key informant interviews of external stakeholders

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Appendix 4: Preliminary Report

Exploratory Needs Assessments of Key External Stakeholders

Table of contents

1. Introduction

1.A Purpose 1.B Background

2. Methods

2.A Instrument Design

2.B Identification of Informants 2.C Interview Process

2.D Analysis 3. Physician Interviews

3.A Description of informants 3.B Summary

3.C Interview questions and key responses 4. Health Maintenance Organization (HMO) Interview


4.C Interview questions and key responses 5. Non-Governmental Organization (NGO) Interviews


5.C Interview questions and key responses 6. Conclusions and Recommendations

7. Interview Questionnaire Scripts

7.A Physician Interview Script 7.B HMO Interview Script 7.C NGO Interview Script

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1. INTRODUCTION

1.A Purpose

The California Department of Public Health (CDPH), with financial support from the Association of State and Territorial and Health Officials (ASTHO), performed a needs

assessment of the Department’s capacity to handle the public health impacts of climate change. The needs assessment was informed by interviews with CDPH staff, the local

health officer’s survey, and exploratory key informant interviews of external stakeholders, the results here focus solely on the interviews with external stakeholders.

The purpose of the needs assessment process was to gather information to help CDPH better prepare for climate change. The needs assessment consisted of 3 parts:

1) Interviews with CDPH with staff representing programs whose topic areas have a natural overlap with climate change 2) Surveys of health officers of local health departments, who are natural partners

to the state at the local level 3) Exploratory key informant interviews with select external stakeholders

The rationale behind the external stakeholder interviews was to explore needs and opportunities with other key stakeholders that we know play a role in climate change or

work with populations vulnerable to climate change. These included three stakeholder groups comprised of seven physicians, one health maintenance organization (HMO), and

two environmental justice oriented non-government organizations (NGOs). These assessments were not intended to be comprehensive (neither in the scope of questions nor in respondents contacted), nor to be compared with each other.

We conducted a preliminary analysis identifying key themes. This level of analysis was

appropriate given the small number of respondents interviewed per stakeholder group.

We set out to learn how each of these groups perceive and are responding to climate

change and health and what type(s) of collaborative relationships they are engaging in to further their efforts. In addition, we wanted to know how they are interacting with the

communities they serve, especially vulnerable populations in California. We hope to use the information generated from the interviews to inform a process and

improve understanding of public education materials for climate change and health and provide ideas to either inform communication and identify partnerships and ways of

thinking about climate change. This is a preliminary report. The interviews resulted in a rich source of information that

can be further analyzed.

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1.B Background

Climate change is a growing crisis for California and presents a particular challenge,

known as the climate gap, which will impact low-income communities and communities of color. The climate gap refers to the inequalities of climate change and the impacts climate change has “on people of color and the poor.”1

Climate change will be of particular significance for communities of color in California,

as they are known or predicted to:

disproportionately suffer more during extreme heat waves

have a higher exposure to breathing dirty air

will pay more for basic necessities such as electricity, water, and food

have fewer job opportunities as crises may reduce jobs in sectors such as agriculture and tourism2

The three stakeholder groups targeted in this needs assessment all work in some way to support and respond to the environmental impacts and health needs of low income

communities and communities of color. Further descriptions of these groups can be found within their respective sections.

2. METHODS

2.A Instrument Design

Project staff created three separate key informant interview questionnaire scripts, each specific to a respondent category (i.e. physicians, HMO, and NGOs). While the

questions were designed specifically for each category, all questionnaires aimed to elucidate information about knowledge or perception of climate change and health; how

climate change aligns with their roles and responsibilities; and perceptions of the role of CDPH in climate change. For each set of interviews we used a list of public health concerns.

The list referenced for the NGO and HMO interview scripts was informed by an

augmented list of climate change impacts, which were informed by environmental health indicators of climate change developed by the State Environmental Health Indicators Collaborative (SEHIC). In addition, the Public Health Chapter (IV) of the State

Adaptation Strategy (released in December 2009), was also consulted.

1 Morello-Frosch, Rachel, Manuel Pastor, James Sadd, Seth B. Shonkoff. (2009). The Climate Gap: Inequalities in How Climate

Change Hurts Americans & How to Close the Gap. Los Angeles, CA: Program for Environmental and Regional Equality. p.5



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2.B Identification of Informants

As mentioned previously, all three stakeholder groups play a key role in working with

vulnerable communities, preparing for climate change, or responding to climate-change related events. They are also key target audiences for CDPH outreach, education, and partnership efforts around heat, preparedness, and vulnerable populations, and climate

change.

For the physician interviews, the principal investigator identified the doctors selected based upon their affiliation with medical associations, universities, or NGOs. Their research interests are focused on environmental health. We relied upon relationships and

partnerships that the California Environmental Health Tracking Program (CEHTP) has established through their data portal development and outreach work. We contacted, via

email and phone, seven doctors, interviewed individually. They are among the leading researchers and advocates in areas of environmental health.

For the HMO interview, the principal investigator identified the HMO. The HMO contact was facilitated through CEHTP’s Tracking Implementation Advisory Board member, a

research director employed by the HMO. We contacted, via email, one of the largest HMOs in the state of California. Two informants were interviewed at the same time.

For the NGO interviews, the Deputy Director for the Center for Chronic Disease Prevention and Health Promotion identified the groups. We then contacted the NGOs via

email. Four informants were interviewed, two from each organization. Informants from the same organization were interviewed at the same time.

2.C Interview Process

For the physician interviews, project staff conducted the interviews in-person and by phone. The interviews were audio-recorded with permission from the informant and later

transcribed. All informants provided permission for recording. The interviews lasted 45 to 60 minutes.

