4
How Have California Communities in Transition Framed Health Disparities for Action?

Mildred Thompson introduced the session described in this chapter by talking about why this Institute of Medicine workshop was held in California. In considering the issue of changing demographics, there was no better place to begin than California. In California, the conversations go far beyond white and black and include immigrants, Native Americans, Latin Americans, and Asian Americans. It is an opportunity to be inclusive and to bring everyone to the table.

Three California communities were profiled: East Palo Alto, Fresno, and South Central Los Angeles. Individuals from each community discussed the issues surrounding the demographics, health, and new populations coming into the community. They presented information about how the different groups worked together and how the different groups framed the issues. Finally, individuals from each community discussed what has been effective in bringing attention to health disparities issues. After the presentations by the individuals from the three communities, Tony Iton shared his thoughts about and reactions to the presentations.

EAST PALO ALTO

Luisa Buada, R.N., M.P.H. Chief Executive Officer, Ravenswood Family Health Center South County Community Health Center, Inc.

Luisa Buada described her background working in community health centers for the past 35 years. She is currently the chief executive officer



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4 How Have California Communities in Transition Framed Health Disparities for Action? Mildred Thompson introduced the session described in this chapter by talking about why this Institute of Medicine workshop was held in California. In considering the issue of changing demographics, there was no better place to begin than California. In California, the conversations go far beyond white and black and include immigrants, Native Americans, Latin Americans, and Asian Americans. It is an opportunity to be inclusive and to bring everyone to the table. Three California communities were profiled: East Palo Alto, Fresno, and South Central Los Angeles. Individuals from each community discussed the issues surrounding the demographics, health, and new populations com- ing into the community. They presented information about how the differ- ent groups worked together and how the different groups framed the issues. Finally, individuals from each community discussed what has been effective in bringing attention to health disparities issues. After the presentations by the individuals from the three communities, Tony Iton shared his thoughts about and reactions to the presentations. EAST PALO ALTO Luisa buada, R.N., M.P.H. Chief Executive Officer, Ravenswood Family Health Center South County Community Health Center, Inc. Luisa Buada described her background working in community health centers for the past 35 years. She is currently the chief executive officer 

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 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA of the Ravenswood Family Health Center, a federally funded community health center. History of East Palo Alto East Palo Alto is a city of 2.5 square miles and was incorporated 25 years ago. It sits physically between the 101 freeway and the southwest end of the San Francisco Bay. East Palo Alto is in San Mateo County, which is also home to several of the wealthiest communities in the United States (Atherton, Palo Alto, Menlo Park). Historically, East Palo Alto began as an unincorporated agricultural area of nurseries, orchards, and family farms. Even today, although the nurseries have disappeared and there are few family farms left, sidewalks remain unpaved. Buada described the houses with picket fences and flower gardens in East Palo Alto as being “reminiscent of a sleepy Central Valley town.” The majority of the residents in East Palo Alto (80 percent of the popu- lation) were African American families up until the 1980s. These families were driven out of the nearby predominately Caucasian areas by de facto segregation and redlining. These protective ordinances (as described earlier by Mindy Fullilove) prohibited the sale of homes to nonwhites until 1947, thereby pushing these families into cities that ring the margin of the San Francisco Bay, adjacent to heavily polluted industrial areas. Other examples of these Bay Area cities (besides East Palo Alto) are Marin City, Vallejo, and Hunter’s Point. In the 1980s, an influx of Latino and Polynesian immigrants seek- ing low-income housing moved into East Palo Alto. Today, more than 56 percent of the population is Latino, 7 percent is Pacific Islander (primar- ily Tongans, with some Fijians and Samoans), and only 22 percent of the population is African American. However, in contrast to East Palo Alto’s wealthier neighbors in the county, most residents live in poverty or do not earn a living wage. In San Mateo County, a “living wage” is calculated to be 400 percent of the poverty level; this is due to the high cost of housing in the county. In East Palo Alto, 77 percent of school-age children qualify for free or reduced- cost lunches. The unemployment rate is nearly 10 percent, whereas the average for the county is 4 percent. In the patient population served by the Ravenswood Family Health Center, 63 percent are uninsured and one-third prefer to communicate in a language other than English. Other challenges that East Palo Alto residents face include drug and alcohol addiction and the associated violence, involvement with the crimi- nal justice system, and destabilized families. The community has no major supermarkets. The prevalence of diabetes and the rate of mortality from

