In 50 Texas counties without cases, is it a lack of the coronavirus or a lack of testing?

When the daily email from state health officials lands in his inbox, Kimble County Judge Delbert Roberts skips straight to the K’s: Will today be the day, he wonders, that his community will join the majority of Texas counties by marking its first case of the coronavirus?

Even though he’s so far made it to the ‘L’ counties without a blip, he’s more resigned than relieved.

It’s “inevitable,” he said, that his 4,408-person county 120 miles northwest of San Antonio will join those with positive cases. “I would not bet a nickel that some of us haven’t had it and got over it.”

Roberts’ Kimble County is a member of a desirable crowd, its numbers dwindling every day: Texas’ zero-counties, 50 in number, the mostly small, rural communities that have yet to confirm a single case of the new coronavirus. They are remaining socially distant and cautiously optimistic, in many cases following the governor’s broad directives but going no further, hoping against hope their status doesn’t change but knowing it likely will.

Why have these communities been spared, even as the virus ravages cities as major as Houston and as remote as Clarendon?

One possible explanation: They haven’t. In rural communities, where there are few health care providers, testing is scarce, and the true picture may be obscured.

“Our confirmed case counts are a function of testing and not a function of the spread of the disease,” said Ben King, an epidemiologist at Dell Medical School. “I highly suspect that infections and particularly the asymptomatic and mild symptom cases just aren’t being captured.”

In pandemic times, being remote is a blessing and a curse. It’s easier, residents say, to keep the virus from jumping from person to person. It’s also harder to detect it when it does.

In his sparsely populated county, “we don’t bump into each other,” Roberts joked.

But “the distance also works against us,” said Brian Weis, the chief medical officer for the Northwest Texas Healthcare System hospital in Amarillo. Patients have to travel far for any kind of medical care. “There’s certainly a deficiency in testing all those small areas,” Weis said.

State officials are making policy decisions — last month, to delay issuing a statewide stay-at-home order, this month, to reopen the economy in stages — based on state data which still indicates that about a fifth of Texas counties have been untouched by virus. But that data may be missing cases in rural communities where testing is scarce.

“#noteveryplaceisthesame,” U.S. Sen. John Cornyn, a Republican, tweeted earlier this month, including a Texas map that showed more than 100 counties at zero cases. Three weeks later, that number has been cut in half.

In Foard County, two hours north of Abilene, residents would have had to travel 80 miles to Wichita Falls to get tested, said County Judge Mark Christopher. Neither he nor the state health department is aware of anyone in his 1,408-person county who has been tested.

Roberts offered a blunt explanation for his county.

“I’m not gonna drive 50 miles to Kerrville to be tested,” he said.

Several county judges acknowledged that there could be cases they simply didn’t know about. Others believed their communities remain healthy.

“We’re a small town — you’d hear,” Christopher said.

Many local leaders were baffled, pointing to spread-out populations or sheer luck.

Edwards County — about 70 miles each from Kerrville, Uvalde and Del Rio — has more square miles than people. “So we’ve been socially distancing for, oh, probably 150 years,” county Judge Souli Shanklin said.

“We’re probably not doing anything that any other county in Texas isn’t doing,” Roberts said. “We’re disproportionately fortunate or lucky. How about that?” He laughed.

“Divine grace,” offered up Garza County Judge Lee Norman. In his West Texas community of 6,288, a few residents have been tested but none has been positive for the coronavirus so far, he said.

“Could someone have had it and just doesn’t have the symptoms? I suppose so,” Norman said. But “if it’s prevalent in a community, you’re gonna see some severe cases” — and his town hasn’t.

Without confirmed cases, local leaders like Hall County Judge Ray Powell said they’re hard-pressed to issue strict regulations like those adopted in Austin and Houston — or to ensure compliance if they did. Powell, whose neighbor in the Panhandle has one of the highest infection rates in the state, said because his county lacks a clinic, he’s not even sure if anyone in his community has been tested. But he suspects his community isn’t virus-free.

“It’s just hard for me to believe,” Powell said. “Somebody, somewhere is carrying that virus. Surely, surely they are.”

Shanklin recently told a group who had reserved a county hall for a graduation party that he wouldn’t stop them from holding the celebration.

“Use your head on this. Be a grown up,” he told the organizers, though he also promised they would not be ticketed if they proceeded. The party was ultimately canceled.

An April study from researchers at the University of Texas at Austin suggested that even in counties that are reporting zero cases, there is a 9% chance of an undetected outbreak. With one detected case, that risk increases to 51%.

The true prevalence of the virus is often obscured by insufficient testing and the high proportion of individuals who experience mild infections or do not experience symptoms at all, the authors wrote.

“You won’t detect what you’re not looking for,” said Spencer Fox, one of the study’s authors. “If you’re a county that has reported zero cases, seeing our estimate of roughly 10% epidemic probability should be kind of alarming — it should be an indicator that you should be looking for cases if you’re not.”

According to the most recent data released by the Texas Department of State Health Services, more than 80 counties had had fewer than 10 residents tested as of April 13. The state concedes its tally is incomplete — in some counties, for example, the state indicates there have been cases and fatalities but no tests — but it shows that in counties with fewer tests, there tend to be fewer cases. In the majority of the counties reporting zero cases, state data shows fewer than 10 tests have been performed. In more than a dozen counties, the most recent state data reports that zero tests have been performed.

State officials have started ramping up testing in rural communities, an effort that may shrink the group of zero-case counties or perhaps eliminate it entirely. The Texas National Guard plans to deploy as many as 25 mobile units that will rove around “the rural areas of Texas that haven’t had the opportunity to be served,” Texas Division of Emergency Management spokesman Seth Christensen said.

One such unit was in Rocksprings, the seat of Edwards County, on Friday.

In the absence of widespread testing, county leaders have been left to wonder. In Hall County, rumors circulated for a while that two employees of a local gas station had contracted the virus — but no official data ever made its way to local leaders. In Edwards County, Shanklin recently quashed a theory that one woman had picked up the virus during a dialysis appointment.

In Foard County, folks are starting to think back to this winter, when they had a widespread bout of what most thought was a bad flu.

“Who knows?” Christopher said.

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