It was a Friday night, and Ivan Melendez, the public health authority for Hidalgo County, Texas, had been on the job since 7 am. He was preparing to put in another 10 hours of work as he parked outside Edinburg Regional Medical Center, about a half-hour drive from the Mexican border.
He knew what to expect inside the hospital, where an office space had been converted into a temporary Covid-19 floor with about 50 beds separated by curtains. For months, he had witnessed scenes that had once been unimaginable: bed after bed of intubated and dying patients; people forced to catch last glimpses of their loved ones by phone because they couldn’t be bedside; doctors and nurses collapsing into tears amid all the suffering.
“The other patients are looking at them not wanting to be intubated because they know what that means: They’re slowly dying,” Melendez said.
For Melendez, who has been in the thick of the pandemic since March, it’s a crisis that’s been both professional and personal in nature: He had to intubate his former sixth-grade teacher, and a nurse he’s known for 30 years is dying. He contracted Covid-19 himself and technically recovered weeks ago, but he’s still feeling sluggish. He nevertheless continues to visit five Covid-19 units at hospitals across the county every single day.
“It’s just a nightmare,” he said. “It’s a completely surreal world. When you’re driving down the expressway, you see these very well-appointed hospital buildings with beautiful landscaping and nice windows. But if people could see inside those walls, it would change their attitude. It would change their behavior.”
Hidalgo is one of four counties in Texas’s hard-hit Rio Grande Valley, where there have been more than 37,000 confirmed Covid-19 cases and hospitals have been operating at full capacity. The area, which is overwhelmingly Hispanic, has some of the highest coronavirus death rates outside of the Northeast — in Hidalgo County, there are roughly 90 deaths per 100,000 people, surpassing other hot spots, including Miami-Dade County in Florida.
The surge came in the wake of Texas’s move to reopen on May 1, earlier than most states, a decision that has come to haunt Gov. Greg Abbott, a Republican, as the state has become another cautionary tale of the pandemic. But it’s also emblematic of a national trend: Hispanics are dying at a disproportionate rate.
The crisis in the valley is one that government officials in the region had sought to avoid at the outset of the pandemic, knowing that health inequities — almost a third of residents are uninsured — and a high prevalence of underlying health conditions would leave their residents particularly vulnerable to the virus.
At first, the region seemed to be winning the war against the virus. A stay-at-home order that went into effect in March appeared to stave off a spike in cases. But cases started rising in the valley after Abbott began Texas’s phased reopening on May 1. At that point, there were about 800 cases across the region. But a month later, cases had almost doubled and, by July 1, they had multiplied almost tenfold.
Rural hospitals have been overwhelmed, as have neighboring hospital systems where they have typically diverted patients. A second disaster, Hurricane Hanna, which struck in late July, has further stretched emergency resources. While the number of new cases reported across Texas appears to be in decline, the valley still has over 15,000 active cases, showing no sign of significantly slowing transmission.
The state government has since stepped in to offer the region critical assistance in the form of medical personnel, emergency facilities, and extra testing capacity. But the virus has already wreaked devastation in these borderlands, where more than 1,000 have died as of August 6. And the end is nowhere in sight.
“If people in other parts of the country do not heed the warnings and learn from our circumstances, they will be afflicted, too,” Joel Villarreal, the mayor of Rio Grande City in the heart of Starr County, said. “Today, it’s in the Rio Grande Valley. Tomorrow, it might be somewhere in Middle America.”
How the outbreak in the Rio Grande Valley got so dire
The Rio Grande Valley runs through Texas’s southernmost tip, encompassing Hidalgo, Cameron, Starr, and Willacy counties and a population of almost 1.4 million people. It’s dotted with small cities, like Rio Grande City and McAllen, that thrived on cross-border trade until the pandemic hit and Trump shut down the US-Mexico border. Outside the cities, thousands of the valley’s poorest residents, mostly recent Mexican immigrants, live in “colonias” where basic infrastructure, such as clean water and solid waste disposal, is lacking.
Villarreal said he first conferred with medical experts, city officials, and first responders in February to determine how they would prepare for the arrival of the virus. At the time, they knew how devastating it could be for their community given just how medically vulnerable their residents are.
Residents of the Rio Grande Valley have a higher-than-average incidence of underlying conditions, including diabetes, obesity, and heart disease, that put them at greater risk of complications from the virus. More than a third of families live in poverty and many are uninsured, meaning they rely on community clinics or emergency rooms for medical care. And they tend to live in multigenerational housing, where younger family members who are more socially active could easily infect their parents and grandparents.
“Medical experts agreed it wasn’t a matter of if but when it was going to come to us,” Villarreal said.
Before the state government acted, Rio Grande City instituted a number of preventive measures, including a lockdown, curfews, and travel restrictions. All the mayors of Starr County, as well as the county judge (the county’s chief executive), agreed that these kinds of extraordinary measures were necessary to contain the virus, he said.
But when Abbott decided to reopen Texas’s economy without input from Starr County, local officials’ authority to continue to enforce these emergency protocols dissolved. They could no longer tailor their response to the situation they were observing on the ground: As in other parts of Texas, people were taking advantage of opportunities to socialize, including on Memorial Day and the Fourth of July, leading to a rise in cases. And there was a high level of transmission occurring at the family level, Melendez said.
As an already medically underserved area pre-pandemic, the Rio Grande Valley faced a crisis of hospital capacity when the virus tore through the region.
