By Sandra Guerra, MD, MPH

COVID-19 Pandemic & Public Health in San Antonio

By Sandra Guerra, MD, MPH

2020 was a year of unexpected events. The COVID-19 Pandemic disrupted life for so many this year, often in ways our community had not experienced since the 1918 influenza pandemic. Public health was placed in the spotlight instantaneously as the scientists with knowledge on combating a pandemic, the providers of scarce resources in testing, and the primary responders gathered information for public dissemination and education. Through these areas, San Antonio Metropolitan Health District served as the lead agency in responding to the pandemic.

As a backdrop, the San Antonio Metropolitan Health Department was thrust into a response for which no agency in the United States could have adequately prepared. What the city had going for it were a few valuable gems that are rarely discussed, which ultimately saved lives. First, at the health department, the primarily female and diverse leadership team was highly experienced, educated, dedicated and widely respected. Under the leadership of the Assistant City Manager, Dr. Colleen Bridger, the team was crafted over years of smart hiring and trusted leadership during challenging times. Secondly, the city leadership chose to respect the health department’s guidance and regulations. Under Mayor Ron Nierenberg and Judge Nelson Wolff, the department was provided verbal, financial and political support. Third, the most impactful professionals in our community during the pandemic were two doctors whose names are now recognized by the entire city.

The Local Health Authority, Dr. Junda Woo, came to the role 5 years ago as an OB/Gyn and former writer for the New York Times. She was thrust into the spotlight, skillfully translating the science into practical terms that could be used by elected leaders, epidemiologists, school boards, business owners and the public. Through her legal authority under state law, Dr. Woo was able to help curtail outbreaks in long term care facilities and other environments. Another doctor, Dr. Anita Kurian, a former family physician in India and executive public health leader in Texas, was the ultimate leader of the response. Normally responsible for communicable disease programs, and as the pandemic exploded, Dr. Kurian quickly assumed the task of shepherding a public health workforce of over 520 people working all aspects of the COVID response. Physician leadership was a significant contributor in the race to beat the pandemic. I was honored to join this team of science leaders in July, almost 5 months into the pandemic. The lessons learned below are from the combined experiences of the amazing leaders of the San Antonio Metropolitan Health District.

HERE ARE THE TOP 10 LESSONS LEARNED IN THE PANDEMIC

1. Responding in a Public Health Crisis Requires a Multi-agency Emergency Response

For San Antonio, the public health crisis of the pandemic required a Unified Command and multiagency response. San Antonio Metropolitan Health District, San Antonio Fire Department, South Texas Regional Advisory Council, City Manager’s Office, Mayor’s Office, Bexar County, University Health System, UT School of Public Health, the Bexar County Medical Society and many other crucial agencies became instrumental in ensuring the response was comprehensive, timely and robust. Most of the agencies dedicated a substantial portion of staff and resources to responding to the Pandemic, often 7 days a week, long hours, and in alternative work sites for most of the year. The agencies each responded in their areas of expertise and greatly expanded their impact. For instance, San Antonio Fire Department used their Mobile Integrated Health program to provide COVID testing at Skilled Nursing Facilities to control outbreaks.

This Emergency Response System had previously been used in responding to natural disasters, such as people evacuated from hurricanes to San Antonio. That experience, plus tabletop exercises in preparation for a pandemic, led to established roles and responsibilities of the same organizations in 2020. But beyond the textbook plans and ability to execute the plan, responding to a crisis required trusted relationships between organizations which took years to build during smaller events and even being partners during a non-event. The interagency relationships that public health depended on required the care that any relationship needs…communication, trust, dedication and mutual celebration for good work.

2. Public Trust in Science is Fragile

Earning the public’s trust in science, medicine and evidence-based healthcare had been taken for granted by most for many years. What we learned this year is that when people’s health is threatened, they look for alternative plausible solutions and explanations. This is human nature and as physicians, we are accustomed to second opinions and internet searches when we give a challenging diagnosis. For many scientists, it was alarming to see the same reaction on a population basis; some blamed politics, others blamed the novel-ness of the virus, others blamed system failures or even competing views of scientists, but in the end, the result has been the same. The public’s trust in science is fragile.

