Dr. Carrie de Moor has a nasty cough, and she's not sure if it's allergies or one of the common respiratory infections that have been spreading since Hurricane Harvey hit southeast Texas late last month.
She's been sleeping in a trailer adjacent to her free-standing emergency room and urgent care clinic in Rockport, Texas, which was devastated by Harvey's winds and flood waters. The clinic had only been open for two weeks when Harvey hit.
De Moor is home in Dallas now for a few days with her children but will soon head back to the clinic, which is overwhelmed by people crowding in for stitches, tetanus shots, ear infections and skin rashes.
"We were seeing numbers outpacing anything we were prepared to take care of," said de Moor, an ER physician who is CEO of Code 3 ER and Urgent Care.
Physician volunteers have been cramming into the trailer and sleeping on the clinic floors as they tend to as many as 90 patients a day.
Lara Hamilton describes a similar scene at Christ Clinic in Katy, west of Houston.
"We typically see about 200 patients a week. In the first week we saw triple that," said Hamilton, a registered nurse who is executive director for the clinic. Volunteer doctors from as far afield as Vermont, Minnesota and Oregon have brought cots and are camped out in the clinic and at other nearby facilities, offering their services as needed.
"They're showering at the YMCA," Hamilton said.
No one single entity has authority over health matters in Texas, which has a history of turning away federal funding and oversight and which has a limited Medicaid program. County health authorities like the one in Harris County take care of issues like mosquitoes, clean water, inspecting restaurants and some vaccinations, but free and charity clinics like Christ Clinic and for-profit operations like Code 3 struggle in the best of times to fill in the gaps.
Now, post-Harvey, they are overwhelmed.
Zika mosquito 'heaven'
So far, there's no big epidemic to cope with. The Harris County Health Department had to squelch rumors that plague was being spread by flood waters. Plague is carried by fleas, not in water.
But there are plenty of other messes left behind by Hurricane Harvey's floodwaters.
They include masses of mosquitoes, respiratory infections and a dramatic worsening of the day-to-day ills that people could cope with in normal times, but that get out of control in a crisis.
"We are seeing people who have just been eaten up by mosquito bites," Hamilton said. "Typically, people won't go to the doctor for mosquito bites." But the combination of standing water, a lack of electricity and the need to work outside means a lot of exposure.
"People are working outside all day long, cleaning up their homes," said Hamilton. "The doors are standing open because they are carrying debris in and out."
Aerial spraying for mosquitoes started this week, said Chris Van Deusen, spokesman for the Texas Department of State Health Services. They're bringing in heavy ordnance for the job, including an Air Force reserve wing from Youngstown, Ohio flying specially equipped C-130 aircraft.
Expected to get worse
"As the floodwaters recede, mosquito numbers are going to start going up," said Dr. Peter Hotez, dean for the National School of Tropical Medicine at Houston's Baylor College of Medicine.
"There's just debris everywhere. It's like Aedes aegypti heaven."
Aedes aegypti are the mosquitoes that carry viruses such as dengue and Zika virus. Stagnating water in ditches, bayous and flooded fields will breed other mosquitoes that spread West Nile virus.
No one's sure how much worse things will get, but Dr. Umair Shah, who heads the Harris County health department, is sure it will get bad.
He says teams are trying to replace mosquito traps pulled out hurriedly ahead of Harvey's floods. "It's good we removed them," he said. They would have been washed away, but now it will take time to get back up and running to monitor where disease-causing mosquitoes are breeding.
Patients are also beginning to come in with more urgent problems as they run out of insulin or blood pressure medications, said Jody Hopkins, CEO of the Texas Association of Charitable Clinics.
"For some of our clinics who supply insulin, a lot of them lost it because they lost refrigeration," Hopkins said.
And people are starting to show up with depression, anxiety and post-traumatic stress disorder.
"I think mental health is going to be huge," Hopkins said. "A patient came and said, 'I worked at Dollar General and the store is wiped out. I am out of a job.' That has a huge impact," she said.
Hamilton said Christ Clinic has already seen a big uptick in visits from people needing help from the licensed clinical social workers and psychologists helping out at the facility.
"Typically, a mental health provider will see eight to nine patients a day," she said. "We saw 32 mental health patients in one day this week."
Harris County's Shah said he was struck by the experience endured by an evacuee staying in a hotel. "Every time the air conditioning came on at the hotel, she heard the water dripping and she started having flashbacks to the rain and the rising water. That was true post-traumatic stress," Shah said.
It may sound trivial, but if a child loses a lovie, it can affect that child for years, Shah said.
"If you have a 5-year-old whose favorite toy has now been thrown out -- the conversation you have now, if done well, can promote mental health. If not done well, it can cause more psychological trauma," said Shah.
Authorities are cutting through red tape as quickly as they can. The state medical board is expediting licenses for out-of-state doctors to practice and schools have loosened immunization requirements.
"Last night a waiver came through for mold remediators," said the health department's Van Deusen.
As long as they register with the state health department, mold contractors can work without a license for as long as the disaster declaration is in effect.