Abortion providers in Texas are apocalyptic over Supreme Court ruling: 'This is a dark day'

Abortion providers and activists bashed the U.S. Supreme Court's decision to leave Texas' new abortion law in place, arguing the high court's ruling failed to dismantle the Lone Star State's novel enforcement method that has citizens file lawsuits against physicians and clinics suspected of violating the new law.

"This is a dark day for abortion patients and for physicians and providers," said Marc Hearron, senior counsel for the Center for Reproductive Rights. "It is also a dark day for anyone who cares about constitutional rights."

On Friday, the U.S. Supreme Court issued a decision that kept a new law restricting abortion to about the first six weeks of a patient's pregnancy but ruled abortion providers could continue their legal challenge of the law.

While the Texas law is about abortion, the fact the majority opinion did not shut down how the law is enforced — via lawsuits filed by private citizens against abortion providers — was one of the most troubling aspects of the court's decision, Hearron said.

"If a state can prohibit the exercise of any constitutional right that's disfavored in that state and get around federal court review by allowing private citizens to sue someone for exercising that constitutional right, then it's hard to say where this scheme ends. Today's decision is a marker that says every constitutional right is now at risk."

Amy Hagstrom Miller, president and CEO of Whole Woman’s Health, which operates several clinics in Texas and is the chief plaintiff in case before the Supreme Court, said the decision presents even more problems for clinics. "This does not feel like a green light, and the risks for clinic staff and physicians remain great," she said.

Julia Kaye, staff attorney for the Reproductive Freedom Project at the American Civil Liberties Union, calling the decision "shameful." She said the decision ignored 50 years of legal precedent and empowered states who have enacted more than 100 restrictions on abortion across the county just this year.

"There was no reason for the Supreme Court to accept this case at all, if not to undermine Roe," Kaye said, referring to the landmark 1973 case, Roe v. Wade, which legalized abortion.

For now, officials at Whole Woman’s Health say they will continue to abide by the Texas law that now bars abortions once an embryo's cardiac activity is detected — at about the six-week mark in a pregnancy — because the law has not actually been blocked in the courts.

For now, providers said, the battle continues.

“Our fight against this law is not over, and Whole Woman’s Health is here for the long haul,” Hagstrom Miller said. “We hope this law is blocked quickly so we can resume the full scope of abortion care we are trained to provide.”

If the court does eventually strike down the law, medical providers can go back to performing abortions up to the 20th week of pregnancy.

But the law, providers say, has already had a chilling effect on staff who want job stability, on patients who remain unclear what their rights are and on the funding and longevity of the clinics themselves.

"While I’m glad that we are able to move forward with the suit, the [Supreme Court] ruling today does very little for Texans who are pregnant today," said Dr. Stephanie Mischell, a Texas family medicine physician. "We are practicing in the same reality of the past 100 days: Patients must access abortion within an incredibly narrow window or be forced to continue an unwanted pregnancy."

When Texas imposed the most restrictive abortion law in the nation in September, doctors and clinics were forced to move quickly to get their patients to out-of-state providers as they waited to see if the law would pass constitutional muster at the nation’s highest court.

“It's going to take a long time for Texas to rebuild,” Hagstrom Miller said. “And this is the damage that is intended from this law.”

Prolonging the uncertainty is the fact that the decision could mean little in the long term depending on how the Supreme Court rules on a Mississippi law, a decision that could result in an overturning of Roe v. Wade.

When Gov. Greg Abbott signed into law what was then known as Senate Bill 8 on Sept. 1, it became illegal to perform abortions when the fetus is showing cardiac activity, around six weeks into a pregnancy.

But the law came with a unique enforcement feature. It relies not on the government to enforce the legal restrictions, but citizen lawsuits against providers and anyone who helps someone access an abortion. As a result, physicians and clinics now face costly legal battles if anyone believes they have violated the restrictions and performed an abortion beyond that period of about six weeks.

Many physicians have already dropped out of abortion care networks, providers say, or reduced the level of care they can give desperate patients because of the threat posed by these lawsuits.

Also, abortion providers have seen a significant drop in the number of women they are able to serve under the new restrictions, and there are fewer calls for those services as well.

Patient numbers for the four Whole Woman’s Health clinics in Texas have dropped by about two-thirds since the restrictions were put in place, Hagstrom Miller said.

Texas has fewer than two dozen abortion clinics, but there are individual providers who perform them at other types of medical facilities or at private practices. All of them are affected by the new law.

"I hope that this ruling and the state ruling from yesterday mean that the courts are recognizing the harms of this law and more good news will come as we continue this fight," Mischell said. "But given the harm of being denied the legal right to abortion, people need and deserve more immediate relief."

Unvaccinated Texans make up vast majority of COVID-19 cases and deaths this year, new state data shows

New data from the Texas health department released Monday proves what health officials have been trying to tell vaccine-hesitant Texans for months: The COVID-19 vaccine dramatically prevents death and is the best tool to prevent transmission of the deadly virus.

Out of nearly 29,000 Texans who have died from COVID-related illnesses since mid-January, only 8% of them were fully vaccinated against the virus, according to a report detailing the Texas Department of State Health Services' findings.

And more than half of those deaths among vaccinated people were among Texans older than 75, the age group that is most vulnerable to the virus, the study shows.

COVID-19 was deadlier for unvaccinated Texans across age groups

Reported deaths from mid-January to October show that most COVID-19 deaths occurred among unvaccinated younger and older Texans.

COVID-19 deaths among Texans
Age groupUnvaccinatedVaccinated
18-29 years339< 10

Note: Most people became eligible for COVID-19 vaccines in late March.Source: Texas Department of State Health ServicesCredit: Mandi Cai

"We've known for a while that vaccines were going to have a protective effect on a large segment of our population," said Dr. Jennifer A. Shuford, state epidemiologist. "By looking at our own population and seeing what the impact of the vaccines have been on that population, we're hoping just to be able to reach people here in Texas and show them the difference that being fully vaccinated can make in their lives and for their communities."

The state health department study covers most of the positive cases and COVID-19 deaths reported in Texas among residents from Jan. 15 to Oct. 1. It's the first time state officials have been able to statistically measure the true impact of the vaccine on the pandemic in Texas — which has one of the highest death tolls in the nation. The majority of Texans ages 16 and up didn't become eligible for the vaccine until late March.

State health officials also found the vaccine greatly reduced the risk of virus transmission, including the highly contagious delta variant that ravaged the state over the summer.

Only 3% of 1.5 million positive COVID-19 tests examined since mid-January occurred in people who were already vaccinated.

State researchers matched electronic lab reports and death certificates with state immunization records, and measured cases and deaths since mid-January, a month after the first shots were administered in Texas.

The study was done using data similar to those used by other states that conducted similar studies and methods recommended by the U.S. Centers for Disease Control and Prevention, Shuford said.

And while the outcome was not particularly surprising, Shuford said, officials hope that the new data will increase trust in the benefits of the shot.

"Texas is a unique place; it's got a lot of diversity, geographic and population-wise," Shuford said. "We know that some people want to see actual numbers and that they want to see it for their own community. And so we are hoping that this reaches some of those people who have been hesitant and really just questioning the benefits of the vaccines."

