Testing shortages hamper coronavirus response in Big Bend and beyond

“I would say I’m 60 to 70 percent confident that I have coronavirus,” said one Alpine resident.

ALPINE — Denis Foley suspects he might have coronavirus. Earlier this month, the 64-year-old Alpine resident and his wife returned from a family trip to Colorado, which has seen community spread of the virus.

“I would say I’m 60 to 70 percent confident that I have coronavirus,” said Foley, a self-described science nerd. He says he’s had the trademark symptoms, a high fever and a dry cough.

When the Foleys returned to Alpine on March 15, local health officials at Big Bend Regional Medical Center were already advising anyone coming from Colorado or other coronavirus hotspots in the United States to self-quarantine. As a precaution, the Foleys did just that.

And then Denis’s symptoms started, and the couple decided to call their healthcare provider. Their doctor told them to keep self-quarantining — not to come in for a test.

Foley, for what it’s worth, didn’t really want to be tested. “My preference, just personally, is to stay away from the medical-industrial complex if at all possible,” he said. But as a statistics enthusiast, he was still surprised that local doctors weren’t more curious to learn his results.

“If they asked me to come get tested, I probably would have, just out of statistical curiosity,” he said. And without more widespread testing in Texas and the tri-county region, he worries “we’re not really going to understand what’s happening accurately.”

As coronavirus spreads across the United States, causing deaths from New York to Houston, the Big Bend region and Texas have so far been spared the worst. But here, just like in the rest of the country, a lack of available tests is already hampering response efforts.

While President Donald Trump has promised that anyone who wants a coronavirus test can get one, health workers in the Big Bend and beyond admit they’re having to choose who gets tested. And stories like that of the Foleys — of people who think they have the virus but can’t confirm it — are already trickling out.

Without a better grasp on coronavirus cases nationwide, health officials at the state and federal levels have imposed sweeping rules on everyone, from shuttering bars to encouraging people to practice social distancing. But advice like that might only help so much.

Figures from countries with more robust testing, like South Korea and Iceland, show that up to 50 percent of coronavirus patients don’t have symptoms but can nonetheless spread the disease. Meanwhile, countries that, at least at first, focused testing efforts on severe or symptomatic patients — like Italy — have since seen their cases balloon and their medical system overwhelmed.

The Trump administration has promised for weeks to ramp up coronavirus testing. But in the meantime, doctors in the Big Bend region have to make tough choices about who gets one.

John Ray, a doctor at Preventive Care Health Services, which runs medical clinics in Presidio and Brewster counties, was blunt about the reality of who’s getting tested. The clinic, he says, is saving tests for “people who are basically sick enough to be hospitalized.”

“It’s not really an ideal situation,” he said.  “We’re just trying to be careful with what test kits we have.”

To qualify for a coronavirus test, Texas residents typically must first get a referral from their primary care physician. When a patient calls Preventive Care Health Services, the clinic goes through a screening process with them. The clinic then decides on a case-by-case basis who should get testing, Ray said.

At a Presidio City Council meeting earlier this month, representatives for Preventative Care Health Services said they had five tests at each of their three clinics for a total of 15 tests in Presidio, Marfa and Alpine. Doctors can take swabs from patients and then send them to a number of labs for testing, including at least two private labs (which sometimes send back a refill of tests) or a state-run lab (which doesn’t).

Ray estimates they’ve run “a handful” of tests but couldn’t provide detailed figures on how many tests have been run at PCHS or across the region. “I’m not sure there’s a clearinghouse for that information,” he said.

Asked  about its protocol for determining who gets a coronavirus test, the Big Bend Regional Medical Center said it was evaluating patients on a case-by-case basis and following testing guidelines set by the Centers for Disease Control and Prevention. The CDC has recommended limiting tests to certain cases, including health-care workers and hospitalized patients with coronavirus symptoms, though the health agency now also encourages clinicians to “use their judgement.”

In an interview last week, Ruth Hucke, a spokesperson for the hospital, said BBRMC was first testing people with symptoms for the flu and then testing them for coronavirus if the tests came back negative.

