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.

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