Three days before Thanksgiving, the White Pine County Commission called an emergency meeting to discuss the coronavirus pandemic.

The county’s COVID-19 cases had doubled in just a month, representing White Pine’s first spike in cases since the beginning of the pandemic. In fact, cases were surging in almost every county across Nevada: A virus that, over the summer, hit urban Clark County the hardest extended its reach into some of the most remote portions of the state, including rural White Pine, nestled against the Utah border.

But the county commission’s concern that Monday was in the form of a resolution up for a possible vote addressing Gov. Steve Sisolak’s latest coronavirus health and safety directive. The directive reimposed limits on gatherings and restricted occupancy at certain kinds of businesses, including restaurants, bars and gyms.

Rural counties have for years chafed at the rules imposed on them from hundreds of miles away in Carson City. That long-simmering tension has only worsened during a pandemic that has become political. 

To much of rural Nevada, which is overwhelmingly conservative, Gov. Steve Sisolak is the southern Democrat who wants to take away their personal freedoms by making them wear masks, imposing restrictions on their businesses and telling them who they can and can’t socialize with. They’ve protested outside of the governor’s mansion and some have even tried to recall him.

And on that day, White Pine County had again reached a breaking point. The resolution, as drafted, was, essentially, a rebellion against the state. It proposed telling government agencies they were not permitted to issue fines or warnings within the county related to Sisolak’s emergency health and safety directives or anything else relating to the coronavirus pandemic. 

It also proposed mandating that all officials from outside the county, including inspectors with OSHA and the Nevada Gaming Control Board, check in with the sheriff’s department upon arrival to town and quarantine for 14 days “due to the high risk nature of exposure by routinely visiting non-compliant establishments outside the community (in more densely populated regions.)” If they didn’t, they would be ordered to leave the county.

The commission ended up tabling the resolution until its meeting last week, when commissioners passed a milder version directing, in a non-binding fashion, the sheriff and district attorney to use their discretion not to enforce and prosecute the governor’s directives — and establishing a $50,000 county fund to pay the fines incurred by businesses related to those directives. It also kept in place the 14-day quarantine for officials from outside of White Pine but removed the required check-in with the sheriff.

While it’s unclear what kind of an impact the White Pine County resolution will have, the message from the commission was clear: Businesses in our community are hurting and we don’t want the governor telling us what they can and can’t do, period. Eureka County, and possibly other rural communities, may consider similar resolutions in the near future.

But to those in rural Nevada who see the value of mask wearing, social distancing and even, in some cases, modest capacity limits on businesses, there’s a lot more nuance to the conversation than that. Like their neighbors, they don’t want to be told what to do by Carson City — they, too, value their individual freedoms. However, they also believe in science and that they have a responsibility to use their individual freedoms to wear masks and limit their exposure to those outside of their households to help their communities.

“It’s not about you. It’s a courtesy to other people,” said state Sen. Pete Goicoechea, a third-generation rancher from Eureka who represents several rural counties, including White Pine. “If I do run into somebody or I do have to go into the parts store or the post office, I do put a mask on. It’s to protect people around me. I don’t think it’s so much about rights as it’s just a courtesy to people.”

Getting that message across to their communities is a vital concern right now. Private gatherings, where individual choices about how to socialize and whether to wear a mask, are driving the spread of COVID-19 in much of rural Nevada. It’s a problem facing the entire country but one uniquely challenging in the rural West where freedom is precious, mistrust of government runs high and hospital beds are scarce.

“This is the first time that I’ve ever seen medicine become political, and it’s a terrible, terrible idea because medicine should be based in science,” said Matt Walker, CEO of William Bee Ririe Hospital in Ely. “Medications, mask wearing, some of this stuff has been politicized and we really need to separate them.”

Some rural officials worry if people don’t start taking their individual responsibilities in preventing the spread of COVID-19 seriously, the state government will impose even more restrictions. The current health and safety directives are in place through Tuesday, at which point the governor could decide to impose new, even tougher restrictions — like the new shutdown in neighboring California.

