboring states with and without mask mandates, and looked at case, hospitalization and death rates across those borders. And they used a statistical regression analysis, controlling for a host of variables including the distance from a county with a statewide mask mandate to one without and Google mobility tracking data.
Their answer: Nearly 1,900 Missourians who died of COVID-19 would have survived 2020 with a state mask mandate.
On a per-capita basis, Missouri ranks No. 7 in the country in potential lives saved, behind other states with Republican governors that have resisted universal mask rules, like Florida and Georgia. Across the U.S., the researchers estimated that roughly 87,000 lives were saved in 2020 because of state mask mandates and an additional 58,000 would have been saved with a nationwide mandate.
“The question of mandates is always, ‘Are people wearing them?’ There’s going to be a certain level of fatigue and initial attitudes but what we’ve found is yes, some people are going to be convinced to use the masks with the mandates,” said Rui Mano, a senior economist at the IMF and one of the study’s co-authors.
In response to both the IMF finding of lives saved and the Saint Louis University research on the Cardinals virus spread, the governor’s office, the attorney general’s office and the Department of Health and Senior Services did not respond to requests for comment.
The St. Louis County Department of Public Health, while declining the comment on the mask mandate studies, said in a statement that “wearing masks is a proven strategy to reduce the transmission of COVID-19” and that it “strongly encourages everyone in our county to wear a mask in public places indoors, and in any situation in which social distancing isn’t possible.”
Still, both teams of researchers and public health experts say vaccine availability and the rise of new variants, such as the omicron strain, only reinforces the idea that mask mandates should be considered.
One of the more challenging obstacles to the effectiveness of any government policy is its uptake among different demographic groups. In the U.S., those camps have been defined by researchers in clearly partisan terms: Republican versus Democrat.
The IMF team looked at attitudes about mask wearing, by using a proxy: Political party affiliation through voting records at the county level in the 2020 presidential election. Republican voters were assigned a more negative attitude about masks, Democrats a more positive view. Other substitutes for attitudes about masks, such as mask adherence surveys, were found to be lacking, namely because they don’t employ random sampling and usually rely on email or website clicks.
Using voting records, the researchers made a key finding: While mask mandates reduced cases, hospitalizations and deaths no matter the political leanings and attitudes about masks, the impact of mask mandates in negative attitude, Republican-leaning counties was less pronounced.
That finding is echoed by those who argue that, at this stage of the pandemic, with vaccines widely available, the tradeoffs for mask mandates simply aren’t worth it.
In Pennsylvania, the Democratic Gov. Tom Wolf and his administration have spent more than 18 months engaged in a series of pitched battles with the Republican-controlled General Assembly over his pandemic management policies. GOP lawmakers repeatedly accused Wolf of overstepping his mandate and bypassing the legislative branch.
That anger found voice in May when Republicans pushed through, and voters approved, a constitutional amendment limiting the emergency powers of Wolf and all his eventual successors. In June, GOP lawmakers voted to terminate the administration's COVID-19 emergency declaration.
Earlier this month, the majority-progressive Pennsylvania Supreme Court dealt Wolf another blow, as it toppled the administration’s mask mandate for K-12 schools and child care facilities. The high court ruled that Wolf's acting health secretary overstepped her authority, and should have used the customary regulatory channels to seek the mandate.
Pennsylvania has reported 1.89 million COVID-19 cases since the pandemic began. With more than 2 million people in the commonwealth fully vaccinated against the coronavirus, the majority of COVID-19 hospitalizations are unvaccinated or not fully vaccinated individuals, according to state data.
Statewide, hospitals have struggled with capacity as cases continue to rise — urging those eligible to get vaccinated if they haven’t already.
Earlier this month, Geisinger, one of Pennsylvania’s largest health systems, announced it ran out of beds, reporting that health care workers were practicing “waiting room medicine” on patients who waited up to 20 hours for care. After months of warning, Centre County’s only hospital, Mount Nittany Medical Center, turned away ambulances due to increased COVID-19 patients and cautioned possible service cuts. A UPMC spokesperson told the Capital-Star that every facility was operating near capacity.
