The City of San Antonio’s (COSA) Metropolitan Health District (Metro Health), a PHAB accredited agency, is located within the city of San Antonio and Bexar County which serves over 1.5 million residents as the 7^th largest city in the United States and the 2^nd largest city within Texas. Bexar County, Texas is a majority-minority metropolitan county with a population of 2 million inhabitants. Latinos account for three-fourths of the overall Bexar County population and three-fifths of its population identify as people of color (i.e., identifying as anything other than non-Hispanic white). Many of the BIPOC (Black, Indigenous, and People of Color) living in Bexar County’s disenfranchised neighborhoods are negatively impacted by socioeconomic inequities, and experience disproportionately higher rates of infection and/or death from COVID-19. These marginalized neighborhoods in San Antonio are in areas where hospitals and medical clinics are sparse, schools are underfunded, grocery stores offer fewer healthy options, and residents’ lack of transportation make it difficult to reach many of these needed facilities. According to the CDC’s community characteristics, 16.3% of Bexar County residents live in poverty, which is higher than the state average of 15.4% and the national average of 10.5%.

The COVID-19 Community Response and Equity Coalition (CREC) has served an important role in convening a wide variety of partners and stakeholders in supporting San Antonio’s COVID-19 response, and has accomplished several projects including:

·         the creation of the COVID-19 Self Screening Online Survey;

·         the creation of several educational documents for community members including the 3P messaging concept (Prevent, Protect, Provide);

·         the creation of peer influencer social media campaigns;

·         the generation of a public health policy risk matrix for social gathering;

·         recommendations to County Judge Nelson Wolff regarding the re-opening/closures of bars within Bexar County; and

·         providing recommendations to Metro Health leadership to update the COVID-19 progress and warning indicators.

Current CREC membership includes over 250 members representing more than 100 organizations across the public health, healthcare, academia, and community sectors. Metro Health has served as the convener and facilitator of the CREC since its inception and thrives in this ongoing relationship built on mutual respect and a desire to collaborate effectively to improve the health of the community and combat COVID-19.

On January 7, 2020, Wuhan, China first confirmed a cluster of COVID-19 cases; and the US first reported cases on January 20. San Antonio made international headlines in February when evacuees from Wuhan arrived at Lackland Air Force Base to complete quarantine. On March 2^nd, San Antonio Mayor declared a "local state of disaster and a public health emergency" over COVID-19 concerns. This declaration occurred prior to the World Health Organization classifying COVID-19 as a pandemic on March 11^th. Bexar County has experienced over 300,000 cases with almost 5,000 deaths associated with COVID-19. The September 2021 COSA Epidemiological Report shows Hispanics constitute the majority of COVID-19 cases and account for a larger proportion of cases compared to the general population of Bexar County.

At the inception of our local epidemic, in March 2020, Metro Health organized the innovative COVID-19 Testing Task Force, to increase access to testing. This Task Force included a variety of partners including health systems, laboratories, urgent care clinics, physicians, fire department, non-profits, and pharmacies. In April 2020 the Mayor and Judge convened the Health Transition Team (HTT), including infectious disease physicians, hospital leaders, epidemiologists, ethicists, and public health experts, to provide guidance toward reopening safely. In May 2020, the COVID-19 Testing Task Force broadened its role and became the COVID-19 Community Response Coalition (CRC) based on community needs and the recommendations of the HTT. Its mandate was to provide support for: developing and monitoring progress and warning indictors, expanding access to specimen collection and laboratory testing for COVID-19, ensuring adequate case investigations and contact tracing, creation of local policy and health alerts, and coordination of education and enforcement activities. The coalition provided critical guidance and oversight to the public health response through five working groups (Indicator Monitoring, Testing & Lab Reporting, Contact Tracing, Enforcement & Education, and Policy & Health Alerts). Prior to the 2020 – 2021 school year, the PreK – 12 Ad Hoc workgroup formed to provide guidance and oversight on COVID-19 guidelines for school-aged children.

