Step 3: Assess public health interventions

Selecting community adaptation programs to lessen the impacts of climate change, with a specific focus on vulnerable populations

For Step 3, consider the most suitable health interventions for the identified climate-related health impacts of greatest concern in the jurisdiction. To jumpstart brainstorming, see examples of interventions (i.e., smart urban design, environmental controls, training health care providers) on this section’s key resource. BRACE grantees partnered with CDC to produce intervention literature reviews to support getting started on this step.

BRACE Step 3 requires a review of scientific, evidence-based reports and community-based data from existing assessments and plans, a review of community priorities already identified, cross-sector and interdisciplinary groups, focus groups, or informational interviews. Planners can also review lessons learned from past interventions and learn from similar jurisdictions who may be further down the path. Consider selecting interventions that would support or be complimentary to ongoing adaptation work in the community. Learn from community partners’ expertise in what desired and effective climate adaptation looks like and work together to identify interventions that can enhance their vision and strategies.

Prioritize upstream changes more likely to address root causes of inequity

When adaptation actions only focus on individual behaviors, the symptoms of inequity may be addressed, but not the root causes. By focusing on upstream changes, which are often policy oriented, you may be able to alter some of the social determinants of health that exert such a strong influence on health outcomes. This often implies cross-sectoral collaboration across levels of governance with agencies of labor, transportation, education, corrections, economic development, housing and public safety (i.e. Health in all Policies). This may also take the form of participating in health impact assessments (i.e. Health Impact Assessment, Promoting Equity through the Practice of Health Impact Assessment) and equity impact assessments for proposed policies stemming from other sectors.¹

CONDUCT A RACIAL EQUITY IMPACT ASSESSMENT

A systematic assessment is a way to examine the potential impact of proposed adaptation policy or program on different racial and ethnic groups. Here are some suggestions that can help you have more confidence that a plan meets your racial equity goals and to minimize unanticipated adverse consequences:

Complete the assessment with people with diverse backgrounds and perspectives.
Engage different stakeholders — especially those who might be the most impacted — in the development of the proposed adaptation policy or program.²
Determine how the proposed policy or program will affect each group.³
Examine how the proposed policy or program will result in positive and equitable impacts.²
Document and evaluate the impacts to ensure success over time.²

LEARN MORE ABOUT HOW THE COMMUNITY IS ALREADY ADAPTING

Regardless of a jurisdiction's access to technology or funding, rely on community members as experts of historical trends and environmental health in their community. An intervention can be particularly effective when it equips community leaders with tools and resources to effectively advocate on behalf of their communities’ health. A strong partnership between public health agencies and community-based organizations can yield more equitable, sustainable solutions. The following are a few additional tips to further develop community partnerships:

Work with community members to understand what adaptation efforts are already in place and where resource gaps exist. Get a sense of what strategies or priorities have already been identified by priority communities.
Invest in communities through financial and technological resources so that they can further their programs and reach at-risk individuals. Consider how public health interventions can build community adaptive capacity within priority communities.

Spotlight

With increasing temperatures, harmful algal blooms are more common and poison shellfish more frequently. For generations, the Lummi Tribe of Washington State has tested the safety of shellfish by testing it on the tongue for a tingling sensation.⁴ Although this traditional ecological knowledge is powerful, some lower levels of harmful biotoxins cannot be detected by the tongue. Recently, tribal natural resources staff has used technological advancements and lab testing to determine shellfish safety for consumption.⁴ In addition to official statements from the Lummi Natural Resources Department, community leaders amplify information about beach closures due to biotoxins.^4,5,6

PREPARE TO RESPOND TO ACUTE AND LONG-TERM MENTAL HEALTH NEEDS

People with mental health conditions are at greater health risk from extreme weather events, due to such factors as psychiatric medications side effects and dependency on services or medical supply chains that may be inaccessible after disasters.⁷ Additionally, following a traumatic event like a flood, people often experience stress, depression, anxiety, and post-traumatic stress disorder. Critically, trauma can increase with each climate related disruption.⁸ Below are a few recommendations for how to prepare and respond to acute and long-term mental health needs:

Use a trauma-informed approach and integrate mental health considerations into all intervention plans. While this step benefits all people who may be traumatized, it is absolutely critical for individuals with pre-existing mental health conditions.
Work with community leaders to provide culturally appropriate care.⁹
Identify warning systems and evacuation strategies that can serve a diverse population with a variety of mobility capabilities, technology access, literacy, and language comprehension.

