Do San Antonio and Bexar County each need their own public health department?

“We are engaging in this billboard campaign because Metro Health, as the de facto agency for the county, was not giving us appropriate resources,” then-Commissioner Trish DeBerry said at an August meeting of Commissioners Court.

Less than a year later, Bexar County announced that it was forming a public health division under the county-owned University Health system.

Top city officials were caught unaware.

City Manager Erik Walsh said he was surprised by the move, “especially given how closely we’ve worked with the county over the last two years.”

During the COVID-19 pandemic, San Antonio and Bexar County leaders worked together many times. But the announcement highlighted a breakdown in communication between the two governments around public health.

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Some members of City Council are wondering what the new county public health division will do that Metro Health can’t.

“I’m obviously concerned about it because I don’t want to see two different agencies overlapping and wasting taxpayer money,” said Councilman Clayton Perry, who represents District 10 on the Northeast Side.

Bexar County is spending $60 million of its federal pandemic relief funds on the public health division, calling it a “once-in-a-generation” opportunity. The agency is in the planning stages, but county leaders say it will complement the work of Metro Health, not duplicate it.

For more than a decade, the city has had a so-called interlocal agreement with University Health, the public hospital district of Bexar County, for Metro Health to provide services to Bexar County residents who live outside city limits.

University Health has paid the city about $190,000 a year for those services. They include dental health, sexually transmitted disease control, tuberculosis control, laboratory services, immunization and epidemiological surveillance.

The two sides renewed the agreement annually. But this year, it was allowed to expire April 1 — shortly after the county went public with its plans for the new public health department.

Walsh said the city would continue to offer public health services to residents of unincorporated areas while city officials try to negotiate a new agreement with the county.

County spokeswoman Monica Ramos said Bexar County has already taken over many of the services provided for in the agreement.

Still, Dr. Bryan Alsip, chief medical officer and executive vice president of University Health, said he doesn’t expect the agreement to disappear, although adjustments may be necessary.

“I still believe there’s a need for a version of that agreement,” he said.

Before the county’s announcement, city and county officials had been talking about updating the agreement to reflect Bexar County’s rapid population growth.

The city of San Antonio has more than 1.4 million residents. Bexar County has slightly more than 2 million, and nearly 600,000 of them — 29 percent — live outside the city limits.

The county’s population has been growing faster than the city’s, according to the Census Bureau. Bexar County added nearly 300,000 residents from 2010 to 2020, a 17 percent jump. Over the same period, the city’s population grew by 107,000, or 8 percent.

“In the next 10, 20 years, I wouldn’t be surprised to see a million people living outside the city of San Antonio,” County Judge Nelson Wolff said. “We’ve got to prepare ourselves for that.”

Data on Metro Health services shows they are concentrated within city limits. For example, of COVID-19 vaccine doses administered by the agency, just 6.1 percent went to residents living outside city limits, according to a city spokesperson. Of patients treated at Metro Health clinics, around 7 percent are from outside the city.

Ramos said the county is better equipped to reach people in unincorporated communities, many of whom have limited internet access and get their news outside of mainstream San Antonio news outlets.

“Their needs are a bit different, and the way they receive information is not necessarily the same,” Ramos said. “Those things need to be looked at.”

Public health plan

University Health stepped up its game in responding to the pandemic, Wolff and Ramos said. Hospitals, nurses and doctors were on the front lines of treating COVID-19 patients, and the county health system set up a mass vaccination center at Wonderland of the Americas mall that administered more than 500,000 doses.

The city operated a drive-thru mass vaccination site at the Alamodome. Medical personnel at that location administered more than 226,700 doses. Both closed in March amid declining demand for vaccinations.

Bexar County’s new public health division will do more than just pandemic response. Initially, its work will focus on the basics: food inspections and licensing, air quality and hazardous waste containment.

In addition, University Health plans to study public health disparities and so-called social determinants of health, such as access to education, adequate wages, healthy food, and safe living and working conditions. To do so, the county will invest in new software to track health data.

Data is also a key part of Metro Health’s new strategic plan. But even when they study the same problems, Alsip said, the city and county can collaborate by sharing data.

County Commissioner Tommy Calvert, representing Precinct 4 on Bexar County’s East and Southeast sides, envisions an agency that tackles epidemic diseases, nutrition and food insecurity, in-person outreach and more.

Metro Health focuses on much of the same. The city also employs community health workers who try to build relationships in neighborhoods.

Perry isn’t the only council member worried about duplication.

So is District 3 Councilwoman Phyllis Viagran, who represents the South Side.

“I need more transparency from the county,” Viagran said at a council briefing shortly after news broke about the new public health division. “They are not being transparent. They are not working with us. We’re getting our information from the news.”

She later said she’s excited about University Health’s plans, announced last fall, for a new hospital on the South Side. It’s the same location where the county’s public health division will be headquartered.

Viagran is frustrated that her constituents often have to travel farther than North Side residents do to get access to medical care. She hopes University Health’s plans for the area will help.

She’d also like to see City Council have power to make appointments to the University Health board to facilitate better communication and collaboration.

Wolff said it’s not unusual for city and county officials not to notify each other about new initiatives. The county didn’t get a heads-up when Metro Health announced its new strategic plan this month, Ramos said.

Alsip of University Health said county officials have always collaborated with Metro Health and will continue to do so. He pointed to a joint city-county plan in the early 2000s to improve intergovernmental relationships. He sees the new health division as a way to further align efforts.

Mayor Ron Nirenberg agrees.

“Any effort to improve local health outcomes is welcome,” Nirenberg said. “While we might not know the full details of this new initiative, there’s no reason for this … to cause friction.”

Public health investments

Local governments across the country have jumped at the chance to expand public health services in light of the pandemic.

Many experts have said COVID-19’s initial devastation was in part a result of declining investment in public health. Agencies best positioned to respond often lacked resources.

Now many local leaders say the San Antonio area needs to be better prepared for future pandemics.

Justin Rodriguez, Precinct 2 county commissioner representing the West Side, said the county’s effort will fundamentally change the delivery of public health services.

“This was not in any way doing something that was counter to or disruptive of what Metro Health’s doing in our community,” Rodriguez said. “It was really just expanding beyond those resources.”

Calvert said city officials weren’t the only ones taken by surprise by the new public health division. He’s heard complaints from business executives and neighborhood association leaders, who said they wanted more information and an opportunity to offer input.

There’s still time for that, Calvert said. He wants to re-examine the powers Commissioners Court handed over to Metro Health in the interlocal agreement.

How will those conversations look in the future?

“All the entities will be at the table,” Calvert said.

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