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Understanding Systems of Health and Community Resilience
INTRODUCTION
This chapter provides an overview of the current state of health and community resilience in the Gulf of Mexico region, including highlights of some of the more significant previous efforts to assess and enhance health and community resilience in the Gulf region. This chapter contextualizes the challenges faced by communities located in the Gulf region, as these
differ from challenges faced in other areas of the country, and it defines some overarching key terms and concepts related to health and community resilience that are important for framing the remainder of the report.
The definition and attributes or concepts ascribed to resilience are myriad and require a multidimensional assessment to fully appreciate. Concepts of resilience have continued to grow and evolve depending on the context and intent ascribed to the use of the term for a particular individual, community, or system. A selection of definitions of resilience grouped by scientific discipline show the diversity of definitions to date (Graveline and Germain, 2022; Table 2-1).
TABLE 2-1 Main Definitions of the Term Resilience Within Different Scientific Disciplines
| Field/Discipline | Definition | Reference |
|---|---|---|
| Ecology | A measure of the persistence of systems and of their ability to absorb change and disturbance and still maintain the same relationships between populations or state variables | Holling, 1973, p. 14 |
| Social–ecological systems | The degree to which a complex adaptive system is capable of self-organization and the degree to which the system can build capacity for learning and adaptation | Adger et al., 2005, p. 1036 |
| Mathematics, physical sciences, engineering | The ability of a material or system to bend or resist without breaking, and the speed at which it returns or “bounces back” to equilibrium after a displacement | Aldunce et al., 2014, p. 255 |
| Psychology, psychiatry, social sciences | The process, outcome, or capacity of individuals and communities to resist, recover, and return to baseline functioning after a misfortune, stress, or external shock | Aldunce et al., 2014, p. 255 |
| Risk management, disaster risk reduction | The ability of a system, community, or society exposed to hazards to resist, absorb, accommodate, adapt to, transform, and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management | UNDRR, 2021 |
| Climate change adaptation | The capacity of social, economic, and environmental systems to cope with a hazardous event or trend or disturbance, responding or reorganizing in ways that maintain their essential function, identity, and structure while also maintaining the capacity for adaptation, learning, and transformation | IPCC, 2018, p. 557 |
SOURCE: Graveline and Germain, 2022.
SOURCE: Graveline and Germain, 2022.
While there are myriad permutations of resilience, in recent years the technical understanding has converged around two core characteristics across applications. Resilience is based on the building of adaptive capacity, and resilience supports increased effectiveness of response and recovery. From the specific perspective of the risk and disaster management fields, resilience is used to describe the ability of individuals or communities to overcome natural disasters in the context of the four dimensions of risk management: prevention, preparedness, response, and recovery (Graveline and Germain, 2022). As seen in Figure 2-1, the evolution of resilience from a risk management perspective is shown through the representation of concepts such as bouncing back, bouncing forward, and building back better within the risk management framework (Graveline and Germain, 2022).
A resilience activation framework proposed that access to social resources would promote adaptation and disasters recovery (Abramson et al., 2015; see Figure 2-2). This model differentiates resilience attributes—described as human, economic, social, or political capitals—at the individual level from those at the community level and illustrates how access to such resources in an integrated fashion can bolster resilience especially for individual mental health after a disaster.
SOURCE: Abramson et al., 2015.
PREVIOUS EFFORTS TO ASSESS HEALTH AND COMMUNITY RESILIENCE IN THE GULF REGION
While there are a number of past and ongoing efforts to assess health and community resilience in the Gulf of Mexico region, most are limited by either the scope of the hazards considered (hurricanes, the Deepwater Horizon oil spill, etc.), the resilience factors explored (perhaps one or two of economic, psychological, social), or the effects on health assessed (behavioral, environmental, disease morbidity and mortality or well-being) (Box 2-1). This committee was charged to look across the full scope of an all-hazards perspective on disasters and assumed a broad lens through which to explore both the facets of resilience, and the effects on health and well-being. There are some important advancements since past efforts. Most prominently, this report explicitly addresses both health and community resilience as two interconnected but separate determinants of community health and well-being. Furthermore, we are deliberately taking a more holistic approach to equity beyond disparities, to encompass in addition to health, more intentional decision making and governance. This report also places more emphasis on not only attaining health and community resilience, but also factors influencing sustainability.
ATTAINING AND SUSTAINING HEALTH AND COMMUNITY RESILIENCE
Often communities most in need of becoming resilient are unable to advance to the stage of sustainability. Evidence suggests that four key factors are integral for bridging existing gaps in the health and community resilience enterprise: (1) appropriate integration of proximal and distal indicators of health; (2) a holistic systems approach; (3) sufficient financial and human resources, effectively charged and coordinated; and (4) equity in the context of resilience. Each of these factors is described below.
