Cara Ellen Modisett fields the usual battery of questions every time she visits the doctor: Is she feeling well? Did she travel abroad? Has she been in contact with someone known to have the coronavirus?

Then, late last month, Modisett’s physicians in Roanoke, Va., added an unexpected query to their list. “They asked whether I had been to Myrtle Beach,” said Modisett, 47.

With summer in full swing, scores of Americans have booked hotels, hit the boardwalk, and camped out along the popular South Carolina coast. The unexpected rush of vacationers has helped rejuvenate a local economy left in tatters this spring when the pandemic closed shops and halted travel nationwide.

But it has also turned the Myrtle Beach region into a coronavirus hot spot and a startling example of the difficult, and perhaps deadly, calculation some cities and states face about when to reopen.

Dozens of locals, visitors, and business owners describe a beach that has been packed at times over past weeks, with few people wearing masks and maintaining safe distances from one another. The city did not require facial coverings when businesses reopened in May; last week the city council voted to implement a mandate.

The safety lapses resulted in a surge of infections in Horry County, where Myrtle Beach is located, according to public health officials. The local total does not include countless tourists who contracted the virus while visiting and unwittingly have taken it back home to multiple states, including Kentucky, Ohio, Virginia, and West Virginia, where Gov. Jim Justice, a Republican, recently warned people to “think twice” about traveling to Myrtle Beach.

Some residents and travelers alike are now wondering whether Myrtle Beach reopened too quickly, forgoing critical safety precautions in an attempt to salvage much-needed tourism revenue. But government officials and business leaders have stressed that a prolonged closure would have resulted in irreparable harm to workers and their families, underscoring the complexity that many localities face in a pandemic that at times has pitted economic recovery against public health.

"For Myrtle Beach, it was a survival decision," said Brenda Bethune, the city's mayor.

"We all expected once we opened up, and people started coming from other areas, that we would see those [case] increases and we certainly have," she said. "On the other hand, how do you keep things closed, and keep people out of work, when families have to pay their bills?"

The Fourth of July presents an even larger challenge for Myrtle Beach — “historically the busiest week of the year,” Bethune said. The three-day weekend is a critical part of the roughly 100-day summer calendar, when most businesses race to make enough money to survive the slower winter months.

The challenge facing Myrtle Beach is shared by major tourist destinations nationwide: The very characteristics that make their cities and states so attractive to vacationers also represent some of the greatest risks for spreading the coronavirus.

Beginning in March, governors imposed a wide array of restrictions on hotels, beaches, bars, and restaurants, hoping to ensure that some of these normally densely packed places did not become breeding grounds for infection. Epidemiologists say some of the moves have prevented even more deaths during a global health emergency that has killed nearly 130,000 people in the United States.

But the restrictions have also carried economic costs, resulting in fewer travelers and fewer dollars generated for tourism-dependent governments and businesses alike. A grim study conducted in June for the U.S. Travel Association, a Washington-based trade group for the industry, predicted a $505 billion decline in travel spending by the end of the year, reducing U.S. economic output by $1.2 trillion.

"To ignite an economic and jobs recovery, these businesses need to be able to open," said Tori Emerson Barnes, the association's executive vice president for public affairs and policy.

The pandemic had just started to wane in some parts of the country when South Carolina Gov. Henry McMaster, a Republican, lifted some of the restrictions he had imposed, paving the way in April for Myrtle Beach and its surrounding communities to open their hotels fully by mid-May.

The news delighted local business owners, who had watched their revenue plummet during the two months when their businesses were closed because of the pandemic, said Karen Riordan, the president of the Myrtle Beach Chamber of Commerce. An estimated 40 percent drop in sales compared with the same period a year earlier threatened to cripple an economy that depends entirely on tourists, about 20 million of whom vacationed on area beaches in 2019, she said.

Myrtle Beach initially expected the vacationers to return at a slow trickle. Instead, throngs of travelers soon descended on its sandy shoreline and its nearby resorts and golf courses by mid-May. Visitors clumped together on the sand, packed the boardwalk and its shops and restaurants, and fully booked out some hotels in just a matter of days.

