2019 State of Health Equity at CDC Forum Part 1

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 I PDV 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 deliver communication and interdisciplinary partnerships I had the pleasure of being part of a small planning committee that put this forum together my sincere appreciation gratitude is extended to each of them for all of their hard efforts and the planning of this year’s 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.Lee dr. Leana sly burn doctor boy yay captain deer on burton julio descent della Pierre Kayla Johnson ma Oh hurry captain Bobby Rossellini uh dr. Ross who’s not here today dr. Aaron Thomas dr. patty Tucker Joe Valentine and dr. Amy Walken so again on behalf of this committee in our office we appreciate your attendance and participation on today’s agenda we’ll have two opening presentations and then to panel discussion consisting of two presenters and a discussion the discuss it will be providing brief reflective comments after the panel presentations and then facilitate a 15-minute Questor 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 and recommendations and to answer any final questions before we begin today’s forum a few housekeeping items if 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 om h h e at cdc.gov we have staff who will be monitoring this for questions on the agenda you also know that we will have one physical break and although it’s a short break we would present you being respectful of the time we turn it back to the room since we want to stay on schedule as much as possible because we have a four agenda if you need to step out before then or afterwards we would ask you do so in between 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’ll 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 om h h e intranet site click on events then click on 2019 c form and the survey link will be at the top of the page there valuation will be available right after the forum ends today and will be open until next Friday February 8th up until 5 o’clock p.m.For you to submit your responses we really value your feedback and your responses will be completely anonymous for those of you interested in cartoon education credits you can look on the screen or note on the back of your agenda the link or 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 you to dr. Lee Andrews library and retinyl dr. red yeah start with a bird [Applause] Thunderbird currently serves as director for the office of minority health and health equity at CDC and Rear Admiral Steven Redd is deputy director for the Public Health Service and implementation science and also serves as director of the center for preparedness or response please welcome them for the opening remarks good morning everyone 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 a community centered health equity framework I think yesterday I was told we had around 270 registrants and it 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 and 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 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 and public health emergencies 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 morning everyone let me welcome everyone to this forum on behalf of dr.Redfield this as we Anders 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 to our to our nation and it’s 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 our overall public health efforts are going to somehow achieve health equity without that deliberate action I think this is the 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 have 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 were we had really done everything that needed to be done I would say that in a health emergency the kind of the 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 a health emergency and there are two barriers that we face and that we need to overcome in in working on in the health equity zone the first is one of trust and the 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 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 there’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 a access to resources so again let me welcome everyone I want to especially welcomed our guests who have traveled from afar dr.Rodriguez from Puerto Rico mr. stripling from New York City and I think we’re I don’t see Dan dodging out there from Washington but I he’s on the agenda so I’m assuming that he’ll be here as well thanks very much our first presenter this morning as he comes forward it’s dr. Amy wolken Dodd Walken is the senior advisor for at-risk populations here at the Center for preparedness and response here at CDC dot wolken 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 experiencing includes vulnerable populations and emergencies health impacts of extreme weather events community health assessments chemical and Radiological terrorism and and tox and toxic epidemiology or to say that word dot Walken has altered more than 75 peer-reviewed articles and book chapters on disaster epidemiology environmental epidemiology and surveillance she received her doctorate public health from the University of North Carolina at Chapel Hill her master’s of science and public health from 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 um Amy Wilkin 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 want to make sure that we’re all in 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 an 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’s certain groups of people that 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 asper and 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 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 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 our restrictions or limitations on an individual that may require assistance before during or after an emergency and often the sea-mist framework is used to determine who these people are and so CMAs 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 in response to information so for an example this may include individuals who are deaf or hard of hearing if they cannot hear the the information that we’re 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 and emergency 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 when you might think about pregnant postpartum 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 maybe have a certain vulnerability that you have today that you don’t have tomorrow independence individuals who function independently as long as they’re not separated from their devices assistive technology or service animals so for an example one 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’s 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’s social reasons that factor in here so this might include persons who are dependent on mass transportation or persons with disability so the CMAs 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 a HHS tool that has Medicare beneficiaries that are electric dependent now that only clues about 2.4 million people so this is a small amount of people that were thinking about when we’re thinking about at-risk populations so we also talked about populations in 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 who might be thinking about children older adults racial and ethnic minorities when this population