A small town dragged its feet on COVID-19 mask mandates. Now residents are paying the price. – USA TODAY

DODGE CITY -- 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, Kansas, a politically red cattle community of some 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 pandemics first wave.

But then a second wave hit Dodge City. People started getting sick again.

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

COVID-19 has spread fast and deadly 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 on Aug. 7, and within two months, people in rural counties were almost twice as likely to have contracted COVID-19 within the last week compared to people who live in urban areas. Counties with city populations that total 20,000 to 250,000 people like Dodge Citys 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.

The rural communities were kind of lulled into complacency, feeling they were naturally blessed with open spaces and big sky and that COVID-19s 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, said Mayor Joyce Warshaw. But it wasnt 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. Warshaws aunt also recently 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 others health and well-being," she said.

But weeks later, residents openly defy the mandate. And, as of early December, police had done nothing to enforce it.

At Red Beard Coffee on Gunsmoke Street earlier 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 recent visit by USA TODAY.

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

At the Ensueno Boutique on 2nd Avenue, owner Andres Lima, 61, said hes been requiring customers and staff to wear masks since the summer, regardless of what the government required. His store has bilingual mask rules posted on the front doors, and store clerk Esthela Cisneros is pregnant.

Its for the safety of the people who work here and for the people who come in, he said, speaking amidst wedding gowns and sparkling quinceaera dresses. Some people say Im not sick, but we tell them, 'thats not the problem. For your safety, you need to wear one.'

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

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.

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 like 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 cowboy's riding toward the sunset welcomes visitors to Dodge City, Kansas.Trevor Hughes, USA TODAY NETWORK

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 recent U.S. Census Bureau estimates.

The community is surrounded by cattle feedlots that supply Dodge Citys two meat packing 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.

Show captionHide captionWorkers wear protective masks as they walk outside the National Beef meatpacking plant, Tuesday, May 19, 2020, in Dodge City, Kan. Ford County, home to...Workers wear protective masks as they walk outside the National Beef meatpacking plant, Tuesday, May 19, 2020, 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 due to outbreaks in the county's two meatpacking plants.Charlie Riedel, AP

COVID-19 was first discovered in Kansas in early March and, as the disease 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 packing plants led to a rise in cases that, at one point, made Ford County one of the worst hotspots in Kansas.

In Kansas like most of the U.S. the virus has disproportionately harmed non-white 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 meat packing plants that hire many Hispanic workers, including the two beef processing plants in Dodge City.

Vehicles drive down Wyatt Earp Boulevard in Dodge City, Kansas.Trevor Hughes, USA TODAY NETWORK

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

The city 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.

Lets 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 on July 3. Lets lead on this response to overcome this fast-spreading danger to our community.

But many people refused. And 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 cell phone data. By early July, counties with small cities also were back to normal levels. Urban residents were slower to return, with visits to retail and recreation sites averaging about 15% below pre-pandemic levels.

And the week of Independence Day, 75% of rural residents and 73% of small city residents left home compared to 68% of people 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 were battling 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, youre the stupid crybaby.

Wearing a mask, Esthela Cisneros works at Ensueno Boutique in downtown Dodge City, Kansas. Her boss, Andres Lima, said he's been requiring both staff and customers to wear masks inside the store for months.Trevor Hughes, USA TODAY NETWORK

The lower infection rates earlier in the year made it easy for officials, particularly those in redcommunities like Dodge City that supported President 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 a CDC analysis of data from the Kansas Health Institute.

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

Its 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 recent 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 to 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 also 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.

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, such as requiring students and staff to wear masks, placing hand sanitizer in high-traffic areas, spreading seats at least six feet apart and disinfecting routinely.

But while face coverings were required at schools, local leaders still hadnt approved a mask mandate, so face coverings were optional in other public areas. That meant more chances for the disease to spread from outside the schools to inside.

And it did.

A picture of Comanche Middle School in Dodge City, Kansas.TREVOR HUGHES, USA TODAY NETWORK

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

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

Frerichs awoke in the middle of the night on Oct. 29, freezing cold and with a fever. It came out of nowhere, she said, as had the pain in her stomach that 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 were falling.

