SIOUX FALLS, S.D. — South Dakota Gov. Kristi Noem on Monday showed no sign of budging from her hands-off approach to the pandemic, despite finding herself among a dwindling number of Midwest governors holding out against mask mandates and facing a death rate in her state that has risen to the highest in the nation this month.

As the virus has steadily grown into a full-scale health crisis across the Midwes t, the Republican governor has remained resolute — sticking to the limited-government ideals that have made her a rising star in the conservative movement and arguing that government mandates don't work. But she finds herself the subject of increased scrutiny for the approach, especially after neighboring Iowa and North Dakota last week moved to require face masks in some settings.

South Dakota has reported 219 deaths in November — about a third of all its deaths over the course of the entire pandemic. The COVID-19 deaths have sent the state to the top of the nation in deaths per capita during November, with nearly 25 deaths per 100,000 people, according to data from The COVID Tracking Project.

But Noem has no plans to issue mask requirements. The governor's spokeswoman Maggie Seidel pushed back against arguments by public health experts that a mask mandate would dramatically reduce the spread of the virus, pointing out that states like Illinois, Minnesota and Wisconsin have also experienced significant virus waves despite having strict mandates to wear face coverings.

"The facts are simple: mask mandates, harsh lockdowns, massive testing and contact tracing haven't worked – in the United States or abroad," Seidel wrote in an email.

But South Dakota currently has the nation's second-worst rate of new cases per capita, according to Johns Hopkins researchers. There were 2,047 new cases per 100,000 people, meaning that roughly one out of every 49 people has tested positive in the last two weeks.

The only state where new cases per capita are worse, North Dakota, moved to require masks and limit the size of gatherings on Friday. The situation there has grown so desperate that hospitals are preparing to ask medical workers with coronavirus infections but no symptoms to staff COVID wards.

"Our situation has changed, and we must change with it," said Republican Gov. Doug Burgum in a somber video message.

Iowa Gov. Kim Reynolds, a Republican, also moved last week to require that people wear masks if they join indoor gatherings of 25 or more people.

However, Noem has been willing to take more extreme stances than those governors. While in recent months they have encouraged — but not required — masks, Noem has repeatedly raised doubts on whether wearing a mask in public helps prevent infections and said she will let people decide if they should wear masks. She also welcomed massive events this summer like the Sturgis Motorcycle Rally and the state fair.

The approach has given her significant influence within the Republican Party. She spoke to incoming GOP members of Congress this weekend in Washington, D.C., and posted photos of Monday meetings with members of President Donald Trump's Cabinet. She was not wearing a mask in any of the photos.

Meanwhile, the deaths in South Dakota continue to mount. But people in the state who believe a mask requirement would prevent deaths have given up on hoping the governor will act.

"She's dug her heels in," said Shannon Emry, a Sioux Falls pediatrician who joined a small rally on Monday calling for the City Council to pass a face-covering mandate. "That's why I feel the last resort is down to the cities."

Last week a proposed ordinance to require masks in the state's largest city failed after the mayor issued a tie-breaking vote against it. Several city council members plan to give it another try this week, the Argus Leader reported.

Emry said that many in the medical community are worried they will only see more cases and more deaths. She called the governor's stance "reckless."

"Our numbers are awful. We have some of the highest numbers in the world," she said. "If we don't take some action, it's only going to get worse."