Abstract
Objectives:
The objective of this project was to demonstrate and assess approaches of urban local health departments (LHDs) to simultaneously address climate change, health, and equity; incorporate climate change into program practice; and participate in their jurisdiction’s climate change work.
Methods:
From January 2016 through March 2018, the Center for Climate Change and Health created learning activities, networking and relationship-building opportunities, communication platforms, and information sharing for 12 urban LHDs in the United States. We used administrative data and conducted interviews with participants and key informants to assess success in meeting learning collaborative goals.
Results:
LHDs developed diverse projects that incorporated internal capacity building, climate and health vulnerability assessments, surveillance, and community engagement. Projects fostered greater LHD engagement on climate change, broadened community partnerships, and furthered LHD integration into jurisdictions’ climate planning. LHD engagement helped shift the dialogue in the community and jurisdiction about climate change to include public health.
Conclusions:
LHDs have skills and expertise to rapidly partner with other governmental agencies and community-based organizations and to help communities identify vulnerabilities, take action to reduce the health harms of climate change, and—through Health in All Policies approaches and community partnerships—to ensure that climate policies are optimized for positive health and equity outcomes.
Climate change is the greatest public health challenge of the 21st century 1,2 and exacerbates health inequities. 3 For example, low-income families are less likely than higher-income families to have the insurance or financial resources to rebuild their lives after a severe weather event. The public health community is well positioned to play a leading role in addressing the health impacts of climate change through preparedness, prevention, research, partnerships, and policy. Policy advocacy at the national level aims to lessen the impact of climate change on health, especially by mitigating greenhouse gases in the energy sector. However, the public health community at the local level plays a crucial role because many public health activities, opportunities for greenhouse gas mitigation, and climate impacts occur at the local level. 2 (Mitigation in this article refers to reducing greenhouse gas emissions. Adaptation refers to adjustments in human and natural systems in response to actual or expected climate change, which moderates harms or takes advantage of beneficial opportunities.) Local health departments (LHDs) are frontline responders to climate-related disasters and inform, educate, and empower their jurisdictions to take actions that mitigate and adapt to climate change. Many LHDs already have partnerships in the most affected communities and a broad mandate to protect and promote health. LHD engagement with other agencies in climate planning can optimize the health and health equity benefits of climate action. Yet, few LHDs are engaged in this issue. 4
To help build local climate and health capacity, the Center for Climate Change and Health (CCCH) of the Public Health Institute in Oakland, California, organized and led a learning collaborative 5 for urban LHDs from January 2016 through March 2018. The goals of the learning collaborative were to build LHD climate and health capacity, demonstrate strategies LHDs can use to incorporate climate change into current practice, and enhance participation in local and regional climate change mitigation, adaptation, and resilience work.
We describe the learning collaborative and its impact on LHDs and their communities and identify lessons learned. Although previous efforts, such as assessments of needs and capacity building on health climate change, were aimed mostly at state health departments, 6 -9 the CCCH-convened learning collaborative was unique in its exclusive focus on LHDs and climate change, health, and equity.
Methods
Eligibility, Recruitment, and Response
CCCH disseminated a request for proposals through its networks and national organizations representing local public and environmental health agencies (Figure). Applicants had broad discretion to develop projects (Table 1) that addressed climate mitigation, adaptation, and resilience, and that
Overview of the learning collaborative process of the Center for Climate Change and Health and local health departments.
Projects of local health departments in the climate and health learning collaborative, 12 sites, United States, January 2016–March 2018
built LHD capacity to address climate and health equity across public health programs, integrated intersectoral action, integrated a health equity lens, and incorporated community engagement.