For the HMO interview, project staff conducted the interview by phone. The interview was audio-recorded with permission from the informants and later transcribed. The

interview lasted 50 minutes.

For the NGO interviews, project staff conducted the interviews in-person. The interviews were audio-recorded with permission from the informants and later transcribed. All informants provided permission for recording. The interviews lasted 60 to 80 minutes.

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2.D Analysis

After transcription, the responses were examined for key words and were hand-coded.

Results from each of the three respondent groups were analyzed separately for key themes and overall conclusions. All responses were examined together to understand areas of convergence and interest as related to information and training needs that could

be provided by CDPH.

3. PHYSICIAN INTERVIEWS

3.A Description of informants

We identified physicians as a priority stakeholder for the exploratory needs assessment because they provide essential medical response during heat-related emergencies, and their participation is essential to climate change preparedness activities. They also work

directly with communities vulnerable to climate change such as the poor, working class, and communities of color.2

We interviewed physicians who are known to be experts in climate change or environmental health and are affiliated with academic institutions and non-governmental

organizations (NGOs). As experts in the fields of medicine and environmental health/climate change, they were most likely to provide insights into the perceptions and

needs of physicians in general, while also providing their own insights into needs and strategies to integrate climate change planning and response into the medical field.

3.B Summary

Some things that stood out in the interviews included:

Responses reinforce our assumption that physicians do deal with populations that

will be affected by climate change/ health impacts of climate change.

Educating medical students about environmental health and climate change is an important upstream activity. The suggestion about needing to make change at the

curriculum level was seen as accurate but challenging.

The medical and professional associations are obvious places to conduct outreach,

as they are already utilized as a resource by physicians for trainings. However, there is a gap in the most associations’ knowledge about climate change.

Respondents felt that CDPH does have a role to play, both with regard to improving emergency response and with conducting outreach and education to

medical providers.

2 Cordova, R., M. Gelobter, A. Hoerner, J. R. Love, A. Miller, C. Saenger, and D. Zaidi. 2006. Climate Change in California:

Health,Economic and Equity Impacts. Redefining Progress: Oakland, California.

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3.C Interview questions and key responses

The interview questions have been organized into the following topic areas: knowledge

and background; roles and responsibilities; and support structure and training. Below, the interview questions are outlined according to those categories, followed by key responses by some of the informants.

3.C.1 Knowledge and Background

a. Describe the field of medicine you practice and what community you serve

The field of medicine practiced included general family practice, emergency, medicine, occupational environmental medicine and pathology. Respondents

served communities in Fresno, Ventura, and the Bay Area (San Francisco, Contra Costa, Santa Clara, South San Jose).

b. Have you had any formal training in environmental health?

Only two respondents had formal training on climate change. One informant was exposed to climate change information during their MPH training.

All respondents stated that the environment is an important component to the overall health of their patients. They indicated an awareness of the negative

health outcomes associated with climate change. Issues identified included: heat waves, air pollution, respiratory health, infection disease, and extreme weather events.

One informant who is identified as an “expert” in the field has engaged in

activities to increase awareness among the medical community of the health impacts of climate change.

c. What are some of the health outcomes of climate change, specifically for the

populations of patients you serve?

Responses included:

high rates of asthma

an increase of “acid rain effects on lead paint structures, which re-prompts another era of concerns with lead for the pediatric

population.”

links between asthma and carbon dioxide emitted from congested

freeways

“our car culture leads to detrimental health effects by decreasing

exercise and increasing accidents and commute stress.”

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A reoccurring theme of the interviews was the concern over poor air quality and respiratory effects.

One respondent said that, in their practice, the most acknowledged

consequences of climate change were decreased drinking water quality and heat-related illness.

d. Where do you get your information on climate change and health as a

health care practitioner?

Respondents listed the following resources

Physician for Social Responsibility online information

literature reviews

attending professional forums and meetings

sharing information with colleagues (most often cited)

3.C.2 Roles and Responsibilities

a. What role do you see climate change and environmental medicine playing

in today’s medical school education?

One respondent indicated that very little is being done, explaining that there needed to be “active people willing to engage students in occupational and

environmental medicine. We would welcome curriculum change.”

The respondent believed “environmental medicine is important and should be taught in the schools.” In order to do this, one respondent said that there is a need “ through preventative medicine or public health’s office of Emergency

Management, to put together a clear set of learning objectives that are modern and could mesh with existing curriculum and link to topics being taught in

health policy.”

b. Should your role as a physician be directed towards individual patients or

the population at large?

All respondents answered both. A common belief among the respondents was that, while they treat individual cases, they are also involved in the public health system.

One respondent stated, “The disciplines of [public health] and the medical

practice are split. If you are going to be a good practicing physician, the more public health education you have, the better off you are.”

c. Has outreach to the most vulnerable populations on the impacts of climate

occurred (or has the idea to discuss it been initiated) in your place of work?

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Asthma and poor air quality were mentioned by most of the physicians as one

of the most serious climate change related health threats to vulnerable populations.

Examples of activities included:

Participation in Medical Advocates for Healthy Air as a venue to outreach to vulnerable communities on the health effects of poor air

quality. This respondent also noted that the Central Valley Air Advocates develop outreach materials for Latinos, working class, and

field workers that have been used by the medical community

Providing lung disease patients with information on outdoor air quality

using information from the EPA Air Now website as source, as well as educating about Spare the Air alert days and the need to avoid

spending times outdoors during on these days

One respondent’s institution is addressing health impacts of climate

change, with their partnership with Health Care Without Harm as the initiating action within the HMO. Healthcare without Harm is an

“internal consortium of group to make healthcare delivery, in hospitals in particular to make them environmentally sustainable.”

