How Extreme Weather, Health, and Communities Connect

rj_0Richard Jackson, MD, MPH, is a Professor at the Fielding School of Public Health at the University of California, Los Angeles. A pediatrician, he has served in many leadership positions in both environmental health and infectious disease with the California Health Department, including the highest as the State Health Officer. For nine years he was Director of the CDC’s National Center for Environmental Health in Atlanta and received the Presidential Distinguished Service award. In October, 2011 he was elected to the Institute of Medicine of the National Academy of Sciences. He is also a member of the Climate for Health Leadership Circle.
 
Everyone remembers his or her first experience with extreme weather. I grew up in northern New Jersey and the early 1950s brought an especially active series of tropical storms. In 1955, Hurricane Diane roared through the Northeastern United States. I vividly recall the street where I lived crisscrossed with downed oak and elm trees and the city impassable for miles around. As a child, the storm was the most exciting show I had ever witnessed. Downed electrical wires sparked at the curbsides and neighbors scrambled to check on their homes and each other. I soon saw my neighbors pulling large branches from the roofs of their homes and covering the damage with tarps. I heard the fearful whine of chainsaws and the grunting and chugging of heavy equipment, backhoes, and grapple-skidders. The roadways were slowly cleared. For some reason we had not lost water supplies, though electricity was out for about 10 days. I felt like quite the little frontiersman as I went out to collect scrap twigs and dried branches that could be burned in the fireplace to keep our home warm during the 10 days (although I don’t think we really needed the warmth, the adults probably needed some task to keep us boys busy).
 
hurricane_katrinaMy experiences were tame compared to those of the children in New Orleans in 2005 or those in Coney Island 2012. When bad outcomes ensue, such as the inundation of New Orleans with Hurricane Katrina, we initially blame them on an “Act of God,” but before long we realize that this act of nature has been amplified by shortsighted design and inadequate building codes. The disaster of Katrina was magnified by bad levees, slapdash building, and residential siting in inundation zones. All made worse by a dysfunctional system of local governance, especially the police department. The New York region is overall wealthier than New Orleans and was better prepared for Superstorm Sandy, but the populations at risk were far larger. Similarly, though, in the case of Sandy, many of the bad outcomes were predictable and could have been prevented, such as the inundation of NYU Medical Center and of the city of Hoboken, or the loss of $100 million worth of new railroad rolling stock because it had been thoughtlessly sidelined parked in a known flooding zone.
 
Extreme weather events allow us to see our communities at their best, and sadly at their most unseemly. The communities that are the most resilient—the ones that function well and recover most quickly—bring to their recovery an important mix of financial and infrastructure assets that are perhaps the most critical element in resilience and recovery. In “Tornado Alley” people living in brick homes with basements and with steel tiedowns for the foundations and roofs survive violent windstorms better than do the low income persons living in trailer parks. People with financial assets, such as a remote vacation home or a large SUV to help evacuate them in order to stay with unimpacted relatives, managed Hurricane Katrina far better than those with few resources. Those with adequate homeowners’ insurance policies rebuilt far sooner, and they rebuilt homes that were “up to code” and more resilient than the ones damaged or destroyed. And in the same way, those living in countries where national assets can be rapidly deployed to assist also manage more effectively than those with more limited assets.
 
Protecting health and being resilient in the face of extreme weather requires more, however, than solid financial resources. It requires a narrative of survival and of recovery. And that narrative must be personal and connected not just to the family, but also to the community, municipality, and jurisdiction. Studies of recovery after disasters demonstrate that families and neighborhoods where there was strong pre-existing social capital, namely community organizations, churches, and a strong volunteer culture, as well as competent and effective local governance, recovered from calamities more quickly than those without this. Communities that lack financial and social capital are more likely to fail to recover from disasters and end up in a diaspora; with persons and families scattered thousands of miles in every direction. This is what happened to many of the poor in New Orleans after Hurricane Katrina. At times a diaspora is exactly what is needed—not all locations are suitable for human habitation or redevelopment. For example, swampy areas subject to regular flooding may be good farmland but they are unlikely to be ideal for residential building. Desert areas can be turned into agricultural land, or even cattle feedlots, but only with enormous inputs of energy, water, and agricultural chemicals, including fertilizers and pesticides. Creating habitation on unsuitable land is rarely a good long-term investment.
 
In my role in public health I have had substantial experience in health leadership roles following various crises and disasters. When I was with the California Department of Public Health, we had to address droughts, immense wildfires, floods, earthquakes, mudslides, as well as civil insurrections. When I was head of the National Center for Environmental Health at CDC we had to address hurricanes in Florida, massive floods along the Mississippi Valley, and inundations in the low country, and even the Piedmont on the East Coast, particularly the Carolinas. My Center developed and administered the National Pharmaceutical Stockpile, which was directed and funded by Congress to be mobilized in the event of terrorism and pandemic threats; it was first deployed on September 11, 2001. In addition, CDC’s Refugee and International Health group was located in NCEH; it was frequently called on to respond to refugee crises in many parts of Africa, the Middle East, Asia, and elsewhere. Each of these crises brought its own set of needs and different demands for response. And each of the various assistance groups tended to bring its own set of skills and supplies, ranging from drinking water and meals-ready-to-eat, all the way to temporary shelters and portable surgical hospitals. But in my own experience, the assets and help most often needed more than any other were: good intelligence (what is going on with whom, where, when, and for how long), solid management, and robust communication.
 
