At-Risk Individuals, Behavioral Health, and Community Resilience: Preparedness and Response for Vulnerable Communities

Natural disasters, hurricanes, heat waves, public health emergencies, mass violence, emerging infectious diseases, terrorist attacks. The potential threats to our nation’s health security are incredibly diverse, but they share two things: (1) they will disproportionately affect certain groups, and (2) the most pervasive health impact will be psychological. By understanding who is most likely to be affected and suffer long-term harm, we can better prepare our communities for known threats and for emerging threats we are just beginning to understand.

OUR MOST VULNERABLE NEIGHBORS

That certain populations are at greater risk is not news. Research on the psychological consequences of disasters consistently shows that children, older adults, and pregnant and postpartum women are at higher risk for psychological distress after extreme weather events. Some others—such as those with preexisting mental illness, those who are economically disadvantaged, those experiencing homelessness, and emergency responders—also are at higher risk for negative outcomes after these events.¹ The disproportionate impact of disasters on people with disabilities led to a series of high-profile lawsuits from 2007 through 2017 that ultimately compelled local communities to improve the integration of people with disabilities into planning, for example, 911 services, emergency shelters, and airport emergency plans.²

Building on the understanding that we can identify a priori populations most at risk for adverse consequences following a disaster, Congress inserted multiple provisions promoting inclusive planning in the Pandemic and All Hazards Preparedness Act. On June 24, 2019, the president signed the Pandemic and All Hazards Preparedness and Advancing Innovation Act of 2019 to reauthorize the act.³ The new law reaffirms and enhances provisions to ensure integrative preparedness planning by requiring that the US Department of Health and Human Services (HHS) consider the needs of children, pregnant women, older adults, and people with access and functional needs across the entire preparedness, response, and recovery enterprise.

Further underscoring the critical need to focus on the most vulnerable members of our society, the new law establishes three new federal advisory committees under the HHS secretary: the National Advisory Committee on Children and Disasters (reinitiated after sunsetting in 2018), the National Advisory Committee on Seniors and Disasters, and the National Advisory Committee on Individuals with Disabilities and Disasters. These committees provide a unique opportunity for nonfederal experts to provide advice and consultation for preparedness and response activities such as preparedness grants, state emergency preparedness and response activities, drills and exercises, and the medical and public health needs of targeted populations.³

BEHAVIORAL HEALTH NEEDS ARE HEALTH NEEDS

When the HHS assistant secretary for preparedness and response released the national health security strategy in January 2019, the stated aim was to “protect the nation’s physical and psychological health . . . when threatened by incidents that result in serious health consequences whether natural, accidental, or deliberate.”⁴ The inclusion of psychological health is no small matter. It serves as recognition that the psychological consequences of disasters are often the most severe and pervasive health effects. In fact, research shows that many people exposed to weather-related disasters experience stress or serious psychological consequences such as posttraumatic stress disorder, depression, and general anxiety. Although the majority recover over time, a significant percentage of people exposed to these events develop chronic mental health dysfunction.¹ Addressing these mental health needs is a critical part of health preparedness. Failure to do so can result in long-term harm or increased risk of retraumatization in a future event.

“COMMUNITY” IN COMMUNITY PREPAREDNESS

Promoting health resilience is inseparable from promoting overall community resilience. As the HHS National Biodefense Science Board stated in its report on health resilience, “Health underpins all other resilience sectors. Any activity undertaken by any sector involved in preparedness, response, or recovery ultimately aims to protect or improve human health and well-being.”⁵

As the HHS National Biodefense Science Board report suggests, it is impossible to conceptualize a resilient community that does not address the health needs of the entire community. Federal actions are only a starting point. True community preparedness requires effort at every level of society. Accordingly, the national health security strategy emphasizes the collective responsibility of federal, state, local, tribal, and territorial governments, along with public and private partners, communities, families, and individuals to achieve health security.

So how can we build our capacity to address the unique preparedness needs of the most at-risk groups while also preparing for the psychological needs of the whole community? The advisory committees I have described suggest an answer. We need to hear from the experts. Every community (including federal partners) has people with relevant knowledge gained from academic training, on-the-job learning, and lived experience. We should include those with expertise on behavioral health, children, older adults, and people with disabilities. Some communities have unique needs, such as homelessness or limited English proficiency, that should also be considered. This knowledge must be accessed throughout the planning process, especially during the threat and risk assessment phase. It is too late to think about disproportionately affected subpopulations after we complete a risk assessment or finalize a response plan. Failure to plan for the needs, including psychological needs, of the whole community before an event means responders will spend more time addressing those needs after an event. Failure can result in unnecessary suffering.

Experts should be engaged and allowed to share their perspective on what constitutes the biggest threats. Housing and transportation, for example, might be outside the purview of typical health preparedness plans, but risks associated with access to transportation and safe housing might constitute a significant health threat during a disaster. If harm reduction is truly our goal, we must listen to expertise regarding the people most likely to suffer in a disaster.

All individuals, families, and communities face adverse events. These events frequently have a disproportionate effect on specific groups in a community and often lead to psychological consequences. Frequently, a community’s greatest vulnerabilities can be identified a priori. As a nation, we devote significant time and resources to addressing the consequences of adverse events. More attention to addressing the needs of our most vulnerable neighbors throughout the preparedness, response, and recovery phases can reduce suffering and harm in our communities. From a federal perspective, we have made a lot of progress. But we have more work to do.