BISMARCK — For more than a month, doctors pleaded with Gov. Doug Burgum to institute a statewide mask mandate. As North Dakota's COVID-19 outbreak grew steadily worse this fall and the state cemented its place as the worst outbreak in the country, the drumbeat for direct action grew steadily louder, with some doctors pivoting to a more drastic demand for business shutdowns in recent weeks.

But while hospitals teetered on the edge of their maximum capacity, Burgum consistently rejected a mandate even as he beseeched residents to put on masks. The governor's faith in the "personal responsibility" of North Dakotans looked so entrenched that, by last week, doctors seemed resigned to a reality that the policy many of them had called for may have no viable shot in North Dakota.

Then Burgum reversed. In an executive order announced late Friday night, Nov. 13, the governor rolled out a series of new mitigation measures, including a statewide mask mandate — with an infraction penalty provision — and a 10 p.m. curfew on all bars and restaurants in the state.

The decision was rejoiced in medical circles even as some doctors lamented that it came so late.

"I fully support the mandate when it was done on November 13," said Dr. Stephen McDonough, a former top North Dakota Department of Health official who publicly called for a statewide mask mandate in mid-August. But McDonough, who estimates that as many as 500 lives could have been saved with a mandate implemented on Sept. 1, added that the news came as a shock because the governor had spent so many months downplaying the state's risk. "There has been way too much happy talk. The situation has been much more serious than has been discussed," he said.

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Burgum's office did not respond to multiple requests for comment on this story.

The mandate was a welcome surprise to North Dakota doctors, many of whom had criticized Burgum's pandemic response and expressed confusion about where he was taking his medical cues. Dating back to late July, the governor's office cited Dr. Joshua Wynne, dean of the University of North Dakota Medical School, and Dr. Paul Carson, an infectious disease specialist at North Dakota State University, as leading advisors on the state's pandemic response.

However, the two doctors were not consulted about the possibility of a statewide mask mandate or other mitigation strategies during the fall surge until the last week of October. By the time Wynne and Carson were invited to discuss new statewide responses with top state officials, North Dakota had been leading the country in new per capita cases and deaths for nearly two months. In the three weeks that passed between their meetings and the announced mandate, North Dakota's active virus numbers exploded into exponential growth.

'The governor's ear'

For over a month and a half, North Dakota has navigated its deadliest stretch of the pandemic without medical expertise at the top of its health department. This vacancy — combined with Burgum’s hesitance to take extraordinary steps to stem the virus' spread — stoked confusion among North Dakota doctors about how much medical direction the governor was getting and whether he was listening.

The state's cycle through three different chief health offers — Mylynn Tufte, a nurse, who stepped down in May, Dr. Andrew Stahl in August and Dr. Paul Mariani after a two week stint in September — seemed to suggest a rift between the governor's pandemic response and recommendations of the medical community, a division suggested by Mariani in an official resignation statement noting that Burgum's decision to rescind a quarantine order made his continuation in the position "untenable."

Since Mariani’s departure, the health department has been led by its former chief operating officer Dirk Wilke, who has degrees in business, law and communications but no medical training. Most often, the state names four North Dakota doctors as its primary pandemic advisors: Dr. Joan Connell, a Bismarck pediatrician and the state’s field medical officer, Dr. Guy Tangedahl, a Bismarck geriatrician, along with Wynne and Carson.

Multiple times in the deadly stretch of the last month, Burgum pointed to the support of his physician advisors, insisting that both he and the health department had more than enough medical expertise on hand. But some prominent doctors commented that this medical input wasn't showing up in the results.

"There was frustration among the medical community as to what was actually being implemented as to the medical advice," said Dr. Andrew McLean, a UND psychiatry professor and member of the state's Medical Advisory Committee, adding that it wasn't clear whose input was being heard in the state's response strategy. "There were lots of different voices, some through formal channels, some through informal channels, but it wasn't made necessarily clear who had the governor's ear (and) who had the health director's ear."

Burgum was also frank about his disagreements with public health experts during the last month's surge, acknowledging at a press conference in early November that his physician advisors had pushed him for "more mitigation sooner." While the governor said that he and these advisors shared a common goal, he acknowledged that they diverged on just how to reach it. "Do you get there with the heavy hand of government or a strong reliance on individual responsibility?" he asked, alluding to his own resistance to mandates on mask compliance or business operations. "Those are two perhaps differing approaches. In the end of the day, that all falls back on me."