Detailed descriptions of the LHDs and their projects are available elsewhere. 10 CCCH offered grants of up to $40 000 per LHD during 2.25 years (January 2016 through March 2018). Thirteen LHDs submitted proposals. Six LHDs received funding for 2.25 years (Denver, Colorado; Los Angeles County, California; Minneapolis, Minnesota; New Orleans, Louisiana; Philadelphia, Pennsylvania; and Seattle–King County, Washington), 3 LHDS received funding for 2 years (Maricopa County, Arizona; Milwaukee, Wisconsin; and Multnomah County, Oregon), and 3 LHDs received funding for 18 months (Tulsa, Oklahoma; Macomb County, Michigan; and Columbus, Ohio). One health department left the collaborative after 8 months and was not included in this evaluation.
Learning Collaborative Structure and Process
LHD staff members participated in 2 in-person meetings (one at kickoff and another 15 months later), bimonthly webinars, bimonthly one-on-one telephone calls with the LHD project team and CCCH staff members, and resource sharing through a shared computer network drive and listserv. In the months before the kickoff meeting, CCCH requested that awardees spend time familiarizing themselves with and gathering information about activities on climate change in their jurisdiction and among their partners. To structure this information gathering, CCCH developed 4-6 questions that were specific to each LHD based on potential gaps identified in their applications. We discussed the findings with the LHDs during the first one-on-one telephone calls. We conducted one-on-one telephone calls informally and confidentially to review accomplishments, discuss strategies to address barriers, and exchange technical assistance.
Before the kickoff meeting, we asked LHDs to complete an online survey to rank the importance of potential webinar topics. We then sequenced the webinars to reflect the rankings and the timeline of common activities. For example, at least half of the projects proposed creating climate-health vulnerability maps as a key first step. Thus, the initial webinar focused on vulnerability mapping. The 90-minute webinars featured subject matter experts from CCCH and outside organizations and presentations by LHDs highlighting their projects, followed by a discussion of the topic among all LHDs and experts.
Evaluation
We conducted a qualitative evaluation to assess whether individual LHD goals and CCCH goals were met. We requested that the goals for each project be enumerated in the contractual scope of work. Along with the goals, the scopes of work listed objectives, timelines, and deliverables, such as reports, presentations, and meeting minutes. We synchronized the payment schedule with the timeline for deliverables so that we could have materials to objectively determine whether the goals specified in the scopes of work were met. We used publicly available information from jurisdiction websites, administrative data, and questionnaires and interviews of key informants. Administrative data included the original applications, quarterly reports, contract deliverables and materials, and notes of in-person meetings and one-on-one telephone calls. CCCH staff members developed questionnaires and interview guides for learning collaborative participants and key informants, which included identification of major accomplishments, impacts of the LHD project, unexpected opportunities, challenges, and areas for improving the learning collaborative process.
We described characteristics of LHD staffs and subcontractors/consultants, intraorganizational partners, jurisdictional and community-based organization (CBO) partners, capacity-building activities, steps to include vulnerable populations and health equity, project integration with LHD programs and communications, and outreach and inter- and intraorganization relationship building.
Each LHD nominated 2 key informants: 1 represented LHD leadership and the other represented a governmental or CBO partner. Three CCCH staff members interviewed key informants in semistructured, 30-minute telephone interviews that took place in the penultimate month of the learning collaborative. CCCH staff members conducted debriefings after each interview to identify key themes. Additional details about the methods, questionnaires, and protocols for evaluation are available elsewhere. 10
Results
Description of the LHDs and Their Projects
LHDs were diverse in geography (Midwest, South, East Coast, and West Coast), size of populations served (365 000 to 10 million population), number of staff members (100-4500 employees), annual budgets ($14 million to $893 million), and nature of projects (Tables 2 –4). Each community had substantial racial/ethnic and geographic health inequities within their jurisdictions. The lead program for the learning collaborative project was environmental health at 5 LHDs, emergency preparedness at 4 LHDs, and epidemiology at 1 LHD; 2 LHDs had joint leads in environmental health and emergency preparedness. All LHD projects had a component on climate change adaptation, and 5 LHDs conducted an adaptation project, such as rainwater harvesting, improved epidemiologic surveillance, assessing heat vulnerability in home-bound populations, mosquito surveillance, or interventions in faith-based communities. Six LHDs conducted a community-engaged assessment of vulnerability to climate change, and 2 LHDs emphasized internal capacity and strategic planning. All LHDs partnered with either municipal or county governmental agencies, CBOs, and/or academic institutions. Most learning collaborative participants hired 1 part-time staff member or an intern or contracted with a local university.
