Nationally, available data from the CDC and other sources reveal that Black and Latinx Americans account for a disproportionate number of COVID-19 related cases, hospitalizations, and deaths.1–4 A vast and growing body of research suggests that racial disparities in mortality are associated with underlying differences in comorbidities that are shaped by the influence of structural racism and access to health care.5,6 Because COVID-19 is a novel coronavirus, the public, elected officials, and even scientists are continually learning how to mitigate its devastating impact. While the learning curve may be slow in some ways, there is widespread scientific agreement regarding the use of facial coverings to slow, if not prevent the spread. By mid-July 2020, masks were mandatory in 21 states, with more states considering the adoption of such policies.7 Yet, mask usage in the U.S. has proved controversial and selectively adopted.
In June of 2020, a national poll found that less than two-third of Americans agreed that it was important to wear a mask8 and only a slightly higher percentage (73%) of Americans stated that they had worn a mask in a public setting.9 Researchers have sought to uncover political, social, and cultural factors that shape mask usage, finding that political affiliation and voting patterns shape adherence to public health guidance regarding masks.8,10 Other studies have extended this work, finding that following specific news sources is associated with knowledge and perceptions of COVID-1911 which shape mask usage and efforts to socially distance.12 Adoption of mask wearing has not only been mixed in the U.S., it has also led to contentious public debates about mask mandates which are believed by some to infringe on civil liberties. Further contributing to uneven mask usage is a significant amount of misinformation circulating regarding the effectiveness of masks, creating what public health experts have called an “infodemic.”13
Few studies have explored other social or cultural factors that underlie mask usage, especially considering the continued severity of the pandemic and striking racial/ethnic disparities in COVID-19 infections and outcomes. It is important for researchers to understand when and in what contexts Americans feel compelled to wear masks specifically and follow public health guidance more generally. It is plausible, for example, that reasons for refusing to wear a mask may differ by race or ethnicity. While some White Americans contend that mask requirements infringe on their civil rights,13 there may exist a mask conundrum for Black Americans. After mask requirements were implemented across the country, several news outlets featured stories highlighting the concerns of Black communities regarding the risk of police profiling of Black men wearing face coverings.14–16 By early June, multiple accounts of Black men targeted for wearing masks - and for not wearing masks - were documented across the country.17 This lose-lose scenario is epitomized by Aaron Thomas, an educator in Ohio: “I want to stay alive but I also want to stay alive”.18 At the same time, survey data showed that Black and Hispanic Americans were more likely than White Americans to report concern that they would require hospitalization from COVID or unknowingly spread the disease to others, supporting mask wearing among these populations.19
Because severe COVID-19 cases and associated deaths have been concentrated in communities of color in the U.S., it is possible that mask wearing reflects different perceptions of risk related to COVID-19 exposure and outcomes. More specifically, because American communities continued to be segregated by race,20 white Americans may feel less vulnerable to COVID-19 because fewer individuals in their close proximity may have become infected or have been killed by this novel illness. This in turn, may be associated with individuals’ decisions to wear masks to protect others around them. There is compelling evidence that contemporary forms of racism such as color-blind racism or racial apathy are common among white Americans.21,22 It is important to consider, therefore, whether White Americans may not be as motivated to wear masks if this practice is perceived primarily as helping nonwhite Americans. According to prominent pediatrician, public health advocate, and scholar Rhea Boyd, “opposition to public health interventions, like masking, have also become a material manifestation of America’s racism, particularly anti-Black racism”.23 In this study, accordingly, we ask whether decisions to wear masks is associated with who is dying from COVID-19 in the surrounding community. To our knowledge, this is the first study to quantitatively examine how mask usage relates to differential outcomes in COVID-19 deaths by race.