[Editor’s note: This week on the blog, we are highlighting some key takeaways from a recent learning collaborative offered by Migrant Clinicians Network, National Association of Community Health Centers, Harvard’s Center for Climate, Health and the Global Environment, and Americares. Here, in this reprint from the summer issue of Streamline, we start with clinician experiences, and MCN’s approach to the first 48 hours. For more on this topic, check out last week’s blog post, Can Health Centers Affect Climate Change? A Review of the Landscape, and Call to Action. Stay tuned for tomorrow’s blog, where we cover the ripple effects of high heat.
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Climate change is impacting health care provision – and community health centers are taking note. At the recent Patient-Centered Climate Resilience Learning Collaborative, offered by Migrant Clinicians Network, Harvard T.H. Chan School of Public Health’s C-Change, Americares, and the National Association of Community Health Centers, clinical and administrative teams from across the United States and Puerto Rico spoke of facing droughts, tornados, wildfires, heat, hurricanes, and other climate-fueled disasters. These challenges are of course on top of their pre-existing stressors, from serving new migrant populations, to lacking sufficient staff, to the pandemic, to patients’ uncontrolled chronic illnesses, to social determinants of health. As health centers grapple with disaster upon disaster, some are seeking new organizational pathways to better prepare. In this article, we review some of the concerns that were recurrent among participants, plus promising approaches and numerous resources to help health centers begin to manage the challenging, and often deadly, effects of the climate crisis in their own communities.
 

Shared Experience: Climate Crisis Across the Country

The type of disasters that communities were experiencing varied according to geography, with West Coast wildfires and drought in contrast with East Coast hurricanes and flooding, among other disasters. Yet, despite their differences, many health centers encountered similar constraints to providing care during and after a disaster.

Infrastructure – both at the community level and within the health center – was regularly noted to be unstable during disasters, which reduced staff ability to serve patients. “With the extremes of weather… the infrastructure of the community breaks down,” noted one participant from Oregon. When roads close or public transportation shuts down, patients are unable to reach the clinic – and, often, staff are not able to, either. Clinics may be cut off from supplies, additionally impacting care. One participant noted that their valley location can easily be isolated by wildfires when the main road is closed; another in Hawaii relies entirely on airplanes for supplies and staff, which are grounded in poor weather. In such situations, some staff choose to leave the clinic walls, providing urgent care in the community directly, yet there are funding limitations to direct community care, since such services may not be eligible for reimbursement despite a disaster, and may be felt more acutely if the clinic’s revenue is already impacted due to closure.

Staffing is a perennial concern at health centers. During a disaster, many – or all – staff members may be personally affected, needing time to take care of emergency needs for themselves and their families, including evacuation. After the exodus of many health professionals from their professions during the COVID-19 pandemic, some health centers continue to be unable to hire enough people to be fully staffed. Turnover – which reduces staff knowledge and cohesion when a disaster plan needs to be implemented – further degrades emergency response. Meghan Peck, Emergency Management Specialist for the Community Health Center Association of Connecticut noted that emergency plans are dependent on a full staff: “We have a roadmap – but do we have the bodies to fill it?”

The indirect effects of disaster may spread over wide geographic areas. Clinics in the San Francisco Bay Area were hundreds of miles away from the dangerous paths of recent California wildfires, but the extremely thick smoke – visually evident in the orange skies and falling ash -- heavily affected Bay Area residents. Within health centers, HVAC systems struggled to consistently keep air clean, while brown outs and black outs threatened consistent electrical supply. Communities and their health centers were exposed to hazardous conditions for many weeks, causing a health emergency, even if the communities were not at direct risk from fire. In Connecticut, Peck’s community saw an influx of Puerto Rican refugees in the months after Hurricane Maria. “Because of staffing issues, our concern at this point is, if we were to have that again – say, this summer, a hurricane hits the Atlantic basin – do we have the appropriate resources and staffing levels” to care for an increase in patient population, of people fleeing a disaster?
 

