New study explores staffing priorities and challenges at local public health departments

The COVID-19 pandemic drew attention to the critical need to invest in our nation's public health infrastructure and rebuild local public health departments, many of which have been losing staff for years. Although there's been an infusion of new grants and funding from the Centers for Disease Control and Prevention and the federal Coronavirus Aid, Relief and Economic Security (CARES) Act, among other sources, little research has been conducted to identify strategies to invest these funds optimally, or to help health departments determine best practices for addressing their staffing needs.

A new study from the University of Minnesota School of Public Health (SPH) helps fill this gap, analyzing the staffing priorities of local health departments (LHD) in Minnesota—and exploring the barriers Minnesota's LHDs are confronting to achieving adequate staffing levels.

In the study, which was published in the Journal of Public Health Management and Practice, researchers surveyed 97% of the 72 county and city health agencies throughout Minnesota in June and July of 2022. The study examined three key areas of concern to LHDs—staffing needs and priorities, financial constraints to hiring and external barriers to recruitment.

They found:

External factors contributing to hiring challenges include lack of affordable child care, housing and transportation options.

"As local health departments seek to take advantage of new funding opportunities to staff up, this research will help guide governmental public health leaders as they identify staffing needs and priorities, as well as identify barriers to maintaining optimal staffing levels," said Harshada Karnik, SPH researcher and lead author of the study. "We believe this is a roadmap local health departments can use to identify emerging needs that reflect their new roles and responsibilities, and to attract, and retain staff."

The researchers also emphasized that agencies that are able to offer benefit programs that address external factors—such as child care, housing and transportation—may be better positioned to retain staff.

Karnik is a researcher at SPH's Center for Public Health Systems.

More information: Harshada Karnik et al, Staffing Local Health Departments in Minnesota—Needs, Priorities, and Concerns, Journal of Public Health Management and Practice (2023). DOI: 10.1097/PHH.0000000000001729

Citation: New study explores staffing priorities and challenges at local public health departments (2023, June 12) retrieved 13 June 2023 from https://medicalxpress.com/news/2023-06-explores-staffing-priorities-local-health.html

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What people want: Regenstrief-IU study explores patients’ perspectives on diabetes self-management apps

INDIANAPOLIS – Diabetes is a huge and growing public health problem affecting millions of people in the U.S. It’s a disease in which patient self-management, supported by health information technology, can potentially prevent or reduce complications, improve quality of life and lower medical expenses.

There are more than 1,400 apps available for cell phones and tablets to help individuals living with diabetes manage their disease over the course of their lives, but use of these apps has been low. Getting diabetes patients who require insulin to continually use an app for support remains challenging. A new study from Regenstrief Institute, Indiana University Richard M. Fairbanks School of Public Health and Indiana University School of Medicine researchers explores diabetes patients’ perspectives on what they want from an app.

“To gain a better understanding of diabetes patients’ health behaviors and what they think is important for a diabetes app to do, we looked at patient motivation and studied  views of app acceptability and usability as well as other factors that encourage use of these programs for successful disease self-management,” said Helen Fu, PhD, MSN, BSN, a postdoctoral public and population health informatics research fellow at Regenstrief Institute and IU Fairbanks School of Public Health, who led the study. “We are especially interested in apps that are commercially available at no charge because these apps are accessible to the many underserved and low-income individuals living with diabetes.”

“Important questions that should be asked of all health apps, not just apps for diabetes, include, do they make the right calculations and do they make appropriate recommendations to patients?” said study co-author Regenstrief Institute Research Scientist Titus Schleyer, PhD, DMD. “In this study we went beyond these basic questions and looked at how patients interact with apps and investigated factors that influence user success.” Dr. Schleyer co-directs the Regenstrief and Fairbanks School of Public Health Indiana Public and Population Health Informatics Fellowship program, funded by the National Library of Medicine, part of the National Institutes of Health. 

The 92 adult study participants had taken insulin for an average of 12 years. They reported a wide variety of diabetes complications including short-term memory loss, retinopathy and mobility impairment with the use of a cane, walker or wheelchair. The majority (70 percent) had type 2 diabetes.

Most study participants wanted diabetes apps to save time regardless of functions, specifying that the app should be efficient and easy, requiring minimal user effort. Patient-friendly terminology and display and easy-to-understand reports were important to them as well.