The need to improve health communications became increasingly apparent as existing disparities worsened within Bexar County. In response, the CRC adapted its focus throughout the course of COVID-19 to respond to community needs using innovative practices and partnerships. In August 2020, City Council officially declared racism as a public health crisis within San Antonio. This resolution committed the city to root out systemic racism throughout local government based on the racial disparities seen during the COVID-19 pandemic. The CRC pivoted to utilize an equity approach and evolved into the COVID-19 Community Response and Equity Coalition (CREC) in November 2020. This change ensured future efforts put equity at the center of every decision. The CREC remains committed to providing education, resources, advocacy, and access to information and services surrounding COVID-19 to ensure that marginalized populations within San Antonio are prioritized. Some examples include:

·         The first Bexar County Community Health Worker (CHW) Summit in January 2021. This summit celebrated the work of CHWs and addressed challenges and needs shared by CHWs. The Bexar County CHW Summit is now recognized as the Bexar County CHW Partnership (BCCP) and continues to advocate for CHWs.

·         The first Virtual Community Forum in June 2021 invited community members to provide feedback on policy suggestions. Participants stressed the interconnection of the policy priorities which included food insecurity, housing security and the digital divide.

·         Creation of a social media influencer campaign to increase awareness about safe COVID practices through peer influencers who provide their unique voice and style. Social media influencers were assigned specific topics including anti-vaping, asthma, diabetes and vaccines. Each influencer boasts 10,000 to 60,000 followers.

These innovative examples are indicative of how the CREC is anchored to Metro Health function, ensures alignment of efforts given limited resources and demonstrates the importance of being agile on the ground.

Metro Health employed several tools to identify geographic areas needing the most assistance, including COSA’s innovative Equity Atlas (https://www.sanantonio.gov/Equity/Initiatives/Atlas). The Equity Atlas has been vital in assisting with the development and implementation of targeted outreach by the CREC which highlights demographics, disparities, and limited infrastructure distribution. It illustrates the disproportionate number of people of color with low-income households as centralized in specific areas within San Antonio. The use of the Equity Atlas is integral in targeting efforts to create COVID-19 informational townhalls and vaccine clinic locations.

In July 2021, Metro Health received the US Health and Human Services, Advancing Health Literacy (AHL) grant, naming the CREC as the community and stakeholder committee. The Health Literacy team will collaborate with the CREC and community members in planning the health literacy activities to ensure the cultural and linguistic needs are effectively addressed, as well as target all AHL efforts based on health disparities.  The AHL disparity impact statement highlights 22 target zip codes clustered in Bexar County’s western, southern, and eastern areas, as being in the top 25% in at least two of the following COVID-19 indicators: positive case rate, active case rate, and death rate. According to the 2019 American Community Survey, the 22 zip codes contain an aggregate population of 651,062. This area represents one-third of the Bexar County population, but as of April 2021, this area accounted for 52% of deaths, 43% of positive cases, and 40% of active COVID-19 cases in the county.

The AHL project, called Health Confianza, is an innovative partnership between Metro Health, University of Texas Health Science Center San Antonio (UT Health San Antonio), University of Texas at San Antonio (UTSA) and the CREC. Health Confianza will demonstrate the effectiveness of working with local community-based organizations utilizing a health literacy model to increase the availability, acceptability and use of vital information and services to help prevent the spread of COVID-19.

In a targeted effort to move health equity forward, the CREC will remain focused on addressing the disproportionate impacts on marginalized communities and allow for bi-directional feedback and collaboration of community voice.

The CREC is currently co-chaired by Metro Health’s Director, Claude Jacob, and UT Health San Antonio Assistant Dean for the MD/MPH Program, Dr. Barbara Taylor. The CREC originally formed as the Testing Task Force under the direction of then Metro Health Director, Dr. Dawn Emerick, in March 2020 in response to the COVID-19 pandemic. The COVID-19 Testing Task Force was first convened on March 18, 2020, to support expanded, equitable access to COVID-19 testing throughout San Antonio and Bexar County. The Testing Task Force was successful in improving access to testing in marginalized neighborhoods and bringing together public and private partners to quickly increase COVID-19 testing within San Antonio and Bexar County. The Task Force effectively increased specimen collection/testing sites beyond the government supported mass testing locations and recruited more laboratory partners to assist with the analysis of the test kits.

During the Community Response Coalition (CRC) phase, the six working groups (Indicator Monitoring, Testing & Lab Reporting, Contact Tracing, Enforcement & Education, Policy & Health Alerts and the PreK – 12 Ad Hoc work group) allowed for Metro Health to grow its partnerships and relationships across various sectors who were all affected by growing impositions of COVID-19. Partnerships included local school district teachers and staff as well as superintendents, and students; local bar and restaurant owners, laboratory and medical personnel, individuals from academia, public health professionals, community health workers, and various other departments within COSA who pivoted to redirect their staff and resources to COVID-19 efforts.

