In Starr County, Texas, the pandemic has become a "before and after" story — before the state took over, and after it did.
The large but sparsely populated county on the Texas-Mexico border had managed to keep the coronavirus contained in the early months by imposing 14-day quarantine restrictions on people who tested positive, closing businesses before the state ordered closures, linking with private businesses to provide testing, and implementing a curfew with fines and jail penalties.
Then, Texas Gov. Greg Abbott overrode the local decisions and began a phased-in reopening of businesses in the state in April.
“They took the teeth away from us to be able to enforce anything,” said Alberto Perez, the city manager for Rio Grande City, the largest city in the county with a population of more than 64,000.
In the two months after Abbott exerted his authority, Starr County has watched its handful of cases — on many days there were no new ones — steadily climb and spike this month.
On June 22, the county, located in the Rio Grande Valley, saw a peak of 75 new cases. It had reported no deaths from the virus until Tuesday, when there were three. The county had recorded 407 total cases of the coronavirus by Friday, compared to the nine cases it had up to April 29, the day after Abbott made clear his rules trumped those of local officials.
“It has been a dramatic change here,” said Dr. José Vasquez, the local health authority and head of the Starr County Memorial Hospital Board.
As the county was forced to reopen businesses, the reopenings created a “false sense that it was OK to get together to go out, to gather between families,” and that led to a significant increase in cases, Vasquez said.
"The governor erred," Carlos Martinez, a Rio Grande City restaurant worker, said. "We were doing very well" under the stricter regulations.
He acknowledged the stricter rules had an economic impact on businesses, but said "health is more important" because "without health, there is no economy."
Across Texas, the closings had taken their economic toll and there had been pressure to reopen as unemployment rose. Texas' economy was also being rocked by the drop in oil prices.
But Rose Benavidez, president of the Starr County Industrial Foundation, which helps the local government and businesses develop the local economy, said the county’s early experience shows there is “always a way to try to reconcile the safety and the economic needs of our county."
"We know there’s metrics to try to get a feel for how things should go, but our community can be an example of how quickly things went wrong,” Benavidez said.
Most of the cases at the beginning of the pandemic were travel-related, meaning a person who had traveled from outside the county brought it into Starr County. But over about the last month, the county has seen a lot of community and family spread, sometimes through family gatherings, Perez and Vasquez said.
In one family alone, up to 20 people have been infected, Vasquez said.
“For six to eight weeks in my county, we were able to get the situation very, very well controlled. There was a time where we went through 21 straight days without any COVID cases. At some point, we had eight to 10 cases, where in the neighboring counties they had about 200 cases,” Vasquez said.
“That is no longer the situation here after the governor released activities and we went back to business, and the measures we had taken were lifted and the capability of imposing restrictions and fines … were lifted. We have seen a dramatic increase in our numbers,” he said.
Vasquez said the county has increased testing, but he said the increases in cases cannot be attributed to testing alone.
On Friday, after four straight days of more than 5,000 new COVID-19 cases for a total of 22,743, Abbott scaled back on the capacity allowed for restaurants and ordered bars to close by noon (but allowed for them to continue with takeout and delivery sales), closed rafting and tubing businesses that are popular in summer with young people, particularly in Central Texas, and issued requirements for permission to hold certain gatherings of 100 or more people.
“At this time, it is clear that the rise in cases is largely driven by certain types of activities, including Texans congregating in bars,” Abbott said in a statement.
As in other states, the county is seeing many of the new cases in younger people, many in their early 20s, who are not becoming as ill as older residents. But they still have the potential to spread the virus to their own parents or grandparents or older residents who will need critical care.
Vasquez said he and other medical personnel are very concerned about whether they could handle an increase in hospitalizations. The county is one of the poorest in the nation and the state, is majority Latino, and many are not insured or are underinsured.
The county has a 49-bed hospital. Critical cases usually go to a hospital in McAllen, about 50 minutes away, but neighboring Rio Grande Valley counties are seeing their hospitalizations and emergency room numbers increase too, Vasquez said.
Neighboring Hidalgo County has had 2,503 positive cases with 947 in the last four days, while Cameron County, where Brownsville is the largest city, has had 1,881 cases, with 335 between June 23 and 25.
“We have now several hospitals which are having to turn away patients because they are at full capacity,” Vasquez said.
Rural hospitals in Texas were facing challenges before the coronavirus hit, but their woes have been amplified by the pandemic, said John Henderson, CEO and president of the Texas Organization of Rural and Community Hospitals.
Of the 157 rural hospitals in Texas, defined as hospitals in counties with populations of 60,000 or less, about 30 to 40 don’t have ventilators and many don’t have ICU beds, he said. Staffing too is an issue because rural locations may lack specialists, such as critical care physicians and pulmonologists.
Henderson said 44 percent of Texas’ rural hospitals had negative operating margins and in 2019, 60 of the 157 in the state had less than 30 days cash on hand. Congress included money for rural hospitals in the coronavirus relief package it approved in March to help with the strain on their budgets.
Benavidez said local officials succeeded early in getting the public to follow the Centers for Disease Control and Prevention guidelines and accept other precautions.
She said as the governor scales back his reopening, he could consider one more thing.
“The governor was very astute when he started," she said, "knowing officials knew their community locally really well and knew what their community responded to. And if we had more latitude to work on that, I think we’d have a much better public response.”