Participants in the study said that a useful app could improve their sense of competence by helping them monitor data, create analysis reports and gain knowledge about reasons for blood glucose being out-of-range so they could plan behavior change. Some appreciated receiving information that guided them in adjusting their insulin dose.

Many said that apps improved their sense of autonomy when they showed if their blood glucose was trending high or low in relation to time of the day and day of the week.

Additionally, participants appreciated enhanced connectivity through which their clinicians could receive emails or print reports of home-monitored data via the app to better understand patients’ self-management behaviors. 

“In a future study we plan to learn more about diabetes patients and ways to use health information technology to help them live more successfully with their disease,” said Dr. Fu. “We hope to find out which populations and subpopulations have the most trouble with disease management and to gain a better understanding of what well-designed tools might look like and share this information with clinicians and app developers.”

“There are many factors to consider -- for example, older people may be unable to use the same apps as younger people – as we work toward long-term adoption of diabetes apps to support self-management by patients, as well as promote the integration of diabetes apps into the telehealth setting for clinicians,” said Dr. Schleyer.

“App Design Features Important for Diabetes Self-management as Determined by the Self-Determination Theory on Motivation: Content Analysis of Survey Responses From Adults Requiring Insulin Therapy” is published in JMIR Diabetes.

This study was supported by the Robert Wood Johnson Foundation Future of Nursing and Sigma Theta Tau International–Zeta Chapter. Dr. Fu was funded as a postdoctoral research fellow in Public and Population Health Informatics at Regenstrief Institute and Fairbanks School of Public Health, supported by the National Library of Medicine of the National Institutes of Health under award number T15LM012502. Dr. Schleyer received support from the Indiana Clinical and Translational Sciences Institute (funded in part by award number UL1TR002529 from the National Institutes of Health, National Center for Advancing Translational Sciences) Clinical and Translational Sciences Award and the Lilly Endowment, Inc. Physician Scientist Initiative.

Authors and affiliations

Helen N. C. Fu1, 2, Jean F. Wyman3, Cynthia J. Peden-McAlpine3, Claire Burke Draucker4, Titus Schleyer1,5, and Terrence J. Adam6, 7.

1Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States.

2Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States.

3School of Nursing, University of Minnesota, Minneapolis, MN, United States.

4School of Nursing, Indiana University, Indianapolis, IN, United States.

5School of Medicine, Indiana University, Indianapolis, IN, United States.

6College of Pharmacy, Department of Pharmaceutical Care & Health Systems, University of Minnesota, Minneapolis, MN, United States.

7Institute of Health Informatics, University of Minnesota, Minneapolis, MN, United States.

About Titus Schleyer, DMD, PhD

In addition to his role as a Regenstrief Institute research scientist, Titus K. Schleyer, DMD, PhD, is the program director for learning health informatics at Regenstrief Institute and is a professor of biomedical informatics at Indiana University School of Medicine.

About Regenstrief InstituteFounded in 1969 in Indianapolis, the Regenstrief Institute is a local, national and global leader dedicated to a world where better information empowers people to end disease and realize true health. A key research partner to Indiana University, Regenstrief and its research scientists are responsible for a growing number of major healthcare innovations and studies. Examples range from the development of global health information technology standards that enable the use and interoperability of electronic health records to improving patient-physician communications, to creating models of care that inform practice and improve the lives of patients around the globe.

Sam Regenstrief, a nationally successful entrepreneur from Connersville, Indiana, founded the institute with the goal of making healthcare more efficient and accessible for everyone. His vision continues to guide the institute’s research mission.

About the IU Richard M. Fairbanks School of Public HealthThe Indiana University Richard M. Fairbanks School of Public Health is committed to advancing the public’s health and well-being through education, innovation and leadership. The Fairbanks School of Public Health is known for its expertise in biostatistics, epidemiology, cancer research, community health, environmental public health, global health, health policy and health services administration.

About IU School of MedicineIU School of Medicine is the largest medical school in the U.S. and is annually ranked among the top medical schools in the nation by U.S. News & World Report. The school offers high-quality medical education, access to leading medical research and rich campus life in nine Indiana cities, including rural and urban locations consistently recognized for livability.