Spotlight

Ellicott City, Maryland, suffered catastrophic damages due to massive floods in 2016 and 2018. The two storms caused more than $32 million in physical damages,^10,11 as well as countless mental health challenges. In response to the immediate need for mental health resources, a network of mental health practitioners called HELP-U provided free crisis counseling services to residents and connected them with other providers for longer-term care.¹² In developing long-term adaptation, Howard County launched the Ellicott City Safe and Sound plan in 2019.¹³

buildings demolished by flooding

Photo courtesy Maryland GovPics, via Flickr Creative Commons

UNDERSTAND COMMUNITY PRIORITIES

It is critical to understand the community’s priorities when selecting an intervention strategy. Interventions may have ancillary effects that may seem inconsequential to some but hold important cultural significance to others. To understand these consequences, engage your jurisdiction’s at-risk communities to gain insight about current circumstances, past experiences, preferences, needs, and relevant practices.

For example, for indigenous populations who live closely with their natural environments, biodiversity loss often has physical and mental health consequences. These can include the loss of healthy foods in traditional diets and mental anguish caused by disruptions to ceremonies, cultural practices, and daily life. Thus, an adaptation plan that focuses on preserving culturally valued plants or animals may be seen as a more important priority than one from a traditional public health perspective.

Consider the intersectional impacts of a proposed intervention. How may a ban on burning impact the cultural traditions of an indigenous group? How could an environmental intervention impact a food source central to a traditional diet? How would a shift in land use alter a community’s access to a place of spiritual significance?
Understand your jurisdiction’s history of decision-making and which populations were included, excluded, and impacted. Consider the lasting impact of this historical trauma in the population’s relationship with local government.
Communities are diverse and unique; it is vital to account for the various needs within communities (e.g., by age, disability status, geographic area, race/ethnicity, sexual orientation, socioeconomic status). Engage with community leaders and other existing partnerships when determining strategy, design and implementation.¹⁴

Spotlight

Fishing and seasonal burning hold immense personal and spiritual significance to the identity of the Karuk tribe, located in California. It is not just a matter of what one eats, but also the values that are involved in harvesting and managing these resources. Changes in these traditions have created community stress for the Karuk people, contributing to emotions of grief, shame, stress and powerlessness. The Karuk people have developed adaptations and interventions by coordinating with other departments and incorporating resolution to societal conflicts, including counseling and cultural and spiritual community programs. They are also focused on economic development strategies to protect culturally relevant jobs.

ANTICIPATE AND ADDRESS BARRIERS TO OUTREACH AND ENGAGEMENT

Critical information regarding climate-related health threats often does not reach at-risk populations. Some residents may have limited or no access to smartphones, computers, television, or the internet. Others may face linguistic barriers or feel distrustful of the government due to past experiences. You can take several steps to ensure that critical health information is reaching a jurisdiction’s at-risk populations:

Offer public health resources in a variety of languages and with options for individuals with hearing and visual impairments.
Provide printed materials to common gathering places, like places of worship and recreation centers to reach people with limited technology access.
Build relationships with trusted messengers, like local health care providers, religious leaders, and teachers, who can effectively share health information.

Spotlight

New York City’s Be A Buddy program helps at-risk community members build climate adaptation through education and awareness. The program aims to build community knowledge through creating social connections between volunteers and individuals at risk from extreme heat. In case of a climate-related emergency, local residents registered to the Be a Buddy network will be contacted and assisted by local volunteers from the community. This is an initiative led by THE POINT in partnership with the Mayor’s Office of Recovery and Resiliency “COOL NEIGHBORHOODS NYC” program, the NYC Department of Health and Mental Hygiene and the Fund for Public Health NY.

EXAMINE PROPOSED INTERVENTION'S IMPACT

Some adaptation actions are more drastic than others. Especially when you are planning an adaptation that will require high costs (economic or social), assess your agencies capacity to manage and implement an adaptation.

Evaluate financial resources at hand and conduct budget projections to determine costs associated with climate change adaptation efforts. As part of this process, determine if new partnerships and grants could supplement the intervention budget. Additionally, work with your agency to finance for climate events and associated health impacts.
Review climate models and geographically similar case studies to establish a realistic timeline for the jurisdiction’s needs in the coming years so that you can plan ahead. Take advantage of resources such as the National Climate Assessment to view how climate change is impacting your region, and learn how states and cities are adapting.

Relocation
Perhaps the most disruptive public health intervention is community relocation or managed retreat. For some coastal communities, relocation is the only option due to repeated flood disasters from coastal storm surges and heavy rainfall. For populations united by a shared culture, it may be critical for individual wellbeing to relocate to safer areas as a cohesive unit. While invariably more expensive and complex than individual household relocation, staying together is vital to the propagation of cultural practices, shared way of life, and social support network.

