Perhaps the most profound takeaway from the 2016 Bexar County Community Health Needs Assessment, which was officially released Tuesday and can be downloaded here, is that, in Bexar County, your health depends on where you live.

According to the 160-page assessment, which analyzed a number of social determinants and their effects on health outcomes among various populations in the county, those living in less affluent zip codes experience poorer overall health than those living in wealthier areas. Residents in zip codes in the inner city – on the near-Westside, near-Eastside, and most of the Southside – experience higher rates of diabetes and obesity, for example, and thus have a much shorter life expectancy – sometimes by nearly 20 years – than those living on the North and Northwest sides of town.

From the 2016 Bexar County Community Health Needs Assessment
From the 2016 Bexar County Community Health Needs Assessment

Overall, Bexar County ranks 95 out of the 100 largest United States counties for life expectancy, said Steve Blanchard, Ph.D., data committee chair of the Bexar County Health Collaborative, during the official health assessment release at the D.R. Semmes Family YMCA Tri Point’s Grantham Center Tuesday. The Health Collaborative – which is made up of health professionals and engaged citizens and organizations – produces the report every three years to give health professionals and residents a comprehensive update of the county’s health status. Blanchard and other Health Collaborative representatives Tuesday presented several of the key health concerns and social influencers – as well as areas of improvement – identified in the report to a crowd of more than 200 people.

Data Committee Chair Steve Blanchard overviews the Community Health Needs Assessment. Photo by Scott Ball.
Bexar County Health Collaborative Data Committee Chair Steve Blanchard overviews the Community Health Needs Assessment. Photo by Scott Ball.

To download the 2016 report’s executive summary in English and/or Spanish, click here.

Regarding the disparity between life expectancy rates, racially-ethnic groups – predominantly Hispanics – carry the burden of this “premature death,” Blanchard said. These groups also experience lower levels of income and education, and have more limited access to health care compared to non-Hispanic white communities.

But these trends aren’t new, more than one Health Collaborative representative said. And as Bexar County’s population continues to grow, the organization aimed for this year’s assessment to lead to resolutions, especially since the Hispanic population – which “experience(s) more conditions that harm health than do non-Hispanic whites, and face structural and systematic barriers to resources and well-being” – is expected to increase from 59%-66% by 2050.

“For these reasons the rapid growth of the Hispanic population is one of the single most important drivers of the current and future health and well-being of the Bexar County population overall,” the report states.

Social inequalities and health; From Bexar County Health Collaborative 2016 community health needs assessment

The 2016 assessment places an emphasis on analyzing the social factors that affect certain health outcomes so that the community as a whole can look at the issues from an “upstream perspective,” Blanchard said. As indicated in the chart below, “upstream factors,” such as certain social inequities, affect “downstream factors,” such as disease and mortality.

Analyzing the “upstream factors” means digging deeper and moving beyond simply treating diseases and health conditions to tackling prevalent and reoccurring health issues at their root causes, which typically involve poverty and a lack of health education and public safety, among other things, Blanchard said. In doing so, the poor health trends in at-risk areas can be reversed over time, starting with the current generation of children.

“Really, the most critical social determinants are ones that affect developing children and have ripple effects on their life cycle,” said Dr. Robert Ferrer, Health Collaborative board chair.

Poor health literacy is an issue that the report refers to as “a stronger predictor of health outcomes than income, employment status, education level, race/ethnicity, and age,” which can “reinforce existing health disparities.”

From the 2016 Bexar County Community Health Needs Assessment
From the 2016 Bexar County Community Health Needs Assessment. (click to enlarge)

“Not enough (nutritional) information is being presented to people,” Bexar County Judge Nelson Wolff said before the report findings were presented. Diligently working to more easily provide that valuable information to consumers when they purchase food – such as calorie amounts, fat content, and more – is one way to make at-risk communities more aware of their healthy and unhealthy eating choices, he said.

Poverty is described in the report as “one of the single most powerful ‘upstream’ factors harming health and well-being.” In Bexar County, 18.4%, or more than 335,000 people, are living in poverty, a statistic that has remained relatively steady since 2010. Most of those living in poverty are concentrated in zip codes on the near-Eastside and near-Westside.

Along with poverty, Blanchard touched on several other elements that impact the health and well-being of residents in at-risk areas. Many of San Antonio’s aging houses are in the inner city and often contain lead-based paint, which puts residents at a greater risk of lead poisoning, he said. There is also a large concentration of alcohol retailers in these neighborhoods, he added, and the abundance of vacant homes, which often attract crime or vagrants, deters neighbors from venturing outside for exercise.

“In neighborhoods where there’s a lot of vacant housing, that (safety and) cohesiveness is not there,” Blanchard said, making the neighborhood feel unsafe – another factor linked to low life expectancy.

