WASHINGTON (NYTIMES) - As the nation heads into what public health experts are calling a "dark winter" of coronavirus illness and death, public health experts are coalescing around US presidential candidate Joe Biden's call for a "national mask mandate," even as they concede such an effort would require much more than the stroke of a presidential pen.
Over the past week, a string of prominent public health experts - notably, Dr Anthony Fauci, the government's top infectious disease specialist, and Dr Scott Gottlieb, a former commissioner of the Food and Drug Administration under President Donald Trump - have said it is time to seriously consider a national mandate to curb the spread of the virus.
Overseas this week, President Vladimir Putin of Russia became the latest foreign leader to impose a national mandate for citizens to wear masks.
Mr Trump is opposed to a mandate, and Mr Biden has conceded that a presidential order for all Americans to wear masks would almost certainly face - and most likely fall to - a legal challenge.
Mr Biden, the Democratic presidential nominee, echoed the "dark winter" language during the most recent presidential debate, and he is already using his bully pulpit to promote and reinforce a culture of mask-wearing. If elected, he will almost certainly do more.
Mr Biden has already said that, as president, he would mandate masks on all federal property, an executive order that could have wide reach.
He could use his authority under federal transit law to require masks on public transportation. He could also prod governors who are resisting mask mandates to at least require masks in public buildings in their states.
But that is delicate terrain in the United States, where Mr Trump has turned the act of wearing - or not wearing - a mask into a political statement.
Public health and legal experts say it would be far better for Mr Biden - or Mr Trump, for that matter - to use his powers of persuasion to convince Americans that covering one's face to curb the spread of the virus is a patriotic or civic-minded action.
"Instead of making it about the president's coercive authority under law, it should be about whether the president can support a norm that supports public health, which is in people's self-interest," said professor Harold Hongju Koh, a law professor at Yale University and an expert in national security and human rights.
Mr Trump, however, has shown little interest in supporting such norms.
At a rally Wednesday (Oct 28) in Arizona, he mocked California's mask mandate, saying, "You have to eat through the mask."
Experts say there is growing scientific evidence that face masks can considerably reduce the transmission of respiratory viruses like the one that causes Covid-19.
Even when mask-wearing does not prevent infection, some experts argue it may reduce the severity of disease by diminishing the intensity of a person's exposure to the virus. Research also shows that states that have passed mask mandates have had lower growth rates of Covid-19, beginning on the day the mandate was passed.
In a study published last week in the journal Nature, researchers at the Institute for Health Metrics and Evaluation at the University of Washington estimated that "universal mask use" - when 95 per cent of people wear masks in public - could prevent nearly 130,000 deaths from Covid-19 in the coming months, though those numbers are based on certain assumptions and could change if people alter their behaviour.
Currently, only 69 per cent of Americans wear masks, according to data gathered by the institute.
Even so, any hint of a sweeping federal requirement would "go over like a lead balloon" and "divide and harden areas of the country in opposition," said Mr Joel White, a Republican strategist with expertise in health policy.
Mr White said the Trump administration's policy of letting state and local leaders decide about masks was "a far better way to go." But that has not produced the kind of compliance that public health experts say is necessary to reduce the spread of the virus.
As of last week, 33 states and the District of Columbia required mask-wearing in public, according to a list compiled by AARP. But in certain parts of the country, especially heavily Republican states, resistance is deep - even when cases are soaring.
Many people in rural areas view masks as unnecessary for them because they do not live in crowded cities; in North Dakota, coronavirus cases are rising faster than any other state in the nation, but according to the University of Washington's data, only 46 per cent of North Dakotans wear masks.
Governor Doug Burgum, a first-term Republican seeking reelection, is firmly opposed to a mandate, saying that while he favours wearing masks, people should do so out of "personal responsibility."
During a visit to the state Monday, Dr Deborah Birx, the White House coronavirus response coordinator, upbraided North Dakotans after a private meeting with the governor and business leaders.
"Over the last 24 hours, as we were here and we were in your grocery stores and in your restaurants and, frankly, even in your hotels, this is the least use of masks that we have seen in retail establishments of anyplace we have been," she told reporters, according to The Bismarck Tribune.
And this week in Texas, a court fight erupted over Governor Greg Abbott's statewide mask order, which included an exemption for polling places. On Tuesday, a Federal District Court judge declared the exemption invalid. On Wednesday, a federal appeals court halted that order, issuing a temporary stay to give the court time to consider an appeal.
Some public health experts fear that Mr Trump - who routinely mocks Mr Biden for wearing masks and whose aides often forgo them even as the White House has become its own coronavirus hot spot - has so poisoned the discussion around masks that wearing them will always be construed as a political statement.
"This is the biggest challenge that is going to be facing an incoming administration - assuming a new administration comes in," said Dr. Leana Wen, a former health commissioner for Baltimore.
Experts are floating ideas about how to change norms. Major retailers like Walmart and Target already require masks in their stores.
Democratic Representative Donna Shalala, who was President Bill Clinton's health secretary, said she would get other business leaders on board.
She also suggested that insurance industry executives might be persuaded to adjust their policies to require that businesses mandate mask-wearing by customers and employees in order to receive coverage.
"You simply require it for getting something that you have to have," she said. "That's how we drove cigarettes out of buildings."
Dr Joshua Sharfstein, a professor at the Johns Hopkins Bloomberg School of Public Health, said the federal government could write "a model policy that states and cities could follow."
Dr Helen Burstin, chief executive of the Council of Medical Specialty Societies, said there is ample precedent for the federal government to impose restrictions - or create financial "sweeteners" for states to do so - when public health is at stake.
In a 2005 transportation bill, Congress allocated $500 million (S$683 million) for states that had laws making it a crime for drivers not to buckle their seat belts. Today, seat belts are required in the front seat of cars in every state except New Hampshire.
In 1974, Congress imposed a national highway speed limit of 55mph, effectively seizing a state responsibility.
"There's a presumption that a mask mandate would have to be backed up with fines and set off scuffles with law enforcement," Dr Gottlieb wrote in an opinion article published Monday in The Wall Street Journal.
But, he added, that is not necessarily so: "There are lots of things we do because there is a community expectation of civil behaviours: No shoes, no service. Clean up after your dog. Many of these are even codified in city ordinances."
There is some evidence that norms are changing.
Mr Chris Christie, the former governor of New Jersey, is now proselytising about wearing masks - a lesson he took away from his own bout with Covid-19, which he believes he contracted either at a ceremony at the White House's Rose Garden for then-Judge Amy Coney Barrett's nomination to the Supreme Court or during debate preparations with the president.
In a recent opinion piece in the Journal, he offered his readers some advice: "Wear it or you may regret it - as I did."