DODGE CITY, Kan. – In the midst of a worsening pandemic, as coronavirus cases climbed, elected leaders in a former frontier town famous for its gunfights faced a choice.

They could pass a mask mandate at the urging of health experts or reject the measure blasted by some as a violation of their personal freedoms.

The five commissioners of Dodge City, a politically red cattle community of about 27,000 people, had resisted such measures all summer and into fall. Like other parts of rural and small-city America, Dodge City had mostly returned to normal after shaking off the pandemic’s first wave.

Then a second wave hit. People started getting sick again.

By the time commissioners passed the mask mandate Nov. 16, more than 1 of every 10 county residents had contracted the virus. At least a dozen had died.

Update: Kansas mayor resigns after backlash to USA TODAY story on city’s mask mandate, citing phone and email threats

Kansas National Guard member Jessica Pal collects a sample at a drive-thru COVID-19 testing site May 20 in Dodge City, Kan. Army and Air Force medical guard units have tested 100-200 people daily.

COVID-19 has spread fast in Dodge City and other small towns where residents ignored public health guidelines and refused to wear masks. Many people lived as they always had, going to work, shopping and visiting friends without worry.

In communities where mask-wearing has become a political inflection point, the toll of the virus has surpassed even the most terrifying early days seen in America’s big cities.

A USA TODAY analysis found that in recent months, the weekly rates of newly reported cases are highest in rural counties and only slightly lower in other non-metropolitan communities.

The trend started Aug. 7, and within two months, people in rural counties were almost twice as likely to have contracted COVID-19 within the past week compared with people who live in urban areas. Counties with city populations that total 20,000 to 250,000 people – such as Dodge City’s home of Ford County — show a similar gap, reporting 54% more cases in the previous week than metropolitan areas on average.

Since mid-November, the weekly rate of COVID-19 deaths in rural America has been higher than it has ever been in urban counties.

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“The rural communities were kind of lulled into complacency, feeling they were naturally blessed with open spaces and big sky and that COVID-19’s a metropolitan problem,” said Dr. Lee Norman, secretary of the Kansas Department of Health and Environment. “But the chickens have come home to roost.”

Dodge City officials knew COVID-19 was serious from the start, Mayor Joyce Warshaw said. But it wasn’t until the threat of flu season and the rise in national cases that the city commission felt compelled to pass a mask mandate, she said.

By then, Warshaw had been personally affected, as her daughter had contracted COVID-19. Warshaw’s aunt died from the virus.

“We just felt like we had to do something, so everybody was aware of how important it was for everybody to be responsible for each other’s health and well-being,” she said.

Weeks later, residents openly defy the mandate. As of early December, police had done nothing to enforce it.

Warshaw resigned Dec. 15, days after this story appeared online, describing threats to her safety.

At Red Beard Coffee on Gunsmoke Street this month, there were no signs reminding people to put on masks. Neither the staff nor most customers wore them.

At Tacos Jalisco on Wyatt Earp Boulevard, signs in English and Spanish alerted customers to the mask protocol, but neither staff nor most customers wore them inside during a visit by USA TODAY.

Wearing a mask, a worker at Dodge City Brewing in Kansas cleans the bar behind a sign reminding customers they are required to wear a mask inside when not eating or drinking, next to a “complaint department” sign with a mock grenade.

Business owners who try to enforce the mask mandate often face resistance.

At the Ensueño Boutique on Second Avenue, owner Andres Lima, 61, said he’s required customers and staff to wear masks since the summer, regardless of government rules. His store has bilingual mask rules posted on the front doors, and store clerk Esthela Cisneros is pregnant.

“It’s for the safety of the people who work here and for the people who come in,” he said amidst wedding gowns and sparkling quinceañera dresses. “Some people say ‘I’m not sick,’ but we tell them, ‘That’s not the problem. For your safety, you need to wear one.’”

As of Dec. 4, authorities had issued no tickets for violations of the mask ordinance. The police department had received only a few complaints about people flouting the rule, Dodge City Police Chief Drew Francis said.

Other complaints, he said, have come from opponents of the mandate.

“We have taken several complaints from community members speaking directly to officers about their position that this is unconstitutional government overreach and wanting to know if the police department is going to allow itself to be used to oppress the people,” Francis said.

COVID-19 in the Wild West

Steeped in Wild West lore, Dodge City prides itself on the independent cowboy ethos.

In the 1800s, it served as a destination for cattle headed for the railroad, attracting cowboys, gamblers, buffalo hunters and soldiers. The city became famous for its saloons, outlaws and legendary lawmen such as Wyatt Earp. It cemented its place in modern history when it served as the backdrop for the television show “Gunsmoke” for 20 years.

