Texas enabled the worst carbon monoxide poisoning catastrophe in recent U.S. history

"Texas enabled the worst carbon monoxide poisoning catastrophe in recent U.S. history" 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.

Sign up for The Brief, our daily newsletter that keeps readers up to speed on the most essential Texas news.

This article is co-published with ProPublica, a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

It was also produced in partnership with NBC News.

Lee este artículo en español aquí.

HOUSTON — When Shalemu Bekele awoke on the morning of Feb. 15, the townhouse he shared with his wife and two children was so cold, his fingers felt numb.

After bundling up in extra layers, Bekele looked out a frosted window: A winter storm had swept across Texas, knocking out power to millions of homes, including his own, and blanketing Houston in a thin layer of icy snow.

“It was beautiful,” Bekele, 51, recalled thinking as he headed outside to snap photos of his two children, ages 7 and 8, playing in their first snow. After a few minutes, he sent them back inside to warm up under blankets as he cleared ice off his car, unsure if he would be expected to drive into work.

Bekele’s wife, Etenesh Mersha, 46, meanwhile, made a fateful decision, one repeated by scores of Texas residents who lost electricity that week. Desperate to warm up, she went into their attached garage and turned the key to start her car. As the engine hummed, it provided power to run the car’s heater and charge her phone while she talked to a friend in Colorado — at the same time, filling her garage and home with a poisonous gas.

There was no carbon monoxide alarm in place to warn the family of the invisible danger. None was required under local or state law.

When Bekele went back inside 30 minutes later, he found Mersha slumped over in the driver’s seat, poisoned by the fumes flowing from the car’s tailpipe. Confused, he shook her and called her name. Still on the line, the friend in Colorado pleaded over the car’s speakers for someone to explain what was happening.

Not knowing what else to do, Bekele, a devout Christian, ran and grabbed holy water from inside and splashed it on his wife’s face, as his children cried and shouted: “What’s wrong with Mama? What’s happening?”

That’s when Mersha vomited. Suddenly starting to feel ill himself, Bekele wondered if they’d all been sickened by the eggs he’d made for breakfast. Panicked, he sent the kids inside to grab towels to clean up their mother. Before they could return, both children collapsed onto the floor inside.

Bekele fainted next, landing with a thud on the garage’s concrete floor as the car continued to run.

After the power flicked off in millions of homes across Texas during the state’s historic freeze in mid-February, families like Bekele’s faced an impossible choice: risk hypothermia or improvise to keep warm. Many brought charcoal grills inside or ran cars in enclosed spaces, either unaware of the dangers or too cold to think rationally.

In their desperation, thousands of Texans unwittingly unleashed deadly gases into homes and apartments that, in many cases, were not equipped with potentially lifesaving carbon monoxide alarms, resulting in the country’s “biggest epidemic of CO poisoning in recent history,” according to Dr. Neil Hampson, a retired doctor who has spent more than 30 years researching carbon monoxide poisoning and prevention. Two other experts agreed.

In the aftermath of the unprecedented wave of poisonings two months ago, Texas lawmakers have taken few steps to protect residents from future carbon monoxide catastrophes. That choice caps more than a decade of ignored warnings and inaction that resulted in Texas being one of just six states with no statewide requirement for carbon monoxide alarms in homes, ProPublica, The Texas Tribune and NBC News found.

Instead, Texas has a confusing patchwork of local codes, with uneven protections for residents and limited enforcement, all of which most likely contributes to unnecessary deaths, health policy experts said.

At least 11 deaths have been confirmed and more than 1,400 people sought care at emergency rooms and urgent care clinics for carbon monoxide poisoning during the weeklong Texas outage, just 400 shy of the total for 2020. Children made up 42% of the cases. The totals don’t include residents who were poisoned but did not seek care or those who were treated at hospitals and urgent care clinics that do not voluntarily report data to the state.

Black, Hispanic and Asian Texans suffered a disproportionate share of the carbon monoxide poisonings, ProPublica, The Texas Tribune and NBC News found based on a review of statewide hospital data. Those groups accounted for 72% of the poisonings, far more than their 57% share of the state’s population.

Over the past two decades, the vast majority of states have implemented laws or regulations requiring carbon monoxide alarms in private residences, often on the heels of high-profile deaths or mass poisonings during storms.

But in Texas, where top lawmakers often promote personal responsibility over state mandates, efforts to pass similar carbon monoxide requirements have repeatedly failed.

