Public Health Agency Responses and Opportunities to Protect Against Health Impacts of Climate Change Among US Populations with Multiple Vulnerabilities
During the past several decades, unprecedented global changes in climate have given rise to an increase in extreme weather and other climate events and their consequences such as heavy rainfall, hurricanes, flooding, heat waves, wildfires, and air pollution. These climate effects have direct impacts on human health such as premature death, injuries, exacerbation of health conditions, disruption of mental well-being, as well as indirect impacts through food- and water-related infections and illnesses. While all populations are at risk for these adverse health outcomes, some populations are at greater risk because of multiple vulnerabilities resulting from increased exposure to risk-prone areas, increased sensitivity due to underlying health conditions, and limited adaptive capacity primarily because of a lack of economic resources to respond adequately. We discuss current governmental public health responses and their future opportunities to improve resilience of special populations at greatest risk for adverse health outcomes. Vulnerability assessment, adaptation plans, public health emergency response, and public health agency accreditation are all current governmental public health actions. Governmental public health opportunities include integration of these current responses with health equity initiatives and programs in communities.
KeywordsClimate change Adaptation planning Vulnerable populations Populations with multiple vulnerabilities Health equity
During the past several decades, climate science indicates that the average earth surface temperature globally has increased unprecedentedly [1, 2]. In the USA, average surface temperature increased successively since 1970, with years 2000–2009 recorded as the warmest decade and 2016 as the warmest year [3, 4]. During the next several decades, temperatures in most US areas are projected to increase from 2 to 4 °F, and by the end of the century 3– to 10 °F, depending on heat-trapping gas emissions . Temperature elevations (also causing ocean warming, glacier melting, and sea level rises) have resulted in increased frequency, intensity, and duration of heavy precipitation or rainfall, hurricanes, flooding, and heat waves [1, 2, 3]. Consequences of these extreme temperature and climate events include wildfires and air pollution [1, 2, 3]. Extreme events and their consequences already have direct, adverse impacts on human health and disruption of mental well-being [1, 2, 5, 6, 7]. Extreme events also have indirect impacts through food- and water-related infections and illnesses [1, 2, 5, 6, 7]. As the climate continues to change, impacts on human health are projected to continue and advance [2, 5, 6, 7]. WHO conservatively projects 250,000 excess deaths each year globally from 2030 to 2050 because of heat and certain water- and vector-borne illnesses resulting from climate change . Health-sector costs alone by 2030 are estimated to total US $2–4 billion annually (excludes costs in agriculture, water, and sanitation) .
Adverse health outcomes among racial and ethnic, low-income, limited English proficient (LEP) and undocumented immigrant populations by multiple vulnerabilities due to climate change event
Climate cange events
Types of vulnerability
Limited adaptive capacitya
Temperature Extremes/Heat Waves
Social, economic and medical barriers of populations such as lack of air conditioning, inability to pay utility bills, and limited access to transportation, cooling centers and health care. [21, 22, 23, 24, 25, 26]
Populations found to have increased emergency department visits, hospitalizations, and premature deaths related to extreme heat events. [21, 22, 23, 24, 25, 26] (In some instances, public health adaptive interventions prevented these outcomes. [27, 28, 29])
Residence primarily in majority-minority states and major cities on the coast. [10, 11, 12, 13, 17] These locations are at risk for damage and flooding with release of hazardous materials (e.g., (New Orleans and Hurricane Katrina). [30, 33, 34]
Populations are unable to protect themselves because of educational, language and cultural barriers, poor-quality housing, lack of access to transportation, shelters, limited or no insurance coverage, and lack of social connectedness. [33, 34, 38, 39, 40, 41, 42]
Poor Air Quality
Air Pollution: exacerbation of illness (e.g., cardiovascular and respiratory diseases) and increased risk of hospitalization and premature death in these populations. [6, 52, 53, 54, 55, 56, 57, 58, 59, 60]
Wildfires: exacerbate underlying, disproportionately occurring asthma and cardiovascular disease and increased premature deaths directly related to elevated heat in these populations. 
