>> Good morning, everyone,
and welcome to our 2019 State of Health Equity at CDC forum. Building Equity and
Community Resilience in Public Health Emergencies. Sponsored by the Office of Minority Health
and Health Equity. I'm Craig Wilkins, senior
advisor within the office and I'll be serving as
your forum moderator. It is an honor to welcome each
of our special guest speakers and discussions and to each of
you for joining us this morning. And for those of you
joining us by IPTV. As noted on the agenda, the
purpose of today's forum is to apply a health equity lens to public health emergency
preparedness, response and recovery activities
through deliberate communication and interdisciplinary
partnerships. I had the pleasure of being part
of a small planning committee that put this forum together. My sincere appreciation and
gratitude is extended to each of them for all of
their hard efforts in the planning of this event. Their names are printed
on the agenda, but I would like
for them to stand as I read off their names very
quickly and then recognize them with a round of applause.

Dr. Leandris Liburd. Dr. Boyett, Catherine Deron
Burton, Julio de Santali Pierre, Kayla Johnson, Ma Ohiri,
Captain Bobby Roselinia, Dr. Ross who's not here today. Dr. Aaron Thomas,
Dr. Patty Tucker, Jo Valentine and Dr. Amy Walken. [ Applause ] So again, on behalf of this
committee and our office, we appreciate your
attendance and participation. On today's agenda, we'll have
two opening presentations and then two panel
discussions consisting of two presenters
and a discussion. The discussion will be providing
brief reflective comments after the panel presentations, and then facilitate a 15-minute
question and answer session. At the end of the
second panel discussions, we will have a closing
synthesis panel where each of the presenters
will be invited back up to share any final
comments, recommendations and to answer any
final questions.

Before we begin today's forum,
a few housekeeping items. I you didn't register before
you came in, please do so. For those of you who are
participating by IPTV, you will be able to email your
questions to We have staff who will be
monitoring this for questions. On the agenda you will also note
we will have one official break and although it is
a short break, we would appreciate you
being respectful of the time, returning back to the
room, since we want to stay on schedule as much as possible
because we have a full agenda. If you need to step out
before then or afterwards, we would ask you do so in
between the presentations and panel sessions to lessen
distraction for our presenters.

On behalf of the office, we
would appreciate you completing and returning a brief
evaluation that's designed to provide feedback
about this forum. If you are registered
for the conference, you will receive a link to an evaluation survey
in your email box. For those viewing
the forum on IPTV, we may not have your
registration information, so please go to OMHHE's
internet site, click on Events, then click on 2019 C form,
and the survey link will be at the top of the page. The evaluation will be available
right after the forum ends today and will be open until
next Friday, February 8th, up until 5:00 PM for you
to submit your responses. We really value your feedback and your responses will
be completely anonymous. For those of you interested in
continuing education credits, you can look on the
screen or note on the back of your agenda the link
where they will be available.

The activity and passcode
is also noted there as well. And if you haven't
already done so, please silence your
electronic devices. Throughout this morning, I'm here to answer any
questions that you might have. Now I have the distinct
privilege of introducing to Dr. Leandris Liburd
and Rear Admiral Dr. Redd. Yeah. Dr. Liburd? [ Applause ] Dr. Liburd currently serves
as director for the Office of Minority Health and
Health Equity at CDC. And Rear Admiral Stephen
Redd is deputy director for the Public Health Service
and Implementation Science and also serves as
director of the Center for Preparedness and Response. Please welcome them for
the opening remarks.

>> Good morning, everyone. >> Good morning. >> And I add my welcome
to Captain Wilkins, to the seventh State of
Health Equity at CDC forum. We couldn't be more
excited or more pleased by the response to
this year's forum. That will situate public health
preparedness and response in the community-centered
health equity framework. I think yesterday I was told
we had around 270 registrants. And that's absolutely
a record for us, and so we're very
excited about the interest and the participation.

I also want to thank our guest
speakers for their participation in this important convening,
and for their willingness to share lessons learned
in emergency preparedness from a variety of
unique perspectives. I also want to acknowledge
Captain Wilkins and his leadership in bringing
together the planning committee and building the kind
of relationships we need to advance the science
and practice of health equity at CDC. So please join me in
giving him a hand. [ Applause ] So for those who are new to
the forum, what is the state of health equity at CDC forum? We describe it as an
agency-wide assembly to examine CDC's progress in
the implementation of policies, programs, surveillance and
research that contributes to reducing health disparities
and achieving health equity. Pursuing health equity
is, relatively speaking, a more recent goal
in public health. For some it is viewed as an
aspiration, a lofty vision.

