Radically Reimagining our Systems

In the pursuit of health equity, merely using the word "equity" is not enough; it requires a commitment to sustained and challenging work. Genuine progress can only be achieved through actions that go beyond mission statements, akin to the day-in-day-out dedication required to demonstrate love to one's family.

Richmond Racial Equity Essays — 2021 Series
Danny TK Avula, MD, MPH

Anyone who has been on the leadership team of a health organization in the past few years can tell you that when it’s time to update your strategic plan or submit a proposal for funding, the word “equity” goes front and center. Organizations across the region (my own included) use “equity” whenever possible: we are equity-driven, have an equity lens and an equity framework, are building toward equity, and share pro-equity posts on social media. But using the word “equity” is not the same as committing to do the difficult and sustained work it requires to realize equity in the Richmond Region. The more we use the word “equity” as a catchall for our good intentions, the more we dilute its meaning and make it a harder goal to reach.

There’s a world of difference between including the word “equity” in a mission statement and really living into that mission in every decision an organization makes. It’s not unlike the concept of love-- I regularly tell my wife and kids that I love them, but it’s not using the words that leads them to believe it.  It’s the day-in-day-out showing up.  The listening, the time spent together, the navigating through hard things.  It’s doing the work that helps them know that I love them. Our organizations can’t just use the words, ; we’ve got to do the work.  And it has to be serious work-- not just doing a little bit more than we did before, but doing the long, hard, system-changing, and soul-changing work.  We have to actually believe in, and actively work towards, a future where everyone, regardless of the school they went to, the neighborhood they grew up in, or the color of their skin, has the opportunity to achieve a state of health and wellbeing. And we’ve got to do whatever it takes to get there.

To be clear, I’m not trying to preach as someone whose organization has figured out how to do whatever it takes.  Like everyone else, we have our own hurdles to overcome.  There is much work to be done around issues like equitable pay, and having a workforce and a leadership team that is more reflective of the diverse communities we serve throughout Henrico and Richmond. But we are approaching the work with intention and commitment, and we are on the journey.  What follows are a few reflections of what it looks like for organizations to do this work, in the substantive and unremitting manner that will be required to see real change in our region.

Recognize that our Systems Perpetuate Disparity

Recently, our health department’s Director of Health Equity, Jackie Lawrence, wrote in a message to our staff that our work ought to “radically reimagine, plan, and implement systems changes that remove obstacles, ensure resilience, and highlight joy in communities of color.” It’s a powerful charge-- one that compels us to keep our eyes focused on the systems that have perpetuated disparities in health outcomes among Black, Latinx, and Indigenous Americans for decades, and simultaneously inspires hope by focusing on the resilience and joy present within these communities.  

Over the past decade, we have invested heavily in an expansion of services that goes beyond the four walls of our health department. We have opened health access points in eight public housing communities and other low-income neighborhoods to better serve black and brown people who historically have had less access to preventive services.  As we built relationships in these neighborhoods, we were introduced to residents who had tremendous expertise, knowledge of their community, and the deep trust of their neighbors.  This led to the building of our Community Health Worker program, which has fundamentally changed the way we work with and for vulnerable communities.  We reimagined our system of care in order to lower barriers to access and increase trust: instead of requiring residents to come to our building and see our experts, we are employing experts from within communities and offering care to residents in familiar and accessible spaces right in their own neighborhoods.  

Develop Cross-Sector Solutions

One major advancement in the field of Public Health over the last 20 years has been the recognition and characterization of the Social Determinants of Health, and the development of interventions that appropriately address those determinants.  We now clearly understand that health outcomes are not simply a function of whether you have access to a doctor, but rather a complex interplay of health behaviors, the physical environment, and social factors like education level, income, or stable housing.  

This deepening understanding of the social determinants has pushed us to begin thinking more holistically about the clients we serve-- we now screen for things like housing instability and barriers to employment, and offer navigation support as residents connect with other organizations to address these broader issues.  This cross-sectoral approach has required a much higher level of coordination and alignment between different governmental agencies and nonprofit organizations, and we have been growing a team of Social Workers who are equipped to navigate people through this maze of supports, recognizing that many of our clients will not have the opportunity to achieve a state of health and wellbeing without addressing these crucial underlying determinants.

This cross-sectoral work is important at the individual level, but even more so at the systems  level.  Increasingly, our work has focused on conveying the population health impacts of investments in affordable housing, safe green space, or bike and pedestrian infrastructure.  Working towards true health equity-- a state where everyone has a fair and just opportunity to be as healthy as possible-- is going to require thoughtful collaborations and investments across the health, housing, community planning, and economic development sectors, among others.

