Issue 20: Struggling to breathe: How a health department is working with community members to reduce air pollution and improve health equity in Oakland
Thursday, October 25, 2012If you search the web for articles on ways to improve health, headlines touting the benefits of a better diet and increased exercise will likely top the list. You might also see suggestions like, "get plenty of rest," "drink more water," or "limit caffeine and alcohol." But if you approach Sandra Witt, former deputy director of policy, planning, and health equity for the Alameda County Public Health Department in California's Bay Area, with the same question, her response might surprise you. Health, she'll tell you, begins long before you start your morning jog. Health often stems from where you live. In fact, where people live can matter more than personal behavior or even genetics in influencing how healthy they will be and how long they will live. Our surroundings affect what educational opportunities we have, how much money we make, how clean our water is — even the pollution levels we're exposed to. And each of these things can help or harm our health, regardless of how well we eat or how much we exercise. At the population level, when barriers to health become more concentrated in some communities than others, the consequences can be devastating. Such barriers can result in greater absences from school and work, higher rates of disease and disability, more trips to the hospital, and an increased risk of premature death. They can cause the babies born in one zip code to have lower birth weights than those born just a few miles away. Or the children in one neighborhood to be at greater risk of developing asthma than those in an adjacent part of town. Still, these differences in our communities — and resulting disparities in health and mortality — don't just happen. They stem from decisions that individuals and institutions make that, intentionally or not, advantage some groups while disadvantaging others and, over the long term, manifest themselves in our bodies. Called health inequities, they are systemic, unjust and preventable. And public health departments across the country are realizing that, to be as effective as possible, they need to pay attention to them. This is the story of one neighborhood's struggle to tackle the underlying causes of such inequities. It is also the tale of how a public health department is taking innovative steps — such as partnering with community groups and building internal capacity — to join in that struggle to reduce and prevent inequities, and how other health departments can do the same.Unequal health in Oakland
Situated along California's coastline, Oakland is the state's eighth largest city. It is known for its rich history of sports and culture, ethnic diversity, and ongoing political activism. The city has a mild climate, with clear, sunny skies the majority of the year. And it is a perfect spot to take in some local jazz or panoramic views of the Golden Gate Bridge. The New York Times named Oakland fifth on its top 45 list of places to visit in 2012, citing sophisticated restaurants and a newly reopened Fox Theater as two of the city's main draws. A shipping hub, Oakland is also a major economic engine and conduit for international trade. It is home to the country's fifth busiest container port, moving cargo for some of the world's largest retailers like Wal-Mart and Costco. But there is a flip side to the city's reputation: Oakland frequently makes national headlines for its high rates of violence and struggles with racial and economic inequality. On New Year's Day in 2009, for example, a white police officer working for Bay Area Rapid Transit, the area's subway, shot and killed an unarmed black man who was lying facedown on a subway platform in Oakland. While the community decried through peaceful protest what it saw as a racially motivated act, the media focused on the actions of a small group of people who turned to violence. On January 7, 2009, a few rioters torched cars and broke the windows of local businesses. Over the course of the next year, other mostly peaceful protests were also tinged with violence, and mass media devoured the story, often creating an overly simplified portrait of Oakland as a place where people have to live in fear of being killed. A similar theme of violence runs through mainstream media coverage of Occupy Oakland, the city's demonstrations as part of the Occupy Wall Street movement against social and economic inequity. Although many of the protests have been nonviolent, stories of chaos, vandalism and bloodshed fill the news. When a January 2012 demonstration involving police-civilian skirmishes and tear gas culminated in mass arrests, journalists were quick to the story, wagging a scolding finger at the city of Oakland and its residents. After seeing TV footage of the protest, one writer described the scene as "more like a civil war than a nonviolent march."1 This is the Oakland that the mainstream media hold up to the rest of the nation. Headlines alternate between casting the city as a cultural mecca and crime-ridden catastrophe. And in the process, an important piece of the story too often gets overlooked: the real-world effects the city's complex environment has on the people who live there. In particular, Oakland's social and political climate affects the health of its residents and workers, who have strikingly different rates of death and disease, depending on what part of the city they live and work in. A white person born in the Oakland Hills, an affluent part of the city, can expect to live 15 years longer than an African-American born in West Oakland. As a baby, that same white person from the hills is 1.5 times less