In Texas, it literally requires a disaster — like a pandemic — before the state records precise information about vaccinations. As a result, there is a record for every single COVID-19 vaccine dose of the name and age of the person who received it plus the date it was administered. Normally, vaccination records are shown to schools by parents, but details of all vaccinations are not regularly kept by a state registry in Texas, unlike nearly every other state, because it's a voluntary system.

However, state officials still don't have official numbers on how many vaccinated people were hospitalized with COVID-19 because hospitals are not required to report that level of data under state law.

But the state's largest hospital districts and counties have reported that at least 90% of the hospitalized Texans with the virus were unvaccinated.

The state's new health data comes as Republican state leaders grapple with local cities and school districts about masking, which has been proven to reduce transmission of the virus, and with federal officials over vaccine mandates.

About 53% of the Texas population is fully vaccinated. More than 70,000 Texans have died from COVID-19 since the pandemic began.

Immunity heading into the holidays

The new report is particularly well-timed, officials say, because gatherings throughout the holiday season could touch off another surge as families get together — many of them for the first time since last year — and around 9 million Texans remain unvaccinated.

Texas saw its deadliest surge of the pandemic in January, when more than 400 deaths were reported daily at its peak, a trend health officials said was likely a direct result of the holidays.

The recent Texas Coronavirus Antibody Response Survey, commissioned by the state health department in partnership with the University of Texas System, estimated that about 75% of Texans — roughly 22 million people — likely have some level of protection against the virus, either by natural immunity from being infected or through vaccination.

But that doesn't mean infected people are immune indefinitely or that they shouldn't get the vaccine, health experts say.

In fact, doctors, scientists and health officials urge those who have been infected to get vaccinated anyway, saying the vaccine provides a strong boost in immunity even to those who have some level of natural protection.

The Texas CARES study found that fully vaccinated participants showed significantly higher antibody levels than those who were unvaccinated but had been infected.

A week ago, the CDC found that while both vaccination and natural infection provide about six months of protection from infection by the virus, the vaccine provides a "higher, more robust, and more consistent level of immunity" than natural infection does.

And while the fact that a solid majority of Texans are estimated to have some protection from the virus bodes well for the state in its fight against the pandemic, Shuford said, it still means that millions of Texans are vulnerable to severe illness or death from the highly contagious virus, without any vaccine or natural immunity.

"Those susceptible populations can still get infected, and the holidays are the perfect time for that," she said. "Thanksgiving, Christmas, New Year's. These are all times that people gather together, and COVID-19 can easily be transmitted at these gatherings."

Mandi Cai contributed to this report.

Disclosure: University of Texas System has been a financial supporter 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.

It’s cheap, easy to make and in demand overseas. So why can’t this Texas-born COVID-19 vaccine break into the US market?

The day before COVID-19 claimed its first Texas victim in 2020, Dr. Peter Hotez was a guest on the popular Austin-based podcast "The Drive."

After 10 years of research into coronavirus vaccines, Hotez and his Houston team needed an infusion of cash to build on their past work and make a vaccine that could, as Hotez told listeners then, "rescue the world" from the deadly emerging coronavirus pandemic.

"You'd think that people would be pretty eager to support us to move this forward, but so far it hasn't happened," the Houston pediatrician and vaccine scientist told the host, Dr. Peter Attia, on March 14, 2020.

By the following week, major cities in Texas began to shut down to avoid widespread community outbreaks.

But Hotez's plea worked. The donations started coming in support of efforts in the deadly new pandemic at the Baylor College of Medicine at the Texas Children's Hospital Center for Vaccine Development, co-directed by Hotez and Dr. Maria Elena Bottazzi in Houston — both of whom are celebrated pioneers in the area of vaccines for neglected tropical diseases like chagas and schistosomiasis.

Among the gifts was a $1 million infusion of cash in May 2020 by the philanthropic arm of Texas-based Tito's Handmade Vodka, whose director of global impact and research, Sarah Everett, was tuned in when Hotez asked for help in reviving their research.

"We decided that somebody should help restart that work immediately," Everett said.

Now, nearly 18 months later, the Houston team's vaccine, called Corbevax by its maker in India, is cheap, has no patent, can be made by many vaccine producers globally — including those in low- and middle-income countries — and is poised to receive approval for widespread global use.

The Indian government has promised the biopharmaceutical company Biological E Limited, which is making the vaccine in that country, that it will buy 300 million doses with the potential for more.

A halal version of the vaccine, for use in Islamic countries because it doesn't contain animal-based ingredients, is also about to start clinical trials in Indonesia.

And later this year, the company hopes the vaccine will be endorsed by the World Health Organization for use globally, which could open the doors to quicker authorization in several countries that need it.

But here in the United States, this "truly Texas vaccine," as its creators like to call it, has no home.

A Texas-style vaccine

The fact that the vaccine even exists can be traced to a lot of Texas money, including funds from The Robert J. Kleberg, Jr. and Helen C. Kleberg Foundation and the M.D. Anderson Foundation. Several high-level and anonymous individual donors pitched in, as well as the JPB Foundation in New York.

Those donations funded a vaccine prototype with the initial doses mixed in the Houston lab and transferred to Biological E in India in May 2020. By November, BioE began clinical trials of the vaccine in India, where the delta variant was first identified and which has one of the lowest vaccination rates in the world. Total cost from creation to market was between $5 million and $7 million, Bottazzi said.

The U.S. government has yet to get on board. Operation Warp Speed, the public-private partnership created by the federal government to accelerate treatments and vaccines for COVID-19, spent none of its billions at the Houston lab.

Most experts, including Hotez and Bottazzi, agree that's because most of the funding and the attention — and the bets — are on the vaccines made earliest in the pandemic, and with the newest technology, by Pfizer, Moderna and Johnson & Johnson and a few others.

"We're pushing the new ways because they're better and faster," said Dr. Benjamin Neuman, a Texas A&M University virologist who has been doing coronavirus research since 1996, though he was not involved in any of the approved vaccines' development. "Why wouldn't you want to have it all?"

Competition from new tech

The mRNA vaccines by Pfizer and Moderna use messenger RNA, a molecule the virus needs to produce a "spike protein" and bind to human cells, to prompt the immune system to produce antibodies against that protein. Five years ago, Neuman said, that process hadn't been made effective yet.

But by the time Hotez was making his plea on Attia's podcast, Moderna was already starting up clinical trials of its mRNA vaccine in partnership with the National Institutes of Health, the biomedical research arm of the U.S. government and the largest center of its kind in the world.

And by late 2020, when BioE was rolling out its phase 1 clinical trials with Corbevax in India, Pfizer was already getting emergency use authorization from the U.S. Food and Drug Administration.

The Bottazi and Hotez vaccine relies on a production process very similar to the way the Hepatitis B vaccine is made that's been produced and used around the world for decades. The two argue that the familiarity with the process and the ease with which the materials can be gotten makes it easier to quickly ramp up global production compared to the newer vaccines, even if they came onto the market a little later.

But aside from a handful of philanthropies who can see the value of the domino effect — more vaccinations outside this country help lower infections around the world and here — Hotez and Bottazzi have heard nothing about producing or distributing here at home.