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 CALIFORNIA COMMUNITIES IN TRANSITION diabetes are four times as high as they are in other places in the county. The high school dropout rate is at 65 percent. Nearly half of all fifth graders are overweight or obese. Responding to These Challenges Despite these challenges, Buada stated, East Palo Alto residents have found ways to collaborate and work together. In the Ravenswood Fam- ily Health Center, the clinic operates in response to the needs of a diverse community. For example, all services are aligned to the mission statement of the clinic. All clinic hiring decisions consider not only job qualifications but also cultural heritage, language skills, and an interest in prevention; 85 percent of the clinic’s staff members speak either Spanish or Tongan. Clinic staff members are trained in mediation, conflict resolution, and group problem solving. Because of the community’s growing interest in prevention, the Ravenswood Family Health Center established a 4-year collaborative called “Get Fit East Palo Alto.” This collaborative helped to support a local farmer’s market that opened in the spring of 2008. More recently, the clinic received a grant from the federal Office of Minority Health to create a project called “Multicultural Community Health Connections.” African American, Latino, and Pacific Islander health navigators are working with the community on diabetes education and screening, with a particular focus on health education, nutrition, and avoiding chronic disease. Finally, despite the socioeconomic challenges, the residents of East Palo Alto are resourceful, creative, and resilient. Nonprofit organizations are working together with faith-based groups to improve the health and well-being of the community, often with few material resources at their disposal. Melieni Talakai, R.N. Vice‑Chair, board of Directors, Ravenswood Family Health Center Melieni Talakai trained as a nurse in New Zealand and has lived in East Palo Alto since 1982. She is a nurse at the San Mateo County Mobile Clinic and is on the board of directors of the Ravenswood Family Health Center. As a native Tongan, she still thinks about the challenges that Tongan patients face in the U.S. health care system, how the U.S. system is linked to health care back home, and how she can help. In Tonga, residents are provided with free health care. In the United States, Talakai stated that with the majority of Tongans, health is not the top priority, especially in

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 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA this country, where new immigrants have so many more issues competing for attention (for example, employment and housing). This makes disease prevention even more of a challenge. The Tongan Community in East Palo Alto Talakai estimated that between 10,000 and 15,000 Tongans live in the Bay Area. However, there is not a Tongan physician in the community, and there are only a few Tongan nurses. This makes it difficult to find solutions for health problems affecting the Tongan community. She also added that this creates a sense of urgency for the community because of the pipeline problem: it will take another 15 years or so for Tongan children to grow up and be trained as physicians and nurses. Even within the community, Talakai stated, framing must be used. For example, to reach the Tongan community, one must work through the faith community. East Palo Alto has, she estimated, eight Tongan churches, with the membership in each church ranging from 20 to 100 people. Collabora- tions with the Tongan churches focus on providing access to care, including, for example, invitations to the local health fair, which was a major success. About 600 Tongans, Samoans, and Fijians attended. This was important, because it provided evidence to San Mateo County that the Tongan com- munity has health needs that are not being addressed. Ruben Abrica City Council Member, East Palo Alto City Council Ruben Abrica is a former mayor of East Palo Alto and is currently a member of the city council. His professional background is in teaching and educational research. East Palo Alto recently celebrated its 25th anniversary as an incorpo- rated city. Abrica stated that he believes that without this effort to become incorporated as a city, the displacement forces that East Palo Alto residents face would have been too strong for them to deal with. One of his specific goals as a member of the city council is to provide health insurance to every child in East Palo Alto. As a former mayor of East Palo Alto, Abrica con- vened a community health roundtable to focus on issues of environmental justice. In discussing the importance of framing, Abrica used an example from his own political career that involved, as he described it, “this whole black- brown issue.” When he was first elected to the city council, Abrica was the only Latino elected in a predominantly African American community. Despite this, he stated, no one in the media ever asked him the question “How is it that a Latino managed to get elected in a mostly African Ameri-

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 CALIFORNIA COMMUNITIES IN TRANSITION can community?” However, when he lost an election in the late 1980s, Abrica stated, the first question that the reporters asked was whether he had lost because he is Latino. Abrica described East Palo Alto as having been a majority minority community for over 40 years. Today, however, although it is still a majority minority community, East Palo Alto is now predominantly Latino rather than African American. This has led to a number of inherent tensions. For example, Abrica stated, sometimes “I had to speak bilingual to power,” meaning that he had to present the Latino perspective in the political con- text. Another of Abrica’s sayings is that “We are one city.” At the same time, there are many different communities, and he noted that there are many ways to conceive of community: ethnic, racial, cultural, religious, and linguistic. Abrica emphasized the importance of reframing East Palo Alto as a new city. To have self-determination and responsibility for governing, it was important to incorporate as a city. However, unlike other cities, the mayor and city council members in East Palo Alto have no office, no staff, and no budget. In short, Abrica emphasized the importance of always working together and confronting inequality. If leadership does not adapt to change, this can lead to a loss of resources and activity. Douglas Fort For youth, by youth Founder and Director, Intervention/ReEntry/Street Team Services Douglas Fort discussed health disparities in “the hood.” More specifi- cally, his focus was on the clientele that most people do not talk about: prostitutes, hustlers, and gang members (Crips and Bloods, Sureños, and MS-13s). This clientele does not have access to the services that are pro- vided to other groups. Fort described these people as having “the disease of violence.” More specifically, he explained that murders and shootings are health problems, and correlates with redevelopment and gentrification efforts as well as disinvestment. Redevelopment and gentrification led to the availability and use of crack cocaine, the easy availability of weapons, a lack of social capital, and poor educational opportunities, said Fort. This was all a part of the community in which Fort grew up, and according to him, the same things that happened to the African Americans in the community are now hap- pening to the Latinos in the community. African Americans have moved out of East Palo Alto to other communities in the Bay Area, such as Antioch