What Reparations Actually Bought

In 1990, the U.S. government began mailing out envelopes, each containing a presidential letter of apology and a $20,000 check from the Treasury, to more than 82,000 Japanese Americans who, during World War II, were robbed of their homes, jobs, and rights, and incarcerated in camps. This effort, which took a decade to complete, remains a rare attempt to make reparations to a group of Americans harmed by force of law. We know how some recipients used their payment: The actor George Takei donated his redress check to the Japanese American National Museum in Los Angeles. A former incarceree named Mae Kanazawa Hara told an interviewer in 2004 that she bought an organ for her church in Madison, Wisconsin. Nikki Nojima Louis, a playwright, told me earlier this year that she used the money to pay for living expenses while pursuing her doctorate in creative writing at Florida State University. She was 65 when she decided to go back to school, and the money enabled her to move across the country from her Seattle home.

But many stories could be lost to history. My family received reparations. My grandfather, Melvin, was 6 when he was imprisoned in Tule Lake, California. As long as I’ve known about the redress effort, I’ve wondered how he felt about getting a check in the mail decades after the war. No one in my family knows how he used the money. Because he died shortly after I was born, I never had a chance to ask.

To my knowledge, no one has rigorously studied how families spent individual payments, each worth $45,000 in current dollars. Densho, a nonprofit specializing in archival history of Japanese American incarceration, and the Japanese American National Museum confirmed my suspicions. When I first started researching what the redress effort did for former incarcerees, the question seemed almost impudent, because whose business was it but theirs what they did with the money?

Still, I thought, following that money could help answer a basic question: What did reparations mean for the recipients? When I began my reporting, I expected former incarcerees and their descendants to speak positively about the redress movement. What surprised me was how intimate the experience turned out to be for so many. They didn’t just get a check in the mail; they got some of their dignity and agency back. Also striking was how interviewee after interviewee portrayed the monetary payments as only one part—though an important one—of a broader effort at healing.

[From the June 2014 issue: The case for reparations]

The significance of reparations becomes all the more important as cities, states, and some federal lawmakers grapple with whether and how to make amends to other victims of official discrimination—most notably Black Americans. Although discussions of compensation have existed since the end of the Civil War, they have only grown in intensity and urgency in recent years, especially after this magazine published Ta-Nehisi Coates’s “The Case for Reparations” in 2014. In my home state, California, a task force has spent the past three years studying what restitution for Black residents would look like. The task force will deliver its final recommendations—which reportedly include direct monetary payments and a formal apology to descendants of enslaved people—to the state legislature by July 1.

In 1998, as redress for Japanese American incarcerees was winding to a close, the University of Hawaii law professor Eric Yamamoto wrote, “In every African American reparations publication, in every legal argument, in almost every discussion, the topic of Japanese American redress surfaces. Sometimes as legal precedent. Sometimes as moral compass. Sometimes as political guide.” Long after it ended, the Japanese American–redress program illustrates how honest attempts at atonement for unjust losses cascade across the decades.

In February 1942, following the attacks on Pearl Harbor, President Franklin D. Roosevelt signed Executive Order 9066, authorizing the incarceration of more than 125,000 Japanese Americans mostly on the West Coast. In the most famous challenge to the legality of Roosevelt’s order, Fred Korematsu, an Oakland man who had refused to report for incarceration, appealed his conviction for defying military orders. The Supreme Court upheld Korematsu’s conviction in its now notorious decision Korematsu v. United States. Families like mine were forced to abandon everything, taking only what they could carry.

After the war, many former incarcerees, weighed down with guilt and shame, refused to speak about their experience. But as their children—many of them third-generation Japanese Americans—came of age during the civil-rights movement, calls for restitution and apology grew within the community. In 1980, Congress passed legislation establishing a commission to study the issue and recommend appropriate remedies. After hearing testimony from more than 500 Japanese Americans—many of whom were speaking of their incarceration for the first time—the Commission on Wartime Relocation and Internment of Civilians concluded that “race prejudice, war hysteria and a failure of political leadership” had been the primary motivators for the incarceration. The CWRIC also recommended that $20,000 be paid to each survivor of the camps.