“We’re probably one of the most conservative counties in the United States. We don’t like to be told what to do. When all three county commissioners and your appointed officials and other elected officials are masked up around town, people notice it, and this isn’t a political statement,” said J.J. Goicoechea, chair of the Eureka County Commission, the Eureka County health officer and Pete Goicoechea’s son. “We’ve got to keep the damn schools open and keep these businesses open. We can’t afford not to.”

A spike in rural Nevada

To hear some of those in rural Nevada tell it, they really thought for a time that they had escaped the worst of the COVID-19 pandemic. 

As cases surged in Clark County over the summer, they stayed relatively low in the rest of the state. Washoe County and some rural counties, including Elko and Nye, saw bumps in cases over the summer, but nothing compared to what was happening in Southern Nevada.

Even Humboldt County, which at the beginning of the pandemic had more COVID-19 cases per capita than any county because of an early outbreak there, thought it had gotten the situation under control.

“Things were going really well several months ago, the number of cases we were seeing in Humboldt County had really gone down and I was really impressed with what we were seeing and then starting between a month and six weeks ago we started to see a major ramp up in the number of cases,” said Dr. Charles Stringham, Humboldt County’s health officer.

Humboldt, as of Saturday, has the third most COVID-19 cases per 100,000 in the last 30 days behind only Pershing and Mineral counties. There’s no secret to the spike in Humboldt County. Stringham said it’s the same story being told across the country: People started growing tired of following coronavirus health and safety protocols and engaging in riskier behaviors just as the weather turned, driving people indoors where viral spread is more likely.

On top of that, Stringham said there’s a continued reluctance among people to believe that it is those they know best — friends, family and neighbors — who are the greatest danger to them. Of course, it’s not because they pose any greater danger than the rest of the population, but because people tend to let their guard down with those they know best, giving the virus an opportunity to strike.

“Under ordinary circumstances, it’s a great thing to hug peripheral family members. A cousin comes to town and you might give that person a hug. That’s the way we’ve always done things,” Stringham said. “But the rules with COVID have changed, and what is dangerous is what has changed and, in a lot of cases, behavior has not.”

Even when people are trying to be careful, delays in receiving the results from COVID-19 tests — a significant problem in rural Nevada — has made it harder for people to appropriately isolate themselves if they have contracted the virus or been exposed. In White Pine and Pershing counties, which are experiencing the worst of the delays, it usually takes about six days for test results to come back.

“When I’m five or six days waiting to know if someone is positive, the spread can just be outrageous in that amount of time,” said J.J. Goicoechea, who has served as Eureka County’s health officer since the prior health officer’s resignation. “When you have a gold mine with 2,000 employees or one with 600 employees or one with 150 employees, those crews are around each other for 12 hour shifts for those four or five days you’re waiting for those test results to come back from one of those crew members.”

Officials across rural Nevada, however, say they’ve seen good compliance with mask-wearing in public this fall, possibly because people have realized the risk that strangers pose to their health as cases continue to rise. Terry Reynolds, director of the Department of Business and Industry, told the COVID-19 Mitigation and Management Task Force on Thursday that OSHA is now seeing “very good compliance” with coronavirus health and safety rules, characterizing any issues that have come up as isolated events.

Humboldt County Manager Dave Mendiola said compliance with mask-wearing was slow to come about early on but that once businesses made it mandatory, people realized that they had two choices: Wear a mask or not shop in that business.

“At that point, you don’t have a choice. If I’m going to feed my family, I’m going to put a mask on,” Mendiola said. “People have realized this thing is contagious."

Rurals vs. the state

There is, however, little love in rural Nevada for state OSHA inspectors. 

J.J. Goicoechea said the most recent inspector who visited Eureka had “not a lot of bedside manner” and was “pretty aggressive” in his approach to enforcement. Now, as a result, there’s a push for Eureka to pass its own resolution — “pretty much just telling the governor to go pound sand,” Goicoechea said — similar to the one in White Pine County.