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8 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA and Pittsburg. Latinos have now moved in to East Palo Alto, and the same things are going to happen, according to Fort. Fort also described the state of mind of a gang member. In the East Palo Alto area, it is the Crips and the Bloods; in Los Angeles, it is the Norteños and the Sureños. This problem exists regardless of skin color. This is a problem of not valuing one’s self and therefore not valuing education or property. According to Fort, youth join gangs because they have no sense of identity. Discussion, East Palo Alto Following the presentations, John Andrews, from the American Indian Healing Center in Whittier, California, and a previous resident of the area asked the East Palo Alto panelists about the relationship between Stanford University (located in Palo Alto, California) and the Ravenswood Family Health Center. In particular, given the 63 percent uninsurance rate in East Palo Alto, he wondered about the difficulty of accessing specialty care at Stanford Medical Center. Luisa Buada responded that the Ravenswood Family Health Center does lease pediatricians and obstetrician-gynecologist providers from the Lucille Packard Children’s Hospital (part of the Stanford Medical Center). In this way, women and their children have access to services. However, uninsured adult patients must go to the San Mateo County facility, where there is a 3- to 5-month delay for specialty care. Buada also noted that the center does train Stanford medical students, but she emphasized that when students come to work in the clinic, they are working to meet the community’s needs first. There has to be, she stated, “mutual benefit” for furthering student education while meeting the needs of community residents. FRESNO Keith Kelley President and Chief Executive Officer, Fresno West Coalition for Economic Development Keith Kelley is the founding executive of the Fresno West Coalition for Economic Development, which is a community development corporation. West Fresno has the highest concentration of poverty in the city of Fresno, which is the largest city in the San Joaquin Valley.

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9 CALIFORNIA COMMUNITIES IN TRANSITION The City of Fresno Fresno is the agricultural capital of the world. The top five counties in the San Joaquin Valley gross more money from fruits and vegetables than anyplace else in the world; Fresno is number one in the world. At the same time, said Kelley, there is disheartening news about the San Joaquin Valley. A newspaper article in the Fresno Bee stated that, according to The Measure of America: American Human Deelopment Report 2008- 2009, of the 436 congressional districts in the United States, the district that includes Fresno ranks last in income, health, and educational attainment. Similarly, in 2005, Brookings Institution researchers studied poor neighborhoods in the United States. Because the study was performed after Hurricane Katrina, the researchers expected that New Orleans would be the poorest neighborhood in the country. In actuality, however, New Orleans was number 2 and Fresno was number 1. According to Kelley, if the San Joaquin Valley were a state, it would be the most impoverished state in the United States. At the same time, the state of California has the fifth-largest economy in the world. The economic disparity is thus obvious. Despite the wealth in the state as a whole, the San Joaquin Valley has been passed by. Kelley related a story about Alan Autry, the outgoing mayor of Fresno. He had criticized California governor Arnold Schwarzenegger for “bal- ancing the budget on the backs of the cities in California.” The governor decided to put some money into the San Joaquin Valley, which led to the formation of the Central California Partnership. This partnership, in turn, led to interest from foundations focusing on health disparities in the area. For example, The California Endowment is partnering with the Fresno West Coalition for Economic Development on an initiative called California Works for Better Health. The Fresno West Coalition for Economic Development focuses on business development in the Fresno West community. The organization is currently partnering with another nonprofit organization called Social Compact. Social Compact uses a drill-down methodology to determine the assets in a neighborhood that is seeking economic development. This process involves looking at nontraditional data sources such as building permits, utility usage, and banking patterns to create a picture of a com- munity’s economic health. Knowledge of the assets of a neighborhood is a critical tool in encouraging economic investment in the community. Another success story involved the founder of the Fresno West Coali- tion for Economic Development, Myser Keels. He mobilized the community to lobby for a supermarket in West Fresno, and he succeeded. Residents now have access to fresh fruits and vegetables. This was the start of the Fresno West Coalition for Economic Development.

