On Monday afternoon, paramedic Theresa Fitzpatrick inched her Dodge Dart through a brand new drive-in testing center for COVID-19 in the small South Texas border city of Edinburg, a dozen miles from the Rio Grande. She had been wracked for a week with a dry, hacking cough ever since picking up a patient who had just crossed the international bridge with similar symptoms.
But she hadn't been able to get a test since seeing her doctor last week, until a local university opened up drive-thru testing sites in her home county on Monday.
"They haven't been testing people, that's the problem," said Fitzpatrick, a mother of four who earns $16 an hour as a paramedic for a private EMS company. "It just seems like the forgotten man down here."
Hours earlier, Dr. Martin Garza, a pediatrician and former president of the Hidalgo-Starr County Medical Society, spent his lunch break drafting a plea to border-area lawmakers for help finding more testing kits.
Garza noted that at-risk areas such as South Texas, with lower numbers of confirmed cases, are precisely where enhanced testing is needed to detect and prevent a fatal spread of the virus, as is unfolding in New York City, New Orleans and smaller cities like Athens, Georgia.
"We have all heard, 'If (only) we had been able to test sooner,'" he wrote. "Well the 'sooner' is still available in our community."
While many places across the country are struggling to get enough testing, the problems are magnified in the Rio Grande Valley. It has among the highest poverty rates in the state, nearly half of its residents don't have health insurance and chronic health conditions are rife.
Two weeks ago, Texas Gov. Greg Abbott promised that all those who need a coronavirus test "will get one," but public health officials, politicians and doctors up and down the Rio Grande say that hasn't happened and they are scrambling to assemble sufficient testing kits. Hidalgo County, the largest in the Valley, is only able to process 20 government tests a day, officials said this week.
In the border city of Laredo, 80 miles upriver from the Rio Grande Valley, a cluster of residents died on four consecutive days starting Sunday, bringing the city's COVID-19 death toll to five, just below that of the state's largest city Houston as of Friday morning. The first four were women in their 60s to 97. The latest was a 43-year-old man. Health authorities say all five suffered from underlying health conditions.
Also troubling to local health leaders is that the highest percentage of the city's 65 positive cases is the result of some form of community contact.
As Laredo reeled from the deaths, its Mexican sister city, Nuevo Laredo, announced its first two positive cases this week, including a 56-year-old man who had recently traveled to Dallas. Health experts believe cases in Mexico are vastly underreported because of almost nonexistent testing there.
Responding to the threat, some border cities took drastic steps, including setting up roadblocks to catch people violating orders to shelter in place and requiring masks inside public buildings.
In many ways, the situation along the Texas border reflects the chaotic manner that the second-largest state in the country, with the highest percentage of people lacking health insurance, has approached the issue of testing — and the pandemic itself. Unlike some governors, Abbott, a Republican, had declined to impose a mandatory statewide shelter-in-place order, instead urging counties to make their own decisions. On Tuesday, he did issue such an order urging most people to stay home.
Texas as a whole also has lagged when it comes to testing. It's completed more than 50,600 tests so far, more than double what it had less than a week ago, but it still ranks among the lowest in the nation in per-capita testing, well behind other large states such as New York and California, according to a ProPublica analysis. At least 70 people have died in Texas.
Abbott's spokesman, John Wittman, referred questions to the state's Division of Emergency Management.
Seth Christensen, that agency's spokesman, said in a statement that the state is available to assist "every mayor and county judge" across Texas. He said that swabs are in short supply nationally, but that the state is trying to procure more from the federal government and private companies.
He said private health care providers should also make an effort to obtain testing supplies through the private sector to "ensure we are leveraging every available avenue."
To ward off the virus spreading across international borders, President Donald Trump has largely closed border crossings to "nonessential" travel, but epidemiologists say that's not the solution to an epidemic that has likely already taken root on both sides of the Rio Grande.
"The answer is not closing the border," said epidemiologist Benjamin King of the University of Texas at Austin. "It's aggressive testing on both sides."
Population at Risk
The Rio Grande Valley is a world away from the state's largest regions, Houston and Dallas, which have seen the most cases. It is a sprawling mix of rural farmland and urban spread that is home to more than 1.3 million mostly Hispanic residents and shares river frontage with a bustling Mexican border region of factories, busy land crossings and outbreaks of drug cartel violence.
The Valley's population is particularly vulnerable to the virus, experts say. About half a million Texas border residents live in so-called colonias across the U.S. side of the border, which often lack basic amenities such as running water. Roughly one in three people in the Rio Grande Valley is diabetic, a major risk factor for complications from COVID-19. And one in 10 of the state's undocumented population lives in the region, with potential immigration consequences often making them fearful to seek help.
"My concern is not only that it is circulating without our knowledge, but we also have a population at high risk for severe disease," said Dr. Joseph McCormick, an epidemiologist at the Brownsville campus of the University of Texas Health Science Center at Houston. "I don't think it will take very long at all to overwhelm the facilities at our hospitals."
Hidalgo County, the largest in the Rio Grande Valley, has about 2,000 hospital beds, compared with about 14,000 in Houston.
McCormick, who helped investigate the first-recorded Ebola outbreak in 1976, blamed the lack of testing on the state and federal government.
"The state is depending on the federal government to bring tests in and that hasn't happened. … I don't know why the state hasn't done more," he said. "Our folks are now relying more on private labs."
"Some Very Sick People"
On Monday, UT Health RGV, which is part of the University of Texas Rio Grande Valley School of Medicine, began drive-thru testing in Brownsville and Edinburg.
In a few days, its hotline received almost a thousand calls and health workers were seeing "some very sick people," said Dr. Linda Nelson, senior director of clinical operations heading the initiative. "Some of them can't even talk on the phone without coughing."
