Dr. Ravi Kavasery says he sees systemic racism at work every day on the job.

Kavasery is a physician with AltaMed Health Services, one of the nation’s largest federally qualified health clinics that serves about 300,000 patients in Los Angeles and Orange counties. About 90% of AltaMed’s patients are on Medi-Cal, California’s Medicaid health program, most are Latino immigrants or children of immigrants, some are undocumented and roughly 25% are uninsured.

“The very first thing I see is patients who are scared to seek medical care because of policies such as the ‘public charge’ rule,” he said, referring to the Trump administration’s rule that could penalize immigrants who receive social services such as food stamps, Medicaid and certain housing benefits, disqualifying their applications for permanent residency in the United States.

“The public charge rule actively discourages immigrants and people of color from seeking medical care. It’s an excellent example that shows the link between systemic racism and public health. You see unequal access and health outcomes.”

So far, since the on-camera killing of George Floyd in Minneapolis on May 25 by a white police officer, which sparked protests across the nation, and numbers showing communities of color such as Blacks, Latinos and Pacific Islanders disproportionately affected by the coronavirus pandemic, dozens of cities and counties across the nation have declared racism a public health crisis and vowed to make changes to address these inequities.

San Bernardino County was the first in California to make the declaration on June 23. Supervisor Josie Gonzales, who spearheaded the effort, said it was the right time for the county to take the crucial step.

“This was our ‘a-ha’ moment,” she said. “The need for this declaration has been there for a very long time. But, in government, you need to build consensus and, many times, you wait for the right people to get in office. We had four other supervisors who were not afraid to support this resolution. This needed to be said aloud.”

Following in the county’s footsteps, the city and county of Los Angeles also made the declaration, as did a handful of cities in the Inland Empire — Redlands, Riverside, Fontana, Moreno Valley and, most recently, Rialto. Nationwide, as of Friday, 83 governmental entities, including cities, county governments and one state government (Wisconsin), had declared racism a public health crisis, according to the American Public Health Association’s website.

Pushback from community members

The declarations also have experienced some pushback from community members. The Inland Empire Citizens Action Committee and Foothill Taxpayers Association issued a memorandum with the subject line: “Get Out! Rescind the Countywide Vision.” Linnie Drolet, who sent out that memo to elected officials, declined to comment.

The memo, however, calls San Bernardino county supervisors “out of control” because “they cave in to political correctness.”

“The nation is involved in unprecedented civil events,” it states. “The board has cuddled up to overt Collectivist/Marxist rhetoric, in response to the George Floyd case.”

It also calls systemic racism “an oxymoron,” saying that if racism is considered systemic or chronic, it becomes a problem that can never be solved.

“The goal is to institutionalize racism and convince us it is part of our American heritage,” the memo states. “If racism is defined as systemic or structural, the narrative is set in stone to demand reparations from the current generation to the current generation of blacks and people of color. Defining it as systemic indicts the entire nation for the sins of past generations without a trial.”

Longtime Rialto resident Keith Vaughn said he is concerned that the declaration “is not founded on scientific evidence, but is politically motivated.”

“We need to talk about legitimate issues such as children growing up without a father in these communities and economic issues that lead to bad choices and bad behavior. They are lumping everything into one pot and calling it systemic racism.”

Link between racism, public health

Narrowly focusing on individuals as opposed to the systems that foster racism and breed inequities is one of the biggest barriers to understanding systemic racism, said Dr. Camara Phyllis Jones, family physician, epidemiologist and past president of the American Public Health Association.

Jones, who has been talking about this issue for nearly two decades and is widely credited for planting the seeds for these declarations, said significant research exists in the medical and scientific community that establishes the link between systemic racism and public health.

Those who want to learn about the impact of racism must think beyond individuals, and about the system as a whole, she said.

“People ask where are the (Black) fathers,” Jones said. “Well, they are in prison because of mass incarceration, which we know disproportionately affects Black men. And we need to start asking why. Why would a woman choose to raise a child as a single parent if there was another way? Why would people choose to live in poverty if there was another way?”

Health is not created in health sectors or by individual behaviors alone, Jones said, adding that to understand the full picture, one has to look closely at the social determinants of health, those factors that are beyond individual genes and behavior.

“They are the context of our lives,” she said. “Look at where people live. Do they live in a neighborhood where they can access fresh fruits and vegetables? Even if they are available, what do they cost? Grocery stores are not even located in some of the poor neighborhoods. On the other hand, these communities are located right next to toxic, polluted dumpsites.”