Science is not immune to challenges and is built on testing assumptions. Yet that rigorous scientific process that we were trained on has come under scrutiny to respond in the speed needed when the threat is ubiquitous. The rigor was viewed as bureaucratic. The statistics were perceived to be gaming a system or advancing a political view. The recommendations on safety were seen as overbearing or not truly protective. The actions by the government officials to impose quarantines or close places of congregation were challenged as overreach and stifling civil liberties. Theories around public health hiding information were as abundant as the theories around hidden motives in inflating numbers or providing guidance. The work of public health was met with legal, social and intellectual push-back.

So, what does this fragility of trust in science mean going forward? It means as scientists, we must recommit to having meaningful, honest conversations with patients, peers and the community on a regular basis, not simply in times of crisis. We must respect the decisions of people without condemnation or fault. We must educate to the best of our knowledge and give options when they are available. And we continued on page 14

must adapt to the environment around us to meet the needs of the person in their entirety, not just the physical; learn what drives their belief system and accommodate where they are in accepting the world as it has changed. And finally, recognize that the system used for rigor in science is the counterweight to the art of medicine.

3. Counting in a Pandemic is Tough

Being transparent is essential during a crisis. The pandemic was no exception. Many governments turned to data as a presumed unmitigated source of truth and a community impact index. Yet, during the COVID Pandemic in San Antonio, the situation was like Americans watching football games; the community looked to daily number updates of cases, deaths and outbreaks on television, radio and other media channels. Government agencies were quick to share what they knew of the case counts and overall impact in multiple formats from social media, local news and even the Mayor’s “Daily Briefing” on television (and other broadcast modalities). The desire to be transparent is the culture of the San Antonio government to make sure citizens make informed decisions.

Yet with the commitment to transparency, the challenge public health officials faced to account for cases became the focus, instead of the message of safety. For instance, though COVID-19 was a reportable condition, recognizing laboratories were overwhelmed in the early days of the pandemic, meaning sometimes a result was available 10-12 days after collection. This delay in confirmatory diagnosis added to a delay in reporting to public health. As lab capacity improved, the official definition of a COVID case continued to evolve in public health, so some persons were able to be included in official counts, while others were pending further investigation. Simultaneously, determining which COVID tests could be used based on the condition of the patient also added complexity to the case counting. Finally, due to the testing surge, some large laboratories and hospitals were reporting cases in batches, often weeksto-months delayed. Then, there was the challenge in death reporting. Sadly, many people in San Antonio have died with COVID ever since the pandemic began. The complexity of “cause of death” reporting was not different during a pandemic, but the public rightfully wanted the information faster than the normal death records process would allow. This led to accepting unofficial reports from facilities or the coroner to show severity of illness to our community but had to await official confirmation weeks-to-months later, after a death certificate was available to review. The reconciliation process added fuel to the conspiracy theories saying numbers were inflated to increase payments from the government or to sabotage a political candidate.

The reality was simply this: counting cases during a pandemic is not clean due to the complex health care and public health systems we have in Texas that existed prior to the pandemic. There is a lag time between when people get care and how that information is shared. It is not like going to the ATM and pulling out cash where your bank account is updated instantaneously. I wish it was! But sadly, think of it like the days when you wrote a check for a purchase and never knew when it would be cashed; your account could be flush with money and then suddenly overdrawn. Ideally, our community would see the statistics as a gauge more than a definitive marker for COVID in the community.

4. Contacting Contacts Has Always Been Difficult

The role of public health has always been to confidentiality notify contacts of reportable communicable diseases. There are different tactics that have been employed by public health experts over the years based on the disease, the environment, and the next steps the “contact” must take. For instance, a person who has been diagnosed with tuberculosis would identify the places where they spent more than 8 hours with others while indoors. For measles, which is more easily transmitted, a sick person would describe every environment they were in over 2 days prior to symptom onset. For a sexually transmitted infection, a person would share the information they knew of intimate partners they had in the last 2 months. But when it came to COVID-

19, the asymptomatic or pre-symptomatic person posed a problem in spreading the disease. Though many clinicians know this attribute is not unique to the coronavirus, public health becomes concerned when a silent spreader may be unknowingly exposing persons at higher risk.

Public health, with their partners, took on the daunting task to notify people who were exposed to a confirmed case. They made phone calls that were unanswered half the time. They waited for return calls. Based on the situation, some employers or schools were notified. Long term care facilities were notified to stop admissions if a resident was found to be positive. Universities suspended team games when members got sick. The work of notifying was a tremendous undertaking that included education, resource sharing and empathy.