Populations disproportionately work in outdoor jobs (e.g., agricultural, postal and utility workers), live in unhealthy and poor housing, or are homeless  Also, vectors spread more widely and more rapidly because populations live in conditions of crowding, substandard infrastructure with poor sewage, drainage, and storm water management, and substandard drinking water systems. [6, 21, 33, 34, 35]
Vector-borne diseases among these populations may exacerbate increased underlying conditions like diabetes if infected. 
Food and Water-Related Illnesses
Illnesses spread more widely and also occur more severely among these populations with underlying health conditions. 
Food Safety, Nutrition, and Distribution
Populations unable to spend an even larger portion of their household income on food than households with higher socioeconomic status and unable to gain access to inexpensive high-quality food during shortages. [6, 67]
Exacerbation of underlying social and health conditions in these populations (e.g., hunger, malnutrition, poor diets, obesity, diabetes, hypertension, and cardiovascular diseases). 
Mental Health and Stress-Related Disorders
To prevent populations with multiple vulnerabilities (PMVs) from experiencing adverse health outcomes (or risks), adaptation interventions, as outlined in a 2014 Intergovernmental Panel on Climate Change (IPCC) report, are important steps such as vulnerability and exposure reduction and incremental and transformational social adjustments . Furthermore, a 2010 National Research Council (NRC) report calls for equity and justice as guiding principles and priorities for adaptation decisions such that populations with a higher degree of vulnerability are helped to become resilient . The NRC acknowledged that governmental public health agencies, in addition to promoting mitigation interventions across sectors, can assure that effective adaptation measures are in place to minimize health impacts by identifying the most vulnerable populations and by convening and collaborating with partners to develop adaptation plans .
To support the primary purpose of this article, we briefly review adverse health outcomes due to climate change among the largest PMVs who are identified as populations of concern in a 2016 publication of the US Global Change Research Program (USGCRP) titled The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment . The primary purpose of our article is to discuss current responses of governmental public health agencies and their future opportunities to protect PMVs from climate impacts through adaptive action as major mitigation efforts continue to reduce carbon dioxide and other heat-trapping gases , particularly in vulnerable communities overburdened by environmental pollution .
Adverse Health Outcomes Experienced by Populations with Multiple Vulnerabilities
The principal pathways by which these vulnerabilities impact health adversely are discussed in the 2016 USGCRP report  and are not included in this article to prevent redundancy. We summarize the adverse health outcomes among PMVs relative to their vulnerability in Table 1 [10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70]. PMVs are essentially defined as low-income if family income is below 200% of the federal poverty threshold , as racial and ethnic minorities using classifications from the Office of Management and Budget , as limited English proficient if they are 5 years or older and speak English less than “very well” according to the US Census Bureau , or as undocumented immigrants if foreign-born non-citizens who reside in the USA and are not “legal immigrants” .
Many of the adverse health outcomes experienced by PMVs because of climate change result from interactions among their multiple vulnerabilities. For example, the increased sensitivity to climate impacts because of underlying health conditions interact with limited adaptive capacity to cause adverse and severe health outcomes such as hospitalizations and premature death. Limited adaptive capacity because of social, cultural, and economic factors such as limited education, literacy, English proficiency; lack of air conditioning, food, transportation, and access to health care, medications and social connectedness; and discrimination interfere with PMVs ability to gain access to needed medications and health care. In addition, these vulnerabilities summarized in Table 1 independently and collectively hamper the ability of PMVs to respond adequately to climate events—due to high poverty among some populations, language and cultural barriers, and non-citizenship status of others—limiting their access to and use of health care and other social services [33, 34, 38, 39, 40, 41, 42]. These circumstances also make them more hesitant to seek out help . Interactions of these multiple vulnerabilities were already reported among victims of Hurricane Katrina. Many racial and ethnic minorities with underlying health conditions and living in poverty were unable to evacuate and died or suffered severe morbidity during and after the hurricane [36, 37, 38].