A steel cutout of cowboys riding toward the sunset welcomes visitors to Dodge City, Kan.

Dodge City is the most populous town in Ford County and one of the largest cities in western Kansas.

Almost a third of residents are foreign-born; 62% are Hispanic. The median household income is $52,000, about 10% lower than state and national averages, according to U.S. Census Bureau estimates.

The community is surrounded by cattle feedlots that supply Dodge City’s two meatpacking plants, which employ thousands of people. Along the main street, Wyatt Earp Boulevard, car parts stores sit alongside heavy-equipment dealerships and fertilizer depots. Large gas stations sell diesel fuel to power the steady stream of trucks delivering cattle to the processing plants and hauling beef products to stores nationwide.

Workers wear protective masks outside the National Beef meatpacking plant May 19 in Dodge City, Kan. Ford County, home to Dodge City, has the most positive COVID-19 tests per capita in the state in large part because of outbreaks in the county’s two meatpacking plants.

COVID-19 was first discovered in Kansas in early March, and as the virus picked up steam, Gov. Laura Kelly, a Democrat, ordered a temporary, statewide stay-at-home order. Schools closed. Businesses shuttered. People stayed home.

Still, the disease spread furiously through Ford County. On March 17, officials announced the first case of COVID-19 in the community. Soon, viral clusters that started in the meatpacking plants led to a rise in cases that made Ford County one of the worst hot spots in Kansas.

In Kansas, like most of the USA, the virus has disproportionately harmed nonwhite and Hispanic families. Statewide, the rate of reported cases is twice as high among Hispanic residents and the rate of deaths is 27% higher. (Kansas does not publish race or ethnicity COVID-19 data at a county level.) Especially in the spring and summer, numerous outbreaks were identified at meatpacking plants that hire many Hispanic workers, including the two beef processing plants in Dodge City.

Vehicles drive down Wyatt Earp Boulevard in Dodge City, Kan.

City commissioners began holding meetings online in April and received regular updates from health officials. Dodge City leaders promoted good hygiene, social distancing and wearing masks, though they stopped short of a mask mandate.

The commission resumed its in-person meetings off and on over the next few months. When they met in person, they sat at tables with more space between the elected officials, who regularly wore masks.

“Let’s look at wearing a face covering as our statement that we are working to make Dodge City the best place to be,” the city wrote on its Facebook page July 3. “Let’s lead on this response to overcome this fast-spreading danger to our community.”

Many people refused. When the lockdowns of the spring expired, mobility tracking data shows many rural and small-city residents quickly resumed their normal lives.

In June, people in rural communities across the country, on average, visited retail and recreation establishments at rates similar to before the pandemic, according to Google cellphone data. By early July, counties with small cities were back to normal levels. Urban residents were slower to return: Visits to retail and recreation sites averaged about 15% below pre-pandemic levels.

The week of Independence Day, 75% of rural residents and 73% of small-city residents left home compared with 68% in metropolitan areas, according to the analysis.

While Dodge City officials continued to stave off a mask mandate, residents on both sides of the issue battled each other on a community Facebook page.

“I live in a free country,” one person wrote in July. “I will not wear a mask. Quit being a stupid crybaby liberal.”

“The arrogance and ignorance is just comical,” another person responded. “Like I said, no one is asking you to give up a kidney. If you define freedom by wearing a mask, you’re the stupid crybaby.”

Esthela Cisneros works at Ensueño Boutique in downtown Dodge City, Kan. Her boss, Andres Lima, said he’s required staff and customers to wear masks inside the store for months.

The lower infection rates earlier in the year made it easy for officials, particularly those in communities such as Dodge City that supported President Donald Trump, to brush aside the advice of doctors, scientists and other health officials. By early August, 77% of 105 counties in Kansas did not have a mask mandate, according to an analysis by the Centers for Disease Control and Prevention of data from the Kansas Health Institute.

Reduced case counts over the early summer months created a false sense of security, said Norman of the state health department.

“It’s not unique to the rural areas, but the rural areas were less likely to stick with masks, social distancing, limits on restaurant patronage and the like,” Norman said.

A study by the University of Kansas Institute for Policy and Social Research found a 50% drop in the spread of COVID-19 in Kansas counties that had a mask mandate compared with those without. Last month, the CDC published an updated version of the analysis, reaching the same conclusion: Mandates worked to reduce infection rates, and places without them saw faster case growth.

The political battle over masks has frustrated medical professionals in already stretched-thin rural hospitals, who are seeing sick people flooding into ill-equipped facilities. Leaders of metropolitan care centers are worried as smaller facilities ask to send their patients.

