My family and I recently spent four nights camping in rain and snow at 10,600’. Even with baggies as vapor barriers, socks were soaked by the end of the day, so I ordered the boys to sleep with their wet socks next to their body in order to dry them out. Needless to say, my order wasn’t well received, but it ensured that they had at least one pair of dry socks at all times, even by day five.

I also recently voted to extend a Teton County health order (found here) that masks should be worn in indoor spaces frequented by the public. It hasn’t been well received either. After all, in a county where well north of 90% of the people who can be vaccinated are vaccinated, the need for a mask order seems like a bunch of b.s. The perceived infringement of a mask order on personal freedoms is more acute and more hotly debated than ever. And like sleeping with wet socks, wearing masks, even to avoid bad health outcomes, isn’t fun.

Nor is this why I ran for county commission. When I was first elected in 2014, my responsibilities as a commissioner to uphold state law and promote the health and welfare of county citizens didn’t include the responsibility to make complex decisions related to epidemiology. That authority was left to state and local health officers, chosen for their expertise in health, medicine and/or epidemiology. But this year the Wyoming legislature limited the authority of those experts by mandating that no order may remain in place for more than ten days unless extended by the corresponding local elected body, thus placing such fraught decisions in the hands of people like me and my four fellow commissioners, none of whom are trained to make such decisions.

I could have punted and simply followed the strong recommendation of the County Board of Health to extend the order. After all, last winter masking in public indoor spaces was broadly accepted and helped keep our schools open and community economically afloat. But now, with very high county-wide vaccination rates, why should I support a mandate? I decided to do my own research and, while giving significant weight to the recommendation and information provided by the Health Officer and Board of Health, make my own decision. As well, I recognize the weight of a government mandate, value community input, take seriously the intent of the new law that is meant to bring such decisions closer to the people and am, by nature, curious.

We received over 600 emails commenting on the order. I read them all or scanned the ones that were obviously duplicates and based on a mass-email template. Throughout the pandemic I’ve read hundreds more emails, many demanding stricter non-pharmaceutical interventions and many calling for no interventions at all. I also did my best to track headlines and read articles and studies on COVID and COVID interventions from a broad array of sources.

Many folks who commented against mask mandates cited statistics, studies and research to back their claim that masks were ineffective. Others for the mandate supported their claim by citing their own sources. On occasion both sides cited the same sources but interpreting them differently. Some emails were from health professionals; most were from folks who had no more training than I in epidemiology. I did my best to review the statistics and read the studies they cited. I respect everyone’s stance and value everyone’s input so long as it reflects a sincere commitment to the best interests of the community.

I ultimately voted in favor of the mandate. Many of you may differ vehemently as to whether there should or should not be a mask mandate. Regardless, I think well of you. What follows is a description of my own path towards my decision.

My commitment as a commissioner is to promote the health and welfare of the community. Regarding this pandemic that means to do what I can within my statutory powers to support policies that reduce deaths, serious illness and hospitalizations due to COVID so that our hospital can sustainably service all the health needs, not just COVID related, of all the people throughout the broader Teton region. When I look back on my role as a commissioner during the COVID pandemic, I’ll need to answer the question, how well did I balance the benefits of actions I supported on COVID morbidity, mortality and serious healthcare outcomes (like overwhelmed hospitals) with the costs, such as the diminution of freedoms and negative socioeconomic impacts? Did I do everything that I could, given my position, to thread the needle between bad health outcomes with higher levels of COVID deaths, COVID hospitalizations, and COVID-related closures (of schools and businesses), and bad outcomes associated with costs to personal freedom and economic pursuits?

Here are some of the pieces of information and data I took into consideration, linked to their sources:

Mortality rates and causes—On state and nation-wide levels COVID has resulted in excess deaths. Data is not specific to Teton County, but as of September 3rd Teton County, Wyoming had recorded 11 deaths due to Covid. St. John’s handles patients from neighboring counties, and some deaths that have occurred at St. John’s were patients from outside Teton County. As of September 5th, Wyoming has had 858 deaths where Covid was listed as the cause or a significant cause of death. In 2020 Wyoming had 5,983 deaths compared to 5,121 in 2019. Out of the 862 deaths, COVID was the cause or a contributing factor to 528. Based on data compiled by the Economist, nationally and globally excess deaths appear to be vastly undercounted. Recently the Economist published a follow up article with more specific numbers. So, while Teton County has avoided the worst of impacts due to excess deaths caused by COVID, state, national and global excess deaths suggest that it behooves Teton County to keep a lid on COVID infection rates.

That said, Teton County is healthier overall than most counties, so it’s in our favor that excess deaths due to COVID are higher in counties that have poorer health. And our vaccination rate is very high. Almost 99% of the population 12 or older has had at least one shot. This is a stunning accomplishment. And rates of hospitalization and severe illness among those vaccinated for COVID are much lower than among those not vaccinated.

Yet on September 2nd, it wasn’t looking good for our local hospital. Levels of COVID morbidity and trends in infections were headed sharply higher. Around 26% of our hospital’s ICU beds were occupied by COVID patients and about 19% of our hospital’s total beds were occupied by COVID patients. The moving 7-day average hospitalization admissions, hospital bed occupancy, cases, infections were all trending up. Public comment at our county meeting indicated that hospital staff, were strained, worn out and stressed.