In the USGCRP report, adverse health outcomes of climate change already have been observed among PMVs such as racial and ethnic minority populations, including African Americans, Hispanics, American Indians, Alaska Natives, and limited English proficient populations and certain immigrant populations . These outcomes are due to extreme events such as heat waves and extreme weather events such as Hurricane Katrina, poor air quality, food safety issues, increased infectious diseases, and psychological stressors. Adverse health outcomes are further compounded when populations with multiple vulnerabilities are also children, pregnant women, and older adults or persons who work in occupations largely outside or have functional limitations and disabilities . Public health opportunities discussed in this article may also protect other populations with multiple vulnerabilities such as seniors aged 65 and older who are medically fragile and are minorities and are of different ethnicities.
Governmental Public Health Responses
The framework for the governmental public health response to climate changes was laid out in a landmark article published in 2008 , although public health actions began earlier. The framework applied the 10 public health essential services to and showed how these services addressed the geographic and population variability and complexity of climate change impacts . The 10 services are (1) routine health monitoring to identify problems; (2) diagnosing and investigating health problems and hazards; (3) informing, educating, and empowering people about health issues; (4) mobilizing community partnerships to identify and solve climate health problems; (5) developing policies and plans that support individual and community heath; (6) enforcing laws and regulations that protect health and ensure safety; (7) linking persons to needed personal health services and providing health care when unavailable; (8) assuring a competent public health and personal health care workforce; (9) evaluating effectiveness, accessibility, and quality of personal and population-based health services; and (10) conducting research for new insights and innovative solutions to health problems . Today, governmental public health actions have been expanded to create specific programs that address health impacts of climate change directly such as the Climate and Health Program of the Centers for Disease Control and Prevention (CDC), which is described in this section . There are also broader public health actions now to further strengthen governmental public health infrastructure and routine performance through accreditation of public health agencies  and outreach procedures for public health emergency response as described subsequently .
National Climate-Related Public Health Initiatives
Key national public health programs and initiatives that can build resilience to health impacts of climate change among populations with multiple vulnerabilities
Public health program/initiative
CDC Climate and Health Program 
16 states and 2 cities
-Identification of methods and models for identifying and responding effectively to most vulnerable in area
-Climate science updates, technical assistance and resources
-Increased public awareness about health impacts of climate change
-Vulnerability assessment tool
-Identification of most vulnerable areas and populations
CDC Operationalization of Outreach to At-Risk Populations 
Populations disproportionately at risk during emergencies nationwide and internationally as appropriate
-At-risk desk within the Incident Management Structure
Increase access to and acceptability of resources to reduce health disparities associated with emergencies
-Establishment of community of subject matter experts with expertise in outreach to and communication with populations with multiple vulnerabilities
-Revision of procedures for developing communication materials
Public Health Accreditation 
Local, tribal and state public health agenciesa
Voluntary participation in accreditation using nationally recognized, practice-focused and evidence-based standards such as community health assessment, cultural competency and a community health improvement plan.
Improving and protecting the health of the public,
HHS EJ Implementation Plan 
US minority and low-income populations and Indian tribes
Policy development; education and training; research and data collection, analysis, and utilization; and services
Make targeted populations and communities more resilient by reducing toxic exposures in environment
HHS National Prevention Strategy 
US population and vulnerable populations by applying elimination of disparities across strategic directions and priorities to reach everyone
Building healthy and safe communities, integration of community and clinical preventive services, and empowering people to make healthy choices in priority areas of tobacco free living, prevention of drug and alcohol abuse, healthy eating, active living, injury and violence-free living, reproductive and sexual health, and mental and emotional health
Make communities more resilient by reducing populations with underlying health conditions, including improved mental health and eliminating health disparities
HHS National Partnership for Action to End Health Disparities 
US racial, ethnic and underserved populations
Increase awareness of health disparities, strengthen leadership, improve health and healthcare outcomes, improve cultural and linguistic competency and workforce diversity, improve research and diffusion of research and evaluation outcomes
Make communities more resilient by reducing and eliminating health disparities in the population
CDC Public Health Emergency Response Activities
In an effort to ensure that CDC considers the needs of PMVs, CDC is operationalizing outreach to these populations as part of its public health emergency response procedures . The Office of Public Health Preparedness and Response (OPHPR) led the agency in identifying populations who are often at risk during public health emergencies and added an at-risk desk to its incident management structure, the role of which is to provide expertise from around CDC regarding the needs of and outreach to identified at-risk populations . In support of this function, CDC’s Emergency Management Program gathers demographic information from stakeholder groups in order to tailor communication and outreach activities (CDC, unpublished information).