3.C.3 Support Structure & Training

a. What medical or professional associations do you belong to?

Responses included:

American Public Health Association (APHA)

American Academy of Family Physicians

Physician Social Responsibility (PSR)

California Medial Association (CMA)

One respondent described the interconnectedness of these medical professional associations in efforts to support policies. For example, PSR

relies on CMA and APHA as two venues to raise awareness among the medical community and “bring mainstream medicine to be in support of

public health.”

b. Do your medical/professional associations provide resources or training

opportunities on the health effects of climate change?

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All respondents answered “no”. They did point out that APHA and PSR were exceptions, providing “some resources” on the health effects of climate

change.

Many felt that health care reform issues have taken precedence over climate change legislation, and that this was reflected in the activities professional associations are addressing.

One respondent also noted that organizations that are expected to educate

physicians are not doing so. The respondent suggested it may be due to “dueling science on whether climate change is real.” They also noted that large organizations can be more conservative and are “less likely to jump into

a controversial topic.”

c. Are there any health related training topics that you are interested in

learning about?

Responses included:

disaster preparedness

anticipated changes with toxins associated with climate change

local and regional impacts (i.e. how health care providers would be effected and the affects on vulnerable populations)

d. What types of information do you rely upon from CDPH?

Respondents identified the Occupational Health Branch and the Environmental Health Investigation Branch (specifically the California

Environmental Health Tracking Program, the California Biomonitoring Program, and the California Safe Cosmetics Program database, a program of the Occupational Health Branch).

What role should CDPH play in supporting physicians in the context of

climate change and health?

Responses included:

CDPH “should work with state and local medical and nursing

organizations by raising awareness through co-sponsoring events related to climate change and health, and local memberships.”

“CDPH is great about putting out alerts on a whole range of issues,” and should integrate climate change related disasters into the present

alert system.”

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CDPH should pursue preemptive response efforts (e.g. wildfire

communications).

CDPH should increase partnerships with public universities where

“medical schools and residents” can receive relevant information in their primary training

4. HEALTH MAINTENANCE ORGANIZATION (HMO) INTERVIEW


We identified Health Maintenance Organizations (HMOs) as a priority stakeholder for the exploratory needs assessment because, at a very large scale, they provide essential

preventative and treatment services to communities vulnerable to climate change such as the poor, working class, and communities of color.

These communities’ ability to deal with the potential health impacts of climate change is dependent on access to quality care.3 For example, five major cities in California (Los

Angeles, Bakersfield, Fresno, Sacramento, and Visalia) have the highest levels of air pollution, as well as the highest population of low income communities of color.4 If temperatures increase due to climate change as predicted, low income and communities

of color living in these five cities in California will be more exposed to air pollutants associated with climate change: particulate matter, ozone, nitrogen dioxide, sulfur

dioxide, and carbon monoxide.5 Greater exposure to these pollutants can cause an increase in respiratory ailments.6

We selected one of the largest HMOs in California for the interview. The HMO was chosen because of its commitment to community health and the environment, as well as

its track record of being a pioneer in greening hospital facilities. We interviewed two representatives from the HMO. These representatives worked in the HMO’s Environmental Stewardship program, which is responsible for instituting sustainability

into all aspects of the HMO’s work for the purpose of reducing health risks associated

3 Cordova, R., M. Gelobter, A. Hoerner, J. R. Love, A. Miller, C. Saenger, and D. Zaidi. 2006. Climate Change in California:

Health,Economic and Equity Impacts. Redefining Progress: Oakland,California. p. 71


Change Hurts Americans & How to Close the Gap. Los Angeles, CA: Program for Environmental and Regional Equality. p .13



6 Cordova, R., M. Gelobter, A. Hoerner, J. R. Love, A. Miller, C.Saenger, and D. Zaidi. 2006. Climate Change in California:

Health,Economic and Equity Impacts. Redefining Progress: Oakland,California. p. 72

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with environmental factors. Many of these are coordinated with the HMO’s “Community Benefits Program.”

4.B Summary


HMOs have a role to play as a large industry, not just as the more obvious health

care provider. It was interesting to see that they were addressing climate change on both fronts.

As a large organization, the HMO has the ability to actively support policy initiatives and utilize their social capital to inform policy. This indicates a fair amount of upstream thinking with regards to how policies related to climate

change will affect health, which will affect them as an organization and the overall health status of their members. The role of the physician in patient

education was echoed here. The HMO system might be another way to outreach to and educate physicians that wasn’t mentioned in the physician interviews.

HMOs offer opportunities for patient education through outreach and education

materials, so they are an important partner/intermediary between CDPH and the public.

Other HMOs may not be as progressive, and one conclusion to draw is that this HMO may be a model or leader in the industry. There also may be a role for

CDPH in working with other HMOs.

An affirmation that CDPH is seen as a legitimate source of information and

should play a leading role in researching and communicating about climate change.


The interview questions have been organized into the following topic areas: Climate

change initiatives, collaboration efforts, and priority areas. Below, the interview questions are outlined according to those categories, followed by key responses by some

of the informants.

4.C.1 Climate Change Initiatives

a. How does climate change factor into your organization’s operations?

The respondents answered that their “entire model of operation attempts to be beneficial to the environment.” The respondent noted, “…Our priorities

include climate action because each priority involves an environmental factor that contributes to disease.” Climate action is one of four strategic priorities

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for the whole organization. Elements of their climate action include energy conservation, using renewable energy, and reporting greenhouse gases.

The respondents also noted that among their priorities, the most important was

prevention, including prevention of environmental contributors to disease. Prevention is “part of (the HMO’s) core mission, and it’s easily incorporated into how (the HMO) provides and delivers care.”

b. What is your HMO doing to promote sustainability initiatives?