“People are suffering and dying,” said Dr. Angela Hewlett, medical director of the Nebraska Biocontainment Unit at the University of Nebraska Medical Center. “People are continuing to gather in groups and go out to restaurants and bars. I would ask people to stop politicizing the virus, stop politicizing the masks. This is not a political issue. This is life and death.”

COVID-19 in schools

Like many others nationwide, Dodge City schools reopened in August, offering both in-person and virtual classes. About 95% of the 7,000-plus students returned for in-person learning, said Dodge City Public Schools spokeswoman Kerri Baker.

The schools implemented numerous safety measures, requiring students and staff to wear masks, placing hand sanitizer in high-traffic areas, spreading seats at least 6 feet apart and disinfecting routinely.

Though face coverings were required at schools, city officials still hadn’t approved a mask mandate, so they were optional in other public areas. That meant more chances for the disease to spread from outside the schools to inside.

And it did.

Comanche Middle School in Dodge City, Kan.

From Sept. 1 to Dec. 1, more than 370 students and school district staff tested positive for COVID-19, Baker said. The football team canceled its last game of the season after three players tested positive and six others were in quarantine.

Sabrina Frerichs, an elementary school teacher, was among the victims of the second wave to hit Dodge City.

Frerichs awoke in the middle of the night Oct. 29, freezing cold and with a fever, after a pain in her stomach had been bothering her for days.

Within a week of testing positive, Frerichs said, she could barely eat or drink. She grew weaker, and her blood-oxygen levels fell.

The 39-year-old was admitted to a hospital, where she stayed on oxygen for four days. When she came home – exhausted and aching badly – she needed to use an oxygen machine.

Frerichs’ husband and three daughters came down with less serious cases of COVID-19. Frerichs’ 14-year-old son avoided the illness.

“I worry about the burden financially this is going to take on my family,” she said, adding she has been planning school lessons while recovering at home. “Insurance won’t cover everything. I worry about the long-term effects on my health.”

Frerichs keeps her opinions on a mask mandate to herself because of the divisiveness in the community over the issue.

Frerichs has continued to battle aftereffects of the virus, including tremors in her hands, intermittent tingling in her hands and feet, rapid heart rate, palpitations and shortness of breath.

Even brushing her hair or getting dressed has been exhausting.

“I never thought covid did all of this,” she posted Nov. 27 on Facebook. “Stay healthy and safe please.”

The first symptom for Karyn Garcia, 29, a teacher’s aide, was blinding migraines. She thought it was stress, so she took Tylenol and continued working and caring for her two kids.

Two weeks later, exhaustion set in, along with shortness of breath, body aches and fever. A test at the local expo center confirmed she had COVID-19.

Garcia went into quarantine with her children, neither of whom got the virus.

This isn’t like any other virus, she said. The bone-crushing weariness, the up and down fever – it feels different, she said.

“It’s scary, to be honest,” Garcia said.

COVID-19 patients fill hospitals

Though Frerich has a doctor nearby, many rural communities and small towns suffering the most during the COVID-19 surge don’t have hospitals or clinics, forcing people to drive long distances to get care or discouraging them from even trying.

Hewlett, with the University of Nebraska Medical Center, said tests can be hard to come by in rural areas, and the turnaround time for results can take a week. By then, if people aren’t quarantining, the disease may have spread.

“Our social bubbles are bigger than we think,” Hewlett said.

Wellhealth is a new organization testing for COVID-19 at the Western State Bank Expo Center, sent to Ford County by the Kansas Department of Health and Environment.

Medical professionals in rural America are exhausted, she said. They work multiple shifts and are worn down from wearing gowns, gloves and N95 masks for hours on end. Doctors in private practice help carry the load by picking up shifts, Hewlett said.

Dodge City’s Western Plains Medical Complex has only 10 intensive care unit beds and six ventilators, but officials say they have not been at capacity – yet.

Kansas National Guard member Roy Manns writes down results as he runs samples through a COVID-19 testing machine at a drive-thru site May 20 in Dodge City.

Southwest Kansas counties have a total ICU capacity of 22 beds at 18 hospitals for the region’s roughly 143,000 residents, state officials report.

On Sept. 1, those hospitals reported 17 ICU patients, including nine with COVID-19. By Dec. 7, 18 of the 21 ICU patients were being treated for COVID-19, and only one staffed bed remained open. Sixty-three people with COVID-19 filled other inpatient beds.

The state sends ventilators to hospitals throughout southwest Kansas because they see so many COVID-19 patients, Norman said. Thanks to that effort, state figures show the region has not been close to running out of ventilators this fall.

Some hospitals ran out of beds and transferred people to Denver or other cities in Kansas, though the state doesn’t publicly track those numbers. The ability of larger hospitals to accept new patients could run out as case numbers rise locally and in surrounding communities that rely on metropolitan facilities for critical care.

