SACRAMENTO, Calif. - Pastor Dan Ostring promised parishioners that, as Christians began marking their holiest week on this Palm Sunday, the Rivers of Living Water Church would be open for the fellowship, song and sermon that they have always celebrated together.
He kept his public pledge, despite receiving hate mail all week warning that he would "burn in hell" if he opened the cross-covered doors of his tiny church. A few miles away, across the wide American River, a church more than 100 times larger than Ostring's was shuttered late last month after scores of parishioners and a senior pastor tested positive for the novel coronavirus.
Seven people, including Ostring, took their places in the five rows of pews, which made social distancing achievable almost by default. Communion was offered in individual cups. The sermon, delivered by parishioner Rafael Palma, did not mention the pandemic afflicting the nation. He focused instead on "Christ's death and resurrection" with Easter Sunday a week away.
"If we stop all churches for this, what will be the next crisis that shuts the churches?" said Ostring, 63, who acknowledged that if his church were larger he might not have held the public service Sunday. "We don't want anyone here to get sick. But we also do not want to violate our right to the free practice of religion."
For the religious, one of the crueler elements of the coronavirus and its potent contagiousness is that places where people go in times of fear, in search of solace in faith and in friends, are shuttered in many states to stop the spread of the disease. Churches, temples and other places of worship nationwide - where congregants sit close, take Communion, share hugs and handshakes and pecks on the cheek - have served as hothouses for the virus, with religious gatherings exacerbating outbreaks in New Rochelle, New York; Washington; Glenville, Illinois; and Sacramento, among others.
These open-or-close decisions, often made by politicians at the state and local levels of government, to some appear to place constitutional religious rights in conflict with the demands of public health at a time when more than 1,000 Americans are dying each day because of the virus. Services live-streamed on Facebook and drive-through worship have been used as workarounds from Florida to California.
The in-person gatherings in some cases go against many stay-home orders and bans on assemblies of more than 10 people, which President Donald Trump has endorsed. Eight states do not have such orders, but there have been arguments within the White House that a national regulation should be put in place as infections accelerate.
Here in California, where Gov. Gavin Newsom, a Democrat, announced a statewide stay-home order two weeks ago, more than 14,000 people are infected with the virus and 330 have died. The rate, in the northern parts of the state at least, is slowing. But the state lags in testing, so the numbers might be low estimates.
More than a dozen states exempt churches from their stay-home regulations, arguing that the government is exceeding its constitutional power to shut down a religious institution, regardless of the public health questions at stake. California does not, officials say.
Florida Gov. Ron DeSantis, a Republican who under pressure last week issued a statewide stay-home order, said he was exempting churches from his order, arguing that the government does not have the authority to effectively force them to close.
But some houses of worship, and gatherings of religious leaders, have proved particularly dangerous in areas where the virus has been prevalent.
Amid the outbreak here in Sacramento, Mayor Darrell Steinberg, a Democrat, made clear that disregard for the prohibition of church gatherings could prompt police intervention. Steinberg's wife serves as cantor at the city's largest synagogue, which now streams its services online.
"This is a time when people are coming to church for hope and meaning, and in that way faith has never been more important," said Steinberg, a member of Congregation B'nai Israel, one of the oldest west of the Mississippi. "I believe passionately in the free exercise of religion, but I must say I am outraged that anyone would use the free exercise of religion to justify gathering together at this time."
"To claim that the free exercise of religion is absolute and outweighs the obvious life-and-death risk of praying together right now," Steinberg continued, "well, it's blasphemy itself."
Sacramento police have been advised that in some cases it might be permissible to disperse a congregation. Steinberg said those acts would only happen when there is a "blatant disregard" for the prohibition.
"We're not going to use arresting people as the way to address this," the mayor said. "Social pressure is much more appropriate, and that social pressure includes making it clear that these are legal orders being defied."
The concern extends nationally, given the reach of the virus, from megacities to small towns.
In late February, six people who attended an Episcopal church conference at the Omni Hotel in downtown Louisville, Kentucky, tested positive for the coronavirus. North Carolina public health officials say "multiple cases" of the virus are linked to a March event held by Faith Assembly Christian Center at the Millennium Hotel Durham, despite a ban on gatherings of more than 100 people at the time.