Jones points out that the Environmental Protection Agency has a name for these communities — “sacrificed neighborhoods.” These are communities where business is done in pawn shops and poorly funded schools lack educational opportunities, she said.

“How could these factors not have an impact on public health? How could it not affect people’s physical and mental well-being?”

The value of human lives

Racism is so ingrained in the system that most don’t give it a second thought, said Gilbert Gee, professor at UCLA’s Fielding School of Medicine. He gives the example of a wrongful death case where a child is struck and killed in a crash. When attorneys seek compensation in such cases, they calculate that value or worth of the case, for example, by looking at how much that child would have earned had he or she worked until the age of 65.

“If that child is a white male, perhaps that number would be $1 million,” he said. “If that were a woman, that person would only make 75 cents to the dollar. So, the value instantly comes down to $750,000. Now, imagine that number going lower and lower if that person were a black male, female or any other person of color. We’re literally putting a value on human lives based on race.”

While individuals might not hold racist or bigoted views, it has been strongly embedded in legislation and policies that work to the advantage of some, and to the disadvantage of others, Gee said.

When it comes to the history of medicine, race and biology have always been inextricably linked, he said. For example, older, flawed studies determined that Black people did not require anesthesia because “their bodies are different.” While that belief may no longer exist today in society, those attitudes are alive and well in areas of medicine such as in spirometry, a common test used to determine a person’s lung function, he said.

“Even today, spirometers have a race correction factor, where the underlying assumption is that white people breathe differently than Asians or Black people or Latinos, which is simply not true,” Gee said. “It’s based on flawed science.”

How declarations can help

In May 2019, Milwaukee County in Wisconsin was the first U.S. county to declare racism as a public health crisis. The move was not driven by a singular event, but by studies that showed a long history of inequity in the county, which continues to be one of the most segregated places in the nation, said Paula Tran Inzeo, director of Mobilizing Action Toward Community Health (MATCH) with the Population Health Institute at the University of Wisconsin, Madison.

“The city and the state as well as several community organizations have talked about racism for a long time,” she said. “We have among the worst infant mortality gap that is driven by race. So mobilizing and naming racism as a problem was a very important step.”

Inzeo said there is no question that structural racism affects the health of communities of color.

“Racism has an impact on access to social determinants such as food, housing, jobs and education,” she said. “Therefore, people have poor health outcomes with regard to immune function, chronic stress loads and chronic diseases. The toxic stress they experience due to racism and discrimination puts their bodies in a constant state of fighting. The get sick sooner and stay sick longer.”

The question now is whether the declarations will remain mere pieces of paper or create positive change. Inzeo said the institute now works with nearly 100 local organizations in Wisconsin, such as hospitals and schools, to set goals for diversity in hiring and measuring health outcomes. She says at least in Milwaukee County, there are strong signs of progress over one year.

The county has adopted tools to systematically evaluate their programs and practices to advance equity, Inzeo said. And in April, their Board of Supervisors signed into law a measure that commits the county to achieving racial equity by identifying and eliminating racism in its policies and practices.

“This offers the regulatory piece in terms or really holding the county accountable,” Inzeo said. “It is a shift from declaring in word to codifying in law and policy.”

Is there hope for change?

For the city of Riverside, which has traditionally leaned conservative, the declaration was a giant first step toward positive change, said Councilwoman Gaby Plascencia, the first Latina on the City Council.

“Riverside’s demographics have changed not just by ethnicity, but also in terms of political climate,” she said, adding that the declaration in her city is not going to be just a piece of paper. “We’ll be looking at community partners, to change policies that are not inclusive. We’ll look at gaps in the health care system, in education, the justice system. This declaration will be a conversation starter.”

In Riverside, the city’s Human Relations Commission will take a close look at the issue and make recommendations, Plascencia said. She choked up as she talked about how she has felt the glare of racism when she was asked to show “papers” to prove her immigration status, or when she hears some refer to individuals of color as “the Blacks” or “the Latinos” in public meetings.

The process to make change must be community-led as opposed to county- or city-led, said the Rev. Samuel Casey, executive director of Congregations Organized for Prophetic Engagement, which was among several groups that pushed hard for this declaration.

“The real pushback is going to come when we actually need to allocate resources to make these changes,” he said. “I think there will be a pushback when we do studies around law and justice. It’s going to be something we’ll have to deal with as a community.”