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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.

  • I remember the jingle and the warning: “Click-it or Ticket”
    For Covid I propose : “Mask It or Casket”

  • I can’t see New Hampshire’s Governor supporting a mask mandate, we are the “Live Free or Die State” and as the article notes the only state without a seatbelt law and no helmet law. Many wear masks but NH doesn’t like to legislate behavior. We are surrounded by states that do mandate masks.

  • I read this somewhere. Maybe it would work. It invokes the successful, “Click It or Ticket” campaign:
    “Mask It or Casket”.

  • I am so sick of government controling every aspect of my life. They tell me if i want to ride in a car i dont have a option but to chain myself to it .if i want to ride a motorcycle ,bicycle ect. I have to wear a helmet.if i want to put gas in a vehicle i have to pay for gas then give the government 2 times the price of the gas in extra taxes in ny the government even regulates what cooking oil i can use .the government wanted to outlaw the burkas that Muslim women wear observing religion stepping on religious beliefs but now the government mandates i must cover my face .we all know the seatbelts are not because the government cares about you it is only to give more profits to the insurance companies just like the cooking oil regulation .the mask mandate is to save insurance companies from costs of treating covid .most all laws are to protect profits of big business and the government. When the hell will government care about the citizens and stop punishing the people just to increase profits of big business.

    • Alfred, here’s another way to think about government-dictated health actions. If you were to visit an under-age-55 rehabilitation center, you would find a large sum of young patients who were injured (predominantly brain injuries) in motorcycle and car accidents who’d been unbuckled and un-helmeted. Their recoveries reach into months and often years. They have to sell everything and claim Medicaid or Medicare to pay their inpatient and eventual outpatient recovery bills. Those are your and every other tax-paying American’s dollars. We all have always paid for the individual’s freedom of choice to be neglectful.

  • Data on masks reducing droplets is incontrovertible. Proving that they reduce transmission of this virus won’t be completed until long after vaccines or widespread infection have solved the problem– and I would prefer using masks to getting the infection. The question is whether after one gets the vaccine he or she can drop using the masks. I would hope that any insistence on masks is either time limited or is rapidly dropped once this pandemic is no longer a problem, but governments don’t move very quickly on things like this.

    • Unfortunately, the information that I have been given is not looking like we will be able to ditch the masks even after vaccination! With the roll-out of a vaccine quickly there will still be much we don’t know about it just due to the shorter time they have had to look at how it acts in those who received it. Several questions will remain to be answered:
      1. How long are you protect?
      2. Does that protection keep you from getting it or just getting a severe case?
      3. If you can just get a mild/asymptomatic case, can you spread it still to others?
      As you can see, just those 3 questions alone, make the fact of ditching the mask pretty slim! Until a bunch of the population is immunized, and some of the above data is collected I’m afraid we will remain masked. As with all vaccines in history, some later ones will come out that is better, or we may end up with another annual/bi-annual vaccine, or who knows. It is a coronavirus after all!

    • It should be flexible and re-evaluated on a regular basis. If done properly, and we all masked up today through late December, I strongly believe we could have a decent holiday and a wonderful new year. Then the vaccine would be near and our numbers would be way down. A mandate like this should not be necessary, but many have proven they cannot make the correct decision on their own. We can only beat this if we work together ❤.

  • Interesting that this is coming from the anti ‘mass incarceration’ crowd. No talk of prospective penalties either. I wear it because of the reduced inoculum argument. If others don’t that’s their problem. Follow the big 3; hand hygiene, face cover and distancing. I’ve been fine and also been around plenty of the genral public.

    • Given that cloth (non-medical) masks primary benefit is spraying a much smaller plume of droplets to OTHER people, I’d say if others don’t wear their masks the problem affects all of us.
      Glad you’ve been well, but N=1 is a pretty small sample.

  • I believe seat belts are effective at higher speeds, but in city traffic with slower speeds they don’t make any difference. Even the article says it that legislation was past mainly because of the money spent on treatment. I don’t think any of the lobbyists had the health of the people in their hearts, it was mostly about saving a buck.
    I really hope that wearing masks don’t become a law. It will be violating my personal freedom. We were created to breathe air freely without any obstruction. Breathing air is one of the most essential thing in order to live along with water and food. The government should be taking care of many other important issues and not try to make decisions on my behalf. Let’s find cure for cancer for example or end world hunger, how about fixing the pollution, the oceans are full with plastic. We cannot allow our freedom to be taken away. Today they will make us wear masks, tomorrow they will put curfews and prevent us from going out ( it is already done in other countries) . What next??

    • 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.

    • Passive restraints (such as air bags) are more effective because…they’re passive; they don’t depend on people not being lazy or thinking about the welfare of others. They became mandatory only in 1989–long after they were available.
      Of course, those who are against mandatory mask wearing are likely vaccine-hesitant too–they need their “freedom”.
      Now, if anyone could mandate a passive means of stopping transmission, THAT would be something.

    • Passive restraints are effective when added to active restraint– seat belts. They can actually cause harm if not wearing a belt. And I agree a gold standard would be a passive way of preventing anyone from spreading to another– but there isn’t anything you can put in the air or water that will do that for the foreseeable future, and environmentalists would oppose such if it existed, so we have to deal with the social separation, masks, and hand washing.

  • The problem with mandating community masks is there is no solid scientific data that they prevent transmission. N95 and surgical masks are an exception as they are far more effective at reducing transmission than the myriad of home grown community masks. I recently reviewed 25 papers on masks with a focus on community use, the results are inconclusive. Where they are most effective is in hospital and other high exposure settings. Unlike seatbelts, the mask data is just not there.

    • I agree with you Eileen. I do, however, wear a mask any time I go in a public building such as a grocery store. The article cites a modeling study, but in order to model anything some assumptions would need to be made about the degree of effectiveness masks provide in preventing the spread of disease. We could look to South Korea where mask wearing is universal, and assume that has helped contained the spread of disease there. But, Korea also practices a level of testing, contact tracing and forced quarantine that would never be acceptable or practical here. So, it’s hard to tell to what degree the masks actually help even there. We need some hard, convincing evidence that masks are effective. (Common sense would indicate they help some)

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