Rural Minnesota has reported at least nine coronavirus cases traced to a church; and 43 fell ill, one fatally, after attending a March 15 service at The Life Church of Glenview, in Glenview, Illinois, a Chicago suburb. At least 10 members tested positive for the coronavirus. The service was held several days before the Illinois governor imposed a stay-home order.
There are other cases. But none has reached the scope of the tragedy at the Bethany Slavic Missionary Church, a 3,500-member congregation that occupies a fenced compound in southeastern Sacramento.
Public health officials say 71 congregants of the church, a major gathering place for the city's large Eastern European immigrant community, have been infected by the coronavirus. As of Saturday, that infection number accounts for 18% of Sacramento County's total cases. Ten people have died in the county.
The church is now closed, its high gates locked to outsiders and a police car parked outside the main sanctuary. Signs posed are in English and Russian, one in large print on the front door announcing: "No Any Services."
Among the sick is senior pastor Adam Bondaruk, who has been at the church for three decades. The church administrator, Viktor Lyulkin, said by phone that Bondaruk has been hospitalized and is in stable condition.
"We'll find a way to celebrate Palm Sunday and Easter as a community when this is all over," Lyulkin said. The church held one online service Sunday.
Houses of worship are susceptible as coronavirus hot spots for a simple reason: They bring people together, said Jennifer Nuzzo, an epidemiologist at Johns Hopkins University. A Centers for Disease Control and Prevention publication this past week noted that singing, which can disperse the respiratory droplets that carry the virus, is another aspect of the concern about places of worship.
The service at Rivers of Living Water Church includes performers using an electric guitar and drums, and Ostring plays the piano as the congregations sings. The service began Sunday with a brief prayer and a long hymn. No one wore a protective face mask.
"This is a tough situation because when people are under stress you don't want to remove their stress coping mechanisms," Nuzzo said.
On a quiet Palm Sunday in Jupiter, Florida, families trickled into one of the few churches in Palm Beach County that is still offering in-person services.
"We're offering hope," said Jill Barry, whose husband, Steve, is a pastor at Ascend Church. "We're keeping social distance, but we want to keep our doors open to people."
Roxroy Edmondson was literally keeping the door open - holding it so people wouldn't have to touch it to get inside the storefront church.
"I don't feel connected online," Edmonson said as he offered hand sanitizer to congregants who entered. "It feels so much better to me to have the message in person."
A poll released this week of Protestant pastors found that the number of churches holding services dropped from 99% on March 1 to 64% by March 15, and then to 7% by March 29, according to Lifeway Christian Resources. Lifeway is the publishing division of the Southern Baptist Convention.
Polls also have shown that those who lean conservative politically are more skeptical of the virus's seriousness and danger. Until early March, Trump falsely claimed the coronavirus cases were decreasing and said the disease would disappear "like a miracle."
Polls also show that those who attend church more frequently are much more likely to identify as or lean Republican. Forty-four percent of the GOP leaners go to religious services at least weekly, compared with 29% of Democrats.
Texas Gov. Greg Abbott, a Republican, declared last week that religious services are essential to the lives of Texans. Pastor Jason Sides used Facebook Live to tell his flock that he was determined to open Christian World Ministries in San Antonio.
Sides had held a prayer service on Wednesday, and 75 people came into the 1,000-person sanctuary for the first time in weeks.
"If church is as essential to you as a trip to the pharmacy or Walmart, the doors will be open," Sides said Wednesday. "We will be trusting God to take care of us."
But by the weekend, Sides had had second thoughts.
San Antonio city leaders pleaded with churches on Friday to use remote services. Sides said he struggled with the decision, keeping in mind the dozens of calls from members telling him their homes were not safe, their marriages were falling apart, their jobs lost.
"We hear a lot about the external, the import of washing hands and not touching the face," Sides said. "But what of the internal?"
The solution for Sides was another drive-in service, at which the pastor uses a public-address system to preach from atop the flatbed of an 18-wheeler.
Church member Tracy Williams said she would rather be in the church sanctuary but that there was something beautiful about sitting in the car, in the sunshine, lifting her hands out the window. When Sides spoke a word that resonated, the members honked their horns for an "Amen!"
