When Soul 2 Soul Sisters announced in June it would offer grants of up to $350 to Black women facing financial hardship, Niyankor Ajuaj expected to see maybe 100 applicants.

Instead, more than 700 people requested the grants before applications were cut off, and the Denver-based organization is still raising money to help all of the people who are trying to cover necessities like rent and child care, said Ajuaj, who handles communications for the group, which focuses on Black women’s health.

Many people were struggling before the pandemic, and those who lost jobs in earlier phases still haven’t recovered, she said.

“Since vaccine rollout has been happening, the narrative was that everything is fine,” she said. “So many people are being left behind.”

In 2020, protests over police killings of Black people crashed into a pandemic that disproportionately sickened people of color. The state health department, Denver Public Health and others vowed to push for change, but the same disparities became clear when it was time to distribute vaccines: those at the highest risk of catching COVID-19 were less likely to get the shot.

And now that the vaccine is widely available and the urgency to address the pandemic has faded, some are worried that momentum to address those bigger-picture inequities in health will be lost, too. While getting back to the way things were before the virus might sound good, a return to “normal” would still mean people living in some parts of Denver are dying a decade sooner than those in more-affluent neighborhoods.

Johnny Williams, an educator with the Black Community Health Action Response Team in Denver, hopes that the pandemic will result in a lasting investment in neighborhoods and people who those in power often overlook. The gaps that became so obvious due to COVID-19 are nothing new, he said.

“People don’t just need to be addressed when there’s an emergency,” he said. “The problem is to get people (in power) to accept it, because they don’t see themselves in those people.”

Lawmakers have taken at least one step toward addressing the bigger picture.

SB21-181, which Gov. Jared Polis signed in early July, requires most state departments to assess their operations and determine whether they’re creating or reinforcing disparities, and then to develop a plan to fix any problems they find. The bill applies to the departments of Labor, Transportation, Public Safety, Local Affairs, Education, Corrections and Higher Education, as well as the agencies traditionally dealing with health.

Sen. Rhonda Fields, one of the bill’s sponsors, said the pandemic’s disproportionate effect on people of color illuminated how health, education, economic wellbeing and other factors intertwine.

“It’s not just about having access to health care,” she said. “It’s about housing. It’s about wages.”

The goal is to hold state agencies accountable for how well they include diverse groups, and how their policies help — or hurt — not only people of color, but also other underserved groups like low-income people and those living in rural areas, Fields said. The scale of the issue is more than a legislative committee can handle, and those doing the work need to be responsible for finding solutions, she said.

“It can’t just be me. It can’t just be the governor,” she said. “It’s going to take every one of us.”

A “crisis” in public health

A slew of studies over the last year found Black patients were more likely to be treated in low-quality hospitals; that people of color were more likely to be exposed to air pollution from fine particles; and that places where people were exposed to higher levels of fine-particle pollution had higher COVID-19 death rates, which could be one factor in why people of color were more likely to be hospitalized or die from COVID-19 and died at younger ages than white victims of the virus.

In April, the Centers for Disease Control and Prevention called racism a “public health threat” for the first time, because it limits who has access to the building blocks of good health, like a well-paying job, appropriate health care, and safe and affordable housing.

The Colorado Department of Public Health and Environment made a similar statement about two weeks later, calling racism a “crisis” for public health. More than 100 cities, states and other public organizations have made similar declarations, including the Denver City Council and the boards of health in Boulder and Jefferson counties, according to the American Public Health Association.

Dr. Camara Phyllis Jones, an epidemiologist who specializes in the health effects of racism, said in a webinar that it’s noteworthy that cities and states are declaring racism a public health threat, but that doesn’t mean much if they don’t make it clear how they’re going to tackle systems that reproduce worse outcomes for people of color — and then put money into making changes.

“It’s necessary but insufficient” to name racism as a threat, she said.

Jill Hunsaker Ryan, executive director of the state health department, said the department recently hired three people for “top roles” focused on equity within the agency and in community programs focused on the environment and disease control. This year, the legislature created a new Environmental Justice Task Force within the health department, which will work with other agencies and affected communities, she said.

“For CDPHE, it starts with addressing all public health problems by examining the inequities that cause them,” she said in an email.

The health department also is trying out different ways to involve communities, starting with neighborhoods around the industrial areas of Commerce City and north Denver, Hunsaker Ryan said. They’ve contracted with community advisers, notified people via text message of the opportunity to comment on regulations, and used parent-teacher conferences as an opportunity to talk about public health, she said.

“The (COVID-19) emergency isn’t over, particularly for disproportionately impacted communities, and we have to act quickly. We are doing so while committing to developing long-term, broad strategies,” she said. “We know we have to do both simultaneously.”

In Denver, much of the focus now is making sure the health department staff is trained about what it means to focus on equity going forward, said Bob McDonald, executive director of the Denver Department of Public Health and Environment. Once everyone is on the same page, they can start a process of evaluating what they could do better, making changes and adjusting the plan based on community feedback, he said.

“Before we start to make changes, I want to make sure all hundreds of our staff know what that means,” he said.

People in public health have known about disparities for some time, McDonald said, but the pandemic threw them into sharper relief. For example, the department quickly learned how important transportation was, because people in some of the hardest-hit neighborhoods couldn’t get to Ball Arena — then known as the Pepsi Center — for COVID-19 testing, he said. The department later changed its strategy to focus on test sites in high-need areas, as well as testing vans.