Actions identified by the respondents included:

Responding to greenhouse gas mitigation measures and measuring and

reporting of greenhouse gas emissions, which is supported by the California Climate Action Registry

“Developing 15 megawatts of on-site solar energy by the middle of

next year (2011) at 15 different facilities”

Efforts discussed “to reduce the amount of energy that we use, (such

as) lighting retrofits and upgrades, lights out programs, and purchasing energy-efficient equipment, like laptops, desktops, monitors that are

energy-star certified”

4.C.2 Collaboration Efforts

a. Has your group engaged with state or local public health departments or

environmental health programs?

The respondents stated that “direct connection with a state agency…would be done through the community health initiatives”, which is resided within the

Community Benefits Program. However, the HMO’s environmental stewardship program works to support community health initiatives to inform and support public policy.

The HMO’s Community Benefits Program is responsible for informing public

policy and engaging with state and local health departments. However, the organization’s primary goal at the community level is to support local health initiatives, such as “safe routes to schools, adequate playgrounds, and

planning that inspires active transportation.”

The respondents further described their efforts around climate-related public policy. These efforts included:

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Supporting Assembly Bill 32 (AB 32), a law enacted in 2006, also

referred to as the Global Warming Solutions Act.

“Actively opposing Proposition 23”, which is a California ballot

initiative that is on the November 2, 2010 ballot in California to suspend AB 327

The respondent described AB 32 as “a good law and protective of public health….It is critical to communicate to our members and communities that

climate change is a health issue and if we don’t reduce greenhouse gas emission, we will suffer serious consequences.” The HMO is “actively

advocating keeping greenhouse gas reduction laws in place in California. ” a1. Please describe additional partner groups that you engage with on this

topic?

The respondents then identified other non-governmental partners, including Healthcare Without Harm (HCWH), Practice Green Health, and the Center for Environmental Health (CEH). The HMO, in partnership with CEH,

“launched a healthier hospitals initiative.”

The respondent described these partnerships as part of “reaching outside of our organization, working with communities and with activities in the healthcare system to promote this work and really create massive change in

the marketplace.” The partnerships are a “way to get the community voice into the work that we do.” By collaborating with organizations like HCWH,

the HMO is able to “reach out to a larger community and (utilizing this outside expertise to help) prioritize things that make the biggest impact.”

4.C.3 Priority Areas

The organization was given a list of 10 climate change/public health concerns8

and was asked to identify the areas where they were involved (see Survey

Instrument for HMO for the complete list of climate change/public health concerns referenced above).

7 Ballot Pedia. California Proposition 23, the Suspension of AB 32 (2010)

http://ballotpedia.org/wiki/index.php/California_Proposition_23,_the_Suspension_of_AB_32_%282010%

8 Public Health Concerns Regarding Climate Change (sample list): a) Heat waves and heat-related illnesses b) Extreme

weather events i.e. storms or floods c) Droughts and wild fires, d) Vector-borne infectious diseases, e) Water- or food-borne diseases f) Anxiety, depression or other mental health conditions g) Quality or quantity of available fresh water h) Quality of the

air, including air pollution i) Health care services for people with chronic conditions during service disruptions, such as extreme

weather events j) Unsafe or ineffective sewage and septic system operation k) Food safety and security l) Housing for residents

displaced by extreme weather events m) Vulnerable populations n) Built environment

http://ballotpedia.org/wiki/index.php/California_Proposition_23,_the_Suspension_of_AB_32_%282010%25

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From the list, health care services for people with chronic disease conditions was most relevant. Vulnerable populations and continuity of services were

also identified. According to the respondent, the HMO is “extremely interested in addressing health disparities and closing the gap so that people

who are in minority communities or groups don’t suffer from adverse health effects because they’re in those communities.”

The respondents also indicated that other items on the list are areas that they already see as presently being a concern; “heat-related illness, increase in

infectious diseases, and lots of the other things…are very real and very threatening….It’s why climate action is one of our top four priorities for environmental stewardship.”

a. Is there anything else not listed that should be considered? (follow-up from

prior question)

One concern was the cost of energy and water. “Climate change …is also

going to impact (the HMO’s) ability to operate.” Furthermore, “this will also affect the economic well-being of (the HMO) members, which in turn affects

their health.” Obesity was also mentioned as being a “high priority” for the organization.

The respondent said, “Clearly there are feedback loops associated with obesity and climate change, and anything that we can do to mitigate climate change

will help obesity and visa versa.”

b. In your opinion, what is the most important problem or issue around

climate change that should be addressed in California at the present?

The respondent said, “The links between obesity and climate change.…Obesity is a very high priority for us, as is healthcare in general.….Even if we’re dealing with climate change, obesity would be a high

priority, and it stays up there on the list as we talk about how to deal with climate change and what kind of repercussions we need to be aware of.” The

respondent further elaborated that this connected with their community health initiatives, in areas such as active transportation.

Education was also important, and educating physicians is a link to providing patient education and awareness. Physicians, “regardless of whether they are

attuned to the whole climate issue or not, …are seeing an increase in asthma and obesity….Some of the solutions for them will be related to climate….”

The HMO has also adopted “organizational guidelines around climate change”, which follow these five guiding principles:

“understand (climate change) better”

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“assess and avoid our own impacts”

“continue with improvements”

“support industry standards that promote an appropriate response to

climate change”

“inform public policy”

The organization’s guidelines are not just about clinical practice, but about “how as an organization we think about (climate change).”

c. What is your communication strategy around climate change?

While the HMO does not have a specific climate change communication strategy, they do have data and messages about “how the environment is

connected to people’s health.”

