Virus striking both rich and poor areas
Cases based on ZIP codes in S.A. also can reveal who is getting tested
Some of the highest coronavirus rates in San Antonio are found on opposite sides of the economic spectrum — from the city’s poorest neighborhoods east of downtown to the Dominion, an affluent enclave filled with multimillion-dollar homes.
When the city began reporting the number of coronavirus cases in San Antonio ZIP codes, the first hot spot appeared in 78209 — home to Alamo Heights and Terrell Hills, among the wealthiest neighborhoods in San Antonio.
But as testing has become more accessible since March 13, when San Antonio reported its first coronavirus case unrelated to the evacuees who quarantined at Joint Base San Antonio-Lackland, the infection rate in each ZIP code today paints a vastly different picture of where residents have tested and screened positive for the disease.
Besides clusters in ZIP codes containing Bexar County Jail and Southeast Nursing and Rehabilitation Center, where outbreaks have caused infection rates to soar five to seven times the county’s average, some of the areas with the highest rates are scattered widely across San Antonio.
Public health experts say the data showing numbers of cases and infection rates in each ZIP code can be used to shed light on developing hot spots. But perhaps even more accurately, those maps can be used as a reflection of where people are — or not — getting tested.
“Folks who get tested are the ones who get diagnosed, so by that token, are (those maps) reflecting the number tested? Yes,” said Dr. Anita Kurian, assistant director of the Metropolitan Health District. “Is there a probability or a possibility that the number of cases we are
reporting are a gross underestimation of cases that are really out there? Quite possibly.”
Texas was initially among the worst states in the country when it came to testing per capita, a problem exacerbated by the fact that it sometimes took up to 10 days to get results back from private labs. It meant that local officials were forced to navigate the first few weeks of the pandemic with a limited understanding of where infections were gaining ground.
When San Antonio began releasing data that showed the number of cases in each ZIP code, for example, the first appeared in 78209, home to Alamo Heights and Terrell Hills. Parts of the county where higher concentrations of families live in poverty, such as the South Side, saw an initial absence of cases.
Cherise Rohr-Allegrini, an epidemiologist who previously served as San Antonio’s pandemic flu coordinator and recently worked on San Antonio’s public health transition team, said the reason behind the early spike in affluent neighborhoods was twofold. Families that live in 78209 tend to be wealthier than the city as a whole, which meant they had the disposable income to fund Spring Break trips to ski resorts or Europe — places where the virus had already spread.
Secondly, families with higher incomes are more likely to have health insurance and a relationship with a primary care doctor, Rohr-Allegrini said. Initially, that was one of the only ways to get tested.
“Those folks — if they feel sick — they go to the doctor,” she said. “If you’re a poor person on the South Side with no health insurance, if you feel sick, you stay home. You don’t go to the doctor to get tested.”
Today, some wealthy communities are still seeing some of Bexar County’s highest infection rates. Take 78257 — the ZIP code home to the Dominion, where residents have included Tommy Lee Jones, Steve Austin and Spurs stars. Last year, George Strait’s hilltop mansion was listed for sale there for $8.9 million.
That ZIP code has the fifth-highest median household income in the county — more than $118,000 per year, according to census estimates. Only 4 percent of the people who live there don’t have health insurance — a figure nearly four times less than the county average uninsured rate, according to census estimates.
According to Metro Health data as of Thursday evening, 78257 had a rate of about 1.2 coronavirus cases per 1,000 people — about 30 percent higher than the average ZIP code. Its northern neighbor, 78006, which spans over expansive ranch estates in Northwest Bexar County and up to Boerne, is also among the ZIP codes with the highest rates of cases.
“That’s why we have all our efforts on setting up additional testing sites in the neighborhoods where probably they don’t have access to health care coverage or transportation to a site to get tested,” Kurian said.
When the virus began to appear across San Antonio, city-run testing was limited to people with symptoms who were considered to be most at risk, such as health care workers, emergency responders and people with compromised immune systems. Other residents were told to seek out testing from their primary care doctors. Some went to free-standing emergency clinics.