Appropriate Integration of Proximal and Distal Indicators of Health
Ungar and Theron (2020) examined how resilience can positively influence mental health when distal health indicators, such as social support (capital), are integrated with proximal ones, which are usually at the individual level. Thus, the more systems that resilience-enabling mental health interventions influence at the same time, the more likely these are to build the psychological capacity that individuals require to cope well with severe or chronic exposure to adversity, now and in future. The community capitals are now a well-recognized component of resilience (NASEM, 2019a; see Figure 2-3). However, this recognition has not yet fully resulted in a sustainable systems approach to integrate all capitals, limiting the effect of interventions addressing any individual capital.
A Holistic Systems Approach
In the aftermath of natural disasters, most disaster response actions focus on evacuation, providing temporary shelter, and restoring physical structures. While many public-sector agencies—federal, state, and local—are active in the immediate pre- and postdisaster phases, such focused influx of resources is neither seamlessly coordinated nor sustained over time. Ineffective policies and misaligned roles and responsibilities further hamper achieving systems-level strategies. A systems approach to health has long been advocated (Kaplan et al., 2013); however, this approach still focuses on the individual’s relationship with the health system. Likewise, precision medicine strives to deliver the “right intervention to the right patient at the right time,” where the focus remains at the individual level (Khoury et al., 2022). In contrast, a systems approach integrating both the individual as well as community and environmental determinants is accomplished by using a precision public health approach that seeks to deliver “the right intervention to the right population at the right time” (Khoury et al., 2022). A systems approach to resilience requires this latter strategy be designed to tailor community-centered interventions and increase the likelihood for sustained health improvement.
SOURCE: NASEM, 2019a.
To foster a holistic systems approach to health and community resilience, the committee suggests that its findings, conclusions, and recommendations be considered in the light of a health in all domains approach introduced in the 2015 National Academies report focused on building healthy, resilient, and sustainable communities following disasters. It is the committee’s hope that practitioners will consider a holistic approach to applying the conclusions and recommendations in this report. These conclusions and recommendations are not intended to be primarily additive, but rather concepts and activities to be integrated into the existing structures in most cases, and additive only where critically necessary.
A key determinant of sustained health and community resilience is the state of the public health infrastructure. Across the Gulf states, achieving and sustaining health and community resilience is hampered by a fragile public health infrastructure. While progress has been made since Hurricane Katrina, many communities lack robust resources supporting the public health infrastructure services: a quantitatively robust transdisciplinary workforce, a well-functioning organizational setting, and interconnected
information and knowledge systems, developed, maintained, and capable of integrating disparate data sets to inform tailored community-engaged interventions (Baker et al., 2005).
Sufficient Financial and Human Resources, Effectively Charged and Coordinated
Attempts to fund systems integration to advance health and community resilience have followed several major disasters, most notably Hurricane Katrina and the Gulf of Mexico oil spill. Financial support from foundations and some federal agencies such as the Rockefeller Foundation and the Centers for Disease Control and Prevention and others resulted in the creation of resilient cities and chief resilience officer positions, Centers for Public Health Preparedness, and the Public Health Ready program to support local health departments (Baker et al., 2010; Rockefeller Foundation, 2019; Summers and Ferraro, 2017). Once the funding streams halted, many of these investments were not sustained, significantly affecting attempts to create holistic systems-driven approaches to community resilience.
In addition to the challenge of limited financial and human resources countering the challenges associated with health and community resilience, the use and yield of these resources are affected by challenges of coordination and management. Coordination and management are challenged in two ways. First, the coordination of discrete resources that contribute to health and community resilience is spread across disparate organizations ranging from health departments, social services departments, departments of education, and community development. Secondly, the lack of community engagement in decision making and priority setting regarding funding allocation establishes a high likelihood of funds being misdirected, which may result in decreasing rather than strengthening community resilience. Recent research suggests that the intersection of interests, advocacy, and policy making in funding allocation may also play an important role (Mishori, 2019). The roles of interests, advocacy, and the sometimes incongruent policy process in the health and resilience of communities and its interplay with social determinants and other factors are ripe for more detailed and consistent exploration.
Equity in the Context of Resilience
In “An Introduction to Equity-Centered Design,” published by the Bill and Melinda Gates Foundation (Gates Foundation, 2022), emphasis is placed on linking human-centered design thinking with equity centeredness. Human-centered design (HCD) is a framework that outlines a process for problem solving and is characterized by a strong, consistent focus on the human perspective and is applicable to processes involving research, design, or problem solving. In general, the HCD process repeatedly cycles
through four phases: (1) empathy building, (2) rapid ideation, (3) testing, and (4) iteration. Five common risks have been identified that frequently surface in design when HCD is used as a standalone process for designing and solving problems: status quo design, misrepresentation of users, uneven power dynamics, techno-solutionism, and accountability deficit. These risks can appear at any phase of the design process. Deliberate and explicit prioritization of equity in the design process is necessary to prevent reinforcing and acting on systemic oppression.