Such tailoring enhances audience receptivity to and understanding of messages—attributes of particular value in times of crisis when stressors impede trust and comprehension [82, 83, 84, 85]. Tailoring is a part of CDC’s overall approach to provide equitable access to health and safety information, including information on protecting oneself from the effects of climate change.
Public Health Accreditation Board
To strengthen the public health infrastructure and improve routine public health agency performance, the Public Health Accreditation Board (PHAB) offers an accreditation process for state, local, tribal, and territorial public health agencies . As of August 2016, 150 local, tribal, and state public health agencies and one integrated state system of 67 local health agencies are accredited . An accredited public health agency meets national standards based on the 10 essential public health services. The accreditation standards drive public health agencies to develop and use documents such as a community-driven health improvement plan, an agency strategic plan, and an emergency operation plan. Throughout standards, there is strong attention to understanding emerging trends; use of assessment data and identification of jurisdiction-specific needs and issues; and addressing health equity, cultural competency, and vulnerable populations. The accreditation process and national standards are driving attention to important topics and actions, which could strengthen the preparedness and response of communities to health impacts of climate change and improve actions taken to address threats faced by vulnerable populations by more strongly motivating public health agencies to take actions required to address their needs. In addition to meeting overall standards, accredited agencies meet specific cultural competency standards that could include PMVs .
Public Health Opportunities: National Initiatives to Eliminate Health Disparities and Achieve Health Equity
To prevent differential health impacts among PMVs relative to their counterparts during climate events, intentional public health strategies are needed. An example of a national governmental public health action successful in reducing health disparities is the dual strategy that achieved record high age-appropriate vaccine-specific coverage among all children in the USA, thereby eliminating vaccination inequities among children [86, 87]. The dual strategy includes simultaneous implementation of evidenced-based universal interventions that reach the general population and targeted evidence-based interventions that reach the most vulnerable—such as low-income and racial and ethnic minority children [86, 87]. Taking a dual strategy approach—by integrating climate-specific programs (such as the BRACE framework), public health emergency preparedness and response, and public health accreditation as largely universal interventions to reach the general population with key HHS health equity initiatives intentionally designed as interventions targeted to reach the most vulnerable populations—should strengthen the adaptive response among PMVs.
Key HHS public health initiatives to reduce health disparities, achieve health equity, and address the social determinants of health (all goals of Healthy People 2020)  can augment current govermental national initiatives to prepare for and respond or adapt to the health impacts of climate change among PMVs. These HHS initiatives include the Environmental Justice Strategy and Implementation Plan, the National Prevention Strategy, and the National Partnership for Action to End Health Disparities [16, 77, 78]. All of these initiatives are discussed in this section. Integration of these health equity initiatives with specific and broad public health actions against climate change can lead to program co-benefits and synergy.
HHS Environmental Justice Strategy and Implementation Plan
The 2012 HHS Environmental Justice (EJ) Strategy and Implementation Plan delineates actions to address environmental health disparities experienced by minority and low-income populations and Indian tribes . Environmental justice is defined as the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income in the development, implementation, and enforcement of environmental laws, regulations, and policies . This definition was developed in response to a body of literature and community advocacy indicating a disproportionate burden of environmental pollution among minority and low-income populations and Indian Tribes in the USA . The 2012 HHS EJ Strategy and Implementation Plan builds on the 1995 HHS EJ Strategy to protect the health and advance the economic potential of communities overburdened by pollution and other environmental hazards . The four interrelated parts of the 2012 strategy are linked to climate change polices and directives such as policy development and dissemination; education and training; research and data collection, analysis, and utilization; and services . The 2012 HHS EJ Strategy and Implementation Plan provides a roadmap for HHS agencies to develop their own environmental justice strategies and plans, to enhance accountability, and to promote collaboration and meaningful community partnerships. The HHS EJ plan and progress reports include drivers and levers of climate-specific initiatives that overlap with the EJ strategy . Climate-specific EJ initiatives include the following: improving public health and emergency response systems, empowering communities to leverage climate adaptation and mitigation strategies, and providing climate change guidance and educational outreach. Interdisciplinary collaborations between public health planners and health equity partners that implement the HHS EJ plan could more effectively identify some critical risk-prone areas and reduce exposure of populations with multiple vulnerabilities to these areas. Assessments could even be conducted among local partners such as non-profit environmental agencies to determine their impact on health inequities.