Drive Change with Data

The call to equity requires leaders to target investments and interventions in communities where they are needed most.  We cannot do this consistently and reliably without local data, disaggregated by race.  

The COVID-19 pandemic has consistently revealed how racial inequities seem to be coded into our nation’s DNA.  COVID-19 disproportionately hospitalized and killed Black and Latinx people across the country, largely due to the reality that those residents make up a higher percentage of frontline essential workers who did not have the option to work from home, and that they have more severe underlying conditions that put them at higher risk of serious complications from the disease.  Having clarity about the impact of COVID-19 on different races and ethnicities gave Public Health practitioners and policymakers the ability to direct financial support and vaccination efforts to the communities that needed them most.

The ongoing work to achieve equity will require that we keep the data, disaggregated by race, in front of us at all times.  Whether we’re talking about infant mortality, incarceration rates, or income inequality, it is essential that we know the disparities we’re trying to resolve, and that we’re able to measure our progress.

Partner with the People

Over the years that we have sought to center our work on health equity, we have learned that we must engage the people we are seeking to serve as authentic partners in this work.  This has required  intentional and significant effort, as these are often the same people who have historically been left out of shaping our government’s institutions.

Building trust, engaging leaders, and ensuring the community has a voice-- these are skills we have developed over time, but they are not second nature.  There are still occasions (more than I would like to admit) where we fall into the trap of believing “government-knows-best,” and jump immediately to implementation.  When we don’t take the time to listen to the community, earn trust, and let community leaders drive the process, we end up implementing programs with less buy-in and little ultimate impact on health and wellbeing.  But we also miss an opportunity to help residents claim their own agency in protecting their health and the health of their community, and any real progress toward health equity will require deep commitment in every community, now and into the future.


The commitments I outlined here might seem like a tall order, but I am more hopeful than ever that they can be accomplished with real commitment by organizations across our region because we saw it happen during the COVID-19 pandemic. The pandemic exposed and exacerbated every racial and economic inequity in our region, and organizations across sectors collaborated, invested, sought the counsel and leadership of residents, and generally reimagined care and change like never before. When a new challenge arose, we found the partnerships, funding, and capacity to lift up an equitable response. We put the work we had hoped to do on hold and rearranged our staffing and budgets to commit to addressing the urgent public health crisis at hand. But racism has also been declared a public health crisis in Virginia, and the roots and impacts of racism deserve just as urgent a response from our government agencies, nonprofits, health systems, philanthropic leaders, and communities in the days ahead.

Now more than ever before, I am ready for that kind of radical reimagining: for a commitment not to return to business as usual but to keep leaning in together and doing the hard work required to achieve racial and health equity. To listen well to our vulnerable communities and engender trust. To acknowledge the systems and structures that work to create disparities, and to keep the data in front of us to monitor our progress towards eliminating those disparities. Our communities deserve no less, and now that the pandemic has shown us what we are capable of, we owe it to our communities, our organizations, and ourselves to continue to invest more where more is needed, for as long as is needed, until racial and health equity are fundamental realities, not strategic ideals, in every community we serve.

About the author

Danny TK Avula, MD, MPH

Dr. Danny Avula is the Director of the Richmond City and Henrico County Health Departments. In January 2021, Governor Northam appointed Dr. Avula to lead the Commonwealth of Virginia's unprecedented COVID-19 vaccination effort. He is a public health physician board certified in pediatrics and preventive medicine, and he continues to practice clinically as a pediatric hospitalist. After graduating from the University of Virginia, he earned his medical degree from the Virginia Commonwealth University School of Medicine. He completed residencies at VCU and Johns Hopkins University, where he also earned the Master of Public Health degree. He is an Affiliate Faculty member at VCU, where he regularly serves as an advisor and preceptor to graduate and medical students. He is a former Board Chair for the State Board of Social Services and the Richmond Memorial Health Foundation, and has been honored annually as one of Richmond’s “Top Docs” since 2013. In 2019 he was a recipient of the Virginia Center for Inclusive Community’s Humanitarian Award and a Richmond Times-Dispatch “Person of the Year” honoree, and in 2020 was named Style Weekly's "Richmonder of the Year." At home, Danny’s time is devoted to life with his wife and five kids, and to learning how to be a good neighbor in the rapidly changing community of North Church Hill, where he has lived for the past seventeen years.

Danny TK Avula, MD, MPH
About the author

Danny TK Avula, MD, MPH

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