by Fernando A. Guerra, MD, MPH
and John Berlanga, MPA
San Antonio Metropolitan Health
District’s (Metro Health) annual
public health assessment is a
snapshot of our community’s current
health status. It also compares the City
of San Antonio with the state and the
rest of the nation while offering some
indication of the progress we are making
and the tasks that remain. It has been
developed through a statistical analysis
of birth records, communicable disease
reports, school records and other
sources. The goal of Health Profiles
2006 is to encourage public and professional
discussion regarding medical and
daily living conditions that affect the
overall health of Bexar County’s entire
metropolitan population.
Ten Zip Codes
Metro Health has identified ten zip
codes as high-risk areas for public health
concerns connected with young families
(zip codes 78201, 78207, 78210, 78211,
78221, 78223, 78227, 78228, 78237,
and 78242). Metro Health selected these
zip codes based on high numbers of births to single mothers or births to
school-age mothers.
Children born to these mothers
often carry the extra burden of a
poverty-impacted environment. Single
mothers and their children are among
the poorest and most severely distressed
in San Antonio, with 48 percent
in poverty (American Community
Survey, 2006). Many of these families
are in their second or third generation
of poverty. Teen mothers, single mothers,
low-income mothers, along with
the undocumented and uninsured, are
concentrated in the ten zip codes listed
above. Researchers have identified
the effects of poverty connected with
domestic violence, juvenile crime,
alcohol abuse, drug addiction, and
school failure.
Community Priority Issues
Figure 1 displays the age distribution
of Bexar County’s population,
demonstrating that the majority of the
population is younger than 40 years
old. A significant portion of the public
health picture in San Antonio revolves
around the needs of children, adolescents,
and young families.
Community priority issues of this
population include:
• Educational disparities
• Teen pregnancy
• Substance abuse
• Juvenile crime
• Unplanned pregnancies and births
• Low birth weight (LBW) infants
• Child abuse
• Neglect/domestic violence
• Medically uninsured/lack of routine
health care
• Diabetes, hypertension, and obesity
Education, Teen Pregnancy, Substance
Abuse and Juvenile Crime
Most educational and neurological
experts agree that the first five years of
a child’s life lay the groundwork for a
child’s emotional, social, linguistic,
and cognitive development. Brain
development is most intense from 0 to
3 years. How many children in San
Antonio begin their first day of kindergarten
unprepared for school? Sadly,
we know from decades of experience
that many of those who start behind,
stay behind. Math is the “gatekeeper”
course for students seeking higher education
of any type, or even for those
seeking meaningful work. For example,
a student who finishes high school
must then take a placement exam at
any one of the colleges and universities
in mathematics. Toyota screens for
math skills for their line positions, and
CPS Energy has a math qualifying
exam for workers (Table 1).
Academic failure may lead to
teenage pregnancy, higher dropout
rates, and possibly higher incidence of
crime. For the school year 2005–2006,
the Texas Education Agency reports
152,892 (52 percent) Bexar County
students are at risk for academic failure.
Rates are highest among African
Americans, Hispanics, and low-income students. These children tend
to live in economically disadvantaged
districts, defined as eligible for free
or reduced-price meals under the
National School Lunch and Child
Nutrition Program. San Antonio benefits
from early learning and Head
Start programs. The healthy development
of young children should continue
to be a priority for San Antonio
and the nation (Table 2).
Maternal-Child Health Care
Currently, 50 percent of all births in
Bexar County require Medicaid assistance
to cover the mother’s medical
care during pregnancy (Table 3).
Medicaid funds 85 percent of births
spaced too close together.
Medicaid funds 80 percent of births
to teen mothers.
Birth outcomes can be improved for
uninsured women by providing preconception
care. Women who are
young, single, working part-time, or
unemployed are at highest risk for
being uninsured. Based on pilot tests
conducted in San Antonio in 2007,
among 40 survey participants, 72 percent
of mothers claimed they did not
plan on getting pregnant.
Note: About 2000 births to undocumented
mothers occurred in Bexar County each
year. Emergency Medicaid funds these
births, which are not included in the above
statistics. Emergency Medicaid covers the
infant and pays for the delivery.
