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If public health officials want to get people to wear masks to curb the spread of Covid-19, they might take a lesson from what is now a widely accepted aspect of American life: buckling up.

Beginning in the 1950s, the effort to get people to adopt seat belts took legislation, enforcement, and public health campaigns. And, especially in its early days, it was met with misinformation and pushback, especially around personal freedom.

“Industry didn’t want to bring up the issue of safety,” Ralph Nader, a consumer activist and early seat belt champion, told STAT. “They were selling high performance, speed, and glamour.”

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He and other seat belt advocates — including trauma surgeons and insurance companies — spent years lobbying hard for legislation. The pushback got personal. “We were accused of being un-American, and asked why we didn’t go back to Russia, and why we wanted to be the national nanny,” said Nader.

Opponents put up plenty of misinformation. Nader remembers warnings — not borne out by research — that seat belts would crush people’s organs in a crash. Fred Rivara, an injuries expert and professor of pediatrics at the University of Washington, remembers an unsubstantiated claim that any positive effects would be cancelled out by people dying when they couldn’t escape fiery cars.

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Still, a few car companies, Ford and Volvo among them, began offering seat belts as an option. But without an accompanying public information campaign, sales of cars equipped with seat belts didn’t take off.

After years of pressure, President Johnson signed legislation in 1966 that required seat belts in all passenger vehicles and created a national traffic safety agency.

Rivara credits science for the federal action. “Studies showed that wearing a seat belt improved your risk of surviving a crash,” said Rivara. “That was key.”

To get buy-in from the public, safety advocates aired ads with a “buckle up” jingle, while the Ad Council introduced popular crash test dummies Vince and Larry in public service announcements. The dummies were regularly seated in cars and slammed into walls; viewers were encouraged not to be dummies. By the 1980s, the fight was no longer so much about whether seat belts worked; the evidence is clear they save lives. It became about personal freedom.

“Saving freedom is more important than trying to regulate lives through legislation,” an anti-seat-belt activist wrote in a letter to the Chicago Tribune in 1987.

Still, starting in 1984 with New York, states began passing seat belt mandates. The federal government eventually gave extra highway funding to states with tough laws. Meanwhile, new designs were making seat belts more comfortable and effective.

“Over the years it became a habit,” said Howard Markel, a historian and professor of pediatrics at the University of Michigan, who as a teenager in the 1970s remembers figuring out how to disable the buzzer on lap belts (he regrets that now). “It was the law that made it universal,” he said.

Today seat belt usage is high — in 2019, it was 91% nationally. States where cops are authorized to pull over drivers not wearing seat belts score higher than states where cops can only ticket if they’ve pulled a driver over for something else. Even in New Hampshire, the only state without any kind of mandate, seat belt use is 71%.

Motorcycle-helmet laws have had a bumpier ride. At one point, in no small part in order to get federal highway construction funds, 48 states required helmets. But after Congress dropped the funding in 1976, half of the states reversed their laws, including Washington.

In 1988, Rivara and his colleagues published a study on the cost of care for motorcyclists who wound up in the ER at a large Seattle hospital. The study found two-thirds of spending on those patients came from state and federal coffers, and the state legislature passed a helmet law the next year. Still, only about half of states now have such a law.

What might that all mean for the future of a mask mandate amid Covid-19?

Mandates did not work well for masks in the 1918 influenza epidemic. “There was even an anti-mask league to fight the law,” said Markel. But he noted that there wasn’t any research at the time showing that masks would be protective. And they might not have been, given the use of porous gauze masks.

This time around, though, masks are well-known to be a powerful tool that can reduce transmission of the virus. According to AARP, 33 states and the District of Columbia now have some sort of mandate. A recent Centers for Disease Control and Prevention report found that 89% of people reported wearing masks by June, up from 78% in April. (Mask wearing estimates vary. The Institute for Health Metrics and Evaluation, for example, estimates that mask use has never gone above 65%.)

An October modeling study projected that universal mask-wearing in the US could save 130,000 lives by the end of February.

But a mandate could be a bit of a haul in states, particularly those led by Republicans. For example, Gov. Doug Burgum of North Dakota, a newly reelected Republican, adamantly opposes a mandate. He told the New York Times while he thinks wearing masks is a good idea, people should do so out of “personal responsibility,” not because of a law. And in the politicized world of the Covid-19 response, some local jurisdictions have refused to enforce state rules.