"As soon as we opened, there were people standing in line waiting," said Michelle Kerscher, the general manager of the Gay Dolphin Gift Cove, a 74-year-old, 35,000-square-foot souvenir emporium on Ocean Boulevard, the main drag along the beach. "We didn't expect to see demand to be so high immediately."

The rush of outsiders left some residents, travelers, and shop owners anxious, fearing that perhaps too many people had come too quickly. Adding to their fears, before Myrtle Beach reopened for business, it did not require that residents and visitors wear masks, considered one of the easiest, most effective ways to cut down on the spread of the coronavirus.

Bethune, the city's mayor, and her fellow council members said they had to defer to state officials, including McMaster, who generally has questioned the effectiveness of such blanket orders.

With no requirement to do so, few families that came to Myrtle Beach actually wore masks, alarming public health experts and heightening the risk of infection.

Teresa Meyer, 55, was delighted to see the influx from out of town at the Palace Resort, a 23-floor getaway overlooking the ocean where she has lived for seven years. Many of the units are rented out every summer season, and without those tourists, "people were losing money," said Meyer, who serves on the Palace Resort's homeowners association board.

The resort tried to encourage guests to stay socially distant from one another and wear masks, but few followed the recommendations, Meyer said. Instead, families crammed with their beach chairs and umbrellas into elevators, not keeping their distance from other tourists or covering their faces — turning the elevators into a “petri dish” for the virus, she said.

"People came on vacation and thought the virus did," Meyer continued, adding: "We opened too hard, too fast, without the proper safety mechanisms."

Tourists have packed into Broadway at the Beach, a complex of stores, bars and restaurants about a mile from the shore, where Kimberly Luksic and Maxwell Narvarra, 26-year-olds from Atlanta, said a hot-sauce shop recently was handing out free samples of its spicy condiments on chips to eager patrons. (They didn't partake.)

An Italian buffet about a block from Ocean Boulevard had spaced out diners and tables, as recommended, but "everyone working there wasn't wearing a mask," said Willis Glasgow, a resident of nearby Florence, S.C.

At the Tanger Outlets, a shopping mall in Myrtle Beach, so few people were wearing masks the final weekend in June that Harold Reaves and his wife, from the state capital, Columbia, didn’t even bother to get out of their car. Reaves, 55, figured that on a Saturday most tourists would be checking in or out of their hotels. Instead, they were horrified to find congested sidewalks, so they turned around, opting not to take a risk.

"We're definitely staying away," he said.

Inside one of the mall’s sports and apparel stores, Bree Cowan, 20, said she had seen a steady stream of customers trying to come in without masks. “We’re doing the capacity limitations and stuff, and we’re doing the necessary precautions,” she said. “The visitors, the tourists, the locals coming in … they’re not.”

The flood of tourists — and the lax policy on masks — appears to have contributed to an uptick in coronavirus cases. “It seems good for the economy that we bounced back that quickly,” said Gregg Smith, a member of the Myrtle Beach City Council. “But as we’re seeing now, having all those people here is really creating an issue and creating more positive [coronavirus] tests.”

“People forget about social distancing, people remove their masks, people throw caution to the wind, and they’re out there to enjoy summer on the beach. And immediately after our numbers started to rise,” said Barbara Jo Blain-Bellamy, the mayor of the nearby city of Conway. She contracted the coronavirus about a month ago.

Cities and states outside of South Carolina have reported a similar increase in infections stemming from families that traveled to Myrtle Beach last month. Six states have warned their residents not to visit South Carolina or specific parts of the 60-mile coastline region known as the Grand Strand.

In Kentucky, health leaders specifically raised the possibility that Myrtle Beach hotels have contributed to one of that state’s outbreaks. “If you or someone to whom you are close has been to Myrtle Beach in the past two weeks, please be aware that you have a good probability of having been exposed to the novel coronavirus,” Steven Stack, that state’s public health commissioner, said in a statement late last month.

Bethune, the mayor, stressed that Myrtle Beach is unlikely to take the aggressive step to close the city’s beaches to combat the recent spate of new coronavirus cases. With businesses in the red, an economy on the precipice and a city confronting its own share of financial headaches, Myrtle Beach simply can’t afford it, she said.

“The fact of the matter is this virus is here for a while,” Bethune continued. “I believe it’s very unrealistic to say we have to shut down again. … We have to learn how to live with it.”