"Why weren't conventional vaccine technologies given the opportunity of being at the same table as all these other technologies?" Bottazzi said.

The answer, Neuman says, is that while conventional technologies — or what he jokingly derided as "the obvious answer" — have a role in global vaccine development, the newer vaccines are stronger than the traditional types that Bottazzi, Hotez and other scientists around the world are developing.

Newer vaccines also have a quicker production process than the conventional vaccines, said Neuman, a member of the international committee that named SARS-CoV-2, the virus behind the COVID-19 pandemic.

But Neuman agrees that the newer vaccines have distribution challenges: the tangles of intellectual property patents, the availability of materials to produce billions of doses in a short period of time and the logistics of a more complicated transport and storage process.

Those challenges can be solved, Neuman said, but until then, the majority of the planet should be vaccinated "by any means necessary," including with conventional vaccines like the one created by Bottazzi and Hotez, if it proves to be safe and effective.

"Whatever gets the job done the fastest as long as it's safe for everybody involved," he said.

'One plane flight away'

While the Houston team waits for a production and distribution partner, the team fields calls every week from other countries asking them for help getting access to the vaccine, Bottazzi said.

They ask if they can get the spare doses that Americans are declining or if they can get connected to BioE to export to them from their Indian-made stocks — or if the scientists will share the formula for the prototype.

The scientists share the formula with any country or lab who asks for it and help in other ways, however they can.

"We're kind of practicing our own version of Texas vaccine diplomacy," Hotez said.

Vaccination rates for developing countries are still in the single digits. About 38% of the world population is fully vaccinated against COVID-19. Many African countries, such as Sudan, Kenya and Ethiopia, have a rate below 2%.

In India, where nearly a billion doses of three different vaccines — Covishield, Covaxin and Sputnik V — have been distributed, more than 80% of the population remains unvaccinated. In Brazil, less than a third of the country is inoculated.

"We're one plane flight away from seeing a variant that developed in a country that has very little vaccine end up on our shores and set off a new wave of the pandemic," said Dr. James Cutrell, an infectious disease expert at UT Southwestern Medical Center.

Right now, the World Health Organization is already monitoring several variants that have been traced to developing countries including Indonesia (21% fully vaccinated), Peru (with one of the highest COVID-19 mortality rates in the world), Colombia, the Dominican Republic and South Africa.

"Much of sub-Saharan Africa, large swaths of Latin America and other places like that — they really don't have access to the [mRNA] vaccines," said Cutrell, an associate professor in the department of internal medicine. "That makes it really important and attractive to have some of these cheaper, easier-to-distribute — but hopefully similarly effective — vaccines with more traditional technology, which I think this vaccine and other vaccines like it can contribute."

American problem, international solution

As the world scrambles for doses to meet the vaccination demand elsewhere, this nation's vaccination effort has flagged, hitting a wall of hesitation by a significant portion of the American public that is declining the new vaccines, although they have proven to be safe and effective.

Hotez and Bottazzi believe their vaccine would likely be more accepted by those who don't trust a vaccine that is unfamiliar to them, like those by Pfizer and Moderna.

But from the start, inoculating reticent Americans was never the Houston team's first priority.

Bottazzi and Hotez began their work developing coronavirus vaccines as part of their mission at the National School of Tropical Medicine, where Hotez is dean and Bottazzi is associate dean, to inoculate developing nations against tropical viruses.

Fast forward to January 2020, when SARS-CoV-2, the virus that causes COVID-19, was setting off alarms in the U.S. medical community. Bottazzi and Hotez began working to repurpose their coronavirus research program to develop a vaccine against the new virus and distribute it to the same countries they'd focused on throughout their careers.

The speed with which the Pfizer and Moderna vaccines were developed and the fact they used newer formulas seemed to spook some Americans and helped fuel politically motivated misinformation campaigns that chipped away at public acceptance. And as this nation's vaccination rate hovers around 57%, it's a matter of debate what is needed to achieve a higher level of immunity as a country.

Neuman said he isn't so sure that a more familiar vaccine formula would change a lot of minds in the United States, where the resistance appears to be more political than scientific.

"I think that comes from a lot of different places, and I think the main place is sort of, 'You're not the boss of me,'" he said. "'Who says you get to tell me what to do?' And I don't think it matters what it is."

Even if it would make a difference, the path to emergency use authorization for a COVID-19 vaccine in this country starts with money — for research, for trials, for materials — and ends with firm commitments from the U.S. to support its mass production.

The Bottazzi-Hotez shot, at this point, has neither.

And so Hotez, who is an internationally known and outspoken warrior against the anti-vaccine movement, and Bottazzi redouble their attention abroad to protect Americans who can't or won't protect themselves. If they can get more of their vaccine overseas within a few months, they can keep the variants from percolating and landing on U.S. soil.

"It's a pretty ambitious, audacious goal," Hotez said. "But I think we could get there."

Disclosure: UT Southwestern Medical Center has been a financial supporter 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.

At least one major Texas abortion provider resumes procedure lawmakers tried to prohibit -- after judge blocks near-total ban

"At least one major Texas abortion provider resumes procedure lawmakers tried to prohibit, after judge blocks near-total ban" was first published by The Texas Tribune, a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.

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At least one major abortion provider on Thursday resumed providing the procedure to patients who had been previously shut out by Texas' near-total ban, less than a day after a federal judge temporarily halted enforcement of the law.

"Last night we reached out to some of the patients that we had on a waiting list to come in and have abortions today," Amy Hagstrom Miller, founder and CEO for Whole Woman's Health, which runs four clinics in Texas and half a dozen in other states, said during a Thursday press call. "Folks whose pregnancies did have cardiac activity earlier in September, and we were able to see a few people ... right away, when we opened the clinic."

Whole Women's Health is also booking consultation and abortion appointments for the coming days for patients who were unable to get abortions because they were too far along in their pregnancies, Miller said. Some other clinics in Texas have told her they're doing the same, she said.

But many other providers and doctors affiliated with Whole Woman's and other clinics are waiting until more solid rulings come, she said.

Texas appealed U.S. District Judge Robert Pitman's Wednesday night's ruling that put a temporary block on the law, the most restrictive in the nation because it allows abortion only in about the first six weeks of a pregnancy, before most realize they are pregnant. If the Texas law is ultimately upheld by higher courts, it won't protect providers who perform those services during the legal pause on enforcement while the law makes its way through the legal process.

The case is now before the 5th U.S. Circuit Court of Appeals in New Orleans.

"That is part of why you don't see every clinic in the state opening immediately," Miller said. "Many of our physicians and staff are afraid that would, if the injunction is knocked down in the future, allow for these vigilantes to come back and sue us for every abortion we did in the interim. ... It's really the retroactive clause that gives people pause."

Miller said her company is trying to serve as many people as possible for as long as the temporary injunction issued by Pitman lasts. Patient phone calls began pouring into the clinics on Thursday as word of the federal court in Austin's action spread.

"The phone call volume has increased," she said. "There's actually hope from patients and from staff, and I think there's a little desperation in that hope. Folks know that this opportunity could be short lived."