And for others it is a
definable set of actions that when taken together
create communities where all people
have the opportunity to attain the best
health possible. We come to the pursuit of health
equity at the intersection of action and aspiration. For example, to advance
health equity at CDC, we must first believe that
it is possible for all people to attain their best
health possible, and then we must identify
indicators, measures and tools for monitoring trends
and health disparities and health inequities. We must identify criteria based
on the best available evidence for best practices in achieving
health equity across a range of public health conditions. We must promote policies that support reducing
health disparities and achieving health equity. And we must clarify and promote
organizational structures that facilitate the
integration of health equity in programs and research. The presentations that we
will hear today will provide real-world and actionable
examples of what it means to apply a health equity lens
in public health emergencies. I look forward to all
that will be shared today and how we might
use this knowledge to achieve CDC's mission.

So welcome again and I know
you're going to get a lot out of today's gathering. And thank you for
your participation. [ Applause ] >> Good morning, everyone. Let me welcome everyone to this
forum on behalf of Dr. Redfield. As Leandris described, this
is one in a series of meetings to try to bring focus
to our work in eliminating health inequity, or bringing health
equity to our nation. And it really is a testament
to our belief that we have to take deliberate action
to improve health equity, that this is not something that
is going to happen on its own, that our overall public
health efforts are going to somehow achieve health equity
without that deliberate action.

I think this is a case where the
rising tide doesn't necessarily rise all boats. And so today's meeting is a way
to bring some focus to that. I would like to say that
we really are needing to put more energy into this
in the domain of preparedness and responses to
health emergencies. When I worked in the
Influenza Coordination Unit, it was a big part
of our activity. And I felt that we really
hadn't achieved what we needed to in order to make sure that when a pandemic came we
had really done everything that needed to be done. I would say that in a health
emergency, kind of the currency that we need to address
is that of information. That people need
information to take action to protect themselves
and to do the things that will reduce the impact
of the health emergency. And there are two barriers
that we face and that we need to overcome in working in
the health equity zone. The first is one of trust.

And for historical reasons,
the lack of confidence that many populations have,
that when the government or the establishment recommends
a certain course of action, that that's what you
really should do. So that area of trust
is very important. The other area is
one of capacity. So if you don't have
access to transportation and the recommendation
is to evacuate, that's going to be a problem. So I think that's another
area that we need to work on, is making sure that when
we make a recommendation, the groups that we're
making the recommendation, actually have the
capacity to do the thing that they're being
recommended to do. And that can be a
functional limitation, or it can be access
to resources. So again, let me
welcome everyone. I want to especially
welcome our guests who have travelled from afar. Dr. Rodriguez from Puerto Rico, Mr. Stripling from
New York City. And I don't see Dan Dodgen
out there from Washington, but he's on the agenda,
so I'm assuming that he'll be here as well. Thanks very much. [ Applause ] >> Our first presenter
this morning, as she comes forward,
is Dr.

Amy Walken. Dr. Walken is the senior advisor
for at-risk populations here at the Center for Preparedness
and Response here at CDC. Dr. Walken focuses on
improving the resilience of at-risk populations
to natural and human-caused
disasters, disease outbreaks and other adverse events. She provides scientific
expertise for emergency preparedness
and response activities. Since joining the CDC in 2002, Dr. Walken has led
numerous national and international
outbreak investigations and emergency responses. Her research experience
includes vulnerable populations and emergencies, health impacts
of extreme weather events, community health
assessments, chemical and radiological terrorism
and toxic epidemiology. Hard to say that word. Dr. Walken has authored more
than 75 peer-reviewed articles and book chapters on
disaster epidemiology, environmental epidemiology
and surveillance. She received her
doctor of public health from the University of
North Carolina Chapel Hill, her master's of science
in public health at Emory University, and
her bachelor's degree from the University of Georgia.

Please join me in
welcoming Dr. Walken. [ Applause ] >> Thank you, Craig. Good morning. I'm Amy Walken. I'm the senior advisor
for at-risk populations with the Office of Science
and Public Health Practice, the Center for Preparedness
and Response. This morning I'm going to talk
about preparing and responding to emergencies through
a health equity lens. And the goal is to frame
the rest of the talks that we're going to
hear this morning. So before I talk about the
subject, I always like to talk about terminology
because a lot of people like to use different words and are comfortable
with different terms. And I want to make sure that
we're all on the same page for which parts of the population we're
trying to address. So at-risk populations refer to
individuals or groups of people who may not be able to access and use the standard
resources offered in emergency preparedness
response and recovery.

And we know from
previous emergencies — and we see this for every
single emergency regardless of the type. And including the most
recent hurricane emergencies that we went through — have shown that there are
certain groups of people who face disproportionate risks. Some people like to use
the term individuals with access and functional
needs. You'll hear this term
from FEMA and from ASPR. And in the next few slides
I'll go through that term. And sometimes we just group
them all together and talk about populations that
are specifically at risk, and I'll explain why
we do that as well. So access and functional
needs address a broad set of needs irrespective of a specific status,
diagnosis or label. This term is very
useful when you're trying to allocate resources
and you need to know what exactly
the needs are.

