How Healthy Is America’s Public Health Infrastructure?
By Jeff Turrentine
From day to day, our public health infrastructure — the people and systems we've put in place to keep populations, as opposed to individuals, healthy — largely goes unnoticed. That's because when it's working well, its success takes the form of utter normalcy.
Never mind that a vast number of people from a wide variety of fields — science, medicine, law, engineering, education, advocacy, and public policy — must work tirelessly (and often thanklessly) to grace our everyday lives with that blissful sense of normalcy. If you pour and drink a glass of tap water, head outside to take in some fresh air, then come home and prepare dinner, you can thank a public health worker for making every step of that routine healthier.
But there are times when we suddenly become very aware of just how well our public health systems are, or aren't, working. Today, in the midst of a pandemic, we're living through one of these moments. Our public health infrastructure is being tested. And as the COVID-19 crisis continues to intensify, it has become glaringly apparent in most parts of the country that this infrastructure is underfunded and overstressed.
A Washington Post article from two weeks ago, written before "social distancing" became part of our lingua franca, explored some of the reasons why. Because public health infrastructure targets the entire populace, the article observed, its mission "has been consistently overlooked in a country that puts a premium — and spends more money per capita than any other — on treating individual sick people. Its victories are soon taken for granted." The author cites figures from a 2019 paper published in the American Journal of Public Health showing that our country's investment in public health is currently $19 per person annually. According to experts in the field, that's $13 less than what it should be.
Meanwhile, we Americans spend, on average, almost $11,000 per person annually on treatments for the various diseases and conditions that routinely befall us. When people complain about the oppressive costs of health care, it's this back-end spending that they're talking about. But guess what? The country could lower these costs significantly by making smarter investments at the front end — i.e., spending more to protect the health of the public as a whole.
"There's a real need for people to see how the public health agenda directly protects everyone's well-being by addressing the root causes of disease and early death," said Vijay Limaye, an environmental health scientist at NRDC's Science Center. Investments in public health also help to make individuals more resilient. As an example, Limaye noted that "our country's progress on cleaning up air pollution has sharply reduced the burden of disease, including heart and lung conditions that put certain people at higher risk of severe illness from the coronavirus."
And right now, as local and state officials struggle to persuade some in their communities to heed the warnings against gathering in groups, another aspect of our public health infrastructure has risen in importance: communication. Few Americans knew what "flatten the curve" or "social distancing" meant three weeks ago. But thanks to creative, relentless messaging and the power of the internet and social media, Limaye said, "we're able to get the word out about the urgent need to slow down the rate of infections and better equip our health-care professionals on the front lines."
Though President Trump and some state officials have expressed impatience with social distancing measures that have closed businesses and caused unemployment to soar, there's little question that these are effective strategies for slowing transmission rates. Kinsa, a health technology company that makes digital thermometers and tabulates data on its customers' readings and reported symptoms, said the number of people exhibiting flulike symptoms such as fever began dropping precipitously and immediately after social distancing rules went into effect in places like New York City and Northern California. The same data set also reveals that incidences of flulike illness increased in cities and regions that were late in taking action, such as South Florida.
In the gap between those two trajectories, we see the difference between a robust, nimble public health response and an ill-prepared or hesitant one. And when you compare nations, the importance of early and accurate data collection — combined with powerful, consistent messaging — becomes even more apparent. South Korea was hit hard by the coronavirus in late February and early March, at one point reporting almost 1,000 new cases in a single 24-hour period. But thanks to a national strategy that has emphasized testing, social distancing, self-isolation, and GPS- and cell-phone-aided tracking and communication, this country of almost 52 million people reported only 64 new cases on Monday.
That's how public health infrastructure is supposed to work in the midst of a pandemic. "Other countries like South Korea are miles ahead of the United States on early and aggressive disease tracking and targeted health-risk communication, using things like location-based phone applications," Limaye said. "It's time that we harness 21st-century tools to better protect our citizens. In the year 2020, the public demands timely, transparent, and trusted information. There's simply no excuse for delays or deficiencies in reporting testing and health data."