Lawmakers introduced a slew of bills aimed at overhauling the state’s electric grid after the storm, which had its most devastating effects from Feb. 14-17. Temperatures plunged into the single digits, nearly 4.5 million Texas homes and businesses lost power at the peak of the storm, and more than 150 people died, many of them frozen in their homes.

Demands for change triggered a series of resignations but, with virtually all of the media and legislative focus on the regulatory failures that caused the power outage, little attention was paid to carbon monoxide alarms. The result was a significant missed opportunity to pass reforms after “an entirely preventable public health crisis,” said Emily Benfer, a visiting professor at Wake Forest University School of Law in North Carolina who specializes in housing health hazards.

Lawmakers this year are considering a broader modernization of state building codes that is unrelated to February’s storm. If the measure passes, it would require carbon monoxide alarms in some new homes and apartments, but not those built or renovated before 2022. And it would allow local governments to opt out.

“It’s completely shocking,” Benfer said. “In a single week we have concrete evidence of a state government’s willful disregard for the health and safety of the most vulnerable residents of the state.”

“Public health disaster”

Bekele and Mersha came to Houston from Ethiopia a decade ago with dreams of a better life for their family. For years, they lived in a small apartment and set aside their earnings as gas station clerks until they could afford to buy a home. In 2017, they purchased the three-bedroom townhouse in southwest Houston where they planned to watch their son, Beimnet, and daughter, Rakeb, grow up.

Looking back, Bekele doesn’t remember if anyone notified them that the home lacked carbon monoxide alarms. State law requires that information to be disclosed when single-family homes are sold, but there is no policy in Houston or across Texas that would have required the previous owners to install one.

“I’ve never been told about carbon monoxide before,” Bekele said, speaking through an interpreter in his native Amharic.

The first thing he remembers after passing out on the morning of Feb. 15 was waking up in the back of an ambulance. He thought he’d only been knocked out for a few minutes, oblivious that it was now after midnight. He and his family had spent more than 12 hours unconscious inside while the friend in Colorado, unaware of their address, frantically searched on social media for family members who could direct emergency responders to their home.

Bekele started to ask the paramedics what happened to his wife and children but blacked out before he could get the words out.

The ambulance driver navigated ice-covered roads to deliver Bekele to Memorial Hermann Hospital in the Texas Medical Center. The hospital was overrun with patients like Bekele. Medical staff were treating so many people for carbon monoxide poisoning that the department was running out of beds and oxygen tanks, said Dr. Samuel Prater, the medical director of the hospital’s emergency department.

“We’ve never seen anything like this,” Prater said later.

Each year, the Memorial Hermann Health System treats about 50 patients for carbon monoxide poisoning at its 20 emergency rooms in Houston and surrounding counties. But that Monday, staff at Prater’s ER alone treated more than 60. Across the Memorial Hermann system, one of the largest hospital chains in the Houston region, 224 patients sought care for carbon monoxide poisoning during the freeze and power outages — more than four times its annual volume of such patients, according to data provided by the hospital.

Prater worked quickly to get more oxygen tanks to the ER and to set up emergency triage protocols to prioritize the hospital’s limited hyperbaric chambers. The chambers, which deliver oxygen at high pressure to more quickly flush carbon monoxide from patients’ bloodstream, are a standard treatment for halting the damage done by serious cases of CO poisoning.

With the power still out in millions of Texas homes and temperatures dropping, Prater asked the heads of media affairs at Memorial Hermann and UTHealth’s McGovern Medical School, where he’s a professor, to reach out to news outlets to help warn residents about the dangers of carbon monoxide.

“In no uncertain terms, this is a public health disaster,” Prater said at a televised news conference a day later, urging people who’d lost power not to bring charcoal grills or portable generators inside. “Additionally, never run your vehicle inside your garage and then get inside that vehicle as an attempt to get warm.”

In an interview later, Prater explained what was at stake: Carbon monoxide is a colorless, odorless gas that, at high concentrations, can kill within minutes. In serious cases, those who survive may suffer from permanent brain damage and other long-term health problems, including memory loss, blindness and hearing damage.

Almost 80% of patients treated at Memorial Hermann facilities for carbon monoxide poisoning that week were Hispanic or Black, even though those groups account for 55% of the population in the greater Houston region. The majority of patients came from neighborhoods that the hospital identified as home to “vulnerable populations.”

