The Kresge Foundation

Evaluation of Climate Change and Public Health Learning Collaborative for Urban Health Departments

Prepared for

Center for Climate Change & Health Public Health Institute Oakland, CA http://climatehealthconnect.org

2/1/2018

Table of Contents

Executive Summary ...... i I. Background ...... 1 Context and Goals ...... 1 The Kresge Learning Collaborative for Local Health Departments ...... 1 Outreach and Application Review ...... 2 Description of the Applicants ...... 5 Prior Efforts ...... 17 Other Contextual Issues ...... 21 Overview of the Learning Collaborative Process ...... 21 CCCH Staffing of the Learning Collaborative ...... 21 Communications ...... 24 Evaluation ...... 24 In-Person Meetings ...... 25 II. Projects Synthesis ...... 33 Local Health Department Integration ...... 33 Local Health Department Capacity Building ...... 35 Health Equity and Community Engagement ...... 36 Challenges ...... 36 Lessons Learned ...... 37 III. Evaluation of CCCH ...... 41 LHDs Feedback on the Role of CCCH as the Learning Collaborative Sponsor ...... 44 IV. Recommendations and Next Steps ...... 46 V. Individual Health Departments ...... 48 A. Philadelphia Department of Public Health ...... 48 B. Tulsa City-County Health Department ...... 59 C. Macomb County Health Department ...... 68 D. Columbus Public Health ...... 77 E. Minneapolis Department of Public Health ...... 84 F. Los Angeles County Department of Public Health ...... 95 G. Denver Department of Public Health and Environment ...... 104 H. Maricopa County Department of Public Health ...... 113 I. Multnomah County Health Department ...... 121 J. New Orleans Health Department ...... 132 K. City of Milwaukee Health Department ...... 142 L. Seattle-King County Public Health ...... 151 Appendix A. Integrating Climate and Health into Local Health Department Programs ...... 161

EXECUTIVE SUMMARY

Background

Climate change is the greatest public health challenge of the twenty-first century. Local public health departments have a crucial role to play in addressing climate change in their local jurisdictions. Yet, there is a significant void of support from state and federal health agencies for comprehensive local public health responses. Lack of budgetary resources, lack of expertise, and issue polarization appear to contribute to this inaction.1 To address this gap, the Center for Climate Change and Health (CCCH) at the Public Health Institute organized a "Learning Collaborative for Urban Local Health Departments" (LC) funded by the Kresge Foundation. CCCH's broad goals for the learning collaborative were to:

• Support LHDs to demonstrate a variety of ways in which urban local public health departments can develop, integrate, scale-up and replicate approaches that simultaneously address climate change, community health and vulnerable populations, and health equity.

• Demonstrate approaches that successfully build capacity to incorporate climate change into local public health department program practice and/or enhance local public health department participation in on-going local and regional climate change mitigation, adaptation and resilience work.

Process and Structure of the Learning Collaborative

Eligibility was restricted to local health departments (LHDs) serving urban jurisdictions (cities or counties) with a population of 350,000 or more. Over 24 months (January 2016 to December 2017), LHDs were required to develop their own project and participate in bimonthly interactive consultation, bimonthly webinars, peer-to peer training, resource sharing, reflection, two 2-day in-person meetings, and evaluation organized by the CCCH sponsor.

LHDs had broad discretion to choose their project as long as they addressed slowing (mitigation) and/or preparing (adaptation/resilience) for climate change. LHDs were encouraged to specifically address health equity, integrate community engagement, and build climate and health capacity across multiple LHD programs. To support and incentivize participation, CCCH offered small grants of up to $40,000 over two years per awardee.

Description of Awardees and Their Projects

Thirteen health departments responded to a formal request for proposals and received awards (Table 1):

Table 1. Local Health Departments in the Learning Collaborative 1. Columbus Public Health (Ohio) worked with faith-based organizations to share information about climate change and health in the African American and Hispanic communities and identified strategies to assist congregations interested in taking action to reduce greenhouse gas emissions and increase sustainability and resilience. Columbus Public Health also introduced a climate, sustainability, and health education module and climate resilience actions for elementary school students in several local schools. 2. City and County of Denver Department of Environmental Health (Colorado) initiated a Denver Neighborhood Climate and Health Vulnerability project. This project integrated public health data and climate science in a mapping tool that provided greater insight for governmental planning agencies and community-based organizations into the neighborhoods and populations most vulnerable to climate related health impacts. Additionally, the learning collaborative project informed the Health in All Policies work happening across sectors. 3. Los Angeles County Department of Public Health (LACDPH) (California) launched a new internal initiative to engage its programs in implementing LACDPH’s Five Point Plan to Reduce the Health Impacts of Climate Change. As a component of this work, LACDPH developed actions plans to address at least one element of the Five Point Plan, including an Extreme Heat Response Framework that enhances its preparedness for and response to extreme heat events. In conjunction with the development of the Five Point Plan, LACDPH convened a cross-departmental Climate Action Group that collaborated to action plans to implement the Five Point Plan. LACDPH also chaired a cross-sector workgroup to develop an urban heat island mitigation plan. 4. Macomb County Health Department (Michigan) formed a Climate Change Resiliency Coalition, which assessed the health and preparedness of residents devastated by a recent major flood, and incorporated the Coalition into the planning process of its community health needs assessment. 5. Maricopa County Department of Public Health (Arizona) identified the needs of homebound populations during extreme heat events, assessed the sufficiency of existing services, and created a broad community coalition of governmental agencies and community-based organizations to elevate the recognition of climate change and health and improve capacity for this vulnerable population. Maricopa County Department of Public Health also hosted a series of workshops, Bridging Climate Change & Public Health, to bring together diverse stakeholders and establish critical climate and health actions. 6. City of Milwaukee Health Department (Wisconsin) worked with city and community partners to expand urban agriculture and climate resilience by linking rain water harvesting and green infrastructure to urban gardening projects that benefited disadvantaged populations, specifically homeless and low income populations. In addition to installing rainwater harvesting systems, the project produced a resource guide and workshops to address specific climate and health risks and build community resilience.