So for example if you have
an American Red Cross shelter and you're triaging
people coming in, knowing that an older
adult is coming in doesn't tell you
a lot of information. It doesn't tell you
what their needs are. However, if we can
look specifically at their access needs or
their functional needs, we can know where to
allocate those resources. So access needs are based on
access to social services, accommodations, information,
transportation, medication. And function-based needs are
restrictions or limitations on an individual that may
require assistance before, during or after an emergency. And often the CMIST
framework is used to determine who
these people are. And so CMIST stands
for communication, maintaining health,
independence, support and safety and transportation. Communications. This is individuals who may
have limitations that interfere with the receipt of and
response to information.

So for an example, this
may include individuals who are deaf or hard of hearing. If they cannot hear the
information that we are trying to give them, they cannot
take protective actions. Likewise, individuals who have
limited English proficiency. So it's important that we're
pushing out our messages in the languages that
people are speaking. But not just to make
translations, but to have cultural
translations as well. We need to make sure that
our messages are in line with their culture and our
interventions are in line with the cultures as well. Maintaining health. So individuals who
require assistance in managing their chronic
disease, receiving medication and treatment or
operating medical equipment to sustain life.

Domestically, from natural
disasters the thing we see the most in emergencies is
exacerbation of chronic disease. And so we need to think
about what we can do for these populations. So we might think about individuals
with chronic disease. We might think about
pregnant/post-partum women. So this brings up a good point, that these vulnerabilities
are temporary. They may not be something that
you have over your lifetime, and during the course of
your life this may change. You may have a certain
vulnerability that you have today that
you don't have tomorrow. Independence. Individuals who function
independently, as long as they are not
separated from their devices, assistive technology
or service animals — so for example we
might have individuals with a disability
or older adults.

Support and safety,
this is individuals that require additional
personal care assistance, experience higher
levels of distress or support for personal safety. So this includes both your
physical health as well as your mental health. This may include groups
of people like children, depending on their age and
their developmental abilities. And individuals with
cognitive limitations. And finally we have
transportation. This one is pretty
self-explanatory. Individuals with transportation
needs because of age, disability, injury,
poverty, legal restriction or those without a vehicle. So you see there's health
reasons that factor in here.

There are social reasons
that factor in here. So this might include
persons that are dependent on mass transportation or
persons with disability. So the CMIST framework
allows us to figure out who these people are,
especially during a response. However, it can be difficult
ahead of time when you're in the planning stage to figure out who fits nicely
into these buckets. We don't have very good
databases for this. We have some databases. For example, we have
Empower which is an HHS tool that has Medicare beneficiaries
that are electric-dependent. And that only includes
about 2.4 million people, so that's a small amount of
people that we're thinking about when we're thinking
about at-risk populations. So we also talk about
populations as a whole because these numbers are a
little bit easier to enumerate.

We can use databases that
we have such as the census and other surveys to
figure out who fits into specific categories based on socio-demographic
characteristics. And we know that there
are certain populations — these may be referred to
as at-risk populations or vulnerable populations. Some people don't
like those terms. A lot of people do not like to
consider themselves vulnerable. But we do know that
these populations suffer disproportionate
harm in a disaster. So you might be thinking
about children, older adults, racial and ethnic minorities. And this population
approach allows planners to enumerate these
populations based on census data and
other surveys. And we have tools such as the
Social Vulnerability Index which we'll hear Dr. Breysse
talk about in a few minutes. It's also important
to consider that each of these vulnerabilities
I'm talking about are overlapping
and intersecting.

So we cannot think about them
separately, but race, poverty, access to healthcare
for example overlap. And we have to think about
their interrelationship to one another. So now I want to
move into talking about inequities
and emergencies. So we know that there is
unequal access to resources and opportunities
in this country. That is also coupled with
unequal exposure to hazards. For example, low-income and predominantly minority
communities may have less access to resources in terms of
wealth, power or healthcare. Those same populations
may be more prone to a natural disaster
and other threats. So for example, communities
of color are often situated in vulnerable areas as a result of discriminatory
housing practices. This has happened
both historically and is still happening today. Hurricane Katrina cut across
racial and socioeconomic lines. We know it impacted
much of New Orleans.

However, neighborhoods
and people with the most severe damage
were communities of color living in poverty and lacking services and infrastructure
needed to recover. So not only are certain
populations being impacted more during the actual event,
but it's also more difficult for them to cope or to
recover due to a lack of access to resources afterwards. So I want to bring up this map
that shows the intersection of vulnerability and hazard. And I've pulled this from the
National Environmental Public Health Tracking Network which
sits in the National Center for Environmental Health
where Dr. Breysse leads. And I pulled up two maps. One came from the Social
Vulnerability Index, and I pulled up the
poverty score for Georgia.

And you'll see the areas in yellow are areas
of high poverty. And then I pulled up a flooding
map and so these are the areas that are more likely to flood, and the dark orange are those
areas more likely to flood. And you'll see the intersection
between the two areas, so those who have less
resources are also more likely to experience a flooding event. So now I want to talk
about a health-equity lens. As you heard Dr. Liburd
say, that we are starting to apply a health equity lens
to chronic disease management, to disease management. That has been recognized. And now we want to move
to apply the same lens to public health emergency
preparedness response and recovery. And this is to address
disparities to ensure that we're not inadvertently
creating them during our response and our recovery
and our planning activities. And also that we're not
exacerbating them during an emergency. So there's underlying
vulnerabilities and we want to make sure that we're
not exacerbating those. So there's many barriers to address disparities
and vulnerabilities.