The First 48 Hours: Community & Health Center Preparation

Marysel Pagán Santana, DrPH, directs Migrant Clinicians Network’s Puerto Rico office, and the multitude of community mobilization projects aimed at equipping health centers and their communities ahead of climate disasters. In Puerto Rico, numerous devastating hurricanes, coupled with an economic crisis, a set of deadly earthquakes, and the COVID-19 pandemic, drastically impacted Puerto Ricans’ health. MCN’s efforts on the Island seek to empower communities to care for themselves when a disaster occurs, partnering closely with the health center, and keeping those most likely to be negatively impacted – like people with chronic illnesses, very remote residents, or people experiencing overlapping social determinants of health – at the forefront. While community mobilization planning happens primarily at the community level, community health centers play a critical role, Dr. Pagán Santana says. Additionally, those health centers can greatly benefit from a mobilized and organized community.

For example, during Hurricane Maria, Dr. Pagán Santana noted, Hospital General Castañer, a rural health center in a mountainous area in central Puerto Rico, suddenly became the disaster hub. With the community’s only helipad, the health center became the sole source of clean water and supplies that were flown in. It also acted as the de facto headquarters of local agencies coordinating response, like the health department and FEMA. Of course, many members of the community gathered at the health center for supplies, which removed some staff focus from the health center’s core tasks of caring for the emergency health needs of community members, to coordinating and organizing crowds and supplies. “They suddenly needed to be the one to distribute supplies in the community, but how do you plan to do that if you don’t know what the community needs are? How do you communicate what you’re going to do, and have the trust that you’re going to get to the community’s needs, without them coming to the health center?” These are the questions that a community mobilization plan would outline, to ensure that a community’s needs are understood – before the disaster requires supplies to be distributed. Critically, says Dr. Pagán Santana, the enactment of such a plan would have an important side benefit: the rush of community members to the health center for non-medical reasons would not occur, because the community would be aware of the health center’s emergency protocols and communication would continue despite the emergency.

“Communication and transparency are really important for people to stay calm” during an emergency, she said, so health centers must build these communication strategies ahead of time. “You must integrate the communication plan into the health center’s operations, but also the health center needs to let the community know exactly what their plan is. That communication of the plan is key for community leaders to then deliver that message to the community.” Participation in the community’s mobilization plan also builds the trust necessary for people to know the health center will enact the strategies they have outlined, should a disaster hit. “If in an emergency scenario, the community begins to enact its plan in the first 48 hours, that gives you at the community health center time to assess what you need, how you’re going to do the deployment of aid, how to staff the emergency, how to prioritize among patients. But if the community is unprepared, you’ll have this influx all at once. The capacity to have health care operations continue, and being able to direct and deploy your resources and staff effectively can come a long way if you have a community that knows what to do for the first 48 hours.” 

Resources:

• MCN’s Climate Justice page (Available in English and Spanish): https://www.migrantclinician.org/climate-justice
   
• Heat-Related Illness Clinician’s Guide (Available in English and Spanish): https://www.migrantclinician.org/resource/heat-related-illness-clinicians-guide-june-2021.html
   
• Environmental Education [Videos, Resources and Curriculum] (Available in English and Spanish): https://www.migrantclinician.org/explore-environmental-justice-and-worker-health/environmental-education.html
   
• Heat-Related Illness and Farmworkers - Training Curriculum and Facilitator Guide (Available in English and Spanish): https://www.migrantclinician.org/resource/heat-related-illness-and-farmworkers-training-curriculum-and-facilitator-guide.html
   
• “Deepening the Divide: Health Inequities and Climate Change among Farmworkers,” written by MCN’s Marysel Pagán Santana, Amy Liebman, and Claire Seda and published by the Journal of Agromedicine: https://doi.org/10.1080/1059924X.2022.2148034