A Great Divide: Kansans Line Up on Opposite Sides of a Mask Mandate

They called it a “natural experiment.” It wasn’t a randomized controlled clinical trial—there was no working hypothesis, no end points were set. The “intervention” group was the 24 counties that complied with Gov. Laura Kelly’s June 9 statewide mandate on mask wearing, effective July 3. The control group was the 81 counties that chose to opt out (as permitted by state law). The test site was Kansas, population 2.9 million—of whom some 1 million were not convinced of the need for masks.¹

On August 5, in a televised news conference, Lee Norman, MD, secretary of the Kansas Department of Health and Environment, showed a simple chart that basically described what had happened in Kansas between July 12 and August 3, plotting the difference in COVID-19 cases between counties requiring masks and those that didn’t. The chart would spark controversy—but also, perhaps, change.

Norman compared the number of cases per 100,000 people in each county in the 2 groups, on a 7-day average. An orange line on his chart showed a distinct and drastic drop in cases in the compliant counties, versus a blue line cutting a steady course through the noncompliant counties. “What we’ve seen through this,” Norman said, “is that [in] the counties with no mask mandate, there’s been no decrease in the number of cases per capita.” In fact, there was an increase. By mid-August, the seven-day rolling average incidence had dropped by 6%, to 16 cases per 100,000, in the mandated counties. By contrast, it had increased by 100%, to 12 per 100,000 in the non-mandated counties.^2,3

Pushback

The mask mandate itself was extremely controversial in Kansas. So, it wasn’t surprising that the chart also inspired pushback. The information wasn’t inaccurate, but the way Norman presented it was, the critics charged. The lines for the 2 groups followed separate vertical axes, making the differences appear “more dramatic.” An analysis by 2 leading newspapers, the Kansas City Star and the Wichita Eagle, however, “broadly confirmed” Norman’s data.4 And a November 20 US Centers for Disease Control and Prevention (CDC) report further supported Norman’s July findings: During those first 2 weeks, “Kansas counties that had mask mandates in place appear[ed] to have mitigated the transmission of COVID-19.”3 This, despite the fact that the mandated counties started out with high case rates.

At least 13 of the 24 mandated counties also recommended or mandated other mitigation strategies, such as limits on the size of gatherings and restaurant occupancy, which may have had a “synergistic effect,” the CDC report says. But sensitivity analyses pointed to mask use as being critical.³

For months, Kansas had kept the case numbers down. Kelly was the first governor in the country to close school buildings, for instance. But the advantage disappeared. Norman tweeted in July that Kansas was a “shining example of success, only to squander it.”5 “Sad,” he wrote. “Kansas is now as of today in the top 14 states for the MOST rapid COVID-19 spread and in the top 14 states for having the LEAST restrictions on activities. [Another analysis put it at a tie for 13th place.] Do you think those 2 things are related?”⁶

Inevitably, the lines between the 2 groups blurred. Borders between counties are permeable, people mingle. One week into the statewide mandate, 1 in 4 Kansans was under no obligation to wear a mask.

Thus, hospitals have been flooded with patients from both “sides” of the issue. According to the Kansas Department of Health and Environment, between July 18 and November 25, the number of adults hospitalized with confirmed or suspected COVID-19 went from under 300 to nearing 1200.⁷ Statewide, about 37% of staffed ICU beds were available at the end of November. Hospitals in Topeka, Wichita, and Kansas City were holding patients in recovery rooms, emergency departments, and converted hallways while they waited for beds.⁵

The counties with mandates account for about 2/3 of the state’s population and contain most of the urban areas. October was the deadliest month of the pandemic in the Kansas City metropolitan area, surpassing 50,000 total cases, with 176 deaths.8 And that was before the Thanksgiving holiday.