Molly Duane, staff attorney for the Center for Reproductive Rights who is working with Whole Woman's, said cases like this one could take years to shake out, but patients and clinics are running out of time.

"The fact remains that providers and patients in Texas cannot wait until this case or any other is finally adjudicated to final judgment — that process takes years," Duane said. "What we know is that there are many brave providers out there in Texas who are relying on the assurances they got [from the ruling], and that number I believe will continue to grow."

The new Texas law — Senate Bill 8 — went into effect Sept. 1, forcing all major abortion clinics to stop offering abortions after an embryo's cardiac activity is detected, which can happen before many people know they're pregnant. Some providers have stopped offering the procedure altogether out of fear of litigation, while others have had to curtail their services and shut down access to anyone beyond about six weeks into a pregnancy.

SB 8 relies on enforcement not from the state, but by private citizens who would sue abortion providers and anyone involved in helping someone get an abortion after a “heartbeat" is detected. Medical and legal experts say embryos at this developmental stage don't yet possess a heart.

Wednesday's order from the federal court in Austin opened the door, at least temporarily, to expanding those services to people seeking to terminate their pregnancies up to 18 weeks. But the law is constructed in such a way that people who violate it, even while it is being temporarily blocked, could be vulnerable to litigation if the law's enforcement were to be reinstated and any existing suits could continue. The lawsuits can be filed up to four years after the procedure.

Already, abortion opponents have threatened to file suits and watch for potential violators to sue if the law is ultimately upheld.

A decision from the 5th Circuit on whether to uphold the law or further weaken it could come as early as Thursday.

Officials with Planned Parenthood of Greater Texas, which offers reproductive health services to people across the state, could not be reached immediately on Thursday. But officials with the national organization said late Wednesday that the organization was “hopeful" that the ruling would lead to a return to previous services — although no timeline was offered.

“This fight is far from over," Alexis McGill Johnson, president of Planned Parenthood Federation of America, said in a Wednesday statement.

Until Wednesday's order by Pitman, Texas' new law successfully flouted the constitutional right to have an abortion before fetal viability established by Roe v. Wade in 1973 and subsequent rulings. That's because of that novel private-citizen enforcement layer.

It capped conservative lawmakers' decadeslong war to block access to the procedure, and Texas' fast appeal to the 5th Circuit was expected.

Disclosure: Planned Parenthood has been a financial supporter 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.

Correction, Oct. 7, 2021: In a previous version of this story, the name of the federal judge who issued a Wednesday ruling was misspelled in one instance. His name is Robert Pitman, not Robert Pittman.

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2021/10/07/Texas-abortion-law-providers/.

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The delta variant is wreaking havoc on most of Texas — but not El Paso. Here’s why.

El Paso resident Carlos Martinez was relieved in June when the number of COVID-19 hospitalizations and deaths were dropping in his community.

Martinez, 25, started going to restaurants for the first time in months, seeing friends and going out again after being careful for more than a year.

Then the highly contagious delta variant began to take hold across Texas and the rest of the nation in July, and the numbers started to climb again across the state.

Martinez, who is vaccinated, said he went back into isolation to help reduce the spread of the virus in El Paso, where COVID-19 killed so many people late last year that the county had to use inmates to help with the overflow of bodies at the morgue.

But while delta raged through most of the state's 254 counties in July and August, breaking records and overwhelming hospitals in both rural conservative areas and sprawling liberal metros, El Paso — with one of the highest vaccination rates in the state — has been relatively unscathed by the most recent surge.

"We held our breath after July Fourth, but we didn't see the increase we thought we'd see in terms of hospitalizations," said Martinez, a local government employee.

While some other metro areas like Austin reported record high numbers of COVID-19 patients in their area hospitals just last month, and while statewide hospitalizations came close to eclipsing the January peak of 14,218, El Paso-area hospitals, which serve nearly a million West Texas residents, haven't come close to their previous highs.

El Paso's peak for COVID-19 hospitalizations was just over 1,100 in mid-November, said Wanda Helgesen, director of BorderRAC, the state's regional advisory council for local hospitals. On Thursday, the number of people hospitalized for COVID-19 in El Paso was 127. In fact, the city's daily hospitalization numbers haven't broken 200 since March, according to the Texas Department of State Health Services. Hospitals are seeing an increase in patients, have occasionally seen their ICUs fill up and are having the same staffing problems as the rest of the state, she said, but have so far been able to handle the uptick. Most of the pressure is related to non-COVID patients, many of whom had been waiting to get treatment for other problems, she said.

"We do have a surge of patients but not to the extent that other parts of Texas are having," she said.

Helgesen and others say much of the credit can be attributed to the area's high vaccination rate, widespread compliance with masking and social distancing, and a strong partnership among local community and health care leaders.

"It is amazing," Helgesen said. "It is absolutely a credit to our community. I really think it was an all-out effort."

The share of COVID-19 tests in El Paso that come back positive is hovering around 6%, while the statewide positivity rate is three times that at 18%.

And while COVID-19 patients, most of whom are unvaccinated, took up more than 30% of hospital capacity in some areas and more than 20% statewide last week, in El Paso they accounted for only 7% of patients in local hospitals.

For a city with one of the state's highest per-capita COVID-19 death counts, the numbers present a rare glimmer of good news for the traumatized residents of this West Texas border city.

"Compared to the rest of Texas, we're in heaven," said Gabriel Ibarra-Mejia, assistant professor of public health at the University of Texas-El Paso. "That doesn't mean we are free from COVID, but we're doing much, much better than most of the rest of the state. The numbers don't lie."

Civic and health leaders say they aren't ignoring one important fact: El Paso's surges have been weeks behind the rest of the state throughout the pandemic, so it's possible that the region's own delta-fueled spike could still be ahead.

"We aren't letting our guard down," Helgesen said.

El Paso Mayor Oscar Leeser, who lost his mother and brother to COVID during the winter surge, said the reason the city and county have enacted recent mask mandates, in defiance of Gov. Greg Abbott's ban on them and in spite of lower numbers, is because the potential for another surge is still real.

"We do worry and we want to make sure that we don't have any spikes," he said. "You always want to be proactive and you always want to be prepared."

Sense of community helps COVID response

El Paso was in the national spotlight in November when it had one of the highest COVID-19 death rates in the country.

Images of county jail trustees in black-and-white stripes moving body bags into eight mobile morgue trucks outside the understaffed medical examiner's office were a shocking illustration of the heavy toll the virus took on the community.

During the fall, the number of hospitalized coronavirus patients in El Paso shot up nearly tenfold between September and November, at a time when the numbers dropped and restrictions were relaxed in most other parts of the state.

El Paso's COVID-19 cases and hospitalizations remained relatively high well into the early springtime while the rest of the state was experiencing a decline as vaccines became available.

"Today, El Pasoans may be taking the delta surge more seriously than residents in other areas that were less hard hit because of that traumatic time," said Chris Van Deusen, spokesperson for the Texas Department of State Health Services.

"El Paso experienced one of the biggest crises of the pandemic with hospitals absolutely overrun by COVID patients last year, and the communal memory of that period and the measures that helped the city and region cope may be helping people take the current situation more seriously," he said.