The National Prevention Strategy
The National Prevention Strategy (NPS) is a key national initiative that includes targeted interventions as components, which could improve the resilience of populations with PMVs . The NPS goal is to increase the number of Americans who are healthy at every stage of life . To accomplish this, one of four strategic directions is to eliminate health disparities and is applied across the other three strategic directions and nine priority areas to reduce the burden of the leading causes of preventable death and major illness in the USA for everyone .
Three of the four strategic directions include the following: building healthy and safe communities (clean air and water, affordable housing, sustainable and economically vital neighborhoods, making healthy choices easy and affordable); integration of community and clinical preventive services by expanding quality in both; and empowering people to make healthy choices . An example of integration of community and clinical preventive services is enabling access to clinical preventive services by using community interventions such as transportation, child care, and patient navigation interventions . The nine priorities can reduce sensitivity to climate impacts because they include tobacco free living, preventing drug abuse and excessive alcohol use, healthy eating, active living, injury and violence-free living, reproductive and sexual health, and mental and emotional well-being . If the NPS is fully implemented, all communities, including those having substantial PMVs to climate change, can become more resilient to climate-related health impacts by reducing the exposure and sensitivity of PMVs.
National Partnership for Action to End Health Disparities
The National Partnership for Action to End Health Disparities (NPA) is a targeted umbrella initiative led by the HHS Office of Minority Health . The NPA was established to mobilize a nationwide, comprehensive, community-driven, and sustained approach for combating health disparities and for moving the nation toward achieving health equity . This is accomplished by systems-oriented, cross-sector, partnership-based, and community-driven approaches to eliminate health disparities . Goals of the NPA in the National Stakeholder Strategy for Achieving Health Equity are to increase awareness of the impact of health disparities and actions needed for improving health for racial, ethnic, and underserved populations; to strengthen the leadership for addressing health disparities; to improve health and healthcare outcomes for racial, ethnic, and underserved populations; to improve cultural and linguistic competency and the diversity of the health workforce; and to improve data, research, and diffusion of research and evaluation outcomes . Climate change activities could benefit from the guidance of HHS NPA regional health equity councils  and state minority health directors and contacts , and their work with community health workers on how to educate, engage, and empower PMVs to climate change. These councils, directors, and contacts have established trusted partnerships in underserved and minority communities. These partners can assist communities in adapting to the health impacts of climate change by reducing exposure and sensitivity and improving adaptive capacity of populations such as providing vaccines at no cost.
Health in All Policies and Multi-Sectoral Partnerships
This example highlights the importance of a dual adaptation plan today and throughout the twenty-first century in all US communities. The example describes the demographic, health, and environmental characteristics of an actual southeastern, coastal, and urban county  that anticipates climate change. Given the diverse demographic, socioeconomic, and underlying health characteristics of the county, an effective adaptation plan is required to overcome social and health barriers of the population, which draws on a broad, diverse coalition to reach everyone. In this county, one of the five persons lives below the federal poverty level; one of the two adults aged 25 and older did not graduate from high school on time; one of the two persons is identified as a racial and ethnic minority; one of the five persons has no health insurance; one of the three adults is obese; one of the 10 adults has diabetes; nearly one of 10 adults has asthma; nearly one of 10 adults has a chronic obstructive pulmonary disease, emphysema, or chronic bronchitis; and 0.4 per 1000 adults are hospitalized annually for heart disease. A dual adaptation plan that includes health equity councils and minority health directors who implement the HHS health equity initiatives can meet the needs of PMVs, enabling the public health agency to reach everyone in the county.