Maternal Indicators
Among Bexar County residents,
26,194 births were recorded in 2006.
This data maintains a trend that concerns
the health district:
• 50 percent of deliveries funded by
Medicaid;
• Increasing numbers of single mother
births;
• Increasing rate of late prenatal care
births; and
• Increasing rate of low birth
weights/premature births.
*Note: Data on 2006 infant mortality
rates is not yet available from the State; we
used locally collected deaths. All death data
for the State will be released at a later date.
Unplanned Births and
Low Birth Weight Births
In 2006, Bexar County had 411
very low birth weight (VLBW) infants
in addition to 127 births from
other counties.
Childbirth-related costs are the single
largest component of health care costs
for many employers. The average cost of
a normal, healthy infant delivery in the
United States is about $6,400. One
unhealthy birth can cost anywhere from
$20,000 to more than $1 million per
infant. Those highest costs can be attributed
to VLBW infants (those < 1.5 kg).
In addition to the direct health
care costs, the related indirect costs of
increased absenteeism, higher disability
costs and lowered productivity
magnify the problem. Studies indicate
that being at risk for having a
low birth weight baby is not a genetic
predisposition but is due to variable
factors, including stress (Maternal
and Child Health Journal, Vol. 5,
No. 2, 2001). Young mothers with
existing children have a much more
difficult time with balancing employment,
childcare, and advancing
their educations.
In 2006, Bexar County had 2,543
low birth weight (LBW) infants. These
newborns are at greater risk for health
problems throughout life, but especially
in the first year of life. These problems
include asthma, cerebral palsy,
learning disabilities, insulin resistance
syndrome, hypertension, and cardiovascular
disease.
In 2006, 3,590 children and young
adults (under 20 years old) were newly
diagnosed with a sexually transmitted
disease (chlamydia, gonorrhea, syphilis,
AIDS/HIV). That includes 12 new cases
of AIDS/HIV. In the age group 20 to 29 years were found 5,531 newly diagnosed
STDs, including 59 new cases of
AIDS/HIV.
However, San Antonio continues to
enjoy high rates of childhood vaccination
against preventable diseases.
The National Healthy People 2010
program has a goal of reaching 95 percent
of all children (ages 19 to 35
months) with proper vaccinations.
Some areas of Bexar County are close
to this goal already; however, we still
find pockets of children under-immunized
for diphtheria, tetanus, pertussis,
polio, measles, mumps, and rubella.
Additionally, the Centers for Disease
Control and Prevention Advisory
Committee on Immunization Practices
recommends that infants receive the
Hepatitis B vaccine at birth. In Bexar
County, 20 percent of all newborns in
2006 did not receive Hepatitis B protection
at birth.
Child Abuse and Neglect
and Domestic Violence
Another serious health issue affecting
children in San Antonio is child
abuse. In 2006, Bexar County had
5,755 confirmed victims of child abuse
or neglect. Within the ten zip codes,
42 percent of reported and confirmed
cases of child abuse and neglect were
noted. Child abuse is 10 times more
likely to occur in families where
domestic violence is present. Council
Districts 2 and 5 have the highest rates.
Metro Health recommends support for
childcare programs and services for
new mothers and fathers to help
reduce child abuse.
School districts do not follow San
Antonio city boundaries; however, San
Antonio Police Department (SAPD)
domestic violence cases can provide
some useful information by school district.
Edgewood, Harlandale, and San
Antonio ISD have the highest rates.
Young, low-income parents often have
difficulty balancing the demands of a
new child with the other stressors they
face (Table 4).
Uninsured and Lack
of Routine Health Care
State officials warn that the biggest
problem in Texas is a surging population,
about twice the national growth
rate (23.5 million in 2006, up 12.7
percent from 2000). In Texas, nearly
24 percent are medically uninsured,
compared to a national average of
about 15 percent. According to the
Census Bureau, Texas has the highest
percentage of medically uninsured
people among the states. Small businesses
dominate the economy, and
yet only 31 percent of those with 50
or fewer employees offer insurance
in Texas.