There are several other factors that likely play into El Paso's relative success at keeping the delta variant at bay and people out of the hospital, state and local health officials and residents say.

There may be a high level of natural immunity among local residents, which medical experts say appears to keep COVID-19 sufferers out of the hospital in the slight chance they are reinfected, health experts say.

There has been wide acceptance of the monoclonal antibody treatments, which Helgesen said kept at least 300 people out of hospitals during the last surge and, because the area never closed its regional infusion center as other areas did when numbers went down in the spring, is likely keeping people out of hospitals now, too.

The city's geography is also a factor: It is hundreds of miles from the nearest major population center, and it borders New Mexico, which has one of the highest vaccination rates in the nation at 61% fully vaccinated.

And the Walmart mass shooting two years ago, in which 23 people were killed on Aug. 3, 2019, contributed to an increased sense of community and empathy that tends to lend itself to widespread compliance with masking and vaccinations, said local resident Steven Wysocki.

"That El Paso Strong thing has been resonating ever since the Walmart shooting," he said. "So that's another thing. 'Let's protect our community.' It's on a personal level. It's a strong sense of family and community responsibility. Even though El Paso's population is close to a million, we're still a small town."

Van Deusen said the tragedy likely engendered trust in the local pandemic response.

"There does seem to be a sense of community and trust in local leaders and public health … that can go a long way to helping promote a cohesive community response to a crisis," he said.

When Abbott lifted statewide mask mandates and business limits in March, civic leaders in El Paso begged their residents to keep wearing masks, and most businesses continued to limit their services voluntarily throughout the spring, Leeser said.

Wysocki, a 51-year-old disabled Army veteran, says most people seem to be taking the latest statewide surge seriously.

"Any store I go to, every place I go, people have got their mask and they put it on," he said.

El Paso among most vaccinated counties in Texas

But it's the high vaccination rate in El Paso that most are saying is the main factor in the community's relative success at tamping down the impact of the delta surge.

Nearly 62% of all El Paso's residents are fully vaccinated, compared with 49% statewide. Of those who are eligible to get the vaccine, ages 12 and up, the rate of fully vaccinated residents climbs to nearly 75%. And almost 97% of all El Pasoans age 65 and older, the age group at the highest risk of hospitalization and death, have had at least one shot.

By contrast, only about one-third of residents in the Panhandle and East Texas are fully vaccinated.

"We've done a really, really good job of making sure our community was vaccinated, and that's made a huge difference," Leeser said. "And when we talk about 'we,' it's not just the city of El Paso. It's the county, the county judge, University Medical Center, the private providers, everyone in the area. We all rallied together, and it's been one continuous message we've been getting out to the community."

The COVID-19 vaccines do not guarantee that recipients won't get the virus, but they are highly effective at keeping infected patients out of the hospital and almost 100% effective at preventing death from the virus.

Wysocki got his vaccine as soon as he could, as did the rest of his family.

He caught the virus several months before the vaccine came out and was bedridden for several days, an episode he said motivated his whole family.

"Everyone in our family immediately got the shots [when they were available]," Wysocki said. "No one wanted to go through that."

El Paso County Judge Ricardo Samaniego said a big part of the success is because El Paso residents are used to looking out for each other.

"We know how to do this," he said. "We know how to come together. We've done it before, and we're going to do it again."

Chris Essig contributed to this report.

Verbal and physical attacks on health workers surge as emotions boil during latest COVID-19 wave

When the security guard at Methodist Hospital San Antonio met the visitor at the door of the children's emergency room on a Saturday afternoon in early August, the officer's request was simple: The man needed to get a temperature screening to make sure he showed no early signs of COVID-19 before entering the hospital.

The man refused, became agitated and began angrily shouting, pulling out his camera to record the guard and hospital staff.

The scene got so tense that San Antonio police were called, but the man — whose identity and reason for wanting to enter the hospital weren't included in a police account of the incident — stormed off in anger before the officer could arrive.

It was, relatively speaking, a small blow-up, but Texas hospital workers and health care officials say incidents like it have been rising in both number and intensity this summer as tensions boil during the delta-fueled fourth surge in COVID-19 hospitalizations.

"Our staff have been cursed at, screamed at, threatened with bodily harm and even had knives pulled on them," said Jane McCurley, chief nursing executive for Methodist Healthcare System, speaking at a press conference five days after the incident in the children's ER. "It is escalating. … It's just a handful at each facility who have been extremely abusive. But there is definitely an increasing number of occurrences every day."

Nurses and hospital staffers are historically vulnerable to workplace violence due to the nature of their jobs, where they deal with people who are having bad reactions to street drugs or mental breaks and often have to give bad news to patients or family already in extreme pain or emotional distress.

Half of all Texas nurses reported verbal and physical abuse at work in 2016 - the last year Texas health officials surveyed them about it.

But the pandemic has exacerbated the stress that can escalate into threats and violence, as people are now contending with not just the virus but also job loss and other stresses, said Karen Garvey, vice president of patient safety and clinical risk management at Parkland Health & Hospital System in Dallas.

Garvey said confrontations at Parkland just this year have included "people being punched in the chest, having urine thrown on them and inappropriate sexual innuendos or behaviors in front of staff members. The verbal abuse, the name-calling, racial slurs … we've had broken bones, broken noses."

Visitors and patients assaulting hospital staff "was an epidemic before the pandemic — it was just silent to the public," she added. "Health care workers have been dealing with this for years, and it's become more pronounced with the COVID pandemic."

The pandemic-related rise in tensions across the U.S. is not unique to the hospital industry. Airlines are reporting an increase in aggressive passengers as flight attendants take self-defense classes. Police are reporting an increase in violent crime and road rage incidents.

A similar phenomenon emerged last year when retail and grocery workers became front-line enforcers of mask mandates and limits on gatherings and indoor activities. And it resurfaced last month when parents aggressively confronted teachers at schools over oft-changing mask rules.

But unlike airlines, which can permanently ban passengers, hospitals are more limited in how they can respond or prevent those instances.

A 2013 Texas law made it a felony to assault an emergency room nurse, but legislation that would have expanded that to include nurses in other areas of a hospital died in the Texas Senate earlier this year. A bill addressing the issue is currently being considered in Washington by the U.S. Congress.

With hospitals reporting historic nursing shortages as the pandemic drags on, the fear is that the "alarming rate" of escalation will be the last straw for nurses who are physically worn out after fighting a pandemic for 18 months, thin on compassion for people who need care after choosing not to be vaccinated and afraid for their own personal safety, said Houston pediatrician Dr. Giancarlos Toledanes.

"With the escalation of this violence toward health care workers, we're going to lose the workers that are deemed essential," Toledanes said. "If the problem continues to compound, then I think it's going to make it much more difficult to staff these hospitals."

"Tempers are high"

The Texas Department of State Health Services doesn't track incidents of aggression against hospital staff outside of its regular surveys, the next of which will be done next year, a spokesperson said.

But as health officials across Texas watch hospital ICUs and pediatric units overflow with record numbers of mostly unvaccinated people, they say the surge in aggression toward health care workers is obvious.

