Building Healthy Communities

An Enduring Legacy of Racial Inequality Persists in the U.S.

As a medical student, while wandering around East Baltimore, I looked into the eyes of children and saw the absence of hope, an absence of light.  These kids were barraged with a message every single day of their lives that they weren’t valued, that they didn’t matter.  They internalized that message—a message rooted in racial inequality—and that caused frustration and anger and eventually despair and a loss of hope.  What has led to the loss of hope?  In the United States, there is an enduring legacy of racial inequality.  A legacy that manifests itself in multiple forms such as the school-to-prison pipeline; undocumented adults being excluded from health insurance; children growing up in communities where toxins from industry are more common than access to safe, green spaces.  A legacy that translates into a feeling of powerlessness and hopelessness in low-income communities. This powerlessness, or lack of agency, has profoundly adverse health consequences.

Zip Codes Matter More than Genetic Codes

Beyond the loss of hope, there is a loss of life expectancy.  In places throughout the United States, in our very own golden state, your zip code is more important predictor of your health than your genetic code.  Research shows that in many areas nationwide, a mile can mean 15 more years of life for someone living in an affluent neighborhood as compared with someone living in an underserved community, just several blocks away.  The unrelenting chronic stressors present in American low income environments callously steals years of life expectancy.

How does this work physiologically?  When our bodies perceive a stressor, through the brain, the hypothalamus sends a message to the pituitary gland.  The pituitary gland, in turn, sends a message to the adrenal glands which thereafter release a cascade of hormones.  One of those hormones is cortisol.  Science shows that being devalued, marginalized, feeling like you don’t belong, raises cortisol levels in your blood.  Cortisol is good for you when you’re in an extremely stressful situation, but when one is constantly bathed in cortisol due to feeling these stressors of being marginalized and being told (directly or indirectly) one is less worthy, less valuable, and in a constant state of fear and anxiety, it changes your physiology completely. It makes you more prone to cardiovascular disease. It makes you more prone to diabetes. It makes changes in your brain.  This kind of chronic stress, which is driven by the policies that we have created is as lethal as any knife or any gun.

Although 80+ percent of what affects our health happens outside the health care system, we still operate through the medical model.  The medical model is a $3.5 trillion-dollar enterprise which says bad behavior produces disease which produces premature death.  As such, we use ambulances and emergency rooms to try to prevent death.  We use 15-minute clinical encounters to try to change the course of disease, and we use brochures and pamphlets to try to change people’s behavior.  The problem is that the odds are stacked heavily against low-income Californians, particularly communities of color.  As such, a visit to the doctor’s office will not remedy a lack of affordable housing in a community; poor air quality; unsafe drinking water in disadvantaged communities; the impacts of historic redlining; the disproportionate suspension and expulsion rates of black youth; nor the lack of green space in a community.  As the largest health foundation in the State of California, The California Endowment (TCE), in 2010 embarked on creating a model that recognizes health happens outside of the health care system.

Building Healthy Communities

If racial inequality has been the kryptonite for the United States, what is the remedy?  In California, Building Healthy Communities (BHC) has been a prescription for the chronic stress in communities and has provided an antidote to the loss of agency, the loss of hope, and the loss of light in kids’ eyes.  BHC is a ten-year, $1 billion, place-based initiative by TCE that aims to transform 14 communities by: building power (social, political, and economic); implementing proven health protective policy; and changing the narrative about what produces health (beyond health insurance and individual behavior).  The 14-places are: Boyle Heights, Central Santa Ana, Central/Southwest/Southeast Fresno, City Heights, Del Norte Adjacent Tribal Lands, Eastern Coachella Valley, East Oakland, East Salinas (Alisal), Long Beach, Richmond, Sacramento, South Los Angeles, South Kern, Southwest Merced/East Merced County.  These communities were selected because they have been devastated by health inequities, the grant-making history, data, and key stakeholder interviews.  They were also selected because they represent California’s incredible diversity across race, geographic location, and political orientation.  They are California’s future.

A Spotlight on Fresno

The San Joaquin Valley consists of eight counties–San Joaquin, Stanislaus, Merced, Madera, Fresno, Kings, Tulare, and Kern.  With over 4 million residents, this region is more populous than 23 states while also being younger than other areas of California.  Areas within three of the eight counties in the region have representation in the BHC initiative.

