Resistance to COVID-19 controls in an anthropologist's home town

As the COVID-19 pandemic reached the US Midwest, Okoboji, a small rural community in Iowa, decided not to follow public health guidance on masking and eschewed physical distancing. When medical anthropologist Emily Mendenhall visited her home town, the spectacle of unmasked people flocking to restaurants and bars alarmed, perplexed, and intrigued her. Why had Okoboji rejected public health advice even as its COVID-19 case counts rose, and deaths followed?

Mendenhall's Unmasked: COVID, Community, and the Case of Okoboji begins in 2020, before COVID-19 vaccines were available, and mostly concerns the controversy around the use of masks. Okoboji is overwhelmingly white and votes Republican. After a brief shutdown, the Iowa Governor left regulatory decisions about COVID-19 measures to local authorities. As COVID-19 stormed the US east coast, Okoboji and the Midwest generally remained less affected. When COVID-19 arrived in Okoboji, many of those who got infected were healthy, young people who worked or spent time at tourist spots. At first, no one died. Mendenhall began anonymised interviews with people in the community, attended public meetings, and scanned the media, bringing an insider-outsider lens to her role as a participant observer. She was not neutral—she wore masks and mainly interviewed people outdoors.

Okoboji relies on visitors for its economic wellbeing. Masking and physical distancing had financial consequences. Some locals were fatalistic about the risks of COVID-19, often related to Christian beliefs. Some residents, often women, believed masks were harmful, especially to children. Men were likely to invoke personal freedom as a rationale for remaining unmasked. One respondent claimed some families “had their kids run through Walmart when they had COVID-19 to infect others and build immunity in the community”.

What emerges is a lack of social solidarity beyond small friendship circles. People saw it as everyone's right to look after themselves. Some deplored this stance as lack of caring, but they were not the majority. The author's brother-in-law was a county health official and countered internet rumours. But among the sources of disinformation are other medical doctors. Her interviews show Mendenhall to be a careful listener, gently probing and prompting. Her approach humanises people and successfully conveys that the decision to reject public health measures was not made by bad people.

Mendenhall considers how Okoboji's trajectory, which she does not doubt resulted in avoidable deaths, occurred at the intersection of racial identity and status. Most of Okoboji residents are white. Acknowledging insights from Jonathan Metzl, she quotes his argument that “deeply modern-day American backlash conservatism demands that lower- and middle-class white Americans vote against their own biological self-interests as well as their own economic priorities”. Deprived of status previously assured by whiteness, did Okoboji residents find dignity and autonomy in resistance to public health measures? Did they see lethal consequences as acceptable trade-offs? During Mendenhall's school years, farming supported most Okoboji families. By her graduation, farming had virtually disappeared and income became dependent on tourism and big box stores. But such reflections are Mendenhall's own, and ideas about racial identity and contagion are not often broached in the interviews.

Partisanship in the acceptance of COVID-19 vaccines in the USA is well established, with strikingly lower vaccination rates among people who are white and vote Republican. Mortality tracks with political beliefs in ways that should be better understood. Before COVID-19, Bor and others showed former US President Donald Trump was more likely to carry communities where life expectancy had stagnated or declined. Krieger and colleagues analysed COVID-19 deaths by US Congressional district and found that Republican-controlled areas had up to 25% higher COVID-19 mortality rates than Democrat-controlled areas—deaths were highest when the executive and legislative representatives were all Republican, as in Okoboji.

Communities can collectively confront pandemics. During the 17th century, the English village of Eyam imposed a cordon sanitaire, successfully sparing its neighbours from plague while losing over a quarter of its population. Some 250 years later during the 1918 influenza pandemic, Gunnison, a mining town in Colorado, USA, decided to isolate to avoid infection. Those who wished to leave could do so, then no one else could enter, or return to the town. There were no influenza deaths. In places like Okoboji in the 21st century, such community-wide action seems impossible to contemplate. From Mendenhall's perceptive book, we learn some reasons why.

Unmasked: COVID, Community, and the Case of Okoboji Emily Mendenhall, Vanderbilt University Press, 2022 pp 312, US$28·95 ISBN 9780826504524