Mask mandates have generated intense fights throughout the pandemic, sparking comparisons to early battles over seat-belt laws, which were similarly divisive when they were introduced in the United States in the 1980s. As they have with masks, opponents initially derided seat belts as uncomfortable and constricting, and they portrayed state laws requiring the restraints as government overreach. “Seat-belt laws steal our freedom,” proclaimed a 1989 editorial. “This has nothing to do with public safety,” another seat-belt law opponent argued in 1986. “It’s personal safety, and people should have the right to choose for themselves.”
Yet, there are key differences between seat-belt laws and mask mandates. While the mask requirements started with adults, the first passenger restraint laws in the United States targeted children. And although both seat-belt laws and mask mandates became highly politicized, the state that paved the way for seat-belt requirements in the United States was a relatively conservative state in the South — Tennessee — rather than a more liberal one in the Northeast or the West, where the first mask mandates were passed. Understanding and learning from this history could help make public health measures less polarizing.
By the 1970s, most developed countries had adult seat-belt laws, but, despite numerous attempts, no U.S. state had managed to pass similar measures, in large part because car manufacturers had lobbied against them.
Everything changed, however, when children became the focus of passenger restraint laws. The efforts of Robert Sanders, a pediatrician in Murfreesboro, Tenn., and his wife, Pat, precipitated this shift. The two were so persistent in meeting with state politicians, including a young Al Gore, about child safety seats that they became known as “Dr. and Mrs. Seat Belt.”
Robert Sanders didn’t set out to become involved with public health or politics, but in the 1970s, he was asked to join a state automobile accident prevention committee, and his traffic safety advocacy arose from that work. As a pediatrician, Sanders already knew that car accidents were a leading cause of death among young children in the United States, killing hundreds of toddlers and infants each year. But through the accident prevention committee, he learned about studies that showed child safety seats, which represented new technology at the time, could reduce childhood traffic deaths by up to 90 percent. He became convinced that every child passenger deserved the protection of a car seat, which meant requiring them by law rather than merely encouraging parents to use them.
Crucially, the auto industry didn’t oppose child safety seats as vigorously as it did adult seat-belt laws because requiring drivers to use child safety seats — a car accessory — didn’t require anything of auto manufacturers. Politicians and the public also generally accepted laws designed to protect young children more readily than those aimed at adults.
Still, although they avoided an auto industry campaign to torpedo their bill, Robert and Pat Sanders encountered plenty of resistance. In an oral history conducted by the American Academy of Pediatrics in 2004, the couple recalled one state representative who refused to support the legislation unless a “babes in arms” amendment — allowing parents to hold infants in their laps — was added. The representative had fond memories of watching his son and daughter-in-law drive up to his house with their newborn child in the front seat and didn’t want to deprive other families of that experience. It took the deaths of several infants in accidents while sitting in their caretakers’ laps to get the amendment removed.
The Sanderses also remembered that Tennessee Gov. Ray Blanton (D) expressed hesitation about signing the bill until his grandchildren’s pediatrician persuaded him to do so. Other clinicians attended legislative committee meetings about the bill, and Robert Sanders made sure they sat in the front row so they could make eye contact with lawmakers. “That busy physicians would appeal to legislators in regard to a political issue that wasn’t self-serving, except for the safety of little children, was considered refreshing by many Tennessee lawmakers,” he later wrote.
The Tennessee child safety seat law went into effect in 1978 and was effective almost immediately, more than doubling car seat usage within the first few years and reducing childhood traffic fatalities by 70 percent. Other states, starting with Rhode Island, passed similar laws shortly thereafter, and by the mid-1980s, every state had some form of child passenger restraint legislation on the books.
Adult seat-belt laws followed, starting with New York in 1984. Although a vocal minority objected to them, most Americans accepted the new rules, perhaps because they had already become used to buckling up their children. Car manufacturers also accepted the laws, refocusing their opposition on air bag requirements.
The resulting laws have been overwhelmingly successful. In 2022, about 90 percent of American drivers use seat belts, compared to only about 14 percent in the early 1980s, when the first seat-belt laws were passed. Most Americans today instinctively put on a seat belt when they get into a car, and the idea of not wearing one as a political statement, a common occurrence in the 1980s, now seems absurd. Meanwhile, the National Highway Traffic Safety Administration estimates that seat belts save roughly 15,000 lives per year.
Tennessee helped the nation achieve this goal, and the state sees its pioneering role in the history of seat-belt legislation as a point of pride. At a 2008 event commemorating the 30th anniversary of the landmark legislation, then-Gov. Phil Bredesen (D) said: “Tennessee has always been a visionary place, and the people of Tennessee have always known that nothing is more important than the safety and well-being of our children.” Still, while Tennessee continues to have some of the strongest seat belt and child safety seat laws in the country, its leadership in traffic safety has not translated to other areas of public health.
For example, Tennessee has some of the highest gun death rates in the country, but it recently passed a permitless carry law, despite objections by local physicians. This past Christmas, a stray bullet killed a 12-year-old boy who, only weeks earlier, had written to Gov. Bill Lee (R) opposing the new law. Further, during the coronavirus pandemic, the state has passed laws that deprived health officials of their authority to close schools and banned most mask mandates. The state’s Department of Health also fired its vaccine director, pediatrician Michelle Fiscus, after she faced political backlash for acknowledging the existence of a 1987 doctrine that allows teenagers to get vaccinated without parental consent. Tennessee has experienced high rates of hospitalizations and deaths because of covid-19 this winter, which experts have attributed to the state’s low vaccination rates.
Nevertheless, it would be wrong to assume that Tennessee or other conservative states cannot enact groundbreaking public health policies. After all, support for and opposition to public health measures often span the political spectrum. Massachusetts in the 1980s was one of the first states to mandate seat belts, but voters repealed the law in 1986, and it wasn’t reinstated until 1994. In the 2010s, Mississippi had the highest childhood immunization rates in the United States while vaccine hesitancy caused measles and whooping cough outbreaks in more-liberal states, such as California. Ultimately, public health victories and failures can happen in any state, no matter how progressive or conservative they may seem. Recognizing this and focusing on strategies that broaden support for public health policies could help to depoliticize mask mandates and similar measures in the future.