I'm just going to
highlight a few, and Dr. Redd had
mentioned some of these. One of these is a
layered disaster. So as I mentioned earlier,
hazards tend to harm segments of the population that were
already disadvantaged before a disaster. There's differential
vulnerability for people where they work, where they
live and where they play. Government mistrust, this
is what Dr. Redd brought up, that there is historical
and current mistrust of the government
and institutions. So if we're using the government
and certain institutions to get out our messaging, they
may not be received because there's not a
trusting relationship there.

Diverse communities often
do not feel respected and they may not have
the political power to garner their necessary
resources. Organizational resilience. There's a lot of
organizations out there that address the day-to-day
needs of at-risk populations. However, these organizations
themselves are often vulnerable. So often these are
nonprofit organizations or nongovernmental
organizations. When these organizations
go through an emergency, they may exhaust their
yearly budget for a response and are not able to
continue to provide services. So we need to make
sure that those who are helping these
populations on a day-to-day basis
are resilient.

And misconceptions. In the past, people
with disabilities for example may have been
perceived as unable to care for themselves, unable to
function in daily activities and unable to make decisions
about their health and welfare. We know this is not true, and
that there's many strengths that we can harness
from these groups. But because of these and
other misconceptions, segments of the population
are marginalized, causing systemic exclusion
from the social environment. So now I want to talk
about a couple of ways to address these barriers and hopefully we'll be hearing
a lot more about these successes as we hear from our
other speakers. Collaboration. So we need to collaborate
across all sectors. So for an example, during a
response, the Portland Bureau of Emergency Management
has social services and emergency management
in the same room. So this allows them
to work together and to build off
their strengths. Engagement. The way we engage
partners in the community, who we engage and how we engage.

So for example, the city of Berkeley ensures their
community emergency response teams or their CERT teams mirror
their community with inclusive and accessible training courses. So they offer it in a
location where those who are disabled can attend, where you can get public
transportation to it. They offer it during times when
working parents can come in. They offer free childcare
to make sure that those who are going to
be responding look like the community
that they're helping.

Representations. We want representation
in our organizations, whether we're talking about
research organizations, our government organizations. So an example is the
Bill Anderson Fund which supports students
from underrepresented groups as they complete graduate
programs related to hazards, disasters and emergency
management. And so these students
receive a fellowship to continue their studies and
are mentored by other experts in this area to help
bring more students from underrepresented
groups into this field. So now I want to flip this lens. I've been talking about
applying a health equity lens.

And there are some of you in
this room who may not work in emergency response, but
the population that you work with for example,
individuals with HIV, are going to be impacted
by an emergency. So have you thought
about a preparedness lens for these populations? I like to say that everybody
is involved in emergencies. And so we're going to
ask these questions later on in the synthesis panel. I just want you to plant a seed
to be thinking about these. If you're working with
a specific population — so if you work day-to-day in
chronic disease for example, have you considered how
your population is impacted in an emergency? And while you're working to
improve their day-to-day, are you working to
improve how they will cope with an emergency? And for those of you
who have been working in the health disparities field,
how can you take your successes and help us apply it to emergency preparedness
and response? So in summary, there's
many social, economic and health disparities at
the root of vulnerability that persist during
an emergency.

We need to address the
needs of at-risk populations in emergencies which includes
improving their day-to-day life. So can we address our social
determinants of health and harness the strength
of these groups? So for example, we
know that a lot of minority groups have
very close-knit societies. How can we take advantage
of that and use it in emergency response? So I want you to think about
how we can apply a health equity lens to address gaps and
identify individuals and groups who need additional support. And likewise, how can you
apply a preparedness lens to all health policies
and practices to help build resilience
among those most at risk? So I thank you. I think we're going
to hold questions until after Dr.

presentation. Thank you. [ Applause ] >> Thank you, Dr. Walken. Our next presenter is
Dr. Patrick Breysse. Dr. Breysse is currently the
director of the National Center for Environmental
Health and the Agency for Toxic Substances
and Disease Registry. He came to CDC December of 2014 as the director of
NCEH and ATSDR. Dr. Breysse leads CDC's efforts
to investigate the relationship between environmental
factors and health. Dr. Breysse came to CDC from Johns Hopkins
University Bloomberg School of Public Health where he was
on faculty for nearly 30 years. His primary appointment
was in the department of environmental health
sciences with joint appointments in the school of
engineering and medicine.