But that, of course, would require a much greater investment than what America is currently making. In the 2019 paper on public health spending mentioned above, the authors recommended creating a $4.5 billion public health infrastructure fund that could generate new, permanent resources for state and local governments across the country. That probably sounded like a lot of money to any legislators who bothered to read the report when it came out. But now lawmakers are hashing out the final details of a $2 trillion relief package designed to save an economy that's been ravaged by the rapid spread of a dangerous communicable disease.
Let's hope it helps. And let's hope that all of us come to understand the importance of social distancing, hand washing, and other strategies for combating the spread of the coronavirus — strategies brought to you by the highly informed, highly dedicated public health professionals who are always looking out for us, 24/7, whether we're struggling through a pandemic or just going about our day.
Reposted with permission from onEarth.
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Kevin T. Smiley
When hurricanes and other extreme storms unleash downpours like Tropical Storm Beta has been doing in the South, the floodwater doesn't always stay within the government's flood risk zones.
New research suggests that nearly twice as many properties are at risk from a 100-year flood today than the Federal Emergency Management Agency's flood maps indicate.
Flooding Outside the Zones<p>About <a href="https://furmancenter.org/files/Floodplain_PopulationBrief_12DEC2017.pdf" target="_blank">15 million</a> Americans live in FEMA's current 100-year flood zones. The designation warns them that their properties face a 1% risk of flooding in any given year. They must obtain flood insurance if they want a federally ensured loan – insurance that helps them recover from flooding.</p><p>In Greater Houston, however, <a href="https://doi.org/10.1111/j.1539-6924.2012.01840.x" target="_blank">47% of claims</a> made to FEMA across three decades before Hurricane Harvey were outside of the 100-year flood zones. Harris County, recognizing that FEMA flood maps don't capture the full risk, now <a href="https://www.hcfcd.org/floodinsurance" target="_blank" rel="noopener noreferrer">recommends that every household</a> in Houston and the rest of the county have flood insurance.</p><p>New risk models point to a similar conclusion: Flood risk in these areas outstrips expectations in the current FEMA flood maps.</p><p>One of those models, from the <a href="https://firststreet.org/flood-lab/research/2020-national-flood-risk-assessment-highlights/" target="_blank">First Street Foundation</a>, estimates that the number of properties at risk in a 100-year storm is 1.7 times higher than the FEMA maps suggest. Other <a href="https://doi.org/10.1088/1748-9326/aaac65" target="_blank" rel="noopener noreferrer">researchers</a> find an even higher margin, with 2.6 to 3.1 times more people exposed to serious flooding in a 100-year storm than FEMA estimates.</p>
What FEMA’s Flood Maps Miss<p>Understanding why areas outside the 100-year flood zones are flooding more often than the FEMA maps suggest involves larger social and environmental issues. Three reasons stand out.</p><p>First, some places rely on relatively old FEMA maps that don't account for recent urbanization.</p><p>Urbanization matters because impervious surfaces – think pavement and buildings – are not effective sponges like natural landscapes can be. Moreover, the process for updating floodplain maps is locally variable and can take years to complete. Famously, New York City was updating its maps when Hurricane Sandy hit in 2012 but hadn't finished, meaning flood maps in effect <a href="https://projects.propublica.org/nyc-flood/" target="_blank">were from 1983</a>. FEMA is required to assess whether updates are needed every five years, but the <a href="https://www.fema.gov/cis/nation.html" target="_blank" rel="noopener noreferrer">majority of maps</a> <a href="https://www.oig.dhs.gov/sites/default/files/assets/2017/OIG-17-110-Sep17.pdf" target="_blank" rel="noopener noreferrer">are older</a>.</p><p>Second, binary thinking can lead people to an underaccounting of risk, and that can mean communities fail to take steps that could protect a neighborhood from flooding. The logic goes: if I'm not in the 100-year floodplain, then I'm not at risk. Risk perception <a href="https://doi.org/10.1088/1748-9326/ab195a" target="_blank" rel="noopener noreferrer">research</a> backs this up. FEMA-delineated flood zones are the major factor shaping flood mitigation behaviors.