San Antonio’s demographics almost seem tailor-made to put people at risk for the worst outcomes of COVID-19.
It’s a city that’s long struggled with generational poverty, where people of color make up the majority and certain underlying health conditions, most notably diabetes, are higher than the national and state averages. Data collected by states during the pandemic suggest race and socioeconomic status can make significant differences in survival rates of those who contract the virus.
So far, the numbers suggest San Antonians infected with COVID-19 may face worse outcomes. The percentage of known infections in Bexar County that ended in death reached 3.8% on Sunday, April 19, higher than the rates reported by officials in Dallas, Harris and Travis, the state’s three other most populous counties. (See accompanying chart.)
Those preliminary numbers would hardly stand up to scrutiny in a scientific journal. It’s unclear how many untested cases are still in each community, for example, and they’re not statistically significant enough to take other factors into account.
But we do know this: San Antonio’s high poverty rates for black and Latino residents have contributed to the health problems facing those communities. Our city’s high poverty rates account for lower health outcomes in the city’s disproportionately poor areas, a 2019 study by San Antonio Area Asset Funders Network and Texas Appleseed found.
One in seven people in Bexar County have diabetes. In one of the city’s most vulnerable zip codes, 78205, that number is closer to one in five. That’s above both the Texas average of roughly 10% and national average of around 9%.
“It’s quite clear that the risk of contracting COVID-19 doesn’t appear to be higher in older people and people with diabetes, it’s just that the health outcomes tend to be a lot worse,” said Curtis Triplitt, director of diabetes research at the Texas Diabetes Institute, part of University Health System.
Triplitt points out that diabetes can also lead to cardiovascular and kidney diseases which also put people at higher risk for death from a COVID-19 infection.
Beyond having higher rates of higher rates of chronic illnesses such as diabetes and hypertension, black and Latino communities also tend to be uninsured at higher rates than Anglo populations.
Nationally, the early data suggest that African Americans are especially vulnerable to the disease. Surgeon General Jerome Adams, who is black, has even weighed in on the way the virus is having poor and minority communities particularly hard.
“I have heart disease and spent a week in the ICU due to a heart condition, and I actually have asthma and I’m pre-diabetic,” Adams told CBS News in an interview. “I represent that legacy of growing up poor and black in America and I, and many black Americans, are at higher risk for COVID. It’s why we need everyone to do their part to slow the spread.”
Blacks make up 7% of San Antonio’s population, according to the U.S. Census Bureau, but as of April 19, they accounted for 28% of Bexar County’s COVID-19 deaths. Non-Hispanic whites, which make up 27% of the city’s population, accounted for just 23% of local deaths. Latinos, which represent roughly 62% of the population, accounted for 46% of deaths.
Compounding the risk for San Antonio’s low-income residents is their higher risk for exposure to the coronavirus where they work. Poor people are less likely to have jobs they can work from home, experts point out, while grocery clerks and food service workers are frequently forced to work in conditions where maintaining six feet of social distance is difficult if not impossible.
San Antonio and Bexar officials recently made it mandatory for people to wear masks in public places, and local employers appear to be respecting those rules. However, Fred Campbell, an internal medicine specialist with UT Health San Antonio, warns that employees at retail businesses are often at the mercy of customers’ respect for social distancing rules.
“There’s nothing to prevent somebody from crowding an employee to complain about service or selection, which seems to be happening a lot right now,” Campbell said.
Many of those workers are also forced to make tough choices about staying on the job when they worry they may be becoming ill. A study by the Institute for Women’s Policy Research, and promoted by the Working Texans coalition, found that 39% of workers in the state don’t receive paid sick time.
“From a health professional standpoint, during a pandemic like this, there should be some kind of accommodation for sick leave,” Triplitt said. “I say that because we can’t be sending a mixed message that we want people to stay home if they’re displaying symptoms yet we’re expecting them to suffer economic consequences if they do.”
Triplitt also worries people with diabetes and other health conditions may be vulnerable to worsening their condition during quarantine if they fail to keep up with exercise and can’t get access to the healthy food they need. Recent studies show that as many as one in five people in Bexar County live in food deserts, or urban areas where it’s difficult to find fresh food at low costs.
