MINOT, N.D. — From his desk at Trinity Health in Minot, Dr. Casmiar Nwaigwe sat at the center of one of the worst COVID-19 outbreaks in the world.

Like most North Dakota cities, Minot passed through the spring and summer of the pandemic largely unconcerned about the virus that was tearing through distant and more densely populated regions of the country.

Still, Nwaigwe, an infectious disease specialist, worried from the time of the state’s first positive case of COVID-19, registered outside Minot in March, that his city in north-central North Dakota could be in for a long road.

For weeks, Nwaigwe urged his neighbors and patients to take the virus seriously, emerging as a leading medical critic of North Dakota's slow-footed response. In the last month, the doctor's warnings have become reality. Since Oct. 1, Minot's surrounding Ward County has ballooned from 174 active virus cases to a peak of nearly 1,400 last week. Before the start of October, the county had reported just 11 virus deaths. Since then, 94 more people have died.

This recent viral surge has put Ward County at the head of North Dakota's outbreak. Of the state's seven most populous counties, Ward has the densest concentration of active virus cases, at 163 for every 10,000 residents. Minot has become a paragon of North Dakota's pandemic crisis: a nightmare nexus of virus skepticism, underestimated rural spread, delayed action and an overburdened hospital system.

While larger North Dakota cities have managed to keep barely afloat thanks in part to bigger medical systems — Bismarck has two hospitals and Fargo has three — Minot has nearly buckled under the staffing pressures forced onto its only hospital. While the city is home to about 50,000 people, Trinity serves a vast swath of northern North Dakota, sometimes accepting patients from as far away as eastern Montana, a total coverage area that Dr. Jeffrey Sather, the hospital's chief of staff, estimated reaches close to five times Minot's population.

To accommodate the recent surge, Trinity converted a full floor and a half into a COVID-19 unit. In recent weeks, Sather said, the hospital has been on diversion more than off, meaning that it has most often been too full to accept transfers from rural hospitals in the surrounding area. The virus has also gutted the hospital’s front-line roster and exacerbated staffing shortages: At one point in early November, close to 140 Trinity staffers were out on quarantine.

“I have to watch someone suffocate to death every day, sometimes multiple times a day,” Sather said in an emotional press conference earlier this month, describing how the hospital's staffing crunch had left patients waiting outside the emergency division, unable to receive care.

Nwaigwe, who has worked at the hospital for 12 years, said some of his longtime patients are among the dead. “I feel it personally,” he said.

“When I say that every death from this is a preventable death, I mean it,” he added. “Every single one.”

Funeral home pushing its limit

Among the North Dakota cities that enacted mask mandates, Minot did so relatively early, installing an unenforced directive almost four weeks before the statewide mandate. But convincing people in town to take the virus seriously was difficult, even as Ward County began to regularly register new virus cases in the triple digits.

“We’re at the point that we didn’t want it to get to,” said Jennifer Weichmann, the county’s emergency management director.

Schatz Crossroads, a 24-hour truck stop and a Minot institution, remains a watering hole for locals, many of whom haven't gotten on board with masking guidelines.

“A lot of people that probably fight it — a majority of them are probably our customers,” said Krista Marshall, the operations manager at the truck stop. While Schatz removed tables and required employees to wear masks in response to the recent surge, Marshall said she isn’t eager to police her customers. Schatz is the sort of place that Minot old-timers have long frequented for comfort meals and familiar faces. Some regulars still stop in for their scheduled meetings with friends. “I feel for them,” Marshall said. “You can set a clock to some of it.”

Still, Marshall said she’s seen a shift in Minot in recent weeks, as the local case numbers and virus deaths have become unavoidable. It seems like practically everyone in town knows somebody who has lost a loved one, Marshall said. Just that morning, one Schatz employee’s father died from the virus.

