As COVID continues to rear its ugly head, in San Antonio we’ve seen cases inching up for the last few weeks. Yes we’re testing more. An increasing positivity rate means we’re finding cases, which is the only way to stop it spreading undetected.

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In March, I wrote about what we’d likely see in San Antonio. And we did. In July, Black and Hispanic/Latinos disproportionately affected. Also in March, I wrote about T3: testing, tracing, tracking (isolation/quarantine).

In April, the mayor of San Antonio had the wisdom to pull together experts from across the city to develop a “Transition Plan.” The goal was to determined how/when to re-open. That got circumvented with premature orders from the governor, before we had systems in place. And starting in June, leading into July, we saw the inevitable spike. We’re heading in that direction again.

And SA weren’t the only ones to write about it. Nationally, the story was the same.

So what do we do?

Lead with Equity.

It was spelled out in the April 28 document. We’ve learned more but most of it still applies:


These progress indicators include:

  1. A sustained decline in the number of new cases of COVID-19 ≥ 14 days
  2. The ability to perform tests for the virus in all people with symptoms of COVID-19, their close contacts, and those in public facing roles
  3. Effective contact tracing capacity to identify all close contacts of people diagnosed with COVID-19 and offer testing to those for whom it is indicated
  4. A prepared healthcare system that can safely care for all patients, including sufficient hospital capacity, workforce, and PPE for healthcare workers

For safe re-opening, we recognize that our community needs more education about COVID-19, improved access to testing for COVID-19, and an expansion of our existing public health capacity for contact tracing and follow up. We also must focus our efforts on those who are medically at risk and on marginalized populations.

Principles for a Common-Sense, Street-Smart Recovery with a Focus on the Most Marginalized

San Antonio should prioritize the needs of those most impacted by the COVID-19 pandemic by focusing response and recovery efforts in low-income communities, communities of color (Latinx/Hispanic, Black/African American, Indigenous and Native, Asian/Pacific Islander, etc.), and LGBTQIA+ communities. This is an intersectional strategy that ensures that all who are highest risk are reached, including people with disabilities, the medically vulnerable, low wage frontline workers, imprisoned individuals, housing insecure individuals, seniors, and many others., as when these individuals are also low-income and/or from communities of color they are the most at risk. We recognize that we have not distinctly named all of groups of people who are disenfranchised, but they are all included, as we use the term marginalized populations to explicitly refer to the communities most at risk due to systems and structures of oppression.

San Antonio can best meet the economic needs of businesses and the public, by recognizing the contributions of, and paying fairly for, the labor of essential workers and their families. As we begin to think about recovery, we must commit to become a better and more equitable city and a better and more just nation than we were before this pandemic.

Recommended Actions

Action: Center Racial and Economic Equity

Centering racial and economic equity must be at the core of this recovery and be a required core principle of the response and recovery efforts in all City Departments, county efforts, COVID-19 task forces, and committees.

Why? Low-income people and people of color will experience the worst impacts of this crisis. Therefore, now is the time to step up efforts to sustain equity gains that have already been made and secure more.

Action: Put Marginalized People First and Make Sure They are in the Room

The scale and duration of relief must match the scale and duration of the need and low-income people and people of color must shape the recovery decisions that affect their lives and communities. Ensure representation of marginalized community members on all COVID-19 response related task forces and committees.

Why? Since 2013, the overall poverty rate for the City of San Antonio has remained at 18–20%, indicating that about one in five individuals are experiencing the financial and social burdens of poverty. Poverty is one of the most important determinants of health, longevity, and quality of life.

Roughly 60 percent of Americans do not have enough savings to cover a $1,200 emergency expense. Two out of three households of color do not possess enough savings to sustain themselves for three months if their income were disrupted; and one-third of African Americans and Latinos have no financial assets at all. Building the long-term financial security of low-income households and households of color involves harnessing an array of resources and institutional supports that enable vulnerable families to thrive and move up the economic ladder.

We must address the dire human need and support people to manage their lives by protecting and expanding the safety net for everyone, regardless of status, and delivering emergency aid in the form of direct cash payments, debt forgiveness, rent and mortgage relief, loans and grants for small business owners, and other measures, with specific outreach to marginalized communities.

In Bexar County, 15% of Latinx/Hispanic community members do not have health insurance. In the Black/African American community, more than 30% do not have health insurance. In he past 12 months, 24% of Latinx/Hispanic adults and almost 18% of Blacks/African Americans (non- Hispanics) did not see a doctor due to cost. In the LGBTQIA+ community, the lack of culturally competent care layered on racial and economic inequities has led to even greater health inequities. In the past year, 46% of LGBTQIA+ people surveyed said they have avoided seeing a healthcare provider in the past year and 30.8% said they had been refused health care. The challenges our marginalized residents face in accessing health care discourage them from visiting a doctor when sick. As a result, individuals in this situation will not seek health care until severely ill, which is worse for their health and worse for the healthcare system.