Starr County’s only hospital had 48 beds for a population of almost 65,000; by the Fourth of July, it was at capacity. Previously, the hospital had sent patients to neighboring hospitals in Cameron County, but they, too, were operating at full capacity at that point, issuing emergency alerts to residents’ mobile devices ahead of the holiday weekend. Some patients had to be flown to Dallas and San Antonio because of the lack of beds, but others were simply turned away.
“Unfortunately, Starr County Memorial Hospital has limited resources and our doctors are going to have to decide who receives treatment, and who is sent home to die by their loved ones,” Starr County Judge Eloy Vera wrote on the county’s Facebook page on July 23. “This is what we did not want our community to experience. ... We must be responsible for ourselves and our loved ones.”
Hurricane Hanna — which made landfall on July 25, causing flash flooding and downed power lines across the Rio Grande Valley — only complicated officials’ response to the pandemic. Cities stocked up on extra personal protective equipment on account of the storm, with some dipping into their cash reserves to do so. For people forced to evacuate their homes, the state set up emergency shelters with reduced capacity in order to comply with social distancing guidelines, handed out face masks and sanitizers, and administered mobile Covid-19 testing and temperature checks.
“During a time of having a hurricane while also in the midst of an infectious disease pandemic, people gathering in shelters is a particularly compromised situation,” Abbott said during a press conference.
The situation has since stabilized somewhat, in part because the state government has enlisted additional doctors and set up temporary Covid-19 care facilities to relieve the pressure on hospitals.
But Melendez is still working 20 hours a day.
“All I’ve been living is Covid,” he said. “I get calls all night long, all day long.”
The Rio Grande Valley is a microcosm of the coronavirus crisis facing Hispanics nationwide
The Rio Grande Valley is overwhelmingly Hispanic, including many recent immigrants who came across the border from Mexico and Central America and some without legal status. It’s no surprise that the valley has been particularly hard hit — state and national data shows that Hispanics have been dying at a disproportionately high rate from Covid-19.
Hispanics account for about 40 percent of Texas’s population, but preliminary state data shows Hispanics have accounted for about 51 percent of the state’s more than 7,800 fatalities that have been investigated by public health authorities as of August 6. And on a national level, Hispanics between the ages of 45 and 54 are at least six times more likely to die from the coronavirus than white Americans.
They are more at risk because of where they work and where they live, and because of limited access to health care, Carlos Rodríguez-Díaz, a professor at George Washington University’s Milken Institute School of Public Health, said.
In other parts of the country, meatpacking plants — where almost half of workers are Hispanic — became the epicenter of coronavirus outbreaks. In Texas, many Hispanics work in the service industry in customer-facing roles where they are more likely to contract the virus, Rodríguez-Díaz said. When the state began to reopen and business activity resumed, that risk only increased.
It’s also more difficult for some Hispanics, particularly 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 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.
Local officials wish help had come sooner
Abbott visited the Rio Grande Valley on July 28 to evaluate the damage from Hurricane Hanna and determine what more needed to be done to relieve pressure on hospitals. By then, the case count in the valley had climbed to over 26,000.
“We were in a dire situation,” Villarreal said. “If we would have continued in the same direction, we would have had many more lives lost.”
Abbott has since taken a number of measures to aid the coronavirus response in the valley. He has provided more than 1,600 medical staff to hospitals facing personnel shortages across the valley and an additional 200 or so in the city of Laredo along the Mexican border, Chris Van Deusen, a spokesperson for the Texas Department of State Health Services, said.
Abbott also opened a temporary Covid-19 ward at a convention center in the city of McAllen earlier this week with the capacity to treat up to 50 patients under intensive care and 200 patients who are in recovery but not quite ready to be discharged from the hospital. These kinds of alternate care facilities have already been set up in Laredo and Pharr as well, and another one is slated to open in Harlingen, in Cameron County.
“This temporary facility in McAllen will lessen the strain on the region’s hospitals until we can contain the virus and bring hospitalizations back down,” Abbott said in a press conference during his visit.
The state has also expanded free testing capacity in cooperation with the federal government, commissioning a “testing surge” in Hidalgo County and another high-volume testing effort in McAllen. And the federal government has sent two 85-person US Army Reserve medical forces to the Rio Grande Valley to support hospitals in the cities of Harlingen and Edinburg.
But while the governor has followed through on giving local officials in the valley their “wish list,” Melendez says they have needed this kind of help for weeks.
“It would have been nice if we had it four weeks ago,” he said. “In hindsight, we could have responded sooner with more resources, especially doctors and nurses.”
Melendez said there are also still some areas where they could use more support: Skilled nursing facilities, for example, remain hot spots of infection among people who are highly vulnerable to complications from Covid-19, and if they had more trained people, they could be conducting more frequent inspections to ensure compliance with Covid-19 preventive measures. Hospitals in the valley could also use more medical personnel and bed space, as well as more education campaigns, billboards, and public service announcements to help impress upon residents that transmission starts with them.
And going forward, there has to be some effort to address the underlying health inequities that led the valley to be so vulnerable to the coronavirus in the first place, Melendez said. If there had been more investment in improving access to primary care and health infrastructure in the region, residents might have been healthier and more successful in fighting off the virus.
How officials respond now to these ongoing challenges will dictate whether schools have any chance of opening in the Rio Grande Valley later this year. With case counts and deaths still mounting — more than 37,000 cases and 1,038 deaths as of August 6 — Melendez says he can’t in good conscience recommend that they open, and the 22 school superintendents in Hidalgo County agree. He’s done the calculations and it would mean overwhelming hospital capacity again.
“How in the world can I put another 5,000 or 6,000 people in the hospital?” he said. “I can’t do that.”