Central/Southwest/Southeast Fresno is one of those places.  The City of Fresno is an agriculturally rich community whose fruits, vegetables, and other nutritious products literally feed the world.  However, the City of Fresno is also home to large areas of food deserts and high concentration of liquor stores.  In fact, among California’s 10 largest cities, Fresno has the highest concentration of retail stores licensed by the state to sell beer, wine, and liquor. On the ground, this means that the people, farm workers, who pick the food that feeds the rest of the world often do not have enough to eat while also living in neighborhoods where it is more likely to have access to a liquor store than to a grocery store.  Cities like Fresno were amongst the hardest hit by the recent collapse of the housing market while also registering the largest upticks in concentrated poverty growth.  These are systemic issues that can be remedied.  We have the power to change these inequities.

TCE is working to create a whole new approach to health.  In California, TCE put a billion dollars on the table.  It is a billion-dollar bet that the communities suffering from negative health impacts have the power to create change in their communities.  As such, we are organizing people to come together and those people are feeling the agency and belonging needed to change the conditions in their very own neighborhoods.  In communities like Fresno, this means ordinary people are being mobilized by their own neighbors to make extraordinary changes happen.  For example, Fresno BHC partners played a key role in the implementation of the Affordable Care Act (ACA) and Medi-Cal expansion.  They were ready to do outreach, education, and enrollment so that as many community residents had health insurance coverage.  In addition to outreach/education and enrollment, they were part of changing the narrative around Medi-Cal while building people power.  It is not by chance that Fresno had some of the highest numbers of Medi-Cal enrollment.  This is the direct result of a coordinated outreach/education effort by BHC partners that ensured eligible individuals understood the benefits of enrolling and then ultimately enrolled.  With enrollment rates above 45% in Medi-Cal, the people in Fresno gained access to the doctor’s office.  They also owned their power and led the charge when it came time to elevate the need to cover all Californians.

In 2014, the Board of Supervisors in Fresno decided that they wanted to cut off health care to 5600 low-income undocumented residents.  Many of those residents are the very same farm workers who toil in the fields to feed us every day.  The Board of Supervisors, following their normal protocol, attempted to do so in the dark of the night over the holidays.  Their attorneys even tried to convince a judge to do so without providing notice to the impacted parties.  BHC partners (community residents, youth, non-profits) did not allow it.  They organized and fought a David versus Goliath battle.  For the first time, the Fresno County Board of Supervisors felt the pressure of a grassroots led effort who was fully committed to standing alongside undocumented residents.  Ordinary people stood up and said this will not happen on our watch.  The fight in Fresno inspired other counties to expand coverage for undocumented residents, it led to a robust conversation amongst Californians about the importance of Health for All, and those same partners were also part of the transformative victory of getting Health for All Kids in 2015.  With BHC partners from throughout California at the table, California passed a law that allows all low-income undocumented children and youth under 19 years old to enroll in full-scope Medi-Cal.

Hope for the Future

Over the course of these ten years, we have learned a great deal vis-à-vis the implementation of BHC.  We have been humble enough to listen directly to on-the-ground partners which has led us to adjust our course over the past few years so as to better reflect the desires of the community.  We have also learned to be hopeful for the future as it is possible to build power, implement policy, and change the narrative.  In California, we have evidence that investing in place-based work can create transformative changes.  We have 5 million people newly insured across the state with health insurance; 260,000 undocumented children with full scope Medi-Cal; and, 1 million people who are eligible to reclassify their low-level felonies into misdemeanors.  We are also making a dent in the school-to-prison pipeline.  In California, we have 400,000 fewer suspensions and expulsions across the state.  As such, kids are staying in school and they are learning and on track to participate in a 21st century economy. Building Healthy Communities is driving a movement throughout the state. Partners from impacted communities are showing the rest of the country that we can rebuild a state for all of us.

Please join Patty James, EatRx Director of Nutrition and Culinary, and co-chair of the Health and Medicine Forum at The Commonwealth Club in San Francisco to hear Dr. Iton’s update on Building Healthy Communities, to be held at The Commonwealth Club, Thursday, August 22, 2019 at 6:00 pm. 

Anthony Iton, M.D., J.D., MPH PhD, is is Senior Vice President for Healthy Communities at The California Endowment, a private, statewide health foundation whose mission is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. Dr. Iton oversees the implementation of Building Healthy Communities (BHC), the foundation’s 10-year, billion-dollar, 14 site, multi-sectoral, place-based initiative designed to improve health status of 1 million low income Californians. Prior to that Dr. Iton served for seven years as the Alameda County Health Officer, and subsequently Public Health Director where he oversaw an agency with a focus on preventing communicable disease outbreaks, reducing the burden of chronic disease and obesity, and managing the county’s preparedness for biological terrorism.

Learn more about Dr. Iton’s work at

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