“They’re telling us, we’ll wear a mask because you’re telling us to wear a mask, but if that guy comes back, we want to run him out of town,” he said.

Goicoechea lauded Sisolak’s decision to establish a Local Empowerment Advisory Panel, or LEAP, in the spring to decentralize the coronavirus health and safety decisions being made at a state level. But under the current three-week pause, which applies statewide, those old tensions are bubbling up again.

“That’s why we’re seeing so much pushback in the rurals right now,” Goicoechea said. “They’ll take it from Elko, they’ll take it from Eureka, they’ll take it from Battle Mountain because they trust us.”

In line with that, he said he would like to see more of a shift back to that decentralized, county-by-county approach to COVID-19 in the rural communities.

“If I had my way and could be king for a day, I would say, ‘Counties, you take control of this. We’re going to put this back on you. We’re not seeing the spread in the businesses. Go to 50 percent, wear your masks, you’re going to do everything right and we’re going to take your liquor license if it’s not right,’” Goicoechea said. “At that point it is 100 percent on that business owner to make sure those doors stay open.”

Some rural officials do, however, acknowledge the rock and a hard place that the governor sits between in trying to balance the state’s health needs with its economic needs. Lyon County Manager Jeff Page described the general attitude in rural Nevada as, “Sisolak sucks and the government has no authority to tell me what to do.”

“I wake up every morning thanking God for a couple of things: That I’m still alive, that my wife’s still in the house with me, and that I’m not the governor,” Page said. “Whether I agree with his politics, that poor bastard, whatever he does is going to be wrong. He has made some real difficult decisions, and I do whatever I can to support what he's doing.” 

Page praised the involvement of two people — Nevada COVID-19 Response Director Caleb Cage and Nevada National Guard Lt. Col. Brett Compston — in the state’s COVID-19 response. Page has known Cage for the last dozen years, including while he served as head of the state Division of Emergency Management under Gov. Brian Sandoval’s administration, and Compston since he was born, as he grew up in Yerington.

“These aren’t people who wake up every morning saying, ‘Gee, I wonder how I can screw the citizens of Nevada,’” Page said. “They’re truly concerned about the health of the citizens of Nevada.”

The difficulty broadly, though, is that COVID-19 has become political. Sisolak, a Democrat, is saying one thing. President Donald Trump, a Republican, is saying another. And much of rural Nevada only voted to support one of those two men.

“The challenge is somehow this became a political issue both at the national level, state level and local level,” Page said. “I don’t give a crap which side of the fence you’re on, Democrat, Republican, it's a public health issue.”

Hospitals teeter on knife’s edge

Officials in rural Nevada have tried to focus their messaging to the community around their hospital infrastructure. Though Nevada is known for ranking at the bottom of all the wrong lists when it comes to health care, the situation is even worse in rural Nevada where the health care infrastructure is particularly fragile.

Each rural county has at most one hospital — if they’re lucky to have a hospital at all. The hospitals are small, with between four and 25 acute care beds, and face staffing challenges even in non-pandemic times. 

“We’re kind of at a difficult spot because Humboldt County has enough residents that the virus can spread very quickly, yet we don’t have enough residents that there is redundancy in our health care delivery system,” Stringham, the county's health officer, said. “We only have one hospital, but if we had a major ramp up in cases, we would overwhelm the hospital.” 

One challenge for rural hospitals is they haven’t been able to transfer patients out to the nearest urban hospital for higher levels of care as easily because those hospitals are also overwhelmed. Hospitals that are accustomed to transporting patients to Las Vegas, Reno and Salt Lake City are now scouring for placements in San Jose, St. George and Idaho.

Joan Hall, president of Nevada Rural Hospital Partners, said Grover C. Dils Medical Center in Lincoln County had to go around begging hospitals to take a non-COVID patient who needed surgery. When they finally got a hospital in Salt Lake City to accept, the patient had to be driven by ambulance from the hospital in Caliente to the airport in Panaca and then flown to Salt Lake City.

