To cope with an outbreak of coronavirus cases that began in March and accelerated in May, San Antonio’s health department has diverted 317 out of 427 of its employees to fighting the pandemic.

“We are building the team to put out the fire in the middle of the fire,” said Colleen Bridger, assistant city manager and interim director of the San Antonio Metropolitan Health District.

But before the crisis, the work those employees did largely depended on what grant funding was available that year. Interviews with former San Antonio Metropolitan Health District directors and a review of the department’s revenues over the past decade paint a picture of a health department with unstable funding and shifting priorities.

Roughly two-thirds of the department’s $42 million annual budget comes from mostly federal grants, which fund approximately 70 percent of its full-time employees. Many of those positions come and go with short-term grant programs, with staff often having to be reassigned to other initiatives when the funding runs out.

The City has increased the department’s stability by upping its contribution to Metro Health from $11.5 million in 2010 to $15.7 million in 2020. That funding pays for 131 positions, mostly those involved in administrative and financial work, restaurant inspections, and fighting communicable disease.

The State of Texas provides the smallest share of regular funding to Metro Health, with total grant funding ranging from $1.8 million to $3.8 million annually over the past decade.

Bridger, who came to San Antonio from the health department in a medium-sized, semirural North Carolina county to take the top Metro Health job in 2017 is serving in the role again after former director Dawn Emerick resigned five months into the job. Emerick had clashed with Bridger over what Bridger described as insubordination and Emerick’s inability to understand and explain the coronavirus to the public.

Where Bridger, Emerick, and other former Metro Health directors agree is that protecting the public’s health on a city-wide scale is an under-appreciated, under-funded profession whose value has become blindingly obvious because of the coronavirus.

“Why is it that people get the need to fully fund fire departments even when there aren’t fires, but they don’t get the need to fully fund public health even when we’re not in the middle of a pandemic?” Bridger said. “Somehow, we missed our opportunity to communicate the essential nature of a strong responsive public health system.”

Interim Metro Health Director Colleen Bridger (right) speaks to the new COVID-19 operations center located in the Alamodome where case investigators and data-centric epidemiologists work to track the coronavirus. Credit: Scott Ball / San Antonio Report

Recent polls show that San Antonio residents are paying much more attention to the health department as a result of the pandemic. In initial results of a City budget survey in June that drew more than 14,600 respondents, residents picked public health as their top choice of 10 priorities for the next City budget, ahead of public safety, streets, and parks.

Funding varies year to year

One of the hallmarks of the U.S. health care system is that the country spends much more on healing someone after they’re sick than on keeping them well in the first place. In 2014, public health accounted for only 2.65 percent of health spending from federal agencies, according to an analysis by the City University of New York School of Public Health.

Bridger described the differences between public health and medicine, as most people know it.

“What [the medical system does] is treat people once they’re sick. What public health does is stop people from getting sick,” Bridger said. “In a way, people conflate the two. And in another way, people see us as kind of in the way of this giant medical machine that does really well when people are sick.”

Charitable giving also fills some of the gap, with institutions such as Methodist Healthcare Ministries, Baptist Health Foundation, and Kronkosky Charitable Foundation donating millions annually to health initiatives.

A few of Metro Health’s services – women’s, infants, and children’s clinics (WIC) and immunization programs, for example – receive steady funding each year. Metro Health has continued offering WIC, immunizations, and sexually transmitted disease tracking and treatment, even during the pandemic.

Other federal grant programs have only lasted one to three years. Funding tied to bioterrorism preparedness, the Zika virus, and the Ebola virus have all come and gone as Congress has reallocated the funding elsewhere.

“Public health is rightly criticized for taking its eye off the ball and just running after the latest grant money that’s available,” said Dr. Thomas Schlenker, who directed Metro Health from 2011 to 2015. “Which I tried not to do, but there’s a lot of pressure to do that, actually.”

In the decade before the pandemic, funding for disaster preparedness for public health agencies had seen a steady decline, according to a report by the nonpartisan think tank Trust for America’s Health.

Two programs provide most of the funding for emergency preparedness at local health departments, according to the trust. Those are the U.S. Centers for Disease Control and Prevention’s Public Health Emergency Preparedness cooperative agreements with state and local governments, as well as the Hospital Preparedness Program run by the U.S. Department of Health and Human Services.

From 2002 to 2020 federal funding for the CDC’s program dropped from $940 million to $675 million. Funding for the hospital program declined from $515 million in 2004 to $275.5 million in 2020.

Bridger said that the federal government’s investment in public health disaster preparedness proved vital as the virus took hold. Following the anthrax bioterrorism incidents of 2001, public health departments in the mid-2000s received funding to learn the incident command system used by emergency responders. It required five levels of training, including two full days of face-to-face instruction.

“I shudder to think what we would have done in this pandemic had we not had that funding and that experience,” Bridger said. “Thank God we did it because we all spoke the same language” when coordination was needed most.

But short-term grants, even timely ones, aren’t enough to address San Antonio’s existing health landscape, one where many San Antonio residents are trapped in a slow-moving disaster. The city is known for its relatively high rates of obesity, diabetes, and asthma, among other chronic health issues.

Metro Health soon will lose one of the biggest pots of federal funding it receives to tackle some of these problems, Bridger said. Medicaid waiver funding that Metro Health began receiving when Texas elected not to expand Medicaid under the Affordable Care Act will expire without action from state and federal lawmakers, she said.

