We haven’t reached that point where we have all these great health outcomes. But we’ve reached the point of acknowledging that there is action we can take.
—Ana Sandoval, San Antonio City Councilwoman
San Antonio, Texas
2018 RWJF Culture of Health Prize Winner
A Booming City Embarks Upon a Health ‘Renaissance’
Many longtime San Antonio residents describe their hometown as one of the biggest cities that no one knows.
They say this as a point of pride, and it speaks to the rapid transformation of this South Texas behemoth: In four decades, the home of the Alamo and Riverwalk has doubled in size to a current 1.5 million people, making it the seventh largest city by population in the United States and second in the state to Houston.
With a population that is 60 percent Hispanic, San Antonio offers reminders of its past, like the Mission San Juan Capistrano from 1731, and glimpses of its future, seen in the new shops and residences going up in the upscale Pearl District. But as the city adds an average of 25,000 people a year, partners in the public and private sectors are taking a hard look at entrenched problems to ensure that this 300-year-old community expands into the next century on solid footing and in a way that benefits everyone.
San Antonio is confronting a long history of income inequality and segregation along ethnic and racial lines, and responding to community needs by tackling some of the root causes of poor health that have plagued the city for generations.
Over the last 20 years, the community has made a strong commitment to sustainable change, with groups rallying around such challenges as reducing food insecurity; lowering teen pregnancy; improving mental health services; and facing the intertwined problems of homelessness, substance abuse and incarceration. The work extends to changing policies and entire systems in order to create the conditions for healthful living for the next generation of San Antonians.
The city has also revamped how it responds to people in a mental health crisis. It was the first city in Texas to raise the legal age for purchasing tobacco products from 18 to 21 years and successfully led a statewide effort to downgrade truancy from a criminal to civil offense. Residents have put early childhood education at the forefront, approving a sales tax increase in 2012 to fund pre-K classes for all children.
Councilwoman Ana Sandoval, District 7, San Antonio, Texas.
John W. Bull, presiding judge at San Antonio's municipal court and fifth-generation San Antonian.
“Just like the city is going through an urban renaissance, we’re going through a thought renaissance,” says City Councilwoman Ana Sandoval, an MIT-trained engineer whose family came to the city from Mexico. “We haven’t reached that point where we have all these great health outcomes. But we’ve reached the point of acknowledging that there is action we can take.”
John Bull, a fifth-generation San Antonioan who, as the presiding judge of the city’s municipal court, worked to change the way the judicial system interacts with young people, sees the Culture of Health Prize as recognition of San Antonio’s uniqueness—“finally.”
“San Antonio’s got a lot of charm and it’s got a lot of challenges,” he says. “You have the right people in place now to address those challenges.”
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Kristy and Rodolfo Valenzuela, who have four children, including 6-month-old Zadie, had reservations about sending their oldest son Arlo to pre-K classes. “I was scared to put him in school so early,” Kristy, 26, says. But the experience has prepared the child for school and now the couple’s 4-year-old daughter is eager to enter pre-K. “It’s amazing how fast he picked up things,” Rodolfo says of his son. San Antonio’s commitment to early childhood development is supported by a 1/8 cent sales tax that provides a sustainable source of funding for high-quality, full-day preschool. The program serves 2,000 children a year at a low cost or no cost to parents.
Communications Specialist Jessica Jackson monitors 9-1-1 calls for mental health emergencies that are tracked by the new Law Enforcement Navigation system. Launched this year, the system directs police and emergency responders to transport patients in a mental health crisis to the nearest facility with psychiatric care, bypassing the emergency room. The program is run by the Southwest Texas Regional Advisory Council, which already coordinates trauma transfers through its MEDCOM Communications Center. Thirteen hospitals and treatment centers participate in the project, which requires sharing information on open beds. In a 500-square-mile city, “it’s helped us coordinate much better,” says San Antonio Police Chief William McManus.
Gabrielle Alanis, a college intern at the San Antonio Food Bank, releases water from an ancient irrigation system called an acequia, which carries water from the nearby San Antonio River to irrigate fields. In a unique partnership that reflects the collaborative spirit in San Antonio, the National Park Service has leased 50 acres at the UNESCO World Heritage site to the Food Bank, which will use the farmland to teach not only clients, but also supporters how to grow and harvest crops. “If you can grow your own fruits and vegetables,” says Michael Guerra, the chief development officer of the Food Bank, “you’ve taken care of a lot of your food security.”