likely to be born premature. As a child, he or she is 2.5 times less likely to be behind in vaccinations, and as an adult, three times less likely to die of a stroke. These startling statistics come from a report the Alameda County Public Health Department (ACPHD) published in 2008 called "Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County."2 These differences are not random, the report explains. Nor are they the result of any biological difference between blacks and whites. In fact, black-white differences in life expectancy weren't always so great. Data gleaned from death certificates show that in the 1960s in Alameda County, the disparity was minimal.3 Since then, however, social and health inequities have continued to grow. This trend is the consequence of both historical and present-day laws and practices that have fueled racial segregation and perpetually restricted the power, opportunity and resources available to the mostly low-income, black residents of West Oakland. At the same time, they have advantaged the mostly white, affluent residents living in the Oakland Hills. For example, in the 1950s, the city of Oakland wanted to find a way to connect the southern part of Alameda County to the Bay Bridge, allowing people to travel to downtown San Francisco more easily. So they developed plans to build a two-tiered overpass called the Cypress Street Viaduct that would lead traffic from city streets onto the interstate. The trouble was, they built it through the middle of West Oakland, bisecting the region and displacing hundreds of residents and dozens of businesses. The viaduct cut off a substantial portion of West Oakland from downtown, isolated the community, and increased residents' exposure to noise and air pollution.4 Community residents and activists later prevailed in getting traffic rerouted around the city after the viaduct collapsed in the 1989 Loma Prieta earthquake.5 This speaks to the community's strength and resilience in spite of great obstacles; however, the area remains blighted and continues to struggle against other inequities. Not surprisingly, then, the people who are more likely to have a home that captures those panoramic views of the Golden Gate Bridge and those who are more likely to encounter police brutality typically are not one and the same. They may live just miles apart and claim the same city as their home, but Oakland's low-income people of color and their wealthy white counterparts inhabit starkly different worlds. Current policies and systems mean that they have different options for where they send their kids to school; get exposed to different amounts of marketing for tobacco, alcohol and junk food; encounter different degrees of discrimination; and even breathe different air. And for the low-income, black Americans (and increasing numbers of Latinos, Asians and Native Americans) in Oakland whose schools are poorer, healthy food options are fewer, experiences with racism are greater, and air is more polluted, these conditions add up to greater amounts of stress, which has physiological consequences. The constant elevation of stress over time can harm all major organ systems. It can raise blood pressure, increase heart rate and spike levels of cortisol, a key hormone that affects immune function. Too much cortisol over long periods of time can impair mental function, inhibit children's development, and lead to a variety of chronic diseases.6In other words, it can devastate health. ACPHD's report goes on to detail the social, economic and political causes of health inequities, not just for those living in Oakland, but for everyone. And it shows that if you want to improve health for entire populations, then those root causes are where you have to intervene which is exactly what ACPHD is doing. The health department is using a combination of media advocacy, internal capacity-building, and collaboration with residents, community groups and other government agencies to increase awareness about health inequities and to combat them. Ultimately, ACPHD recognizes that although the story of health inequities in Oakland is a daunting one, it has an upside: It can unite people to work together for real change.Seizing an opportunity for action
The Alameda County Public Health Department has long had a focus on understanding why some people get sick more and die sooner than others. And as its report "Life and Death from Unnatural Causes"7 reflects, it keeps its eyes open for opportunities to act. So when, in 2007, leaders from the West Oakland Environmental Indicators Project (WOEIP), a community group that, among its many efforts, was working to reduce diesel pollution and related health risks near the port in West Oakland, approached leaders at ACPHD and asked them to join the effort, it didn't take much convincing for ACPHD to say yes. Both groups knew that West Oakland has the highest mortality in Alameda County. Of the 15-year life expectancy gap between African-Americans born in West Oakland and white people born in the Oakland Hills, 14 of those years come from an increased burden of chronic disease8 — not infectious disease, injury or violence. West Oakland has the highest rates of coronary heart disease, congestive heart failure and emphysema.9 It also has the highest rates of asthma, with West Oakland children ages four and younger visiting the emergency room at a rate that's nearly three times the county average.10 WOEIP and ACPHD (as well as numerous community organizations like the East Bay Alliance for a Sustainable Economy) also knew that much of West Oakland's higher burden of asthma and other chronic disease relates to the area's heavier exposure to air pollution.11 Highly trafficked interstates border West Oakland. And the