Characteristics of local health departments that took part in a climate and health learning collaborative,a by site, January 2016–March 2018b
a The learning collaborative is an organized and facilitated approach to capacity building on the topic of climate change and public health that includes teams from multiple local health departments (LHDs) coming together to learn, apply, and share methods, ideas, and data.
bData sources: Data were compiled from LHDs’ applications to participate in the learning collaborative and publicly available documents of websites of the LHDs and their jurisdiction. Additional details of the LHDs are available at http://climatehealthconnect.org/wp-content/uploads/2019/11/Kresge_Learning-Collaborative-Evaluation_2.1.2018.pdf. 10
Climate strategies or threats and organizational characteristics of local health departments that took part in a climate and health learning collaborative,a by site, January 2016–March 2018b
a The learning collaborative is an organized and facilitated approach to capacity building on the topic of climate change and public health that includes teams from multiple LHDs coming together to learn, apply, and share methods, ideas, and data.
b Data sources: Data were compiled from LHDs’ applications to participate in the learning collaborative and publicly available documents of websites of the LHDs and their jurisdiction. Additional details of the LHDs are available at http://climatehealthconnect.org/wp-content/uploads/2019/11/Kresge_Learning-Collaborative-Evaluation_2.1.2018.pdf. 10
c Mitigation refers to reducing greenhouse gas emissions.
d Adaptation refers to adjustments in human and natural systems in response to actual or expected climate change that moderate harms or take advantage of beneficial opportunities.
Partners and previous climate change activities of local health departments (LHDs) that took part in a climate and health learning collaborative,a by site, January 2016–March 2018b
a The learning collaborative is an organized and facilitated approach to capacity building on the topic of climate change and public health that includes teams from multiple LHDs coming together to learn, apply, and share methods, ideas, and data.
b Data sources: Data were compiled from LHDs’ applications to participate in the learning collaborative and publicly available documents of websites of the LHDs and their jurisdiction. Additional details of the LHDs are available at http://climatehealthconnect.org/wp-content/uploads/2019/11/Kresge_Learning-Collaborative-Evaluation_2.1.2018.pdf. 10
c Mitigation refers to reducing greenhouse gas emissions.
d Adaptation refers to adjustments in human and natural systems in response to actual or expected climate change that moderate harms or take advantage of beneficial opportunities.
Meeting Goals
LHD capacity building
All LHDs engaged in internal capacity building, but the internal capacity building varied widely in intensity and success. Several LHDs targeted upper management through interviews, which helped educate managers, increase buy-in, and identify opportunities for broader engagement within the health department and with external partners. The Los Angeles County Department of Public Health and Public Health–Seattle & King County engaged in proactive but labor-intensive activities to build internal support and capacity for the integration of climate change into LHD programs. Public Health–Seattle & King County created a blueprint of key LHD actions to advance climate change and health. 11 Most LHDs conducted educational outreach to managers and staff members using venues such as all-employee or divisional in-services, lunchtime seminars, and regular meetings of executive leadership, managers, and staff members.
Integration of health and climate planning processes
Ten of the 12 LHDs integrated climate change and health into internal and jurisdictional climate planning, implementation, and policy development. We observed bidirectional integration of (1) climate change into LHD processes and (2) public health into climate change planning processes led by city or county offices of sustainability or other governmental agencies. Examples include the following: The Macomb County (Michigan) Department of Public Health used the Mobilizing for Action through Planning and Partnerships process in its 2016 Community Health Needs Assessment, designating climate change as a key “force of change.”