“We need to take what we’ve seen and adapt and learn from it,” he said. “I will always remember how difficult it’s been for communities that don’t have the same resources as others.”

The pandemic showed that Americans have a tough time understanding how structures affect health and the risk of disease, Jones said. States prioritized people at high individual risk, such as senior citizens, when distributing the vaccine, but gave less attention to people whose jobs put them in contact with the public, which is a form of structural risk, she said.

“Sympathy and empathy are important, but what we need are protections,” she said.

History shows opportunities, and limitations

In 2020, 19% of Americans said racism was the country’s biggest problem — the largest share since 1968, when 20% said the same thing, according to the Commonwealth Fund.

There is some precedent for a new focus on civil rights translating into real changes in the health system — if not always dramatic improvements in people’s lives.

While they haven’t gotten as much public attention as voting rights, health issues were part of the civil rights movement in the 1960s, said Merlin Chowkwanyun, an assistant professor of sociomedical sciences at Columbia University’s Mailman School of Public Health.

One of the era’s biggest victories was ending formal segregation in hospitals, after the federal government decided that hospitals that rejected patients or kept them in different wards because of race wouldn’t be eligible to get paid by the newly created Medicare program.

“That’s a big victory,” he said. “What it doesn’t end is unequal access.”

Since hospital segregation ended, the gap in life expectancy has narrowed somewhat, but not disappeared. Black children born in 1960 could expect to live about seven fewer years than white children, according to data from the CDC. In 2016, the gap was 3.4 years.

Communities of color still deal with unequal access to health care, but some of the bigger causes of the gap in life expectancy can’t be solved within hospitals, Chowkwanyun said. If people are living in polluted areas, often in crowded housing because their jobs don’t pay enough, it’s more important to deal with the conditions that make them sick than to focus on just trying to treat their symptoms, he said.

“All of the health care solutions in the world aren’t going to do you much good,” he said.

Williams, with the Black Community Health Action Response Team, said some of the factors driving health disparities in Denver can’t be fully addressed without significant changes to the way the environment is set up, so that people aren’t living in heavily polluted neighborhoods. People living in highly industrial areas, like Globeville, have a life expectancy that’s about 10 years shorter than those living in more affluent parts of the city, like Washington Park, according to Virginia Commonwealth University.

In the meantime, communities near highways or other large sources of pollution might ask for filters to help clean the air inside their homes, Williams said. Cities or the state could also subsidize health care for people who are dealing with the consequences of how the environment is set up, he said.

Lucy Molina, a community activist who is running for City Council in Commerce City, said it’s no accident that pollution is concentrated in areas where most people are poor and Latino, Black or Native American. Companies assumed people there weren’t interested in knowing how pollution might affect them, and families who don’t speak English, don’t know how to petition their elected officials, or are working multiple jobs can’t effectively fight back, she said.

Molina lives about a mile from the Suncor Energy oil refinery, and was struck by how different her brother’s home in Lakewood is — the sky was clear enough to see the stars, and the air smelled like fresh-cut grass, not industrial waste. In her neighborhood, it’s become almost normal for families to have multiple members with cancer and for kids to deal with migraines and nosebleeds, she said.

“We are a sacrifice zone,” she said. “If that is not environmental racism, I don’t know what is.”

Scientists made the connection between poverty, living conditions and poor health as early as the mid-1800s, when studying outbreaks of typhus in what’s now Poland, according to an article in Nature. W.E.B. DuBois first made the point in the United States by looking at the age when people died in Philadelphia: people of all backgrounds died earlier in the least healthy places, but Black people were most affected because they were more likely to live in those neighborhoods.

Most people wouldn’t fault a plant given contaminated water if it didn’t bloom, Williams said, but they don’t always have the same understanding for each other. While in theory, people could move to a healthier area, that’s often not practical, given the cost of housing around Denver, he said.

“The question is, would you live in that neighborhood, would you go to that school, would you shop at that store?” he said. “If it’s not good enough for you, why is it good enough for someone else?”

From the ground up

For changes to take hold, we need to get away from the idea that one person, or group, can only gain if another loses, said Jones, the epidemiologist. Everyone, including white Americans, benefits if more people of color are reaching their full potential, she said.

And any progress is going to require patience, Jones said. People who worked low-paying front-line jobs often went to low-performing schools; low-performing schools typically have less property tax funding to work with; and the amount of property tax an area generates now reflects how much banks, governments and individuals invested in a neighborhood decades ago, she said.

“We as a society, today, need to be willing to plant an acorn so our grandchildren have shade,” she said. “It didn’t just so happen that people of color and white people are living in very different conditions.”

Williams said hiring trusted messengers needs to be part of state and local health strategies going forward. People who look like the communities they’re trying to reach and live in the same neighborhoods can get out information about resources and how to navigate the system, he said.

Brandy Emily, health equity branch chief for the state health department, said some of the infrastructure built during the pandemic will be used to address communities’ diverse needs going forward. The health department put a point person in charge of working with local partners to promote vaccines in each region, and the same structure will give the state a way to find out what health problems communities have and what resources they need, she said.

“We’re developing programs that will last beyond” COVID-19, she said. “We know the needs of the state vary, depending on where you are.”

Jon Jacobo, health committee chair of the Latino Task Force in San Francisco, said it’s key to build trust before asking communities to take your word on health matters. The task force started with distributing food boxes at the beginning of the pandemic, which meant people trusted them when they went door-to-door offering testing, and later ran campaigns promoting mask-wearing and vaccination, in partnership with the city health department, he said in a webinar.