Rural Texas Counties May Have Fewer COVID-19 Cases But Less Tests

For many of the North Texas counties permitted to reopen at double the capacity, fewer cases have been coupled with far less testing

A hospital staff member holds a coronavirus testing swab during the COVID-19 pandemic on May 4, 2020.
Photo by David L. Ryan/The Boston Globe via Getty Images

When Archer County Judge Randy Jackson got the call about two weeks ago from the state offering a pop-up mobile testing site, he turned it down.

As metro areas across Texas report hundreds of new cases of the novel coronavirus daily, Archer County just received its first confirmed case two weeks ago. With a population of roughly 8,500 near the Texas-Oklahoma border, the county has developed its own system, screening residents for symptoms, and sending them north to Wichita Falls or south to Olney to be tested, Jackson said.

"We're spread out more and we don't have the industry like bigger urban areas do, so we kind of had to initiate our own protocol," Jackson told the Fort Worth Star-Telegram. "We're taking care of ourselves."

Archer County is one of more than 100 Texas counties that have five or fewer active COVID-19 cases and have been approved by the Texas Department of State Health Services to reopen their businesses at 50% capacity as a result —while the remaining counties are restricted to 25% capacity.

The greater capacity was a facet of Gov. Greg Abbott's phased approach to reopening Texas businesses he announced last month. There is criteria in place to bring that increased capacity down to 25% if a county surpasses certain thresholds, including more than three positive cases per 1,000 residents. But for many of the North Texas counties permitted to reopen at double the capacity, fewer cases have been coupled with far less testing.

Their populations are a small fraction of Tarrant County's more than 2 million residents -- with some surrounding counties with as few as 9,000 people. But state data shows many have conducted far fewer tests per capita than some of the region's more populous counties.

And Archer County wasn't the only one to decline the state's offer of a mobile test site that could have boosted their testing capabilities -- if only for a day. Seth Christensen, a spokesman for the Texas Division of Emergency Management, confirmed in an email that the counties of Jack and Montague have also "chosen to use local assets and testing capabilities to complete testing in their county." Jack and Montague's county judges did not respond to requests for comment.

Public health experts have warned that sufficient testing is a key component to understanding the level of spread in a community -- and that without it, the virus may be spreading undetected.

Chris Van Deusen, a spokesman for the Department of State Health Services, wrote in an email that data on hospitalizations and deaths has shown otherwise.

"There has generally been less COVID-19 in rural areas where people tend to have fewer interactions, and there hasn't been evidence through hospitalizations and deaths of widespread, undetected disease," Van Deusen wrote. "We encourage everyone who thinks they may have COVID-19 to be tested whether it's through doctor's offices, clinics, hospitals or public sites like the state mobile testing sites."

As of May 15, Archer County had conducted 31 tests, according to state data -- or about 3.6 tests per 1,000 residents.

Earlier this month, before the county had seen a confirmed case, Jackson was hopeful that the virus had skipped over his county. At the time, he knew it might be overly optimistic, but he's seen good compliance from residents, and churches and businesses abiding by social distancing guidelines if they do choose to reopen.

"I won't be surprised if we have one, but I'm kind of hoping that we stay clean throughout the deal," Jackson had said.

That changed when the county saw its first confirmed case, according to DSHS data. Catherine Troisi, an infectious disease epidemiologist at the UTHealth School of Public Health in Houston, said it would be surprising if a rural county escaped the virus' spread.

"They're just going to get it later than the big cities, the urban areas," Troisi said. "And again, without testing, you don't have a complete picture of what's going on."

In an effort to bolster testing across Texas, mobile test sites have been sent throughout the state in collaboration with the Department of State Health Services, the Division of Emergency Management and the Texas Military Department. Staffed with Texas National Guard members, the sites are available to any local official who requests one. So far, they had tested over 30,000 people in 210 counties, Christensen wrote.

If the site had been offered in the early days of the outbreak, Jackson said he might have considered it. But in his view, what Archer County has been doing is working.

"I did not want the National Guard to come in and 10 to 15 health care personnel, fully decked out in [personal protective equipment] to scare everyone and make them panic," Jackson said. "And also, I didn't want sick people from other counties coming in. So I respectfully declined that offer."

Meanwhile, to the east, Clay County Judge Mike Campbell accepted a mobile testing site when it was offered. Like many of North Texas' rural counties, social distancing comes naturally to Clay County, where about 11,000 people are spread out across roughly 1,100 square miles.

"We knew going into this that while we're not as vulnerable, we're certainly not immune," Campbell said. "For us, we felt like it's better to know than be fat, dumb and happy."

Clay County has seen three confirmed cases, and all have recovered. According to DSHS data, 91 tests have been conducted, resulting in nearly 8.7 tests per 1,000 residents -- although Campbell reported only 38 have been tested through Clay County's hospital.

State data may differ from local figures, as the state includes all testing, regardless of where the test was done, Van Deusen wrote.

Campbell received the results from the mobile testing site and said that all 13 tests came back negative. And while residents can get tested locally, Campbell felt it was important to offer the mobile site as a free option to residents.

Public health experts and virologists have cautioned that easing restrictions and reopening businesses is likely contribute to an increase in the virus' spread. And John Gibson, the assistant dean of medical education at the Texas College of Osteopathic Medicine at the University of North Texas' Health Science Center, said that even for rural counties testing needs to increase.

"We've got to be able to test several hundred people in a day and maybe have that going on several days a week," said Gibson, who specializes in rural health care.

Archer and Clay counties border Wichita County, which had 78 confirmed cases as of May 14. But it's also tested more, with 3,177 tests, or about 24 tests per 1,000 residents, according to county data. Wichita County Judge Woodrow "Woody" Gossom Jr. said increased testing opportunities also need to be coupled with easy access for residents -- which can be a hurdle in rural counties.

"You still got to get the people to go do it," Gossom Jr. said. "What people don't know, they fear and so they assume it's not being done safely."

Rural counties often rely on each other for resources -- especially for health care. If a Clay County resident's condition was bad enough to need a ventilator, they would need to go one county over to Wichita County to be treated, Campbell said. And residents have often been tested in counties outside of where they reside, sometimes causing delays in results being reported back to local officials.

In those instances, patients awaiting results should continue to isolate themselves to ensure they don't possibly spread the virus if they're infected, Van Deusen said.

"If anything good can come from this, maybe it's a realization of how critical and how fragile rural hospitals are," Campbell said.

While many counties surrounding Tarrant County have received the approval to reopen at 50% capacity, not all business owners are immediately taking advantage of the opportunity.

Jeralyn Parkey, the owner of Bull Malarkey's Smokehouse in Henrietta, said she and her husband have been operating with a skeleton crew of six employees. Despite the relaxed restrictions, they have only allowed curbside, delivery and dining on the outdoor patio.

They've started to develop plans for a reservation-only system to allow dining-in soon. But they're waiting until it's safe for all customers -- from the young to the elderly who are higher-risk -- and for themselves.

"My husband is the cook, and so it's not that we are afraid of the virus. We feel like we're healthy people. But also if he was to get sick or if I was to get sick, that completely jeopardizes our whole restaurant and our income," Parkey said. "Once you open your doors up, you're still putting yourself at risk for sure."

County judges across North Texas said mandates are subject to change at a moment's notice if they see a spike in cases.

Residents' common sense and personal responsibility toward their community is something rural officials have come to rely on as churches resume services and businesses reopen. In Clay County, Campbell said there's not enough deputies to enforce restrictions if residents across the county began to violate them.

"Life has risks, and we have to take those risks from time to time," Campbell said. "You're just depending on everybody staying in their lane and doing what they're supposed to do."

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