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In graphics: How covid-19 infections have skyrocketed in states that have not required face masks

The list of governors who ordered face masks to be used in public has grown in response to the uptick in coronavirus cases in the United States. The states that are reporting the worst outbreaks have one thing in common: they do not require (or until recently did not require) the widespread use of face masks.
6 Jul 2020 – 08:07 PM EDT

Under growing public pressure, President Donald Trump on Wednesday finally endorsed wearing face masks, although his reasoning left some scratching their heads.

“I’m all for masks,” Trump said during an interview, despite previously saying the image didn’t suit a wartime president, and accusing reporters of wearing them to be politically correct.

But Trump insisted there was still no need for a national mandate despite a sharp rise in coronavirus cases.

The example set by Trump’s attitude to face masks reflects a national dilemma that has seen each state adopt its own measures, resulting in a patchwork of policies that public health experts have criticized for allowing the virus to continue to spread.

"The science is clear"

The Florida Medical Association President Dr. Ronald Giffler issued a statement last week saying that wearing a facemask can save lives.

“The science is clear. Asymptomatic infected individuals can release infectious aerosol particles while breathing and speaking. Not wearing a mask or face covering increases exposure, whereas universal masking greatly reduces the spread of viral particles,” Giffler said.

Some states, cities and counties have adopted mandatory facemask ordinances, both in stores and anywhere outdoors, except for people exercising or with certain medical conditions that affect their breathing.

Some 18 states have required the mass use of facemasks by the general public, Texas being the latest addition on Thursday, according to the National Governor’s Association.

Six states have drawn up criminal charges or citations for non-compliance with face mask ordinances, while six have chosen to impose fines, according to the COVID-19 US State Policy Database created by the School of Public Health at Boston University.

Some 19 states have limited orders requiring facemask use only by certain businesses that require close personal contact, such as hairdressers.

States that imposed early mandatory facemask orders for the general public, mostly in the North-East and Mid-West – such as New York, New Jersey, Michigan and Illinois – have been better able to control the spread of the virus, in some cases managing to flatten and reduce the curve.

In states that have chosen not to impose widespread use of facemasks, they have generally seen a spike in new cases, in some cases at alarming rates of growth, such as in Florida and Arizona. Texas also saw a dramatic spike in case numbers, prompting the Governor of Texas, Gregg Abbott, to end his resistance to mandatory facemasks, while also imposing a $250 fine for those caught without one.

California has also seen a major spike in cases, prompting it to impose a facemask ordinance on June 18, however it has yet to see a decline in the coronavirus spread.

"Significant decline"

In a study published of state mandates published online, professors Wei Lyu and George L. Wehby found “a significant decline in daily covid-19 growth rate after mandating facial covers in public, with the effect increasing over time after signing the order.”

Specifically, the daily case rate declined by about one to two percentage-points over time. While that might seem small they calculated that between 230,000 to 450,000 covid-19 cases may have been averted as a result, prior to the study ending May 22. The spike in cases in the southern states over the last two weeks likely has added thousands more cases to that calculation.

They also found no evidence of declines in daily covid-19 growth rates with employee-only mandates in stores and businesses.

Political factor

There is also a noticeable ideological divide. Most states that have imposed facemask requirements are run by Democratic Party governors who say public health must be the top priority. Those that do not are generally Republican-controlled, where political leaders say they prefer to respect individual choice.

“We have smart political leaders, but their belief systems are getting in the way of their intelligence,” said José Szapocznik, a professor of public health at the University of Miami.

So far, in most states where cases are rising, hospitals have been able to cope, in large part because the majority of new cases involve younger, healthier people.

“Young people are not getting hospitalized by huge numbers,” said Szapocznik. Still, he said, “there are more younger people being hospitalized because more younger people are getting the virus because they’re not used to wearing masks.”

After weeks of being stuck at home in Miami, young people flocked to local restaurants and dance clubs after they were allowed to reopen June 4. Social distancing rules required use of facemasks on the dance floor, in close proximity to others, but not at tables.

"I still got it"

“My friends and I have been trying to be really good about it. We don’t kiss when we greet eachother and we do the elbow thing. But I still got it (covid-19),” said Sofia, 22, who asked that her last name not to be used. She said she believes she got the virus after her brother went dancing at Tucandela Bar in Miami. “ I feel bad because it was five days before I got tested. I could have spread it in places I’ve been, like the supermarket,” she added.

Health officials worry that could change if older, and less healthy people end up being infected. Sofia and her brother are now quarantined in theibedrooms. Their parents also got tested but the results came back negative.

The larger number of young covid cases is likely due to more testing which means is that the outbreak across the south is being recognized at a somewhat earlier stage than the first outbreak in New York was, experts say.

“That’s a good thing because it means that if there’s any window of opportunity for action, it’s like right now and things you do now will have great consequences,” said William Hanage, an epidemiologist at Harvard University, during a conference call with reporters.

Otherwise, community transmission will continue to grow rapidly and reach those who are most at risk.

"In time, those people will start to go to the hospital and they will start to die. May not be immediate. Maybe a couple of weeks, maybe a little bit longer, but it will happen," Hanage warned. The latest spike in the positive cases was especially troubling, he added, because "it's happening in a far larger total population than the outbreaks in the spring were.

Which is why health officials say protective measures, such as facemask, social distancing and washing of hands, is so important. “The outcome is dependent on the behavior of the people more than it does on the public health system or the state government. If people are ignoring the epidemic, it’s going to be very hard to control. And leadership should inspire people to be more cautious,” said Barry Bloom, a public health professor at Harvard University.

The less severe symptoms could also be the result of a mutation in the virus, creating a weaker strain. “Viruses don’t want to kill the host. The virus dies when the host dies,” Dr Andrew Pastewski, the ICU Medical Director at Jackson Medical Center in Miami, told Univision.

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New medical treatments are also helping as doctors learn more about the disease. One medicine Remdesivir is credited with helping covid patients recover faster, reducing the burden on hospitals.
But, as cases rises, hospitals are beginning to reach capacity, especially in Arizona and Texas, causing states to step back from planned reopening of their economies. “As the numbers go up it’s going to hurt the economy again. The only way we are going to save the economy is by getting the virus under control,” said Szapocznik.

Florida and Texas moved quickly this week to close bars and gyms. Counties in South Florida closed their beaches for the July 4th weekend. Miami-Dade County, the largest in Florida, also implemented an indoor and outdoor mandatory facemask order, as well as closing some entertainment businesses, and a 10pm curfew.

Even after Florida reported a new record in daily cases, 10,019, on Thursday, the governor of Florida still declined to order everyone wear facemasks in public.

“The amazing thing is that we knew exactly what to do to bring the numbers down, and what not to do. And we are choosing to do what brings the numbers up,” added Szapocznik.

Sources and Methodology: The map and charts reflect only state-issued orders, not those approved in cities or counties. Each state's ranking is based on data collected by the National Association of Governors and Univision News. The dates of issuance of the orders to stay home, reopening and requirements to wear masks in public come from the database COVID-19 US State Policy database, created by Professor Julia Raifman and students from the School of Public Health of the Boston University. The case and death data comes from the Johns Hopkins Center for Systems Science and Engineering. They appear on the dates they were reported and do not include all infections, only those detected.