Commissioner Byron Reed addresses board members about masks during a Board of Health meeting at the Eastern Idaho Public Health building on Thursday, July 9, 2020.

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In Teton County, the cities of Driggs and Victor have already mandated masks.

If eastern Idaho regional officials approve an order Thursday, "social events and gatherings" could be limited and masks could be mandatory across the county, according to a meeting agenda posted Wednesday.

Compared to the other seven counties that Eastern Idaho Health District's Board of Health administers health policy for, Teton has the highest number of active cases relative to its population, which places it in a higher coronavirus risk level, according to a regional pandemic response plan that the board adopted Tuesday.

Bill Leake, who serves as a trustee representing Teton County on the regional board of health, told the board that the local mandates in place are widely followed, but a county mandate could clear up confusion.

"People are pretty much abiding by it," Leake said. "It actually (would make) it easier for our community if it was at least countywide because we have a lot of businesses outside of the city."

Any mandates that a health district issues would have to carry misdemeanor charges for violators, which could lead to $1,000 in fines and 6 months in jail, attorney Michael Kane told the board last week. Kane, who advises health districts, said cities are allowed to levy lesser punishments with their mandates, such as a simple $100 fine.

Pandemic plan adopted

The mandate discussion came after the Eastern Idaho Board of Health modified and approved a tiered-pandemic response plan that it has discussed for weeks. That plan outlines how regional and local officials should pursue public health recommendations and policies.

The plan sets criteria for four pandemic risk levels in the region — minimal, moderate, high or critical coronavirus risk. Eastern Health District released the plan last week. The board heavily modified the plan at Tuesday's meeting.

Eastern Idaho is currently in the plan's lowest risk level — minimal. 

Two significant changes were made to the plan on Tuesday: a mask mandate was pushed up from high-risk level to moderate-risk level, returning to the same place it was before members tweaked the plan last week; and the metrics to determine how some rural counties will reach the moderate risk level were modified. 

The plan doesn't set in stone any mandates by the health board or local governments. Even if the region reaches a certain risk level, the board must hold a public meeting to vote on whether to adopt a specific order and that order could be tailored toward one area or region-wide.

At least two mandates are included in the plan at different risk levels: a mask mandate in the moderate risk level and a stay-home order, in the critical risk level.

Since last Thursday's meeting, the board solicited comment on the draft plan. Health district director Geri Rackow told the board that 42% of the 498 comments submitted before Tuesday's meeting were in favor of masks.

Last week, a draft of the plan called for a mask mandate in the moderate risk level, but board members pushed it into the high risk level citing concerns with enforcement.

At Tuesday's meeting, several infectious disease experts in the Idaho Falls area pleaded with the board to adopt masks now. Hospitals here aren't overloaded yet, they said, but a mask mandate could drastically reduce the spread of the coronavirus and preserve resources.

Dr. Jared Morton, who directs the hospital program at Mountain View Hospital, told the board that masks work. He referenced a University of Iowa study published last month that indicated "states in the US mandating use of face masks in public had a greater decline in daily COVID-19 growth rates after issuing these mandates compared to states that did not issue mandates."

"As soon as you can possibly do it, please consider it strongly," Morton said of a mask mandate.

Dr. Kenneth Krell, who leads Eastern Idaho Regional Medical Center's coronavirus response effort, told the board that low testing and delays in test processing make it difficult to know how widespread the virus is here.

"We don't know how many cases we have," Krell told the board. Masks can drop the rate of infection spread by half, he said. "We don't have time to wait. We simply don't."

After the medical professionals spoke Tuesday night, board members reversed their previous call and moved the mask mandate back to the moderate risk level. That move came after a tense discussion between board members who sparred over whether to adopt the mandate now, in the plan's minimal risk level, as several doctors urged.

Board Chair Bryon Reed, and health district administrator James Corbett, said a regional mandate isn't right just yet.

Quoting founding father Alexander Hamilton, Reed said: "'Real liberty is neither found in despotism or in the extremes of democracy but in modern government.' I think we've got to be careful of that ... I understand that all the (medical) professionals are saying (to mandate masks now). But we play a different role. We are representatives of the community."

