Lake Okoboji (which is a misnomer; there is no Lake Okoboji, but there are West Lake Okoboji and East Lake Okoboji) postcard, circa 1939. Copyright 2012 by Steven R. Shook. Used with permission.

Emily Mendenhall arrived in Okoboji, her hometown in Iowa’s Great Lakes region, in June 2020 – just as the area became a COVID-19 hotspot. Confirmed cases burst from just eight to 200 in one month. As she later learned, there probably were even more, as many young people skipped testing, accepted their fate and nursed themselves back to health. Cases that tourists contracted in Dickinson County also may have been attributed to their home counties or states.

It was a drastic contrast to the situation Mendenhall, her husband, Adam Koon, and their two elementary school-aged daughters had left.

“I came from D.C., where everything was shut down and everyone was taking it so seriously,” said Mendenhall, a professor of global health in the Walsh School of Foreign Service at Georgetown University. “And then I came to a place where everyone’s like, ‘whatever.’”

As I described in my previous post, Mendenhall and Koon, an assistant scientist in the International Health Department in the Bloomberg School of Public Health at Johns Hopkins University, joined with others to understand why so few Dickinson County citizens heeded public health advice – sometimes with dire consequences. They interviewed nearly 100 residents of the summer destination, most of whom live there year-round.

We’ll look into their fascinating – but in some respects unsurprising – analysis.

Many, if not most, of those Koon, Mendenhall and their colleagues interviewed for their paper in the journal Social Science & Medicine followed public health recommendations. But a significant and powerful minority counteracted that impulse toward safety, mostly to preserve an economy that relies on attracting people primed to party. In an essay for Vox previewing the research, Mendenhall cited at least one case in which those wearing masks faced hostility.

Adam Koon

From the interviews, the team developed four frames: characteristic ways people’s values, upbringing, political views and other factors affect how they make sense of events and experiences. (Koon and Mendenhall analyzed the same results for a second recent paper in Global Public Health, in which they focus on how people’s values and views shape the political scripts and values that, similar to frames, affect how they responded to the pandemic.)

Framing, a common social science tool, analyzes why people see the world as they do, including how they act on those views and respond to what happens to them and their community. Koon, in an email, told me the study found “an array of beliefs that emphasize different values helps explain the fractured local COVID response.”

Koon nails the point my previous meandering post was trying to make: Beliefs, values, political positions and prejudices dominated individual responses to the virus – for good or ill –partly because political leaders ignored or suppressed the science. They instituted weak and confusing health regulations.

“This a problem because government mandates transcend diverging beliefs,” Koon wrote. “They say, ‘this is what you need to do to limit transmission.’ Without that clear voice, uncertainty, ambiguity, and fear eat away at the social fabric of community life … and can allow the virus to proliferate.”

Emily Mendenhall

In fact, Mendenhall argued some government leaders actually harmed public health. Dickinson County residents’ legitimate fear the pandemic would destroy the tourist economy was a powerful force, she said. But some political leaders also set a poor example. In the United States, “we had denialism. We had conspiracy theories. We had a lot of anger,” she said. Even if local public health officials were modeling and promoting masks and physical distancing, “the leadership from the top, as well as the (Iowa) governor, was really undermining” those efforts.

Dickinson County voters went for Donald Trump by two to one in 2020, but it was shocking to hear interview subjects and local officials repeat conspiracy theories the president promoted, Mendenhall said.

“How and why people thought things or believed things had a lot to do with where they consumed their news (and) who their friends are,” she said. Frames are built collectively, much as religions form communal rules and belief systems. Beliefs are constructed through interactions with family, friends and coworkers.

The research explored this connection between identity, social goals and actions, Koon wrote. “We hope that targeted communication and outreach efforts can help reframe the response in ways that resonate with greater segments of the population” so more people adopt health precautions. “We also hope that policymakers will continue to strengthen guidance” to prevent viral transmission.

Interview subjects often harbored internal disagreements about their feelings toward the virus. Most exhibited characteristics of a dominant frame, but also had values that fell into a secondary, sometimes contrary, frame.

The Concern Frame

The largest group of subjects (44) fit primarily into what the researchers called the concern frame, summarized with the sentence, “COVID-19 is a concern because it uniquely affects me or my family; therefore, I will protect myself.” They saw coronavirus as a personal threat and were likely to wear a mask and follow other precautions. They often were at a higher risk of infection because of their age or occupation, such as healthcare or teaching jobs.

“Many people expressing the concern frame asked why people have forgotten the early mantra of the local campaign, ‘we are all in this together,’” the authors wrote – a question I’ve asked myself. “Most also expressed frustration with the ‘political charades’ of neighbors.”