Part of this disparity is a result of where the power outages occurred. Across the state, areas with a high share of residents of color were four times more likely to lose power compared with predominantly white areas, according to an analysis of satellite and U.S. census data released by the Electricity Growth and Use in Developing Economies Initiative, a nonprofit collaboration among five universities.

Once their power went out, families in lower-income communities generally faced greater challenges. Few had relatives they could stay with. Some didn’t have vehicles that could handle icy roads and others lacked awareness of local warming shelters. This left many trapped in freezing homes and at higher risk of carbon monoxide poisoning, said Melissa DuPont-Reyes, an assistant professor at Texas A&M who studies health disparities.

“They have no other option to stay warm,” she said. “They’re going to use whatever means possible, and unfortunately it’s toxic.”

Benfer, the Wake Forest professor, agreed: “The most marginalized communities are also marginalized from information, resources and a safety net they can fall back on in a time of crisis.”

More than 24 hours after passing out, Bekele finally regained consciousness inside one of Memorial Hermann’s hyperbaric chambers. He immediately asked about his wife and kids, he said. A nurse told him he was very sick and needed to rest.

But Bekele kept asking, he said, until finally a doctor sat down at his bedside. He cried when she delivered the news.

His son, Beimnet, was connected to a ventilator in the intensive care unit, the doctor told him.

His wife and daughter, the doctor said, had died before paramedics arrived, poisoned by a gas that until that moment Bekele had never heard of.

Pleading for help

As Bekele was recovering in the hospital, 911 calls continued flooding emergency operators across the state.

In Austin, the state’s capital, Franklin Peña felt increasingly powerless as he watched his 3-year-old son shiver from the brutal cold that engulfed his family’s apartment. On the evening of Feb. 16, after two days without electricity, Peña brought in a charcoal grill to burn wood for warmth.

“My desperation was such that I lost all fear or my head,” Peña said in Spanish during an interview. “The only thing I could think of doing was to bring the grill in.”

Just after 6 p.m., Peña’s wife and two children started to throw up. His own legs shaking, Peña dialed 911.

“Please help me,” he pleaded with the operator in Spanish, according to a recording obtained via a public information request. His wife wailed in the background as he told the 911 operator that his older son, 12, who has a developmental disability, had fainted. Because of their high metabolic rates, experts say, children can be more vulnerable to the effects of carbon monoxide.

“Is everyone out of danger?” the operator asked as Peña explained that they had fled their apartment and were outside in the cold. “They are breathing but they are not doing well,” he responded.

For 30 excruciating minutes, the 37-year-old Mexico native struggled to answer the operator’s questions as his wife and 12-year-old son drifted in and out of consciousness. “Please, sé fuerte mami,” he repeated between sobs, begging his wife to be strong.

An incident report later cited “extreme levels” of carbon monoxide in the family’s apartment, which Peña said had no CO alarms.

None were required.

Texas has given local governments the discretion to establish their own carbon monoxide rules. As a result, requirements vary widely, and no single agency tracks them across the state.

Fort Worth and Dallas require the devices in newly constructed homes and existing multifamily units, but not in most single-family homes. Houston requires them only in new or renovated homes, though it’s now considering a broader requirement that will include existing homes. Most rural communities have less oversight.

Even in cities with stricter regulations, many homes lack the devices.

In 2017, Austin voted to become the first major Texas city to require carbon monoxide alarms in new and existing residences with fuel-fired appliances or attached garages. The change was prompted, in part, by an incident years earlier that left two residents dead.

Peña’s home only had electric appliances, which excluded his apartment from the requirement.

When emergency responders finally arrived at Peña’s home, they rushed him, his wife and 12-year-old son to the hospital with carbon monoxide poisoning. The 3-year-old was given oxygen but not hospitalized. Peña, who works painting and remodeling houses, said all have since recovered but occasionally suffer from headaches and the trauma of what they lived through that night.

“Any time it gets cold, we become afraid,” he said. “If we see any kind of smoke coming out of the stove, we become afraid and everything that happened that day comes flooding right back.”

Emergency room data provided by the state does not reflect the number of residents by city or county who visited hospitals for carbon monoxide poisoning. But 911 call records obtained and analyzed by ProPublica, The Texas Tribune and NBC News show that, in Austin and surrounding Travis County, the majority of the 60 emergency calls for carbon monoxide exposure came from vulnerable neighborhoods, where residents earn two-thirds that of Travis County overall.