community shares real estate with the Port of Oakland, whose continued movement of goods on thousands of trucks and ships keeps the air thick with diesel smoke. Truck traffic through the port has more than doubled since 2000, and port officials expect overall container volume to double by 2025.12 While waiting to pick up cargo, trucks often idle for hours on local streets. Soot lines the windowsills of nearby homes, and asthma inhalers fill too many residents' medicine cabinets. And port truck drivers, who work an average of 11 hours each day and typically lack health insurance, continually breathe concentrated diesel pollution, putting them at increased risk of lung cancer and other respiratory diseases.13 The connection between air pollution and health was no secret to the West Oakland community. Concerned, residents called for change and the West Oakland Environmental Indicators Project took action. WOEIP (whose director, long-time community activist Margaret Gordon, was then a commissioner at the port) worked along with other community stakeholders including the Coalition for Clean & Safe Ports and the Ditching Dirty Diesel Collaborative to persuade the Port of Oakland to put together a task force to help create a policy framework for improving the community's air quality. The task force was composed of a wide range of groups including West Oakland residents, environmental regulatory agencies, labor unions, community advocacy organizations, shipping companies, health agencies and other business stakeholders. The idea, then, was to give the Alameda County Public Health Department a seat at the table so that it could support the group's work with additional health data, help set policy goals, and push the port to implement them. It wasn't the first time that ACPHD had worked with community groups to tackle a complex issue. It wasn't the first time ACPHD and WOEIP had worked together to advance health equity either. In fact, over the last decade, WOEIP and ACPHD have tackled issues as varied as affordable housing and indoor air pollution. But what made the port work unique was its position at the intersection of complex labor conditions. Specifically, the health solution that the Coalition for Clean & Safe Ports, WOEIP, ACPHD, and a segment of the task force were advocating involved a critical but contentious labor solution to ensure that low-income immigrant drivers would not have to shoulder the cost of purchasing new clean-fuel trucks. And this complexity makes it a prime example of how a public health department can infuse a focus on health equity into its daily practice in spite of large obstacles.*Making the connection between labor and health
The connection to labor disputes begins more than 30 years ago during the nationwide deregulation of the trucking industry. With the passage of the Motor Carrier Act of 1980, the industry began its transition away from strong union jobs. Port trucking companies that once paid a living wage and provided port drivers with pensions, health insurance, and a say in their work began denying new hires benefits and forcing them not only to work for less money but also to purchase and pay for the maintenance of their trucks. A 2010 port trucking industry survey shows that many trucking companies have also illegally misclassified their employees, with approximately 82 percent of the nation's 110,000 port drivers now being treated as independent contractors.14 By 2007, the year the task force convened, Oakland's port trucking system — like many others — had become unsustainable and harmful to health, with poorly maintained trucks spewing diesel pollution into the air. Looking to address the issue, the California Air Resources Board passed a regulation requiring trucks servicing any state port to meet aggressive new emissions standards. Yet Oakland's port drivers, most of whom were — and still are — overworked and receiving poverty-level wages15 (a quarter make less than $7.64 per hour16), could not afford the cost of retrofitting or replacing their rigs with newer clean-fuel trucks. Complicating matters, the Port of Oakland had not enacted a mechanism to set industry standards, so port trucking and shipping companies had grown accustomed to reaping profits without having to pay the real costs of moving goods through the port and through West Oakland. This left community residents and port drivers to shoulder the financial and health burden of moving cargo. To be successful, any of the task force's efforts to clean up the air surrounding the Port of Oakland would have to also help shift the balance of power within the port trucking industry. Drivers would need better working conditions and more say over their jobs, and port commissioners, who manage the port's operations, would need greater control over setting port trucking standards. To this end, one potential solution lay in the development of a Clean Truck Program, which the Coalition for Clean & Safe Ports, members of whom participated on the task force, had been encouraging port commissioners to adopt even prior to the task force's formation. Under a Clean Truck Program, companies wanting to service the port would have to first sign concessionary agreements with the port. Each agreement would function like a lease and include certain standards, including that trucking companies hire drivers as employees rather than misclassifying them as independent contractors. Additionally, port trucks would have to be clean and use the best available technology to reduce diesel pollution, and port trucking companies would be required to follow strict truck routes placed outside of residential neighborhoods. Although some routes do currently exist, they are not well enforced. In recent years, the Port of Los Angeles, the busiest container port in the nation, has shown that having a Clean Truck Program works. It implemented such a policy in October of 2008 with a goal of reducing truck emissions 80 percent by 2012.17 Emissions data show the port surpassed that goal a year ahead of schedule.18 The Clean Truck Program illustrates the interconnections between labor, community, the environment and health. For example, without improvements in labor, health goals will languish and vice versa. So when the Alameda County Public Health Department's leaders said yes to the invitation to help clean up operations at the Port of Oakland by participating on the task force, they knew the process would be intense and messy. They also knew it would be well worth it. On both counts, they were right.A two-year process