The CREC currently has over 250 members from over 100 organizations across Bexar County and San Antonio. The CREC is focused on continuing to add community members, community partners and community-based organizations, particularly those representing BIPOC and marginalized communities, as it continues to focus on advancing health equity within San Antonio. Partnering with non-traditional public health organizations such as faith-based organizations and schools allows the CREC to gain valuable perspectives that may have previously been overlooked in decision-making processes.

Currently the two active workgroups within the CREC are Education and Policy & Advocacy. The education workgroup is led by UT Health San Antonio partner Dr. Jason Rosenfeld and Northwest Vista College/SACHWA partner Guadalupe Cornejo and is tasked with creating educational messages & materials, trainings, and providing resources to the community utilizing a peer influencer model. Members of this workgroup represent various organizations from across the city including UT Health San Antonio, various medical offices and providers, Bexar County Medical Society, YWCA, YMCA, Salud America, Education Service Center Region 20, Mayor’s Fitness Council, New Creation Christian Fellowship and Baptist Health, Methodist Healthcare Ministries and others. Through the CREC education workgroup, Metro Health marketing partnered with esd & Associates Marketing to create the COVID-19 Peer Influencer campaign. Peer influencers were selected based on criteria including number of followers, location base, and their target market of followers reached via their social media platforms. The campaign was able to garner 98,440 unique engagements, 11,441 likes, 579 comments and 105 shares via social media outlets. Additionally, this workgroup has created a reflective Storytelling Series within their biweekly meetings which provides partners opportunities to share their specific experiences regarding challenges, successes, and lessons learned over the course of COVID-19. This series provides a space for CREC members to learn from each other and provide feedback to continue developing best practices in all aspects of public health. The Education workgroup is also heavily focused on supporting the Health Confianza project which seeks to increase health literacy in our community by providing linguistically and culturally appropriate information to our community.

The Policy and Advocacy workgroup is led by Metro Health’s Office of Policy and Civic Engagement (PaCE) Public Health Administrator, Sean Greene, and is tasked with identifying and promoting policy priorities that address inequitable impacts of COVID-19 and identifying opportunities and funding sources to address root causes of COVID-19 disparities. Members of this workgroup represent various community-facing organizations across the city including San Antonio ISD, Boys & Girls Club of San Antonio, Center for Healthcare Services, Bexar County Medical Society, Haven for Hope, YWCA, USAA and many others. The Policy and Advocacy workgroup identified nine policy priorities including improving access to healthcare services, improving housing security, improving food security, support for fair policing and justice system, safe spaces for physical activities, addressing the digital divide, improving social support, support of equity-driven approaches to economic security, and supporting the expansion of transportation access.

Over the past year and a half, the CREC has fostered collaboration between Metro Health and a wide range of community members and organizations. The ability to support synergy among partners participating in the workgroups has improved Metro Health’s overall ability to respond to community needs. For example, partnerships within the CREC have allowed Metro Health to set up pop-up vaccination clinics across the city in an effort to provide increased access to vaccinations. This unprecedented level of collaboration, born out of the urgency of the COVID-19 response, can serve as a model for future action.

As the COVID-19 pandemic evolved and more data became available, constructed mapping began to unfold the story of region-specific disparities in health outcomes, with positive case counts, low testing numbers, and the burden of the digital divide. The CREC’s Indicator Monitoring workgroup helped to developed three public dashboards that provide comprehensive, up-to-date information on key indicators relevant to understanding, tracking, monitoring, and responding to COVID-19 locally. Led by Metro Health’s Chief of Informatics, the workgroup assembled to solicit feedback from partners to ensure intelligible information was being distributed to a variety of audiences. Indicators included a surveillance dashboard, a key indicators dashboard, and a self-screening and hotline-calls dashboard. These dashboards are an important resource to communicate pertinent COVID-19 information in a transparent, easy-to-understand, and visually appealing manner. Information is provided through an equity lens, allowing partners to identify and target locations and subpopulations that are most vulnerable to and most impacted by COVID-19. Finally, they provided an accurate timeline and assessment of COVID-19 transmission and disease burden. As San Antonio moved towards re-opening, the key indicators dashboard highlighted city progress and warning indicators that were linked to a color-coded risk level system. Institutions within San Antonio including UTSA and Alamo Colleges utilize the dashboard to set organizational policies surrounding COVID-19. This invaluable tool will enable future efforts to act swiftly and pivot accordingly when subsequent outbreaks threaten public health and will protect our healthcare system from being overwhelmed.