Many of the problems being reported in recent months include disagreements over masking and screening protocols that people don't have to follow in other places, particularly after most mandatory protocols were banned in recent months by Gov. Greg Abbott, officials said.

Confrontations are sometimes caused by hours- or dayslong waits in emergency rooms that are so full of COVID-19 patients that there is no room for anyone else, health care workers said.

"Tempers are high," said Carrie Kroll, director of advocacy for the Texas Hospital Association. "To the point where some systems are putting a security guard at check-in because family members are getting so abusive over the masking and some of the other screening things they need to do."

Families are often upset when they can't visit someone due to COVID-19 rules that limit the number of people who can be bedside or even come inside the hospital, said Serena Bumpus, director of practice at the Texas Nurses Association.

"When our family members are sick, we want to be there by their side, and it's not that easy to be by our loved one's side anymore because of this increase in the number of COVID patients in our facilities," she said.

At the Katy campus of Texas Children's Hospital west of Houston, Toledanes said some parents get verbally abusive over rules that require them to wait for COVID-19 test results before more than one parent is allowed into a room with a sick child.

"With their child in the hospital and they're the only ones handling everything, it obviously gets stressful," he said. "It's escalated a lot more, especially now that we've gotten a little bit stricter with our policies" due to the surge.

Health workers face online harassment

The threats follow health care workers online as well, and often have to do with philosophical differences over what have become political hot buttons such as masking and vaccinations, Toledanes wrote in a recent column for the online medical magazine MedScape.

"Online, healthcare workers, who advocate for masking or vaccination, are often subject to death threats, threats to family members, and verbal abuse on social media," he wrote. "Veiled threats of 'we know who you are' and 'we will find you' follow physicians who advocate for masking in schools."

At Parkland, some of the administration's actions to protect the workers include a staff of six mental health peace officers — known as the Law Enforcement Intervention for Environmental/Patient Safety staff — who are specially trained to respond to high-risk incidents, Garvey said. Administrators have developed a flagging system in the patient record which identifies patients who have been identified as known risks to staff, she said.

Some hospitals have hung signs in hallways reminding families to be courteous and patient with the overworked staff.

In mid-August, the escalating reports prompted the Texas Hospital Association to take to social media with an image of an exhausted nurse's face, mask pulled below her chin.

"Don't forget the person behind the mask," the image reads.

Inline article imageThe Texas Hospital Association distributed this message on social media in response to a surge in verbal and physical attacks on medical workers. Credit: Gorodenkoff Productions OU

McCurley said that the increasing violence this year is made worse by the contrast in attitudes workers are seeing now compared with a year ago, when the public seemed to understand that nurses and hospital staff were standing between them and the deadly pandemic.

"We were seen as health care heroes and our community responded with love and support, food and gifts, drive-by parades, buses and motorcycles and airplanes, and we felt so much love and support. It gave us the courage to go in and face our own fears of the unknown in the beginning," McCurley said at the August press conference. "Today, those health care workers are experiencing abusive behavior by patient families. It's unfathomable that it's occurring, and it has to stop."

Disclosure: Texas Children's Hospital and the Texas Hospital Association 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.

Desperate Texas doctors turn to antibody treatments to slow down surging COVID-19 hospitalizations

What surprised Texas retiree Kathy Hardman most was not that she got COVID-19 five months after being fully vaccinated.

And it was not even that she qualified to receive an increasingly popular — yet still largely unfamiliar — experimental treatment that had been prescribed to some of the most powerful people in the country.

What shocked the 66-year-old grandmother of four was that the monoclonal antibody infusion therapy, estimated to decrease chances of hospitalization by up to 70%, was available to her at her hometown hospital in Mount Pleasant, a community of 15,000 in rural Northeast Texas.

"It's amazing to me that we have this available to us in little old Titus County," Hardman said on Friday, less than 24 hours after she was diagnosed and got her infusion at Titus Regional Medical Center.

The infusions are, in fact, more available and accessible to Texans than ever before, with ever-loosening restrictions on who may qualify, more people hearing about them and an increasing number of doctors across the state learning about the therapy and prescribing it to their patients suffering from COVID-19.

The Regeneron treatment, the therapy being used by state-run infusion centers, was used by both then-President Trump last fall and Gov. Greg Abbott last week after they each were diagnosed with COVID-19. Houston-area Congressman Troy Nehls posted on social media he received the treatment Saturday, after testing positive for the virus. The therapy uses antibodies developed in a lab and injected into the patient, usually through an IV drip, to help their own antibodies fight the virus.

Abbott and other state leaders, including the directors of the state's health department and emergency management divisions, have pushed the experimental infusion therapy since it was given emergency use authorization for certain patients by the U.S. Food and Drug Administration in November.

But after a slow response by an initially skeptical medical community and by hospitals that were too overwhelmed by the pandemic to devote time or space to offer the hourslong treatment appointments, the therapy is finally being recognized as an important part of the arsenal against a virus that has roared back this summer.

Demand has increased across the country as COVID-19 cases have exploded. The therapy's distributor, AmerisourceBergen, has sent 136,932 treatment courses of monoclonal antibody therapies to Texas since December. More than a quarter of them, nearly 37,000 treatment doses made by Regeneron, arrived this month, according to the Texas Department of State Health Services.

There are now about 140 doctors' offices, hospitals, clinics and infusion centers in Texas that can not only administer the drug, but order it directly from the company, making it easier to keep it in stock.

The treatment is free for patients, who are required to have a prescription and meet certain guidelines.

"We prescribe it all the time," said Dr. Emily Briggs, a private physician in New Braunfels who was hesitant about the therapy at first but began prescribing it in March after learning more about it. "We're using it a lot. The unfortunate truth is that my patients who are unwilling to get the vaccine want us to throw everything at them when they get this virus."

And more are catching the virus every day in Texas, where the delta variant is being blamed for what health care officials describe as the worst surge in infections that the state has seen since the pandemic began.

The result is twofold: a spike in hospitalizations of unvaccinated people, who represent more than half of the Texas population but more than 95% of patients hospitalized with COVID-19, and a strain on intensive care units. More than 100 hospitals have reported few or no ICU beds available in the past week.

On Thursday, 10,772 new confirmed cases and 3,285 new probable cases were reported across the state, and 12,841 people were in Texas hospitals with COVID-19.

COVID-19 surge prompts state to reopen infusion centers

Those grim statistics are the main motivator behind the sudden re-emergence of previously shuttered mass infusion centers as a primary tool in helping keep the hospital system from buckling under the strain of too many patients.

Most of the centers supported by the Texas Division of Emergency Management that had opened at the end of 2020 and early 2021 were closed or turned over to locals months ago, when hospitalizations and deaths dropped in the wake of mass vaccination efforts.

Mobile treatment units and hospitals kept offering infusions, but the mass centers weren't needed as much because the hospitals were able to handle patient loads once again. In June, Texas providers received fewer than 2,000 monoclonal antibody treatment courses, according to the Texas Department of State Health Services.

Throughout the January surge, Abbott and other state leaders criticized the low rate of prescriptions that physicians were writing for the therapies, which were arriving to the state on a weekly allotment through the U.S. Department of Health and Human Services.

