When Milwaukee County became the first jurisdiction to declare racism a public health crisis in 2019, it had among the worst health outcomes in Wisconsin. It was also one of the most segregated areas of the country, with a high Black mortality rate.

The county’s Office on African American Affairs and Wisconsin’s Public Health Association set out to find out why, despite being one of the most economically robust areas of the state, residents’ health is so poor and disparities are so wide.

The team uncovered that racism and discrimination was the main cause of the disparities, said Jeff Roman, the county’s chief equity officer. In response, the county declared that racism has a profound impact on the public health of county residents. Since then, Roman says, it’s informed local policies, practices, and procedures.

“That declaration has really centered the approach to our work to focus on racial equity in health,” said Roman. Most of the strides in the community have been around awareness, learning, and unlearning, and shifting how large institutions operate, even if only marginally.

Declarations of racism as a public health crisis spread across the country in 2020 after the murder of George Floyd and revelations of the pandemic’s disproportionate impacts on Black Americans. Around 260 cities, counties, school boards, health associations, and public health departments have declared racism as a public health crisis.

There’s been little measurable impact, if any. In some communities, the declarations haven’t resulted in any real action. Others have established task forces and offices devoted to racial equity or funding efforts to address gaps and engage the community.

But some experts see it as an important first step in recognizing the systems and structures that perpetuate racial disparities, as opposed to faulting individuals.

“There’s no model for what this work looks like,” Roman said. “There’s no checklist. There’s no course. There’s no template.”

COVID-19, policing, housing, and health care are among the most common areas the declarations reference as targets of improvement efforts. Many committed to improving diversity in leadership and staffing, advocating for anti-racist policies, and narrowing the gap on persistent health disparities. Some referenced the need to improve data collection on racial inequities, a need for improved community engagement, and increased funding for addressing disparities.

They are “acknowledging that racism — and not race — is a social determinant of health,” said Regina Davis Moss, associate executive director of public health policy and practice for the American Public Health Association. “It’s a driver of poor health outcomes and health disparities.”

Most of the declarations were made before November 2020. Since then, the number of new resolutions has dwindled, said Dawn Hunter, director of the Network for Public Health Laws’ southeastern region office. States in the Southeast, where the country's history with racism bleeds heavily into local policy and community dynamics, have among the fewest declarations issued.

Other regions of the country have about equal numbers of declarations, Hunter said, regardless of how socially progressive a specific community might be. And official votes within city councils and county commissions to pass the resolutions do not necessarily fall along party lines.

Among the declarations that have taken hold in the Southeast, the preambles often reference history like the slave trade and names of those murdered by local law enforcement officers. In the West, the resolutions come with more references to healing from trauma, Hunter said.

Yet their power to shift the paradigm on racial disparities can be limited. They are not legally enforceable.

“Declarations are really statements of intent that can drive action,” said Hunter, “but they don’t require anything of anybody.”

Although there are similarities across them, how invested each community and organization is in using the resolutions as a motivation toward legitimate change varies. The city of Akron, Ohio, made a declaration in June 2020 and launched a task force to develop a five-year equity plan. In December 2021, surrounding Summit County released a “Racism as Public Health Crisis Assessment.” Further south, a declaration by the city of Ardmore, Oklahoma, mentioned a need to consider tools to eliminate racism with no indication of an action plan.

While the declarations connect the effects of racism and discrimination on physical health, the toll on mental health is often overlooked.

Many of the policies lack clear definitions of racism and a focus on mental health, said Davis Moss, of the American Public Health Association. “We need to talk about promoting healing if we want to make meaningful progress towards equity,” she said. “There’s deep division and there’s trauma in a lot of these places.”

Because the racial disparities are built on more than 400 years of racism and discrimination, experts say it may be too soon to tell if the declarations — most less than two years old — have been more than symbolic statements.

“It’s a little early to tell whether or not it’s moving the needle,” said Jaime Slaughter-Acey, a social epidemiologist at the University of Minnesota, who has spent years explaining to other scientists and researchers why racism is a critical component to understanding health outcomes. “Health disparities shrink and grow and shrink and grow over time. They can shrink and grow for a number of reasons.”

When you look at the maternal mortality gaps, she said, the disparities were most narrow in the late 1960s, early 1970s. That correlates to the passage of the civil rights legislation of the mid-1960s, when the federal government required hospitals to desegregate in order to receive Medicaid funding.

“You have these policies that are more anti-racist in nature and that are dismantling structures, and they have a profound impact on the health of Black people,” said Slaughter-Acey, “but in order to see it you need a little time to pass.”

Because racism permeates so many layers of American society, levels of accountability for progress in achieving equitable outcomes are expansive.

“In a way I think we’re all accountable,” said Slaughter-Acey, “just in different ways.”

While the Biden administration, the U.S. Centers for Disease Control and Prevention, and the National Institutes of Health set agendas, local communities hold the power to shift disparities as well, she said.

The declarations add some accountability. “It’s hard to name a problem that you can’t see and don’t talk about,” said Slaughter-Acey. “If we actually focus on structural racism, then we can modify the impact of racism much, much, much earlier on. That’s huge.”

This story has been updated.

Margo Snipe is a health reporter at Worldacad. Twitter @margoasnipe