A Question of Numbers
While San Antonio’s Metropolitan Health District has been fairly transparent about the data that breaks down how minority communities are affected by COVID-19, that’s not necessarily the case for the rest of the state.
Part of the problem, observers say, is that three years ago Texas defunded an office specifically created to examine racial inequities in health issues.
The state created its Office of Minority Health Statistics and Engagement in 2010, charging it with studying and resolving racial disparities. Its two dozen full-time employees were charged with tackling institutional racism in the state’s health systems.
While small, the agency counted successes. After researching Child Protective Service numbers, for example, it discovered that state-provided transportation services the didn’t accommodate larger families or fit in with their schedules. After addressing those issues, the number of cases where mothers passed up medical care for their kids dropped, according to a report by Austin public radio station KUT.
However, facing a budget shortfall during the 2017 legislative session, lawmakers defunded the $2 million-a-year program. While there’s been little public discussion of the decision, at least one advocate for the office told KUT that lawmakers justified the defunding by saying individual state agencies could track the numbers on their own.
“I think that defunding that office was cosigning for all these health outcomes to get worse in communities of color across the state,” former Office of Minority Health Statistics staffer Lauren Lluveras told the radio station.
Last week, state Representative Shawn Thierry, D-Houston, drafted a letter to Republican Gov. Greg Abbott asking that he appoint an emergency COVID-19 racial disparities task force to examine how racial bias figures into who gets testing and access to treatment.
“As we know, data collection is lacking, and so one of the things I asked for in the letter is the task force would study the impact of these demographic factors on the morbidity and mortality rate,” Thierry said.
Into the Neighborhoods
Metro Health officials say they understand the importance of making sure San Antonio’s black and brown communities understand their elevated risks from COVID-19. Earlier this month, the district’s Community Health and Prevention team began visiting low-income neighborhoods to do community outreach.
Before Easter weekend, liaisons were walking parks in low-income neighborhoods to let people know of pending closures and also answer questions about the pandemic. Last week, they delivered more than 5,300 door hangers to households in the East Side’s Council District 2.
During one outing, a team encountered two separate gatherings of residents clearly not observing social distancing recommendations, said Mario Martinez, Metro Health’s assistant director of environmental health and safety. One needed a reminder that their proximity put them at risk, while the other claimed to be completely unaware of the guidelines.
“This is all coming down rather quickly, so it’s very difficult to change these behaviors,” Martinez said.
Beyond those with diabetes and cardiovascular diseases, Metro Health also recognized that COVID-19 poses special threats to people with asthma, another disease with high prevalence in San Antonio. In 2015, 14.7 of 10,000 children 17 or under were hospitalized for asthma in Bexar County, compared to just 8.3 per 10,000 for the whole state.
Several weeks ago, Metro Health began rejiggering its SA Kids BREATHE asthma program to include wellness checks with any person ever referred to the program to ensure they understand the risks posed by the pandemic.
Martinez said his team’s work has been centered on East, South and West San Antonio neighborhoods defined in an “equity atlas” of U.S. Census tracts showing the city’s highest rates of poverty and most tenuous access to health care.
“All of our efforts are focused on these communities of color because of the risk underlying conditions such as diabetes and hypertension represent,” he said.
History of Inequality
During a recent conference call with reporters, black Texas lawmakers pointed out that the state’s repeated refusal to expand Medicaid and its efforts to overturn the affordable care act have left minority residents especially vulnerable to the effects of the pandemic.
The sweep of COVID-19 through the state merely highlights issues that have existed for years in the state’s minority communities, said Harris County Commissioner Rodney Ellis.
“By not expanding Medicaid, people don’t have access to insurance,” he said. “[R]espiratory problems in neighborhoods hurt blacks and Hispanics to a great extent, there are more environmental issues [and] environmental racism is creating problems. One of the biggest industries before the coronavirus hit was opening diabetes clinics in minority communities.”
Kandice Webber, a critical care nurse and Black Lives Matter organizer, said she hopes the pandemic wakes people up to the fact that Texas’ black and brown residents have borne the brunt not just of this health crisis but others before it.
“COVID-19 is just the way it manifests this time,” she said. “There will always be another COVID-19 until we address the structural racism this county has forced on us.”
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