"I know people may not understand, but for me, church is a big part of my life and as long as something is set up within the church and it's within the confines of the law, yes I am definitely going to go to church," said Williams, 56, of San Antonio. "People are feeling isolated, and there is strength in being in the house of God, hearing the word and gathering with like-minded believers."
The Rev. Tony Spell, pastor of the megachurch Life Tabernacle outside Baton Rouge, Louisiana, has been defying an emergency order by the governor banning gatherings of more than 50 people. Police on Tuesday issued a misdemeanor summons to Spell, who says that he had 1,000 people in his church Sunday and that he was planning to hold services again this Sunday.
"We feel we are being persecuted for our faith by being told to close our doors and not gather," he said. He noted that some stores are open, including clinics that perform abortions. "You're saying religion isn't essential, but Target is."
Palma, who preached at Rivers of Living Water in Sacramento on Sunday, said he is not afraid of the virus. "Not at all, not at all," the 43-year-old said. "I have my faith. I don't fear this and never have."
In a baseball cap declaring "God is in Control," Gary Works took his seat on a bench along the side of the Sacramento sanctuary, about the size of a large suburban living room. The other church he attends regularly, River Valley Baptist, closed for the day.
"But Pastor Dan is my mentor and this is where I want to be," Works said.
Works is a recovering methamphetamine addict who was at one time homeless; he has been sober for 18 years. During that time, he said, he has missed no more than five Sunday services at the church.
"I just don't miss church," said Works, 69. "This is a big part of my recovery, and I'm not going to abandon what has saved my life."
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Boorstein reported from Washington, Hernández from San Antonio, and Rozsa from Jupiter, Florida.
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Ed Singer's mobile phone rang at 2 a.m.
Pleasant View Nursing Home was running out of oxygen, a hospital official told Singer, the health officer of rural Carroll County, Maryland. Without 16 additional tanks, some of the most fragile coronavirus patients might not make it through the night.
The day before, 66 of the 95 residents of the nursing home in Mt. Airy, Maryland, had tested positive for covid-19. One, a man in his 90s, died in his bed. By morning, another resident would be gone.
The nursing home's medical director was nowhere to be found, according to two government officials, who said the doctor later explained he was self-quarantining because he believed he had been exposed to the virus. Nurses with limited supplies and little supervision were struggling to treat rapidly deteriorating patients. Singer had spent hours the previous day searching for backup, to no avail. A paramedic who responded to a 911 call found the halls eerily quiet, with staff members masked and not talking, and ragged coughing audible from behind closed doors.
The crisis at Pleasant View is an East Coast version of the tragedy at Life Care Center of Kirkland in Kirkland, Washington, where scores of elderly patients were sickened by covid-19, and 40 died. It foreshadows challenges other nursing homes face across the country and in the greater Washington area as the pandemic bears down. As of Friday, residents and staff at 60 Maryland nursing homes have tested positive for covid-19, Gov. Larry Hogan said. Health care workers are dangerously low on gloves, masks and other protective equipment. At one facility outside Richmond, 133 people have tested positive, and 17 have died.
In the predawn hours of last Sunday morning, Singer was able to secure 14 oxygen tanks from the Carroll County emergency medical services department. Just over 36 hours later, the Maryland National Guard arrived with doctors and supplies.
But the fast-spreading virus had already overwhelmed the nursing home's staff and filled nearby hospitals to capacity, according to interviews with 18 people directly involved in the crisis. By Friday, 99 residents and staff had tested positive. Forty-two people were hospitalized, and six were dead. Three more people would die the next day.
"I was screaming at my boss, saying I needed more resources," Singer said. "Maybe I should have screamed louder."
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Mt. Airy is a bedroom community of 10,000 residents that sits on the border of Carroll and Frederick counties, 45 miles north of Washington, D.C. Most days, said Mayor Pat Rockinberg, it looks like something out of a Hallmark movie - a quiet town, where the most pressing emergencies are water main breaks or roving cows blocking traffic.
The nursing home sits atop a hill, a family-owned facility that has operated for more than four decades. Residents live four to a room, and 83 percent have dementia, according to the Maryland Health Care Commission. The facility received a one-star rating for staffing from Medicare, which bases its rating on nurses per patient and offers from one to five stars.
