Examples
1)    Lack of control over policy represents a barrier to progress	“… racism in our context is not about the personal issues (although, that is still part of the problem). But the core issue is policy and how they are put into place, whether their intent is maligned, or whether their intent is benign but the outcome is malign. You need to examine the motivations (for policy) but also understand the ramifications of that. One thing I think about is even if there is a policy put into place for the best of reasons, but their outcomes are disparate, we need to be able to say that it didn’t work the way we thought and it’s time to scrap it.” - Public health official, #2 ___________________________________________________________________________________________ “Because of the government structure in Virginia and the way our local governments function in relationship to the state, having additional freedoms at the local level would really make it easier for us to address some of the systemic policy issues. Letting state legislators give localities additional freedoms to make policy changes I think would have a huge impact.” - Public health official #1 ___________________________________________________________________________________________ “It’s about leveling the playing field and the playing field is about opportunity – what you will find is that it is the uneven opportunities that create these disparities. So, let’s make sure that the policies are such that everyone is able to achieve that if you want it – it shouldn’t be that it is harder for individuals in some groups (e.g., LGBTQ, black) to [achieve their goals]." - Public health official #3
2)    Funding, staffing, and time as scarcities	“We are working a lot of hours to do everything that we need to do. It is currently pretty tough right now with the resources that we have but we do it because it’s the right thing to do ... I think the things we need to further [our abilities] is additional capacity. What we would love to be able to do is to hire more people who come from our different communities in [our city]. For example, people who speak different languages can conduct outreach work and do additional trust/relationship building. Part of it is the funding but another part is the timing barriers/hurdles in the hiring process that make it time-consuming.” - Public health official #1 ___________________________________________________________________________________________ “Obviously time and resources [are challenges]. This is why, in [our county], we always engage the community. Community comes first. Because that way we are able to leverage the wealth of expertise and resources in an incredibly diverse community such as [ours]… when we engage the community to do the work for and with us, that is where sustainability can be found. Time [is always a challenge] but if you don’t invest you won’t reap the rewards. For me the return on investment is great so I am happy to put the time in as needed." - Public health official #3 ___________________________________________________________________________________________ “A lot of challenges, of course, will be dedicating time and resources to it as well as having a standardized approach across the state. [It will be interesting] to see the initiatives that come from VDH central office and how those approaches are implemented in the districts – but I think the districts know their communities well and the issues that they face. We do have a lot of flexibility to implement initiatives that we think will work but [it would be beneficial] to have the support and resources from the state.” - Public health official #4
3)    Progress will be slow and incremental	“It is a painstakingly long process... we’ve all been in places where we have heard [problems] get talked about, but when you are back in your office, you tend to forget or lose the enthusiasm.” - Public health official #3 ___________________________________________________________________________________________ “I think that maintaining momentum and sustaining some of these efforts [is a significant challenge]. Sometimes, when things become a big issue, [it is possible] to lose track of it as the months progress but I hope it is not something that we lose sight of. That’s why I believe it so important for it to be known as a public health issue and to continue to raise awareness of it by collecting and showing data as evidence of it in order to call it out.” - Public health official #4
4)  Responsibility rests with everyone	“...the solution does not only rest with us – it rests with the village. We mobilized the village to, first, understand the problem so that, in doing so, each discipline is looking and making that adjustment on their own." "Leveling the playing field is about creating a level playing field of opportunities for all. That is why it is beautiful that the village comes together to solve this because those opportunities don’t only lie in access to healthcare, but it is also in banking, housing, and everywhere. This work is for everybody [in all sectors] to understand how the work they have authority over creates environments that negatively and disproportionately impacts certain groups of people and doing something about it.” - Public health official, #3 ___________________________________________________________________________________________ “This issue requires engagement across all levels and sectors and some of these things will require a legislative approach whether that is at the county council, state legislative level, or even the federal legislative level. We mainly work on the issue [of racism]at the county and state level, while the federal level is subject to far greater forces that we can muster alone. But if there are enough places doing it with momentum and movement then you start to affect that federal level too.” - Public health official #2 ___________________________________________________________________________________________ “Partnerships are huge for our health district –we have tremendous partners with the local hospitals, universities, and non-profits in [our city]. They have been incredible and committed to health equity efforts – in fact, one of our non-profit partners provided us with the funding to work with the Institute for Public Health Innovations to even provide the health equity training for our coalition. For us, I believe our partnerships are key, especially for [an issue] as deeply rooted as racism, everyone needs to be at the table.” - Public health official #4