One example about messages is about “ways people can be more sustainable” and how the HMO is being “more sustainable.”

d. What role should CDPH play to facilitate efforts to inform the public about

climate change and health?

According to the respondent, “ The department can be a powerful voice for the health effects of climate change… these effects are not well

understood…people still think it’s something far off into the distance.”

One specific example raised was the link between wildfires and climate change. The informant said, “Climate change causes conditions that result in wildfires, but people don’t get that.”

5. NON-GOVERNMENTAL ORGANIZATION (NGO) INTERVIEWS


We identified non-governmental organizations (NGOs) that are involved in the area of social, economic, and environmental justice as a priority stakeholder for the exploratory needs assessment because they are focused on policy, research, community development

activities, and other services related low income communities and communities of color.

We selected two NGOs because of their role in local and regional policy efforts and their link to supporting low income communities and communities of color. As stated previously, these communities will be most vulnerable to the health and other impacts of

climate change. We interviewed each NGO separately. Two NGO representatives were present at each interview.

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5.B Summary


The NGOs’ actions are driven by the community needs that relate to health signals

that serve as an outreach opportunity to discuss the health impacts of climate change. These efforts should be directed at CBOs as well as NGOs.

NGOs play an intermediary role in bringing together different resources and expertise

for systems change. As far as the implications for climate change and CDPH, this signals that we should look to NGOs to play this intermediary role between CDPH

resources and communities. Or another option is CDPH directs different types of resources to each type of group. This area needs further exploration before drawing conclusions.

More exploration is needed around the idea about the best ways to engage with CDPH, especially the issue about pros and cons of direct communication between

locals and state. However, it was very clear that the state should do a better job and making important information available, accessible and relevant to affected

communities.


The interview questions have been organized into the following topic areas: NGO’s

Approach to Health; engagement with state and local public health/environmental health departments; capacity and response to climate change; priority areas of importance; and State Government involvement. Below, the interview questions are outlined according to

those categories, followed by key responses by some of the informants.

5.C.1 NGO’s Approach to Health

a. How does health affect the nature of your consideration and or a driver in

your work?

One NGO provides viable economic solutions for the communities it serves, grounding this work in the local community struggles. To do this, the NGO identifies entities that have greater capital and reaches out to begin discussions

with them.

Health is a peripheral component of the missions and visions for both NGOs. The respondents recognized health as a “critical piece, as major environmental health concerns at the community level are founded in health and health

provides another frame to discuss issues of equity.”

Both NGOs were either utilizing health as a separate program piece or articulating health as a priority within all program areas. The community-based organizations that the NGOs work with have identified health as a

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priority during discussions about the environment, so the NGOs are required to be responsive to this interest.

b. How is health addressed in the policy initiatives your group advocates for?

The respondents both mentioned the theme of “equity.” These groups recognized the value of examining the health connections and providing a health analysis on a policy initiative or design to raise environmental and

socio-economic concerns.

The first group has used health indicators to examine how well a community is being serviced, and presenting the information as part of the economic externalities that low-income and communities of color are faced with, and

highlight these areas in a policy arena. Currently, group one is going through a “re-visioning process for their health program” and is trying to integrate

health across other programs in their organization. Group two views “health outcomes as disparate across race and class,” which

provides another framework to discuss issues of equity. At the same time group two was also cautious to not put health above other issues.

Group two, for example, shared how systems differ across communities in terms of access and the level of services provided and used East Palo Alto as

the example to show the inequity in the way resources are distributed to commuter rail systems versus bus systems and the imbalance of resource

distribution across communities.

For group two, public transit is one of the key strategic program areas that

raise concerns of economic opportunities, access, environmental quality, and safety. This group was also clear to make the distinction that “we have not

thought of ourselves or communicated our work from a public health lens.” However, group two, as an organization is trying to look at all aspects of their program work and trying to understand the health aspects that they have not

considered as a factor in their program work.

Group two’s capacity to understand the health data and develop a health argument has been supported by building collaborative partnerships with health organizations in the Bay Area, such as Human Impact Partners.

A foundational concept for the type of programmatic work both groups

engage in became more apparent after they were asked “how would you

describe the work you do and how it contributes to communities you serve?”

The common concept emerged among both groups that focused on “systems change,” which was either described as “figuring out viable solutions that are

grounded in the local community struggle.” Group one said, “now our current body of work is more about systems change and trying to impact policies, to

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influence the types of jobs, transport is available in poor, working class and communities of color.”

5.C.2 Engagement with State and Local Public Health/Environmental Health

Departments

a. What types of activities has your group engaged in with state or local public

health/environmental health departments?

Both provided a very different response, but have engaged with government agencies at either the local and/or state through coalitions and networks that focused on specific content areas.

Group one had less interaction with local agencies, but more interaction with

the state agencies that focus on the environment, such as the Office of Health and State Planning.

Group two had more interaction with local city/county offices that include local health departments because of the local activities they are engaged in.

This group has programs that are county and city specific, related to planning, housing, and transit.

Group two said that while its engagement is limited with state agencies, it does function as a “watch dog” group, overseeing enforcement and functions

of the Housing Corporation Development. The type of support that agencies have been able to offer the groups has been

through providing analytical resources, which act as a “neutral entity that provides data and facts to better inform community concerns.”

Group one has done more outreach to state agencies, engaging in climate-related policies and community benefits funding, which has been a point of

entry in work to inform state officials of the gaps in regulations.

5.C.3 Capacity and Response to Climate Change

a. What types of climate change-related activities has your organization been

involved in?

One NGO has begun working on climate policy related to AB 32 and AB 1405. They were invited to participate in AB 32 discussions by the California Air Resources Board in part due to their knowledge of small, minority-owned

business communities. They are also one of the leading groups opposing Prop 23.

