Extreme Heat Governance: A Critical Analysis of Heat Action Plans in California

Extreme heat events have adverse effects on population health, causing heat-related illnesses, such as heat exhaustion and heat stroke, but also exacerbating underlying medical conditions, such as cardiac and respiratory diseases, through various mechanisms.¹ In the United States, from 2000 to 2010 there were approximately 28 000 recorded heat-related hospitalizations, and between 2004 and 2018, an average of about 700 people died because of heat-related illnesses, making heat the deadliest weather-related hazard in the United States.^2,3 These figures do not represent heat morbidity and mortality that were not attributable by International Classification of Diseases (Geneva, Switzerland: World Health Organization) Ninth Revision (1980) or 10th Revision (1992) code to a confirmed diagnosis of heat-related illnesses, which likely results in underreporting.⁴ Additionally, the health consequences of extreme heat are amplified by sociodemographic vulnerabilities and our built environment. As extreme heat events continue to increase in frequency and intensity, individuals, communities, and the municipalities in which they live will need to prepare and adapt.

Health impacts from high ambient temperatures have led many municipalities to develop plans to respond to extreme heat events. These plans are sometimes referred to as excessive heat emergency plans, heat-health response plans, or heat action plans (HAPs). Many European countries implemented HAPs following the 2003 European heat wave.⁵ In the United States, a number of cities have developed HAPs,^6,7 although the vast majority of US cities and regions rely only on local National Weather Service offices to issue heat advisories based on heat index forecasts that may not be linked to local HAPs.⁸

In 2020, the US Centers for Disease Control and Prevention (CDC) released a technical report on the summary and strategies for HAPs and ascribed their focus to emergency response planning or long-term planning for extreme heat. The report identifies that plans can stand alone or be an annex to an all-hazards plan and specifically identifies emergency preparedness and management activities when coordinating plans.⁹ Although the CDC report is not a step-by-step guide or an all-inclusive approach to how to specifically prepare or coordinate a HAP, the reference to emergency operations plans and the location of HAPs in all-hazards mitigation plans suggest that extreme heat is an event that consistently requires an emergency response and is best understood in that context. However, climate change will increase the likelihood and frequency of extreme weather events, such as extreme heat, and these events have increased substantially over the past decades and will continue to affect regions of the globe regularly.¹⁰ We argue that the increasing frequency and regularity of these events move them from emergencies to an issue to be planned for with preventive health plans.

Since the terrorist attacks of September 11, 2001, the public health legal frameworks that emphasized preparedness have shifted to a concept that emphasized emergencies. This framing emphasizes an emergency as an event that overwhelms the capacity of the health care system.¹¹ One of the defining characteristics of an emergency is its unpredictability or its unforeseeability. Given that these events will be more frequent, the health and public health systems must move the approach to extreme heat events from emergency to more traditional public health governance structures, usually located in departments of public health or in close coordination. This move supports two very important conceptual shifts. First, it situates the effects of the climate crisis more clearly in the regular governance structures of the state as a long-term policy consideration. Second, it supports the transition of our public health care systems to a climate-resilient model. Keeping the frameworks entirely in offices of emergency services abrogates the duty of the state to grapple with the climate crisis as a long-term reality.

Public health departments can be ideal partners and leaders in addressing climate and health issues, particularly those at the local jurisdiction. They are usually the designated government agency that is tasked with protecting the health of communities, are a trusted voice with close ties to the communities they serve, and have a proven ability to confront and overcome complex health issues, such as climate change.¹² Guidance on HAPs is not new but has not been implemented equally across regions. Additionally, even information about extreme heat on local and regional government Web sites can be sparse, and coverage is not always the same.¹³

We used local public health jurisdictions in California to examine how HAPs are organized and implemented to protect populations from the health impacts of extreme heat. We argue that extreme heat events should be in the jurisdiction of public health response and that these organizations are key to leading or closely supporting efforts to reduce the health impacts associated with extreme heat.