For Thompson-Larson Funeral Home, a family-owned facility abutting the hospital downtown, the death toll has been almost too much to handle. Wes Burkart, the home's funeral director, said the recent COVID-19 surge has coincided with a rash of overdoses in the area and brought in business at levels they have never seen before. Thompson-Larson staffers are working long, taxing hours with almost no reprieve, and logistical challenges of handling COVID-19 victims' bodies and arranging safe funerals has stretched them even further.

“It’s terrible. I’m coming in to work at 6, 6:15, and I’m leaving at 8:30 or 9 o’clock at night and probably not taking supper,” Burkart said. “You’re just going, trying to get paperwork done and other stuff. There’s just a lot of stuff behind the scenes that has to be done.”

In non-pandemic times, Burkart estimated that Thompson-Larson holds close to 30 funerals a month. But recently the funeral home had 30 funerals on its immediate docket, a schedule they hoped to clear within a week. For now, Thompson-Larson has been shipping in caskets in record quantities for the small facility, and just last week, the funeral home staff retrofitted a storage area into additional morgue space.

If the local outbreak doesn’t subside soon, Weichmann said Ward County may have to take extraordinary measures to handle the volume of deaths. The emergency management director has been at the ready to request a refrigerated mobile morgue truck from the state Department of Health if the local funeral homes need it, a last-resort step that North Dakota has so far managed to avoid.

And while Weichmann is hopeful that Minot will escape without the need for such a drastic step, she worries that, for many people in her county, the pandemic remains a clash of individual rights more than a crisis of public health.

“How do you convince somebody like that to care about their neighbor?” she asked. “That right there is the question that we are all struggling to answer.”

'Excruciating days'

Slowly, over the last month, Minot’s bars and restaurants have gotten quieter. Masks have appeared in more frequency around town. But while outward signs of the stealthy virus have only recently cropped up, the costs of the pandemic were apparent in local senior centers more than a month ago. Many nursing homes and long-term care centers in the city have struggled to contain bad outbreaks. On Nov. 5, Edgewood Vista reported 62 positive residents and 44 positive staffers. That same day, Trinity Homes, a 230-bed facility operated by Trinity Health, hit its peak, reporting 72 positive residents and 90 positive staff.

The dire situation up the road at Trinity hospital left some of these nursing home residents with little option for escape. With Trinity at or near capacity for most of the last month and other major hospitals hours away managing crises of their own, Nwaigwe said some Minot elderly have forgone treatment altogether, “electing to die quietly in the nursing homes rather than be transferred to Fargo.”

Somerset Court, an assisted living facility at the edge of town, was almost completely insulated from the virus all year. Before Minot’s recent surge, the facility had registered just two asymptomatic positive tests back in July. But things changed sharply in early October when Somerset staff sent one under-the-weather resident to Trinity and learned that the woman was positive for COVID-19. LeAnna Heupel, a resident services coordinator at Somerset, said staffers immediately shepherded the woman’s close contacts into isolation and waited “two excruciating days” for the next facility-wide testing event.

In a fell swoop on that day, Somerset went from zero positive tests to 58. The total number of positives climbed to 84 in the weeks following. In a facility with about 120 residents, 21 people died. And the virus came and went like lightning: By the end of last week Somerset was back to zero positive cases.

As the virus tore through Somerset, Heupel recounted that she texted her siblings to relay each new death. “I was telling them, you know, number whatever died,” she said. “I started writing down in a notebook: number one, when they died, number two, and their importance, what they meant to that community.”

Heupel said that to her and others at Somerset, the 21 people who died were more than numbers, and she wanted to record her memories of each. Among them were two of the facility's priests, a professor at Minot State University, a couple and old family friends.

“The saddest part about it is, on Thursday, we went in and told a few people that they had it,” Heupel said. “They were not sick. They looked at us like we were crazy. And then by the next Friday they were gone.”

Readers can reach Forum reporter Adam Willis, a Report for America corps member, at awillis@forumcomm.com.