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Neither NGO feels their work is directly related to addressing climate change. However, their work does relate to climate change through their built

environment focus, as well as their knowledge of local and regional concerns of communities of color in California.

b. Each group was given a list of 10 climate change public health concerns

and was asked to identify the areas where their organization is involved (see

survey instrument for NGOs for the complete list of climate change/public health concerns that are referenced in this question).

Both groups mentioned built environment. The areas where they diverged were food security and vulnerable populations. Group one is moving towards

food justice issues as it is going through a re-visioning process of its health program to incorporate food justice as part of healthcare and work force

diversity. Group two immediately identified with vulnerable populations and housing

for residents displaced by extreme weather conditions, but made the distinction that for the communities they serve, the extreme disaster is

secondary to the foreclosure crisis. The other areas that stood out for Group two included quality and quantity of

fresh water, unsafe or ineffective sewage and septic system operations, food safety and security. This interviewee described these three public health

concerns as ongoing issues the organization is addressing in their development work.

Both groups were asked to think about additional concerns that need to be added to the list. Group one said “healthy housing” should be prominently

mentioned as a public health concern based on their work in the central valley and in south of Richmond.

Group two added the use of “brown fields” and the “movement of goods and freight” as two areas of public health concerns regarding climate change. They

mentioned how the issue of heavy trucks is not being properly addressed in climate change legislation and that this is a big issue for low income communities of color for both the south coast and the Bay Area residents.

Group two also noted that public health concerns should also think about how

transport falls on the list that was provided. For example “do people have safe transport access and do people have the ability to leave town in an emergency?”

c. Do you see climate change as an issue that contributes to the organization’s

general concerns regarding low income communities of color and

vulnerable populations?

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The responses for both groups emphasized the key theme of climate change as

an issue that either that “highlights” or “connects” in different ways to different groups. For group one, they recognized climate change issues and

consequences allow them to frame community development priorities. Group two emphasized climate change impacts on the environment and health

can only exacerbate current situations among the most vulnerable populations. This group sees climate change as an opportunity to make connections to the

root problems that have not always been visible, such as connections with urban development and access to transit systems that have historically not benefited all populations equally.

Climate change serves as a connector to highlight existing problems. More

specifically, this group also recognized that even as climate change policy initiatives at the national, state, and local level are being discussed the “ones that can’t participate are the ones most affected.” They see this as an

opportunity to couple climate change with existing issues that their organization addresses to position the voices of the poor, working class, and

people of color to be able to be part of the decision making process surrounding their communities.

5.C.4 Priority Areas

a. In your opinion, what is the most important problem or issue around

climate change to be addressed in California at present? And why?

One NGO responded that “jobs” and the “economics of climate change policy” presented the greatest possibilities for health mitigation.

The other NGO responded that “amplifying the voices and concerns of the most vulnerable populations” and positioning those voices to be part of the

decision making process as mitigation measures and adaption initiatives are discussed in the policy making arena was a priority.

5.C.5 State Government Involvement

a. In response to the issues we discussed today and the efforts being made by

your organization do you see a role for state agencies or state government

facilitating a process to address community concerns that may be related to

climate change? If so, what improvements can be made to increase

cooperation and support?

The respondents commented on the importance of the role of state

government, but acknowledged barriers and limitations, both perceived and

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actual towards achieving greater participation between state agencies and local organizations exist. For example,

One challenge for state agencies is to increase the public access to

information and to translate this information so that it is understandable to populations that have the potential of being greatly

affected. The respondent elaborated that it is a structural challenge for state agencies to

be able to translate information at the community level. While state agencies have a wealth of information to share, “this is a juncture that is a difficult one

to turn into action on the ground.” When asked about possible solutions, responses included

A process could be facilitated by increasing the role of working groups

where both state agencies and local organizations including NGOs are represented. Development of working groups would be desirable, and it would be a “natural role for state agencies to facilitate a process and

have more stakeholder representation.”

However, one respondent cautioned, “the work I’ve done with state agencies has been through a local jurisdiction. To reverse this process and have more direct communication with the state could potentially clog the issues at the

state level and get us further away from our work with local and regional agencies.”

6. CONCLUSIONS AND RECOMMENDATIONS

The findings of the exploratory key informant interviews suggest that the climate change and health is a reality and people are trying to find ways to articulate and respond to its impacts.

The groups interviewed recognize that climate change presents an opportunity to make the

connections between the environment and health. All three groups provide a different perspective and are utilizing different means to link climate change to their priority areas.

The key stakeholder interviews provide CDPH with ideas to explore:

Internal discussions within CDPH

Outreach and education activities

Partnerships

Additional needs assessments

Further analysis of these data (if needed)

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The summaries provide ideas for internal discussions within CDPH, around a process to inform public education and communication tools focused on the health impacts of climate change.

The physician and HMO interviews reveal that HMOs provide an arena with which they can

address climate change and that Doctors can be spokespersons. The key interview groups provided a window of the value of partnerships, identifying potential

relationships for CDPH to consider. All of CDPH’s programs do their work with and through partners. Addressing climate change will require a multi-disciplinary approach that will involve

a diverse group of partners. CDPH needs to explore how to work with the segments of the population that are represented by the three groups to further develop strategies to build community resilience around climate change.

As this is an “exploratory” study, further needs assessments and analysis of this qualitative data

may be useful in understanding the different types of strategic directions to develop around community outreach and public education materials.

Most importantly, the NGOs working on environmental justice issues provide a broader view on how climate change connects to social equity issues. This is an area that CDPH could assess

further through conducting a more in depth needs assessment focused on the community based organizations that identify as environmental justice groups to better understand how their program content areas align with the public health impacts of climate change and how health

impacts are being communicated.