While these needs seem self-evident, they are rarely concurrently present, and I assert, the most commonly neglected need following these crises is effective communication. Many times I have been in the room with elected officials, physicians and health leaders, public safety personnel including police and fire, and emergency management experts, where each one narrowly focused on his or her own expertise. And then each looked to a third-party “expert” to confront a critical and urgent element of the response—that essential element is: communication. Yet, each of these leaders would delegate the task of communications to someone else: a public relations expert, or to a writer, or to a telegenic junior staff member. These “experts” frequently persisted in the belief that providing distressed disaster victims a list of facts once a day is adequate communication. But they fail to realize that effective community engagement is a two-way process. This near-predictable behavior reflects a fundamental misunderstanding of communication. Communication is not merely talking to or at people. Communication is—not just talking—but listening. Communication only occurs as a two-way activity. Just as every child is told “you have two ears and one mouth because you’re supposed to listen twice as much as you speak,” so those responding to extreme weather events and disasters need to hear and behave in the same way. Those in leadership roles must be listening clearly and synthesizing information, planning ahead; not merely directing traffic or offering dictates. Members of the community who are suffering must be conversed with, not just in their own language, but also in their own dialect and educational level. It is important to understand the cultural aspects and norms of the communities as you plan to communicate and take action around extreme weather events.
 

Photo by DAVE GATLEY/FEMA News

Photo by DAVE GATLEY/FEMA News

When I was in North Carolina following Hurricane Floyd, I visited many of the shelters that had been set up in the school gymnasia and armories. I repeatedly heard the community members express anxiety about epidemics of typhoid. After listening to distraught members of the public express fears about a typhoid epidemic, we would patiently explain that there were no typhoid bacilli in the area and that the likelihood that this would occur was negligible. Our reassurances were dismissed. People who were frightened, isolated, and distraught repeatedly insisted that they wanted “typhoid shots,” an activity I considered worthless, especially compared to all the other more urgent needs that people had. Then I hit on it—the most common health threats in these situations resulted from drinking contaminated water and food; these needs were being well taken care of. But after major disasters such as earthquakes and tornadoes, the most common injury people sustained was puncture wounds to the feet. The landscape was covered with pieces of lumber, broken boards, and other debris with wood shards and exposed nails sticking up. After the wearing of personal safety equipment such as heavy-duty work shoes, the most important health protective contribution we could make to these folks was to raise their immunity to tetanus, or lockjaw. Yet puncture wounds were seen as a personal threat and liability, perhaps the result of carelessness, rather than a community or public health threat. To respond to an actual public health danger to the community, we then set up clinics to administer a tetanus toxoid vaccine in the form of TDap shots. The immunity to tetanus would be far more useful and last ten years, and also to the good, they received boosters against diphtheria and pertussis (whooping cough). The act of waiting in line with one’s neighbors and receiving this useful injection carried far more benefit, both medically and in terms of anxiety reduction, than almost any other action we could have taken. Listening is what created this community benefit. This kind of clinical management at a community level is somewhat similar to actions taken in clinical medicine, where what the patient is saying they are worried about, and what the doctor knows they should be concerned about, are not in agreement. In these situations the patient needs to feel listened to and well cared for, and the doctor must with good conscience do what is best for that person.
 
Climate experts say that extreme weather will be on the increase because of planetary warming and our ignoring the community health signs and symptoms of global, unchecked dependence on fossil fuels. Sea levels have been rising at the rate of about a centimeter per decade, which means that oceans are about a third of a foot higher than they were during Hurricane Diane. Storm surge and saltwater intrusion into freshwater resources create greater threats to safety, health, and infrastructure. Warmer atmospheres hold not just more energy but hold more water vapor, and the combination of more heat and more humidity can be deadly in our densely populated cities.
 
Experts say these weather extremes will become not just more frequent but more violent. And weather will not impact merely little neighborhoods but will lead to impacts on large populations. Where droughts prevail and arid lands expand, wind storms will carry even more dust around the world to downgrade air quality and exacerbate respiratory consequences.
 
Diminution of the Himalayan glaciers and the relative drying up of the Ganges River and the Brahmaputra River, combined with sea-level rise in the Bay of Bengal, will lead in this case to large population migrations. Increasing numbers of drought events worldwide would combine with sea-level rise, and the inevitable salination of aquifers used for drinking water, livestock, and irrigation will drive ever larger population migrations. Population migrations always come with major health impacts, and too many start with war and terrorism. And as with everyone’s early life experiences with violent weather, the impacts will be unforgettable. Sadly, the children of tomorrow will have many more weather stories to tell; stories with little charm and a great deal of preventable terror.
 
Extreme Weather, Health, and Communities offers a sample of how society has dealt with extreme weather events, concerns for human health using interdisciplinary approaches to community engagement. It tells of life-threatening moments of terror and of chronic, life-restricting consequences of extreme weather. It takes us through the painstaking cycle of research, education, and payoff, with fewer lives at stake, healthier communities, and a higher regard for climate and weather. Significantly, it reminds us of the need for interdisciplinary and cross-cultural participation in coping with weather extremes.
 
The above chapter appears as the foreword to Extreme Weather, Health, and Communities, Springer (2016).

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