Beginning in 2007, the task force met regularly for two years. Its charge: to identify goals for a Maritime Air Quality Improvement Plan — including a plan to reduce emissions coming from port trucks — that the group would ultimately ask the Port of Oakland to adopt. By 2007, the port commissioners had become more familiar with the inner workings of the trucking industry, thanks in part to the efforts of community groups like WOEIP and the East Bay Alliance for a Sustainable Economy (the co-convener of Oakland's Coalition for Clean & Safe Ports). During that same time, port commissioners were also becoming aware of inefficiencies within the port system and the economic and health consequences that high levels of diesel pollution were having on the community. In 2008, the port adopted a goal of reducing health risks related to diesel pollution from its activities by 85 percent by 2020. It also took steps to reduce emissions, including switching from diesel to electric cranes and offering subsidies to help drivers upgrade their trucks.19 Still, the subsidies fell far short of the money needed for truck retrofits (typically between $15,000-$30,000 per truck, depending on the type of retrofit device20), and diesel pollution remained high. If the community wanted to see the 85 percent reduction goal become a reality, the port would need pushing. After pulling together various health data, the Alameda County Public Health Department helped the task force craft aggressive strategies to improve the health of West Oakland residents and port drivers. They spent late nights poring over the details of the Maritime Air Quality Improvement Plan and, along with other members of the task force, identified hundreds of potential initiatives that could help reduce port emissions, weeded out the ones that weren't feasible, and incorporated only the best into the plan.21 [caption id="attachment_8848" align="alignnone" width="650"]
Together, a wide range of groups including West Oakland residents, environmental regulatory agencies, labor unions, community advocacy organizations, health agencies, and other stakeholders worked to build a movement to reduce air pollution at the Port of Oakland. The groups tackled the issue from many angles, conducting research, crafting policy proposals, and engaging in media advocacy to put community health in the spotlight and keep it there.[/caption]
ACPHD also brought other voices into the mix. With public officials from the city of Oakland, ACPHD co-convened an interagency workgroup (a subcommittee of the task force) that included representatives from the Environmental Protection Agency, California Air Resources Board, and Bay Area Air Quality Management District. The groups met with one another's boards to develop an organized message on multiple fronts, making sure to keep the health argument front and center. Together, they navigated a highly political process to press the port to adopt the best possible goals and the best mechanism for implementing them.
Media advocacy
[caption id="attachment_8849" align="alignright" width="324"]
Sandra Witt, then-deputy director of policy, planning, and health equity for the Alameda County Public Health Department, speaks about the connection between air pollution and local health at an asthma clinic staged in front of the Port of Oakland on February 10, 2009. Photo: Brooke Anderson.[/caption]
The groups leaned on one another, leveraging their strengths to make political headway. One strategy involved getting the story in front of reporters and the public, which is exactly what the Coalition for Clean & Safe Ports and East Bay Alliance for a Sustainable Economy did in February of 2009. That month, EBASE released a report with the Pacific Institute that exposed the health consequences of Oakland's port trucking system, which costs the community $153 million a year in medical expenses related to asthma, premature death, and increased risk of cancer and other diseases. The report, "Taking a Toll," which was reviewed by allies including ACPHD, explained the breakdowns in Oakland's port trucking system and prescribed solutions to help fix it. It also provided the perfect springboard for an attention-grabbing media event: an asthma clinic staged in front of port property.
Organizers at EBASE brought health professionals from the University of California, San Francisco, the Children's Hospital & Research Center Oakland, the Alameda County Public Health Department and other groups to the clinic to provide free screenings to truck drivers and community residents and children. Hundreds turned out in support.22 Leaders from ACPHD spoke at the event, affirming the report's alarming findings, and West Oakland residents and port drivers talked about the effects asthma has had on themselves and their families. The clinic drew media attention, with the story appearing in local papers23and radio producers inviting event organizers to speak on their shows.
