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“Think about the ... decades (and) decades of just fighting to get the conversation about race even centered in the American psyche," she said. “Now people talk about it as a general course of fact.”

Some places' health departments took on the work of the declarations, creating improvement plans centered on . Others turned the work over to task forces and consultants to look at internal work environments or make action plans and recommendations.

Years after the declarations, community organizers and public health advocates in Milwaukee and Sacramento County say not much has changed. Officials counter that it’ll take more than a few years to undo centuries of structural and institutional racism.

But experts, officials and advocates all agreed on one thing: The declarations were an important first step toward creating a racially equitable society. Extensive research shows racism can have detrimental health impacts on people of color, including chronic stress and anxiety and higher rates of heart disease and asthma.

“If we’re not going to name racism in the first place, then we’re not going to start to develop solutions to address it,” said Dara Mendez, who teaches epidemiology at the University of Pittsburgh and studied the early declarations. “... Then the next step is (asking) what are the actions behind it? ... Are there resources? Is there community action?"

Milwaukee's approach

Lilliann Paine wanted to see everyday public health work focus on the intersection of racism and public health, and in 2018 brought the idea to the Wisconsin Public Health Association. Milwaukee, where Black people are the became one of the first cities in the country to adopt a declaration in 2019.

“If racism as a public health crisis was truly operationalized, we would have more people graduating from high school. If it was truly operationalized, people could live to their full potential and not worry about being mistaken by a police officer for having a gun,” said Paine, who was the chief of staff at the city's health department from late 2019 to March 2021. “And those aren’t changes you can speak to overnight.”

Wisconsin's biggest city now has a , released in December, that wants to address racism as a public health crisis in various ways — from increasing voter registration to improving infant mortality rates, which are three times higher among Black infants than white infants.

The plan also highlights the need to improve housing conditions, and one of the health department's key priorities is addressing lead poisoning in older homes. Black children in Milwaukee are up to 2.7 times more likely to have elevated blood lead levels compared to other races, according to the community health improvement plan.

“When the built environment is essentially a poison in your families, you’re going to see health outcomes that affect that,” health department commissioner Dr. Michael Totoraitis said, giving an example that kids might be "deemed problematic at school because they were lead-poisoned and have permanent brain damage.”

Deanna Branch’s 11-year old son, Aidan, got lead poisoning when he was a toddler. She pointed to the dilapidated housing that she and many Black Milwaukee residents have to live in.

“We have to work with what we have and do what we have to do to keep that place safe for our kids," Branch said, adding, "rent is getting higher, but the upkeep of apartments isn’t changing at all.”

Longtime racial equity advocate Melody McCurtis said she's interested in some parts of the plan — but is largely still skeptical.

“When it comes down to tackling racism, I don’t want to see, I don’t want to hear the word ‘explore,’” said McCurtis, who is deputy director of Metcalfe Park Community Bridges, a resident-led community group. “I know you have to explore things, but some of these things, there’s been plenty of research done already … What is the real strategy that’s really going to get folks where we need to be?”

Sacramento County's efforts

Putting money toward racism-as-a-public-health-crisis declarations is an important way for governments to show they're committed to implementing the steps, Mendez said. But money was a rarity in her review of 125 declarations that had been adopted by the end of September 2020.

“It actually is also going to take some financial will and some real investments to create the types of layered strategies that can move the needle on well-being outcomes,” said Guthrie with the Government Alliance on Race and Equity, which works with governments on racial equity in about 20 states. “That doesn’t happen overnight.”

The Centers for Disease Control and Prevention offered millions of dollars in federal grants in for state and local health departments to address racial disparities and develop the workforce.

Sacramento County, California, received $7 million and has used it to to pay various consultants to create an action plan for its health department and to train the staff on implicit bias and racial equity.

The county, which passed its declaration in November 2020, has significant Latino, Asian and Black populations, each with varying . Black infants in Sacramento County had a death rate twice as high as the overall infant death rate in 2020. And between 2010 and 2020, Black, Asian and Hispanic women were all more likely to die during childbirth than white women.

The declaration gave the health department a “green light” to begin addressing equity at the root, county public health officer Dr. Olivia Kasirye said. That included creating a fellowship program for college by 2029 to create a pathway to employment.

Community organizers from Public Health Advocates praise the health department for starting up a health and racial equity unit. But they are frustrated by the lack of outward-facing progress.

A year ago, the organization confronted the county board of supervisors during a meeting over concerns that the county was too focused on internal diversity, equity and inclusion as opposed to racial justice. They were frustrated that the county spent on an out-of-state consultant and didn't put community members on the DEI cabinet — which was established in May 2023, three years after the declaration.

The county also lagged in hiring a DEI chief to oversee the action plan. The Civil Service Commission, which runs the process for choosing and retaining county employees, initially didn't approve the job description because the commission was concerned it would be redundant.

Cephoni Jackson eventually was hired in January. She shared a draft of the yet-to-be-finalized plan, which outlines goals of creating a “culture of belonging," building more inclusive leadership, and coming up with strategies to retain and develop talent. She wants to establish a committee made up of community members by 2025.

The goals don’t have a timeline, and various county leaders are tasked with “championing” each step. Jackson said she’s seeing high energy from employees to begin implementing the action plan, adding: “It’s like the conditions are right for the culture to shift.”

It's progress that's “more than the bread crumbs they've given us," said Kula Koenig, the chief program officer at Public Health Advocates.

And Phil Serna, the county board member who brought forth the declaration, said it's important to recognize what has been done — and what still lies ahead.

“I think in many respects dealing with racism, addressing racism responsibly, is kind of like painting the Golden Gate Bridge, right?” he said. “As soon as you think you’re done, you’re not. You have to go back and start painting again.”

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This story is part of an AP ongoing series exploring the of what is widely called the , which was sparked a decade ago by the fatal shooting of Michael Brown by police in Ferguson, Missouri.

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The Associated Press Health and Science Department receives support from the Robert Wood Johnson Foundation. The AP is solely responsible for all content.