A nurse who identified herself as a Republican and Christian, told the authors, “I’m wearing a mask and I’m like you guys this is not a joke. I’ve been trying to explain to my husband this is serious …”

Although a plurality of subjects held this pragmatic view, Mendenhall said they also were the people most likely to talk to her and her colleagues. Others ignored or refused her interview requests, saying the pandemic had become political.

The Constraint Frame

Based on her team’s research, Mendenhall believes the concern frame was linked to the healthcare industry – the area’s largest employer – and caregivers’ concerns for patients. The constraint frame, meanwhile, was tied to the business community. Just 24 of the people interviewed held this frame primarily, but she thinks a scientific survey of year-round Dickinson County residents would find it’s the most common.

The constraint frame attitude is: “COVID-19 is a constraint because it threatens financial/personal stability; therefore, I will resist control.” These people were concerned but wanted to keep their companies open. Business owners the team interviewed instituted a range of preventive measures, from seeing customers by appointment to directing employees to distance and don masks. But at least one worker reported feeling shamed for wearing a mask because her supervisor believed people needed to catch the virus to build immunity.

Some young people, even those on the front lines of the service or retail industries, also held the constraint frame. One 21-year-old waiter said he hoped to get the virus and claimed many of his friends had fallen ill with it but weren’t tested. “We frequently heard people in the community say, ‘everyone has COVID!’” the authors wrote. While many of the youths acknowledged taking risks, Mendenhall added, they also said they avoided exposing grandparents and other susceptible family members.

The study suggested constraint frame adherents “share an affinity for security, highlighting salient threats to their financial and social stability while (at least publicly) diminishing health and safety concerns.” It added, “in the absence of government mandates, the constraint frame is particularly problematic” because public health precautions “are understood to threaten a way of life.”

The Crisis Frame

The 15 interview subjects who primarily held the crisis frame believed “COVID-19 is a crisis because it has profoundly altered life worldwide; therefore, I will do anything.” They had an outward-looking, community-focused and global perspective, consuming more national and international news and following coronavirus statistics. They often bemoaned Trump’s assertions regarding untested drugs and treatments and adhered to public health recommendations. But they also were less visible because they stayed home and comprised a minority.

“I think first of all you have to be respectful and have empathy for others,” one business owner said. Another said, “I feel we have gone so far from the general moral of what it is to be human and what it is to live in a community to take care of one another.”

Because of the pandemic’s unprecedented gravity, Mendenhall said, those holding this frame “were really embodying that as a crisis: This is not just a concern in my community; it is a concern in my state, in my country, in the world.”

The Conspiracy Frame

Time and attention forbade it, but Mendenhall said she and the team would rather have created a systematic population-wide survey to really understand how Dickinson County residents understood and dealt with the pandemic. Because the county voted strongly for Trump in 2020, she thought it would have found “a large, large group of people who were subscribing to the conspiracy frame. But … I don’t know that.”

Those primarily holding the conspiracy frame believed “COVID-19 is a conspiracy because it isn’t real; therefore, I will do nothing.” At 16, they comprised the second-smallest group of subjects, perhaps because they were less likely to participate in the study.

Conspiracy frame adherents believed “in ‘personal freedoms’ and ‘personal choice” above all else,” the researchers wrote, and discounted the health threat. Many rejected masks and said the coronavirus would go away after the November election, “thinking it was a political gimmick linked to the Democratic Party.”

“I just think people are overdoing it,” a mother told the interviewers. “And I think that a mask on a healthy child for eight hours a day could cause some serious health problems.”

“Sponsors of the conspiracy frame interpret their resistance to social conformity as a faithful adherence to self-constructed values and meaning,” the authors wrote. But examining the data more closely, they said, called into question whether conspiracy theorists “are genuine in their pursuit of freedom or whether they are engaged in a naïve form of mimicry” based on Trump’s “truculent worldview.”

Although Mendenhall thinks there are more conspiracy-frame holders in Dickinson County than the study indicates, she believes most residents cared about slowing the coronavirus. But “there were some people who had a lot of power to make decisions” and whose behavior showed “they didn’t care as much about the community” as about the economy.

That disappointed Mendenhall. She recalled the summer of 1993, when she was a girl and epic flooding struck the area, as it did most of Iowa. On many days she helped fill sandbags for those whose homes were threatened.

“We all came together and collectively responded to this flooding,” she added. Almost 30 years later, she “the community of my childhood felt different. I just couldn’t figure out why people didn’t care.”