A map of Kansas shows a few lonely islands of mask wearing in a sea of noncompliance. Winfield, in Cowley County, is one. William Newton Hospital, Winfield’s main hospital, has a catchment area of about 5 counties. The number of cases in Cowley County has increased significantly over recent weeks, with at last count 1579 cases (Winfield, the county seat, has a population of just over 12,000). That’s actually at the low end. In neighboring noncompliant Sedgwick County, which has another mask-wearing island in Wichita, for instance, cases topped 27,000 at last count, with 150 deaths.⁹

‘Well Trained’

The hospital is as prepared as possible. Melanie Burnett Wilson, clinical educator and infection control coordinator, says, “We’re doing OK for [personal protective equipment (PPE)]. We look daily, we count daily, and we re-fit–test our staff for the multiple sizes of N95s that we’ve had to purchase. We do that because their safety is the number-one thing for us. Our CEO has been amazing with realizing the lengths we have to go to protect our staff. He doesn’t want the staff to take chances with their safety.”

Wilson has worked in infection prevention for 4 years, but says, “I guess you could say I’ve actually worked even longer than that—every nurse works in infection prevention and I’ve been a nurse for almost 18 years here at the hospital.” To meet the pandemic-related demands, she says, “I’ve held additional training on donning and doffing of PPE, handwashing, and safely transporting patients. Together with the environmental services manager, we’ve worked with the environmental services (EVS) staff to ensure that they’re well trained on the proper time to wait before going in to clean, and how to properly clean the COVID-19 rooms after dismissal or transfer.”

The coronavirus came late to the Midwest, especially to the rural areas that make up huge swaths of Kansas. In part because for months it seemed to be a “coast/city” problem, doubts about its seriousness have lingered. But long before the case count picked up speed, health professionals knew that wearing masks was one thing that could help slow it. And that made watching the soaring hospital admissions even more difficult. “I keep seeing the younger patients come in, and those being admitted to the units at my colleagues’ hospitals,” Wilson says, “and it makes me sad. Sad that more people won’t take it seriously, sad that it was made a joke of by so many on social media, and sad that such a simple gesture as putting on a mask to protect those around you is such a hardship. I see many of the healthcare providers so worn out from working themselves to the bone to take care of these patients now that it has hit the Midwest, and then we leave and we see people walking in and out of the stores with no mask. We want to stop and get something to eat on the way home from work, but do we dare, when the people inside the restaurant aren’t wearing masks? Not even those that are serving the food? Nope, we turn around and head home for a PB&J, safer and we know who made it and we can go to bed with a little peace of mind.”

Tricky Situation

The increasing pressure on hospital services is intensified by a winter that experts say will bring a double whammy of a third wave of COVID-19 cases as well as influenza before it’s all through. At William Newton, Wilson says, “We’re preparing for the addition of 2 more COVID-19 rooms on our med/surg floor by making the change to a negative pressure airflow.” But, she adds, “we have to keep the balance between COVID-19 preparation and keeping enough staff and medical care available for our normal cases of winter illness or falls or influenza.

“It will be tricky this year no doubt,” she says, in what may be an understatement.

As the COVID-19 cases have skyrocketed, Gov. Kelly has issued a new statewide mask mandate, which went into effect November 25.⁵ Like the previous one, the new mandate allows counties to tailor the rules, giving them flexibility, Kelly said in a news conference. Counties without a local order will come under the statewide restrictions, although state law still gives county commissioners the ability to opt out.

Maybe the escalating COVID-19 numbers have changed some minds—especially since that “natural experiment” provided visible irrefutable proof that masks could be effective. A number of counties recently decided to “opt back into” the original mandate, Kelly said, and “we’ve seen more that have created their own ordinances.” The mandate also picked up “a surprising amount of support” from the Republican-led state legislature, and a variety of groups around the state, including the Chamber of Commerce. “It’s encouraging, quite honestly,” Kelly said.

A public health campaign led by the Kansas Hospital Association, Kansas Chamber of Commerce, Kansas Farm Bureau, and others is urging Kansans to wear masks, get tested when necessary, and avoid mass gatherings. Kelly has also launched an “influence” campaign, in which community leaders, such as pastors, business owners, and coaches, will “use their influence to combat the virus.”⁵ Kansas is at a “make or break moment,” Kelly said.

But will it be enough to stem the tide? Time will tell. So far, the “experiment” is ongoing—and it’s ever more frustrating for overworked healthcare professionals.