approach allows planners to enumerate these populations based on census data and other surveys we have tools such as the social vulnerability index which we’ll hear dr.Bryce you talked 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 health care for example overlap and we have to think about they’re in a relationship 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 health care 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 or discriminatory housing practices this has happened both historically and is still happening today Hurricane Katrina cut across racial and socio-economic lines we know and impacted much of New Orleans however neighborhoods and people with the most severe damage where 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 pulled this from the National environmental Public Health tracking network which sits in the National Center for Environmental Health or dr.Bracy 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 the flooding map and so these are the areas that are more likely to flood in the dark orange or 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. library say that we are starting to apply 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 whew and dr.Red had mentioned some of these one of this is a layer 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 by 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 these the government and certain institutions to get out our messaging they may not be received because there’s not a trusting relationship they’re diverse communities often do not feel respected and they do not have 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 are not in governmental organizations when these organizations go through an emergency they may exhaust their yearly budget for a response and 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 and 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 the 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 a 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 our research organizations our governmental organizations so an example is the Bill Anderson fund which has support students from underrepresented groups as a 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’s 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 in and 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 gonna 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 persists during an emergency we need to address the needs of at-risk populations and emergencies which includes improving the 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 an 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 that need additional support and likewise how can you apply 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.Pisces presentation Thank You Nikki dr. Walker welcome our next presenter is dr. Patrick brycie dr. Bracci 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 MCH and ATSDR dr. Rossi leads CDC’s efforts to investigate the relationship between environmental factors and health dr. Bracci came to CDC from John Hopkins University Bloomberg School of Public Health where he was on faculty for nearly 30 years his primary requirement was in the Department of Environmental Health Sciences with joint appointments in the School of Engineering and medicine he held leadership position and numerous research centers including the Center for childhood asthma in urban environment the Education and Research Center and Occupational Safety and Health and the Institute for Global tobacco control during his 30 years at John Hopkins dr. Rossi established a long-standing expertise in environmental health as well as a strong record as a leader in the field dr.Brasi 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 as a frequent presenter as scientists meeting and symposiums around the world please join me in welcoming dr. pricey wonderful it’s great to be here this morning so I’d like to talk to you about the social vulnerability index that dr. wall can mention to you a few minutes ago and its role in incorporating social vulnerability factors into disaster management and planning let me begin by introducing a group within the agency for toxic substances and disease registry called grasped grasp is the geospatial research analysis and service program within HHS Dr for over 20 years grasp has led the application of Geographic methods for public environment Health Research within the pam within the cdc and 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 affections disease chronic diseases and injuries so it’s important to realize here that we can 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 little bit of that from dr.Wilkers 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 now let’s step back for a minute and just talk about a little bit about the background the rationale for the social vulnerability index when it comes to social vulnerability there are multiple multiple dimensions of vulnerability there’s a physical vulnerability so you can be vulnerable because where you live in terms whether you’re on a floodplain whether you’re in an old building whether you’re near a volcano or on a earthquake fault there are also helpful abilities exist you can be voted because some pre-existing health conditions 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 dimensions have already been touched on today so all communities exhibit varying degrees of vulnerability to potential disasters both natural and man-made disasters however its communities social vulnerability that in many ways determine how well it responds to recovers and and interacts with a disaster so the social vulnerability refers to the demographic and socio-economic factors that affect resilience in communities in order to manage these hazards studies have shown that socially vulnerable individuals are often less prepared for disaster event less likely to recover from it more likely to be injured or died therefore effectively addressing social vulnerability disease decreases human suffering and reduces post disaster costs this is the test that the grass Social Development 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 social these 15 variables can be further grouped into four major themes what you see in the middle box so these are things that deal with the social economic status household composition and disability minority status and language housing and transportation so these these major domains or domains that 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 and how you address these issues for example you can see on the right hand side there are many characters to go hand-in-hand in a single event so be able to quantify how these go along hmmm is important during the recent campfire it says California many residents were mold mobile homes that were older so we have interacted pretty more than one of these social mobility domains when these factors combined with low income we can see how there’s a lot of intersection among these domains and the single has 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 it 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 well you say I have to sit there with a 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 map anywhere they just try out your phone it tells you where to turn but there’s a lot of important information in 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 