He held leadership positions
in numerous research centers, including the Center
for Childhood Asthma and Urban Environment, the
Education and Research Center and Occupational Safety and
Health, and the Institute for Global Tobacco Control. During his 30 years
at Johns Hopkins, Dr. Breysse established
a longstanding expertise in environmental health
as well as a strong record as a leader in the field. Dr. Breysse collaborated
on complex health and exposure studies around
the world, including studies in Peru, Nepal, Mongolia,
Colombia and India. He has published over 225
peer-reviewed journal articles and is a frequent presenter
at scientists' meetings and symposia around the world. Please join me in
welcoming Dr. Breysse. [ Applause ] >> Wonderful. It's great to be
here this morning. So I'd like to talk to you about
the Social Vulnerability Index that Dr. Walken mentioned to you
a few minutes ago and its role in incorporation social
vulnerability factors into disaster management
and planning. Let me begin by introducing
a group within the Agency for Toxic Substance and
Disease Registry called GRASP. GRASP is the Geospatial Research
Analysis Service Program within ASTR. For over 20 years, GRASP
has led the application of geographic methods for public
environment health research, and within the CDC in the broader public
health community at large.

It's a multidisciplinary
group of scientists that provide expertise
and leadership in applying geospatial
information through environmental public
health, emergency management, infectious diseases,
chronic disease and injuries. So it's important
to realize here that we can visualize
a lot of data. GRASP is a very powerful tool as
you'll see for visualizing data. And you've already
seen a bit of that from Dr. Walken's presentation. I'll show you more. But it's also an
important analytical tool. Remember evidence drives
policy, evidence drives change. And the ability to
look at things in a geographic setting
analytically is crucial for this.

I'll step back for a minute
and just talk a little bit about the background
and the rationale for the Social Vulnerability
Index. When it comes to
social vulnerability, there are multiple
dimensions to vulnerability. There's a physical
vulnerability, so you can be vulnerable because
of where you live in terms of whether you're on a
flood plain, whether you're in an old building, whether
you're near a volcano or on an earthquake fault. There are also health
vulnerabilities that exist. You can be vulnerable because
of some preexisting health condition you might have. But the focus of
this talk is really about the social vulnerability. You can also be vulnerable,
as you heard, because of the social construct
in which you live in terms of the transportation you have, the socioeconomic
status you have. Many of those have already
been touched on today. So all communities exhibit
varying degrees of vulnerability to potential disasters, both
natural and manmade disasters. However, it's a community's
social vulnerabilities that in many ways determine how
well it responds to, recovers and interacts with a disaster. So the social vulnerability
refers to the demographic and socioeconomic factors that
affect resiliency of communities in order to manage these tasks.

Studies have shown that socially
vulnerable individuals are often less prepared for a disaster
event, less likely to recover from it, more likely
to be injured or die. Therefore, effectively
addressing social vulnerability to disease decreased
human suffering and reduces post-disaster cost. This is the task that the GRASP
Social Involvement Index took on for itself. So I don't want to go into
a lot of the nuts and bolts, but I think it's important to understand this is a
very quantitative tool. And so what you see on the
right-hand side are a series of social vulnerability
factors that we can collect from a variety of databases.

And these 15 variables
can be further grouped into four major themes which
you see in the middle box. So these are things that deal
with the socioeconomic status, household composition,
disability, minority status and language, housing
and transportation. So these are the main
domains we can use to assess vulnerability
more broadly. We can quantify all the
factors on the right-hand side and we come up with scores. When you come up with
scores, you can begin to be more analytical in how
you address these issues. For example, you can see on the right-hand side there
are many characteristics that go hand-in-hand
in a single event.

So to be able to quantify how
these go along hand-in-hand is important. During the recent campfire
incidents of California, many residents who were in
mobile homes were older, so we have interaction
between more than one of these social vulnerability
domains. When these factors
combine with low income, we can see how there's a lot of intersection among these
domains in a single hazard. So looking at how they
play a role by themselves and also looking
at how they combine to create an overall
vulnerability is important. So what I'd like to do
is give you some examples of how this looks
and how this works and how we can be quantitative
about it and how we can begin to use it to make decisions
about public health.

So here we see a series of maps. Now I'm a guy who loves maps and
when we used to travel as kids, you know, I used to
sit there with the map in my lap following us as
we drove down the road. Unfortunately, kids don't have
that experience these days because nobody looks
at a map anymore. You just turn on your phone,
it tells you where to turn. But there's a lot of important
information in geography and how things relate
to where you are. We've known for years that
there are many relationships that change over time,
but we also know now that there's relationships
that change over space.

And to be able to
incorporate that understanding into decision-making is really
what GRASP is all about. It's what this Social
Vulnerability Index is all about and it's what we need
to be more aggressive at pursuing in our
public health. So if we look at the
right-hand side of this graph, you can see the four
themes are mapped. And it's a little hard to
maybe read, maybe, perhaps. But on the upper left
is socioeconomic status. The upper right is
household composition. The lower left is race,
ethnicity, language. And the lower right is
housing and transportation.