EXAMINATION OF HEAT ACTION PLANS

To examine the current governance structure of HAPs, we conducted a desk review between August and December 2021 that focused on collecting publicly available written HAPs in California. We defined a “public health jurisdiction” as the lowest level of jurisdiction with public health authority in the state. California has 61 public health jurisdictions; 58 of these are run by a county and three are run by a city.

We conducted online searches using the same keywords for each public health jurisdiction (county/city name + heat plan and/or extreme heat; county/city name + excessive heat emergency; county/city name + extreme weather). We performed searches in Google and on county Web sites with search functions. We gathered and stored Web site links and copies of plans. When the online search did not yield any results, we contacted departments of public health and emergency services to request written plans. We included a plan when (1) a government agency issued it at the public health jurisdiction level, and (2) it was a stand-alone HAP, or the response to extreme heat was a main topic in a multihazard plan (e.g., California’s Local Hazard Mitigation Plan). We did not include public health jurisdictions that did not have an available plan online or that did not respond to our request, under the assumption that a written plan was not publicly available.

We developed a checklist of core elements for HAPs based on previously developed guidelines. The checklist was influenced mainly by the World Health Organization’s “Heat-Health Action Plans: Guidance” but also included criteria to reflect recent reviews of HAPs; improvements in climate surveillance, monitoring, and forecasting; specific needs for vulnerable populations; and effective communication of heat-health information.^7,9,14–18 The checklist consisted of nine core elements that we identified as important for a successful HAP:

• 1.An identified lead body to coordinate HAP with clear guidance on heat-risk governance;
• 2.An accurate (to locality) heat-health warning system, including threshold for action based on local health data;
• 3.Identification and outreach plans (communication and intervention) specifically targeted to vulnerable populations;
• 4.A communication guide for heat-related health information, including general public education and awareness campaigns with an emphasis on health behavior and health promotion;
• 5.Preparedness for social and health systems, including staffing capacity, infrastructure, and health care, including specific procedures for emergency medical services, hospitals, nursing homes, and caretakers of vulnerable populations;
• 6.Strategies for short- and medium-term reduction in indoor heat exposure, including passive and active cooling;
• 7.Long-term planning addressing urban design and building, energy, and transportation policies that reduce heat exposure and projections of future changes in heat morbidity and mortality from shifting demographics and societal conditions;
• 8.Real-term (syndromic) surveillance of heat-health outcomes for emergency and rapid response, including coordination between responding agencies; and
• 9.An evaluation of the HAP, including a comprehensive set of metrics for evaluation and evidence of effectiveness.

Our review of HAPs in California identified 37 (60%) public health jurisdictions with at least one core element identified in the plans. Of these, 24 (65%) jurisdictions had one to three core elements identified, and only seven (19%) jurisdictions had four or more core elements identified. We were unable to identify or access a HAP for 24 public health jurisdictions (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). Of all the plans we identified, no plans were located in departments of public health. We gathered all plans from either county government Web sites or the county agency dedicated to emergency management.

Even with plans partially completed, many of the core elements provided limited information. For example, all plans that contained core element 2— comprehensive heat-health warning systems—only included information from National Weather Services’ advisories or used the National Weather Services’ HeatRisk tool. There was no evidence that plans reviewed local epidemiological data in the development of location-specific heat-health warning systems for their communities. Similarly, plans that were partially completed were addenda or annexes to local hazard mitigation plans, which included information on populations that were generally vulnerable to severe weather hazards, including extreme heat.

Approximately 12 (32%) plans included a description of a “lead body” and some form of “communication plan” to get messages to the public concerning extreme heat events—either before or during the event. Few plans identified ways they specifically “prepared key stakeholders” or identified “short- and medium-term strategies” or “long-term strategies” for reducing exposure to extreme heat in their jurisdiction. There was no evidence that any HAPs contained information regarding “real-time surveillance.”

CONCLUSIONS

Anthropogenic climate change and its consequences are often described as an emergency or crisis, particularly when it comes to the impacts on public health and the exacerbation of social and health inequities.¹⁹ We are not discounting the use of the word “emergency” when describing the threat of global climate change. It implies correctly that urgent action is needed to address the human health impacts of climate change.²⁰ The action, however, is not to avoid the disruptions of anthropogenic climate change but to prepare for them and to manage them as an ongoing characteristic of life in the Anthropocene. The emergency is a collective failure to act, not the extreme heat. Our overall objective is to start to better determine and clarify the policies and governance structures that we can use to accomplish an effective adaptation and to identify gaps that require fundamental changes to governance structures and laws to reduce the magnitude of and prepare for climate hazards, such as extreme heat.

