As the summer of 2020 heated up, the nation's racial divides were once again laid bare.

The COVID-19 pandemic rapidly spread across the country, disproportionately sickening and killing people of color, while protests fueled by the murder of George Floyd by Minneapolis police officers raged in the streets nationwide.

Protesters in the Golden State demanded change. In response, the governing board of California's San Bernardino County declared racism a public health crisis, joining a wave of municipalities vowing to address long-standing racial inequities.

The four years since – in California and elsewhere – have been a meticulous process, consisting of gathering data and managing expectations, Diane Alexander, San Bernardino County’s assistant executive director, told USA TODAY. Though some say progress is slow-going, Alexander still believes change can happen.

Eventually.

"People need to understand that we've been fighting since slavery to do this work, and people want Rome to be built in a day,” Alexander said. “It’s not going to happen.”

Plus, some of the declarations have run into new opposition amid a wave of backlash targeting diversity, equity and inclusion initiatives.

“Progress is steady but slow. But I think that's to be expected when we're talking about making major shifts in policy and an impact,” said Dawn Hunter, a public health lawyer based in Florida who has analyzed the declarations.

Why is racism a public health crisis?

Centuries of racist policies and practices created barriers to housing, education, wealth and employment – called the social determinants of health – which continue to drive disparities in health outcomes for minorities, according to the U.S. Centers for Disease Control and Prevention.

Racial and ethnic minority groups have significantly lower life expectancies and experience higher rates of illness and death from conditions such as diabetes, hypertension, obesity, asthma and heart disease. Awareness of racism's impact on public health isn't new — the American Public Health Association's first resolution regarding race as a public health issue came in the 1960s and a handful of communities including Pittsburgh, Cook County, Illinois, and Milwaukee County, Wisconsin were among the first to declare racism a public health crisis and began addressing it in 2019.

But the coronavirus pandemic highlighted and exacerbated those disparities as people of color experienced higher rates of infection, hospitalization and death and lower vaccination rates. Floyd's murder in Minneapolis acted as a beacon, drawing attention to how racism permeates society, according to city Mayor Jacob Frey.

"I think what Floyd's murder started was a global recognition that yeah, racism is all-encompassing," Frey told USA TODAY.

More declarations followed in 2020 and 2021. By 2022, more than 300 local and state officials acknowledged the crisis, according to a report from The Institute For Healing Justice and Equity, a research institute based at Saint Louis University in Missouri focused on systemic oppression. Though experts said the pace of these declarations has slowed considerably, the trend has continued. In March, for example, the Sonoma County Board of Supervisors in California voted unanimously to approve a resolution by the county’s health department declaring racism a public health crisis.

“For a long time, we did not recognize that racism had a direct impact on health,” said Tia Williams, director of the Center for Public Health Policy at the American Public Health Association, which tracks the declarations. “And so by making these declarations, communities and leaders are acknowledging racism as a driving force for the disparities in health and overall life outcomes.”

What did the declarations do?

Williams said the declarations are a “critical first step” in addressing the disparities, but they vary greatly in what they pledged to do.

A 2021 APHA analysis of 209 of these declarations found 21 included 10 or more specific actions like increasing leadership, staffing and contractor diversity, or working with grassroots groups; 145 included fewer than 10 actions, and 32 included no actions beyond declaring racism as a public health crisis. Williams said the proposed actions typically fell into four categories: data and accountability, policies and programs, community engagement and funding.

In Minneapolis, Frey said the declaration meant ensuring that mental health access is equitable throughout the city and recognizing the effects gun violence has on minority communities and how it creates generational trauma.

"It's about finding ways to prevent long-standing trauma that these communities have faced," Frey said.

One of the data-focused initiatives was San Bernardino County's equity element group comprised of 16 Black people from various community groups, which Alexander said researched the disparities African Americans in the county face. She advised other local governments to take a similar approach and to address inequities with data first. Now, Alexander’s group is developing paid internship placements in community organizations, workshops on grant applications and using consultants to bridge communication gaps.

"We did a whole lot of trying to build and develop this team to understand ways that we could confront racism," Alexander said. "We can declare it's a public health crisis but also get people at tables."

