COMMUNITY DISASTER RESILIENCE AND THE PUBLIC’S HEALTH

David P. Eisenman, MD MSHSUCLA Associate Professor of Medicine and Public Health

Director, UCLA Center for Public Health and DisastersPreparedness Science Officer, LACDPH

Natural Scientist, RAND

USC Masters in Global Health, Summer 2013

Contact: deisenman@mednet.ucla.edu

Topics for the SeminarTopics for the Seminar

The growing role of public health in disasters in the U.S.

The current paradigm of community resilience and how it differs from prior paradigms.

Real-life examples of public health and healthcare interventions in improving resilience.

Disasters as Acts of Disasters as Acts of God or FateGod or Fate

(dis, astro)—roughly, “formed on a star.”

“Acts of God”

Disasters as Acts of Disasters as Acts of Nature.Nature.

Lisbon 1755– Effected everyone

so how could it be act of God?

Root cause is extremes of nature– “Natural disaster”

First modern disaster

Disaster as Intersection of Disaster as Intersection of Nature and SocietyNature and SocietyCarr, (1930): failure of society’s

protections is required in disaster– Thus, man-made– “So long as the ship rides out the storm, so long

as the city resists the earth-shocks, so long as the levees hold, there is no disaster. It is the collapse of the cultural protections that constitutes the disaster proper.”

Disaster as Avoidable Human Creation that Highlights Societal Injustices & Social Vulnerability

Not enough that there is a human component. Now see victims of larger social forces.

Focus on the vulnerability of people.

– People who experience disaster are victims of social forces/powerful interests who have created the conditions for their hazard vulnerability

Viewing as amoral the scientific (traditional) approaches.

– Searching for blame.

Disaster as Highlighting Societal Injustices & Social Vulnerability

Cannono: “disasters are not ‘natural’ (not even sudden ones) because hazards affect people differently within societies and may have very different impacts on different societies. . .”

Public Health changed after 2001…Public Health changed after 2001…

Anthrax attacks put public health on the “front line of the battle for national security”

Public health infrastructure found lacking

New mission: preventing, preparing for, and responding to any act of bioterrorism or public health emergency.

Federal investments led to improved public health preparedness

Strategic National StockpileLaboratory Response NetworkWorkforce improvementsBiowatch/BioshieldMass casualty care

Problem: Isolated elderly in heat waves

Research Need: “evaluating heat response plans, focusing on environmental risk factors, identification of high-risk populations, effective communications strategies, and rigorous methods for evaluating effectiveness on the local level.”

Disaster Risk = Hazard x Vulnerability

Social Vulnerability The differential susceptibility of social

groups to the impacts of hazards, as well as their abilities to adequately respond to and recover from hazards.– Poverty– Senior adults– Physical disability– Children

Katrina highlighted social vulnerabilities in U.S. disasters

The UN Hyogo Framework treats human actions The UN Hyogo Framework treats human actions and vulnerabilities as the main cause of disasters.and vulnerabilities as the main cause of disasters.

Reducing human vulnerability is a key aspect of reducing disaster (and climate change) risk.