HemisFair ’68, the site of the 1968 World’s Fair, fell into disrepair until 2009 when the city created a nonprofit to redevelop the prime downtown parcel. The first project was Yanaguana Park, which opened in 2015, and offers free games and activities for children as well as exercise classes for adults. “This park was designed for the people of San Antonio, not with tourists, in mind,” says Anne Krause, executive director of the Hemisfair Conservancy. San Antonio is rapidly adding parks and trails, thanks to a committed funding stream from a 1/8 cent sales tax, approved by voters four times since 2000.
In San Antonio's District 7, an old, smaller drainage trench alongside West Huisache Avenue now feeds into a new, larger reconstructed storm channel. For the first time, the city of San Antonio is allocating budget dollars for neighborhood infrastructure based on need, as a way of reducing inequities in residents’ quality of life, which can vary greatly depending on where they live. “As a city, we have a commitment to offer a minimum level of service to everyone,” says City Councilwoman Ana Sandoval, who grew up in San Antonio and represents District 7. “No one should live in a flood plain. Sewers should not overflow. Everyone should have a safe sidewalk.”
If residents in San Antonio can’t get to supplies of fresh fruits and vegetables, the fruits and vegetables come to them. The Mobile Mercado, started two years ago by the San Antonio Food Bank, is a mobile farmers’ market that travels to neighborhoods without access to fresh produce. Here, the special truck makes a three-hour stop on the West Side of San Antonio at a parking lot at the Robert B. Green campus of the University Health System. “It gets very easy to target certain schools or neighborhoods,” says Michael Guerra, chief development officer for the Food Bank.
‘An Equity Lens’ to See that Everyone Moves Forward
2016 Culture of Health Prize Winner
A Health Equity Compass
Louisville, Kentucky is targeting places where disparities have the greatest impact to improve education, jobs, and quality of place.
At a City Council meeting in August 2017, Christine Drennon spelled out in stark terms how decisions made a century ago had left San Antonio one of the most economically segregated cities in the country.
As the city began to grow in the early part of the 20th century, inner-city neighborhoods were developed to segregate different races and ethnicities, explained the geographer from Trinity University. These neighborhoods were later redlined by banks, creating dense communities with poor housing stock and little infrastructure. Today, those same communities on the East Side and West Side of the city have life expectancy rates that are as much as 19 years less than in affluent enclaves in the northwest.
“We may have changed the rules about redlining and property, but we never re-did the landscape,” Drennon says.
A boy playing on the splashpad in Yanaguana Park, the newly renovated section of the Hemisfair.
YMCA of Greater San Antonio runs an early learning center for families living at Haven for Hope, a campus that brings many services together.
A promotora, or community health worker, meets with a client to help support her needs and those of her family.
Her comments stoked debate about fairness and justice that led Council members to overwhelmingly agree to apply the concept of equity to the 2018 budget. For the first time, the city allocated funds in one area of spending—work on street repairs, sidewalks, and storm drains—based on need.
The Council was steered by existing data that rated the condition of streets from A to F. “To see the number of failing streets in particular parts of town was very eye-opening for some people,” says Alejandra “Alex” Lopez, the city’s interim chief equity officer. “We’re not taking from somebody. We’re just helping everyone to move forward.”
While the budget approach was a small first step, the Council’s action reflects a larger commitment in San Antonio to broadening the opportunity for everyone to experience better health. The community is confronting entrenched disparities in the quality of life, rooted in practices that kept neighborhoods segregated along racial and ethnic lines.
“It’s not a ‘woe is me’ approach,” says Colleen Bridger, director of the city’s health department. “It’s yup. We have these problems and here’s what we’re going to do about it.”
The road to better health does not begin and end within the walls of a hospital. It’s what happens in the community, and, Bridger adds, requires applying an “equity lens” to remove barriers and steer decisions from budgeting to programming.
The city has emphasized policy changes and systems overhauls. “Fix the policies because policies are what got us into this problem in the first place,” Bridger says.