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

Frerichs'husband and three daughters also came down with less serious cases of COVID-19. Only Frerichs'14-year-old son has avoided the illness so far.

"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."

When it comes to the mask mandate, Frerichs keeps her opinions to herself because of the divisiveness in the community over the issue.

But since being diagnosed, Frerichs has continued to battle after-effects of the disease, 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 on Facebook on Nov. 27. Stay healthy and safe please.

The first symptom for Karyn Garcia, a 29-year-old teacher's aide in the school district, wasblinding 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 immediately went into quarantine with her children, neither of whom got the virus.

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

"It's scary, to be honest," Garcia said.

While Frerich has a doctor nearby, many rural communities and small towns suffering the most during the current COVID-19 surge don't have hospitals or even medical clinics, forcing people to drive longdistances 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 arent quarantining, the disease may have spread.

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

Wellhealth is the 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.JUDD WEIL/DODGE CITY DAILY GLOBE

Medical professionals in rural America are exhausted, she said. Theyre working multiple shifts and are worn down from wearing gowns, gloves and N-95 masks for hours on end. Meanwhile, doctors in private practice are helping carry the load by picking up shifts at the hospital, Hewlett said.

Dodge Citys Western Plains Medical Complex has only 10 ICU beds and six ventilators, but officials say they have not been at capacity yet.

Show captionHide captionKansas National Guard member Roy Manns, from Topeka, Kan., writes down results as he runs samples through an Abbott COVID-19 testing machine at a drive-thru...Kansas National Guard member Roy Manns, from Topeka, Kan., writes down results as he runs samples through an Abbott COVID-19 testing machine at a drive-thru testing site Wednesday, May 20, 2020 in Dodge City, Kan. Kansas Army and Air Force medical guard units have tested 100-200 people daily since setting up the testing site nearly a month ago in an attempt to stem the spread of the new coronavirus.Charlie Riedel, AP

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 hospitalized 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. Another 63 people with COVID-19 filled other in-patient beds.

The state is sending ventilators to hospitals throughout Southwest Kansas because they are seeing so many COVID patients, Norman said. Thanks to that effort, state figures show the region has not yet been close to running out of ventilators this fall.

Some hospitals have run out of beds and are transferring people to Denver or other cities in Kansas, though the state doesnt publicly track those numbers. The ability of those 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 dont 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 doesnt make any intellectual sense. I dont understand it.

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 Dr. R.C. Trotter, who in April urged residents to wear masks on a Kansas radio program. This time, he was urging commissioners to take action.

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

Dr. R.C. Trotter is the Ford County physician's adviser for Ford County, Kans. who is one of three doctors practicing at Family Practice Associates of Western Kansas in Dodge City.JUDD WEIL/DODGE CITY DAILY GLOBE

Its not an invasion of your rights, no more so than you cant drive as fast as you want on the road, and you cant drive without your seatbelt and you cant smoke in this room, he said.

Outside the commissioners room, about a dozen protesters decried the proposed mandate.

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

Casey Fitzgerald told commissioners the pandemic had been overblown.

Ive 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 Im asking you to allow everyone here to remain free and make the choice whether to wear a mask or not

Dodge City residents wait outside of Dodge City City Hall to speak before the Dodge City Commission regarding the mask mandate for the city on Nov. 16.JUDD WEIL/DODGE CITY DAILY GLOBE

A few residents encouraged commissioners to follow the advice of medical professionals.

Laura Williams who has multiple sclerosis and has quarantined herself three times after possible exposures to the virus encouraged commissioners to impose the mandate. Nobody wants a mask mandate or a shutdown, she said. But the virus needs to be controlled.

If you dont know somebody who has been tested positive, whos been hospitalized, whos been ill, or, God forbid, died, youre lucky, Williams said.

Dodge City commissioner Joseph Nuci, who was the sole vote against the mandate, agreed that masks, handwashing and other safety measures help slow the disease. But 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, Gov. Kelly again ordered a statewide mask mandate. Counties across Kansas were allowed to opt out of it, though, because the Republican-led state legislature granted them the power to do so in their summer session as part of a compromise negotiated with Kelly.

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

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A small town dragged its feet on COVID-19 mask mandates. Now residents are paying the price. - USA TODAY