Back in Missouri
Mandates, even in St. Louis and Kansas City and their outlying suburbs, are less supported now than they were in pre-vaccine 2020, said Howard Wall, a professor of economics at Lindenwood University in St. Charles and the executive director of the John W. Hammond Institute for Free Enterprise, whose mission is to foster free enterprise and civil and religious liberties.
Despite acknowledging the “probable” efficacy of masks and mask mandates, and even describing the St. Louis University research as “pretty neat,” Wall — and many like-minded Missouri conservatives, libertarians and independents — say the time for wholesale mask mandates has passed.
“There’s a reason they’re widely hated,” Wall said. “Is it worth the cost when you’ve had vaccines after all this time? When looking at the calculation, for Missouri and looking at the landscape, it doesn’t seem like it.”
Absent a so-called “universal” mask mandate for an entire state or county, retail businesses and restaurants can set their own rules, a pandemic-era variation on, “No shirt, no shoes, no service.”
“One of the most powerful tools business owners have is the ability to say, ‘This is my business and in this place, you’re required to wear masks,’” said Ben Rader, a graduate research fellow with the computational epidemiology lab at Boston Children’s Hospital, who has studied the issue.
Messaging and social norms are also a vital component to an effective mask mandate, researchers have found. Jason Abaluck, an economics professor at Yale University, embarked on an ambitious project in more than 600 rural villages in Bangladesh last year, sending masks to nearly 65,000 households and then subsequently training “mask promoters” and imams to encourage passersby and those attending Friday prayers at indoor mosques to wear them.
There’s a reason they’re widely hated. Is it worth the cost when you’ve had vaccines after all this time? When looking at the calculation, for Missouri and looking at the landscape, it doesn’t seem like it.
– Howard Wall, economics professor, Lindenwall University, St. Charles, Mo.
To test their results, they then analyzed the blood of a randomly-selected group of households showing symptoms from the virus and looked at the effect of masks and messaging.
Receiving free masks didn’t result in a huge change in case rates in the sampled Bangladeshi villages. But the free masks, coupled with the messaging and the creation of a new community-wide social norm, resulted in a startling decrease in transmission of the virus — by as much as 41%.
“What our study suggests is a somewhat common sense point: Oftentimes, the easiest thing to do is to wear a mask. When someone walks into a mall and someone is there saying, ‘Please put on a mask,’ most people just say, ‘OK,’” said Abaluck, one of the study’s principal investigators. “Most people will comply and a tiny fraction might fight over it. We are overstating the degree this is super-politicized. The typical person cares less about politics.”
Perhaps most important to Missourians: The Bangladeshi study found that other strategies to promote mask use — including text message reminders; friendly, altruistic messaging, similar to encouragements or suggested guidance; and financial incentives — didn’t work.
Missouri’s long history with government mandates
Missouri, like many states, has a long, oftentimes conflicted, history with government mandates.
Complying with federal mandates in Missouri often comes only after all efforts at resistance have been exhausted. A law requiring motorists to wear seat belts was passed in 1985 only because failure to do so put federal highway funds at risk.
More recently, the state refused to expand Medicaid eligibility despite major federal financial incentives to do so. That changed only after an initiative petition drive and court battle to enforce the voter-passed expansion plan.
U.S. Sen. Josh Hawley, when he was running for state attorney general in 2016, told the Columbia Daily Tribune in an interview that resisting federal power was the No. 1 priority for that office.
“What we need is somebody who knows how to fight and win against the federal government all the way to the Supreme Court,” Hawley said at the time.
The long-standing attitudes make any government order suspect, Kremer said.
“I am not suggesting that this is unique to Missouri,” said Gary Kremer, director of the State Historical Society of Missouri, “but I am suggesting that this is a central theme to Missouri history.”
In his book, “This Place of Promise,” which chronicles Missouri’s first 200 years, Kremer charts the state’s anti-government movement sentiment since statehood. After a federal bill banning slavery was introduced in 1819, white residents held mass meetings and grand juries to resist any federal mandate to give up their property, in this case Black human beings.
“We were trying to join the federal government as a state and simultaneously threatening to rebel against the government we were trying to join,” Kremer said. “They were trying to oppose what they would call today government overreach. That theme is repeated throughout our history.”
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