To a certain extent, the need for a mask order was based on a race between the more virulent Delta variant and our communities level of vaccination. Based on infections and hospitalizations, the Delta variant seems to be winning. Or perhaps something else is going on that’s preventing the vaccine from protecting the community as I expected it would.

Unfortunately, vaccination rates in surrounding counties are mostly below 50%. Since at least 8,000 people commute into Teton County from these bedroom communities every day, this could be driving our higher rates of COVID and COVID hospitalization.

Whatever the cause, high levels of serious illness relative to local hospital capacity can have dire consequences. Hospitals in Rock Springs are canceling elective procedures so staff can focus on COVID patients. Caseloads in Idaho recently reached levels that hospitals can’t handle without additional support from the National Guard. Schools in Hot Springs County had to revert to virtual learning, stranding kids at home and pulling parents away from their jobs. And caring for COVID patients is exceptionally costly ($51,000 to $78,000 based on age), putting additional stress on our small, rural hospital.

Along with heavy commuter traffic, we are a tourism-based county, and tourism appears to heighten the risk of COVID. I did not find scientific studies on this topic, but many news stories suggest there is a correlation between tourism and higher COVID caseloads and levels of morbidity, mortality and severe health outcomes. Blaine County is similar to Teton County in winter and has experienced worse spikes than Teton County. Coastal cities with high levels of tourism suggest there’s a link between tourism and high caseloads. And heavily visited Black Hills counties in South Dakota experienced spikes in August.

I reviewed economic activity as well. Over the course of last winter, with a mask mandate in place, economic activity was robust. Lodging has been at or above historic levels. Airport traffic is setting records, and sales tax collections are up even compared to 2019. It doesn’t appear a mask order would in any way suppress economic activity.

Furthermore, schools in Teton County are open five days a week for in-person learning, and universal mask wearing appears to be playing a role in that success.

Specific to masks, I think the evidence is compelling that masks, when properly worn, reduce the amount of COVID transmitting aerosol and the distance that it travels upon expiration: “We used a cough aerosol simulator with a pliable skin headform to propel small aerosol particles (0 to 7 µm) into different face coverings. An N95 respirator blocked 99% of the cough aerosol, a medical grade procedure mask blocked 59%, a 3-ply cotton cloth face mask blocked 51%, and a polyester neck gaiter blocked 47% as a single layer and 60% when folded into a double layer.” (Lindsley WG, Blachere FM, Law BF, Beezhold DH, Noti JD. Efficacy of face masks, neck gaiters and face shields for reducing the expulsion of simulated cough-generated aerosols. Aerosol Sci Technol. 2020; in press). And in this study, “Our results indicate that surgical face masks could prevent transmission of human coronaviruses and influenza viruses from symptomatic individuals.”

But masks aren’t perfect: “Airborne simulation experiments showed that cotton masks, surgical masks, and N95 masks provide some protection from the transmission of infective SARS-CoV-2 droplets/aerosols; however, medical masks (surgical masks and even N95 masks) could not completely block the transmission of virus droplets/aerosols even when sealed.” Precautions other than simply wearing masks likely play a much larger role in stemming infections. The fact that COVID cases rose dramatically last fall and winter, with mask mandates in place, clearly suggests that macro factors and levels of adherence to other precautions against COVID can outweigh the effects of a mask mandate.

However my read of much of the science literature on masks and community spread supports a correlation (not necessarily causation) between community wide use of masks and a decline in infections and hospitalizations, other things being equal. In the mask order before us on September 2nd, sources 30 through 40 support a statistically significant correlation between community-wide masking and reductions in mortality and hospitalizations.

There is also evidence, though perhaps less compelling, of a non-trivial probability that, on state-wide or community-wide bases, mask mandates work. For example, this study finds that “Evidence suggests that the potential benefits of wearing masks likely outweigh the potential harms when SARS-CoV-2 is spreading in a community. However, mask mandates involve a tradeoff with personal freedom, so such policies should be pursued only if the threat is substantial and mitigation of spread cannot be achieved through other means.”

This European Center for Disease Control paper was cited by those opposed to the mandate as evidence that mask mandates are ineffective. My take on it is that, while the ECDC concluded that mandates had a low to moderate probability of a positive impact, it gave them a strong nod of approval: “Although there is only low to moderate certainty of evidence for a small to moderate effect of the use of medical face masks in the community for the prevention of COVID-19, the balance of results towards a protective effect across the wide variety of studies reviewed, the very low risk of serious adverse effects and applying the precautionary principle leads us to conclude that face masks should be considered an appropriate nonpharmaceutical intervention in combination with other measures in the effort to control the COVID-19 pandemic…..The evidence regarding the effectiveness of medical face masks for the prevention of COVID-19 in the community is compatible with a small to moderate protective effect, but there are still significant uncertainties about the size of this effect.”