When the mayor heard on March 27 that two Pleasant View residents had tested positive for coronavirus, he was concerned, but not alarmed. At the time, there were just nine cases in Carroll County.
"We thought we were doing fine," said Leslie Simmons, president of Carroll Hospital, who made the 2 a.m. phone call to Singer last Sunday. She has worked at the hospital for nearly 20 years and is the executive vice president of its parent company, LifeBridge Health. "One minute you are fine, and the next minute you are not."
Singer, a military veteran who has been the county's top public health official since 2015, visited Pleasant View after he was told about the first two cases. Donning a gown, mask and gloves, he toured the facility.
Generally, he was satisfied. Employees were being screened when they got to work to see if they had elevated temperatures or respiratory symptoms and wearing protective gear while working with all patients. Patients with symptoms were isolated. Few were visibly ill.
Things changed the next day, March 28.
Stephen Wantz, president of the Carroll County Board of Commissioners, said he felt his stomach churn when he heard the numbers: 64 new cases, meaning nearly two-thirds of the elderly residents were ill. In his 30 years as a firefighter in Baltimore, he had run toward burning buildings. But he said he never felt as much dread as he did at that moment.
Wantz and a second county official said no one could locate the nursing home's medical director, Nandakumar Vellanki, even as officials repeatedly attempted to call him. When they reached him, Wantz added, Vellanki told officials he had been self-quarantining because he was concerned he had been exposed to the infected patients.
In his absence, three nurses were in charge.
"The nurses were attempting to do as much as they could, but they were under no physician's directions," Wantz said. "From day one, there was no medical director."
Singer declined to discuss Vellanki, saying it was for the state health department to determine whether regulations were violated. Fran Phillips, Maryland's deputy secretary for public health, said the doctor's conduct is "definitely something to investigate, for another day."
When contacted by a reporter, Vellanki hung up the phone, saying he needed to see a patient. He could not be reached by a reporter after multiple attempts.
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Singer spent that Saturday in the county health department offices with his staff, calling potential medical volunteers listed in a state database, which has swelled by more than 5,000 names since the outbreak started. They made between 800 and 900 calls for help, Singer said, but few were willing to come, saying the situation appeared to be too dangerous.
Phillips said the state has since hired a network of health care workers - including nursing and medical students and EMTs licensed in other states - to bolster workers at hard-hit facilities like Pleasant View.
But those resources, intended to prepare for the surge officials say is coming, were not available when Pleasant View was grappling with its response.
"It was an unprecedented situation," Phillips said.
The county gave gowns, gloves, face shields and masks to the nursing home, and Carroll Hospital sent one of its own nurse practitioners last Saturday, along with oximeters to measure oxygen saturation in the blood, said Sharon McClernan, vice president for clinical integration at LifeBridge Health. She said the 12 intensive care beds in the hospital were filled by the end of the day.
Meanwhile, the state was struggling to set up a triage team, Singer said. With beds full at Carroll Hospital, patients were being sent elsewhere, and those hospitals were complaining about the influx of patients. Singer's staff members were on the verge of tears.
"We were drowning," said Wantz, the president of the board of commissioners. "Every single day, we said 'we need help, we need help, we need help.' "
Medic Ron Hewitt said he got a call last Saturday night that the nursing home had "essentially blown up." When he drove up the long driveway, he saw dozens of flashing lights from other ambulances. There was a stillness once he came through the door.
Hewitt and his partner were escorted into a room and told the name of their patient, whom they transported to Frederick Memorial Hospital. The masked nursing home aide who was assisting them started to cough at one point. Hewitt said he and the woman made eye contact.
"It's just a cough," she said.
Hewitt, who was wearing protective gear of his own, was not so sure.
"You could see the doubt in her eyes," he said. "Like, 'what am I in the middle of?' "
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Hogan announced the outbreak that Saturday night.
Tracy Shavell had her fears confirmed as she read the news reports. Her father, Gary Holmberg, had been taken from Pleasant View to Carroll Hospital the day before with a suspected case of pneumonia. When she asked staff at the nursing home if there were covid-19 cases at the facility, they told her only that there were no cases in Building A, where her father was living.