San Antonio has gone to voters to raise taxes to offer pre-K classes for all children and to improve parks and greenways; revamped the way municipal court interacts with juveniles to include case managers; and convened stakeholders to collaborate on preventing teen pregnancy.
Partners in the private sector also are teaming up to bridge the opportunity gap. Haven for Hope, an 8-year-old, 22-acre campus with housing and services for people experiencing homelessness, has 69 partners with on-site offices, such as the San Antonio Food Bank, Veterans Affairs, Texas RioGrande Legal Aid, and the YMCA. Tina Guajardo, director of early learning services for the YMCA of Greater San Antonio, says it was “vital” to be within walking distance in order to remove obstacles for parents.
Nina Gallegos drops her children off at the YMCA of Greater San Antonio Haven for Hope Early Learning Center before going to work.
I didn't feel like I was asking for help. I feel like I was getting it.
—Nina Gallegos
It’s not a ‘woe is me’ approach. It’s yup. We have these problems and here’s what
we’re going to do about it.
—Colleen Bridger, director, San Antonio Metropolitan Health District
The proximity made a difference for Nina Gallegos, a 27-year-old mother of three. In the span of a year, she saw just how fragile her life was. When her mother was no longer able to help her with housing and childcare, Gallegos lost her job and could not pay the bills. On top of everything, her car was stolen.
“It’s like I had built a castle in the sand and suddenly a wave washed it all away,” Gallegos recalls.
At the start of 2018, she moved into a family dorm at Haven for Hope and brought her children—ages 9, 6, and 4—to the YMCA next door for free childcare as she looked for work, eventually finding a job as a custodian at another Y location.
“I didn’t feel like I was asking for help,” Gallegos says. “I feel like I was getting it.”
Connecting the Dots Around Mental Health
Ernie Stevens, an officer with the San Antonio Police Department's Mental Health Unit, on a call at a home.
In a dark, cluttered room in a bungalow on San Antonio’s southern edge, Ernie Stevens pulls up a plastic chair and looks directly at a distraught woman in her thirties.
“Let’s talk for a moment,” Stevens says calmly.
The woman’s words spill out in a confused jumble. She hasn’t slept in days. She hears voices. She hasn’t taken her medication. She fears someone is pulling off her skin. "I’m here to help you,” Stevens assures her. “Let’s get you to a facility.”
The police badge around his neck is the only thing identifying Stevens as a member of the San Antonio Police Department. He is one of 10 officers in a dedicated unit that responds only to 911 calls involving someone in a mental health crisis who could be a threat to him or herself, or others.
The unit is part of comprehensive behavioral health care system, involving not only San Antonio police, but also the Bexar County sheriff’s department, regional hospitals and behavioral health centers, and city and county government offices. The shared goal is to keep people from landing in jail or emergency rooms when what they really need is mental health treatment.
“We make sure that if it’s a mental health issue or a substance abuse issue, we do everything we can for you to get treatment and not be incarcerated for that,” says Gilbert Gonzales, director of behavioral and mental health in Bexar County, which includes the city of San Antonio.
For police, the starting point is training. Every officer must receive 40 hours of crisis intervention training—more than the 10 hours required by the state. “Whenever the worlds of the police and people who are in crisis collide, it’s usually a bad outcome,” says San Antonio Police Chief William McManus. Training has been “a game changer,” he adds, by giving officers better understanding and techniques for responding to situations.
The region also has a new routing system—dubbed the Law Enforcement Navigation Center—to steer 911 calls for mental health emergencies. Before, an officer would take a person who needed to be held for observation to the nearest emergency room or, as a last resort, to jail. Now, the individual goes directly to an open bed at a facility with psychiatric services. Eventually, responders will be able to know very quickly through an online portal the name of a person’s doctor or whether someone was just treated or discharged from a facility.
Stevens, a 10-year veteran of the mental health team, said because of the new routing system, officers this past July diverted about 800 patients from emergency rooms to mental health facilities. After the 911 call to help the woman hearing voices, he was able to bring her directly to the closest behavioral health center.
The San Antonio Police Department estimates that it saves about $10 million a year in jail and emergency room costs by diverting people to immediate care.