The results of this type of analysis could help inform the work of CDPH and its local health officers to increase coordination and communication to better respond to the impacts of climate change among the most vulnerable populations.

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7.A Physician Interview Script

Introduction:

Explain: 1) the purpose for the interview; 2) who is involved, CEHTP/CDPH and ASTHO, 3)

why their cooperation is important, 4) what will happen with the collected information and how the community will benefit, 5) will be recorded so that none of their important insights and discussions are missed.

A. Knowledge and Background:

Description of Practice as MD

A1 What field of medicine do you currently practice?

A 2 What community do a majority of your patients come from?

A 3 Have you had any formal training in environmental health?

IF YES: Did it include information on climate change? [where or how?]

A 4. What do you feel about the quality of training you received ?

A5. Do you believe the environment is an important component to the overall health of your patients? HOW SO?

***1. Scientists have hypothesized a variety of negative health outcomes associated with climate

change. Are you familiar with any of them?

If YES: ask them to list what they know?

If NO: based on the type of medicine they practice and their patient population- PROBE them with [Sample list]

A6. In your opinion what are some of the health outcomes of climate change for you patient

population?

PROBE for the YES response: If YES please list specific outcomes [Hand out reference Sample list]

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PROBE for the NO OPINION response: Ok, what are some type of general public health outcomes of Climate Change?

If No to A6: So in your opinion there are NO short term or long term health effects of climate

change?

A7. Where do you get your information on climate and health as a healthcare practitioner?

PROBE: specific websites, individuals, journals etc…

B. Roles and responsibility:

B1. Do you feel your role as a physician should be directed towards individual patients or the

population at large?

GO BACK TO EXAMPLES MENTIONED IN A6: For example you mentioned increase in temperatures… Has outreach to most vulnerable populations in minimizing heat impacts occurred or have these discussions taken place?

B5. Beside basic medical assessment and treatment, do you have a role in preventing some of these health impacts you’ve discussed?

PROBE: IF so how?

B6. Given some of the health consequences of climate change [that you’ve discussed], has your institution developed any proactive measures to minimize the impacts?

(PROBE) For example does your institution have an emergency response plan? (PROBE) Is there a system in place to deal with health outbreaks? How do you receive this type of information?

C. Support and Structure:

C1. Are you affiliated with any medical professional association? Which ones?

C2. Do they provide you with resources or training opportunities on health effects of climate

change?

No to C2: (Where do you receive this type of information?

C3: Do you feel that there exists the support and structure within your professional association to address the health ramifications of climate change? Do you feel that there exists the support and

structure within your place of employment to address the health ramifications of climate change?

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If YES C3: What activities is your professional association/ employer currently doing or planning that address the heath effects of climate change?

If NO C3: Is there interest? (is there something in place to notify them- outbreak/heat).

C4: What do you need to know about the health effects of climate change to better support physicians?

D. Training

D1. Have you attended any formal training on climate change and health?

D2. Do you feel like you need more training?

No D1: Would you attend?

D3. If so, what format of training is of most interest to you?

D4. what topic(s) would be of most interest to you?

D5. Have you participated in raising issues of climate change and health at the political level

(local, state, national, and international)?

PROBE: At what level are you focusing most of your efforts? Why?

D6. Do you see CDPH as resource for information?

IF yes: what types of information do you rely on from CDPH?

IF NO to D6: What type of resource(s) do you use for your information needs as a health practioner?

D7. What role should CDPH play in supporting physicians in the area of health effects of Climate Change?

D8. Do you feel that you could benefit from additional training/information from the state health department regarding the health ramifications of climate change?

D9. Do you recommend that I talk to anyone else, do you have any recommendations?

Sample list

a. extreme health-related morbidity/mortality b. increase frequency and/or severity of asthma and other resp diseases

c. increase frequency and/or severity of allergies d. food bone illness (including seafood) e. vector-borne illness

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f. water-borne illness g. lack of access to clean water

h. potential water contamination i. increased wildfire risk

j. increased frequency and severity of flooding k. increased frequency and severity of drought l. increase frequency and severity of storm surges

m. sea level rise n. increase exposure to pesticides and chemicals in food

o. increased frequency of skin cancer p. increase frequency of eye diseases q. toxic/toxin exposures

r. migration of human population s. worsening of existing chronic illness

t. mental/psychological health from displacement or perception of risk u. other, please specify

Of the above, which, if any, do you think is the largest risk to your region and patient population?

Probing questions to specific health effects of climate change. This example is for heat, but

can be adapted for other types of health effects.

Heat

- What types of patients do you feel might be most vulnerable to heat related morbidity and mortality?

- Have you seen any patients in the past 5 years with a heat-related illness? Do you

think that number has been increasing or decreasing? Why do you think that is? - What steps, if any, are you taking to prevent your most vulnerable patients from

heat-related morbidity and mortality? - Do you feel you have the training and or adequate resources to address heat-related

illnesses to your patients?

- What steps have your professional society taken in terns of planning for and mitigating heat-related illnesses?

- Do you feel that you could benefit from training/education from the state health department on this subject matter?

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7.B HMO Interview Script

Thank you for your participation

This effort is part of a capacity building grant awarded by the Association of State and Territorial Health Officials (ASTHO), for assessing the department’s capacity to respond to climate change and for the development of a departmental strategic plan on climate change. California was one

of five states awarded this grant.

Your input will inform the development of a strategic plan for CDPH's response to the health effects of climate change, promote increased awareness about these issues within the state health infrastructure and strengthen our capacity to respond and prepare for the health effects of climate

change.

Your [Name of HMO] has been identified because of the commitment towards climate change and sustainability as well as addressing community health issues in California.