Dr. Barbara Nelson, the board's physician representative, has consistently said a mask mandate is crucial. "I think we're already behind and we should have done it weeks ago," she said.

Corbett, who helped draft the pandemic response plan, said the board should hold off on a mandate until the pandemic worsens, and that a mandate could be tailored toward a specific city or county, rather than a region-wide mandate.

"I don't think it's a one size approach," he said. "I think we should use (mandates) effectively, should we get to that approach."

Where we are

Eastern Idaho is currently in the best of the four risk tiers, or at the minimal risk level. According to the health district's coronavirus tracker on Tuesday, the region has 5.3 active cases per 10,000 — a key metric the plan uses to determine risk levels, along with indications that hospitals are at risk of being overwhelmed with patients. The plan, which had not been released as of Tuesday afternoon, says these metrics must be met multiple times a week for the region to enter another stage.

If active case rate rises to 10 per 10,000, or if 90% of ICU beds are occupied, the region would enter moderate risk level.

That same rate applies to most counties in the health district to reach moderate-risk level, but board members on Tuesday made an exception for rural counties, saying counties with less than 25,000 residents should need 15 cases per 10,000 people. One example cited as was that if Clark County, which has no confirmed or probable COVID-19 cases, notched just 2 cases, the county would jump it into moderate risk level.

The board applied those special metrics to two counties — Custer and Lemhi — for "both moderate and high risk categories," according to health district spokesperson Mimi Taylor. Clark will be monitored on a case-by-case basis for both moderate and high risk categories.

Representatives for Fremont and Teton, which share a border, opted to stay in the 10 cases per 10,000 people metric. Fremont's rate of active cases, as of Tuesday night, was 3 per 10,000 people.

Eastern Idaho's three most populous counties — Bonneville, Jefferson and Madison — also remain under the 10 active cases per 10,000 people metric.

For those three counties, along with Teton and Fremont, to reach high risk level, the board would look to metrics such as: If the active case rate rises to 20 per 10,000; or if an outbreak occurs at high risk facilities, such as a police department, a hospital, a school or a nursing home.

Eastern Idaho has largely been spared from the unprecedented surge in cases statewide that follows a monthslong process to lift restrictions on social interaction. Cases also remained low here throughout the state's stay-home order in March and April.

In recent weeks, though, area public officials have warned that rapid rises statewide and in neighboring states signal that eastern Idaho's cases will likely rise soon. Experts have also said that delays in testing and sparse testing data prevents them from fully understanding how widespread the virus is locally.

Idaho is currently in Stage 4 of Gov. Brad Little’s four-stage reopening plan. The stage was extended twice, over the past month, as Idaho’s COVID-19 cases rose to more rapidly than ever, sometimes topping national lists for the rate of case increases and for the rate of tests that return positive, which health officials say is a sign that a state is not testing enough people.

After Little largely handed off control of the pandemic to local governments a few weeks ago, a growing number of Idaho cities began mandating masks, a divisive, but evidence-backed public health measure.

Most of Idaho's mask mandates have occurred in cities where Democrats control local politics, including in Boise, Moscow and McCall. Earlier Tuesday, Central Health District mandated masks across Ada County, and hospital administrators in southwestern Idaho called for a statewide mask mandate on Tuesday. The governor told the Idaho Press through a spokeswoman that he has no plans to do so, and that he supports municipalities that want to implement mask orders.

In eastern Idaho, at least two cities have mandated masks: Driggs and Victor. Idaho Falls, Pocatello and Blackfoot all began public talks about mask mandates last week.

The health district board's new plan could shape how other regional and city leaders issue health guidelines and mandates.

Officials said last week that Eastern Health District is working with Southeastern Health District to coordinate pandemic responses for the eastern half of the state. The area's two most populous cities, Idaho Falls and Pocatello, are looking to the health districts to coordinate their pandemic response measures.

Reporter Kyle Pfannenstiel can be reached at 208-542-6754. Follow him on Twitter: @pfannyyy. He is a corps member with Report for America, a national service program that places journalists into local newsrooms.