State and national leaders repeatedly suggested that part of the reason hospitals were becoming overwhelmed during the winter surge was that not enough doctors were prescribing the treatment, which they argued could keep patients from requiring a hospital bed.

Physicians at the time complained that the criteria set by the U.S. Food and Drug Administration and the manufacturers of the treatment limited their ability to prescribe it. A patient's age, the timing of their symptoms and their risk factors all had to be considered. Doctors said too few met all the criteria — and some patients weren't showing up at their offices early enough after the onsent of symptoms for the therapy to work properly.

Several, like Briggs, the New Braunfels physician, did not want to use their patients "like guinea pigs" and preferred to wait until the therapies were more proven.

Then delta hit, driving hospitalizations back up, and this time, the health care community is embracing antibody therapy — and even encouraging each other to use it by putting together public awareness campaigns and training sessions.

On Thursday night, nearly 250 people attended a private virtual town hall for the medical community hosted by the Travis County Medical Society and the Dell Medical Center at the University of Texas at Austin. Its purpose: to answer questions from doctors and nurses about the therapy and encourage them to start prescribing it.

New criteria mean more people qualify for therapy

In May, the FDA expanded the criteria for who can receive it, dropping the qualifying age from 55 to 12, which gave more discretion to the doctors who would be writing the prescriptions. The changes also included new weight guidelines that allow some 75% of Texans to qualify to receive it; the majority of Texans are overweight, which increases the risk of hospitalization for COVID patients.

Regeneron is most effective on people with COVID-19 who have had symptoms for less than 10 days, but the FDA's broad guidelines largely leave the decision of who should receive it up to physicians, health officials say.

In an email to staff at Houston Methodist hospital system on Wednesday, Dr. Robert A. Phillips, executive vice president and chief physician executive, said the hospital has scheduled 867 infusions for this week — more than double the highest number for a single week during the last surge.

The Texas Department of State Health Services sent Houston Methodist 17 nurses to help administer the treatment, he said in the email. They arrived last week.

"As you may know, Gov. Abbott is receiving monoclonal antibody treatment after testing positive for COVID-19. This likely will bring more attention to this treatment, which has proven to cut down on hospitalizations," he wrote.

Nim Kidd, chief of the Texas Division of Emergency Management, said he's glad to see the enthusiasm.

"We've been trying to push these therapies for all Texans, all along," he said. "They work. I'm a 100% believer in that [treatment], personally."

Doctors and state leaders point out that the benefits of the infusion last only about three months and that it should not be used as a substitute for vaccines.

"We are continuing to focus on vaccines as the goal," Kidd said.

"It's kept people out of the hospital"

The mass infusion center at the Bexar County fairgrounds near San Antonio had closed in March, but reopened on Aug. 10 and in just over a week, more than 500 people showed up with prescriptions for the infusions, county officials said. There are nearly 1,400 people in San Antonio-area hospitals with COVID-19, just under the peak the county saw in January.

Bexar County Judge Nelson Wolff said daily new hospitalization admissions have been holding fairly steady in recent days, instead of climbing exponentially as they have been for the past month, and he says it's likely that the antibody infusions are contributing to that.

"It is a significant tool," Wolff said. "What it does is it helps keep people out of the hospital, so I think we're beginning to see some effect of that."

At Titus Regional in Mount Pleasant, Dr. Fritz Thurmond believes the same.

Thurmond oversees all COVID-19-related operations at the hospital, which for weeks has been teetering on the edge of its capacity in a county that's only 28% vaccinated. The number of daily antibody infusions has more than tripled what they were administering earlier in the year, officials there said. The hospital has done about 160 in the past three weeks.

The therapy's "remarkable" efficacy at keeping people with COVID symptoms from becoming seriously ill is likely helping the hospital avoid a critical tipping point, Thurmond said.

"It's kept people out of the hospital, and you know that real estate, especially now, is almost unavailable anywhere," Thurmond said.

Hardman, the Mount Pleasant patient, experienced symptoms for just a few days before she had a fever over 101 degrees, body aches and other flu symptoms. Within a few hours of the treatment, on Thursday evening, her fever was gone. By Friday, she said she felt "almost normal."

"It feels like a miracle," she said. "I'm so very grateful. I've told all of my friends, retirees, if you get COVID, go do this."

Now that the therapy is much more mainstream than it was six months ago, the idea that only the exceptionally needy or the extremely influential can get it isn't true anymore, Thurmond said.

"The reality is that the rest of us can get it, too," he said.

Disclosure: The University of Texas at Austin has been a financial supporter 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.

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US Supreme Court refuses to hear Ken Paxton’s challenge to California law banning state-funded travel to Texas

The U.S. Supreme Court on Monday rejected an attempt by Texas Attorney General Ken Paxton to challenge a California ban on state-funded travel to states with discriminatory laws — a list Texas landed on in 2017 after the Legislature approved a religious-refusal law for adoptions in the state.

The move comes as the Texas Legislature grapples with a slate of anti-LGBTQ bills that business leaders warn could be harmful to Texans and a threat to the state's economy, which is still reeling from the recession that accompanied the coronavirus pandemic.

On Monday, the court, charged with hearing disputes between states, declined to hear Paxton's challenge, filed early last year. The ban prevents California agencies, public universities and boards from funding work-related trips to Texas.

There was no reason given for the denial of Paxton's request, but Justices Clarence Thomas and Samuel Alito dissented. Both were appointed by then President George H.W. Bush, the first Houston Republican elected to Congress. Paxton couldn't be immediately reached for comment late Monday.

In June 2017, shortly after the Texas Legislature moved to allow foster care agencies to use religious reasons to deny same-sex couples the right to foster children, California Attorney General Xavier Becerra blasted the law that he said "allows foster care agencies to discriminate against children in foster care and potentially disqualify LGBT families from the state's foster and adoption system."

The law was authored by state Rep. James Frank, a Wichita Falls Republican who now chairs the House Human Services Committee, and allows faith-based organizations to deny services for certain contraceptives and refuse to contract with organizations that don't share their religious beliefs. It requires providers to refer parents or children to a different agency if they refuse to provide services themselves.

Paxton, who has made religious liberty a top priority of his office, at the time criticized the California statute as an unconstitutional and misguided attempt to police other states.

"California is attempting to punish Texans for respecting the right of conscience for foster care and adoption providers," he said.

But if the move by the Golden State was meant to curb Texas' appetite for anti-LGBTQ legislation, it has not had the intended effect.

Last fall, under recommendations from Republican Gov. Greg Abbott, a state board that oversees behavioral health workers stripped three categories from the code of conduct establishing when a social worker may refuse service to someone: On the basis of disability, sexual orientation or gender identity.

Abbott said at the time that those protections went beyond state law, but the move set off such a firestorm of criticism that the board reinstated the protections two weeks later.

Then last week, members of the business group Texas Competes — composed of more than 1,450 Texas employers, business and tourism groups and backed by big tech companies like Houston-based Hewlett Packard — listed 26 proposals winding through the Texas Legislature that they say will infringe on LGBTQ Texans' rights, "tarnish Texas's welcoming brand" and scare away tourism and business.