At the same time, new evidence emerged showing that the government had suppressed information and lied about Japanese Americans being security threats. In the 1980s, lawyers reopened the Korematsu case and two similar challenges to E.O. 9066. All three convictions were vacated. By 1988, when reparations legislation was making its way through Congress, the legal proceedings and the CWRIC’s findings provided the momentum and public evidence for Japanese Americans to make the case for reparations. The 1988 Civil Liberties Act authorized reparations checks to all Japanese American incarcerees who were alive the day the act was signed into law. (If a recipient was deceased at the time of payment, the money went to their immediate family). The Department of Justice established a special body, the Office of Redress Administration, to contact and verify eligible recipients. The CLA also provided for a formal government apology and a fund to educate the public about the incarceration: safeguards against such history repeating itself.

[Read: Two boy scouts met in an internment camp, and grew up to work in Congress]

Ever since, reparations advocates have invoked Japanese American redress as a precedent that can be replicated for other groups. Dreisen Heath, a reparations advocate and former researcher at Human Rights Watch, told me Japanese American redress proves that “it is possible for the U.S. government to not only acknowledge and formally apologize and state its culpability for a crime, but also provide some type of compensation.” In 1989, then-Representative John Conyers introduced H.R. 40, a bill to establish a commission to study reparations for Black Americans. Proponents have reintroduced the bill again and again.

In 2021, as the House Judiciary Committee prepared to vote for the first time on H.R. 40, the Japanese American social-justice organization Tsuru for Solidarity submitted to the panel more than 300 letters written by former incarcerees and their descendants. The letters described how the reparations process helped Japanese Americans, psychologically and materially, in ways that stretched across generations. (In addition to drawing on that rich source of information for this story, I also interviewed family friends, members of the Japanese American church that I grew up in, and other former incarcerees and their children.)

In one of the letters, the daughter of an incarceree tells how the $20,000, invested in her family’s home equity and compounded over time, ultimately enabled her to attend Yale. “The redress money my family received has always been a tailwind at my back, making each step of the way a tiny bit easier,” she wrote. Just as her family was able to build generational equity, she hoped that Black Americans, too, would have “the choice to invest in education, homeownership, or whatever else they know will benefit their families, and, through the additional choices that wealth provides, to be a little more free.”

The redress effort for World War II incarcerees has shaped California’s task force in highly personal ways. Lisa Holder, an attorney who sits on the task force, first saw the idea of reparations become concrete through her best friend in high school, whose Japanese American father received a payment. The only non-Black member of the task force is the civil-rights lawyer Don Tamaki, whose parents were both incarcerated. Tamaki, like many other people I interviewed, acknowledges that incarcerees have different histories and experiences from the victims of slavery and Jim Crow—“there’s no equivalence between what Japanese Americans suffered and what Black people have gone through,” he told me—but he also sees some parallels that might inform the reparations debate.

Tamaki’s life, like that of many Japanese Americans, has been shaped by his family’s incarceration. As a young lawyer, he worked on the legal team that reopened Korematsu. Tamaki is now 72. In January, he and I met at the Shops at Tanforan, a mall built atop the land where his parents, Minoru and Iyo, were incarcerated. Next to the mall, a newly opened memorial plaza honors the nearly 8,000 people of Japanese descent who lived there in 1942. Neither Don nor I had previously visited the memorial, which happens to be near my hometown. In middle school, I bought a dress for a dance party at the mall’s JCPenney.

In 1942, Tanforan was an equestrian racetrack. After Roosevelt issued his internment order, horse stalls were hastily converted into living quarters. Minoru, who was in his last year of pharmacy school, couldn’t attend his commencement ceremony, because he was incarcerated. The university instead rolled up the diploma in a tube addressed to Barrack 80, Apt. 5, Tanforan Assembly Centre, San Bruno, California. “The diploma represents the promise of America,” he told me. “And the mailing tube which wraps around this promise—the diploma—constrains and restricts it.” Don still has both.

When the checks arrived in the mail in the ’90s, the Tamakis gathered at Don’s house. His parents spent one check on a brown Mazda MPV, which they would use while babysitting their grandkids. They put the other check into savings. “They didn’t do anything extravagant,” Don told me.

To talk about reparations is to talk about loss: of property and of personhood. In 1983, the CWRIC estimated Japanese American incarcerees’ economic losses at $6 billion, approximately $18 billion today. But those figures don’t capture the dreams, opportunities, and dignity that were taken from people during the war. Surviving incarcerees still feel those losses deeply.

