A common sight on the Iowa Great Lakes: Boats lashed together as their occupants drink, mingle and swim. Credit: Copyright 2021 by Tom Gustafson, VisonAIRy Drone, via Instagram.

Every summer, Emily Mendenhall and her husband, Adam Koon, leave their home in the Washington, D.C. area and return to her childhood haunts in Dickinson County, Iowa, home to the Iowa Great Lakes tourist region. It’s a chance for them and their two daughters to see Mendenhall’s parents and sister, enjoy the lakes and relax.

Summer 2020, however, was drastically different. When the family arrived in June, Dickinson County was in the midst of a COVID-19 outbreak, but an anything-goes atmosphere prevailed. Merchants were counting on summer visitors – who boost the local population from 17,000 to around 100,000 – to pay year-round bills. Tourists wanted to ignore coronavirus concerns and enjoy swimming, fishing, boating and partying.

Few government officials seemed interested in acting to slow the disease, which has now killed more than 5,000 Iowans. “I was so surprised that everyone was just kind of like, oh well,” Mendenhall says.

The exceptions were Dickinson County public health officials, who could use little more than public relations to fight the pandemic’s local impact.

Mendenhall and Koon were troubled. So, with the help of family and friends, they used their unique combination of skills to dissect the psychology driving this sometimes-dangerous behavior.

They exposed how Iowans’ social, political, economic and emotional histories and values led them to embrace or disdain public health measures, often to the detriment of public health.

What the couple and their colleagues learned could help public health workers better understand and cope with pandemic-related behavior in other rural, urban or suburban settings.

Earlier this year I wrote a post speculating on what influences people to follow or ignore government’s appeal to personal responsibility to follow public health recommendations to slow the pandemic. Then I found that Koon, Mendenhall and their associates had scientifically examined people’s motivations and perceptions. Their results connect somewhat with my suppositions.

Emily Mendenhall

The team is uniquely qualified to do such a study. Koon is an assistant scientist in the International Health Department in the Bloomberg School of Public Health at Johns Hopkins University. Mendenhall, a medical anthropologist, is a professor of global health in the Walsh School of Foreign Service at Georgetown University. Both study how social and economic forces influence human behavior and the spread and treatment of disease, especially interactions with social and economic factors, and the consequences for public policy.

Koon and Mendenhall have traveled the world, including to India and South Africa, to pursue projects. But the paper they published this month in Social Science & Medicine is as close to home as it gets.

Adam Koon

Mendenhall’s great grandparents bought land on the shores of West Lake Okoboji, the region’s crown jewel, in 1907. Her father, who later served the area as a urologist for more than 30 years, grew up on the vacation resort his parents owned there.

Mendenhall’s sister runs an organic farm in the area. She’s married to Zach Borus, a family physician with a master’s degree in public health – adding to the family’s concentration of medical and scientific expertise. He’s a coauthor on the paper.

Borus also is chairman of the county board of health, operated out of Lakes Regional Healthcare, the county hospital and clinic where he practices. In mid-June, Mendenhall says, Borus found himself fighting a losing battle.

“Everything was so out of control,” she says. “I was pretty shocked that the only arsenal the public health authorities had was public health messaging.”

That included YouTube videos, like this one a fatigued Borus recorded on Tuesday, June 16. “As of this morning, there were 157 confirmed cases in Dickinson County,” he told viewers. That may have understated the actual incidence because it counted only those listing a Dickinson County address, not summer residents or tourists.

“When I talked to you last Monday, it was 55,” Borus continued. “I would guess that by the time that this comes out on YouTube there will be another 10, 20 – who knows?” He also reported the county’s first death from the virus. Over the course of the study, another seven community members died.

Despite an exponential case increase, city and county officials declined the health board’s requests for a mask mandate and stringent business restrictions. Their position had state-level support: Just a few weeks earlier, Iowa Gov. Kim Reynolds had loosened her emergency order, allowing people back into restaurants and bars under certain restrictions. She continued to eschew a face-covering order.

The county’s public health department, including director Katy Burke, could not have done more to address the pandemic, Mendenhall says, but was hamstrung by resistance from business and government.

Desperate to help, Koon and Mendenhall did what they were trained to do: ask questions. “I wanted to know, what is going on?” Mendenhall says. “What caused this extremely rapid increase in cases and why is no one responding to it?”

Mendenhall rounded up almost 100 former Spirit Lake High School classmates, friends, friends of friends and other acquaintances via Facebook and word of mouth. All but a few lived in the county year-round; the rest were summer-only residents. The team excluded tourists to focus on how locals viewed the pandemic.

Mendenhall and coauthors Lori Eich of Georgetown and Abby Adams of Northwestern University interviewed the group of business owners, elected officials, public health practitioners, healthcare providers and others. The team gathered age, gender, income, education and other demographic information, and then asked subjects about the coronavirus, including their concerns, views and values associated with the pandemic. The researchers also observed public school board meetings and interactions on social media and elsewhere.

Like most of the county, the subjects were white and mostly conservative. They fell across a range of incomes, education levels and occupations.

Mendenhall believes the results reflect attitudes across much of rural Iowa, but colleagues elsewhere – including in New York City – have told her the study is relevant to their localities. “People of color and immigrant communities may have really different beliefs and perceptions” than rural Iowa residents, she says. They may also hold different values and concerns. But the paper’s findings are a starting point for other researchers.

In the next post, we’ll dig into the findings – four distinct but overlapping ways Dickinson County residents interpreted and reacted to the pandemic, with drastic implications for how the coronavirus spread.