San Antonio has arrived at a grim milestone. The local health department confirmed the 1,000th death from COVID-19 on Sunday. In total, Metro Health has confirmed 1,016 deaths.
Mayor Ron Nirenberg has a common refrain at the daily COVID-19 briefings.
“We say this every night: Behind every datapoint is a person with a life lived,” he said on July 9, when the city’s total death tally reached 165. “Our hearts are with their families, their friends and their loved ones.”
This question has been asked before, and it’s worth asking again: How did we get here?
The Early Days
There was a time when COVID-19 felt far away and abstract.
For Dr. Ruth Berggren, director of the UT Health San Antonio Center for Medical Humanities and Ethics and medical adviser for Bexar County, the gravity of the then-novel coronavirus first became tangible in January, when New York City began preparing for a potential outbreak.
“You couldn't help but think, ‘This is a globally significant event,’” she said. “And it just went on from there, and things continue to build and build and build.”
At the time, the impeachment trial of President Donald Trump was the bright, shiny object dominating every news program. But as that historic spectacle came to a close, a new event came into focus.
In February, Joint Base San Antonio-Lackland became a quarantine site for American travelers from Wuhan, China — the initial epicenter of the pandemic — and for passengers from the Diamond Princess Cruise Ship. By early March, the Centers for Disease Control and Prevention had already incurred the wrath of local officials by transporting COVID-postive patients to area hospitals for treatment and by prematurely releasing a COVID-positive evacuee who then went to North Star Mall.
“As mayor of this city, I find it totally unacceptable that CDC would release a patient prior to receiving all test results and expose the public to this harm,” San Antonio Mayor Ron Nirenberg said at the time.
It’s impossible to know if the Lackland quarantine was linked to any of the early cases in San Antonio, but local officials believe it’s unlikely.
The World Health Organization classified the coronavirus outbreak as a pandemic on March 11.
On March 13, the first travel-related case in San Antonio was confirmed. The first confirmed case of community spread followed soon after on March 19.
San Antonio and Bexar County issued a series of sweeping emergency orders. First, large gatherings were banned. Then, some businesses were closed and capacity limits imposed. A few days later, on March 21, a woman in her 80s died. She was San Antonio’s first known COVID-19 fatality — the first of more than 1,000.
“We are going to continue to have our health authority in the driver’s seat to make sure that we are answering the call to keep us in front of this curve, to do anything we can to stay ahead of the spread of this disease,” Mayor Nirenberg said at the time.
But, as it turned out, the local health authority had a very powerful backseat driver. Over the next few months, a power struggle between the state and local governments intensified.
The Roots Of The Summer Surge In Texas: Holidays And Reopenings
Texas’ state-level officials initially allowed local governments to drive their localized responses. Gov. Greg Abbott added a few statewide measures in April, including a self-quarantine edict for out-of-state travelers, guidance to avoid restaurants and bars, and a prohibition against visiting gyms, tattoo shops and salons.
But even these restrictions were unpopular with a swath of the population. Their dissatisfaction was most prominently voiced by Lt. Gov. Dan Patrick, who suggested that he and other elderly Americans were willing to die for the economy.
In mid-April, Abbott announced a “strike force to reopen Texas.” The group consisted of four medical advisers and about 40 “special advisory council members,” the majority of whom were finance, retail or restaurant executives.
The state hadn’t ramped up testing enough in March and April to know exactly how widespread the disease was, but even as daily cases steadily rose, Abbott overruled local authorities.
On April 24, retail establishments were allowed to open for curbside delivery. A week later, Abbott allowed restaurants, retail stores, malls and movie theaters to reopen at 25% capacity.
Then, just before Memorial Day, bars reopened with some restrictions.
The governor also stripped local governments of the ability to enforce mask orders. Later, he applauded Bexar County Judge Nelson Wolff for discovering a loophole in the statewide order. Local officials couldn’t enforce mask use, but they could require private businesses to do so.
In a moment of private candor that was secretly recorded, Gov. Abbott acknowledged the likely effects of the fast reopening.
“[A reopening] actually will lead to an increase in spread. It's almost ipso facto,” he said. “The more that you have people out there, the greater the possibility there is for transmission.”
It was an astute prediction. Crowds gathered and bars filled over the Memorial Day weekend.
At the same time, massive protests over police violence against Black people swept the country. But health officials have said the gatherings were probably not responsible for a significant increase in community transmission, primarily because the protests were held outdoors and most participants wore masks.
Different scenes played out inside newly opened restaurants, bars and nightclubs. As the two-week incubation period came to a close, cases began to surge in June. Many of them were traced to bars.
Ernesto Torres owns a small bar in San Antonio. He reopened the establishment just before Memorial Day. Face masks were mandatory for employees and recommended for customers. Pool tables were removed, and capacity dropped to 25% in accordance with the governor’s order.
Shortly after the bar reopened, Torres, a few employees and several customers tested positive for COVID-19. In hindsight, he said he believes the governor’s restrictions weren’t enough.