Dr. Rosemary Recavarren, a pathologist who oversees four hospital laboratories in the Rio Grande Valley, has been worried about this for weeks. She and her staff have been reaching out to the state health department and private testing companies since February, but they were told they were not a priority and that testing kits were allocated to areas much harder hit.
"We are not going to get testing for our machines until probably the end of April," she said.
Eddie Olivarez, chief administrative officer for Hidalgo County's health department, said only about 20% of COVID-19 testing in the region was being conducted by public labs, compared with 80% done through private institutions, because of capacity and because state criteria is more stringent on who can qualify for testing. Patients must have traveled and had known exposure to a confirmed case to be eligible for state tests, whereas private institutions allow more flexibility from each physician in recommending testing.
Olivarez said the Harlingen public health laboratory through which his county does testing can only process about 40 tests a day.
Chris Van Deusen, a spokesman for the Texas Department of State Health Services, said the agency had shipped more tests to the Rio Grande Valley on Wednesday and was working to start a "high-throughput" testing platform that would allow tests at a faster pace.
Most metropolitan areas in Texas rely on private hospitals for some in-house analysis of testing, but almost no hospitals in the Rio Grande Valley currently have that ability, Recavarren, the pathologist, said. They must either send swabs to public health laboratories, which comply with the state's stricter criteria, or to private companies.
But as demand has skyrocketed across the country, companies are now overwhelmed and many Texas health workers said it can take days for results back from Quest Diagnostics and up to two weeks for LabCorp.
Quest Diagnostics said in a statement this week that between March 9 and April 1 it performed more than 400,000 COVID-19 tests across the country, "a sharp influx of test orders that continued to outpace our growing capacity."
But it has since implemented a "higher throughput" diagnostic test at laboratories across the country, reducing the national backlog from 160,000 to 115,000 in a week.
"While we are more confident now in our ability to meet demand and report results for COVID-19 testing than in mid-March, when we were still ramping up capacity, this crisis is fluid and unpredictable, and so is the demand for COVID-19 testing," the company said.
LabCorp said in a statement that it was also working "tirelessly" to increase capacity.
The lack of testing and delay in labs has even metropolitan areas with far more physicians and hospitals struggling.
Bexar County Judge Nelson Wolff, who oversees the state's second-largest city of San Antonio, said its public laboratories can get results in a day, but when they send tests to Quest Diagnostics, it takes up to five days. More than 220 cases have been confirmed there with at least nine deaths, including a nursing home outbreak this week that killed one resident and infected at least 66 of the 84 residents.
In Harris County, home to Houston, the fourth-largest city in the nation, officials have struggled to open enough testing centers, receiving only enough supplies from the federal government for two publicly run sites in the county, testing 500 a day — far fewer than the 10 sites sought by Harris County Judge Lina Hidalgo, the region's chief executive. The city of Houston has another two public testing sites able to jointly run another 500 tests daily.
The metropolitan area is also home to one of the country's biggest medical centers, with many hospitals running in-house testing and analysis, including Houston Methodist, which can test about 250 patients in-house a day.
By Friday morning, at least 955 people in Houston and Harris County had tested positive — the most in the state — and at least 10 had died. The county is home to about 16% of the state's 29 million residents.
Dr. Peter Hotez, a vaccine researcher and dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, has predicted Houston could follow New Orleans as a hot spot in the South. He thinks the Rio Grande Valley is also at risk, due to its high percentage of people living in poverty with diabetes and hypertension.
"Testing is crucial in poor neighborhoods, both on the border or in the urban core, that's the most vulnerable populations," Hotez said. "Wherever there is crowding and poverty, those are the areas I worry about the most."
"A Tsunami Coming"
Starr County, an isolated, mostly rural county with one of the highest poverty rates in the state, bucked the border trend and was the first south of San Antonio to establish a drive-thru testing site in early March, thanks to a partnership between the county, university and a local businessman.
"Our testing here has not been short of anything," Starr County Judge Eloy Vera said. "Anyone who needs to be tested is getting tested."
The effort has paid off, local officials believe. The businessman is footing the first month's bill, and the site has done about 300 tests, with just five people testing positive.
This week, Webb County, slammed with five deaths in four days, finalized a deal to bring 5,000 rapid tests to the Laredo area through a partnership with a local ER provider, Clear Choice ER.
City officials hoped to have the tests up and running by the end of this week, but on Friday announced they had determined the tests were not reliable and that Laredo police would investigate the validity of the kits' FDA certification. Officials said they would continue "scouring the world for testing kits."
Officials are feeling the pressure to slow the virus.
"We only have one shot at this," Laredo City Manager Robert Eads said. "We have to get this right now."
As testing increases and cases rise by the day, border officials brace for what lies ahead.
On Thursday, as 17 more people tested positive in Hidalgo County, including four children under the age of 5, county officials said there was now "clear evidence" of community spread. More than 630 in the county have now been tested, with at least 79 confirmed cases.
Fitzpatrick, the paramedic in Edinburg who struggled to get tested, learned Thursday she was not among them. She plans to return to her ambulance this weekend and hopes her department will receive more of the personal protective gear it needs.
"If we don't do it, who's going to do it?" she said. "There's a lot more down here who will get sick."
A University of Texas at Austin model of potential new COVID-19 hospitalizations released this week showed that depending on the measures taken by local officials, overall cases could reach between roughly 95,000 and 335,000 combined in the metro areas of Laredo, Brownsville and McAllen.
Hidalgo County Judge Richard Cortez, in his strongest words yet, warned "there is a tsunami coming. It hasn't hit us yet."
Disclosure: The University of Texas at Austin and the University of Texas Rio Grande Valley have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.