</p><p>Third, the era of climate change scuttles conventional assumptions.</p><p>As the planet warms, extreme storms are becoming <a href="https://nca2018.globalchange.gov/" target="_blank">more common and severe</a>. If greenhouse gas emissions continue to increase at a high rate, computer models suggest that the chances of a severe storm dropping 20 inches of rain on Texas in any given year will increase from about 1% at the end of the last century to 18% at the end of this one, a chance of <a href="https://doi.org/10.1073/pnas.1716222114" target="_blank" rel="noopener noreferrer">once every 5.5 years</a>. So far, <a href="https://www.rstreet.org/wp-content/uploads/2020/02/195.pdf" target="_blank" rel="noopener noreferrer">FEMA hasn't taken into account the impact climate change is having</a> on extreme weather and sea level rise.</p>
Racial Disparities in Flooding Outside the Zones<p>So, who is at risk?</p><p>Years of research and evidence from storms have highlighted social inequalities in areas with a high risk of flooding. But most local governments have less understanding of the social and demographic composition of communities that experience flood impacts outside of flood zones.</p><p>In analyzing the damage from Hurricane Harvey in the Houston area, I found that <a href="https://doi.org/10.1088/1748-9326/aba0fe" target="_blank">Black and Hispanic residents disproportionately experienced flooding</a> in areas beyond FEMA's 100-year flood zones.</p><p>With the majority of flooding from Hurricane Harvey occurring outside of 100-year flood zones, this meant that the overall impact of Harvey was racially unequal too.</p><p>Research into where flooding occurs in Baltimore, Chicago and Phoenix points to some of the potential causes. <a href="https://www.nap.edu/read/25381/chapter/4#16" target="_blank" rel="noopener noreferrer">In Baltimore and Chicago</a>, for example, aging storm and sewer infrastructure, poor construction and insufficient efforts to mitigate flooding are part of the flooding problem in some predominantly Black neighborhoods.</p>
What Can Be Done About It<p>Better accounting for those three reasons could substantively improve risk assessments and help cities prioritize infrastructure improvements and flood mitigation projects in these at-risk neighborhoods.</p><p>For example, First Street Foundation's risk maps account for <a href="https://firststreet.org/flood-lab/research/flood-model-methodology_overview/" target="_blank">climate change</a> and present <a href="https://floodfactor.com/" target="_blank" rel="noopener noreferrer">ratings</a> on a scale from 1 to 10. FEMA, which works with communities to update flood maps, is <a href="https://www.fema.gov/media-library-data/1521054297905-ca85d066dddb84c975b165db653c9049/TMAC_2017_Annual_Report_Final508(v8)_03-12-2018.pdf" target="_blank" rel="noopener noreferrer">exploring rating systems</a>. And the National Academies of Sciences, Engineering and Medicine recently <a href="https://www.nationalacademies.org/news/2019/03/new-report-calls-for-different-approaches-to-predict-and-understand-urban-flooding" target="_blank" rel="noopener noreferrer">called for a new generation of flood maps</a> that takes climate change into account.</p><p>Including recent urbanization in those assessments will matter too, especially in fast-growing cities like Houston, where <a href="https://authors.elsevier.com/a/1boBRyDvMFW6W" target="_blank" rel="noopener noreferrer">386 new square miles</a> of impervious surfaces were created in the last 20 years. That's greater than the land area of New York City. New construction in one area can also <a href="https://scalawagmagazine.org/2018/01/city-in-a-swamp-as-houston-booms-its-flood-problems-are-only-getting-worse/" target="_blank" rel="noopener noreferrer">impact older neighborhoods downhill</a> during a flood, as some Houston communities discovered in Hurricane Harvey.</p><p>Improving risk assessments is needed not just to better prepare communities for major flood events, but also to prevent racial inequalities – in housing and beyond – from <a href="https://www.npr.org/2019/03/05/688786177/how-federal-disaster-money-favors-the-rich" target="_blank" rel="noopener noreferrer">growing</a> after the unequal impacts of disasters.</p>
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