So just to orient
yourself, as you can imagine, the darker color indicates
a greater vulnerability. So already we can piece together
some components of what it means to be vulnerable by looking at where these vulnerabilities
exist. And these maps are produced
at the census track level. And so we can see that
there's a lot of heterogeneity in the vulnerability across
these four different domains. Now if we combine
them all together into an overall social
vulnerability index, we see on the left-hand side
that we can look at kind of how they all come together. Recognizing however
it's important that areas can have a low
vulnerability in terms of one factor, and
high vulnerability in terms of another factor. While it's important to look at the overall vulnerability
it's also important to understand what
the components are that drive that as well. Because you could be vulnerable
with respect to one factor and not the other factor. That might drive what
you do, what you think and how you analyze your work.

So for example, the
dark areas in housing and transportation are areas where additional evacuation
resources need to be employed. So if you're vulnerable
in terms of transportation and you're told to evacuate,
that's going to be a problem. So you know that
already just in terms of planning purposes you need
to make sure there's resources in order to get transportation
resources to those areas right away. We can also note
the darker areas with socioeconomic
status are areas where additional shelter
resources might be needed because people with lower
socioeconomic status might not be able to secure
additional housing. They might have access
to friends and relatives that live somewhere else. They might not have
the resources to go to a hotel and so forth. So these are some examples of
how we can look at these data. Now there's an important
document that I'd like to point out to you, and this is the
document you see on the right, Planning for an Emergency:
Strategies for Identifying and Engaging At-Risk Groups.

This is a document the Center for Environmental Health
Studies branch wrote with significant input
from the SVI team. It includes a substantial
section on how to use the SVI. So while I can't go through
it in a lot of detail today, we could talk for hours and
have a whole symposium on SVI. I think this is an important
resource for those of you in the audience who are
interested in more data. So the SVI database can
be used to identify areas of social vulnerability,
target interventions. It can facilitate decision
making, it can be combined with other data sources to prioritize resources
going forward. It's population based,
so you can target where the need is greatest. And it has other
contextual information that can help you
understand a little bit about a community's resilience
overall which can lead to planning purposes
or resilience as you know is a community's
ability to prepare, plan for and absorb, recover from and more successfully
adapt to adverse events.

And we know that building
resilience starts before disaster strikes. So while we clearly see the
value in this information in the heat of a disaster
response, the real value of this is in order to target
resources before the disasters hit so that we mitigate the
effects that might be caused by these vulnerabilities. So let's talk about
a couple of examples. So here we see a
variety of maps. These are bivariate
coloropleth maps. And what that means is
they're two different colors, and when you combine the map
overlays, the combination of colors creates a different
pigment that allows you to kind of look at where
those two overlap. And so this has two
sets of maps, so the upper right is
the FEMA impact rank and the lower right is the
SVI rank during Hurricane Sam.

So the FEMA impact
rank is based on surge, wind and precipitation impacts. These are used to assess the
impacts for each county based on the impact of the storm. The bottom right shows the
social vulnerability index. Again, where the darker
blue indicating areas of higher vulnerability,
the darker colors in the FEMA impact also
indicates greater vulnerability. Now on the left-hand side,
if you put the two together, you can see where the two
vulnerabilities map together. The dark purple color indicates where high vulnerability
is overlapping with high impact
from Hurricane Sandy. This is a combination
that as we all recall had devastating impacts. Now it's important
to look at the maps and see how it plays
out visually. But as I said before, it
can also be quantitative. And a spatial cluster
analysis revealed that there was significant
relationship between the FEMA
impact rank and the SVI.

Indicates there's a very
quantitative relationship between the two. So this gives us strength
in thinking that the SVI is in fact a good tool
going forward. Now if we look at
a different impact, we look at Hurricane Harvey. We can see that during Hurricane
Harvey the SVI web page received over 22,000 hits in the
two weeks before Hurricane Harvey online. So this is obviously a tool
that's being used a lot.

And these are some
data generated not by us but by Harris County. And so similar to
what I did before, the maps on the right-hand
side show the four domains, and the map on the left-hand
side shows the overall vulnerability index. You can see that there
are many vulnerabilities that overlap going forward. The darkest areas
on the left map — there are isolated areas as
we've talked about before, particularly in the dark blue
spot in the northwest borders of this county, or the
high housing vulnerability. And lower scores in most
of the other things. So that doesn't mean
we ignore those areas, but we have to focus on those
areas where it's most important. So more importantly, this Harris
County used these data to look at mortality and morbidity. I don't have these data.

The state of Texas
has these data. But they found for example that
approximately half the deaths that were in census
tracks with an SVI in the highest quartile mean that with SVI we can
expect more mortality. They saw a similar result
in terms of morbidity. So going forward we
can also see not just where there's the greatest
impact, but also it leads to health disparities as well. Now this is an example that's
probably closer to home. This is in Georgia and it looks at heat-related morbidity
and mortality. So similar to what we saw
in some of the other storms, we can look at the overlay between on the left-hand
side evening visits, on the right-hand
side mortality. And we can look at areas
where there's high morbidity and mortality, areas where there's high
social vulnerability. If we get to the bottom
line of this graph, we can see that with
every 10% increase in SVI, the rate of heat-related
ED visits increase by 20%. So again, the ability
to be quantitative about this relationship is key. For every 10% increase
in overall SVI, the heat mortality
rate increased by 30%.