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LHDs in Maricopa County, Arizona, and Tulsa City–County, Oklahoma, integrated climate change into heat-illness surveillance and mosquito/West Nile virus surveillance, respectively. The Philadelphia Department of Public Health incorporated climate change into programs for asthma and air quality and analyzed geographical patterns of asthma incidence to prioritize clinical networks for participation in climate outreach and education programs. LHDs in New Orleans, Minneapolis,
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Philadelphia, Denver,
14,15
and Multnomah County (Oregon) performed climate and health vulnerability assessments for extreme heat and other climate threats, in some cases adapting the Centers for Disease Control and Prevention’s BRACE model (Building Resilience Against Climate Effects).
8
LHDs incorporated indicators of social vulnerability to climate change impacts. LHDs in Maricopa and Macomb counties used community-based surveys to assess vulnerability to heat and flooding, respectively, in socioeconomically disadvantaged populations that previously experienced these environmental threats. The Los Angeles County Department of Public Health collaborated with an internal workgroup to develop a strategic plan for LHD climate action, including an extreme heat response plan, and worked with an intersectoral workgroup to develop an urban heat island mitigation plan.
Health equity and community engagement
Participants used various strategies and venues to inform and engage the public, CBOs, and other agency partners, including workgroups (Philadelphia, New Orleans, Denver), community climate health summits (Maricopa County, Milwaukee), committee work integrated into larger community planning processes (Denver, Macomb County), and neighborhood meetings (Minneapolis, New Orleans). LHDs in Los Angeles, Multnomah County, Minneapolis, Seattle–King County, and New Orleans contracted with CBOs that represent socioeconomically disadvantaged communities to inform, seek input from, and empower their constituencies. In some projects, CBOs helped design (Multnomah County) and communicate the results of vulnerability assessments and channeled feedback from neighborhoods (New Orleans, Minneapolis).
Learning Collaborative Process
CCCH established trust with LHDs, especially through in-person meetings and one-on-one telephone calls. One-on-one consultation facilitated honest and nonjudgmental dialogue about the project, progress, and challenges and provided an opportunity for CCCH to prompt and encourage each LHD to move further into less comfortable territory (ie, related to health equity and community engagement). Progress reports augmented project accountability. CCCH made connections among LHDs that faced similar challenges or were doing related work. The talent among the learning collaborative participants and the role played by CCCH were mutually reinforcing. CCCH staff members contributed to credible mentorship: a national leadership role with a broad network of public health contacts, expertise in establishing and managing public health and climate change programs in local and state government, and expertise in climate and health communications, policies, climate science, epidemiology, Health in All Policies, and health equity.
Impacts
We interviewed 22 key informants: 8 LHD senior staff members, 6 city sustainability office staff members, 2 jurisdictional emergency management staff members, and 6 leaders from nonprofit advocacy organizations or local CBOs. The interviews corroborated that the learning collaborative spurred capacity building within LHDs to engage in work on climate, health, and equity within their jurisdictions (11 of 12 LHDs), with intersectoral partners, and with vulnerable communities. Non-LHD key informants reported that LHDs were highly valued partners that added the human health dimension to a previous environmental framing of climate change (10 of 12 LHDs). Key informants emphasized the unique role of LHDs to collect, analyze, and communicate data that link climate, health, vulnerability, and equity (12 LHDs). LHDs and non-LHD key informants acknowledged the severe funding and capacity limitations that impede work on climate, health, and equity (8 of 12 LHDs).