Holmberg, a 77-year-old former D.C. firefighter who had dementia, had moved into the facility in February, his daughter said. She lived nearby in Frederick and visited frequently, and sometimes thought there was not enough staff on the weekends.
In the hospital, Holmberg's condition quickly grew worse. By the time his son, Robert Holmberg, arrived from his home in St. Mary's County around 1 a.m. last Saturday, their father was gasping for air.
"It was the worst thing I've seen," Robert Holmberg said, his voice breaking.
Gary Holmberg died Sunday at 9:30 a.m. Shavell said staff at Pleasant View told her his covid-19 test came back negative, but the hospital said the cause of death was pneumonia and possible covid-19. The family is awaiting test results from the hospital and an autopsy. "He was not supposed to go this way," Shavell said.
The next morning, state health officials asked Singer whether the nursing home could wait until Tuesday for help. Singer said his answer was emphatic: No.
The Maryland National Guard arrived that night. Their doctors determined which patients needed to be immediately taken to hospitals, and the Maryland Institute for Emergency Medical Services Systems figured out transportation and routed them among 14 different hospitals. Meanwhile, officials said 11 more nursing home residents had tested positive - raising the tally to 77 out of the 95 people who lived there.
Hewitt's ambulance again was summoned, along with seven others from Butler Medical Transport.
The situation at the nursing home was wildly different than two nights earlier, Hewitt said. There were triage tags on patients noting who was sick and who needed to be hospitalized.
"It went from, 'we're really not sure what we're doing,' to complete organized chaos," he said. "You could tell the military went in there and did their thing."
On Tuesday, Carroll County family medicine physician Daniel Auckerman arrived. He was the only physician the health department could find who was willing to treat patients at the facility. Before going to Pleasant View, he sat down with his wife and children and discussed the risks and the ramifications, but also the potential for him to help vulnerable patients.
"We talked about that no one is willing to step up," he said. "Everyone seems to be running from this thing instead of confronting it."
Auckerman got to the nursing home at 7 a.m. and did not leave until after 8 p.m. He has been back every day since, writing medical orders and providing oxygen support for covid-19 patients who remain at the facility. He said those who remain there have either tested negative or are positive and have signed do not resuscitate orders.
When Auckerman is not at Pleasant View, he is at his home in Westminister, separate from his family to ensure that if he is infected with coronavirus, he does not spread it to them.
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The situation at Pleasant View has stabilized, Singer said. But some of the biggest questions are still unanswered - including how the virus entered the facility and spread so rampantly.
Hogan has said it is possible an asymptomatic employee was a carrier, but Singer said it is not yet clear how the disease spread and that the county health department is just beginning contact tracing.
On Friday, the state health department ordered all staff at nursing homes and assisted living facilities across Maryland to wear protective equipment when they interact with patients. The same day, leaders at more than 30 senior living facilities sent Hogan a letter warning they are not ready for the projected surge in cases.
They asked for immediate testing of all nursing home residents and staff, requested the state set up isolation centers to treat patients who test positive and asked the county and state to provide protective gear.
Phillips said that because testing and personal protective gear are limited, the state prioritizes testing of symptomatic patients and health-care workers and works with local health departments to get supplies to long-term care facilities.
Nursing homes are particularly susceptible to epidemics because they serve an immunocompromised population that interacts in close quarters. Yet for years, regulatory bodies at the state and federal level have failed to emphasize infection-control measures at nursing homes, said Lona Mody, a professor of epidemiology at the University of Michigan. In part, she said, such measures can seem out of place, because unlike hospitals, a nursing home is a place of long-term residence.
"Imagine knowing a person for 10 years, maybe even seeing them as family, and having to gown up every time you see them," Mody said. "It's not intuitive."
At Pleasant View, 24 employees had tested positive, 34 had tested negative and seven tests were pending as of Friday. Singer said he is focused on ensuring that patients who remain in the facility get the care they need and that the county is prepared for the surge officials say is coming.
On Wednesday, he learned that three residents at a retirement community in the county had tested positive for coronavirus. By Friday, that community - Carroll Lutheran Village - had five more infections.
A woman in her 90s from Carroll Lutheran Village died Saturday, along with three more Pleasant View residents: a man in his 60s and two women in their 80s.