“They don’t have a paramedic, and this patient was pretty critical so the doctor went,” Hall said. “All those things you don’t think about in big cities.”

As a result, some rural hospitals have been keeping patients longer who would normally be transferred to a higher level of care. They’re also discharging patients they might normally keep for monitoring to make space for those who need care more urgently.

“If they’re borderline, they might be okay at home, we’re going to give them whatever meds and care we can here and send them home,” said Hugh Qualls, CEO of Mt. Grant General Hospital in Hawthorne. “We don’t have a home health program here, no hospice, so there’s really not a social safety net, if you will, to check in on them. Those are judgment calls that our nurses or providers have to make based on the greater or more urgent health needs we have.”

When hospitals reach capacity, as Qualls said Mt. Grant did at times in the last month, administrators are left playing a grim game of chess trying to get their sickest patients transferred out to hospitals able to provide higher levels of care while evaluating whether some of their least sick patients might be able to get by at home.

Rural hospitals also have been hit particularly hard by staffing crunches. Unlike urban hospitals, with teams of doctors, nurses and pharmacists, rural hospitals only have one or a few people who do each job. If the one person who can do that job is out sick or has to quarantine because of a possible COVID exposure, there is often no one else to do that job for miles around.

“Larger hospitals at least have more depth,” Walker, the CEO of William Bee Ririe Hospital in Ely, said. “We only have one pharmacist, one ER doctor. If he gets sick, we’re kind of in trouble.”

As a result, some hospitals have had to resort to having staff who have tested positive for COVID but are asymptomatic continue to work, suited up in the appropriate protective gear, including eye protection and N95 masks, or hoods, known as PAPRs.

“Ideally, in a perfect world, we’d have our staff members who are positive only work with positive patients or residents, but we don’t always have the luxury of having sufficient staff to make those choices,” Qualls said. “We suit them up as best as we can to protect them and the residents they work with, and they’re going to have to work with patients that are not positive for COVID. That’s just the reality.”

Another issue rural hospitals have struggled with is just physical space in which to put patients. While Renown Regional Medical Center in Reno turned its parking garage into an alternate care site with more than 700 beds, Carson Valley Regional Medical Center in Gardnerville set up a 20-bed alternate care site in its warehouse. The hospital had to activate that space once last week for a few hours when the main hospital was full.

“We only had to put two patients in there. We actually were on the path to put more, but all of a sudden we had an ability to transfer some of our patients out to another hospital,” Jeff Prater, the hospital’s CEO, said.

Banner Churchill Community Hospital in Fallon and Grover C. Dils Medical Center in Caliente both continued to be stretched past their capacity as of Thursday. Banner Churchill had a hospital census of 30, half of which were COVID-19 patients, but only 25 beds available, while Grover C. Dils had five patients, one of them with COVID, but only four beds.

“Banner Churchill is very capacity constrained. They've had a fairly large number of COVID patients, some of whom have been very, very ill,” Dr. Marjorie Bessel, chief clinical officer of Banner Health, said during a press conference this week. “We've transferred into Colorado from Banner Churchill and we've even transferred all the way down into Tucson here in the state of Arizona to accommodate. We continue to provide a lot of support to that facility and that community to help them manage as best as we can.”

As they struggle to meet the medical needs of their communities, rural hospitals are also trying to combat misinformation. Walker said that William Bee Ririe has had issues with people coming to the hospital who refuse to wear a mask that have escalated to the point where the police have had to come and escort people out. He also said some patients have come in demanding certain medications, even though it might not be the best course of treatment for them.

“Medicine is complicated. It takes a long time to become a doctor or a pharmacist. It’s complicated,” Walker said. “You can’t just become an expert in a month or two of reading things on Facebook.”

Though the situation is grim, hospital administrators are, however, hopeful that the reality is starting to sink in for their communities. They hope people who might have once been a bit more cavalier about the pandemic are starting to take it more seriously.