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0 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA In summary, it is important to identify the assets in a community to build an argument for business development and job creation. This is the approach that the Fresno West Coalition for Economic Development has taken. Lue N. yang Fresno Center for New Americans Lue Yang is the executive director of the Fresno Center for New Ameri- cans, a nonprofit organization that provides services to immigrants and refugees from Southeast Asia. He is a member of the Hmong immigrant community in Fresno. Southeast Asians in the Fresno Area Yang began his presentation by describing several of the health dis- parities affecting the Southeast Asian community in the Central Valley (San Joaquin Valley). The first factor affecting health disparities is the fact that the Asians in that region have the highest rate (40 percent) of limited English proficiency (LEP). In contrast, only 30 percent of the Latino com- munity has LEP. Overall, within the state of California, more than one- third of all Asian residents have LEP. In the Central Valley, the majority of Southeast Asians live in the cities of Fresno and Merced. The lack of language-appropriate interpreters thus affects access to both physical and mental health care services. A second major health disparity involves access to health care. Because many Southeast Asians came to the United States from communist coun- tries, trust is a major concern. Cultural issues are also central to treatment regimens; for example, a patient who does not trust his or her physician’s prescriptions may decide to take an herbal medication instead. Health care workers are often not sensitive to the cultural beliefs of the Hmong, stated Yang. He gave an example of a tuberculosis patient who refused to take her medication because it tasted bad. She was not told, however, to eat food before swallowing the medication. Similarly, a patient who is told that he or she needs surgery might want to check with the clan leader to perform a spiritual ritual first. A third example of health disparities can be described by a situation in which a couple was meeting with a mental health care provider. In the Hmong culture, women do not shake hands; only the men do. Conse- quently, when the clinician shook the woman’s hand, her husband became extremely uncomfortable. Each of these examples highlights the importance of cultural compe- tence in the health care system.

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 CALIFORNIA COMMUNITIES IN TRANSITION Interpretation is also a major problem. It is common for parents who are going to see a health care provider to bring their children who do speak English so that they can serve as translators. However, not surprisingly, the translations from the children are not always accurate or appropriate. This led to a lawsuit against San Joaquin County for failing to provide culturally competent interpreters. In Fresno, only one physician speaks the language of the Hmong, but 30,000 Hmong live in Fresno. This situation makes the lack of workforce diversity in the health care arena a major barrier to reducing health dispari- ties. It also makes it difficult for patients to trust their health care providers. Because that one physician cannot meet the needs of all these people, much of the Southeast Asian community has difficulty accessing linguistic and culturally appropriate medical care. Finally, transportation and lack of child care are major barriers to reducing health disparities for this population. Because of the limited Eng- lish proficiency issue, many Southeast Asians do not apply for a California driver’s license. Similarly, accessing quality child care is a major barrier for the same reason. genoveva Islas‑Hooker, M.P.H. Regional Program Coordinator, Central California Regional Obesity Prevention Program Genoveva Islas-Hooker is the regional program coordinator for the Central California Obesity Prevention Program. She began her comments by pointing out that the three speakers on the Fresno panel represent the three largest ethnic and racial groups in the Central Valley: African Ameri- cans, Latinos, and Southeast Asians. Representing the Latino community, she commented that although Latinos have been the majority group for some time, this is not reflected in their levels of educational attainment, participation in the political process, or access to health care. These dis- crepancies in achievement are areas that contribute to the exacerbation of existing disparities being experienced by the Latino community. Genoveva’s family experiences in the Central Valley are, she stated, a classic example of the Latino experience in the San Joaquin Valley. Many people, when they think of farming, have a romanticized vision of green landscapes and easy living. The truth is very different from this vision, Islas- Hooker commented. Framing this vision of what it really means to work in farm labor is very important in terms of determining the truth for the Latino population in Central California. In his earlier comments, Kelley described the Central Valley as being the agricultural center not only of the state of California but also of the nation. Despite this agricultural bounty, the Latino community experiences major

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2 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA health disparities compared to health outcomes for the white population, and Islas-Hooker believes that this is due to the exploitation of the farm worker population in the region. Although the Central Valley has a great deal of wealth, it is maldistrib- uted within the population. Farm workers, for example, do not make a liv- ing wage, according to Islas-Hooker. Not surprisingly, this limits access to health care services. The communities where farm workers live lack infra- structure, which means there are no sidewalks, no streetlights, no animal control, limited access to healthy foods, and no law enforcement officers. All of these environmental factors limit the possibilities for physical activity and healthy eating, which in turn contributes to the obesity epidemic occur- ring in the Central Valley, particularly in the Latino population. Islas-Hooker described her family’s experience in the Central Valley. Both of her parents immigrated to California from Mexico. Although her father’s family was originally financially well to do in Mexico, years of drought forced them to move to the United States and adapt to a new life as migrant farm workers. Her father ran away from home when he was 12 years old and worked as a mechanic’s apprentice to assist his family. In Mexico, Islas-Hooker’s mother did not receive her first pair of shoes until age 12, an example of the poverty that her mother’s family experienced. She immigrated to the Central Valley at the age of 19, along with one of her sisters. Because both her parents had limited educational opportunities, they were forced to work as farm laborers. Moreover, as immigrants, they lived very secluded from the rest of society, and Islas-Hooker explained that she grew up with no role models who were active in the community. This seclu- sion is what Islas-Hooker believes is at the root of preventing more Latinos from being actively involved in advocating for change. SOUTH LOS ANgELES Maxine Liggins, M.D. Area Medical Director, Los Angeles County Department of Public Health The Los Angeles County Department of Public Health is now a sepa- rate department from the Department of Health Services. This allows the public health department to focus on delivering traditional public health services. Los Angeles County is divided into service planning areas (SPAs), and Maxine Liggins is the area medical director responsible for SPA 5 and SPA 6. These two areas are dramatically different from each other but, she said, are also inextricably linked. SPA 5, which covers Western Los Angeles, is predominantly white (63%), and only 10 percent of the population lives under the federal poverty

