Center to Eliminate Health Disparities
A Health in All Policies Approach to Disaster Recovery: Lessons from Galveston
IOM Committee on Post-disaster Recovery of a
Community’s Public Health, Medical and Social
Services
June 13, 2014
Alexandra (Lexi) Nolen, PhD, MPH
Director, UTMB Center to Eliminate Health Disparities
Center to Eliminate Health Disparities
1. The story
2. The theory, approach, activities and examples
3. Lessons and reflections
Center to Eliminate Health Disparities
The story of Galveston and Ike
Center to Eliminate Health Disparities
Background
Center to Eliminate Health Disparities
Center to Eliminate Health Disparities
Taking stock…
…and perhaps an opportunity
• 70% destroyed or badly damaged
• Pre-storm disproportionate poverty, poor health and social
indicators, and inequities were going to be exacerbated
• Health and safety network gone—UTMB, social services—
leaving highly dependent people even more vulnerable (physical
and communications infrastructures destroyed, social
infrastructure crippled, previous providers now part of the needy)
• Disproportionate number of poor made this extremely
problematic in terms of recovery
• UTMB closed for months and
almost destroyed
Center to Eliminate Health Disparities
The theory, approach, activities, examples
Center to Eliminate Health Disparities
Began in October 2009 with 2 grants
Aim: To increase evidence informed policy making and
planning related to SDH within a context of post-disaster
recovery planning
Hypothesis: Post-disaster planning environments afford
opportunities for accelerating
local planning to address
social determinants of health
and health disparities through
a “Health in All Policies”
approach.
Galveston Health in All Policies Project
Center to Eliminate Health Disparities
Why use a Health in All Policies approach after a disaster? 1. Re-ignited enthusiasm for building a model community
2. Sense of the need to cooperate and willingness to break siloed planning
3. Synchronized planning cycles; engagement across sectors
4. Increased resources to support the interventions to create healthier neighborhoods (creating a virtuous cycle: If you start with a healthy community, the population will be more psychologically, physically, and economically resilient to future disasters)
Need to go beyond healthy lifestyles to policy and planning;
upstream; causes of causes
Center to Eliminate Health Disparities
Cumulative risk and the urgency of a Health in All Policies approach • Transportation
• Access to healthy food
• Social support
• Economic resources
• Childcare
• Employment
• Access to health care services
• Environmental safety and health
• Housing
Not just independent variables, but create domino effects
and vicious cycles, heightened for those with low SES,
resulting in cumulative risk for mental and physical illness.
Center to Eliminate Health Disparities
Center to Eliminate Health Disparities
Center to Eliminate Health Disparities
Two levels of impact of SDH on health 1. If sectors do their jobs and do them well, health will result.
(Recovery is also a health determinant)
Can have middling impact; failure to implement well or incorporate
equity goals can lead to negative health impacts and/or increased
inequity; tendency to miss opportunities and externalization of health
costs of decisions
Inverse care laws work in sectors other than health
2. Intentional considerations of health and health equity are needed
in non-health sector planning in order to advance primary
prevention and mitigate negative impacts of SDH.