So heat events are going
to be with us now — they're going to be a
regular part of our life. And so planning for these,
using these data to identify where the morbidity exists,
where the mortality exists. And how it relates to vulnerabilities
tells you what you need to do to intervene. So this is crucial for
public health moving forward. Now there's many partners
who work with ATSGR in using these data, and we list
some of them on this slide here. We don't have time to go
through all the different roles, but the social vulnerability
index has a big following across the public
health community. So in conclusion, disasters and emergencies are an
everyday part of the world.

In many cases what we used to consider a rare event
is now a more common event. So extreme heat events,
wildfires now are things that we deal with every year. Historically, these
events were rare, but now they're more common
and they're more complex. This makes the SVI tool
even more important. Every part of the nation and
the world is constantly being affected by these events. For more information, please
visit the SVI website, interactive maps,

To see more examples of how
this is being used, you can look at some of the publications
listed on that website. Lastly, I'd just like to thank
the people who are responsible for developing the index. You see them listed here, so Andy Dent is the director
of the GRASP program. Erica Adams, Elaine
Halsy, Bert Flanagan and Greta Wells are all
important contributor to the GRASP program. So with that I think we can
move to questions and answers.

[ Applause ] >> Thank you, Dr. Breysse. So for questions
we have the mics in the middle aisle
there on opposite ends. And then if we want to
open questions to IPTV. So the floor is open for
questions for Dr. Walken and Dr. Breysse at this time. >> Thank you for those really
fantastic presentations. So a question about the SVI,
how often is it updated? Is it a continual updating
because things change, gentrification happens? How often do you
keep that current? >> Yeah. So the SVI is
produced with databases for years 2000, 2010,
2014, 2016. And so it relies on the
census and other data. We're looking at producing a
2018 database once those data are available going forward. So as the census data
becomes available, we will revise the SVI
index going forward.

So currently it's the
most recent data are based on the 2016 data. Everybody's always
shy in the morning. Somebody's moving down. If those of you who don't
have microphones at your desk, you can step to the
microphone in the aisles. >> Sorry, it took me a while
to lumber down the stairs. This is a question
for the first speaker. I noticed that you mentioned
that you do have a focus to some degree on the
resilience of responders. I was wondering if you could
elaborate a little bit more on that and what you
do around that area. >> Yeah. In the Center for
Preparedness and Response, so not out of my
group, out of DEO — I don't know if any of
them are here today. Yeah, I do see some of them. There is a big focus on
responder resilience. We want to make sure that we are
thinking about our responders, that they're going out the
door as capable as they are and have the proper training
and that we supply support to them during a response.

And through NIALS and the
ERN system, there's ways to register responders and
then track them and follow them so that you can watch
their resilience. And then it's an important piece when they come back home
too for them as well. So recognizing that
they're going through a traumatic event
potentially as well. And that event could be
reengaging some previous trauma that they've had also, so it's
very important to think about. >> I'm sorry, I think
I misunderstood and thought you were talking
about those out in the states. >> Yeah. >> Okay. Like state-based
public health. But to that end I
also wanted to then — I'm sorry, that wasn't
a setup question. I also wanted to
put a plug in for — I just became the team lead of the resilience
program that's associated with our occupational
health clinic. And I will have to say that
before I knew about the job, I didn't know they
existed and I think that that's probably very
prevalent across the agency. So we're working on
trying to improve that.

But I was also curious what
others in the states do and I'm sorry, I think I thought that was what you
were referencing. But this is an opportunity
to let CDC folks know that there is a dedicated
resilience program that's based in the occupational
health clinic. >> Yeah. I'd love
the opportunity to hear more about that later. Thanks. >> Good morning. Great presentations. Thank you. I wonder if the vulnerability
index includes populations like those that are incarcerated
and those that are undocumented. Because we know they're
around, and how do you account for those populations? >> Well, I think the
undocumented populations are a challenge because
there's not a lot of data on them by definition. But there are opportunities where there's not natural
based data for a state to include special factors
about vulnerability. And so if a state was
willing to incorporate data where they have it available,
they could certainly do that.

And with respect to the
incarcerated populations, I believe it's everybody,
but I don't know for sure. But that would be an
important group to consider. >> Thanks. [ Inaudible ] >> Thank you. >> I'm going to try again here. Can you give us some examples of where states have used the
SVI database in preparedness and how has that helped
the state level response, or national response? >> Yeah, so the Harris
County example's I think a perfect example. Where they looked very carefully
during the 2017 hurricane season where the damage was, where
the vulnerabilities were, where the morbidity was,
where the mortality was. And they were able to focus
resources aggressively in those areas where they think
they needed them more strongly. So I think that's
a good example.

