How politics, inequity, and complacency undermined Texas’s fight against Covid-19

Texas has become another cautionary tale amid the pandemic.

On Memorial Day weekend, the mood in Texas was optimistic.

It had been just over three weeks since Texas became one of the first states in the country to begin a phased reopening. Confirmed cases of Covid-19, the illness caused by the coronavirus, had been increasing only slightly for three months. Gov. Greg Abbott, a Republican, had allowed bars, restaurants, gyms, retailers, salons, and child care centers to reopen and sports to resume while capping capacity levels for most businesses.

But the warning signs were there, and some experts were already worried. Face masks were only encouraged — not required — in public places where maintaining physical distance from others wasn’t possible. Because Texas had imposed one of the shortest lockdowns nationwide, it hadn’t had much time to suppress cases and build up testing capacity. And it hadn’t achieved a two-week decline in cases, one of the key benchmarks states were supposed to hit before reopening.

Memorial Day weekend didn’t bode any better: Bars in Austin blew past their 25 percent capacity limits; mask-less patrons stood shoulder to shoulder. Partygoers crammed into a swimming pool at one club in Houston. City authorities there received more than 200 complaints about social distancing violations in matter of days.

The weekend crowds left public health officials uneasy. They urged Texans to remain vigilant about practicing social distancing and wearing masks for their benefit and that of their neighbors. But the fatigue of shutdown combined with inconsistent public health messaging at a federal, state, and local level had made people complacent, Umair Shah, executive director of the Harris County health department, said.

“Early on, we fought this virus successfully. We did feel like we had made progress,” he said. “But then you started seeing images of people, especially young people, at parties and in pools and not respecting the fact that we were in the midst of a pandemic. … If you just take your eyes off the ball for just a moment, that’s when it overwhelms the community.”

It soon became clear that transmission had reached alarming levels. On June 16, two and a half weeks after Memorial Day, Texas saw 4,200 new cases in a single day.

A month later, Texas, along with Arizona and Florida, has become a cautionary tale. The number of daily new reported cases is climbing: As of July 22, the state averaged 329 new cases per million residents over the past 14 days, compared to just 37 per million in New York. There have been more than 285,000 new cases reported since Memorial Day; over 4,000 Texans have died from the virus.

Hospital capacity is under strain in some parts of the state, including the hard-hit Rio Grande Valley. Doctors are worried about shortages of an antiviral drug, remdesivir, that seems to reduce the recovery time for hospitalized Covid-19 patients. With hospital morgues overflowing, several counties have requested the same kind of refrigerated trucks that, months ago, lined the streets of New York City.

“We’re building this car as we’re driving it down the freeway,” Dr. David Persse, Houston’s top public health official, said.

The parts of the state that are struggling the most include major cities, especially the Houston metropolitan area, and counties in South and Central Texas and along the Gulf Coast. Hospitals in the Rio Grande Valley borderlands, where over 90 percent of the population is Hispanic and more than a third of families live in poverty, lack resources even in better times; since the first week of July, they have been operating at maximum capacity.

How did it get so bad, so quickly? Public health experts say it’s difficult to attribute the spike to any one factor or event, but it’s now clear that Texas’s reopening came too soon. And the politicization of the state’s response to the virus has made it difficult to pursue an effective public health strategy and reach the hardest-hit communities, they said.

“Initially, when the outbreak starting becoming a concern for us here in the US, we responded appropriately,” Dr. Jason Terk, chair of the Texas Public Health Coalition and a practicing pediatrician, said. “Locking down at the time we did was a prudent thing to do. We didn’t have the carnage that was being experienced in the Northeast and New York City, but that gave us a perception of reality that has not served us so well as we moved forward.”

Texas reopened too quickly, and cases got out of control

Gov. Abbott began the state’s reopening on May 1, with indoor and outdoor dining, retail, movie theaters, museums and libraries facing 25 percent occupancy limits in most counties. Cases did not spike immediately, but the state was also slow to resume activities: In the two weeks after reopening, seated dining recovered by only about 5 percent, according to state-level data from OpenTable.

On May 18, Abbott expanded the reopening to include many more businesses, including day care centers and, crucially, bars.

But it’s likely, experts say, that Covid-19 was spreading silently — it just wasn’t showing up in state data. Coronavirus has a long incubation period: Individuals show no symptoms for five days on average after infection, even though they’re contagious for part of that time. Some never develop symptoms at all. Widespread testing, combined with tracing the contacts of infected people, has overcome this challenge in other countries.

The US, including Texas, has struggled with coronavirus testing. The percentage of tests coming back positive in Texas never dropped below 5 percent, a benchmark experts use to determine if a state is testing enough.

Had Abbott waited a bit longer, it would have been clear that Covid-19 transmission was reaching alarming levels. (His office did not respond to requests for comment.)