They include restrictions on access to gender confirmation health care for transgender children, which is awaiting a debate in the Texas Senate. A bill already passed by that chamber would prevent public school students from participating in sports teams unless their sex assigned at birth aligns with the team's designation.

While that bill would only affect students in K-12 schools, two similar bills in the House would include colleges and universities in that mandate. Last week, the chair of the House committee assigned the Senate's sports bill told the Houston Chronicle that the lower chamber's companion legislation likely doesn't have enough support to leave committee.

The Texas Senate passed the bill on transgender athletes shortly after the NCAA announced that they would only hold national championships in states where transgender student-athletes are allowed to participate.

If Texas lands on that list as well, the state could lose out on as much as $1 billion dollars of economic impact if the NCAA canceled its events currently slated to take place in Texas — such as the 2024 College Football Playoff National Championship game set for Houston and the 2023 Women's Final Four in Dallas, said Lisa Hermes, CEO of the Chamber of Commerce in McKinney, north of Dallas.

Among the states California has targeted with its travel ban is North Carolina, after the state enacted a law requiring state agencies to maintain separate-sex bathrooms and changing facilities.

Texas Lt. Gov. Dan Patrick has championed similar legislation in the past, even making the so-called "bathroom bill" a legislative priority in 2017, but it did not pass.

'An emergency on top of a pandemic': Texas hospital workers scramble as winter storm hampers operations

Icy roads kept a pregnant Texas woman from reaching the nearest birthing center early Monday, so, the medical director of the tiny Bayside Community Hospital in rural East Texas delivered her baby in the emergency room.

Hours later, the water shut down.

For the next three days, staffers at three Chambers Health facilities in Anahuac, outside Houston, pumped water from wellness pools, refilled a 275-gallon storage tank three times and carted drums of water between facilities so toilets could be flushed.

Burst pipes and frozen pumps throughout the community were reportedly the issue, said William Kiefer, CEO of Chambers Health.

"If we didn't have our resources and our people being really clever on how to go about pulling water out of our pool and refilling that [storage tank], we would have been without," he said. "The city and the county were struggling with their own things. …. As far as help, I don't think there was really anything they could have done."

Hospitals across Texas struggled through water outages and food supply disruption in the wake of this week's historic and debilitating winter storm.

Patient logjams, overflowing emergency rooms and hospital beds, exhausted workers, staffing shortages and power outages added to the challenging conditions, hospital officials said.

"To see this type of crisis on top of what we've dealt with, with the pandemic, and to see how our staff have responded, is one of the most awe-inspiring things that I've worked with over the course of my career," said Doug Lawson, CEO of CHI St. Luke's Health in Houston.

The Crosbyton Clinic Hospital east of Lubbock took in residents from a nearby nursing home after that facility's roof partially collapsed, according to the Texas Organization of Rural and Community Hospitals, which was monitoring rural hospitals during the week.

In Brady, east of San Angelo, the icy conditions delayed the delivery of clinical supplies and food to the Heart of Texas Healthcare System Hospital, causing hospital staff to turn to local retailers.

At Olney Hamilton Hospital in North Texas, staff spent the night at the hospital to avoid being stranded at home unable to get to work.

"The rural hospitals across Texas have faced similar challenges to urban hospitals with power outages, water stoppages, reduced or no food deliveries, but they are making it work," said TORCH spokesperson Don McBeath. "Rural areas know they are often on their own, at least for a while, and this is no different."

At Houston Methodist Hospital, officials faced potential problems when patients were being discharged but had nowhere to go. Officials set up areas for patients to wait comfortably until they were transported home or to hotels if the power and water was out at their homes, said Roberta Schwartz, executive vice president at the hospital.

"It is very hard to have people discharged when you're sending them home to a house without power," she said. "You can imagine people's reluctance to leave where they are."

Those who had livable conditions to return to were not always able to leave in the snow and ice. That made discharging patients "one of our biggest challenges" during the storm, David Huffstutler, president and CEO of St. David's HealthCare in the Austin area, said in a Thursday emailed statement.

The lack of services such as outpatient clinics, pharmacies, physicians' offices, urgent care and dialysis centers also increased the pressure on hospitals, Schwartz said.

"They were closed due to lack of water or power, so everyone who needed services from those places came to the hospital," she said. "So our emergency room saw record numbers. It was astounding."

Hospitals canceled elective surgeries, waited days on delayed medication shipments and are having to seek oxygen tanks from outside sources to meet a critical oxygen supply issue, said Carrie Williams, spokesperson for the Texas Hospital Association.

While some issues like deliveries, water pressure and power problems are starting to ease up for some, most in the affected areas are still experiencing challenges, she said.

"For Texas hospitals, this is an emergency on top of a pandemic," Williams said. "They have been on the front lines now with broken pipes, dwindling supplies and water restrictions. There is unimaginable pressure on everyone, patients and staff and families. They see and feel the desperation, and hospitals are doing whatever they can to be there for people."

Water woes

Prolonged freezing temperatures led to several problems with water pressure and water supply for millions of Texas homes, businesses and hospitals. That can severely impact hospitals' ability to perform basic functions, even beyond flushing the toilets.

Several facilities across the state had seen water issues starting on Monday as local systems froze or electricity problems knocked them offline. But the pressures intensified as residents' pipes burst, pumping stations froze, boil notices went out and local officials warned residents to stop dripping their faucets to conserve water.

"Water is key to our ability to power the hospitals," said Lawson, the St. Luke's CEO in Houston. "It is key to our ability to keep air flowing through our systems and to cool many of our medical devices. So when water is lost or we're not able to access a steady supply of water, services in the hospital can be impacted."

Hospitals in both urban and rural areas reported having tankers bring water in to bring up supply and energize water pressure.

At St. David's South Austin Medical Center, officials transferred 30 patients on Wednesday to other facilities "out of caution" after citywide water issues caused three facilities in the area to lose water pressure, Huffstutler said.

At the South Austin facility, the facility's heating system, like many hospitals, uses boilers and experienced problems when the pressure dropped, Huffstutler said.

"We were able to get a water truck in to alleviate the issues on the heating system," he said. "With the water truck and the recirculation of water in the chillers, we were able to create a closed-loop system in the hospital to keep it warm."

Similar issues were reported at some Arlington and Dallas hospitals as well.

At Houston Methodist West in Houston, staffers collected rainwater in big gray laundry carts on Tuesday and used it to fill buckets for toilet flushing when the water pressure dropped, Schwartz said.

The Dimmit Regional Hospital, a 48-bed facility in Carrizo Springs in South Texas, had no running water in the hospital and was using bottled water for drinking, McBeath said.

In South Texas, water problems temporarily shut down laboratory operations at the Uvalde Memorial Hospital after electricity problems in the city shut down the local water pumps. Pool water was being used to flush toilets at the Refugio County Memorial Hospital, McBeath said.

At CHI St. Luke's Health - The Vintage Hospital in Houston, officials were just hours from shutting down the hospital altogether on Wednesday afternoon until water tankers arrived, Lawson said.

"I've only had about three points in my career that we've had to actually access tankers of water to ensure that a hospital's systems remained operational," Lawson said. "That was one of those days."

Disclosure: Texas Hospital Association has been a financial supporter 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.