Structural Inequities and Chronic Disease in Fresno County: A Narrative Review and Multi-sectoral Framework

Despite California's favorable statewide health profile, significant intra-state disparities exist. Fresno County, located in the Central Valley, consistently ranks among the state's worst-performing counties for health outcomes, presenting a critical case study in health inequity. This study analyzes the prevalence of chronic diseases in Fresno County and investigates the underlying factors contributing to this public health crisis. A comparative analysis was conducted using public health data from 2018 to 2021 to assess the prevalence of major chronic diseases, including obesity, hypertension, diabetes, asthma, coronary heart disease (CHD), and stroke. The prevalence rates in Fresno County were compared with those in California, considering social determinants of health impacting Fresno residents. Fresno County exhibits significantly higher prevalence and mortality rates for most major chronic diseases when compared to regional and statewide averages. These adverse health outcomes are strongly correlated with a complex web of interconnected factors, including pervasive poverty, low educational attainment, critical shortages of healthcare providers, severe air and pesticide pollution, and widespread food insecurity. These determinants disproportionately impact the county's racial and ethnic minority populations, exacerbating health disparities. The findings establish that Fresno's chronic disease burden is a direct consequence of structural inequities. We argue that an actionable framework targeting socioeconomic determinants, environmental justice, and healthcare system reform is imperative to address these structural inequities.