Disasters Through the Lens of Disparities: Elevate Community Resilience as an Essential Public Health Service

Weather experts, using wind speed, declared September 2017 the most active Atlantic hurricane season on record. However, wind speed is but one measure of impact. A comprehensive assessment of the immediate and long-term consequences of disasters requires a holistic, “whole community” approach, a term coined by the Federal Emergency Management Agency to encourage a multisectoral strategy to disaster management. However, intransigent disparities faced by many communities living in the path of disasters makes this an elusive concept.

CUMULATIVE COMMUNITY VULNERABILITY

Disasters, natural and technological, profoundly affect the health and well-being of communities, especially those in disaster-prone regions. From Hurricane Katrina, the September 11th attacks, and the Deepwater Horizon oil spill to the salvos of Harvey, Irma, and Maria, disasters continue to be addressed as isolated, acute events. Vulnerable communities face cumulative, not isolated, threats, and disparities exacerbate the impact of each overlaying risk domain. For example, Hurricane Katrina, well recognized as both a natural and technological disaster, demonstrated the triple threat burden: historic health disparities, persistent environmental health risks, and living in a disaster-prone area. The Deepwater Horizon oil spill’s impact on communities of Vietnamese American fisherfolk exemplified the cumulative insults of natural and technological disasters as well as this community’s socioeconomic and health disparities.¹ Against this backdrop, I examine the impact of Harvey, Irma, and Maria on communities.

Protecting the most vulnerable is the proven strategy to protect all. Recent disasters showed that this principle was again ignored in Texas, Florida, and Puerto Rico. Although self-preparedness is an important first step in disaster management, those who live from paycheck to paycheck do not have the luxury of buying three days’ worth of water and food. Even if this was possible, examples from all three disasters showed that response resources were significantly delayed for the most vulnerable communities. Prominently in Puerto Rico, eight days postdisaster, communities still lacked safe drinking water, basic food supplies, transportation, and electricity. Indeed, the success of a disaster response is most accurately determined by the receivers, not the providers.

POLICY AND HEALTH DISCONNECT

To date, we have failed our most vulnerable communities in a three-pronged fashion: (1) failing to recognize that a community’s degree of disaster preparedness directly influences its capacity to recover, (2) failing to address disaster recovery as a long-term process requiring sustained investments of financial resources and human capital, and (3) ignoring disparities as chronic stressors that communities face.

The degree to which a community endures disparities and environmental health threats is directly related to its ability to prepare adequately and recover effectively from disasters. Protecting all communities to the greatest extent possible from natural and technical disasters is the government’s obligation; yet, existing policies, including the Stafford Act,² address primarily disaster response, and aid is released only after policymakers declare the state of emergency. Regardless of how early this occurs before a disaster, the timing fails those suffering recalcitrant health and social inequities.³

The recent hurricanes vividly displayed the disconnect between policy and timely disaster response. In the aftermath of Hurricane Irma, a nursing home in Hollywood, Florida, was allowed to operate with minimal liability insurance, and multiple residents lost their lives. The home delayed evacuation to a nearby hospital until days after losing electricity, leaving residents in heat stress incompatible with life. Although the minimal liability insurance was not the cause of this tragedy, disaster-oriented policies would incentivize more effective and timely action. Similarly, it took almost nine days after Hurricane Maria before the Jones Act was lifted, allowing foreign freight ships to transport food and water to Puerto Rican residents—US citizens disconnected from governmental aid on the mainland.⁴

DISASTER RECOVERY AS LONG-TERM PROCESS

When the spotlight disappears from communities in the acute postdisaster phase, so does the assurance that recovery aid will reach those most in need. Sustained disaster recovery requires the ability to apply for aid; however, lack of transportation and inadequate basic documentation hamper this ability for vulnerable populations, including those in immigrant communities. As was the case in the aftermath of Hurricane Katrina, rebuilding fragile homes and infrastructure was often not an option. Building for community protection calls for a holistic community-driven and participatory approach beyond individual “survival assistance.”⁵

THE IMPACT OF CHRONIC STRESSORS

Many communities affected by the recent disasters rank at the bottom of leading health indicators and face what are now recognized as slow-moving shocks and stressors affecting overall health and well-being: inadequate housing, a poor built environment that hampers access to healthy foods and transportation, environmental pollution manifested in PM2.5 (particulate matter with a diameter of 2.5 μm or less) and greenhouse gases at levels of public health concern, and neurotoxicants such as lead and mercury in drinking water and seafood. Collectively, the burden of these stressors prevents already vulnerable communities from preparing effectively, let alone beginning to recover from the more acute stressors posed by natural and technological disasters. Hence, ignoring these chronic stressors by investing only in the aftermath of acute disasters is a disconnect between the policies intended to protect public health from disasters and the resulting adverse effect on those whose health is most at risk.

CLIMATE CHANGE AS GLOBAL CHRONIC HEALTH STRESSOR

Although the severity and timing of Hurricanes Harvey, Irma, and Maria were unprecedented, climate change is projected to increase the frequency and magnitude of extreme climatic events in the Caribbean and the US Gulf Coast (http://www.ipcc.ch/report/ar5/syr). The 2017 North Atlantic hurricane season, as well as the droughts and flooding in the Caribbean over the past two decades, illustrate the high potential for devastation resulting from these storms.⁶ Many Caribbean countries, particularly small island developing nations, are especially vulnerable to climate change because of their reliance on tourism, agriculture and fishing industries, weak infrastructure, high rates of poverty, and environmental degradation. The failure of the United States to develop and implement public health–driven climate change policies disproportionately affects our Caribbean neighbors.

ELEVATE COMMUNITY RESILIENCE

As with the global epidemic of noncommunicable diseases, we fail to invest where the benefits are most sustainable: prevention. Analogously, investing in disaster preparedness positively affects the success of each subsequent disaster management phase, from detection and response to mitigation and recovery. Yet, despite lessons learned from previous disasters, response funds far exceed preparedness funds.

The root causes of poor disaster recovery can be stopped only by countering the devastating impacts of acute as well as chronic stressors. Disaster aid must prioritize those most vulnerable, regardless of race, ethnicity, income, and citizen status. One potentially daring but promising strategy is to elevate community resilience as an essential public health service and consequently integrate community resilience measures as performance benchmarks of federal, state, and local health agencies. Such benchmarks would be monitored through institutional accreditation processes and incentivized by funding allocations. James Hospedales, executive director of the Caribbean Public Health Agency, says it best: “Normally we can ‘manage’ one storm; we are very resilient. But multiple storms with 15 countries and territories hit, and some more than once, that is overwhelming our normal resilience” (personal communication). Efforts under way to better quantify community resilience should accelerate us on this path forward.⁷