The contact tracers heard stories of the loss of loved ones, job loss, home displacement and theories galore. For some, the burden of hearing heartbreaking tales of families separated, and unaccompanied hospitalizations or video-call, final good-byes, brought the public health worker to tears. Contacting people during a pandemic and hearing how it has impacted them was emotionally challenging.

5. The Waiting Game

The other reason an asymptomatic or pre-symptomatic person is of concern in contact tracing is because once someone was identified as a contact to a confirmed case of COVID, the contact needed to quarantine and wait for test results or symptom onset. Ideally, a person who was exposed would be in quarantine for 14 days, which seemed like an eternity for most. The waiting game was a cornerstone to the COVID-19 pandemic in 2020. “Act as if you have it” was the mantra preached to people who had been exposed and even the public.

After someone was exposed to COVID, or if they had mild symptoms that could be consistent with the virus, the next step was to get a test done. That process was not easy either. Early in the pandemic, the test locations were fraught with long lines (albeit, by car). People hoped they could access the test (“do you have symptoms?”), wanted to know which test would be used and the speed in getting a result. Sure, everyone wanted the rapid test which came about later in the year, but it was challenging to find testing locations and the results were not definitive. Despite knowing a test result should not clear someone to resume normal activities since the virus could still manifest within 14 days after exposure, the community was filled with anecdotes of people using a negative test as a short cut in quarantine requirements. The waiting game was lost.

6. What to DO: Social Responsibility on the backdrop of changing guidelines

As the COVID-19 pandemic spread across the globe, watching other countries shut down in ways that current memories had not experienced was mesmerizing. Limiting travel, shuttering businesses, closing schools, changing behaviors in greeting each other…Americans’ watched and waited. Within a few weeks, the United States grappled with the same dire measures and drastic decisions. Travel as we knew it ceased, schools indefinitely suspended the Spring Break tradition, universities emptied dorms, temporary hospital beds were created, rationing of personal protective equipment became symbolic of a country reeling from the impacts of a deadly virus. Health care workers were the front line of defense and grocery store employees risked their well-being to ensure food and supplies were available to all. Hording of essential items and shortages were often a combination of a fragile justin-time supply chain and human psychology in a crisis. As national public health guidance changed (“masks don’t work well” to “wear a mask all the time”, “test again to see if the virus is cleared” or “don’t test again for 90 days”), the public and clinicians grappled with what to do exactly. People were asked to stay home, limit outings to essential actions like grocery shopping. Over a short time, the list of essential activities increased, the economic strangle-hold impact on business and families emerged, the issues of unsafe home environments, holiday traditions and changing recommendations caused a quick slide back toward a false normalcy. This led to a COVID surge in the middle of summer, when respiratory illnesses rarely spike. The spike in cases, hospital capacity and deaths across the state, led to a statewide mask mandate which ultimately led to a reduction in the number of cases. People eventually settled into a risk-acceptance level that was mitigated by wearing a mask, staying six feet apart and hand washing.

Some risk-taking was inevitable in a population that had grown weary of the changes in life as we knew it. Young people suddenly felt a sense of immunity to the virus and attended college parties or went to bars. Older people missed grandchildren and opted to visit. continued on page 16

Schools recognized challenges with virtual learning and gave in-person classes a try. Long term care facilities were able to allow visitors under certain conditions. Religious services resumed with precautions.

We, as a community, re-learned that shaming people into social responsibility was met with resistance and non-conformity. Positive role modeling was more effective. We re-learned, as a community, that privacy of health information was still important in a pandemic, so efforts to blame the sick was fruitless. We recommitted, as a community, to find ways to protect the vulnerable and recognize how to care for our loved ones in new ways. We, as a community, found out how interdependent we are and how tenuous the relationship between our personal health and the health of those around us are connected.