Requires explicit focus on health and health equity, using evidence
Center to Eliminate Health Disparities
Two approaches
1. Health Impact Assessment (HIA)
--works nicely to raise awareness; can be rapid; but usually “from
the outside” so may not be taken up
2. Intersectoral action
--can be more efficient; but requires inclusion of the health
champions
Levels of integration:
Awareness Cooperation Integration
Center to Eliminate Health Disparities
Our Strategy
Strategy of using opportunistic inputs
• no time, no relationships, no prior work
3 pillars of action
• assembling the evidence base on local challenges in relation to
social determinants of health;
• raising community awareness and knowledge of SDH through
education and engagement; and
• partnering with decision-makers and planners to incorporate
evidence based recommendations into planning processes
Center to Eliminate Health Disparities
Programmatic activities
1. Sediment sampling
2. GIS Mapping of SDH
3. Scenarios Workshop
4. Incorporated pro-health tips into public
information on hurricane preparedness
5. Community Education on SDH (2000+)
6. Briefs: housing, food access and
security, education, general (10)
7. Input on master plans
8. Rapid HIA of City Comprehensive Plan
9. Healthy housing recovery planning
10. HIA on siting of public housing and
healthy neighborhoods
10-1000. Community meetings, focus
groups, feedback sessions
Center to Eliminate Health Disparities
Partners
• UTMB groups
• City of Galveston: City
Council; Dept of Planning;
Families, Children and Youth
Board; Police Dept; Parks
Dept; Comprehensive
Planning Cmte; Recovery
Cmte; Revitalization Cmte
• Housing Authority
• County Health District
• Housing Recovery Committee
• Port of Galveston
•Chamber of Commerce •Neighborhood Associations •Faith Community •Social Services organizations •Civil rights organizations (NAACP, LULAC) •Social justice groups •Community centers •Texas General Land Office •Recovery contractors •Local Donors •Disaster Planning (VOAD) •Coordinating Groups (United Way)
Center to Eliminate Health Disparities
NIH grant
Adapt the HDMT (SCI) to a post-disaster context, test its applicability, and draw lessons more generally on using an intersectoral approach to improve health in a post-disaster planning environment
GIS map 125 health-related indicators in the areas of environmental stewardship, sustainable and safe transportation, social cohesion, public infrastructure/access to goods and services, adequate and healthy housing, and healthy economy
Scenarios to improve pro-health disaster planning
Center to Eliminate Health Disparities
GIS mapping showed SDH got worse…
• Concentrated poverty
and segregation
• Proximity / exposure to
industry
• Food security (desert and
swamp, homeless /
displaced)
• Transportation
• Recreation and outdoor
physical activity
• Housing affordability and
quality
• Pedestrian safety and traffic
calming
• Vendors of alcohol for off-
site use
• Environmental hazards
• Residential proximity to truck
routes
• Infant and child care
• Tree canopy
• Sidewalks and quality
• Community / police relations
• Lack of geographically
distributed primary care
facilities
Center to Eliminate Health Disparities
Scenarios Workshop
• 1 day workshop of 65 local govt and community leaders
• ½ day training on SDH
• ½ day presented “scenarios” and asked participants to
consider how they could improve community resilience
and health through pro-health disaster planning
1. Neighborhood resilience
(displacement)
2. Social services
3. Health care
4. Housing
5. Food security
6. Transportation
7. Environmental health
8. Child care
9. Economic recovery
10. Inclusion
Center to Eliminate Health Disparities
1. Neighborhood resilience
Experience: poorest neighborhoods, with fewer assets, were slowest to
recover in part because of their dependence on institutional resources
and proximity to essential goods and services; the slower return of
poorer residents impacted recovery for all
When a “threshold” of neighborhood residents are able to return, it
supports others in the neighborhood to be able to return
Solution: develop mixed income, mixed use neighborhoods, and support
social cohesion before and after the disaster
What we did (subsequent to the workshop) to integrate into HiAP recovery:
• HIA of the public housing recovery plans
• Input on neighborhood master plans and comprehensive plan
• Initiative on healthy neighborhoods
• Public education on housing quality, social cohesion and
police/community relations
Center to Eliminate Health Disparities
2. Social Services
Experience: social services took hard organizational/staff personal hits,
were slow to get back online, and based on a “charity” model that
may have slowed recovery
Supporting social services that are locally run on a sustainability model
may accelerate recovery and community health
Solution: local social service providers should have more sustainability
oriented planning
What we did:
• Community conversations about sustainable social services
planning (incorporating residents for structural change, not just
“charity”)
• (working with the United Way to develop stronger sustainability for
program planning)
Center to Eliminate Health Disparities
3. Health Care
Experience: primary care services were deployed more deeply into
community, and new models such as nurse-managed clinics
enhanced care delivery; but reverted to former models after “crisis”
New ways of delivering services during crisis may be more effective