relations to change over space and be able to incorporate that understanding in decision-making is really what grasp is all about it’s what the 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 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 the 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 in the case of greater vulnerability so already we can piece together some components of what it means to be vulnerable by looking at where these vulnerabilities exists and these maps are produced over the at the census tract 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 to an overall social voting index we see on the left-hand side that we can look at how they all come together recognizing our support that that areas can have a low vulnerability in terms of one factor and hi Bowman billion terms another factor well it’s important to look at the overall vulnerability it’s also important to understand what the components of that to drive that as well because you can be vulnerable with respect to one factor not the other factor that might drive what you do what you think and how you analyze your work so for example the dark breweries within the housing and transportation are is where additional evacuation resources need to be employed so if you’re vulnerable 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 make sure there’s resources in order to get test transportation resources those areas right away we can also note that darker areas with socioeconomic status or is where additional shelter resources might be needed because people with lower socio mac– 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 this is the the doc you see on the right planning for an emergency strategies for identifying and engaging at-risk groups this is a document the Center for bomber health health studies branch wrote with significant input from the SVI team it includes substantial section on how to use the SVI so while I can’t go through it a lot of detail today we could talk for hours and we have a whole symposium on SPI I think this is an important resource for those of you in the audience who are even more data so the SPI database can be used to Anna Anna 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 its population-based so you can you can target where the need is greatest and it has other contextual information that can help you understand a little bit about community’s resilience overall which can lead to planning purposes so resilience as you know is the community’s ability to prepare plan for and absorb recover from and more successfully adapt 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 disasters it 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 vibrant chloroplast maps and what that means is there are 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 kind of 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 sandy so the FEMA impact rank is based on surge wind and precipitation impacts these are used to assess the impacts reach County based on on the impact of the storm the bottom right shows the sulfur in this is the social vulnerability index again where the darker blue indicating areas the higher vulnerability the darker colors in the female impact also integrate and indicates of greater vulnerability now the left-hand side if you put the two together wait to 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 head as we all recall had devastating impacts now it’s a it’s important to look at the maps and and and to see how it plays out visually but as I said before we can also be quantitative and a spatial cluster analysis reveal that there was significant relationship between the theme impact rank and the SPI indicate 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 RV the SVI webpage received over 22,000 hits in the two weeks before the 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 so similar what I showed you before the maps on the right hand side show the four domains and the map and left hand side shows the overall vulnerability index you can see that there many vulnerabilities overlap going forward the darkest areas on left map but the there are isolated areas as we talked about before particularly in the dark blue spot in the northwest borders this county there were the high housing vulnerability and lower scores and mostly 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 use these data to show 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 tracts with an S VI in the highest quartile meaning that with SPI we can expect more mortality they saw a similar result in terms of morbidity so going forward we can also see not just that there’s greatest impact but it actually leads to health disparities as well now this is a example is probably closer to home this is in Georgia and it looks at heat related morbidity mortality so similar to what we saw in the other storms we can see look at the overlay between on the left hand side edie visits on the right hand side mortality and we can look at areas where there’s high morbidity mortality here’s where there’s high social vulnerability if we get to the bottom line to this graph we can see that with every 10% increase in svi the rate of heat related edy business increased by 20% so again the ability to be quantitative about these relationship is key for every 10% increase the overall svi the heat mortality rate increased by 30% so heat events are gonna be with us now they’re gonna be a regular part of our life so planning for these using these data to identify where he exists worth immortality exists and outraced of Almer abilities 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 ATS you aren’t using these data and we list some of them on this 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 aren’t everyday part of the world in many cases what we used to consider a rare event now our common event so extreme heat events wildfires and our things that we deal with every year historically these events were rare but now they’re more common in the more complex this makes SVI tool even more important every part of the nation in the world is constantly being affected by these events for more information please visit the SBI website interactive maps at s VI dot CDC gov see more examples of how this is being used you can visit some look at some of the publication’s listed on that website lastly I 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 grass program erica Adams Elaine Halsey very Flanagan and Greta wilts are all important contributors to the grass program so with that I think we can move to questions and answers [Applause] thank you dr.Brasi so for questions we have the mics in the middle are they’re on opposite ends and then if we want to okay no question i PT V so so the floor is open for questions for dr. Okun and dr. brassy 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 so the FCI’s produced with databases for years 2000 2010 2014 to 2016 and so it relies on on the on the census and other data were we’re looking at producing a 2018 database once those data are available going forward so as the census data becomes available we 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 moving down if those who don’t have microphones at your desk you can step to the microphone in the aisles sorry 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 your the