“I don’t know how you can be a COVID-19 denier all the while the hospital in your own community is filling up and case volumes are going up dramatically,” Norman said. “It doesn’t make any intellectual sense. I don’t understand it.”

‘What’s next?’

On Nov. 16, Dodge City residents filed into City Hall, where officials were set to vote on the mask mandate.

Among them was Ford County physician adviser R.C. Trotter, who in April urged residents to wear masks on a radio program. He urged commissioners to take action.

Just one infected person affects everyone around them, he said. There can be long-term effects from the disease, such as damage to the brain, lungs, heart and circulatory system.

R.C. Trotter, the physician adviser for Ford County, works at Family Practice Associates of Western Kansas in Dodge City.

“It’s not an invasion of your rights, no more so than you can’t drive as fast as you want on the road and you can’t drive without your seatbelt and you can’t smoke in this room,” he said.

Outside the commissioner’s room, about a dozen protesters decried the proposed mandate.

Most residents who testified said that the mandate would infringe on their rights, that it would be hard to enforce or that children would be psychologically traumatized by having to wear masks.

Casey Fitzgerald told commissioners the pandemic was overblown.

“I’ve been in the community for 12 years, served in the military 21 years, still serving,” Fitzgerald said. “You all know this is the land of the free. So I’m asking you to allow everyone here to remain free and make the choice whether to wear a mask or not.”

Residents of Dodge City, Kan., wait outside City Hall to speak before the city commission regarding the city’s mask mandate on Nov. 16, 2020.

A few residents encouraged commissioners to follow the advice of medical professionals and impose a mandate.

Laura Williams, who has multiple sclerosis and has quarantined herself three times after possible exposures to the virus, said nobody wants a mask mandate or a shutdown, but the virus needs to be controlled.

“If you don’t know somebody who has been tested positive, who’s been hospitalized, who’s been ill or, God forbid, died, you’re lucky,” Williams said.

Commissioner Joseph Nuci, who was the sole vote against the mandate, agreed that masks, hand washing and other safety measures help slow the disease, but he said the mandate was a step too far.

“If we do this, then what’s next?” Nuci said. “Not allowing people to travel? Forcing people to wash their hands as soon as they enter a restaurant?”

On Nov. 18, the governor again ordered a statewide mask mandate, though counties were allowed to opt out of it, because the Republican-led state Legislature granted them the power to do so in its summer session as part of a compromise negotiated with Kelly.

Some, including Ford County, opted out. The three Ford County commissioners, all Republicans, walked into their meeting Nov. 24 and unanimously rejected the mandate.

Ford County is in the minority of Kansas counties without a mask mandate. As of Dec. 2, 66 of 105 counties had a mask mandate, although a quarter of them specified they would encourage compliance but not enforce it, according to a USA TODAY review of information compiled by the state Division of Emergency Management. Fourteen counties have passed resolutions recommending, but not requiring, mask use.

Larry Cook, 64, co-founder and brewer at Dodge City Brewing on 3rd Avenue, said he wished leaders would do more. Cook said he worries every evening about patrons who ignore the prominently posted signs requiring customers to wear masks.

Before the Dodge City Commission votes on a mask mandate Nov. 16, residents are allowed inside the lobby of City Hall to speak to commissioners. Residents who went in to speak had to wear a mask.

“I had one customer come in the other day, not wearing a mask, and I told him he had to,” Cook said. “He just stared at me. I stared at him. And then he said, ‘I don’t eat in commie establishments’ and left. It wears me out. I’m just exhausted all of the time.”

While some in Dodge City continue about their lives as if the pandemic did not exist, life has changed dramatically for some who struggled with COVID-19. Many, such as Karyn Garcia, fully recovered and returned to work. Others suffer from lingering effects of the virus.

Frerichs is dealing with neurological problems from the illness. She has had trouble walking and talking. She sleeps just four or five hours a night because of body pain. She still needs oxygen. Sometimes, her left arm and right leg twitch involuntarily.

She wants everything to go back to normal.

“I think most people sick this long wonder if it will ever end or if they will ever be well again,” Frerichs said. “Well, I’m wondering.”

Norman, the state health secretary, said he hopes the Dodge City mask mandate will help contain the spread in the broader county. He worries that as the holiday season reaches its height and people continue to live near-normal lives, Kansas’ rural communities and small towns will see more dark days.

“Those communities and counties that have not chosen to put in what I’ve called ‘anti-contagion measures,’” he said, “are just denying reality.”

Contributing: Dodge City Globe Editor Vincent Marshall, USA TODAY investigative reporter Jessica Priest, and data reporters Dan Keemahill and Dian Zhang

This article originally appeared on USA TODAY: A small town dragged its feet on mask mandates, and thousands got sick

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