A Health in All Policies Approach to Disaster Recovery .../media/Files/Activity Files... ·...

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


1. The story

2. The theory, approach, activities and examples

3. Lessons and reflections


The story of Galveston and Ike


Background


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


The theory, approach, activities, examples


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


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


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.


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


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


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


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


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)


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


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


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


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


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)


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


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…


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


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


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


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)


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


Lessons and

reflections on future

use of HIA in the

disaster context


…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


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


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


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)


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


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


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


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.


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

mailto:[email protected]

A Health in All Policies Approach to Disaster Recovery .../media/Files/Activity Files... ·...

Documents

Transcript of A Health in All Policies Approach to Disaster Recovery .../media/Files/Activity Files... ·...