They were hard to miss on the corner of a busy four-way intersection at the entrance to Winchester Medical Center: a group of about 20 people - many of them nurses, some in scrubs - protesting the hospital's recent coronavirus vaccine mandate.

Some were on a quasi-strike, skipping a day of work to stand on the side of the road in scorching heat, holding signs that demanded, "NO FORCED VACCINATION."

A 16-year-old son of a health-care worker yelled on loop, "Honk for medical freedom!" and many did. A firetruck honked. An EMT gave a thumbs-up. An ambulance bleeped its sirens and truck driver after truck driver yanked on their horns - until every so often, an angry voice cut through the traffic and a middle finger jutted out the car window.

"'I hope you all get fired!" one driver yelled as he passed the unvaccinated protesters.

"We're going to!" one woman responded. "You'll need us next week!"

The nurses' employer, Valley Health, the parent company of Winchester Medical Center, had given them an ultimatum: Get the shot or face termination. And those standing on the street corner Tuesday had already made up their minds.

Valley Health announced a vaccine mandate for its 6,300 employees at its six locations on July 19, while offering religious and medical exemptions for eligible applicants. The hospital system joins a growing number of medical institutions, universities, governments and companies that have turned to employee vaccine requirements to ensure the safest possible workplaces as the highly contagious delta variant ushers in another deadly wave. For the majority of Valley Health employees, the policy was not a problem; 75 percent are fully vaccinated, the company said.

But in a region where vaccination rates are lower than they are statewide, Valley Health's mandate prompted a furious community debate, with numerous protests outside Valley Health's hospitals in Front Royal and Winchester, and pleas from unvaccinated people demanding intervention from local government to stop the mandate.

In Winchester, 57% of the adult population is fully vaccinated, compared with 66% statewide. Meanwhile, in neighboring rural Warren County, where Valley Health's newest hospital - Warren Memorial Hospital - is located, only 46% of the adult population is fully vaccinated.

Those standing outside the Winchester hospital Tuesday said they had weighed the risks, and despite more than 620,000 deaths from covid-19 in the United States, they still viewed the vaccine as riskier. Some cited exceedingly rare but serious side effects - myocarditis tied to Pfizer-BioNTech's and Moderna's vaccines and blood clots tied to Johnson & Johnson's. Some pointed to misinformation about fertility issues. Others said they were banking on natural immunity after contracting the virus last year.

But for the most part, they described a fear of the unknown, believing the vaccines had not been out long enough to convince them they were safe, while uncomfortable with the pressure - and now, mandates - falling on unvaccinated people to get one.

"We are not 'anti-vax,' " said Brittany Watson, a behavioral health nurse at the Winchester hospital, who started a group called the Valley Health Workers Association to rally others opposed to the vaccine mandate. "We've done all the vaccines that you get when you grow up - but those have been around for decades. But this one, there's so much propaganda around it. It doesn't make any sense."

Her girlfriend, Katie Hart, a certified family nurse practitioner at Martinsville Urgent Care - another Valley Health location - said they might be more willing to consider the shot if they didn't feel coerced.

Now, though, they were willing to lose their livelihoods if that's what refusing the vaccine would mean. Hart said they would not budge. "This is the hill to die on," she said.

The vocal opposition has bewildered community observers who saw their hospital as the last place they would encounter vaccine resistance, only for it to become its most visible battleground.

Elisabet Michaelsen, a retired speech pathologist and home health-care worker, said she moved to Winchester in March 2020 from Prince William County, drawn to the historical small town in the heart of the Shenandoah Valley as an escape from the "hustle and bustle of I-95." A longtime Democratic organizer in local politics, she liked that Winchester was a bit of a blue bubble, surrounded by deep-red Frederick County, and that "almost 100%" of the people she encountered in town wore masks at the height of the pandemic.

Then the protests began.

"I was quite surprised to see there would be vaccine resistance among such an educated and modern health system," said Michaelsen, 75. "To me [the vaccine] is a no-brainer, and I don't understand how you can talk about concepts like medical freedom and so on - what kind of freedom? Freedom to infect the patient you're treating? I don't think so."

She and a small group of fellow Democratic organizers decided to line the opposite side of the street in a small counterprotest supporting the vaccines outside both Winchester Medical Center and at Warren Memorial Hospital in Front Royal earlier this month.