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 CALIFORNIA COMMUNITIES IN TRANSITION line. In contrast, SPA 6, which covers South Los Angeles, is an increasingly Latino community because of the impact of immigration. About two-thirds of the residents of South Los Angeles are Latino, and the number of African Americans in South Los Angeles has declined. South Los Angeles also has the highest percentage of residents under the age of 17, about 35 percent, which is the highest in all of Los Angeles County. This is consistent with other demographic data showing that in the United States the Latino popu- lation is younger than the rest of the population. In Los Angeles County, Latinos are the only racial or ethnic group that is increasing in size, growing from 20 percent of the population in South Los Angeles in the late 1960s to 67 percent of the population in 2008 and comprising 41.7 percent of the population in Los Angeles County in 2008. The residents of South Los Angeles are also more likely to be poor and, therefore, to be covered by Medi-Cal, the state Medicaid program. Twenty- eight percent of the population in South Los Angeles has incomes below the federal poverty limit. Poverty is, stated Liggins, the major cause of health disparities. Beyond poverty, however, there is racism as well. The homicide rate in South Los Angeles is also high; there are about two homicides per day, said Liggins. This makes homicide a serious health disparity issue as well as a major medical problem. Other serious health problems for the Latino and African American communities include obesity, diabetes, hypertension, and low birth weight (Table 4-1). Asthma is also a problem, but Liggins believes that many asthma cases remain undiagnosed TAbLE 4‑1 Population Health Status SPA 6 SPA 5 Percent of Overweight Children in Grades 5, 25.5 16.2 7, and 9 (BMI* > 95th Percentile) Percent of Children with Current Asthma 6 13 Percent of Adults with Diabetes 9.2 4.2 Percent of Adults with Hypertension 25.4 16.7 Percent of Low Birth Weight 7.3 6.4 Teen Births (Per 1,000 Live Births to Mothers 85.7 8.4 15-19 Years) Infant Mortality (Per 1,000 Live Births) 6.5 3.7 Cancer Death Rate/100,000 209 150 *BMI = body mass index. SOURCE: 2002-2003 Los Angeles County Health Survey (http://www.lapublichealth.org/ wwwfiles/ph/hae/ha/keyhealth.pdf).

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8 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA in 2006 and had more than 300,000 patient encounters. The primary goal of the Coalition is to ensure that patients in SPA 6 have sufficient access to quality primary health care services. The Coalition has identified three areas of priority for its patient popu- lation: access to specialty medical care, access to mental health services, and access to dental health care. Access to specialty care was a particular prob- lem, with the waiting period for access to specialty care at county facilities being 6 months to 2 years. Working with a number of supporting organiza- tions, including The California Endowment, the Southside Coalition was able to establish an Early Diagnostic Intervention Center. The Coalition also created a podiatry clinic, which reduced the previous 6-month waiting time to no more than a week for its patients. Relying on collaborations among community health centers, the Coali- tion has focused on improving health information technology and tele- medicine. Because each individual community health center does not have enough resources, the centers must work together to ensure access for poor and hard-to-reach people in the community. Marqueece Dawson Executive Director, Community Coalition Marqueece Dawson is executive director of the Community Coalition, a grassroots, community-based organization that is 18 years old. The Com- munity Coalition does community organizing across racial lines and has about 4,000 members, primarily African Americans and Latinos. Echoing the comments of the previous two speakers, Dawson men- tioned the demographic shift in South Los Angeles that has resulted in changes in the proportions of Latinos and African Americans. However, he noted, the geographic boundaries have not shifted, with people of color still living within these geographic boundaries. This is true of all big cities in the United States, Dawson stated. South Los Angeles is characterized by violence and crime, economic disinvestment, and a lack of social capital. If these social and economic conditions are not addressed, health care out- comes cannot be improved for any racial group. There are other ways to look at the data regarding this demographic shift, Dawson noted. Often, even though the raw number of people in one racial or ethnic subgroup grows, their proportion relative to another racial or ethnic group may fall. In other words, the number of African Americans living in South Los Angeles may not have declined, but the demographic shift might instead be due to the rapidly increasing numbers in the Latino population. Dawson explained that three factors account for the lack of growth in the African American population in South Los Angeles. First, the prison

