Nine months after the pandemic that killed more than 320,000 people in the U.S., Kim Larson is still trying to convince others in her northern Montana county that COVID-19 is dangerous.
As the director of the Hill County’s Department of Health and the county health officer, Larson keeps hearing that the coronavirus is like a bad case of the flu. Around the time Montana’s governor ordered face-coverings in July, her staff saw notes in the windows of several companies denying the state’s right to issue such emergency orders.
For a while, the county of 16,000 along the Canadian border didn’t see much evidence of the pandemic. Only one COVID case was known as of July. That all changed, however, when the nation saw its third surge in the virus in the fall. By mid-December, Hill County had registered more than 1,500 cases – the vast majority since October 1 – and 33 people had died there.
When Larson overhears people say the pandemic safety rules should end, she talks about how contagious the COVID virus is, how some people have enduring effects, and how hospitals are so full that disease care is delaying can.
“We’ve seen the fight before in public health, but you usually have the time to gather your evidence. Research has shown that this really saves lives,” Larson said. “In the middle of a pandemic, you don’t have time.”
Public health laws tend to come long after the shift in social norms and confirm the widespread acceptance that changing habits is worth the common good and that it is time for latecomers to reconcile. But even if decades of evidence shows that a rule can save lives – like buckling up or not smoking indoors – the debate continues in some places with the well-known argument that public restrictions violate personal freedoms. However, this fast-moving pandemic does not offer society the luxuries of the times. State mandates have hired local officials to change behavior while general understanding catches up.
Earlier this month, U.S. Surgeon General Jerome Adams stood next to the governor of Montana in Helena and said he hoped people would wear masks because that’s the right thing to do – especially as hospital stays from COVID increase.
“You don’t want to be the reason a woman at work can’t get a hospital bed,” said Adams, adding a vaccine was on the way. “It’s just a little longer.”
He spoke days after state lawmakers clashed over masks, when the majority of Republican lawmakers came to a committee meeting touting at least one piece of false information about the dangers of masks. By December 15, the Republican majority had not needed masks for the upcoming legislative term, which was due to begin January 4.
And now a group opposed to masks from Gallatin and Flathead counties has filed a lawsuit asking a Montana judge to block the state’s safety rules related to pandemics.
Public health laws usually spark political battles. Changing people’s habits is difficult, said Lindsay Wiley, director of the program of health law and policy at American University in Washington, DC. Despite the misunderstanding that there was a universal buy-in for masks during the 1918 pandemic, some protesters deliberately built rap arrest sheets for becoming maskless in the name of freedom.
She said health officials recognize that any health constraint during a pandemic requires the public’s trust and cooperation for success.
“We don’t have enough police to go around forcing everyone to wear a mask,” she said. “And I’m not sure we want them to.”
Local officials have the best chance of gaining that support, Wiley said. And when elected leaders like President Donald Trump reject his own health policies, it becomes more difficult. In the meantime, public shame like naming exposed people who are selfish or stupid can backfire, Wiley said because if they gave in to wearing masks they would essentially accept those labels.
In the history of public health laws, even rules that had time to produce generally accepted evidence were not guaranteed.
In Montana, it is illegal to drive a moving car without a seat belt. But as in 13 other states, the authorities are not allowed to drag people over for unbuckling. Every few years, a Montana lawmaker, backed by a rally of public health and law enforcement organizations, proposes law to allow seatbelt stopping, arguing it would save lives. In 2019 that request didn’t even make it out of committee, suppressed by the arguments of personal choice and not giving the government too much power.
The main points of opposition to public health laws – whether masks, seat belts, motorcycle helmets, or smoking – may sound the same.
When Missoula County became the first Montana location to ban indoor smoking in public spaces in 1999, opponents said the change would destroy businesses, impossibly enforce and violate people’s freedom of choice.
“They’re the same arguments in many ways,” said Ellen Leahy, director of the Missoula City-County Department of Health. “Public health was precisely at this intersection between what is good for the community as a whole and the rights and duties of individuals.”
Montana passed an indoor smoking ban in 2005, but many bars and taverns were set up by 2009 to keep up. And in some places, debates and court battles continued for a decade to see how the ban could be enforced.
Amid the COVID pandemic, Missoula County was once again ahead of much of the state when it passed its own mask ordinance. The county has two hospitals and a university, which is growing in population with students and commuters.
“If you have to see it to believe it, most likely you will see the effects of a pandemic in a city first,” Leahy said.
Compliance was not perfect and she said the need for strict enforcement was limited. In early December, of the more than 1,500 complaints handled since July, the Missoula Health Department sent shutdown notices to four companies that violated the regulations.
In Hill County, when the health department receives complaints that a company is violating pandemic mandates, two part-time health hygienists who conduct company health inspections speak to owners about why the rules exist and how to live by them. It often works. In other cases the complaints keep coming back.
District Attorney Karen Alley said local health officials reached out to her office with complaints about non-compliance with COVID safety measures, but she did not see enough evidence to initiate a civil case against a company. Unlike other health laws, mask rules did not have case studies to provide a framework for enforcing them by the courts in Montana. (A handful of cases against companies circumventing the COVID rules were still pending in mid-December.)
“Someone has to be the test case, but you never want to be the test case,” said Alley, who is part of a team of three. “It’s a lot of resources, a lot of time.”
Larson of the Hill County Health Department said her focus is still on engaging the community. And she’s happy about some progress. The city’s annual live nativity scene, which usually draws crowds with hot cocoa, became a drive-by event this year.
She doesn’t expect everyone to obey the rules – that is never the case in public health. But Larson hopes enough people will slow the virus down. That could happen. In mid-December, the count’s daily active cases declined for the first time since the peak began in October.
“They are just trying to figure out the best path for your community and get their contributions,” Larson said. “Because we need the community’s help to stop it.”
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
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