The vulnerabilities were more pronounced around Rundberg Lane in North Austin, where Peña lives. A third of the city’s carbon monoxide emergency calls came from the community, which has more than double the county’s proportion of immigrants and refugees. About 4 in 5 residents in the area are people of color and nearly 2 in 5 are not proficient in English, according to an analysis of 911 calls and U.S. census data by the news organizations.

Three miles from Peña’s home, Lucila Montoya’s family brought inside a gas-powered portable stove to cook lunch and a grill with burning charcoal to help keep their apartment warm, not realizing the white-hot coals still emit fumes even after the flames are down.

About an hour later, Montoya felt weak but thought it was her pregnancy. She was due in March. But then her daughter Tifany, 7, started crying and losing consciousness. Montoya grabbed the phone as her husband, José, threw the child on his back and took her outside in the freezing weather.

“My little girl got sick, she started throwing up and is not responding, please,” Montoya, a Honduras native, frantically told the 911 operator in Spanish through an interpreter. “I need you to come quickly. ... She’s barely breathing.”

The 28-year-old mother, who was hospitalized for a day along with her daughter, recalled Tifany saying she couldn’t breathe. “She felt like she was going to die,” said Montoya, whose home didn’t have a carbon monoxide alarm.

“We were so naïve — we almost ended her life and mine,” added Montoya, who has since given birth to a healthy girl. “As a mother, I don’t wish this upon anyone.”

Failed reform attempts

In the weeks and months after the outages, Texas lawmakers scrambled to introduce and pass bills aimed at overhauling the state’s electric grid, with the goal of preventing future disasters.

“When I see people who die of hypothermia, or carbon monoxide poisoning, when I see the disruption to the business community, the people who can’t get a hot meal, can’t get water ... this cannot stand,” Lt. Gov. Dan Patrick, a Republican who sets legislative priorities in the state Senate, declared in February.

But even as lawmakers demanded a wave of complex reforms, they did little to address one of the simplest changes: establishing a statewide requirement for carbon monoxide alarms in homes. The devices cost as little as $15 and health experts say they are critical to preventing carbon monoxide poisoning.

The state’s top three Republicans — Gov. Greg Abbott, House Speaker Dade Phelan and Patrick — did not respond to questions about why carbon monoxide safety wasn’t a legislative priority.

State Rep. Donna Howard, a Democrat from Austin and a member of the legislative committee where energy reforms were discussed, said carbon monoxide wasn’t on her radar. But Howard said the findings from ProPublica, The Texas Tribune and NBC News show that it should have been.

“Clearly we’ve had to have reminders throughout this discussion of the fact that people died,” she said. “We all know how tragic it is, but we get caught up in the politics of the policies and sometimes lose sight of that bottom line.”

Legislation seeking to create statewide regulations for carbon monoxide alarms has repeatedly failed to pass the Texas Legislature, even following major storms that led to a surge in CO poisonings and deaths. A bill filed in 2019 that would have required the devices in rental housing didn’t get a hearing.

Former state Sen. Leticia Van de Putte, a San Antonio Democrat, co-wrote a failed measure in 2007, a year after former state Sen. Frank Madla and his mother-in-law were killed in a house fire. His 5-year-old granddaughter, who was also in the home, died from carbon monoxide exposure.

The measure would have required smoke detectors and carbon monoxide alarms in newly constructed homes and older homes for sale if the residences had fuel-burning appliances.

But the bill did not advance despite the close connection many lawmakers had to Madla and supportive testimony from fire chiefs, an emergency room doctor and a poison control center representative.

Industry groups like the Texas Association of Builders at the time staunchly opposed it, criticizing carbon monoxide alarms as an “unproven technology” that would do more harm than good if required.

“We believe mandating this would create a false sense of security for homeowners and would open up liability for homebuilders should they fail,” Ned Muñoz, vice president of regulatory affairs and general counsel for the group, said during a 2007 House hearing. Muñoz also pointed out that the devices were not yet included in the international building codes that are widely adopted by state and local governments.

Van de Putte can’t shake the feeling that the state’s failure to pass a statewide carbon monoxide policy cost lives in February.

“We have so many things that protect the physical, the tangible, the property,” Van de Putte, a pharmacist, said about current regulations. “By not putting in carbon monoxide alarms, that’s what we’re valuing. We’re valuing property over life.”