In a follow-up teleconference with reporters, Ekta Escovar, a doctor at the health center, acknowledged that “clinicians would like to have more testing capabilities.” But she said the hospital’s practice of first testing people for the flu was backed by science, which showed that less than two percent of coronavirus patients worldwide had co-infection with another illness like the flu.

So far, though, BBRMC has declined to release general information on how many tests it’s run. They’ve cited privacy rules in HIPAA, the Health Insurance Portability and Accountability Act.

“We’re ensuring that we are following HIPAA and patient privacy laws,” Escovar said at the teleconference when asked about local testing figures.

The hospital says its small patient base makes it difficult or impossible to release testing figures without violating patient privacy. And there is some truth to that, said Rolf Lowe, a healthcare privacy lawyer.

Though BBRMC could theoretically release testing figures without violating privacy, it would put them in a gray area, he said. “The hospital is going to rely on HIPAA day-in and day-out until they get a court order making them release that information,” he said.

Lowe gave an example. A man gets bitten by a shark — a rare occurrence — and his name and photo make it into the local paper. The local hospital can’t talk about how it treats shark-bite victims, because one man was already publicly identified as a shark-bite victim.

One exception, Lowe said, would be if the hospital asked for patients’ consent to disclose their coronavirus testing status. But “they’re not asking for consent,” he said. “I can tell you that right now. Health providers haven’t wanted to do that.”

Like much of the country, Texas is now releasing its own regular updates on coronavirus statistics. Thanks to figures published daily by the Texas Department of State Health Services, The Big Bend Sentinel can report that, at press time on Wednesday, 13,235 people Texans have been tested for coronavirus, while 974 people are confirmed to have it and 12 have died.

So far, though, Texas officials have been reticent to release information on where people have been tested. In a state as sprawing as Texas, that’s made it tricky for residents to know how much of a risk they face in their area. And these state-released numbers lag behind case tracking done by Johns Hopkins University, which was the site BBRMC CEO Rick Flores recommended to county commissioners and the press earlier this month.

Take the tri-county as an example. State and local officials have for days stressed that there are still no known cases of coronavirus in Presidio, Brewster or Jeff Davis counties. But without more information on how many tests have been done locally, it’s hard to know what to make of that number. Is that no coronavirus cases out of hundreds of tests run? Or no cases out of just a few?

Governor Greg Abbott initially told local officials on March 12 that there was “plenty of COVID-19 testing capacity,” that testing supplies were “very adequate” and that the supply “far exceeds” the demand. John Hellerstedt, commissioner of the Texas Department of Health Services, likewise told Texans that the testing process was “pretty efficient.” But as Texas struggles to ramp up testing, those projections seem overly optimistic. In a letter to President Donald Trump on Monday, Abbott said Texas was running low on supplies and stressed that “the resources of the federal government are needed.”

In the meantime, local officials are relying on more low-tech measures, like shutting down events and encouraging people to stay in. “Ideally, we’d like to test every person who has symptoms,” said Dr. Ray. “It’s just not physically feasible to do that.”

Still, as long as Big Bend residents stay inside and take other precautions to “flatten the curve” of new infections, he’s optimistic the region can prepare for the worst. And for anyone with minor symptoms who wonders about their coronavirus status, he proposed a kind of ad-hoc test.

“If you have a fever and a cough and you just got back from Seattle,” he said, “You probably have coronavirus.”

That was more or less what the Foleys heard from their doctor. “The advice was to assume you have it,” said Denis’s wife, Rozolen Stanford.

The couple is now about halfway through their self-quarantine and still aren’t certain whether they have coronavirus. They may never be. Denis says his symptoms are abating, but Stanford disputes this.

For the Foleys, the lack of testing has left them wondering about their own health. “We have four grandchildren in Colorado,” Stanford said. “We always expect to come home sick.” But as coronavirus spreads, the couple can no longer assume their symptoms are just from a common cold. A few days ago, Rozolen came down with a fever too.