than traditional approaches, but need to be institutionalized
Solution: consider whether “disaster innovations” offer advantages
over traditional practices, and if so, support institutionalization
What we did:
• Nurse-managed clinic established (for first time in Galveston); has
been sustained
• Primary care workers deployed into community; has not been
sustained
Center to Eliminate Health Disparities
5. Food security and nutrition
Experience: existing food desert was greatly expanded after the storm,
while low nutrition food outlets recovered fairly quickly
Full service grocery stores are becoming less frequent in lower income
neighborhoods, which are themselves often more vulnerable to disaster
Solution: ensure resilience of essential services such as grocery stores
What we did:
• Documented findings on the food desert, along with potential solutions
• Incorporated the issue into community education initiatives and briefs
• Explored options with local economic development group
• Inserted issue into reviews of planning documents when possible
• Highlighted the issue in the media, including a spot of PBS News Hour
and multiple newspaper articles
--has not been resolved…
Center to Eliminate Health Disparities
7. Environmental health
Experience: layer of sediment deposited across the island; though state
tested for enviro exposure, information was not accessible to public
In the rush to return, public information and personal protection actions
are often in short supply
Solution: plan for a public process for identifying, communicating and
providing protection from environmental hazards, especially for
sensitive land use areas
What we did:
• Tested the sediment; presented findings at public meetings
• Provided protective equipment and training to 2,000+ volunteers
• Developed a pamphlet to instruct in use of protective equipment
• Provided other Gulf Communities with personal protection equipment
after disasters
Center to Eliminate Health Disparities
8. Childcare
Experience: many services such as childcare operated on tiny financial
margins, had no capital backup, and either closed or were significantly
delayed in returning, but were vital to recovery and health
When people don’t have trusted, affordable child care, they can’t return to
the community and effectively participate in the recovery process;
ECD is diminished, family mental health and relationships diminish,
and family income declines
Solution: Prioritize recovery of critical “community fabric” services;
include them in SSBG programs and streamline SBL programs;
support regional partnerships and regulatory flexibility to encourage
continuity of employment and service delivery (based on client needs)
What we did:
• Advocate for recovery of affordable, quality child care services
• Support development of longer term plans on ECD
Center to Eliminate Health Disparities
10. Inclusion
Experience: many displaced residents were excluded from the recovery
planning process, including by design; others were excluded or
delayed from recovery benefits due to loss of documentation
Excluding voices is not only unfair procedurally but can set the recovery
process on the wrong pathway and lead to conflict and delays
Solution: include the voice of all persons, such as through qualification
rules based on pre-disaster residency; use ICT, social media, etc.;
ensure electronic retrieval of documents needed for benefits
What we did:
• could not influence planning inclusion criteria and platforms
• held focus groups and public meetings and produced briefs on
“visioning” to raise the voice of excluded
• electronic storage of records needed to access benefits
Center to Eliminate Health Disparities
Center to Eliminate Health Disparities
Public housing recovery work
• 569 units demolished quickly after storm
• Became flash-point in community, due to different “visions”
• Even research and evidence became politicized
Activities:
• Public information on the health impact of the rebuilding options
(testimony, briefs, community meetings)
• Contract with Housing Authority to support healthy scattered site
locations (discontinued)
• HIA of recovery of scattered site public housing; incorporated
development of a tool for a broader Healthy Neighborhood initiative
for Galveston (working toward institutionalization)
Center to Eliminate Health Disparities
Projects in process
Implementation of Healthy Neighborhoods HIA into local
government and community planning, including for the
redevelopment of the hardest hit neighborhood (now
largely abandoned)
Incorporation of Scattered site HIA into public housing
recovery plan
Re-introduction of the rapid HIA of the City
Comprehensive Plan
…Still need to move into Health in All Policies phase
where disaster planning for resilience is effectively
incorporated into planning
Center to Eliminate Health Disparities
Lessons and
reflections on future
use of HIA in the
disaster context
Center to Eliminate Health Disparities
…the (early) dawning reality…two years post-disaster… • Disaster recovery programs are often designed in ways
that have a negative impact on health and health equity
WAY too many players to make this a clean experiment
• Frustration that FEMA wasn’t interested in people, just
bricks and mortar
• Impossible to coordinate funding streams during the
crisis, and leveraging them was difficult
• The “vision” can cut both ways
• Without relationships and a recognized role, it’s difficult to
get a seat at the table
Center to Eliminate Health Disparities