Factors in Evacuation

Message Message understandiunderstandi

ngng

HealthHealth

TransportatiTransportationon

ShelterShelter

MistrustMistrust

Money, jobs, Money, jobs, propertyproperty

Risk Risk perceptionperception

Social Social networknetwork

– At-risk populations are disproportionately harmed

–Children–Older Adults–Racial/ethnic minorities–Chronic illness/Disability

– Communities left out of communication planning

Lessons of Katrina and Sandy

– Large hospitals evacuated– Effect on residents with

functional needs– Long term psychological

consequences

Lessons of Katrina and Sandy

5 Preparedness Items Emergency Plan

AOR %95 CI AOR %95 CI 25-29 0.862 (0.597, 1.245) 1.036 (0.713, 1.504) 30-39 0.927 (0.679, 1.266) 1.060 (0.774, 1.452) 40-49 1.809 (1.316, 2.486) 1.639 (1.191, 2.256) 50-59 1.835 (1.295, 2.600) 1.589 (1.122, 2.251) 60-64 1.203 (0.753, 1.922) 2.194 (1.378, 3.492) 65 or over 1.876 (1.313, 2.681) 1.862 (1.300, 2.668) Latino 0.733 (0.554, 0.970) 1.131 (0.858, 1.491) African American 0.942 (0.676, 1.312) 1.166 (0.839, 1.620) API 0.768 (0.540, 1.093) 1.021 (0.719, 1.450) AI/ Mixed/ Other 0.659 (0.065, 6.653) 1.236 (0.131, 11.630) Less than $10,000 0.491 (0.331, 0.729) 1.130 (0.764, 1.674) $10,000-$20,000 0.499 (0.351, 0.709) 1.190 (0.838, 1.690) $20,000-$30,000 0.611 (0.434, 0.860) 1.488 (1.056, 2.096) $30,000-$40,000 0.772 (0.548, 1.086) 0.908 (0.643, 1.283) $40,000-$50,000 0.756 (0.530, 1.077) 0.730 (0.507, 1.052) $50,000-$75,000 0.738 (0.524, 1.041) 0.973 (0.691, 1.371) Spanish 1.091 (0.760, 1.564) 0.640 (0.447, 0.916) Mandarin 0.826 (0.366, 1.862) 1.104 (0.506, 2.409) Cantonese 0.521 (0.230, 1.181) 0.059 (0.014, 0.252) Korean 0.303 (0.109, 0.840) 0.085 (0.021, 0.337) Vietnamese 0.388 (0.105, 1.435) 0.475 (0.133, 1.695) Very good health 0.896 (0.695, 1.154) 0.812 (0.632, 1.044) Good health 0.812 (0.625, 1.056) 0.631 (0.485, 0.821) Fair health 0.603 (0.428, 0.850) 0.527 (0.372, 0.745) Poor health 0.588 (0.353, 0.978) 0.734 (0.442, 1.219) Disabled 1.141 (0.887, 1.467) 0.983 (0.764, 1.265) SMI 0.610 (0.426, 0.872) 0.891 (0.633, 1.256)

•Programa para Responder a Emergencias con Preparación.

•A culturally targeted educational intervention to promote disaster preparedness among low income Latinos, using community based participatory research (CBPR) methods

•UCLA, Coalition for Community Health (CCH), Los Angeles County Department of Public Health

U.S. Latinos suffer disproportionately from disasters...

Yet are still among least prepared Few culturally tailored programs

– Review of 301 web-sites providing preparedness information found that half did not address racial/ethnic minorities.

– Federal agencies provided “literal translations of English-language materials, with variable consideration of accuracy and cultural acceptability.”

Promotores

Community health promoters = Local lay community residents trained in basic health promotion skills working with fellow community members who are under-served by the health care system.

Use their cultural knowledge, social networks, and leadership role in the community to model behavior, overcome barriers, and create change.

Promotores

Provide connections between community and health care system including informal counseling, service assistance, education.

Improved health care access, prenatal care, health behaviors.

Not previously used in disaster preparedness

Platica

Small group discussion, 1 hour

Led by a trained promotora

Held at community site.

Eisenman, et al., Am J Prev Med, 2009

Disasters are primary care emergencies.

Disasters are primary care emergencies

Demand shocks: increased injury, chronic illness exacerbation, mental distress– 5 of the top 6 conditions treated after

Katrina were chronic disease exacerbations

Supply shocks: diminished staff levels, staff capacity, damaged buildings and supplies

Heart Attacks, Strokes Increased Heart Attacks, Strokes Increased after Japan’s 2011 Earthquake after Japan’s 2011 Earthquake and Tsunamiand Tsunami Heart failure, unstable angina,

MI, stroke, cardiac arrest, pneumonia

Heart failure and pneumonia remained elevated for 6 weeks– Disrupted medications may have

played a role

-Shimokawa, 2012, European Society of Cardiology 2012; http://www.nlm.nih.gov/medlineplus/news/fullstory_128794.html

Preparing the chronically ill is an urgent issue 15% of LAC adults (est 1,085,000) use a chronic

disease medication.

National stockpiles and emergency response plans focus on acute medical and pharmaceutical needs.

No planning for the prescription drug needs of communities sheltering in place or evacuating

Carameli, K. A., Eisenman, D. P., Blevins, J., d’Angona, B., & Glik, D. C. Disaster Medicine and Public Health Preparedness, 2010

Stockpiling medicines is another challenge for public health

Disparities in Medication SupplyDisparities in Medication SupplyPercentage of participants reporting household disaster or emergency preparedness, by preparedness measure and language used in the interview — Behavioral Risk Factor Surveillance System, 14 states, 2006–2010                                

90.6%

51.7%

Preparednessv1.0 v2.0

Resilience is people!

National Academy of Sciences 2012 report focuses on physical infrastructure, insurance, risk prediction

Daniel Aldrich, “Building Resilience” highlights role of human resilience and social capital in recovery and argues that it trumps amount of infrastructure damage and amount of aid received.

Paradigm shift in public health emergency preparedness in emphasizing community strengths as well as simply describing vulnerabilities

Moving from “Me” to “We”Moving from “Me” to “We”

What is Community Resilience (CR)?