Meanwhile, the city had begun tracking where people were getting infected — and who was dying of the disease. A month after San Antonio reported its first case unrelated to the evacuees, Kurian said, it was clear that people of color were dying at higher rates.
Across the nation, the pandemic has disproportionately ravaged black communities, exposing existing inequities in America’s health system.
The disparities soon became present in San Antonio: On April 13, African-Americans made up about 8 percent of the local population but accounted for 13 percent of the cases and one-third of deaths from the disease. As of Thursday, they made up 24 percent of deaths.
The city began a targeted push to increase the availability of testing and education about the virus in areas where families might not be able to afford health care or even the transportation needed to get to a doctor’s office.
Using census estimates, the city identified ZIP codes with the highest concentrations of people of color and families with lower incomes, who are more likely to have existing medical conditions that put people more at risk of serious illness and are more likely to live in environments, such as multi-generational households, that make it difficult to isolate.
Armed with masks and informational fliers in both English and Spanish, a team of city health workers walked door to door in neighborhoods on the East, West and South Sides to educate people on coronavirus disease symptoms, risks of transmission, prevention measures and testing locations. Since April 3, those health workers have combed through more than 100 neighborhoods and distributed 73,000 door hangers.
The city has also offered free testing at walk-up sites on the West Side, where people can get tested even if they lack an ID or health insurance or are asymptomatic. On Thursday, the city opened two other locations on the East Side.
As awareness in those areas increased — and so, too, did San Antonio’s testing capacity — more and more cases were reported there. Today, along with concentrating in some of San Antonio’s richest neighborhoods, the twothirds of the 15 ZIP codes with the highest rates have a higher concentration of residents living in poverty than the county as a whole.
Four Bexar County ZIP codes with some of the highest concentrations of residents living below the poverty level — which, for a family of four, means earning less than $26,200 per year — are also among the top 15 ZIP codes with the highest rates of COVID-19, the disease caused by the virus.
Among them: 78202, which covers San Antonio’s Eastside Promise Neighborhood, where 4 out of 10 residents live in poverty and 3 out of 10 lack health insurance. 78220 and 78225, on the East and Southwest Sides, are also on the list of ZIP codes with highest rates of cases, where nearly one-third of residents live below the poverty line.
Public health experts say the number of cases reported will continue to rise as the city sets up new walk-up testing sites that are accessible for people who’d previously faced barriers to testing. Thus far, about 1,200 people have been tested at the walk-up sites.
Cases are also likely to jump because people without symptoms can now get tested. Data from across the globe has indicated that anywhere from 25 to 50 percent of people with COVID-19 showed no symptoms, though it appears that they might still be able to spread the disease to others. Even at the Southeast Nursing and Rehabilitation Center, 56 of 74 residents who tested positive showed no signs of illness.
Rohr-Allegrini said that makes it even more important to target testing to areas most vulnerable to outbreaks. People living in poverty are more likely to have existing health conditions — such as asthma and diabetes — that might put people at higher risk of falling seriously ill with COVID-19.
Families struggling to climb up the economic ladder also have a greater chance of experiencing crowded living conditions, with multiple generations under one roof.
“Somebody that lives with five people in a home with one bathroom and like two bedrooms, and they can’t fully isolate and one of them has heart disease — all of the people in the house are going to get infected, and at least one of them is going to get ICU care,” Rohr-Allegrini said.
In the first two months of the pandemic, San Antonio hospitals haven’t come close to running out of space for patients. But when moving forward with expanded access to testing, efforts should still be focused on preventing the spread to people who are more likely to need medical care if they get sick.
“It’s just important to understand that when we need to talk about the need to address the disease in marginalized populations, it’s not that there’s something about them,” Rohr-Allegrini said. “It’s that we recognize the overall environment leads to a greater spread of disease, and we want to prevent that for the overall good of society.”