[Read: What my grandmother learned in her World War II internment camp]

Mary Tamura, 99, was a resident of Terminal Island off the coast of Los Angeles. “It was like living in Japan,” she told me. Along with the island’s 3,000 other Japanese American residents, she celebrated Japanese holidays; learned the art of flower arranging, ikebana; and wore kimonos. Then, on December 7, 1941, shortly after Pearl Harbor was attacked, the FBI rounded up men and community leaders, including Tamura’s father. Two months later, Terminal Island residents were ordered to leave within 48 hours. Tamura, who once dreamed of teaching, instead joined the U.S. Cadet Nurse Corps. On Terminal Island, Japanese homes and businesses were razed.  

Lily Shibuya was born in 1938 in San Juan Bautista, California. After the war, her family moved to Mountain View, where they grew carnations. Shibuya’s older siblings couldn’t afford to go to college and instead started working immediately after they were released from one of the camps. Her husband’s family members, also flower growers, were able to preserve their farmland but lost the chrysanthemum varieties they had cultivated.

Shibuya told me that with her reparations check, she bought a funerary niche for herself, paid for her daughter’s wedding, and covered travel expenses to attend her son’s medical-school graduation. Tamura used part of her redress money for a vacation to Europe with her husband. The other funds went toward cosmetic eyelid surgery. “It was just for beauty’s sake—vanity,” Tamura told me.

Many recipients felt moved to use the $20,000 payments altruistically. In a 2004 interview with Densho, the then-91-year-old Mae Kanazawa Hara—who’d given an organ to her church—recalled her reaction to receiving reparations: “I was kind of stunned. I said, ‘By golly, I've never had a check that amount.’ I thought, Oh, this money is very special.” Some recipients gave their check to their children or grandchildren, feeling that it should go toward future generations.

The notion that recipients should use their money for noble purposes runs deep in the discussion about reparations. It helps explain why some reparations proposals end up looking more like public-policy initiatives than the unrestricted monetary payments that Japanese Americans received. For example, a 2021 initiative in Evanston, Illinois, began providing $25,000 in home repairs or down-payment assistance to Black residents and their descendants who experienced housing discrimination in the city from 1919 to 1969. Florida provides free tuition to state universities for the descendants of Black families in the town of Rosewood who were victimized during a 1923 massacre. But if the goal of reparations is to help restore dignity and opportunity, then the recipients need autonomy. Only they can decide how best to spend those funds. (Perhaps recognizing this, Evanston’s city council voted earlier this year to provide direct cash payments of $25,000.)

[Ibram X. Kendi: There is no middle ground on reparations]

Not every Japanese American whom I interviewed deemed the reparations effort helpful or sincere. When I arrived at Mary Murakami’s home in Bethesda, Maryland, the 96-year-old invited me to sit at her dining-room table, where she had laid out several documents in preparation for my visit: her yearbook from the high school she graduated from while incarcerated; a map of the barracks where she lived in Topaz, Utah; a movie poster–size copy of Executive Order 9066, found by her son-in-law at an antique shop.

She first saw the order nailed to a telephone pole in San Francisco’s Japantown as a high schooler, more than 80 years ago. A rumor had been circulating in Japantown that children might be separated from their parents. Her mother and father gave each child a photo of themselves, so the children would remember who their parents were. They also revealed a family secret: Atop the highest shelf in one of their closets sat an iron box. The children had never asked about it, and it was too heavy for any of them to remove, Murakami recalled. Inside the box was an urn containing the ashes of her father’s first wife, the mother of Murakami’s oldest sister, Lily.

The government had told them to take only what they could carry. The ashes of a dead woman would have to be left behind. Murakami and her father buried the box in a cemetery outside the city. With no time or money to prepare a proper tombstone, they stuck a homemade wooden marker in the ground. Then they returned home to resume packing. They sold all their furniture—enough to fill seven rooms—for $50.

Murakami’s family, like the Tamakis, went to Tanforan, and then to Topaz. “The most upsetting thing about camp was the family unity breaking down,” Murakami told me. “As camp life went on, we didn’t eat with our parents most of the time.” Not that she did much eating—she recalls the food as inedible, save for the plain peanut-and-apple-butter sandwiches. Today, Murakami will not eat apple butter or allow it in her house.

After the war, she did her best to move forward. She graduated from UC Berkeley, where she met her husband, Raymond. They moved to Washington, D.C., so that he could attend dental school at Howard University—a historically Black school that she and her husband knew would admit Japanese Americans.