President-elect Joe Biden has said that he plans to ask every governor to mandate masks, and if they refuse, he’ll go to mayors and county executives to plead the case.

But an August Congressional Research Service report suggests that it might take an act of Congress to get a masking policy that covers the entire nation — much like how Congress tapped federal highway funds to get states to pass seat belt laws.

In the end, what worked with seat belts were efforts by public health advocates, financial incentives, state level mandates, enforcement, solid research, and concerted effective public health messaging — all activities that are possible with masks.

  • Why is no distinction being made between masks and face coverings? There is data that supports the benefits of mask wearing in certain circumstances but no data that I’ve seen and I’ve been looking, that a face covering reduces transmission. A mask versus a face covering is an important distinction. Layer on the way masks and face coverings are typically used is at best ineffective and at worst, increasing the risk of transmission, a mask mandate makes no sense. Sadly, I see masks/face coverings being used ineffectively yet giving people a sense of security and they reduce other safety measures.

  • Masks don’t work.

    If anyone tries to make it a crime for me to not wear a mask in public they are likely to get shot.

    But this is all moot now.

    The C19 hysteria will die out before the mediocre political grifter Joe is sworn in.

    It won’t be necessary any longer to affect the election.

  • I was in a T-bone collision at a city intersection with both cars under the speed limit. I had a few bruises and a small scratch, but am sure I would have had more serious injuries, such as my head through the window, without the seat belt. At a state fair, I volunteered to go in the State Police “Convincer”, a seat with a belt on a ramp which simulates a 7 mph parking lot collision. It was absolutely convincing. Insurance companies and legislators don’t know me personally, but not wanting to spend a lot of insurance and tax dollars on my hospital bills or long term care for permanent head injuries is close enough to having my health at heart. The mask is primarily so you don’t endanger others. It may have a secondary benefit of giving you some protection. It is like being required to have your headlights on while driving at night.
    In about two months, NYC lost as many people to COVID-19 as total highway deaths for the whole country in a whole year.

  • I appreciate the background on how seatbelt laws were passed and expect a similar approach may work for masks. That being said, wearing seatbelts and wearing masks are not analogous.
    If I choose to not wear a seatbelt the only one impacted is myself. But if I choose to not to wear a mask, I have the potential to affect all those around me.
    So the argument that some individuals make that wearing a mask somehow impinges on their personal freedom is a specious one. Not wearing a mask impinges on the rights of others. It is more like someone picking up a gun, not knowing if it’s loaded or not and proceeding to pull the trigger while pointing it into a crowd. No one is free to do that.

    • I can’t believe how many people are brain washed in this country. Watching and listening to the news media will not give you all the facts about the real picture of COVID. People say so many people died from COVID, is that the complete truth, what about people that died from other medical conditions and later was written that they died from COVID. What about manipulating pictures and statistics and making everyone Soo scared from this COVID. Yes, that is how you control the masses, With FEAR. Make them fear and they will putt shackles on their own hands. Everything becomes habit, just like seatbelts, in a few years everyone will wear masks and not even think about it. It was like the slavery, at the beginning people were fighting, but eventually they became obedient and worked for their masters. Does anybody know that when you wear mask, you lose your identity, you become faceless, no character. I guess the Democrats won the election, but this country will be going further away from Democracy.

    • Agree with the gun analogy. Legally this is reckless endangerment with a lethal weapon (the virus). That’s a felony. Put away a few felons for 5-10 years due to no mask or wearing it improperly, and we’ll get compliance. Compliance is what America needs. If the populace is too dumb for their own collective good, then it’s the duty of government to intercede with power and boldness – with the police, courts, and incarceration system.

      Personal freedom is the go to excuse for irresponsibility. You’re not free if you’re dead from the virus.

  • Make masks mandatory. Health care workers and business owners are literally pleading for it. Thousands of lives and businesses will be spared. Authorities need to grow a backbone and take charge of protection of a citizenry that is too dumb to chose wiser itself. When a mask is worn, “freedom” is actually gained, not lost.

  • I worked for many years as a certified critical care nurse (CCRN). In that capacity I worked in ICU and the emergency room. Helmets and seatbelts save lives. Masks, social distancing, handwashing and keeping contacts limited do also. Stand up for science, scientists, healthcare professionals and enlightened legislators.

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