This study from the CDC’s Morbidity and Mortality Weekly report finds a correlation between mask mandates and a reduction in hospitalization growth rates due to covid. “…in this study mask mandates were associated with a statistically significant 5.6 percentage-point decline in COVID-19 hospitalization growth rates (p-value = 0.02) ≥3 weeks after the implementation week. Among adults aged 40–64 years, mask mandates were associated with a 2.9 percentage-point reduction in COVID-19 hospitalization growth rates (p-value = 0.03) <3 weeks after the implementation week. Hospitalization growth rates declined by 5.6 percentage points (p-value = 0.02) during ≥3 weeks after the implementation week.”

And this study finds that “Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7 and 2.0 percentage points in 1-5, 6-10, 11-15, 16-20, and 21 or more days after state face mask orders were signed, respectively.”

Finally, results from a massive study done in Bangladesh found a clear correlation between increased mask wearing and reduced infections: “The increase in mask-wearing reduced infections, showing that mask-wearing avoided 1 in 3 symptomatic infections….This was the first large-scale randomized evaluation to demonstrate the effectiveness of masks in a real-world setting.”

That said, some of the science cited in the health order is not as clear as I’d like it to be. For example, the study cited in this order specific to an outbreak on the USS Theodore Roosevelt study did find that “The findings reinforce the importance of nonpharmaceutical interventions such as wearing a face covering” but also notes some caveats, including that it was a convenience sample: “First, the analysis was conducted on a convenience sample of persons who might have had a higher likelihood of exposure, and all information was based on self-report, raising the possibility of selection and recall biases.”

But the studies cited as evidence against the need for masks were not unequivocal. For example, this study was cited by folks opposed to a mask mandate. It’s based on a review of 67 studies on physical interventions to reduce the spread of acute respiratory viruses and found that “The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalizing the findings to the current Covid pandemic.” My emphasis. Part of the reason for not generalizing to this pandemic is that none of the 67 studies were conducted during the current pandemic.

At least one email cited an article from the New York Magazine Intelligencer section casting doubt on the effectiveness of mask mandates specifically for students in schools. The article focused on this study that looked at a sample of schools with about 50,000 students where masks were required versus a sample of schools with about 43,000 students where masks were recommended but optional. Adjusting for county-level incidence, COVID-19 incidence was 37% lower in schools that required teachers and staff members to use masks, and 39% lower in schools that improved ventilation, compared with schools that did not use these prevention strategies. It’s true that the study did not find a statistically significant lower incidence of COVID-19 in schools with mandates specific to students only (my emphasis): “…the 21% lower incidence in schools that required mask use among students was not statistically significant compared with schools where mask use was optional…” But, “…this study highlighted the importance of masking and ventilation for preventing SARS-CoV-2 transmission in elementary schools and revealed important opportunities for increasing their use among schools. A multicomponent approach to school COVID-19 prevention efforts is recommended (2), and requirements for universal and correct mask use among teachers and staff members and improved ventilation are two important strategies that could reduce SARS-CoV-2 transmission as schools continue, or return to, in-person learning.” That seems to me to say that requiring masks can’t hurt.

I also considered what other agencies were doing, especially those critical to national defense. Indeed COVID interventions practiced by the US Military include a mask mandate very similar to Teton County’s.

I also chose to weigh costs (specifically those associated with infringements on personal freedoms) and benefits by comparing fatality rates due to COVID with fatality rates due to motor vehicle collisions. After all, we’ve adopted widely accepted mandates to wear seat belts and set limits on blood alcohol levels while driving. In 2019 there were 36,096 deaths from highway vehicle crashes, or just under 3,700 per day. In 2017 an estimated 14,955 deaths were avoided by wearing seat belts. In Wyoming in 2019 there were 147 highway fatalities or 25.4/100,000 people. Regarding COVID, as of August 28th Wyoming had 835 deaths due to Covid and WY’s 7-day moving average of Covid deaths per 100,000 was 144, or almost the same number of total highway fatalities in one year. If requiring seat belts to reduce highway fatalities in Wyoming by 70 or 80 is reasonable, is it reasonable to require masks to help bring down COVID mortality rates?

Finally, I believe a mandate is fairer than voluntary compliance to a request. For example, under voluntary compliance, one bar might hold concerts where no one wears a mask, quite possibly raising infection rates and hospitalizations and forcing more workers to quarantine. Meanwhile those in the community who voluntarily wear masks shoulder the load for trying to lower infections and hospitalizations.

There’s little to enjoy about having to instate a mandate. Vaccinations were supposed to bring life back to normal. But state, regional and local COVID infection levels, illness due to COVID and hospitalizations indicate we need to do more to avoid the worst costs of this pandemic. In the community update prior to our decision, the District Health Officer pointed out that wearing masks is like putting on a puffy jacket for an additional layer of protection in sub-zero weather. That may be true if masks are worn consistently, properly and when it matters most—indoors at close quarters and in conjunction with other important interventions such as avoiding large indoor gatherings. But I fear compliance will be low in this community where patience with health mandates has worn thin, when mask wearing is highly politicized, and tempers are high. Alas, a mask mandate is likely more like a layer of dry socks. It’s not the one thing that will save your life. But given the alternative, I think it’s worth the effort.