The HCD framework facilitates incorporating equity-centered principles into practice. Examples of methodologies that are centered in equity include inclusive design, participatory design, asset-based community development design (ABCD), and equityXdesign. These methodologies often are used in conjunction with one another to create a multimethod approach. The inclusive design method draws on the full range of human diversity by including and learning from people with various perspectives, while the participatory design works to involve all stakeholders in the design process to better understand user needs. The ABCD strategy is central to equity and focuses on amplifying a community’s existing strengths and assets, inverting the common “needs-based” and “deficit-based” design process.
EquityXdesign merges the consciousness of racial equity work, design thinking, and inclusive collaboration as an alternate, more equitable way to design for change. Embedded in equity-centered principles is accountability. Vian et al. (2020) suggests that transparency and participation are critical enablers of accountability (Figure 2-4). Specifically, enablers should be operationalized to facilitate cocreation, implementation, and follow-up.
SOURCE: Vian et al., 2020.
The Multidimensionality of Equity
A recent publication from Chandra et al. (2022) defines three dimensions of equity:
Procedural equity is the perceived fairness of processes and procedures to make decisions; procedural equity addresses how the concept of fairness is included in approaches and policies, once the equity parameters are set (i.e., for whom are we improving equity). It steps beyond trust to include components such as representation, as well as voice and participation in decision making.
Distributive equity is how social welfare and need is balanced. The concept of distributive equity focuses on allocation and resource management decisions, with attention to the balance of costs, risks, and benefits. Usually, distributive equity considers how decisions are made and benefits are distributed based on the dimensions of need and social benefit. Contextual equity is how existing social conditions influence equity. Contextual equity is the backdrop of both procedural and distributive equity, because this form of equity accounts for the political, economic, social, and intergenerational factors in which populations engage with society, its systems, and its benefits. This includes contextual variables such as access (e.g., access to capital) and power (e.g., in this context, the ability to gain and maintain access to resources).
In the context of urban resilience planning, Meerow et al. (2019) added the dimension of recognitional equity, highlighting the importance of respect for diversity and culture (see Figure 2-5).
SOURCE: Meerow et al., 2019.
SOURCE: Leach et al., 2018.
This approach to equity does not explicitly include the contextual dimension. The dimensions of equity can also be in play when answering the questions “equity for what” and “equity between/for whom.” This is particularly pertinent when considering sustained human-centered interventions to advance health and community resilience (Leach et al., 2018; see Figure 2-6). Many subsistence communities in the Gulf of Mexico region depend heavily on ecosystem services. Pascual et al. (2014) propose a multidimensional model of equity that integrates procedural, distributive, and recognitional equity within the contextual dimension (see Figure 2-7).
EVOLVING UNDERSTANDINGS OF COMMUNITY VULNERABILITY
As described in this chapter, the definition and concepts pertaining to resilience have evolved and adapted over time and according to the context with which it was applied and examined. As the committee members reviewed existing frameworks in their examination of the health and community resilience in the Gulf of Mexico, they were cognizant of the unique confluence of factors that affect people who live in this region.
SOURCE: Pascual et al., 2014.
Individuals and communities in the Gulf face a series of interconnected health threats all exacerbated by historical disparities and inequities (economic, financial, educational, political, etc.), environmental health threats, repeated natural and man-made disasters, and growing threats from the effects of climate change (Figure 2-8).
By examining the complex challenges of historical inequities and disparities, environmental health threats, natural and man-made disasters, and climate change, the committee seeks to develop a framework through which the Gulf can move toward becoming more resilient in the face of overlapping disasters. The next two chapters will show how the factors discussed in this chapter—having a holistic systems approach; the appropriate integration of proximal and distal indicators of health; having sufficient financial and human resources; and equity in the context of resilience—can be applied to what is known about health and community resilience in the Gulf region. Chapter 3 starts this process by examining available data across this region and the need for systematic data collection and integration across systems to foster health and community resilience. The chapter also examines in-depth the role of the social determinants of health and the data needed to facilitate transformative change focusing on inequities rather than just health disparities.
In the following two chapters, the committee will more comprehensively examine the current state of health and community resilience specific to the Gulf of Mexico region and through the lenses of data (integration of proximal and distal indicators of health), infrastructure (the building of a holistic systems approach), human capital, funding, and governance (sufficient financial and human resources, effectively charged and coordinated) to begin to draw conclusions and make recommendations toward progress in the region, while keeping in view the multidimensional nature of equity, and the diversity of hazards and vulnerabilities faced by the communities of the Gulf region.
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