Mixed results
In spite of strong evidence of both the economic and health-related consequences of port operations, the proposal to enact a Clean Truck Program encountered strong opposition from some members of the task force. Reducing diesel emissions would require overhauling the port trucking system and paying for pricey new equipment. With retrofits costing tens of thousands of dollars and new port trucks costing upwards of $100,000,24 low-wage truck drivers couldn't be expected to pick up the tab. But, most port commissioners argued, neither could the port. The state and the district both agreed to supplement Port of Oakland funds and pay a portion of the expenses. Still, those funds combined were not enough to make up for the shortfall. And while passing the expense on to shipping companies seemed like the best option given their large profit margins and the fact that cargo originates from these companies, the idea of making shipping companies pay raised concerns among some commissioners and staff that those companies might take their cargo elsewhere and forgo business deals with the Port of Oakland altogether. Advocates for the Clean Truck Program thought this was simply a scare tactic spread by the shipping companies. By April 2009, the final Maritime Air Quality Improvement Plan that went before port commissioners had been grossly watered down. And although it still contained the ambitious goal of reducing diesel pollution-related health risks by 85 percent, it did not, according to several members of the task force, contain enough concrete actions or enforcement to help the port meet that goal. For example, it lacked a container fee to allow the port to collect funds from shippers to help drivers pay for new filters and other improvements to their trucks. Additionally, the plan did not include a Clean Truck Program, which the board instead decided to consider separately and on its own timeline. Then-commissioner and Oakland resident Margaret Gordon, who helped convene the task force, called the plan a "skeleton": "It's not anything that has a lot of teeth in it because it's still voluntary," she said. In the days leading up to the port's vote, Dr. Tony Iton, then-director and health officer of the Alameda County Public Health Department, spoke before port commissioners to help illuminate the health context for their upcoming decision. And on April 7, the day of the vote, Oakland residents and community leaders came out in large numbers to express concerns about the shortcomings of the plan. Residents helped put a face on the real-world effects that excess diesel pollution was having on the community in the form of increased asthma rates and other health inequities, as well as related financial stress. "This proposal ... is not a long-term solution to the problem," Chuck Mac, Secretary- Treasurer for the Teamsters Local 70 said. "At best, it's short-term. If that's what it is, the cost of the retrofits shouldn't happen on the backs of truck drivers." Randall Bustamante, an English teacher at Oakland's Mandela High, echoed that sentiment: "Too often, low-income means invisible, and I think this commission here can make a difference in making our people more visible and protected." Bustamante advocated that the port pass a container fee so that truck drivers would not have to pay for their own filters, adding, "Every day that we wait is a day that more kids are affected, more lives are endangered, and more families are affected." In addition to supporting a container fee, Jack Broadbent, executive officer of the Bay Area Air Quality Management District, recommended the plan be revised to include a short-term measure to ban non-complaint trucks from entering the port. "As currently proposed, the plan is too passive and too reliant on outside agencies enforcing state and federal regulations and providing subsidies to your tenants and customers," Broadbent said. The board ultimately approved the plan without modifications. Only one commissioner — Margaret Gordon — cast a no vote, citing the lack of enforceable measures as one of her main concerns. Within days of the vote, Broadbent, Iton and the West Oakland Environmental Indicator Project's Co-director Brian Beveridge co-authored an op-ed, criticizing the port for adopting a "toothless and noncommittal" plan that "devalu[es] the health of those who work at or live near the port and its major transportation routes." The commentary, which appeared in the Oakland Tribune, called for a stronger and more sustainable plan requiring costs for reducing pollution be paid for "by the shipping industry and the retail sector whose products are being transported and not low-income truck drivers and community residents."25 Since then, the Port of Oakland has made mixed progress in reducing its impact on the environment and public health. For example, to supplement the Maritime Air Quality Improvement Plan, which was passed without a Clean Truck Program, port commissioners later adopted a similar program** to reduce port truck emissions. However, unlike a full Clean Truck Program, the Port of Oakland's version does not require a lease agreement between port trucking companies and the port. Nor does it set enforcement standards to ensure that trucking companies, not drivers, pay for state-mandated upgrades to port trucks. Consequently, as a January 2010 retrofit deadline approached, although the port collaborated with state and district agencies to help fund expenses, their subsidies weren't enough to fully cover costs. Individual drivers had to then pay the balance or leave the industry. And with even stricter requirements approaching in 2014, the port's meager funding assistance has thus far provided only a stop-gap solution. In spite of setbacks on the policy front, the stakeholder process did lead to other successes. It helped many Bay Area government agencies and other institutions form new relationships and strengthen existing ones. The Alameda County Public Health Department now has a presence on the Bay Area Air Quality Management District's advisory committees. And ACPHD has improved an already robust relationship with the West Oakland Environmental Indicators Project, the group that originally invited the agency to join the port efforts, as well as other groups like the East Bay Alliance for a Sustainable Economy. But perhaps the health department's most important accomplishment that came out of the port stakeholder process was that it was able to take it on in the first place. Ten years ago, it would have been more difficult. "We have spent years building our partnerships and internal capacity to tackle these challenging issues," ACPHD Health Equity Coordinator Katherine Schaff said. "This allowed us not only to understand the port issues that residents were concerned about but also to know what our role should be in addressing them, and to have the capacity to do so."Developing the capacity to respond