And if you want to
refer to the website, I think you can see more
examples of how states do it. There was a comment up front. >> Yes. Hi. Good morning. Excellent presentation. I want to share with you my
experience in Puerto Rico. We reached the community leaders of the federal population
groups, and we found there more
information that we can do it by assessment by people that go and interview members
of that community. Because the community leaders
know the needs of the community, knows the person that really
is [inaudible] and helps us to figure out how we are going to address the problems
of the community. Because the problems of the community are
different [inaudible]. The problem that is in one
community is not the same in the other community. It could be a water source,
it could be accessibility to healthcare, you name it. So I think that maybe in the
future we have to involve more of the community leaders
in this type of interval, because we can get more
fresh and real-time data about the real situation of
those communities and the people who are more vulnerable.

>> Thank you. I think that's well taken. In fact, this data
was meant to be used by local public health
officials to drive the response and to work on preparedness
activities. >> I just want to
comment on that. We do say all disasters are
local, because we recognize that these are national systems
that gives us a starting point. But we have a research
project right now which is actually
piloted in Puerto Rico to collect information
from local leaders. And so at the end of this
research project there will be an app that local leaders can
use to help find out how to get that local information from
your community leaders, whether they're lay
leaders, elected officials.

Because we know that is the best
information that you can get and should be used
to drive response. So thank you for
mentioning that. >> Great presentations. My question is with the SVI, has
there been any effort to partner with say for example local
non-governmental organizations as a way to give aid? So using SVI as a way to
kind of promote aid — because I know there was I
think almost $1 billion given for the Houston hurricane and people were saying
they weren't sure where to I guess put the aid. >> Yeah. I think there's
lots of examples with that. So they worked with
the Catholic charities, they work with a group
called Direct Relief to create an interactive
map identifying vulnerable populations during the
Houston hurricane response.

They even worked with a
legal services corporation to provide legal services to disadvantaged
populations as well. So I think there's
a host of examples where there's nonprofits that
can use this information as well to help guide their efforts. [ Inaudible ] >> So that's a great question. Certainly it is one of
the at-risk populations that we need to consider. Not only do they have
a lack of resources, but they're often marginalized. They don't have the political
power to garner resources. There can be language
barriers, and we call them — some people call them
hard to reach populations, but we need to make more effort
and we also need to make sure that there's policies in place that people can access the
resources we're giving. A lot of times that's an issue. For example in California during
the drought, they were giving out water, but undocumented
people didn't want to come get the water, afraid
about other repercussions.

So it's really important. And when we're putting out
recommendations and policies, making sure that
everyone has access to them including our
immigrant population. So no easy solution,
but definitely on the minds of everyone. >> Keep in mind that
SVI is a tool, right? And it's designed to incorporate
data where those data exist in a platform that can be
useful for policymakers, private citizens, nonprofits
to address these issues. And so as a broader societal
issue, we need to kind of think about how do we gain access to
data on immigrant populations? And if those data
become available, it would be relatively
straightforward to incorporate that into the SVI tool.

>> Okay, one final question. Go ahead. >> Yeah, thanks. It's not really a
question, more a comment. Thank you for the
great presentations and all the great work
with the SVI and so on. I just wanted to comment
on a couple things that have already been said
as far as SVI being used by this state, for
instance in Texas.

They were concerned
about immigrants and undocumented people
and so even though the data as Dr. Breysse said is
difficult to really get and incorporate completely,
there are local organizations who already work
with these groups and who try to reach
out to them. And so when we were in
Texas we were able to meet with those groups and they
were able to use an SVI map to also sort of incorporate where they knew these
people worked and lived. And so it's useful in that case. Another point I think that Dr.
Walken was making was that all of these organizations — it's
not just up to public health, it's not just up to emergency
management, but we realize now after Texas and Puerto Rico and
USVI and these other things, that there's a whole broad range
of sectors as Dr.

Walken said who didn't know that they were
involved in emergency response and recovery until these really
large-scale events took place. And all of the sudden we
realize that we have Department of Housing and Department
of Aging and these other organizations who weren't ready
to do this really. But that their role
is so important because they're the ones
who are protecting a lot of these populations
before an event takes place. So that's an important I think
lesson that we've learned, particularly in the 2017 year. And just lastly, I think when the question is how
do we reach these people, the other thing we need to
learn is where are these folks and how are they
getting information? So in Texas for instance,
some of these folks, the day laborers collected in
a certain place in the morning. That's where they
were and that's where they needed to be reached.

Other folks say in some
communities it's in churches. In Texas we found out that there
was a large Vietnamese group, fisherman, coastal folks,
who were not going to come to the disaster resource
centers. And so we found out
where they were and tried to get the appropriate
people to go and address the community
leaders there. So I mean, it's all
interconnected but I thank you for the presentations that I
think will set a good stage for the rest of the morning. Thank you. >> Okay, thank you. Again, I want to thank
Dr. Walken and Dr. Breysse for very important
presentations. [ Applause ].



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