“People are starting to see there are actually fatalities and these are people they know, neighbors or even relatives,” Qualls said. “It’s starting to hit home. Whether or not that makes a difference, it’s no longer a problem in California or New York. It’s here in little Mineral County.”

Life, liberty and the pursuit of happiness

With COVID-19 cases and hospitalizations still on the rise, elected officials and local government leaders in rural Nevada are trying a new approach — leading by example and being open about their decisions to change their behavior.

“I’ll be honest. I never wore a mask in Eureka until a month ago,” J.J. Goicoechea said. “We’ve got to set a better example. Our commission meetings are all on the telephone, so I’d do it on the phone and then I’d walk out to the parking lot. Now, I’m finding it important to have that mask on when I walk through the front door of the courthouse. Everybody is doing that and you’re not being looked at like a black sheep anymore for wearing your mask.”

Scott Lewis, director of emergency management for Nye County, echoed the importance of leaders setting an example for their communities. He said it can’t just be local emergency management officials hounding people to take precautions.

“A single group can’t do it,” Lewis said. “Our community leaders have to state cleanly and clearly that this is what we’re going to do and not make political stands.”

Page, the Lyon County manager, had planned to fly up and spend a week with his son at Oregon State University but canceled the trip because of COVID. Mendiola, the Humboldt County manager, now takes extra precautions when seeing family.

“Before, we’d have a family gathering. It wasn’t in defiance, it was just, we wanted to get together,” Mendiola said. “Now, we actually talk to each other and say, ‘We’re going to do this gathering in two weeks and have dinner on a Sunday, watch yourself, be careful, do the right thing.’”

He said that even as the county manager out in front on the issue of COVID-19, the importance of following COVID-19 health and safety protocols at home didn’t click for him until he thought about why the county was finding so few exposures in public and so many in private.

“It made sense to me. I’m a reasonable guy. I may have all kinds of beliefs about this thing, but at the end if we can keep exposures from happening in the public sector, why wouldn’t we apply those protocols at all to the private sector?” Mendiola said. “If we do, I’m sensing we would be much better off.”

Rural health officials have no desire to enforce how people behave in their own homes. But they are also trying to stress how important those individual choices that people make in the comfort of their own homes and their friends’ homes are to the overall safety of the community.

“People don’t want us in their homes, we don’t want to encroach into their private lives, but that’s where the virus is being transmitted,” Stringham said. “It creates all of these paradoxes because on one hand a lot of public policy is being restricted toward business, but business is not the problem. We’re punishing businesses even though businesses in general have been the biggest part of the solution.”

However, some rural officials worry that people have become too set in their ways when it comes to COVID to change their personal beliefs. 

“Will it work? I don’t know. I’m very skeptical because people are just hard-headed, they’re tired, they’re over this whole thing,” Mendiola said. “I understand both sides. I understand why they’d be mad. I get it. But if we just keep doing what we’re doing, it’s only going to get worse, especially for our businesses, which is going to affect our citizens.”

But some see glimmers of hope, even amid the challenges.

“I’ve been going since this morning and haven’t been within 10 feet of anybody, you know, it’s me and the dog and a bunch of cows,” Pete Goicoechea, the state senator, said. “But even these old ranch trucks have a mask hanging on the mirror or the gear shift knob. They may be a little dirty, but people are trying to comply.”

The conversation, they say, is one not just about individual liberty but individual responsibility and what people choose to do with their freedom.

“It’s a lot more difficult to fight this virus in a culture that really respects individual rights because more or less everybody is given the capacity to handle this the way they want to. The policies that we write as a culture come to the individual merely as recommendations and then if those individuals decide they don’t want to follow those recommendations, there aren’t really a lot of options we’re willing to take as a culture to enforce those things,” Stringham said. “It pits individuals against cultures and tries to figure out where those happy balances are.”

“It’s all fascinating,” Stringham added, “but very tiring.”