Bexar County reflects the Texas rate,
with about 24.3 percent medically
uninsured. This leads to an overburdened
health care system, as half of
the patients using emergency rooms
(routinely overcrowded) simply need
primary care. Some patients have not
seen a doctor in years. Thus, the greatest
demand for health care is not in
emergency rooms, but at the clinics
and health centers designed to relieve
them. Studies reveal that, although the
uninsured usually receive needed acute
care services, they do not receive
much-needed preventive care for such
life-threatening chronic conditions as
hypertension, diabetes, and heart disease
(Table 5).
Even if everyone were covered, we
lack adequate personnel and facilities
in inner cities and rural areas to provide
care to all. Typically, the problem
of the uninsured is not discussed in
the same conversation as are problems
of health care quality, safety, and effectiveness.
In fact, however, these are
inseparable elements of a high-performing
health system.
Surveillance and Reducing the Rate
and Risks of Chronic Diseases
In 2007, Metro Health was selected to establish a registry for tracking the
prevalence of Hemoglobin A1C as a
measure of diabetes control in our
community. This test is used primarily
to identify the plasma glucose
concentration over prolonged periods
of time. The goal of the registry
is to improve the management and
outcome of diabetic patients. Poorly
managed diabetes may progress
to blindness, amputation, and
heart disease.
Ongoing analysis will be used to
direct prevention and intervention
programs for the San Antonio community
and to determine regional and
state policy. Although valuable information
will be obtained from this
study, the surveillance of A1C lab values
will not identify those unaware
that they have diabetes (50 percent of
the diabetic population), those with
diabetes who lack medical insurance
(25 percent of the San Antonio population),
and those whose A1C levels
are not being actively tracked by their
health care providers.
Health Department Recommendations
for Chronic Diseases
• Emphasize prevention and regular
screenings, increase physical activity,
improve nutrition, encourage smoking
cessation, family planning, and
immunizations.
• Identify our sickest and most expensive,
uninsured patients and create
a case management program to
reduce costs.
• Identify how the health system can be
changed to reduce health disparities.
• Develop surveillance systems to
ensure the health needs of all Bexar
County residents are being met.
• In addition, through the legislative
process, Metro Health was asked to
establish a surveillance and tracking
system to identify and track the prevalence
of cases of community and hospital-acquired methicillin resistant
Staphylococcus aureus (MRSA).
Points to Ponder
As you read this report, we ask you
to look at this strategically: What
needs are not being met? What problems
contribute to unmet health
needs? Who is trying to meet the
demands? How will results be measured?
What outcomes can be reasonably
anticipated? What short-term
actions can be taken to stabilize communities
at risk?
Metro Health’s role is key to understanding
and addressing these diverse
issues. To that end, Metro Health recommends
continuation of communitywide
efforts to:
• Educate policymakers and political
leaders about the significant impact
that health problems can have on the
economic and workforce viability for
a growing and diverse community;
• Identify and work directly with atrisk
groups to provide greater access
and understanding of what steps can
be taken at a personal level to reduce
behaviors detrimental to both adults
and children; and
• Initiate or collaborate in new population-based programs focused on
prevention of disease and reduction
of risky behaviors.
Even as Metro Health begins a new
era of City-County consolidation of
services with University Health System
(UHS) in 2008, the gathering of clinically
relevant and statistical information
about our population will continue.
It is our greatest hope that health
outcomes will improve as our organizational
changes build the foundation
for a High Performance Health Care
System for Bexar County residents.
This article was co-authored by Dr.
Fernando A. Guerra, MD, MPH, FAAP,
and John Berlanga, MPA.
Dr. Fernando A. Guerra is Director of
Health for the San Antonio Metropolitan
Health District and a practicing pediatrician.
He also serves as a Clinical Professor
of Pediatrics at the University of Texas
Health Science Center at San Antonio
and an Adjunct Professor in Public Health
at the Air Force School of Aerospace
Medicine, Brooks Air Force Base, and
Adjunct Professor at the University of
Texas School of Public Health.
John A. Berlanga, Management
Analyst, San Antonio Metropolitan Health
District, has produced the Health Profiles
Report over the past nine years along with
population-based reports indicating the
trends and health status of the community.
He is consistently asked to provide statistical
data and other reference materials that
may assist academic, medical and community
organizations.