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9 CALIFORNIA COMMUNITIES IN TRANSITION population in California is disproportionately African American. The state prison system has 175,000 prisoners, and 45 to 55 percent of them come from Los Angeles County. Of that 45 to 55 percent, about two-thirds come from South Los Angeles. Dawson noted that the number of African Ameri- cans entering the prison system would be considered a migration pattern by scientists studying demography. The second factor for the lack of growth in the African American popu- lation in South Los Angeles is the voluntary departure of black families for the suburbs. These families see this move as a step up and a move away from a dysfunctional community where the social costs of living are high. The third factor is a psychological one. The Latino community in South Los Angeles tends to be made up primarily of first-generation immigrants. They view their life in South Los Angeles as transitory and believe that as soon as their economic status improves, they will move on. This is a mind- set very different from that of the older, more established African American community in South Los Angeles. Dawson terms one of the negative impacts of immigration in South Los Angeles “super exploitation.” By bringing in large numbers of Latinos to work in low-skill jobs—for example, as housekeepers at a hotel—the low- est levels of the working class are destabilized. In the past, virtually any cleaning woman in a Los Angeles hotel would have been African American. Now, it would be difficult to find an African American cleaning woman at any hotel in Los Angeles County. This is true in almost every big Ameri- can city. Dawson described this as “outsourcing without moving” on the part of the hotels. Rather than moving the hotel to Latin America, they replaced their low-wage African American workers with other workers with a weaker bargaining position. The issue of violence also affects relations between the African Ameri- can and Latino communities in South Los Angeles, Dawson said, describing violence as the biggest health issue of all. The number of homicides in Los Angeles (204) is only slightly less than the number of soldiers who died in Iraq (221) from January through July 2008. Iraq is seen as an international crisis, whereas the mayor and police chief in Los Angeles celebrated the fact that 204 homicides was less than the number in any year in the past 25 years. As a community organizer, Dawson believes that conditions in places such as South Los Angeles, Fresno, and East Palo Alto will change only through mass social movements because mass social movements such as the civil rights movement and the women’s movement are what led to wide- spread changes in society. Because many of the new Latino immigrants moving into South Los Angeles are from Central America, where there have been political revolu- tions in many nations, they come to the United States with direct experience

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0 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA in political action. Dawson noted that these recent immigrants can aid with community organizing efforts in creative ways that might not occur to the native-born African American community. He concluded by saying that the outlook for the use of community organizing as a strategy for making widespread changes in South Los Angeles is bright. Discussion, South Los Angeles After the presentations from the South Los Angeles panel, Vickie Katz from the University of Southern California described her own work and asked the panelists a question. Katz described research that she conducted in which she looked at both new and old immigrant communities in 1998 and in 2005. She noted that the African Americans in South Los Angeles had the highest levels of community belonging, civic engagement, and neighborhood pride of any of the groups studied. Additionally, she com- mented on the history of engagement from the perspective of the civil rights movement among individuals in the African American community and how that history of engagement is an inherent strength of the community. Given that South Los Angeles has two separate sets of networks made up of community organizations and other services—the Latino network and the African American network—Katz asked the panel to comment on the challenges and the efforts that are being made to engage people from the two networks to talk about health disparities and other issues. Marqueece Dawson noted that it is true that there are separate net- works of people that are divided along racial lines. In particular, places of worship are among the most racially segregated places where networks congregate; this is especially troubling because places of worship are likely the community institution that has the most contact with its membership. Dawson also speculated that people do not come together across net- works because they perceive it as being too difficult. For example, “block clubs” are organized by people who knock on their neighbors’ doors and invite them to a neighborhood meeting. However, if a person cannot speak the same language as his or her neighbor, it is easy to give up. He noted that community organizations that are larger and better able to deal with logistical issues such as this one need to step in and create a presence. TONy ITON, DISCUSSANT Presentation Themes Tony Iton is the public health director for Alameda County in North- ern California. He was asked to comment on and react to the community panel’s presentations. Iton noted that his job as a public health practitioner

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 CALIFORNIA COMMUNITIES IN TRANSITION is to look at the issues and try to shape solutions from a public health perspective. He described six different themes that he used to categorize the presentations: the notion of place, cultural influences, policy, hidden disparities, media and communications, and power and democracy. Place The first theme that Iton used was the notion of place. Echoing the comments made by Marqueece Dawson, he focused on the idea that the demographics in a community may change and evolve, but the community conditions themselves remain stable. Place matters because it is the home of those conditions, and this, Iton stressed, is the most relevant focus for public health. The field of public health still views communities as simply a collection of individuals and considers that what is needed is to provide services to each individual. Rather, Iton said, what needs to be evaluated are the macro forces that are shaping the lives of the people within the community. In considering the importance of place, Iton noted that it is now pos- sible to use data to more accurately reflect the relationship between health outcomes, educational attainment, housing, economic opportunities, and so on. The advent of the geographic information system technology allows different data sets to be linked to consider these relationships as they flow through the notion of place. Before these new technologies were available, race was seen as the defining variable; now, the context of race in society can be evaluated. Iton commented upon Keith Kelley’s description of the Central Valley as the “breadbasket of the United States,” a place that feeds all of us, yet residents there have difficulty finding fruits and vegetables at the grocery store. Oakland, California, is a similar example, in that it is the home to the fourth largest port in the United States and is thus responsible for bringing inexpensive consumer goods into the region. However, the actual cost of these inexpensive electronics and other items is high because diesel emissions from ships, trucks, and trains directly harm the residents of West Oakland living near the port. In other words, West Oakland residents get all of the costs and very few of the benefits. Similar to the Central Valley, the port of Oakland plays a role in feeding the rest of the United States, but in West Oakland, it is difficult to find fresh fruits and vegetables at the grocery store. Another interesting example of the importance of place was described by Douglas Fort in his comments about East Palo Alto. He said that the environment in which they live infects young people but the rest of the local residents do not pay attention to this. Similarly, there is the idea, described by Dawson, that different people have different relationships