LTRC Projects Disaster Planning Emergency Operation Center Disaster Mitigation Plan Rapid Response Plan Economic Development Downtown Redevelopment Plan Port Expansion Committee Seawall development master plan Galveston Business Incubator Business Incubator/Bio Tech Committee East End Lagoon Nature Park Casino gambling feasibility study Tourism Master Plan Committee Housing, Neighborhoods, Historic Preservation Sustainable Neighborhoods Housing Market Study Housing Rehabilitation/Infill Program Committee Rent-to-Own/Work-to-Own Homes Hazard Mitigation Plan Galveston National Register Historic District Historic Preservation Partnership GHA/GHF Committee Elevation Design Guidelines Facade Restoration Program Preservation/Conservation Institute Committee Health Health Impact Needs Assessment
Education
Community Learning Center
Vocational-Technical Center
Galveston Promise Committee
Natural Resources
Clean Green & Smart Galveston Project Committee
Habitat Eco System Restoration Committee
West Galveston Bay Preserve Committee
Protecting Island resources
Trees for Galveston
Transportation and Infrastructure
Take a Seat Committee Cindy
Pedestrian/Bike Trails (Stroll & Roll)
Smart Street Design Guidelines
Multi-modal Thoroughfares, Bridges Committee
Galveston Houston Rail Committee
Water Systems Improvements
Ike Dike Committee
Galveston Levee System
Desalination Plant Committee
Underground Utilities Committee
Sanitary Sewer Improvements
Stormwater Master Drainage Plan Implementation
UTMB Public Information Project Committee
Land Use Policy Revisions Committee
Center to Eliminate Health Disparities
Entry Points
Failure:
Missed lots of potential policy and planning entry points:
planning fatigue; the evidence has to be ready to go, at the
right moment, and communicated as an opportunity; unified
vision wasn’t there to support proactive inclusion of our work
Success:
Though it has taken too long, we have built relationships and
public understanding, and people now actively come to us to
apply a health lens to their plans
Center to Eliminate Health Disparities
Creating a community vision
Failure:
Could not create a unified vision in the post-disaster chaos; Once
public housing was torn down, “opportunity” to “reduce” poverty
became a goal for some; Low health literacy among public (including
health system literacy and knowledge of SDH) combined with
exclusion of the displaced and poor, political ideologies that do not
value equity, politicization of issues with strong health impact
Success:
Investments in community education and a coalition-building strategy
for projects has resulted in greater understanding of our work and unity
of purpose (or at least utility of the work, e.g. public housing/healthy
neighborhoods)
Center to Eliminate Health Disparities
Health-promoting funding mechanisms Failure:
Urgency and bureaucracy made it impossible to significantly
restructure how (federal) funding is disbursed to have better
health and equity impact; community fabric services ignored
except through Small business loans which came too late; SSBG
is a great opportunity, but needs to support a SDH (not just
individualized case-management) approach
Success:
Flexibility of local institutional/donor funding eventually helped fill
the gap to address SOME “community fabric” services but much
could be improved
Center to Eliminate Health Disparities
Lessons
Improvements in “pro-health planning” may occur immediately after a
disaster, but fade or be pulled back unless institutionalized
Other initiatives may stall, only to be picked up later (play the long
game)
Ideally, strategy should be to engage both HiAP initiatives with a
disaster lens, and Disaster Planning with a health lens
How did the HiAP experience inform recovery planning?
Stronger awareness of pre-disaster planning opportunities that will
not only strengthen health but also accelerate recovery
Collection of indicators related to health and health equity that
have even more pronounced effects post-disaster
Center to Eliminate Health Disparities
Recommendations
1. Tools and guidance for coordinating social services needed,
including for strengthening resilience, accessing funding,
coordinating services, developing sustainable investment
models, etc.
2. “Community Fabric” services need to have heightened
resilience, then better supported for faster recovery and
improved community health
3. Recovery funding should be structured (at least in part) as
an investment in sustainable/institutionalized pro-health
program models
4. Pay attention to potential for cumulative risk, and keep
people at the center of the work
Center to Eliminate Health Disparities
Recs
5. Significant investments should be made in educating
communities on SDH and supporting planning prior to
disasters
6. Reinforcing strategies: Disaster planning and recovery
through a health lens (HiAP); HiAP with a disaster
component
7. More equitable recovery processes and structures are
needed including to support health, health equity, and
accelerate recovery
8. This work needs a champion—not all communities have
a CEHD.
Center to Eliminate Health Disparities
Thank you
Lexi Nolen [email protected]
UTMB Center to Eliminate Health Disparities
Acknowledgements:
John Prochaska, Christen Miller, Rob Buschman—UTMB CEHD
Sharon Petronella, Jon Ward, John Sullivan—UTMB NIEHS Center
Clem Bezold, Institute for Alternative Futures
Georgia Health Policy Center
Center to Eliminate Health Disparities
Center to Eliminate Health Disparities