The CREC has adapted from a Testing Task Force that addressed the needs of increased testing in marginalized communities, to a Community Response Coalition charged with ensuring appropriate mitigation measures. Presently, the CREC has refocused its efforts on directing activities that address the disproportionate impact of poor health outcomes related to COVID-19 further exacerbated by misinformation, lack of accessibility to resources, and systemic, persistent inequities. Throughout the evolution of the coalition, several additional workgroups emerged to address pressing issues that were directly related to the mission of each organization represented. Overtime, these workgroups were dissolved as the needs of COVID-19 changed. Where there were once six active workgroups, two workgroups remain that focus on the CREC related education activities and policy and advocacy initiatives, allowing individuals from all original workgroups the opportunity to refocus their efforts.

CREC members and leadership have verbalized a strong commitment towards sustaining the coalition and broadening its mission beyond COVID-19 towards addressing the social determinants that drive health inequities. The coalitions’ commitment will be further reinforced by providing ongoing training and resources, sharing best practices, and lessons learned. Future efforts will be in alignment with the Public Health Forward movement and the modernization effort underway to provide a reimagined vision for the future of the public health system. Core values will be modeled within Metro Health by continuing to focus on health equity efforts, bridging the racial divide, and strengthening new and existing multi-sector partnerships.

The end goal of the CREC is to support a public health system that continually adapts to meet the needs of the community through evidence-based strategies, where sustainability is created through capacity building, policy changes, and advocacy efforts.

Specific successes of the CREC’s collaborative activity that merit highlighting include:

·         Development and iteration of metrics and the community dashboard – Meetings within the Indicator Monitoring workgroup helped to ensure the metrics being shared out were easily digestible and accessible to community members as well as useful to public health and medical professionals.

·         Expansion of testing and vaccination into neighborhoods with the greatest need, using the COVID-19 Equity Index as a guide – The Testing and Lab Reporting workgroup designed a capacity and demand survey to share with testing partners bi-monthly to determine accurate testing turnaround times and availability of testing capacity locally. The survey also helped to determine the number of free testing sites available to residents. Results from this survey along with the COVID-19 Equity Index informed testing partners where the highest need community members were located which helped to determine placement of future COVID-19 testing facilities.

·         Collaboration on community-wide messaging, including COSA’s “What will it take?” campaign and a social media messaging effort led by peer influencers. Rather than using scare tactics to influence COVID-19 appropriate behaviors and precautions, the CREC and its partners focused on how working together with key influencers could lead to collective success with increasing overall community health.

·         Convening town halls on school reopening and parent/teacher/community concerns about risk in schools – The PreK – 12 ad hoc workgroup worked with several local school districts, parents, students and concerned community members to provide a public forum which allowed San Antonio’s Medical Director to publicly answer and address the greatest concerns regarding COVID-19 and the 2020 – 2021 academic school year. Additional public health directives were issued following this town hall to allay concerns as COVID-19 conditions and CDC recommendations were updated.

·         Hosting the city’s first Community Health Worker (CHW) Summit in collaboration with the San Antonio Community Health Worker Association to support CHW efforts during the COVID-19 response – Over 150 individuals attended the first summit, with 77% of individuals identifying as CHWs or within similar roles. The steering committee has been assembled to guide work to be completed under the CDC Community Health Workers for COVID-19 Response and Resilient Communities (CCR) grant. The CREC will also serve as a partner on this project.

·         Creating policy and advocacy workshops and listening sessions led to specific guidance regarding how to address the impact of COVID-19 on our community. The policy priorities identified have been championed by the CREC and partners as guiding principles for future actions. Many items later appeared during the 87^th legislative session.

·         Providing support for three successfully funded grants – Due to the ongoing efforts and strong partnerships with community-based organizations, academic institutions and non-traditional public health partners, the CREC has been identified as a key partner regarding grants awarded to Metro Health by the Centers for Disease Control and the US Health and Human Services Commission.