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2 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA with the same place. For example, the African Americans in a community see it as a place where they plan to stay and live and raise children and grandchildren. Others living in the same place, however, plan to leave as soon as possible. This affects efforts to organize people and affects power issues among residents. Culture The idea of seeing culture as an asset is a new idea for the field of pub- lic health, Iton said. He cited the East Palo Alto example of the Tongan, Latino, and African American communities all working together. Another suggestion is to encourage African American kids living in South Los Ange- les to learn Spanish. That would have a positive economic benefit for those children and would expand their perspective on their community. In other words, the pubic health community needs to begin to see the concept of culture as an asset. Another aspect of culture can be seen in the immigrants coming to the United States. Many are refugees from authoritarian regimes and have a high level of distrust of any government. This is a critical theme for public health practitioners to keep in mind, Iton noted, as it affects how practitio- ners provide services to this population. Similarly, the notion of conflict between government institutions and cultural communities, that is, the professional approach versus the indig- enous or intuitive approach, is another theme that public health practitio- ners and researchers need to consider. Researchers in particular, Iton stated, tend to go in to a community, observe the community, figure out what is going on, and then leave to publish papers about it. The community is often left wondering what they got out of this experience. This is the notion of “cultural humility.” Iton cited the examples of Stanford University and its relationship to East Palo Alto and Johns Hopkins University in East Baltimore, Maryland. What is the responsibility of these institutions to the communities they work in? These questions are not often asked; so the culture of science, profes- sionalism, and research can be seen as very paternalistic and exploitative. Policy The initial policy issue that Iton discussed was the notion of structural issues. For example, in places where farm workers are the majority of the population, they must still fight for farmer’s markets so they may access fresh fruits and vegetables. This is, Iton, said, a basic structural injustice and one that is exacerbated by the fact that farm workers cannot live on the wages that they are paid for feeding the rest of the nation. This is a major

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 CALIFORNIA COMMUNITIES IN TRANSITION economic and political issue and is one that the public health community needs to be concerned about. In his comments about Fresno, Keith Kelley spoke of the importance of developing the economic argument for investment in low-income areas. This is, Iton said, a kind of framing; it is taking an issue of structural injus- tice and reframing it in terms of benefits to companies making investments in that place. Another example of a structural policy was the decision by policy mak- ers in East Palo Alto to formally incorporate. This effort to take control of a community is a way to resist the displacement that is all too common in low-income communities. Iton recommended that researchers should con- sider investigating this issue of incorporation and its effects on the potential to avoid gentrification. Hidden Disparities Iton’s fourth theme was that of hidden disparities. He mentioned the health issues affecting Pacific Islanders, Native Americans, and individuals with limited English proficiency and the discouraging data showing the shortened life spans for immigrants in the South and Southeastern states as compared to residents in other areas of the United States. This is pri- marily due to obesity and chronic disease rates growing in the South and Southeast. In some ways, Iton said, racial and ethnic groups such as Pacific Islanders, African Americans, Native Americans, and Latinos are the “canaries in the coal mine” for the future of the United States. This is another way of fram- ing the argument so that people can see their own self-interest in addressing the health concerns of racial and ethnic minorities. Media and Communications Echoing the earlier comments of Lori Dorfman, Iton described the tendency of the media to focus on conflicts rather than solutions. He noted the example from Ruben Abrica’s experience in which the media asked him questions only about why he was not reelected and whether it was because he was Latino as opposed to why he, as a Latino, was elected in the first place in the then majority African American community of East Palo Alto. Public health professionals need to be aware of the media’s tendency to focus on conflicts and manipulate public health stories accordingly.

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 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA Power and Democracy Ultimately, Iton said, the discussion is about democracy. Many of the day’s speakers talked about health care, health insurance, and access to health care; yet the places that the community panelists are from are places that have the greatest need but that are experiencing the greatest disinvest- ment in health care resources. Health insurance companies are reluctant to insure people who are already sick and prefer to insure wealthy, healthy people; health care institutions are beginning to do the same. In Oakland, for example, health care institutions are looking to move to the suburbs, where there is a better payer mix. These policies are the direct result of a lack of democracy, Iton stated. Furthermore, citing the example of Islas-Hooker and her focus on educational achievement, it is important to keep in mind that in a democ- racy, the people do have control. Iton summarized this idea by saying that “America is an experiment” and that outcomes are not preordained. This idea, in turn, can help motivate people. The bARHII Framework Iton’s efforts to frame public health more broadly led to the develop- ment of the Bay Area Regional Health Inequities Initiative (BARHII). The framework of BARHII is designed to assist public health professionals in seven Northern California counties with making decisions about how to devote resources to the complex problem of reducing health inequities (Figure 4-2). The three boxes on right side of the framework in Figure 4-2 represent the traditional medical model, which is based on the idea that individual health behaviors shape the risk of disease, which in turn shapes the likeli- hood of premature death. A more recent conceptualization of this model focuses on downstream factors as they affect health status. The boxes on the left side focus on upstream factors, or what Iton refers to as the socioecological context of health. This includes factors such as social status and the quality of the neighborhood. For poor brown and black people, Iton said, there is a place in every major urban area where they are consigned to live. Public health needs to devote resources to building social, political, and economic power in these neighborhoods, Iton noted. However, public health also needs to move upstream and look at the causes of these upstream factors, such as the policies that have resulted in 175,000 African American men being in prison and therefore not being productive members of the economy. Public health professionals, Iton emphasized, need to intervene to