Lessons Learned
The learning collaborative demonstrated that LHDs are an underleveraged national resource. Most LHDs were able to raise awareness, engender interest, build executive leadership support, and identify potential roles for various LHD programs. Ten LHDs reported substantial increases in community awareness and engagement on climate and health. Key lessons learned were the following: LHDs can integrate climate change into existing programs and routine processes, even with limited resources. A small amount of funding for explicit climate change work triggered substantial activity, even in locations where no such work had previously occurred. Core LHD skills, such as analyzing and presenting data, community outreach and engagement, health risk communication, and serving as a convener on health issues, are easily applicable to climate change. Because climate change touches virtually every aspect of LHD work, multiple entry points exist in LHDs for climate and health work. Emergency preparedness and environmental health are adaptation oriented, but other programs aligned with chronic disease prevention, epidemiology, and policy can incorporate mitigation activities. LHDs can foster more robust community engagement on climate change through health and equity. LHDs are trusted and active partners in their jurisdictions and can leverage existing relationships with community partners to engage communities on the issue of climate change, health, and equity. LHD awareness of community vulnerabilities and concerns (including impacts of previous extreme weather events) and LHD efforts to address health inequities, through a focus on the social determinants of health, provide a context and sensitivity for the discussion of climate and health that may allow LHDs to engage with communities in a way that differs qualitatively from the way in which other local government agencies engage with communities. Many opportunities for LHDs to participate in jurisdictional activities related to climate mitigation, adaptation, and resilience are unrealized. The limited engagement of LHDs represents missed opportunities to infuse the concepts of health and equity into climate change planning. More than 50 of the largest US cities participate in national and international initiatives on climate change sponsored by associations of mayors, cities, and nonprofit organizations.
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LHDs can bring their expertise, skills, and community orientation into these processes, and, most importantly, they can bring a health and equity lens that potentially enhances the benefits to disadvantaged communities provided by local government climate action planning. The role(s) of LHDs in addressing climate change and its impacts are not yet well recognized internally or externally.
4,17
Participation in the learning collaborative provided legitimacy for LHD engagement and created a channel for buy-in within the health department and the jurisdiction. LHDs are increasingly aware of and interested in greater participation in work that addresses climate change, but most LHDs lack the resources to initiate activities on their own. The learning collaborative triggered discussion with non–participating LHDs and expression of interest in discussing the activities and learnings (and in participation in future learning collaboratives). For example, informal climate and health exchanges sprung up along the West Coast and along the Colorado Front Range, as well as interest in the feasibility of a climate and health learning collaborative in Ohio. Climate and health vulnerability assessment provides an important entrée for LHD action. A climate and health vulnerability assessment provides evidence for action and offers opportunities for engagement within the LHD, among governmental departments, and in the community. It can focus on population risk factors (eg, homebound persons) or on climate impacts (eg, heat). Inclusion of social vulnerability and social determinants of health is required to address the health equity impacts of climate change. The learning collaborative demonstrated that a vulnerability assessment need not require substantial resources beyond those available within the LHD’s epidemiology programs and/or local universities. Vulnerability assessment provides an important foundation but is not sufficient to guide broad-based action that considers both adaptation and mitigation strategies. Vulnerability assessment is not, however, a prerequisite for LHD action on climate change, as demonstrated by several LHDs (eg, Los Angeles). The learning collaborative provided critical structure and a supportive process. Because few LHDs are engaged in work on climate change and health, the learning collaborative provided important support. Participants particularly appreciated one-on-one consultation and peer support.
Challenges
Communications
Communicating about climate change to staff members, policy makers, and the general public is challenging, because (1) the issue is complex; (2) few examples of materials for nonprofessionals explicitly address climate, health, and equity; and (3) few examples exist of integration of climate change into routine LHD communications. Building on the experience of the learning collaborative, we produced the first guide for LHDs on climate change, health, and equity. 18 The need to develop and implement effective climate and health communications that are field tested and evaluated in multiple public health programs and contexts is urgent. 19
In some jurisdictions, concerns about the political polarization of climate change led to hesitation about speaking openly about climate change and omitting references to climate change from health messages about climate threats (eg, extreme heat, mosquito-borne illness). When LHDs ventured to explicitly discuss climate change, they found that communities welcomed an open discussion about climate change and health, and LHDs received no negative feedback even in politically conservative environments.