Previous studies examining HAPs have done so at the municipal level,^7,21,22 with mixed results, and others have been assessed at the national, state, or regional level.^15,16,23 These studies emphasize the large variability in how HAPs are implemented and assessed at various levels of governance and the ad hoc approach to the issue. High ambient temperatures and extreme heat events are explicitly linked to negative public health outcomes. Although the effects of extreme heat can affect multiple sectors of society, it is the effect on human health and the infrastructure that supports human health that is of primary concern. Public health departments are key to assessing population health, creating policies and plans, and improving health outcomes. Heat-related illnesses associated with extreme heat are preventable, and human health is a unifying organizing principle for considering the impacts of extreme heat and organizing planning for it. We recommend that the governance structure of HAPs focus on the health implications of extreme heat events, as health outcomes are strongly tied to local health department activities and missions and are equipped to coordinate responses over the long term and coordinate closely with emergency management to address immediate responses to extreme heat events.

We acknowledge that the ongoing COVID-19 pandemic has highlighted significant gaps in our public health infrastructure. Climate change is a current and long-term crisis that will further exacerbate structural weaknesses in our public health system and will need significant investment and resources to overcome. To achieve this, programs such as the CDC’s Building Resilience Against Climate Effects and the workforce capacity–building Climate Corps can better fund and staff public health agencies to address climate and health issues. This transition from an emergency framing to a public health framing cannot be an abrupt one, as the Intergovernmental Panel on Climate Change has identified in its most recent report on mitigation that the transitions involved in climate adaptation and mitigation will produce tensions and raise justice and equity concerns that must be managed.²⁴ This requires planning, consensus building, and a clear understanding of context. Emergency operations and management will still need to coordinate and respond to the immediate needs of the community, but preparation and preventive measures through departments of public health will be key to building resilience in communities to future extreme heat events.

In addition, although we identify vulnerability assessment and outreach plans in the core elements of a HAP, we should note that developing plans is one part of the process; community engagement and implementation are other important factors in HAP effectiveness. Health departments have experience in including communities in planning; public health frameworks’ reliance on the social determinants of health and health equity makes public health a natural location for this coordination activity.

To achieve results in governance related to extreme heat in California, coordination among various stakeholders will be needed—no individual or single agency can achieve this alone. In a recent report highlighting adaptation to extreme heat in California, one of the first priority policies the authors identified was a lack of central authority providing coordination, technical assistance, and strategic funding to address extreme heat. Los Angeles, California, recently appointed a chief heat officer, and there is current (as of this writing) legislation in California, AB-2076, that will establish the statewide Extreme Heat and Community Resilience Program.

Departments of public health should be prioritized and provided with strategic funding for technical assistance in addressing the health concerns of extreme heat. Another priority policy identified that local hazard planning, such as local hazard mitigation plans, are likely not preparing municipalities to address extreme heat in their communities.²⁵ Although local hazard mitigation plans are not emergency preparedness plans, many of the elements of HAPs can be found there. There should be a clear distinction between emergency disaster preparedness and public health preparedness, with the latter emphasizing prevention and preparedness in public health agencies to support or lead efforts in developing successful HAPs.

Some limitations of our review stem from information bias on the availability of HAPs and the use of local hazard mitigation plans and other emergency preparedness plans as proxies for HAPs. We acknowledge that health departments are not currently resourced to play this role and that there are significant legal, political, and governance issues that need to be explored and resolved. We urge public health law and policy scholars and practitioners to begin this urgent work. Public health departments can be a natural home for this work. Public health has a strong commitment to health equity, employs population perspectives and systems thinking in its work, and has experience working in communities. Our analysis of HAPs in California makes clear that the ad hoc approach to this issue is not working and that leadership at the state and regional levels is required.