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Socio-Ecological Medical Model DOWN- UPSTREAM STREAM SOCIAL FACTORS HEALTH HEALTH STATUS GENETICS INDIVIDUAL KNOWLEDGE SOCIAL INSTITUTIONAL NEIGHBOR- RISK DISEASE AND MORTALITY INEQUALITIES POWER HOOD BEHAVIORS INJURY CONDITIONS Class Corporations and Environment Smoking Infectious Infant mortality other businesses Race/ethnicity Social Nutrition disease Life Government Physical Gender Physical Chronic expectancy Immigration agencies Residential activity disease status Schools Segregation Violence Injury (intentional and unintentional) CARE HEALTH ACCESS FIgURE 4‑2 Framework for understanding and measuring health inequities. SOURCE: Bay Area Regional Health Inequities Initiative.  Figure 4-2

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 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA change these racist, classist, and discriminatory policies by arguing for the more equitable distribution of resources at the policy-making table. Finally, it must be noted that it is written into the U.S. Constitution that some people are less equal than others. Iton describes this as being an “indelible stain.” To begin to erase this stain, Iton said, there must continue to be discussions about race, the consequences of discriminatory belief sys- tems, and policies that distribute resources in an inequitable fashion. This, too, needs to be a part of public health; public health departments, Iton noted, need to try to change the status quo by using their power. OPEN DISCUSSION The discussion that took place after Iton’s comments primarily focused on the question of the role of public health and public health departments in advancing policy solutions to reduce disparities. Manal Aboelata of the Prevention Institute in Oakland, California, noted that even if all health care providers were providing culturally competent and linguistically appropriate care, this may still be insufficient to equalize health outcomes or achieve health equity. Thus, he asked about the role of leadership in health departments and in public health as a whole. Maxine Liggins, a health department member, stated that the role of the health department should include starting a dialogue with a commu- nity, convening organizations that can function as collaborators, helping to identify resources, functioning as advocates, and being the custodian of data. In short, she said, it should be an institution with a goal and a vision for all of the residents of a community. An example of this role for a health department, offered Liggins, can be seen in the issue of tobacco. It took more than one branch of the govern- ment to solve that problem. Similarly, with alcohol, success was achieved only by collaborating with Mothers Against Drunk Driving, decreasing the number of liquor outlets, and enforcing laws that govern the purchase of both alcohol and cigarettes. Richard Veloz added that Los Angeles County has a responsibility to work and interact with the community groups trying to solve problems relating to prevention and primary care. Douglas Fort offered an example from San Mateo County in California. He noted that the indigenous peoples of the city of East Palo Alto met with the county mental health directors, and in this way, several city nonprofit organizations were given funding to provide mental health care services to underserved clients. Ruben Abrica followed up by adding that city govern- ments must make health one of their top priorities. Roundtable member William Vega asked the panelists about the ade- quacy of the health care that the young men and women who are circulat- ing through the correctional system receive. Marqueece Dawson responded

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 CALIFORNIA COMMUNITIES IN TRANSITION that this is an issue that came up in a federal lawsuit against the state of California. He went on to explain that some African American residents of South Los Angeles violate the terms of their probation so that they will be sent back to prison because in prison, they can receive the health care or surgery that they need but that they believe they do not have access to outside of prison. Nicole Lurie concluded the discussion by raising several provocative questions for the group to consider for the remainder of the day. She noted that there are predictable cycles of community development and migration, which in turn lead to patterns of health disparities that are also predict- able. She suggested that a computer model could be created to look at this problem and predict where the next waves of disparities will occur around the country. Knowing this, how may the conversation be framed for the next generation? How do we change the trajectory of these future cycles? How does the public health community plan for this? REFERENCES Bay Area Regional Health Inequities Initiative. Health Inequities in the Bay Area. Available at: http://www.barhii.org/press/download/barhii_report08.pdf. Los Angeles County Health Survey. 2002-2003. Available at: http://www.lapublichealth.org/ wwwfiles/ph/hae/ha/keyhealth.pdf. Los Angeles County Health Survey. 2005. Available at: http://publichealth.lacounty.gov/docs/ Key05Report_FINAL.pdf. Measure of America. The Measure of America: American Human Deelopment Report 2008–2009. Available at: http://www.measureofamerica.org/2008-2009-report/about/.

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