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What San Antonio’s Public Health Experts Learned from COVID

The CDC was “not there for us,” said Colleen Bridger, an assistant city manager who became the city’s coronavirus czar. “They were inconsistent. They were inaccurate. They were all over the place.”

by Lauren Caruba, San Antonio Express-News / April 2, 2021
(TNS) - Apr. 2—For the past year, Dr. Linda Esuzor has seen the disproportionate effects of the coronavirus pandemic firsthand.
As a hospitalist at Baptist Medical Center in downtown San Antonio, time and again she has treated COVID-19 patients whose social and economic circumstances set them up for worse health outcomes.
There were patients who did not come to the hospital until they were gasping for air. Many were worried about the bill, had underlying health problems that were undiagnosed or untreated due a lack of insurance or had avoided getting tested because they could not afford to miss work.
"A lot of social issues have played a role in determining how patients would do when they get sick," Esuzor said.
Since the coronavirus began spreading in San Antonio in March 2020, it has infected at least 205,000 residents, killing more than 3,100 of them. The once-in-a-century crisis abruptly altered nearly every aspect of daily life. And it tested the resolve of long underfunded public health departments and a decentralized health care system — and laid bare the systemic shortcomings of both.
Like Esuzor's patients, many of the people who became the sickest from COVID were uniquely vulnerable to the virus due to their race or ethnicity, the nature of their jobs, their living situations, chronic health conditions and lack of access to preventive health care or insurance.
Without a unifying federal response, states and cities were left to figure out health regulations on their own. The San Antonio Metropolitan Health District and other health departments struggled to keep up with the highly contagious virus and communicate shifting guidance amid rampant online misinformation and disinformation.
Local hospitals were in danger of being overwhelmed as they were flooded with thousands of COVID patients during surges last summer and winter. There were only so many public health and medical workers to go around, and many grew exhausted as they dealt with enormous workloads and the trauma of mass death.
With rising vaccination levels, Americans have reason to hope that some semblance of normalcy might be restored this year, even if the virus and its variants are still in circulation. As the threat of the virus recedes, medical and public health leaders will begin to assess the damage, pick up the pieces — and do some soul searching.
"We can't forget what happened. We need to take the experience from this and be willing to be critical of all of our mistakes," said Cherise Rohr Allegrini, an epidemiologist who previously worked for Metro Health and the Texas Department of State Health Services.
Communicating through crisis
During times of crisis, local health departments usually take their cues from their state and federal counterparts. But during the first months of the pandemic, both were in disarray.
The federal Centers for Disease Control and Prevention was "not there for us," said Colleen Bridger, an assistant city manager who became the city's coronavirus czar. "They were inconsistent. They were inaccurate. They were all over the place."
That absence of leadership was coupled with abrupt changes to messaging about the importance of wearing masks and the danger of the virus in comparison to the flu. Without proper explanation, flip-flopping guidance can damage public trust, Rohr-Allegrini said.
And it encouraged politicization of the pandemic and the spread of information from suspect sources. The high level of public scrutiny also led to a barrage of abusive calls to city leaders, Bridger said.
"Everybody on the street was an epidemiologist," said Anita Kurian, head of the communicable disease division at Metro Health.
As the months progressed, Metro Health had to continually course correct. The department failed to build up an arsenal of case investigators for contact tracing until it was too late, despite earlier recommendations from an expert panel, and it lacked proper infrastructure to do the work. Dawn Emerick, the new health director, resigned in June amid internal strife and the city's first major wave of infections.
Across the country, the pandemic has been a humbling experience for health departments, which Rohr-Allegrini said tend to be insular and unwilling to accept outside input. Moving forward, she said, health leaders should reflect on how they communicate with the public and partner with community organizations to ensure they are better prepared for the future.
To do that, the funding needs to be there, said Dr. Junda Woo, Metro Health's medical director. Public health departments cannot adequately respond to the next national crisis if their infrastructure is not maintained over time, she said.
"What happens in Washington can be a problem in Florida or a problem in California within hours or days," said Dr. Jason Bowling, an infectious disease physician with UT Health San Antonio and University Health.
Surviving surges
Under normal circumstances, hospitals run on tight margins. To remain as efficient as possible, they are built to adjust staffing and beds based on need, so they do not usually have an excess of either.