An added benefit of looking at more of the “upstream effects” regarding social conditions that influence unhealthy behavior is that it’s more cost-effective, said Anil Mangla, epidemiologist and Metropolitan Health District Communicable Diseases Division assistant director. Bexar County ranks No. 2 for diabetic foot amputations. If diabetes rates – and, thus, the number of A1C tests performed – drops by just 1% among adults with pre-diabetes or diabetes, the County can save $409 million in 20 years, Mangla said. The cost of doing nothing, he added, would amount to about $1.7 million per month.

City of San Antonio Metropolitan Health District Assistant Director of Communicable Diseases Division Anil Mangla gives an overview of the Community Health Needs Assessment. Photo by Scott Ball.
City of San Antonio Metropolitan Health District Assistant Director of Communicable Diseases Division Anil Mangla gives an overview of the Community Health Needs Assessment. Photo by Scott Ball.

“This is something that is doable,” he said. “If we look at people changing their lifestyle…changing their diet and exercise, you can see the significant changes.” Although the percentages may seem small, he added, they will make a significant difference.

While there is clearly room for improvement, Mangla said, the county has a few “success stories,” too. The report shows a steady decline in certain sexually transmitted diseases, such as syphilis, chlamydia, and gonorrhea. There also was a decrease in whooping cough as well as the overall teen birthrate.

“These success stories come (from working) collaboratively with many other organizations,” Mangla said. Decreases in the pre-term birth rate and rate of low birth weight babies were also noted.

The report informs the development of the Community Health Improvement Plan (CHIP), which is a long-term, collaborative effort among stakeholder groups to address the key priority areas identified in report. This year’s CHIP will build upon the one established in 2014.

This year’s five focus areas are:

  • Healthy Eating and Active Living
  • Healthy Child and Family Development
  • Safe Communities
  • Behavioral and Mental Well-Being
  • Sexual Health
From Bexar County Health Collaborative 2016 community health needs assessment

All Bexar County professionals and residents are encouraged to get involved with one or more of these sub-groups that will develop long-term strategies over the next few months in order to improve each area.

In the Model of Population Health (see right image) comparing the 237 Texas counties, Blanchard said, Bexar County ranks 74 in overall health outcomes; 66 in length of life; 125 in quality of life; 15 in clinical care; 63 in health behaviors; 128 in social and behavior factors; and 45 in physical environment.

“We’re not doing quite so well as we think,” he said. “There’s work to be done.”

Wolff said that along with the efforts of local health organizations and stakeholder groups, “getting in the ear of the legislature” and encouraging the leadership to expand Medicaid is also imperative to improving the overall health outcomes and opportunities for our community. Blanchard said that Kentucky’s expansion of Medicaid resources led residents there to report better health compared to Texas residents.

“We know that there’s a great (health) disparity within our community between those (who) have resources and those (who) do not,” Wolff said, adding that Texas ranks low in terms of providing health care for citizens. He explained that the political issues in the legislature that prevent Medicaid expansion across the state have a devastating impact on citizens’ health care. “There’s only so much we can do in a local community with the resources we have.

“I must encourage you, if we’re ever going to do better in the state of Texas, then you’ve simply got to get the ear of the legislature and you’ve got to become more politically active,” he said.

This fall, the Health Collaborative will launch an interactive online portal with most of the data from the 2016 assessment. Once launched, anyone can view and download various data sets online – in the form of graphs, maps, tables, and charts – and organize them by indicators such as geography, race, or ethnicity. City and County leaders can also organize the data by districts or precincts, to get an idea of where their constituents stand on the health scale.

“These aren’t just health statistics. They are measures of our civic performance and we need to think about them that way,” Ferrer said. “Our leaders, our organizations, our employers, all the people (who) care about San Antonio’s civic performance need to think about these life expectancy and morbidity statistics as measures of how we’re doing as a city.”

Vincent Nathan, Metro Health interim director, echoed Ferrer’s words. The Health Collaborative hopes that the online portal will help inform more Bexar County residents and health professionals on the county’s current state of health and engage them in the effort to live healthier lives. They’re also hoping to fund more preventative measures for diseases, such as diabetes or heart disease.

“It’s not just about changing people one at a time, it’s about changing our way of life, and prioritizing how we invest,” Ferrer said.

CORRECTION: A previous version of this article stated “Overall, Bexar County ranks 95 out of the 100 largest Texas counties for life expectancy” when it actually ranks 95 out of the 100 largest U.S. counties for life expectancy.

Top image: Judge Nelson Wolff gives opening remarks at the Bexar County Health Collaborative’s 2016 Community Health Needs Assessment release.  Photo by Scott Ball. 

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Camille Garcia is a journalist born and raised in San Antonio. She formerly worked at the San Antonio Report as assistant editor and reporter. Her email is