Since the failure of the 2007 bill, carbon monoxide alarms have become more reliable and are now required by most state governments and recommended by leading health and safety organizations. The International Code Council first recommended them for many newly constructed and renovated single-family homes in 2009 and apartment complexes in 2012.

In light of the new standards, the Texas Association of Builders has changed its position, said Scott Norman, the group’s executive director. The group now supports requirements for carbon monoxide alarms in newly constructed and renovated residences, Norman said.

“Decades ago, there were questions about the reliability,” he said. “But the codes evolve.”

Fire safety advocates and public health experts say that a statewide requirement for carbon monoxide alarms would better protect residents and help drive home the message about the deadly hazard.

“You don’t know if you’re going to be exposed until it’s too late and you’re sick or dead from it,” said John Riddle, president of the Texas State Association of Fire Fighters, which represents first responders. “A statewide law or requirement would absolutely make things easier.”

In some states that have passed robust statewide rules, there’s been a significant reduction in poisonings, fire safety experts say.

“When the state comes in and requires it, there is continuity across the whole state — there is one message,” said Jim Smith, the state fire marshal in Minnesota, where emergency department visits for carbon monoxide poisoning fell by 45% — from 411 to 226 — in the seven years after the state passed a sweeping law requiring alarms in most private residences. “It is no different than a seat belt.”

In early April, the Texas House passed a bill that would require cities to adhere to more recent health and safety codes for newly constructed and renovated residences. Under the measure, which has not yet been approved by the state Senate, carbon monoxide alarms would be required in homes built after 2022 that have fuel-fired appliances or attached garages. The requirement wouldn’t apply to unincorporated areas unless counties chose to adopt the codes, and cities could opt out of the provision.

The legislation, as written, would not protect millions of Texans who live in already constructed homes and apartments.

Starting over

In Houston, Bekele was well enough to be discharged after a four-day hospital stay, but he did not go home. For days, he sat vigil at his son’s bedside, leaving only to shower at a family member’s house, while a machine pumped oxygen in and out of the boy’s lungs.

Bekele was there, at Beimnet’s side a few days later, to mark his ninth birthday.

Initially doctors told him that his son had “a very low probability to survive,” Bekele said. Even if he did, doctors warned that he’d likely suffer from permanent brain damage. Prolonged exposure to carbon monoxide had prevented oxygen from reaching his brain.

Day after day, Bekele held his son’s hand and begged God to spare his boy.

Then, nearly two weeks after being admitted, Beimnet regained consciousness. Within days, he was off life support and was up and walking around the hospital, slowly getting stronger until he was finally well enough to leave.

Two months later, Beimnet takes pills to prevent a relapse of seizures like the ones he suffered as a result of his carbon monoxide exposure, but he otherwise shows no signs so far of permanent damage.

“He is attending school now and is doing well,” said Bekele, who has since returned to work at the gas station.

This month, Bekele sued nearly a dozen companies that supply power to the state’s electric grid, one of dozens of lawsuits that seek to hold Texas companies accountable for serious injuries and deaths caused by the winter outages. The power companies have not yet filed a response to Bekele’s lawsuit in Harris County District Court but have denied responsibility for outage-related deaths in similar cases filed across Texas.

Bekele doesn’t know what will happen with the case, but he said no amount of money can make up for what he’s lost.

He still hasn’t had the strength to return to the place he and his family called home before his wife and daughter died. Hoping for a fresh start, he took money raised by loved ones on GoFundMe and put it toward the security deposit and rent for a nearby apartment. It’s smaller than their old townhouse, but enough space for just the two of them.

Not long after moving in, Bekele discovered a problem, one that he said he planned to fix as soon as possible: The apartment had no carbon monoxide alarms.

About the data: Statewide emergency room data is from Feb. 13-20 and came from the Texas Syndromic Surveillance system. Patients self-reported their race and ethnicity. A total of 11% of individuals who did not report their race or ethnicity were removed from the analysis. A separate analysis on patient ages removed less than 5% of individuals whose age was missing. Economic and demographic data is from the 2019 five-year American Community Survey and was analyzed at the census tract-level. Unless otherwise noted, areas with EMS calls were compared to the entire Austin-Travis County EMS service area.

Disclosure: Memorial Hermann Health System and Texas Association of Builders 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.

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2021/04/29/texas-carbon-monoxide-poisoning/.

The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.