Spotlight

overhead view of Isle de Jean Charles

The Isle de Jean Charles Band of Biloxi-Chitimacha-Choctaw Tribe resides on a narrow island in Louisiana and has experienced 98% land loss since 1955 due to coastal erosion and salt-water intrusion. The Isle de Jean Charles Resettlement effort is the first federally funded initiative to voluntarily resettle the residents. In 2016, the U.S. Department of Housing and Urban Development funded $48.3 million for the resettlement, and the Louisiana Land Trust is purchasing 515 acres of farmland to serve as the resettlement site for residents. The resettlement’s primary goals are to provide safe new homes, ensure economic sustainability, and preserve cultural identities and traditions.¹⁵ The resettlement planning process has taken over 15 years to unite tribe members who stayed with those who moved to secure a future for the tribe.¹⁶

Maladaptation
Maladaptation happens when “an action taken ostensibly to avoid or reduce vulnerability to climate change impacts adversely on, or increases the vulnerability of other systems, sectors or social groups“ — increasing rather than decreasing vulnerability.¹⁷ To avoid maladaptation, adaptation projects must directly address the social and economic “drivers of vulnerability,” often caused by historical power struggles and imbalances. These drivers influence risk perception, entitlements to resources, and choices about adaptation, and can include social characteristics and cultural values, gender, age, health, social status, ethnicity of individuals and groups, and the institutions in place on the local, national, and international levels.¹⁸ It is important to note that a strategy can have some positive outcomes but still result in maladaptation.

Approaches to adaptation should ensure changes to the climate cause minimal harm to people living in vulnerable communities. This can be done by using a framework of increasing resilience, which emphasizes incremental change to reduce potentially harmful impacts. Adaptation approaches should also better capture the interactions between humans and their environment. For example, in small island communities, placing adaptation goals above the community’s development needs could unintentionally reduce resilience.¹⁸

Assess whether a planned intervention will have larger implications, positive or negative, for a larger metro or contiguous area. Consider different types of potential maladaptation, such as environmental, sociocultural, and economic.¹⁹
For coastal areas, consider applying the Assessment framework: eleven guidelines for avoiding maladaptation in coastal areas.¹⁹
Schipper (2020) offers potential solutions for reducing maladaptation, such as:²⁰
1. Ensuring assessment of the causes vulnerability to climate change includes identification of the different pressures in the lives of community members, which may become drivers of vulnerability when new strategies are implemented.
2. Including all impacted groups in developing a project and ensuring that the most powerful people are not put in a position to increase marginalization among the most vulnerable.
3. Ensuring adaptation strategies are in harmony with development contexts and goals.
4. Addressing poverty and capacity gaps to give people more options and reduce the likelihood that they’ll make choices that more negatively impact their future pathways.
5. Creating a diversity of livelihood options, including training and skills development, through equitable development.

Photo by Mark Townsend, courtesy Louisiana Helicam

ASSESS HOW PROPOSED INTERVENTIONS WOULD SERVE COMMUNITIES

It is vital to consider potential interventions for co-occurring crises. As witnessed and experienced from the COVID-19 pandemic, public health workers, emergency responders, and health care workers, shifted response and recovery efforts to safely serve their communities.²¹ Compound events will also continue to harm our most vulnerable populations, exacerbating existing inequities.²² Some steps you can take include:

Reviewing existing emergency plans and identify potential responses that take compound events into consideration. Consider how these plans would affect the most at-risk in your jurisdiction.
Develop an emergency communications plan outlining information for diverse audiences and disasters.
Considering the growing incidence of electricity blackouts in the U.S., establish relationships with emergency planners and utility providers in advance of emergencies to plan for contingencies involving electrical grid failure.

Spotlight

The American Flood Coalition worked with the American Public Health Association to produce the Dual Disasters Handbook, offering local officials and emergency managers further recommendations related to disaster scenario of flooding during the COVID-19 pandemic.

REDUCE THE RISK OF HUMAN TRAFFICKING

Due to the increased risk of human trafficking following natural disasters, it is critical to consider populations at higher risk in your consideration of public health interventions. State and local disaster behavioral health coordinators are often the first lines of defense against human trafficking after disasters. Several strategies can be employed to mitigate human trafficking due to climate change.

improve community access to clean water, food and safe housing needed to stay in place and not be lured away by human traffickers.²³
strengthen enforcement against traffickers with dedicated training for public safety officials.²⁴
include information about trafficking recruitment practices in responder training, along with strategies for building relationships and outreach with community leaders.²⁵

KEY RESOURCES

Consider these resources from different areas that have implemented community adaptation programs to mitigate the impacts of climate change, with a specific focus on vulnerable populations.