Spread across LHD programs
LHDs were more successful in engaging actors in city and county government agencies than in other programs within their own health department. The learning collaborative focused on relatively large LHDs, for whom it is often difficult to break down intraorganizational and programmatic barriers to communication. LHDs that focused on internal capacity building were more successful in spreading work on climate change across multiple programs than LHDs that focused on a specific project. Commitment and engagement from high-level leadership fostered greater spread of learning collaborative activities within LHDs. Many staff members wanted to be more engaged but were uncertain how to do so given the dearth of precedents or models that integrate climate change into programs with categorical funding and narrowly construed mandates.
Managing success
Several learning collaborative participants discovered an unanticipated level of interest in the health and equity impacts of climate change among both community partners and other agencies, creating a demand for LHD engagement that exceeded capacity. LHDs worked within the limitations of their funding for the learning collaborative, but several LHDs leveraged the project to pursue additional funding.
Resource limitations and competing priorities
LHDs have limited resources, which have decreased in recent years. In addition, LHD staff members are constantly called upon to address immediate needs, such as Zika case investigations (New Orleans), preparing for a Papal visit (Philadelphia), or responding to a giant sinkhole (Macomb County). Senior leaders in many LHDs do not yet see climate change as a priority. Several LHDs noted challenges in community engagement, such as insufficient resources to contract with CBOs, turnover among CBO staff members, and concerns about reaching out before solidifying internal LHD support.
Limited focus on mitigation
Most learning collaborative projects focused on climate adaptation, yet the greatest health co-benefits are likely to be in systems changes that lower carbon pollution (eg, through active transportation and healthy food systems). 20 More opportunities emerged for a mitigation component as LHDs became more conversant with the issue, strengthened their relationships with other agencies, and engaged in discussions with community members about climate change and health.
Strengths
The learning collaborative highlighted several strengths of LHDs. First, routine collection, analysis, interpretation, and dissemination of data on health and its determinants and climate-related environmental exposures support the essential function of assessment. Assessment informs leadership of the health dimensions of the problem, provides information to inform priorities and policies on climate change, and helps managers understand how climate change affects other LHD priorities, policies, and service delivery. Second, LHDs have knowledge and understanding of, and strong relationships with, their communities, which facilitates the bidirectional flow of information on climate change, health, and equity in community engagement. Third, LHDs are increasingly adopting a multisectoral approach to improving health through a focus on the social determinants of health. Multisector collaborations on Health in All Policies and climate, health, and equity functionally overlap and are mutually reinforcing. Finally, LHDs have expertise in communications on challenging health topics; however, this expertise is in its formative stages for climate and health.
Limitations
A limitation of the evaluation was that it was not conducted by independent reviewers. However, the analysis followed a detailed, written evaluation plan; used official documents whenever feasible to independently verify information; examined deliverables including websites and educational materials, interview guides, and meeting agendas; and interviewed persons not directly engaged in the project. We also believe that trust built during the collaborative fostered candid self-assessment by learning collaborative participants that allowed greater understanding of their challenges and achievements.
Public Health Implications
The learning collaborative model is replicable, and with additional resources and coordinated approaches, LHDs can become important actors to counter the threat of climate change. The learning collaborative advanced the field by providing examples of LHD capacity building and community engagement for climate change, health, and equity. LHDs around the country are rapidly adopting a Health in All Policies approach and increasing their engagement with other agencies in their jurisdiction across multiple sectors to address the social determinants of health and health inequities. These initiatives provide a venue to integrate climate change and health. LHDs can advance the dual opportunities to provide a health and equity lens in climate policy and programs and to educate other jurisdiction staff members about the links among climate change, health, equity, and the health benefits of climate action.
Footnotes
Acknowledgments
The authors acknowledge Laura Buckley and Brian Moy of CCCH, who provided technical assistance.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors acknowledge grant support from the Kresge Foundation.
