Unmasked

COVID, Community, and the Case of Okoboji

Emily Mendenhall

• Publisher: Vanderbilt University Press
• Year: 2022
• ISBN:
  9780826504531
• Topic: Politics & International Relations
• Subtopic: Public Policy
• Index: Politics & International Relations

Unmasked is the story of what happened in Okoboji, a small Iowan tourist town, when a collective turn from the coronavirus to the economy occurred in the COVID summer of 2020. State political failures, local negotiations among political and public health leaders, and community (dis)belief about the virus resulted in Okoboji being declared a hotspot just before the Independence Day weekend, when an influx of half a million people visit the town. The story is both personal and political. Author Emily Mendenhall, an anthropologist at Georgetown University, grew up in Okoboji, and her family still lives there. As the events unfolded, Mendenhall was in Okoboji, where she spoke formally with over 100 people and observed a community that rejected public health guidance, revealing deep-seated mistrust in outsiders and strong commitments to local thinking. Unmasked is a fascinating and heartbreaking account of where people put their trust, and how isolationist popular beliefs can be in America's small communities. This book is the recipient of the 2022 Norman L. and Roselea J. Goldberg Prize from Vanderbilt University Press for the best book in the area of art or medicine.

CHAPTER 1

GLOBAL THREATS

I FIRST REALIZED that coronavirus might upend our lives one Tuesday afternoon when Dr. Rebecca Katz stopped by my office. It was March 3, 2020, and she was bustling through the Intercultural Center at Georgetown University. As she swept by, she popped her head into my office as she usually does to say hi.

We are professors who work on very different questions in global health at the Walsh School of Foreign Service (SFS) at Georgetown University. I am a medical anthropologist who studies how people perceive and experience illness, particularly when it is new or foreign to them. Rebecca is an expert in global health security. When coronavirus became a real threat, her phone never stopped ringing. She was the first to raise her eyebrows to me about the news from Wuhan, China, where coronavirus began to spread in December of 2019. Back in January of 2020, she started talking with our colleague and global health law expert Alexandra Phelan about the whispers.¹ They became concerned. I grilled her about what she knew, from where, and what was our risk for it coming to the US.

“I’ve cancelled my travel for the next three months,” Rebecca said as she texted something on her phone. “Beth Cameron came back from a conference last week super sick. I’m not taking any chances.” She had one foot in my office and the other in the hall. She sighed as she leaned against my door in her smart leather jacket. Beth Cameron was not only a good friend of Rebecca’s but also the lead of the Global Health Security Agenda for the Obama administration—clearly, they were talking about this outbreak becoming serious.

“Wait, really?” I responded.

“Yeah, hold on a minute. I have to get back to the president.”

In 2014, during my first year working at SFS, I realized I was entering a whole new world when Angela Stent, a professor of East European studies and expert on Russia, rushed late into a faculty meeting. She apologized; she had been speaking with the president. I nearly spat my lemonade across the table. She was advising the White House after Russia invaded Crimea, a part of Ukraine. I quickly realized how frequently my colleagues consult on issues of national and international security, providing regional and technical expertise.

But Rebecca had been speaking with Jack DeGioia, Georgetown’s president. She was one of five experts gathered to discuss a number of key questions that would inform the next steps for the university in the face of an uncertain pandemic. Already DeGioia was bringing together experts to figure out what to do. What is the risk on campus? How many new cases are in DC (incidence)? How many cases were recorded in the past week (prevalence)? Where are they clustering? Should we close down campus? Do we stay open? Do we pack up students and send them home? All students, or some? What if it’s not safe for them to go home? What if students don’t have space to think, grow, and study? How do we close down or stay partially open and make things equitable? Where do they stay?

Spring break began in three days. Students were planning to trek across the United States and the globe for academic programs and personal travel. We weren’t sure what to do.

The university closed down a week later. We taught virtually for the next year.

SECURITIZE

Before I describe what happened in my hometown, I am going to tell you Rebecca’s story. Her life shows how Americans had for decades planned for a viral threat like SARS-CoV-2—also known as the novel coronavirus or coronavirus disease (COVID-19)—which could shut down airports, shutter businesses, send kids home from school, and devastate families. I heard her describe more times than I can remember how a global pandemic could not only devastate the economy but also upend people’s lives in irreversible ways. For years she worked feverishly developing pandemic preparedness plans in part with the Obama administration. But these plans were forgotten soon after President Trump took office.

Over a double espresso one afternoon, Rebecca told me she had been thinking about infectious disease since she was in third grade. She grew up in a house where her parents were completely entwined in the science of HIV and AIDS. Her father, Fred Katz, a hematologist and blood banker, spent his career at the American Red Cross. Fred Katz was on TV so much during her childhood that he had his own video camera at home. This was unusual because it was the 1980s, when few people had computers let alone video cameras. But these were unusual times. The HIV crisis caused extraordinary stress and uncertainty around the world, and Americans who lived through that time cannot forget the fear many people had about what the virus was and who was infected or infectious. HIV was so stigmatizing that some people suggested marking those who tested positive by tattooing them on the face. But Fred Katz was as calm talking about blood supply during the AIDS pandemic as he was talking about the weather. Fred’s contributions were well documented in a full spread in People magazine in 1983 and the iconic movie of the early years of the AIDS epidemic that came out a decade later, And the Band Played On.