Climate and Health Intervention Assessment: Evidence on Public Health Interventions to Prevent the Negative Health Effects of Climate Change
This guide outlines the findings of the BRACE Midwest/Southeast Collaborative on the evidence of effectiveness of various interventions for reducing the negative health impacts of climate change.

Phoenix, Arizona Program on Heat and Homeless Populations
The City of Phoenix created a coordinated program in response to increased requests to address blight associated

Sitka Tribe Using Collaboration to Address Harmful Algal Blooms
Southeast Alaska Tribal Toxins (SEATT) partnership was formed to combat risks of HABs to subsistence shellfish harvesters.

North Carolina Farmworker Health Program
NCFHP works with local agencies to respond to gaps in health care that would otherwise prevent farmworkers from accessing needed care.

Implementing Interventions for Heat-Related Illness and Wildfire Smoke Exposure in North Carolina
The North Carolina Department of Health and Human Services is utilizing the BRACE framework to address heat-related illness and wildfire smoke exposure in their most vulnerable counties.

The Point Be a Buddy Program to Promote Community Relationships as a Part of Climate Resiliency
The ‘Be a Buddy’ (BaB) program focuses on preparing the Hunts Point community for future climate events through climate health education and community preparedness.

CalBRACE Adaptation Toolkit “Assess Interventions”
The Toolkit includes a series of Health Equity, Environmental Justice and Tribal Resources examples.

Safeguarding California and Climate Change Adaptation Policy
There are resources and examples from the California state government to safeguard people, infrastructure and the natural environment from the impacts of climate change.

Safeguarding California Plan: 2018 Update California’s Climate Adaptation Strategy
Includes examples of the qualitative commenting process for the public health portion on page 58.

Natural Disasters and Human Trafficking Resources
When Disaster Strikes: Promising Practices
National Human Trafficking Training and Technical Assistance Center
How Natural Disasters Can Affect Human Trafficking

Dual Disasters Handbook
This resource aims to help local officials and emergency managers address the dual disaster scenario of flooding during the COVID-19 pandemic.

Equity, Diversity and Inclusion Self-Assessment Toolkit
APHA Affiliate leaders have created a toolkit for organizations that want to gauge their own work on racial equity within their memberships and communities. The toolkit also gives next steps for deepening commitment to equity, and resources for taking next steps.

Government Alliance on Race & Equity
The Government Alliance on Race and Equity (GARE) is a national network of government working to achieve racial equity and advance opportunities for all.

Race Forward
A Racial Equity Impact Assessment (REIA) is a systematic examination of how different racial and ethnic groups will likely be affected by a proposed action or decision. REIAs are used to minimize unanticipated adverse consequences in a variety of contexts, including the analysis of proposed policies, institutional practices, programs, plans and budgetary decisions. The REIA can be a vital tool for preventing institutional racism and for identifying new options to remedy long-standing inequities.

Workforce Development Racial Equity Readiness Assessment is designed as a guide for workforce development organizations and practitioners to evaluate their programs, operations, and culture in order to identify strength areas and growth opportunities. Practitioners can use this toolkit to familiarize themselves with various practices and policies that support institutional racial equity, evaluate their current efforts, and plan action steps.

WORKS CITED

1. How can we prioritize upstream policy change? Health Equity Guide. 2017 June 28. Retrieved from https://healthequityguide.org/strategic-practices/prioritize-upstream-policy-change/

2. Keleher T. Racial equity impact assessment. Race Forward. The Center for Racial Justice Innovation. 2009. Retrieved from https://www.raceforward.org/sites/default/files/RacialJusticeImpactAssessment_v5.pdf

3. Race equity and inclusion action guide. The Annie E. Casey Foundation. 2014. Retrieved from https://assets.aecf.org/m/resourcedoc/AECF_EmbracingEquity7Steps-2014.pdf

4. Hintz M & Solomon T. Shellfish safety biotoxins and red tide. Lummi Nation. 2019 June 24. Retrieved from https://www.nihb.org/docs/10082019/Shellfish%20Safety%20Biotoxins%20and%20Red%20Tide%20Presentation.pdf

5. Protecting natural resources for everyone. Northwest Treaty Tribes. 2019. Retrieved from https://nwtreatytribes.org/publications/magazine/