In times of need, individuals and communities volunteer and spontaneously help each other

“Ordinary skills in extraordinary circumstances.” Community strengths and assets are critical to

recovery. CR is about looking at existing resources and relationships and strengthening them.

CR is a community’s ability to build capacities to rebound from an emergency/disaster event

Levers and Components of CR

Chandra et al, 2011

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Public is an “asset” not something to be commanded and controlled

Community engagement.Social capital and social networks.

“We” vs “Me”

How is Community Resilience different?

The Traditional Emergency Preparedness Approach

1. Focuses on individual households and response readiness

2. Emphasizes the role of government in the initial response

3. Promotes the need for emergency supplies and emergency plans

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How is this different?

The Community Resilience Approach

1.Emphasizes community members working together to plan, respond and recover

2.Promotes the inclusion of diverse sectors

3.Uses collaboration and community engagement for planning, preparedness and response activities

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Involvement and Integration of CBOs and FBOs Enhance Both Response and Long-Term Recovery

• Provide manpower and other resources

– Information and referral

– Direct services (e.g., case management, food)

– Financial support

National strategies recognize need for greater CBO/FBO participation in disaster planning, response and recovery

Examples from across the United States:

• Using promotoras to educate on disasters in Los Angeles

• Connecting residents to social and mental health services after Hurricane Katrina in New Orleans

National Health Security Strategy

2 Goals Build community resilience Strengthen and sustain

health and emergency response systems

10 Strategic Objectives1. Foster informed, empowered

individuals and communities2. Develop and maintain the

necessary workforce3. Ensure situational awareness

10 Strategic Objectives4. Foster integrated, scalable health care

delivery systems5. Ensure timely and effective

communications6. Promote and effective countermeasures

enterprise7. Ensure prevention or mitigation of

environmental and emerging threats8. Incorporate post-incident health

recovery into planning 9. Work with cross boarder and global

partners 10. Ensure that all systems are based on

best available science, evaluation, and quality improvement methods

CDC’s Public Health and Emergency Preparedness Standards

A great step forward in 2011 Important first attempt to define and measure

community preparedness/resilience building and community recovery

Successes & challenges: 11 Sectors defined, preliminary approach to quantify (median number of sectors “touched”); community engagement in planning

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CDC Capabilities for Community CDC Capabilities for Community PreparednessPreparedness

Four functions– Determine risks to the health of a jurisdiction– Build community partnerships to support health

preparedness– Engage with community organizations to foster public health,

medical, and mental/behavioral health social networks– Coordinate training to ensure community engagement in

preparedness efforts

CDC Capabilities for Community CDC Capabilities for Community RecoveryRecovery

Three Functions:– Identify and monitor public health, medical and

mental/behavioral health systems recovery needs

– Coordinate community public health, medical and mental/behavioral health system recovery operations

– Implement corrective actions to mitigate damages from future incidents

11 Community Sectors

1. Business2. Community leadership3. Cultural and faith-based groups and organizations4. Emergency management5. Healthcare6. Social services7. Housing and sheltering8. Media9. Mental/behavioral health10. State office of aging or its equivalent11. Education and childcare settings

76Centers for Disease Control and Prevention. Public Health Preparedness Capabilities: National Standards for State and Local Planning. March 2011.

78Circle of Influence: A Model for Collaborative Research© 2002 Jones, Circle of Influence: A Model for Collaborative Research© 2002 Jones, Martin, Pardo, Baker, and NorrisMartin, Pardo, Baker, and Norris

Resident Experts

Partners

Community

Community

Resident Experts

Goal setting Planning

Responsibility

& authoritySharing of results

Community Engagement Approach

Pilot Communities selected from 8 Service Planning Areas (SPAs) in LA County

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Community Resilience Toolkit Community Resilience Toolkit ModulesModules1. Intro to Community

Resilience and Hazard Prioritization

2. Community Engagement and Leadership

3. Community Mapping4. Psychological First Aid5. Community

Preparedness Coordinator Training

6. Community Forum Planning

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Multimedia Campaign

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Source: BBPR, Inc.

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bereadyla.org

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Publichealth.lacounty.gov/eprp

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Challenges

Conveying the message about CR Leadership development to

embrace CR Building the capacity of

CBOs/FBOs to be effective partners in building CR

How do we build CR? How do we measure our impact?

David P. Eisenman, MD, MSHSDavid P. Eisenman, MD, MSHSdeisenman@mednet.ucla.edudeisenman@mednet.ucla.edu

310-794-2452310-794-2452