“It should have been enough time in conventional thinking,” Persse said. “We now know that this virus has a longer lag in how it’s going to respond. We now know better.”

In retrospect, Memorial Day weekend may have been the last moment of calm before the storm. By May 28, hospitalizations started going up. But the reopening continued.

Abbott ramped up capacity limits for restaurants and bars to 50 percent on June 3, allowing them to seat parties of up to six people. And on June 12, he increased restaurant capacity again to 75 percent, allowing them to seat parties of up to 10 people. The following week, amusement parks, including the Six Flags parks and Schlitterbahn water parks, and carnivals were permitted to open at half capacity.

Consumer activity followed across the state: Spending at restaurants and hotels increased almost 20 percent and merchandise spending jumped more than 25 percent from the beginning of reopening on May 1 to when Abbott started scaling back reopening on June 26.

Abbott has since expressed regret about opening bars, which became hot spots of transmission.

“If I could go back and redo anything, it probably would have been to slow down the opening of bars, now seeing in the aftermath of how quickly the coronavirus spread in the bar setting,” he said during an interview with KVIA in El Paso.

But public health experts in Texas say the reopening should have been slower overall, and more tailored to the different needs of Texas’s 254 counties, recognizing that places with higher levels of transmission might need stricter rules than other parts of the state.

That’s a strategy Abbott has resisted. In April, Harris County issued a mandate that people masks in public. But the day the order was supposed to go into effect, Abbott overrode the restrictions, saying that the county couldn’t unilaterally impose fines on violators. He also prevented local jurisdictions from issuing their own stay-at-home orders as the state was reopening, effectively usurping the power of officials like Shah to manage the virus.

“Taking a one-size-fits-all approach does not work in a state like Texas, because you have large urban counties like ours, and you also have smaller jurisdictions,” Shah said. “And that’s why local ability to enact protections is the critical way to go forward, because we know our communities better than anybody else.”

Mask-wearing and reopening have become particularly politicized in Texas

Texas is a state that prides itself on individualism. In a pandemic that requires collective action to support everyone’s health and well-being, however, that has proved to be more of a vice than a virtue.

“It boils down to what kind of culture we have here. In the state of Texas, we have a very libertarian ‘me’ culture rather than a ‘we’ culture,” Terk said. “We have a tendency to be permissive for individuals to make their own choices and for more local determinations to burden the day. That’s not the case in places where good public health strategies have been articulated.”

Wearing face masks, which have been proven to decrease the risk of airborne transmission of the virus, became a partisan flashpoint in Texas and across the country. A Pew Research study found that Republicans were almost four times more likely than Democrats to say that masks should rarely or never be worn. They may be taking cues from President Donald Trump, who long resisted wearing a mask in public, seemingly to downplay the severity of the US outbreak, and openly mocked his Democratic rival Joe Biden for donning one.

Mostly mask-less protesters gathered at the state capitol in Austin in April to denounce the lockdown alongside conspiracy theorist Alex Jones, founder of the website Infowars, who has called the pandemic a “hoax.” People have resisted wearing face masks in stores that set their own rules requiring it, prompting threats of criminal prosecutions and a violent altercation with one patron at a 99 Cents Only store in San Antonio that was filmed on a cellphone.

“I don’t care. Just because everyone’s doing it doesn’t make it legal,” the man told an employee in the video. “The Texas governor said it’s not legal and I don’t have to.”

Indeed, Abbott long resisted mandating that people wear face masks. He said in April that local governments can’t penalize people who don’t wear masks in public, even over the protests of nine Texas mayors, five of them Republicans, who had requested the authority to do so.

“We strongly recommend that everyone wear a mask,” Abbott said during a press conference at the time. “However, it’s not a mandate. And we’ll make clear that no jurisdiction can impose any type of penalty or fine for anyone not wearing a mask.”

By late June, as Texas was becoming a coronavirus hot spot, Abbott’s approval ratings had sunk to 44 percent, among the lowest of governors nationwide. He brought a halt to the reopening process, reversed his stance on face masks, and threatened another economic shutdown.

But the number of daily new reported cases has nevertheless stayed above 5,000 for weeks.

Texas’s Hispanic population is particularly vulnerable to Covid-19

The virus isn’t affecting all Texans equally. Hispanics, who account for 34 percent of the state’s population, have faced increased risk of contracting coronavirus because of where they work, where they live, and the limited availability of culturally competent health care, Carlos Rodríguez-Díaz, a professor at George Washington University’s Milken Institute School of Public Health, said.

Preliminary state data shows that Hispanics accounted for about 40 percent of the nearly 29,000 Covid-19 cases that have been investigated by public health authorities as of July 21. That’s consistent with how Hispanics have been disproportionately affected by the virus nationally: Among adults ages 45 to 54, they are at least six times more likely to die from the coronavirus than white Americans.