Collecting data was also an important step in North Carolina's Buncombe County, according to Chief Equity and Human Rights Officer Noreal Armstrong. Armstrong is the project lead from the county on the historic Community Reparations Commission, which was formed in July 2020 after the city council in Asheville became one of the first locales to pass a resolution supporting community reparations for Black residents.

One of the first actions taken by the group, which is in the process of making recommendations to local elected officials, including guaranteed income, was to commission an audit to assess harms done to Black residents in the city and county by existing policies, practices and programs.

"I think a lot of people in the community felt like, 'Yeah, we know what's happening, what's going on with all these harms that have been done, because we live it every day'...and the Cease the Harm audit was able to put that into data form and to codify it," Armstrong said.

In King County, Washington, funding was one of the first short-term goals for the committee tasked with addressing racism as a public health crisis, according to Abigail Echo-Hawk, director of the Urban Indian Health Institute. She was apprehensive when she was asked to join the group, having seen too many "tokenizing efforts" nationwide with little follow through, she said.

With assurances things would be different in King County, Echo-Hawk helped form the Gathering Collaborative, a fluctuating group of predominantly Black and Indigenous community members dedicated to undoing the harms of systemic racism. In 2023, the group was able to award $25 million in grants to 123 nonprofits, community organizations, and small businesses to address the crisis.

"The $25 million is a good step, a beginning step but it's also - as we call it in the Gathering Collaborative - it's 'budget dust,'" she said. "It is the tiniest little portion of the overall budget of King County, and we need to see more investments that are looking to undo racism."

Declarations have ‘become a really polarizing issue’

Leadership changes within communities that have declared racism as a public health crisis have led to a handful of rescinded or walked-back commitments, as well as other controversies, said Ruqaiijah Yearby, professor of health law at Ohio State University. She mentioned Virginia as an example. 

In 2021, Virginia became the first Southern state to declare racism a public health crisis, according to APHA's map of declarations. The following year, then-state Health Commissioner Colin Greene told the Washington Post he opposed the declaration, saying, “If you say ‘racism,’ you’re blaming white people.” Though Greene apologized, he was later ousted by the Virginia Senate, the Post reported. The Virginia Department of Health did not immediately respond to a request for comment from USA TODAY.

“It has become a really polarizing issue around racism as a public health crisis because we tend to focus on the fact that we feel people are being blamed, when we need to understand that it is part of the structure of the system of the U.S. and it impacts all of us negatively,” Yearby said. 

In Holyoke, Massachusetts, former acting Mayor Terence Murphy issued an executive order in June 2021, rescinding the city’s declaration because no action had been taken on the plans, according to city documents. Murphy, a former councilman, stepped into the acting role after former Mayor Alex Morse resigned for a job in a different town, according to city council minutes.

Stephen Fay, aide to current Mayor Joshua Garcia, sent USA TODAY a 2021 news story about Holyoke rescinding its declaration in response to an interview request for current Mayor Joshua Garcia. 

The pushback to the declarations is not unlike the growing backlash to diversity, equity and inclusion in higher education and the private sector growing ahead of the 2024 presidential election, experts said. But racial equity work can still be done, even in communities that haven't made an official declaration or have faced opposition to doing so, according to Hunter, the public health lawyer and leader of the Collaborative for Anti-Racism and Equity.

"It's a benefit to have done it. It helps to drive action," she said. "But it certainly isn't a necessary requirement to still be doing health equity work."

What more needs to be done?

The CDC declared racism a public health threat in April 2021 and President Joe Biden has issued several executive orders aimed at addressing racial disparities, but more legislative action is needed, Yearby said.

Democratic legislators in both the House and Senate have continually reintroduced resolutions declaring racism a public health crisis. Yearby said she hopes any federal legislation would go beyond a symbolic statement by providing funding for state or local officials working on the issue and allowing people to challenge the continued health impacts of racial discrimination.

"If done right, it could be used as another Civil Rights Act,” she said.

Ultimately, the long-term goal is not just eliminating public health disparities but eliminating racism altogether, said Echo-Hawk in King County. She doesn't want her grandchildren battling this same crisis, but she knows the work will take time.

"These systems of oppression have been being built for 500-plus years. It's gonna take us some time to undo those," she said.

Contributing: Sarah Honosky, Asheville Citizen Times; Sam Woodward, USA TODAY.