Wilson says, “We look at one of the kids being wheeled in that can’t breathe because they went to a party a few days ago, they hadn’t been to one in months, ‘it was just for an hour,’ and today they just can’t stand that headache any longer, the sinus problem is a bit worse today, and they can’t seem to smell anything. They just wanted to check because they live with their 90-year-old grandma and she hasn’t been doing too well the last few days.”

Kansans are tired of hearing about the virus, tired of being told what to do, she says. But “we, as healthcare providers, are also tired of hearing about ‘it.’ Tired of wearing masks, tired of dry skin from washing our hands hundreds or thousands of times.” Emphatically, “We’re tired of all of ‘it.’”

In an article posted on the Kansas City Star’s website in November, Kansas House Minority Leader Tom Sawyer said, “whether we like it or not, the pandemic isn’t going away…. It’s a harsh reality to face, but we must face it.”⁵

As the times change, some tunes change. Also, in November, Kansas House Majority Leader Dan Hawkins—who in August accused Norman of misleading the public about masks—said Kansas can turn the corner on the virus “if everyone takes personal responsibility, treats the virus seriously and respects one another.”¹⁰

JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

1. Shorman J, Hardy K. ‘People don’t want to be forced.’ How Kansas mask mandate became political tussle. The Wichita Eagle. July 08, 2020 04:49 PM, Updated July 09, 2020 06:52 AM. https://www.kansas.com/article244091222.html. Accessed 11/30/20.

2. Kansas’ ‘natural experiment’ shows masks work, state health official says. Wyandotte Daily. Aug. 5, 2020.
http://wyandottedaily.com/kansas-natural-experiment-shows-masks-work-state-health-official-says/. Accessed 11/30/20.

3. Van Dyke ME, Rogers TM, Pevzner E, Satterwhite CL, et al. Trends in county-level COVID-19 Incidence in counties with and without a mask mandate – Kansas, June 1 – August 23, 2020. MMWR Morb Mortal Wkly Rep 2020 Nov 27;69(47):1777-1781. doi: 10.15585/mmwr.mm6947e2. Accessed 11/30/20.

4. Shorman J, Hardy K. Kansas began requiring masks, then virus cases dropped. Weeks later, ‘the data is solid.’ The Wichita Eagle. Aug. 16, 2020 05:00 AM, updated Aug. 16, 2020 09:31 AM. https://www.kansas.com/news/politics-government/article244959870.html. Accessed 11/30/20.

5. Shorman J. Kansas Gov. Kelly issues new statewide mask mandate as COVID-19 infections soar. The Kansas City Star. Nov. 18, 2020 04:01 PM, updated Nov. 19, 2020 10:51 AM. https://www.kansascity.com/news/coronavirus/article247270469.html. Accessed 11/30/20.

6. Tidd J. Kansas has 13th-fewest restrictions and 13th-fastest coronavirus spread, studies find. The Wichita Eagle. July 07, 2020 09:01 PM, updated July 07, 2020 08:31 PM. https://www.kansas.com/news/coronavirus/article244071972.html. Accessed 11/30/20.

7. Kansas Department of Health and Environment. COVID-19 cases in Kansas. Hospital capacity: Adult hospitalizations. Chart. https://www.coronavirus.kdheks.gov/160/COVID-19-in-Kansas. Accessed 11/30/20.
https://www.kansascity.com/article246748236.html. Accessed 11/30/20.

8. Moore K. Kansas City’s deadliest month: October hits record 176 COVID-19 deaths. The Kansas City Star. Oct. 28, 2020 10:09 AM. Accessed 11/30/20.

9. The New York Times. Kansas COVID-19 Map and Case Count. Updated Nov. 29, 2020, 8:33 PM ET. https://www.nytimes.com/interactive/2020/us/kansas-coronavirus-cases.html. Accessed 11/30/20.

10. Associated Press. GOP Leader says Kansas health chief misled public on masks.
https://www.ksn.com/news/health/coronavirus/coronavirus-in-kansas/gop-leader-says-kansas-health-chief-misled-public-on-masks/. Aug. 11, 2020 08:01 AM CDT, updated Aug. 11, 2020 08:05 AM CDT. Accessed 11/30/20.