In fiscal year 2020, that program provided $8.1 million that went toward preventing teen pregnancy, diabetes, sexually transmitted diseases, and gun violence and enhancing oral health, among other uses.

Metro Health before the pandemic

Different Metro Health officials have focused on these chronic health problems in different ways. One of Emerick’s missions was to have San Antonio declare racism as a public health emergency, as has Dallas County.

In a June email to Councilwoman Ana Sandoval (D7), Emerick summarized how a wave of coronavirus cases crashed against a community that was already struggling.

“Similar to how the COVID-19 pandemic has pulled back the ugly carpet on San Antonio’s severe poverty and economic disparities, it too has exposed the ugly realities of a divested national, state, and local public health infrastructure and workforce,” Emerick wrote.

The email was part of a trove of communications between Emerick and her superiors that the City released in response to an open records request. Bridger responded to Emerick’s email by directing Emerick not to email higher-ups or council members without clearing it with her first.

“You know the City; we’re all about chain of command,” Bridger told the Rivard Report on Thursday. “I want to make sure the City Manager knows things before staff share information with Council.”

But did she disagree with Emerick’s overall assessment? “Not at all,” Bridger said.

The same structural problems were obvious to Schlenker when he moved to San Antonio from Madison, Wisconsin, to take the Metro Health director job.

“It struck me that in general people were very poorly educated here, that they often had very little protection or security in the workplace,” Schlenker said. “The most obvious thing was lack of health insurance. In general, workers seemed almost discardable in San Antonio.”

For Schlenker, the answer was to start by going after a simple, straightforward target: sugary soft drinks. He figured a public health campaign against a beverage would be a good first step in tackling obesity and diabetes.

According to Schlenker, the campaign cost him his job. Then-City Manager Sheryl Sculley fired Schlenker in 2015, citing “unprofessional treatment of women.” Schlenker said Sculley was soliciting funding for the City’s health and wellness programs from big soda companies, putting her at odds with his main initiative.

Bridger says she’s wanted to go deeper, to what she considers the roots of San Antonio’s cycle of poor health. As Metro Health director, Bridger’s main initiative was what she calls “adverse childhood experiences,” or ACEs, and “trauma-informed care.”

While in North Carolina, she had taken to heart an influential study linking ACEs to most of the top 10 preventable causes of death in the U.S., including heart disease, stroke, Alzheimer’s, suicide, and more.

“It just felt like you got a really big bang for your buck, and it really speaks to my personal philosophy, which is the earlier you start to address a problem, the more effective you’re going to be,” Bridger said.

Recruiting and pay

One of the biggest issues Schlenker said he encountered during his tenure at Metro Health was a lack of qualified staff. He found it difficult to recruit people with master’s degrees and other advanced degrees to work at San Antonio’s health department.

When he started at Metro Health, the agency had seven people with “epidemiologist” as their job title, but none of them actually had degrees in epidemiology, he said. Instead, they simply compiled health statistics.

“It was a job classification that applied to people who were in charge of number-crunching,” Schlenker said.

To fill that role, he recruited Anikumar “Anil” Mangla, who held a master’s degree in epidemiology from the University of Minnesota. Mangla left the department in 2016 to take a job as director of the University of the Incarnate Word’s public health program.

Before Schlenker, Dr. Fernando Guerra ran San Antonio’s health department from 1987 through 2010. Guerra, a pediatrician and former battlefield surgeon who served in Vietnam, agreed that for decades, providing competitive pay was a problem at Metro Health.

During his long tenure, Guerra spent part of each day working as Metro Health director and the other part running his private practice. With a family to support, Guerra said he needed the extra income from his pediatrics work.

“My days were quite often 16, 17 hours long,” Guerra said. “But as I look back on it, that’s the only way I could have done it.”

Bridger said the pay disparity between the public and private sectors has improved during her time at Metro Health. She’s often able to get City leadership to make exceptions to hire qualified staffers for specialized roles.

“The base pay is too low, and I think they recognize that,” Bridger said.

Since the pandemic, officials have also recognized the importance of having scientific expertise in the department. A Metro Health spokeswoman said the department currently employs 23 epidemiologists as temp workers dedicated to investigating coronavirus cases, stopping the spread in congregate settings, and data management.

“Boy, do they get it now,” Bridger said. “Everybody can say and spell ‘epidemiologist.’”

However, Bridger emphasizes that while scientists and medical experts should serve in top roles, Metro Health’s strengths lie in its community health workers, sometimes called promotoras. These jobs don’t require advanced degrees, and they often involve helping residents navigate the city, state, and medical system’s bureaucracy to find services they need and advocate for more resources.

One example of community health workers in action is the Healthy Neighborhoods program. That program has placed 10 community health workers in high-poverty areas all over the city working one-on-one with residents to fight childhood obesity, with seemly small achievements that can have bigger payoffs. When health workers coordinated with the City’s Animal Care Services to get stray dogs off the street, kids felt safer walking to their local parks, getting much-needed exercise and outdoor playtime.

Bridger said that’s the kind of work that will continue and hopefully expand after the coronavirus crisis passes.

“You’re not funding us to just sit and wait for the next emergency,” Bridger said. “When you fund us at the level that we need to be able to respond to emergencies, we can do really incredible work in the community in the meantime.”

Brendan Gibbons is a former senior reporter at the San Antonio Report. He is an environmental journalist for Oil & Gas Watch.