resilience of responders I was wearing for good to elaborate a little bit more on that and what you what you do around that area yeah in the Center for preparedness and response so not out of my group at a de oh and if any of them are here today but there 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 the proper training and then that we supply support to them during a response and through NIOSH in the armed system there’s ways to register your responders and then track them and follow them so that you can watch their their resilience and then it’s important piece when they come back home too for them as well but recognizing that they’re going through a traumatic event potentially as well and the that event could be rien gauging 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 stateside yeah I mean it was like state-based public health so but to that end I also wanted to then I’m sorry that wasn’t a set up question I also wanted to put a plug in for so I just making the team lead of the resilience program that’s associated with our occupational health clinic and I 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 um I was also curious what what others in the states do and I’m sorry I think I thought that that was what we were you were referencing but this is an opportunity to let CDC folks know that there is a dedicated resilience program that’s based on the occupational health clinic yep I’m all of the opportunity to hear more about that later Tony – thanks good morning great presentations thank you I wonder if the vulnerable nur ability index includes populations like those that are incarcerated and those that are undocumented because we we know they’re around and how do you account for those populations well I think the undocumented population is are a challenge because there’s not a lot of data on them by definition but there are opportunities when there’s not national based data for a state to include special factors about vulnerability and so if a state was willing to incorporate data where they haven’t available they could certainly do that and with respect to the incarcerated populations I believe it’s in there but I don’t know for sure but that would be an important group to consider thank you I’m gonna try again here can you give us some examples of where states have used the SVI database and in preparedness and and how is that helped the state level response or national response yes so the you know the Harris County example is I think a perfect example or they looked very carefully at 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 and more strongly so I think that’s like 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 upfront yes hi good morning a certain presentation I want to share with you the my experience in Puerto Rico we reach the community leaders of different population population groups and we found there more information that we can do it by assessment by people that go interview people or members of that community because the community leaders know the needs of the community needham knows the person that really are in a real need and help us to figure out how we are going to address the problems of the community in general because the problems of come here of the communities are different I learned one the problem that is in one community is not the same thing in the other community could be water source could be accessibility to health care you name it so I think that they maybe in the future we have to involve more the community leaders in this type of venta board because we can get more fresh and and real-time data about the real situation of day of those communities and the people die but more vulnerable thank you I think that’s that’s well taken in fact this data was meant to be used by local public health officials to drive their response and to work on preparedness act duties I just want a comment on that we do say all disasters are local because we recognize that and these are national systems that that is a gives us a starting point but we have a research project right now which was 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 SBI has there been any effort to partner with say for example local nongovernmental organizations as a way to give aid so using SBI as a way to kind of promote aid because I know there was I think almost a billion dollars given for the Houston hurricane and people were saying they weren’t sure where to I guess paid yeah I think there’s there’s lots of examples of that so they work with the Catholic Charities they’ve worked with the group called Direct Relief to create an interactive map identified rural populations during the Houston hurricane response they even worked with legal services corporations 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 so that’s a great question certainly is one of the at-risk populations that we need to consider not only do they have a lack of resources 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 there we need to make more effort and we also need to make that 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’re 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 exists 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 on immigrant populations and then if those data become available it would be relatively straightforward to incorporate that in the SVI tool okay one final question category 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 and so on I just wanted to comment on a couple things that have already been said as far as you know SBI being used by the state for instance in Texas they were concerned about immigrants and undocumented people and so even though the data as dr.Bryce Lee said it’s difficult to to really get and incorporate completely there are local organizations who you know 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 you know it’s useful in that case another point I think that dr. Walton was making was that all of these organizations you know it’s not just up to Public Health it’s not just up to Emergency Management but we realized now after Texas in Puerto Rico and you know USVI and these other things that there’s a whole broad range of sectors as dr.Logan 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 a sudden we realized that we have Department of Housing and you know 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 a lesson that we’ve learned particularly in this from the 2017 year and just lastly I think when the question is how do we how do we reach these people the other thing we need to learn is where are these folks and how did how are they getting information so in Texas for instance some of these folks had you know the day laborers collected in a certain place in the morning that’s where they were and that’s why they needed to be reached other folks say that in some communities it’s in churches in Texas they we found out that there was a large Vietnamese group fishermen coastal folks who are not going to come to the disaster resource centers and so you know 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 it’s all interconnected that I thank you for the presentations that I think will set a good stage for the rest of that the morning thank you thank you okay I want to thank dr.woken and dr. pricey for very informative presentations [Applause].

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