MENTION: taping for transcription purposes only

Thank you for your participation

Background

1) How does climate change factor into [Name of HMO] workplace safety and stewardship

work? 2) How is health a consideration/driver in the environmental policies/sustainability the [Name of

HMO] adopts as well as the work around informing public policy?

3) How would you describe the work [Name of HMO] is doing in promoting sustainability initiatives and how it contributes to the communities you serve?

4) What types of activities has your group engaged in with the state or local public health departments /environmental health programs?

4a. Have these agencies been able to offer you support or inform parts of your work?

5) What activities has your organization been involved in related to climate change? Could you describe some of the accomplishments?

[Probe: What are the priorities for the program?] 5a. Where would you couple climate change within the issues your program/organization

covers? What is your organization’s approach to climate change?

CDPH is committed to addressing health risks and potential health threats to the most vulnerable populations and we see climate change as being a health threat. [Hand-out sample list, see list of

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Public Health Concerns of Climate Change sample list]. These are some general public health concerns regarding climate.

6a. Does [Name of HMO] view these as climate change issues? Which one stands out the most

to your institutions? And are there others not listed that come to mind? [Is climate change part of the rationale for your involvement?]

7. Do you see climate change, specifically, as an issue that contributes to [Name of HMO]

institutional concerns? 8. Including some of the issues we already discussed, in your opinion what is the most important

problem or issue around climate change to be addressed in California at present? Why is that?

9. What role do you see your organization playing in responding to the potential health impacts of climate change in communities throughout California?

10. Are there resources that your program/organization does not currently have that, if made available, would significantly improve its ability to deal with climate change as a public health

issue? Yes [Follow up with] What are those resources?

Closing

What role can CDPH play to facilitate these types of efforts? Do you see a role for state agencies or state government facilitating the process?

Can you give me some ideas on how the relationship between state and local public health and

organizations like yours can be improved to deal with these issues that may be related to climate change?

Public Health Concerns Regarding Climate Change (sample list)

a) Heat waves and heat-related illnesses? (b) Extreme weather events i.e. storms or floods

(c) Droughts and wild fires

(d) Vector-borne infectious diseases

(e) Water- or food-borne diseases

(f) Anxiety, depression or other mental health conditions

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g) Quality or quantity of available fresh water

(h) Quality of the air, including air pollution

(i) Health care services for people with chronic conditions during service disruptions, such as extreme weather events

(j) Unsafe or ineffective sewage and septic system operation

(k) Food safety and security (l) Housing for residents displaced by extreme weather events

(m) Vulnerable populations

(n) Built environment

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7.C NGO Interview Script

INTRODUCTION

Thank you for your participation This effort is part of a capacity building grant awarded by the Association of State and Territorial

Health Officials (ASTHO), for assessing the department’s capacity to respond to climate change and for the development of a departmental strategic plan on climate change. California was one

of five states awarded this grant. Your input will inform the development of a strategic plan for CDPH's response to the health

effects of climate change, promote increased awareness about these issues within the state health infrastructure and strengthen our capacity to respond and prepare for the health effects of climate

change. We’re conducting an internal need assessment which includes identifying/reaching out to

external stakeholders.

We choose your group because of [Name of Organization] commitment to supporting communities of color and most vulnerable populations on issues of health, environment and social equity.

MENTION: taping for transcription purposes only

1) How is health a consideration or a driver for your work?

2) How is health addressed in the policy initiatives your group advocates for?

3) How would you describe the work you do and how it contributes to the communities you serve?

4) What types of activities has your group engaged in with state or local public health/ environmental health departments?

4a. Have these agencies been able to offer you support or inform parts of your work?

5) What activities has your organization been involved in related to climate change?

[Probe: Do you see climate change as a political opportunity to advocate for political social justice concerns? ]

5a. What is your organization’s approach to climate change?

6) CDPH is committed to addressing health risks and potential health threats to the most vulnerable populations and we see climate change as being a health threat.

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[Hand-out, see list of Public Health Concerns of Climate Change sample list] These are some general public health concerns regarding climate.

Is your organization involved in any of these areas?, obviously I know that some are not relevant.

6a. Does GL view these areas as climate change issues? Which one stands out the most to your organization? And are there others not listed that come to mind?

7. Do you see climate change, specifically, as an issue that contributes to the organization’s

general concerns regarding low income communities of color and vulnerable populations i.e., economic/social/health disparities among vulnerable populations that you serve?

8. Including some of the issues we already discussed, in your opinion what is the most important problem or issue around climate change to be addressed in California at present? Why is that?

CLOSING

9. What role do you see your organization playing in responding to the potential health impacts of climate change in communities throughout California?

10. Are there resources that your program/organization does not currently have that, if made

available, would significantly improve its ability to deal with climate change as a public health issue?

Yes [Follow up with] What are those resources? 11. Do you see a role for state agencies or state government facilitating the process, if so what

improvement can be made to increase co-operation to deal with these issues that may be related to climate change?

Public Health Concerns Regarding Climate Change (sample list)

a) Heat waves and heat-related illnesses?

(b) Extreme weather events i.e. storms or floods (c) Droughts and wild fires

(d) Vector-borne infectious diseases

(e) Water- or food-borne diseases

(f) Anxiety, depression or other mental health conditions

g) Quality or quantity of available fresh water

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(h) Quality of the air, including air pollution

(i) Health care services for people with chronic conditions during service disruptions, such as extreme weather events

(j) Unsafe or ineffective sewage and septic system operation

(k) Food safety and security

(l) Housing for residents displaced by extreme weather events (m) Vulnerable populations

(n) Built environment

key informant interviews of external stakeholders

Documents