We need to improve access to care for our most marginalized San Antonio and Bexar County residents by including health care enrollment efforts in our community outreach actions and by providing resources for medical care options for those who remain uninsured. Recognizing that a lack of culturally competent providers is also a barrier to access for many, we must also create and promote a list of providers who have demonstrated a commitment to full inclusion of treatment for all patients and specifically list which providers are LGBTQIA+ affirming.

Action: Invest in Community Infrastructure

The essential social service organizations must be prioritized for safe re-opening in the first phase, which should include free training and free distribution of essential supplies that can help prevent the spread of COVID-19 in their facilities, such as PPE and cleaning supplies.

Why? The trusted network of nonprofit, cultural, philanthropic, and local institutions that support the well-being and resilience of the most marginalized communities will be called to do more with fewer resources. Their work is urgently needed now and essential for the long road to recovery. We must commit to continuing to channel funds to help them keep services running and adapt to social distancing and online platforms as needed.

We must target investments to people and institutions rooted in and deeply committed to communities, with a track record for getting results for the populations they serve. This must include organizations serving low-income communities, the Latinx/Hispanic, Black and African American communities, and the LGBTQIA+ communities specifically.

Action: Support Free Targeted Testing

Testing, tracing and supported isolation needs to be made free and available for marginalized communities, without the need for a referral, and provided in their neighborhoods and/or via mobile testing units. Testing should include a random sample of asymptomatic and all mildly symptomatic individuals in these populations. Contact tracing efforts must be expanded (please see Indicators and Capacity Section) and their efforts should ensure prompt and prioritized case tracing of people with COVID-19 in marginalized communities.


The Black/African American community in Bexar County have not escaped the nationwide pattern. Black San Antonians account for 25% of COVID-19 deaths and 10% of cases, despite making up only 7.2% of the population. Latinx/Hispanics account for 58% of the cases and 46% of the deaths. Both of these populations experience higher rates of lung disease, diabetes, obesity, and other risk factors for severe COVID-19 Disease

Action: Develop a Community Health Equity Task Force

With the support of the Mayor and Council and County Commissioners Court, it is recommended to launch a “Community Health Equity Task Force” that would be a coordinated effort between the Council’s Community Health and Equity Committee, the Mayor’s LGBTQIA+ Committee, Metro Health, and the Office of Equity.

Why? This task force should be primarily composed of community members from the most marginalized populations (which includes people of color including immigrants and asylum seekers, low-income communities, people with disabilities, and LGBTQIA+) be assembled quickly, and remain in place for at least 18 months, recognizing that the response efforts needed to address health equity disparities will require an extended effort.

Action: Build an Equitable Economy

Prioritize the needs of small and minority owned businesses and their employees.

Why? Providing direct support to workers and helping small and micro-businesses (<50 employees) preserve jobs through the mandated shelter-in-place orders is the best economic policy right now, and will yield the best results for a sustained economic recovery that will benefit everyone. Ensure that the needs of the small and minority owned businesses are addressed during every phase of the re-opening. This could include targeted relief, loans, and guidance on how to implement best practices relating to virus prevention techniques within their businesses. The health of San Antonio and Bexar County residents will also be improved by providing increased support for workforce development programs. April 3rd, 2020, Ramiro A. Cavazos, president and CEO of the U.S. Hispanic Chamber of Commerce, estimated that 1 in 4 Latinx/Hispanic owned enterprises may never reopen, and we know that the health and well-being of our marginalized communities is heavily intertwined with their economic well-being. It is probable that these estimates are considerably higher now, three weeks later, and also higher in San Antonio specifically, based on the high number of Latinx/Hispanic owned enterprises in our city that routinely operate with tight margins. In 2010 there were 37,000 Hispanic-owned businesses in San Antonio, according to the Texas Governor’s Office.

End Quote.

None of this is ground breaking. It’s all basic public health:

Identify cases.

Identify high risk populations

Intervene in high risk populations

In HIV, we know MSM, particularly Black and Latino are at highest risk for HIV infection in Texas. So the state works with community based organizations to bring testing to the community by using mobile testing units, by doing contact tracing, linking HIV+ people into medical care WITH wrap around services such as housing, meals, and community support.

I’ve said all along there are so many similarities between this pandemic and the pandemic that is HIV.

We are entering another wave. It doesn’t matter if it’s the second or third or if we want to call it a peak vs a wave. We will see more cases. We can mitigate the impact through basic public health practices. We said this on April 28.

Dr. Rohr-Allegrini is an epidemiologist and tropical disease scientist currently working to prevent diseases through immunizations.

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