7. The Speed of Science is Slower Than Some Expected

Americans have long lived with the belief that ingenuity would bring a speedy solution to any health threat, especially one that the rest of the world had failed to halt. Yet, what the pandemic has reminded our country is that a solution is not a singular action, medication or vaccine, but an arsenal of smaller steps to success. Those of us in health care and public health know science does not occur at the speed of a one-hour episode of CSI. Instead, science is calculated from known experiences with similar viruses, previous pandemics and technology. Where we did advance…testing capabilities, medications, treatment modalities, innovation in ventilators and mobilization of human resources to hot spots, it seemed as if we were constantly trying to get there faster; rightfully so. There were experimental treatments and need for recovered donors. People across the globe tried home remedies promising protection only to add another health risk that public health had to inform people to avoid. Science was moving, but not nearly at the speed people wanted.

In San Antonio, the city was able to be involved in vaccine clinical trials, treatment trials and gave birth to an innovative testing center that promised to return COVID results in 24 hours for a fraction of the cost. The city was home to the first cases of COVID that were evacuated from cruise ships early on in the pandemic and later helped sister communities across Texas with patients when they experienced surges. These experiences helped build out the robust capabilities that San Antonio was able to leverage in the treatment of people in our hospitals and in the community. Science was not occurring as people expected, but it was occurring every day.

8. Spotlight on Social Determinants of Health

The COVID-19 pandemic had many visuals that will be emblazoned in our minds for decades. Some of those images captured the national media of what was occurring in San Antonio, such as the arena parking lots filled with cars waiting for food assistance from the San Antonio Food Bank. Yet what those in health care already knew before the pandemic, is health is not only what occurs in a doctor’s office but it is driven by social factors such as food insecurity, social isolation, lack of transportation and other issues of inequity. The pandemic highlighted the populations that are disproportionately impacted by the social determinants of health. The ability to access food was often tied to places that were closed or the loss of work pushed families into poverty. Suddenly, the social determinants of health were visible, and palpable. Public health was keenly aware of the magnification of needs since they were speaking to people in the community daily.

We also will not know for years how some decisions such as discontinuing a medication so that you can buy food instead, will impact the productive life expectancy after COVID. What about the decisions to postpone childhood immunizations or the family who lost health insurance when the job was lost? We are unable to predict the long

term sequalae of COVID due to these developing social determinants of health. What we as a community learned is the need to fortify around social determinants of health in San Antonio during “normal” times (yes, we will get there someday) to protect against the push over the cliff in another crisis.

9. Civil Discord and Pandemics

Public health experts were not surprised by the civil discord during the pandemic. History has taught us this is a common finding, though the impetus was unique and heartbreaking for our country. What was surprising was the personal nature of the attacks on our Pandemic leaders. Racism was declared a public health crisis in San Antonio during the COVID-19 pandemic. We know generational disproportionate negative treatment of people of color has resulted in tremendous hardships that impact the health of the community. COVID was another example of a crisis with inequity in health outcomes often based on race. Hispanics were more likely to die of COVID in San Antonio than their peers. And though it is also true that Hispanics have a higher rate of diabetes and other co-morbidities in the city, the question should remain on our minds: why? As public health professionals, COVID has taught us all the factors that led to a lack of equity in health are once again driving health disparities. It is incumbent on all fields of science, health, business and social justice to look at racism as its own health driver and commit to finding solutions.

One of the questions raised during the civil discord was if demonstrations led to more cases of COVID in San Antonio. There were no clear links between peaceful protests occurring outside in masked and socially distant events and known transmission of COVID.

10. There is no silver bullet

The COVID-19 pandemic will end slowly over time. Many are hoping a vaccine will be the solution. What we know is there is no singular silver bullet to stop the pandemic. In previous pandemics, vaccines slowed the spread, but a widely available, safe and effective vaccine is months away. At first, certain groups will be prioritized to get the vaccine, such as health care workers in long term care facilities and first responders. We know there will be people who cannot or will not be able to get immunized. We also know there is a risk of other shortages such as supplies. Treatments will continue to improve and more will be known about risk factors for severe illness. I am optimistic we will overcome this pandemic, but we are still too early to tell the long term sequalae of infection and overall health costs. The solution is not singular but a combination of all the lessons we have learned so far and those yet to come.

The way forward and out of the pandemic is to remain steadfast in our commitment to the health of our community in large and small ways. I am a strong believer that public health is not the responsibility of a city department, but instead it rests on the shoulders of all of living in San Antonio.

Sandra Guerra, MD, MPH is the Interim Deputy Public Health Director of the San Antonio Metropolitan Health District and is a member of the Bexar County Medical Society.