Rebecca’s mother was anything but calm and quiet. Deborah Katz started her career at the National Institutes of Health (NIH) AIDS division in 1982, where she worked with Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases. She stayed for thirty years. Early on in her career, she managed the politics of a clinical trial amid the AIDS crisis in America—navigating who could be enrolled, when, and for how long. At the time, many people from the gay community were dying from Kaposi sarcoma, a rare cancer that develops when people’s conditions advance to AIDS (acquired immunodeficiency syndrome). In fact, so many gay men were infected with the new virus that scientists initially called HIV (the virus), GRID—gay-related immune deficiency, a stigmatizing term associating the virus with homosexuality.² Debbie was often called in the middle of the night to finagle people into studies, particularly those who got really sick fast. It was a time of extraordinary fear and uncertainty.

The 1980s were all-engrossing for scientists studying HIV and AIDS. With both parents working nonstop on HIV, dinner conversations in the Katz household concerned what was going on with research, people, and treatment. Rebecca once said to me, while walking on the C&O Trail along the Potomac River, “my sister and I grew up knowing more about HIV in the eighties than any kid who didn’t have it.” But many people were not as empathetic or understanding and instead feared the new illness. She recalled a plumber entering their house and seeing a huge poster on the fridge that said, “Women don’t get AIDS, they die of AIDS.” He turned around and left. Observing this kind of fear shaped Rebecca’s childhood and cultivated an awareness of what viral threats can do.

In the People spread, Fred Katz said, “AIDS hysteria is potentially as lethal as the disease itself.”³ In both the AIDS and COVID-19 pandemics, the early days introduced a great deal of fear and disbelief because people knew so little about who was getting sick, from where, and why.⁴ Naming and blaming were as common in the early days of the HIV pandemic as they were within the early days of the COVID-19 pandemic.⁵ Not unlike the early stigmatization of the gay community in the early days of HIV, the Sinophobia experienced by many Asian Americans was intensified throughout the COVID-19 pandemic. This xenophobia stemmed in part from President Trump’s unremitting use of “China virus” and “Wuhan virus” in lieu of coronavirus or COVID-19 to politically spar with another superpower and blame it for the pandemic.⁶ The consequences of this political gamesmanship were extraordinary for many Americans who faced unrelenting racism throughout the pandemic period.

There were also many political similarities between HIV and SARS-CoV-2, and I will only mention a few here. For years the Reagan administration ignored the severity of HIV, joking at times about who was dying and why. It wasn’t until the virus spread throughout the country and deaths surged that many scientists and political officials took HIV and AIDS seriously.⁷ Similarly, the Trump administration ignored the severity of coronavirus in the United States for most of 2020, suggesting it was “just the flu” and would “go away.”⁸ In both cases, political negligence could not stymie pioneering medical innovation, which was fueled by unprecedented political activism, money, and urgency. Anti-retroviral therapy (ART) that prolonged life for people living with HIV was developed in five years, changing what was formerly a death sentence into a survivable chronic illness in America.⁹ Coronavirus would see a vaccine within one year—a timeline unfathomable to scientists and the public alike only months before.¹⁰ But who reaped the benefits of these technologies and when was similarly uneven: profits were prioritized over people’s lives and pharmaceutical companies were reluctant to waive patents, thereby making it difficult to make more medicines at lower costs that could reach people around the world.¹¹ These challenges for global health equity remain enormous and reveal why Rebecca’s work matters so much.¹²

Growing up in the time of AIDS had a huge impact on Rebecca. But so did her own infection. Rebecca caught Brucella melitensis while working in a maternal and child health clinic in Karnataka, a state in southern India. It took months to figure out what had made her sick and years to recover. She discovered her infection had been the first agent ever weaponized by the US bioweapons program in 1950. She became obsessed with studying what her disease was, how it was used, and the role diseases played in international politics. This led Rebecca to work on biosecurity at the State Department for fifteen years, asking hard questions: Why do some diseases cause a global stir and others don’t? How do diseases travel across the globe so quickly? What do nations need to do to prepare for the next viral intruder?

I tell her story because Rebecca is one of a handful of academics and practitioners who came together to fuel a movement to put global health security on the national agenda. Rebecca strategized with others in a series of meetings in the Eisenhower Executive Office Buildings next to the White House in 2013. They discussed “what comes next” after President Barack Obama gave two speeches that mentioned global health security.

In 2009, President Obama encouraged countries to work together on many efforts, including health, women’s rights, science, and security, in what is known as the Cairo Speech. The global health security community, including Rebecca, was thrilled by the recognition of how a viral threat could bring the country to a halt. President Obama stated, “Governments that protect these rights are ultimately more stable, successful and secure. Suppressing ideas never succeeds in making them go away.”¹³

Two years later, when addressing the United Nations General Assembly, President Obama spoke of countries coming together and the significance of the International Health Regulations, or IHR. The IHR is an international law that coordinates disease surveillance and global cooperation in the response to outbreaks. The law is decades old, but has been rewritten with increasing concern as viral threats intensified: Ebola. SARS. Avian flu. Lassa fever. Chikungunya.¹⁴

The IHR outlines the rules for trade and travel, as well as hygiene and surveillance, when new viruses spread across borders. In many ways, legal solutions through IHR have become a fixture in facing many risks—from humans, animals, and ecosystems—that contribute to viral threats.¹⁵ Rebecca wrote with our Georgetown colleague Lawrence Gostin in the Milbank Quarterly that the IHR is critical for responding to rapid shifts in the modern world that are now framed as “security risks” for countries who previously had few exposures to such viral threats.¹⁶ The regulations demonstrate how emerging infections are inherently political problems.

By 2012, only 22 percent of countries had implemented the IHR. The Obama administration launched the Global Health Security Agenda (GHSA) in February of 2014 to raise health security on the political agenda. The GHSA caused heads of states to talk about and marshal resources to address global health security. But by then, Rebecca had moved to Georgetown University, where we eventually met. She began to pull away from GHSA because it had become some...