There were maybe four of them - and more than 100 vaccine mandate protesters on the other side of the street, she said.

The uproar over Valley Health's policy materialized first at a Front Royal town council meeting July 26, where dozens of unmasked people, including a number of Valley Health nurses, converged. Edward Scott Lloyd, a former Trump administration Health and Human Services appointee, brought forth an ordinance seeking to ban businesses from firing employees for refusing to get vaccinated.

The ordinance ultimately failed - the town attorney and other council members pointed out that Virginia, as a Dillon Rule state, prevents localities from assuming legal powers not explicitly granted to them by the state. Still, dozens testified in support of Lloyd's ordinance, and the council later "encouraged" businesses not to fire unvaccinated people.

"The same people that always shout, 'my body, my choice' now believe we shouldn't be able to say no to becoming a government lab rat," one woman argued at the public hearing.

One man, Dan Arico, said he was fully vaccinated - but still opposed Valley Health's vaccine mandate. He had weighed the risks too: The vaccine was "experimental," he said - but two friends died of covid. His mother died of covid. He chose the vaccine.

"What I'm asking you to do is give the employees of Valley Health the same kind of choice," Arico said. "Let them look at the evidence. Let Valley Health provide them with as much evidence as they can, and then let them decide."

Jeffrey Feit, a physician and Valley Health's population health and community health officer who worked on the policy, had tried to do exactly that. Before rolling out the mandate, he and other doctors held town halls with employees, taking questions about the vaccine's effectiveness, attempting to stamp out misinformation. "The Internet is not peer-reviewed," he would say. He would bring verified data about the side effects of the vaccines.

They did have a choice to make, he said. And so did Valley Health. Patients had been calling, asking how they would know if their surgeon was vaccinated. The hospitals had to do whatever they could to ensure patients could feel safe and mitigate the risks of a hospital-acquired infection, Feit said, and that meant they had to require employees to get the vaccine.

"If people choose not to be vaccinated despite the evidence and the advice we've given and the information we've shared, and they choose to leave Valley Health or leave health care, we regret that they're leaving," Feit said. "But we respect them. We respect that's a choice people can make. We believe our choice has to be to really ensure the safety of our patients."

It's unclear how many nurses or other staffers may ultimately choose to resign or be fired; a Valley Health spokeswoman said an accurate count won't be available until after the process for seeking exemptions is complete. Staffers have until Sept. 7 to get their first shot.

Lloyd, the Front Royal councilman and an attorney, said dozens of Valley Health workers - he estimated more than 150 - have since reached out to him, some seeking legal defense, and they are now weighing their options.

"We're going to do what we need to do to staff our hospitals" no matter what happens, Feit said.

Margaret Foster Riley, a public health sciences and law professor at the University of Virginia, said the unvaccinated health care workers probably do not have a case that their rights are being violated. The nation has a long history of legal vaccination requirements, especially for health-care workers, she said. What's different is that entities are requiring vaccines that are under emergency use authorization and not yet approved by the Food and Drug Administration.

Still, she said, hospitals could probably make a stronger case that public health during the worst pandemic in a century "outweighs the right to choose whether or not you get to be vaccinated." The case appears even stronger, she said, in light of the delta variant.

The Centers for Disease Control and Prevention labeled the vast majority of Virginia counties, including Warren and Frederick, as having "high" virus transmission. For the first time since April, more than 1,000 Virginians are hospitalized with covid-19, and daily new cases are back to February levels.

Inside Winchester Medical Center, other staffers have watched their colleagues' protestations with unease.

"Being in the health-care profession, it's bigger than just yourself," said Sherri Thorton, a nurse in the emergency room. "You've dedicated your life and your profession to taking care of people and doing no harm to anyone, and I think you have to protect not only yourself but your patients."

More than that, she didn't understand her unvaccinated colleagues' risk calculation.

Since the pandemic began, as the ER's charge nurse, she has treated and interviewed covid-19 patients about their symptoms, and now, their vaccination status.

Even though hospitalizations are up statewide, Thorton said that in her unit it's still not comparable to the first wave of the pandemic. But one thing has stood out, at least in her own experience:

For two months, every covid-19 patient she has seen in the emergency room has not been vaccinated.