Some predominantly Hispanic counties have been hit particularly hard, in part because they live in medically underserved communities. In the Rio Grande Valley, where there have been more than 21,500 confirmed cases, many are uninsured and therefore rely on community clinics or emergency rooms for medical care. They also have a higher-than-average incidence of underlying conditions, including diabetes and obesity, that put them at greater risk of complications from the virus.

The hospitals can’t keep up. Patients are waiting in ambulances parked outside the hospitals for beds in temporary Covid-19 wards to open up, and crematoriums have weeks-long waiting lists.

In other parts of the country, meatpacking plants became the epicenter of coronavirus outbreaks in Hispanic communities. But in Texas, many Hispanics work in the service industry in customer-facing roles where they are more likely to contract the virus. When the state began to reopen and business activity resumed, that risk only increased.

It’s also more difficult for some Hispanics, particularly those who are recent immigrants, to abide by social distancing recommendations because they live in multigenerational or shared housing. Among the members of these households, it’s common that more than one adult will have to go to work and could potentially carry the virus back home.

“We’re asking people to stay at home and quarantine if they might have been exposed,” Rodríguez-Díaz said. “Unfortunately, the housing conditions of many Latino families are not conducive to practice any of those measures.”

Public health resources for Hispanics are also lacking, resulting in confusion about how they should protect themselves from the virus and drawing criticism from Hispanic leaders in the state.

Some Hispanics are less likely to seek medical attention because they find the health care system difficult to navigate. Many face language barriers, making them more likely to experience adverse health outcomes than fluent English speakers. For those who are living in the US without authorization, the fear that seeking medical care could lead to their deportation also serves as a deterrent, Rodríguez-Díaz said. That fear has only ramped up under President Trump, who has publicly derided Mexicans and sought to clamp down on unauthorized immigration from Mexico.

Groups like the US Hispanic Contractors Association have been creating instructions on coronavirus safety practices in both English and Spanish and giving away face masks in Austin — but they say state and local government should also be conducting that kind of outreach.

Shah said he has tried to engage the Hispanic community by reaching out to Spanish-speaking media and forming a race and ethnicity task force within his department to examine health inequities and tailor the response to the pandemic, but acknowledges that officials’ efforts haven’t been good enough so far.

“That’s the direction we need to continue to emphasize,” he said. “Health inequities existed prior to Covid-19, and Covid-19 has just made it markedly worse.”

Texas is finally changing course — but some officials are urging more drastic action

It wasn’t till June 26 that Abbott finally put a halt to his reopening plan. He ordered bars to shut down again, reduced the restaurant occupancy limit to 50 percent, paused elective surgeries in some areas to preserve bed space, and banned river-rafting trips, which had unexpectedly contributed to a spike in cases in Hays County.

And on July 2, Abbott mandated that Texans in counties with 20 or more active coronavirus cases (at that point, most counties) wear masks inside businesses and in public spaces where social distancing is impossible. The penalties for violating the mandate are low: First-time offenders will get away with only a warning and repeat offenders can face up to $250 fines. But the act of requiring masks alone has allowed for more consistent public health messaging.

“Covid-19 is not going away,” Abbott said during a video announcement. “In fact, it’s getting worse. Now, more than ever, action by everyone is needed until treatments are available for Covid-19.”

Still, Abbott continues to give localities leeway to decide whether to permit large gatherings. As part of the July 2 order, he also prohibited gatherings of more than 10 people “unless the mayor of the city in which the gathering is held, or the county judge in the case of a gathering in an unincorporated area, approves of the gathering.”

One North Texas county announced, via a county judge’s order, that large outside gatherings would nevertheless be permitted.

Even counties that are observing the restrictions are facing pushback: Texas Republicans had insisted on hosting an in-person convention in Houston beginning July 16, arguing that their right to gather was protected under both the Texas and US constitutions. The Texas Supreme Court, however, disagreed, and party leaders reluctantly moved the convention online.

With transmission showing little sign of slowing down substantially, Abbott has threatened to issue another stay-at-home order.

“If we do not slow the spread of COVID-19 … the next step would have to be a lockdown,” he said July 10.

On Persse’s recommendation, the mayor of Houston suggested that a shutdown should last a minimum of two weeks:

Houston also decided that the average daily new case count in the city, which has been over 1,000 for weeks, would have to be below 300 before it would consider reopening schools — a number that, Persse admits, is somewhat arbitrary.

But he said that, based on the information they have now, it’s a fair barometer for a slowdown of transmission given that local hospitals were in a much better position when the case count was that low.

The stay-at-home order might be politically unpopular among Republicans in particular, but Persse doesn’t care if it makes him the bad guy.

“I’m going to do my job, and if people like me or dislike me, that’s up to them,” Persse said. “I’m going to do what I can to protect people.”

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