A key link in the chain of care is the 10-year-old Restoration Center, an around-the-clock facility for mental health emergencies that is supported by the county hospital, nonprofits, and government agencies. Located west of downtown, the facility has a sobering center for people who have been arrested for public intoxication, a drug detox unit, and an inpatient psychiatric unit that can evaluate and stabilize a person within 72 hours. For patients who want to take the next step and enter rehab, treatment is available next door at Haven for Hope, a 22-acre campus providing services like medical care, job placement help, and housing to individuals and families experiencing homelessness.
“The nice thing about working in San Antonio is that everybody wants to help,” Gonzales says, with the focus being, “How do we get together to solve a problem?”
Gilbert Gonzales directs Bexar County's Department of Behavioral and Mental Health.
San Antonio Police Chief McManus.
Data Makes Case for Collective Action
When Colleen Bridger talks about childhood obesity, the director of San Antonio’s health department is able to include revealing information about the eating and activity habits of 30,000 of the region’s children and teens, including:
- The number of soft drinks they consumed in a day (16 percent had two or more)
- Whether they ate any vegetables the day before (30 percent had not)
- Whether they had a safe place to play (10 percent responded “no”)
The source of this data was not a federal agency or statewide survey. It came from the Witte Museum, a nearly century-old cultural institution in the Alamo City. The museum—which has everything from a dinosaur gallery to exhibitions on San Antonio’s history—converted an indoor treehouse into an exhibit that uses playful, interactive stations to teach kids and their parents about how the body works, while at the same time asking anonymous questions about eating patterns and physical fitness.
The Culture of Health Prize
The Prize honors and elevates U.S. communities working at the forefront of advancing health, opportunity, and equity for all.
The interactive H-E-B Body Adventure exhibit at the Witte Museum collects anonymous data on visitors' health habits.
A boy uses a stair climbing station at the Witte Museum's H-E-B Body Adventure exhibit.
Visitors jump on an interactive floor station at the Witte Museum's H-E-B Body Adventure exhibit.
We don’t have this data any other way. Now we have it by ZIP code. We can map it and target our intervention.
—Colleen Bridger, director, San Antonio Metropolitan Health District
In essence, the museum has “game-ified” a health survey, says Bryan Bayles, the Witte’s curator of anthropology and health who created the exhibit. Although unorthodox, the information and results provide yet another window into communities.
“We don’t have this data any other way,” says Bridger, who leads the Metropolitan Health District. “Now we have it by ZIP code. We can map it and target our intervention.”
San Antonio’s Culture of Health journey is informed by data and focused on tracking progress. Partners connect across sectors—like a museum supplying information to the city’s health department—and engage in rigorous efforts to collect, share, and analyze data to make informed decisions about how they assess needs, deploy resources and measurably improve health outcomes.
A centerpiece of this collective action is the nonprofit SA2020, which tracks progress in 11 categories affecting the quality of life in San Antonio—everything from education to community safety, health and fitness, family well-being, and economic competitiveness. In 2010, then Mayor Julian Castro posed a question to the city: What do you want your hometown to look like in 2020? The answers informed a set of shared priorities that can be tracked year-to-year through 61 indicators, showing just where the city is making progress, stalling, or falling behind.
“It’s like holding up a mirror and reminding everyone where we wanted to go and where we’re currently situated,” says Molly Cox, president of SA2020. Of the indicators, 70 percent are moving in the right direction. “We can use this to move the needle on things the community said was important.”
A partner organization, Community Information Now, shares that trove of material and crunches even more numbers—such as life expectancy estimates by ZIP code—in order to equip communities with better tools for making informed decisions.
With schools, the P16Plus Council of Greater Bexar County brings school districts to the table with universities, nonprofits and businesses to set goals, identify resources and measure results around the “cradle to career” progress of children. Excel Beyond the Bell comes under the umbrella of the nonprofit council and works with 43 after-school programs—groups like Big Brothers Big Sisters, the YMCA and Boys and Girls Clubs—to coordinate activities and measure results.
Colleen Bridger directs the San Antonio Metropolitan Health District.
A boy climbs a rope at the Witte Museum's H-E-B Body Adventure exhibit.