But that system has its shortcomings. In San Antonio, it only took 1,200 to 1,500 extra patients infected with coronavirus to catapult hospitals into crisis mode. To stay afloat, they had to scale up operations quickly and rely heavily on contract medical workers.
"Health systems work on a fairly predictable pattern of seasonal illness and elective procedures and things that happen in their communities," said Dr. Bryan Alsip, chief medical officer for University Health. "When you throw in a significant amount of excess disease, that tips the balance for a lot of these systems."
While San Antonio's hospitals were able to recalibrate during COVID surges, Alsip said, it came at the expense of other patients, whose delays in care would cause them to come in with more advanced disease.
In most cities, health care is fragmented, a patchwork of systems operated by public and private entities.
That decentralization can make it difficult to work together during an emergency, said Eric Epley, executive director of the Southwest Texas Regional Advisory Council, which manages trauma and emergency services for San Antonio and the surrounding region.
Through STRAC, San Antonio's hospitals and EMS agencies work together on a day-to-day basis, even as they are competition with each other. That level of coordination and communication does not exist everywhere, Epley said. And it proved vital during the pandemic, especially when hospital staff and beds across the city became scarce.
Infectious disease doctors from across San Antonio's hospital systems have regularly met to share best practices.
While the area's hospitals were twice on the verge of being overwhelmed with patients during the summer and winter surges, the city managed to avoid the acute crises experienced by El Paso, the Rio Grande Valley and other areas.
A big part of that, Epley said, was "load balancing."
"If the hospital has a bunch of patients for whatever reason, another hospital has a lot of room, it makes sense for those hospitals to share that load, so no one goes under," he said. "You just have to be able to work together, and that's not necessarily a natural thing in health care markets."
Under-served groups suffer
While COVID is caused by a respiratory virus, it also targets multiple organ systems, putting people with chronic conditions at a great risk of severe illness and death.
The severity of America's COVID crisis could have been mitigated by increased access to primary health care, Bowling said.
"We need to shift more to a prevention first, rather than a reaction type of system," Bowling said. "If you just rely on hospitals alone, we clearly don't have enough hospital beds if everybody starts getting sick."
In many cases, chronic health conditions are linked to social factors that disproportionately affect communities of color and people who are lower income, said Dr. Lynnette Watkins, chief medical officer for Baptist Health System.
San Antonio, with its large Hispanic population, has some of the highest rates of diabetes and kidney disease in the country. Hispanics make up 60 percent of Bexar County residents but three in four of those infected.
"It unmasked the disparities and differences in access to health care," Watkins said.
Vaccination has also been slower among Hispanic and Black populations, who have suffered the most during the pandemic, Rohr-Allegrini said. Those groups are also more likely to distrust medical systems due to historically unequal treatment.
Public health professionals have long known about these structural disparities, she said. Now, at least the public is more aware of them, too.
Vaccines versus variants
For the past several weeks, there has been rising optimism among the public as the availability of COVID vaccines has expanded over the past several weeks.
In early March, President Biden announced that all American adults would be able register for an appointment by May 1, adding that he was hopeful about the safety of gatherings by the Fourth of July. Many states, including Texas, have opened up their eligibility requirements well ahead of that target.
In San Antonio, coronavirus transmission has fallen to its lowest levels since last spring.
But as Texas and other states have begun to relax health measures, the CDC director has warned that the country could see a new wave of cases. It has become a race between vaccination and the spread of more contagious variants.
"There is a lot of cautious optimism about what the next several months might look like," Alsip said. "But we also have been fooled in the past, and the disease has surprised us in so many ways, and may still have some tricks up its sleeve."
However, another surge would likely look different from those that came before.
While some variants are feared to reduce the efficacy of vaccines, the shots should still provide strong protection against severe disease, Bowling said. And many people who are most vulnerable to COVID have already been inoculated, potentially lessening the impact on hospitals.
With the coronavirus still circulating across the globe, the virus is not likely to disappear any time soon. As vaccines are administered and the pool of potential hosts shrink, COVID will shift from pandemic to endemic, Woo said. The virus will continue to spread, but its threat to the public will be greatly neutralized.
Once that happens, Bowling said, it will be tempting to forget and move on. But the time for change is now.
"The timing is now to start assessing: What do we need to gear up and improve?" he said. "This is not the last pandemic that we're going to see."
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