In October, Burgum's repeated rejections of a mandate bubbled over into widespread frustration in the state’s medical community. On Oct. 13, sixty-five North Dakota pediatricians signed an open letter calling for a mask mandate and warning against "a public health disaster this winter," while other prominent doctors vented that the state had ignored their recommendations. Three weeks later, as North Dakota's crisis drew the national spotlight, Bismarck-Burleigh Public Health Director Renae Moch took to the Washington Post op-ed page to call for a statewide mask mandate, arguing that the "personal responsibility" strategy had evidently come up short.

North Dakota Gov. Doug Burgum holds a COVID-19 news conference on Oct. 23. Kyle Martin / The Forum
North Dakota Gov. Doug Burgum holds a COVID-19 news conference on Oct. 23. Kyle Martin / The Forum

Up to that point in late October, Burgum's office had not consulted either Carson or Wynne on plans for a statewide mask mandate or other responses during the recent months of the outbreak, according to Forum interviews with both doctors. Though Burgum cited the two public health specialists as primary resources on the state's COVID-19 response, Carson said he had previously only met with the state's chief operating officer Tammy Miller and members of the health department to discuss testing strategies, contact tracing and nursing home policies. He had not met with the governor directly or been privy to discussions on other possible pandemic response strategies.

Wynne, who serves in three different public health capacities to the state government, noted that none of his roles expressly call on him to consult the governor's office on pandemic containment. But similarly to Carson, Wynne said that while he had many conversations in recent months with Miller and health department officials about testing, contact tracing and even masking policies on university campuses, those conversations were not focused specifically on new statewide strategies, such as a mask mandate.

That changed the week of Halloween. As the federal government intervened to close off North Dakota nursing homes and White House coronavirus coordinator Dr. Deborah Birx visited North Dakota, top state officials assembled for a series of ad hoc meetings with Wynne and Carson. Over three sessions during the last week of October, the two doctors worked with members of the executive branch to draft potential mitigation strategies, in one meeting discussing those options with Burgum himself. Carson noted that one of the available options was essentially holding the same course, but stressed that he "did not consider that a viable option at all."

That same week, several municipalities issued their own mask mandates, creating a patchwork of directives around the state. Burgum praised the local decisions but remained resolute in his opposition to direct action by his office.

By early November case numbers had reached what Carson called an "exponential growth" phase. But by that point, the NDSU professor had all but given up on his hopes for a statewide mask mandate in North Dakota. In interviews and emails with The Forum in the days leading up to the mandate announcement, Carson said he feared his conversations with the governor's office on pandemic strategy had run their course.

"I really doubt that there's going to be any more calls or interaction about other measures to be taken in the state," Carson said one week before Burgum announced the new statewide mandate. "We've given that advice, and so far it’s not being used. I don't think there's going to be any more talk about that."

Tide turns

In the weeks between Burgum's meeting with Carson and Wynne and his announcement of the mask mandate, the state's COVID-19 trajectory took an even sharper upward turn. Calling the outbreak a "runaway train," Carson urgently stressed the need for more direct interventions. "I think that is an unacceptable compromise to keep business as usual," he told The Forum at the time.

In the last week of October and the first two weeks of November, North Dakota rocketed from fewer than 6,000 active COVID-19 cases to more than 10,500. Over the same span, more than 100 people were hospitalized with the virus, and the state recorded another 198 virus deaths.

Then, on Nov. 9, Burgum announced a last-resort move, clearing COVID-positive health care workers to stay on the job in an effort to address the hospital staffing crunch. For many in the state's medical community, this was a bridge too far. The decision drew national attention as it was criticized by two North Dakota nurses unions. Major hospital systems also said they did not intend to implement the new policy. And in taking this step, Connell argued that the state had asked its nurses, doctors and primary care workers to shoulder an enormous sacrifice, even after it had rejected so many of their calls for preventative measures.

"There’s an expectation from health care providers that everyone does their role," Connell said prior to the mask mandate announcement. "That’s from the independent person to the state to the local policymakers. We expect everyone to sacrifice."

But within five days of that controversial decision, facing new levels of national scrutiny and open objection from health care workers, Burgum finally flipped, approving an enforceable statewide mask mandate and other mitigation measures on Friday. The particular combination of interventions that Burgum ultimately announced was among the slate of options workshopped with Wynne and Carson during their late October meetings.

"I think this is the right initial mix of measures to be tried," Carson said after the announcement, expressing that he was extremely pleased to see the steps finally enacted and noting that he will look for signs of their effects in the next two to four weeks. “If we don’t see a flattening of the trajectory, then we need to do more," he said.

Readers can reach reporter Adam Willis, a Report for America corps member, at awillis@forumcomm.com.