During the next several decades, if needs of this demographically diverse population with substantial economic and health burdens are not met, we expect increased injuries, illnesses, premature deaths, and population displacement from an anticipated climate change of an average atmospheric temperature increase from 1 to 4 °F, giving rise to increased precipitation, storm surges and high tides. These events can combine with sea level rise and land erosion that further increase flooding in this county among the population living within four feet elevation of a high-tide level. Furthermore, as a result of relatively high median particulate concentration of 11.9 mg/m3 in county air, heat waves will likely worsen air pollution, which could exacerbate underlying respiratory and cardiovascular health conditions of the county population. These exacerbations can lead to increased emergency department and inpatient hospital admissions, as well as deaths.
Suppose the county implements a dual strategy such that it has an accredited public health agency that delivers essential public health services, including knowledge based on a community health assessment that has been used to develop a community health improvement plan, which informs climate vulnerability assessment and adaptation planning. This county then uses CDC climate-ready tools in collaboration with health equity councils, local minority health directors and their partners such that county officials identified all risk-prone areas and low-income, minority, LEP, and undocumented populations living in the highest risk areas. County officials are also advised that populations at greatest risk for adverse health impacts have underlying health conditions and reside in communities where there are more environmental hazards compared with their counterparts. As such, the county adaptation plan focuses on also anticipating the needs and barriers of PMVs by collaborating further with regional health equity councils and state and local minority health directors and their partners, including community health workers. These trusted partners and organizations then provide culturally competent and linguistically appropriate services to PMVs following the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards) . Also, health equity councils and minority health directors use the local EJ Implementation Plan , NPS , HHS Action Plan to Reduce Health Disparities , and the NPA . These health equity professionals can advise the local public health agency on who are key stakeholders to include in a coalition for creating a community infrastructure that will reduce health disparities overall and create a more resilient community against climate events.
Climate change threatens to exacerbate health disparities , if needs of PMVs are not central to adaptation planning . A dual adaption plan for public health agencies with universal and targeted interventions that include health equity councils and local minority health directors and their partners can likely protect PMVs from adverse health impacts of climate change. Universal interventions such as climate-specific interventions (advancing climate health science, identifying vulnerability, conducting demonstrations, and using tools that identify methods and models for informing adaptation plans, implementation, and evaluation), coupled with broader public health initiatives such as public health accreditation and emergency preparedness and response activities, are largely designed to reach the general population and are considered current governmental public health responses to climate change. Targeted interventions are intentional initiatives to reach the most vulnerable populations such as the EJ plan, the NPS, and the NPA. Integration of universal and targeted initiatives are opportunities to make PMVs and their communities resilient to the health impacts of climate change as well as provide co-benefits to all involved programs [16, 74, 75, 76, 77, 78]. Of the 67 earliest-accredited public health agencies, 25 are already working on climate change; some agencies mention the BRACE framework and vulnerability assessment and 49 are working on health equity and collaborating with partners to address vulnerable populations (CDC, unpublished data). Most public health agencies are not implementing an integrated dual adaptation plan. The USA, other countries, and the WHO have called attention to population vulnerabilities and opportunities for adaptation to prevent adverse health impacts of climate change [94, 95, 96]. The 2010 NRC report on adaptation emphasizes decision making that promotes long-term sustainability, including social, economic, and ecological welfare, rather than focusing only on the short term . We discuss the governmental public health sector in the context of a long-term sustainability approach and suggest a dual adaptation strategy for planning and responding to health impacts of climate change to prevent exacerbation of health disparities.
We thank Dr. Benedict Truman, Associate Director of Science, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, for his editorial comments.
Compliance with Ethical Standards
This study was performed by only employees of the federal government as a part of their routine duties. There were not any external funding sources such as grants, cooperative agreements, or contracts.
Conflict of Interest
All authors are employees of the federal government and have no conflicts. Authors report on public health programs grounded in science.
This article does not contain any studies with human participants or animals performed by any of the authors.
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