Part of working for a public health agency means being pulled in many different directions at once. In the face of tight deadlines and funding constraints, it can be hard to see how all of a health department's efforts connect, let alone be able to work on projects that fall outside of the more traditional realm of providing the community with health programs and services. That ACPHD was able to take a 30,000-foot view of operations at the port, connect it to health inequities in the community, and have the capacity to act happened because of a larger structural reorganization that began long before concerns about the port became widespread. Beginning in the mid-1990s under the leadership of then-director Arnold Perkins, the health department began a process of trying to democratize the institution or, as Perkins has been known to say, "put the public back in public health." His successor Tony Iton, who worked for ACPHD between 2003 and 2009 and served as its director from 2006 to 2009, described the health department before its reorganization as similar to an aircraft carrier, with the people it served being like "dinghies in the water." "It delivered services down but from a high perch," Iton said. The department, he added, was too far removed from the community to really understand the root causes of health inequities. And so ACPHD began changing its form to drive changes in its function. First, it created regional offices that were closer to the communities it served, and it emphasized community capacity-building. ACPHD staff then started participating in neighborhood actions and reconceptualizing the nature of their work to include proactive efforts to prevent inequities rather merely respond to them after the fact. ACPHD staff now understand health equity as being part of the health department's mission, and ACPHD has outlined a three-pronged approach to carrying out that mission, which in addition to community collaborations and partnerships, includes institutional change, and policy and systems change. And each of these areas includes programs, services, research and data.
Today, ACPHD is working to ensure its structural changes and robust focus on equity inform all of the department's operations, from its training of new and existing staff to its delivery of health services. The health department works to create space for all employees to discuss health equity and its root causes and has five cross-departmental strategic planning workgroups that help employees leverage and expand their existing work in creative, equity-driven ways.
For example, as part of a public- and privately funded Place Matters initiative (affiliated with the Joint Center for Political and Economic Studies' national Place Matters initiative) that aims to promote health equity through policy changes in education, economics, criminal justice, land use, housing, and transportation policy, ACPHD staff are building and reinforcing the relationships they have with the community and non-traditional partners.
One of those partners is the Alameda County District Attorney's Office. After discovering that a large number of children who are truant or chronically absent from West Oakland schools stay home because they have asthma, the co-coordinator of one of the health department's Place Matters policy workgroups put the District Attorney in touch with ACPHD's chronic disease director to collaborate on ways to reduce health-related absenteeism and keep youth out of the prison pipeline.
Together, they developed a plan: The District Attorney sends asthma-related truancy cases to the health department, and the health department enrolls them in the asthma program. As part of the program, asthma caseworkers take participants' medical history and do a home inspection to look for environmental triggers for asthma, such as mold. They work with parents to remediate the triggers, which can mean supplying HEPA vacuums or providing mattress and pillow encasings. Caseworkers also help ensure that children are up-to-date on immunizations and prescriptions and conduct follow-ups to maintain progress. And if the health department finds that a child is struggling with other health problems, such as diabetes or mental health issues, it can put the family in touch with additional help. While this doesn't address the larger issue of the connection between concentrated pollution and asthma, it does bring together multiple partners from different county systems to help improve young people's health and keep them in school and out of court and jail.
ACPHD's unique relationship with the District Attorney's truancy program and Alameda County's truancy court, as well as its two-year battle to reduce air pollution at the Port of Oakland, are just two examples of how the institution is using an emphasis on health equity to drive its daily work and open up new opportunities for action. And while ACPHD is quick to highlight the collaborative nature of its work, it also knows that part of its success comes from making sure the public is aware of that work. ACPHD has cultivated relationships with local journalists to make health equity a recurring topic in the news, and it announces its efforts through its own social media networks and website. After all, only with health inequities in full view can people see the need and urgency to eliminate them.