“My bar is about 2,600 square footage,” he said. “What kind of social distances can you have with 80 people in that place? I mean, we couldn't go behind everyone and clean every surface and the restrooms. It's impossible. I don't care who you are, how careful you are. It's impossible.”
Similar situations unfolded across the state. At the time, Governor Abbott wasn’t alarmed.
“The reality is COVID-19 still exists in Texas. It exists in the United States, as well as across the entire world,” he said in mid-June. “And this is going to continue to be the case for at least a few more months, until we have medicines that are able to treat people who test positive for COVID-19, and until we have medicines that are able to prevent people from getting COVID-19.”
Then and now, the only tried and true ways to prevent COVID-19 are the restrictive measures initially adopted by local officials. Experts agree that a rushed reopening while community spread is still active can lead to an intense spike in cases.
Dr. Drew Harris is a population health analyst and an assistant professor at Thomas Jefferson University in Philadelphia.
“Think of it this way: When you have an infection and you take an antibiotic, they always tell you, ‘Take all the pills in the bottle,’” he said. “Because if you stop halfway through — even though you're feeling better — you haven't totally eradicated it. The infection will come roaring back again.”
Abbott pointed to “abundant” hospital capacity as rationale to resume the reopening.
But his reasoning was fraught. Confirmed cases generally follow infection by one to two weeks, and hospitalizations usually follow confirmed cases by a week to 10 days. “Abundant” hospital capacity can quickly become scarce when cases are surging.
In mid-June, Harris County Judge Lina Hidalgo told Houston Public Media that Abbott was correct about the availability of hospital space. But, she said, “This is not the time to tempt fate. We have to get ahead of this, and it's not a matter of finding out how far we can push before our hospital system enters into a crisis.”
By the end of June, Dawn Emerick announced her resignation as the director of San Antonio’s Metropolitan Health District and asked city officials in an open letter to replace her with a person of color. Several weeks later, private drama between Emerick and Assistant City Manager Colleen Bridger became public through emails obtained by The Express-News.
Bridger once served as Metro Health’s director, and following Emerick’s resignation was appointed to the role again in an interim capacity. This has delayed Bridger’s own plans to resign from the city and start a consulting firm.
Texas In Crisis
Across Texas, from the Rio Grande Valley to San Antonio to Houston, COVID-19 came roaring back after the governor’s rapid reopening.
In a stark reversal, Gov. Abbott eventually closed bars on June 26 and issued a statewide mask order on July 2 — two actions that local officials had begged him to take in the weeks after he took away their authority to do so. He also deployed the state’s national guard and other resources to help overwhelmed hospital personnel in COVID hotspots.
Hospitals around the state filled up rapidly and were forced to activate surge capacity.
San Antonio’s capacity crisis affected hospitals in other areas, like Laredo. Dr. Ricardo Cigarroa works at the Laredo Medical Center, which often sends patients out of town.
“And that's a whole other issue because it's difficult to transfer COVID-19 patients,” he said at the time. “Every city's having their challenge right now.”
In early July, military personnel began assisting at hospitals in San Antonio.
Local officials across Texas became regular guests on national news programs. San Antonio Mayor Ron Nirenberg painted a grim picture.
“It’s very dire,” he told CNN on July 14. “And it’s no different in any of the urban centers in Texas where we’re seeing hospitalizations increase and accelerate to the point where we’re now in single digits in capacity with hospital beds, ICUs and ventilators.”
San Antonio, as well as other cities around the state, imported refrigerated trucks for bodies.
State-level officials initially emphasized a falling fatality rate and a relatively steady daily death toll. But their reasoning, again, was fraught. The fatality rate has fallen marginally throughout the pandemic as medical personnel have learned more about best treatment practices, but it still hovers around 2%, and deaths typically follow hospitalizations by anywhere from a week to two months.
The death toll increased accordingly, hitting daily records in late July and early August.
Texas now has more reported COVID-19 deaths than whole countries, like Germany, China and Canada.
Bexar County, an area home to about 2 million people, has more reported deaths than Australia, a continent of more than 23 million.
Across the county, the disease has disproportionately affected communities of color. Locally, “Hispanic/Latino” people make up about three-quarters of all cases, and about two-thirds of all deaths. Both metrics exceed the local share of the population — about 60% as of 2019, according to the Census Bureau.
Gov. Abbott’s decision to mandate masks and close bars in late June and early July may have prevented anywhere from 140,000 to 200,000 additional cases in San Antonio alone, according to mathematical models. But experts agree that a more cautious reopening strategy could have prevented the mid-summer surge — the spike of cases that resulted in the majority of the 1,000 COVID-19 deaths in San Antonio.
Now, daily cases are falling again. So are deaths. But community spread is still active just as schools are set to reopen and as high school and college sports resume. And we won’t know the full impact of another busy holiday weekend until mid-September, just before the flu season starts.
Models show that under current conditions, Texas is likely to add about 130,000 COVID-19 cases by mid-November, bringing the state’s total to about 800,000.
Dominic Anthony Walsh can be reached at Dominic@TPR.org and on Twitter at @_DominicAnthony.
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