6.; Harmful algae blooms. Lummi Natural Resources Department Harvest Management Division. Retrieved from https://www.lummi-nsn.gov/userfiles/705_HABsBrochureFINAL.pdf

7. How extreme weather events affect mental health. American Psychiatric Association. 2019 November. Retrieved from https://www.psychiatry.org/patients-families/climate-change-and-mental-health-connections/affects-on-mental-health

8. Mongilio H. The psychological toll of Ellicott City’s flooding. Environmental Health News. 2018 June 7. Retrieved from https://www.ehn.org/mental-health-impact-of-ellicot-city-floods-2575729082.html?rebelltitem=2#rebelltitem2

9. Morganstein JC and Ursano RJ. Ecological disasters and mental health: causes, consequences, and interventions. Frontiers in Psychiatry. Public Mental Health. 2020 February 11. Retrieved from https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00001/full

10. Poon L. In a town shaped by water, the river is winning. Bloomberg CityLab. 2019 May 24. Retrieved from https://www.citylab.com/environment/2019/05/ellicott-city-flood-control-historic-downtown-memorial-day/589054/

11. Milligan C. Maryland to receive $4.5M in federal funds to repair roads damaged by flooding. Baltimore Business Journal. 2019 February 13. Retrieved from https://www.bizjournals.com/baltimore/news/2019/02/13/maryland-to-receive-4-5m-in-federal-funds-to.html

12. How to get H.E.L.P. U free counseling. Howard – Ellicott Lifting People Up. A Network for Providing Free Supportive Counseling During Community Crises. 2016. Retrieved from http://www.mythrive.net/ellicott/patient_questions_and_answers.htm

13. Wulfhorst E. Faced with floods and suicides, U.S. readies for a warmer world. Reuters. 2019 August 19. Retrieved from https://www.reuters.com/article/us-climate-health/faced-with-floods-and-suicides-us-readies-for-a-warmer-world-idUSKCN1V920Z

14. Centers for Disease Control and Prevention - Division of Community Health. A practitioner’s guide for advancing health equity: Community strategies for preventing chronic disease. US Department of Health and Human Services. 2013. Retrieved from https://www.cdc.gov/nccdphp/dch/pdf/healthequityguide.pdf

15. Isle De Jean Charles resettlement. Louisiana Office of Community Development. Louisiana Division of Administration. Retrieved from http://isledejeancharles.la.gov/about-isle-de-jean-charles-resettlement

16. Bienvenue, Halito, Welcome to Isle De Jean Charles. Isle de Jean Charles. Retrieved from http://www.isledejeancharles.com/

17. Barnett J and O’Neill SJ. Minimising the risk of maladaptation: A framework for analysis. Climate Adaptation Futures, pp.87-94. 2013. DOI: 10.1002/9781118529577.ch7

18. Noble IR et al. Adaptation needs and options. Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects, pp. 833-868. 2014. Retrieved from https://www.ipcc.ch/site/assets/uploads/2018/02/WGIIAR5-Chap14_FINAL.pdf

19. Magnan A and Mainguy G. Avoiding maladaptation to climate change: Towards guiding principles. SAPIENS, Vol. 7;1. 2014. Retrieved from https://journals.openedition.org/sapiens/1680

20. Schipper ELF. Maladaptation: When adaptation to climate change goes very wrong. One Earth, Volume 3, Issue 4. Pages 409-414. 2020 October 23. Retrieved from https://doi.org/10.1016/j.oneear.2020.09.014https://www.sciencedirect.com/science/article/pii/S2590332220304838

21. Natural disasters and severe weather. Centers for Disease Control and Prevention. 2020 September 17. Retrieved from https://www.cdc.gov/disasters/covid-19/covid-19_resources_for_professionals.html

22. A dual disaster handbook: 6 recommendations for local leaders responding to floods during COVID-19. American Flood Coalition. 2021 April. Retrieved from https://assets.floodcoalition.org/2021/04/54c1f9237d0c62c7338df37959a8d177-DualDisasterHandbook4_8_21.pdf

23. Natural disasters and human trafficking. Engage Together. Retrieved from https://engagetogether.com/2018/06/05/natural-disasters-and-human-trafficking/

24. Yan W. The surprising link between climate change and human trafficking. The Revelator. 2018 May 7. Retrieved from https://therevelator.org/climate-change-human-trafficking/

25. How natural disasters can affect human trafficking. ICF. 2019 February 20. Retrieved from https://www.icf.com/blog/health/trafficking-victims-in-disasters