SIOUX FALLS (AP) – South Dakota Gov. Kristi Noem on Wednesday defended those who choose not to wear masks in public, even as her state deals with one of the worst coronavirus outbreaks in the nation.

Those who don't wear masks are making a “personal decision” and deserve respect, the Republican governor said during a news conference. She refused to encourage people to wear masks or socially distance, instead saying the best thing people can do to stop the spread of the virus is wash their hands.

It was the governor's first news conference to address the pandemic in over three months. Although she acknowledged the state's growing health crisis, she defended her approach to tackling the pandemic and showed no sign of issuing a mask mandate or other restrictions.

The ardently conservative state's largest group representing doctors has said it “strongly supports” a mask mandate, and several South Dakota cities now require masks to be worn in stores and public buildings.

“Some have said that my refusal to mandate masks is a reason why our cases are rising here in South Dakota, and that is not true,” Noem said.

Noem said she wears a mask when “appropriate," though she frequently posts photos of herself on social media without one, despite her proximity to others. She said she doesn't believe her powers as governor allow her to issue a mask mandate.

“We talk often about the government’s role in a situation like this in dealing with a pandemic,” Noem said, “At this point, frankly, I’m getting more concerned about how neighbors are treating neighbors.”

She pointed to other states in the region with mask mandates, such as Wisconsin and Montana, that have a higher rate of daily new cases per capita. South Dakota ranks in the top seven states for the metric. And in the last two weeks, the numbers of confirmed new cases and deaths per capita in the state have been the second-highest in the country, according to Johns Hopkins researchers.

The number of COVID-19 deaths has skyrocketed in recent weeks. Health officials have reported 259 deaths in November – about a third of the state’s total death toll over the course of the pandemic.

The only state with worse death and new case rates, North Dakota, on Friday issued a statewide mask mandate and limited the size of gatherings in businesses.

Later Wednesday, state epidemiologist Josh Clayton sent an email to healthcare providers underlining that the Centers for Disease Control and Prevention recommends wearing masks and that “experimental and epidemiological data support community masking to reduce the spread" of the coronavirus.

Noem's approach has received a sharp reproach from public health experts. Dr. Ali Mokdad, a professor of the Institute for Health Metrics and Evaluation at the University of Washington, has become increasingly alarmed with the governor's hands-off strategy, calling it “nonsense" that has led to an outbreak on par with countries that have far fewer health resources.

“Somalia did nothing. Yemen did nothing,” he said. “It’s so sad to compare yourself to countries like that.”

Information published by the Department of Health brought new clarity to the dwindling number of hospital beds in South Dakota. There were about 37 adult ICU beds and 921 general care beds available across the state, according to data released by health officials that distinguished between adult ICU beds and neonatal or pediatric ICU beds.

The largest health care systems say they are operating at or above capacity, struggling with the influx of coronavirus patients combined with people needing other medical care.

Secretary of Health Kim Malsam-Rysdon said the pandemic has worsened staffing shortages at hospitals, but offered the development of a vaccine as a “bright spot on the horizon.” She hoped vaccine distribution, which will prioritize health care workers, could begin as early as December.

But Mokdad, the infectious disease expert, said it was heartbreaking watching the state's failure to prevent deaths and “surrender so close to a vaccine being deployed.”