Absent from the documents that Murakami saved is the presidential letter of apology. “Both Ray and I threw it away,” she told me. “We thought it came too late.” After the war ended, each incarceree was given $25 and a one-way ticket to leave the camps. For Murakami, money and an apology would have meant something when her family was struggling to resume the life that they had been forced to abruptly put on pause—not more than 40 years later. She and her husband gave some of their reparations to their children. Raymond donated his remaining funds to building the Japanese American Memorial to Patriotism in Washington, D.C., and Mary deposited hers in a retirement fund.

A $20,000 check could not reestablish lost flower fields, nor could it resurrect a formerly proud and vibrant community. Still, the money, coupled with an official apology, helped alleviate the psychological anguish that many incarcerees endured. Lorraine Bannai, who worked on Fred Korematsu’s legal team alongside Don Tamaki, almost never talked with her parents about the incarceration. Yet, after receiving reparations, her mother confided that she had lived under a cloud of guilt for decades, and it had finally been lifted. “My reaction was, ‘You weren’t guilty of anything. How could you think that?’” Bannai told me. “But on reflection, of course she would think that. She was put behind barbed wire and imprisoned.”

Yamamoto, the law professor in Hawaii, stresses that the aims of reparations are not simply to compensate victims but to repair and heal their relationship with society at large. Kenniss Henry, a national co-chair of the National Coalition of Blacks for Reparations in America, told me that her own view of reparations has evolved over time. She sees value in processes such as community hearings and reports documenting a state’s history of harm. “It is necessary to have some form of direct payment, but reparations represent more than just a check,” she said.

The Los Angeles community organizer Miya Iwataki, who worked toward Japanese American redress as a congressional staffer in the 1980s and now advocates for reparations for Black Californians, sees the checks and apology to World War II incarcerees as essential parts of a larger reconciliation. In 2011, Iwataki accompanied her father, Kuwashi, to Washington, D.C., to receive a Congressional Gold Medal for his World War II military service. Throughout their trip, he was greeted by strangers who knew of Kuwashi’s unit: the all-Japanese 100th Battalion of the 442nd Regimental Combat Team, known for being the most decorated unit of its size and length of service. As the Iwatakis settled into their seats on the return flight, Kuwashi told Miya, “This is the first time I really felt like an American.”

For decades, former incarcerees have kept memories alive, and now that task falls to their descendants. Pilgrimages to former incarceration sites have resumed since the height of the pandemic, and new memorials, like the one at the Tanforan mall, continue to crop up. “The legacy of Japanese American incarceration and redress has yet to be written,” Yamamoto told me.

In January, my mom and I drove to Los Angeles for an appointment at the Japanese American National Museum. We were there to see the Ireichō, or the sacred book of names. The memorial arose out of another previously unanswered question: How many Japanese Americans in total were incarcerated during the war? For three years, the Ireichō’s creator, Duncan Ryūken Williams, worked with volunteers and researchers to compile the first comprehensive list, with 125,284 names printed on 1,000 pages.

I was stunned at the book’s size, and even more moved by the memorial’s design. On the walls hung wood panels with the names of each incarceration camp written in Japanese and English, along with a glass vial of soil from each site. My mom and I were invited to stamp a blue dot next to the names of our family members, as a physical marker of remembrance. When the museum docent flipped to my grandfather, Melvin, I was reminded that I’ll never be able to ask him what he experienced as a child. I’ll never learn what he thought when, in his 50s, he opened his apology letter. The only additional detail that I learned about him while reporting this article was that, according to my grandmother, he mistakenly listed the $20,000 as income on his tax return.

But through my conversations with surviving incarcerees, many of whose names also appear in the Ireichō, I could see how a combination of symbolic and material reparations—money, an apology, and public-education efforts—was essential to a multigenerational healing process. For Melvin, a third-generation Japanese American, this might have looked like receiving the check. For me, in the fifth generation, placing a stamp next to his name helped me honor him and see his life as part of a much larger story. The project of making amends for Japanese American incarceration didn’t end with the distribution of redress checks and an apology. It might not even finish within one lifetime, but each generation still strives to move closer.

Photo-illustration sources: Buyenlarge / Getty; Corbis / Getty; Dorothea Lange / U.S. War Relocation Authority / Getty; History / Universal Images Group / Getty; Library of Congress; Stephen Osman / Getty; Bancroft Library / UC Berkeley