7. City of Minneapolis Health Department (Minnesota) conducted a citywide climate change and health vulnerability assessment and used the results to target and conduct neighborhood based community conversations/workshops to foster identification of strategies to increase community climate resilience. 8. Multnomah County Health Department (Oregon) worked with a community partner representing communities of color to create a story map using climate, health, and equity-related indicators. The maps clearly illustrated the majority of emissions in Multnomah County are associated with transportation, as opposed to point-source emitters. Therefore, the story map and associated data informed policy strategies by communities of color to strengthen their capacity to respond to climate change, particularly emissions mitigation efforts. This partnership including data-sharing and capacity building continues to inform policy priorities and opportunities. 9. New Orleans Health Department (Louisiana) conducted rapid climate vulnerability assessment to examine current climate change projections for New Orleans and associated health outcomes. This information was shared with community and governmental partners to inform strategies for reducing the impact of climate change in vulnerable neighborhoods. 10. Philadelphia Department of Public Health’s (Pennsylvania) catalyzed the creation of a citywide Climate Change and Health Advisory Group, which became the central coordination point for climate change and health for other city agencies, community-based organizations, health care and home-based service providers for vulnerable populations, and academic and cultural institutions. The project conducted a rapid vulnerability assessment, and produced patient and physician educational materials for asthma. 11. Pima County Health Department** (Arizona) worked with several local community groups to increase the visibility of heat-related illness among low income residents and homeless populations through the public transportation system and outdoor enthusiasts an tourists visiting Arizona. ** As described below, Pima did not complete the two-year commitment. 12. Seattle & King County Public Health Department (Washington) created a blueprint for climate and health action for their local health department through structured interviews of internal and external stakeholders in which knowledge of climate change and health, values, and priorities, were explored and translated into a strategic plan for the health department. Community input and community- led recommendations were central in the development of the Blueprint developed by the Public Health Department. 13. Tulsa City-County Health Department (Oklahoma) increased the capacity to conduct field surveillance of mosquitos carrying emerging diseases and to use the findings to guide education and enforcement activities in disadvantaged communities. Findings from the surveillance techniques informed local ordinances regarding screening mandates in houses and multi-unit dwellings. Additionally, the Tulsa learning collaborative team engaged across department programs to support the establishment of food forests, increasing tree canopy

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and local access to fresh foods, an excellent example of the health and equity co-benefits of climate mitigation strategies.

Learning collaborative participating LHDs are geographically diverse and cover the coasts, upper and lower Midwest and the southwestern United States. All of the health departments operated in communities with a significant place-based and race-based health inequities, and significant low-income and communities of color. The diversity of LHDs is also reflected in the populations served (365,000 to 10 million), number of employees (100 to 4,500), and annual budgets ($14 million to $893 million). The lead program was environmental health in 5 health departments and emergency preparedness in 4. Six health departments conducted a community-engaged assessment and strategic planning process. All 12 LHD projects focused on climate change adaptation, and five conducted a specific adaptation project such as rain water harvesting, improved epidemiologic surveillance, assessing home bound population heat vulnerability, mosquito surveillance, or interventions in faith-based communities. All projects partnered with either municipal or county governmental agencies, community- based organizations, or academic institutions.

Findings

Integration of Health and Climate Planning Processes

In 10 of the 12 LHDs, there was significant integration of climate change and health into internal and jurisdictional climate planning, implementation, and policy development. We observed bi-directional integration of: 1) climate change into on-going and/or routine LHD processes, and 2) public health into climate change planning processes led by city/county offices of sustainability or other governmental agencies.

Local Health Department Capacity Building

All participating LHDs engaged in some level of internal capacity building, but these efforts varied widely in intensity and success. Several LHDs targeted high-level management through interviews, which helped educate management, increase buy-in, and identify opportunities for broader engagement within the health department and external partners. Most of the LHDs conducted educational outreach to managers and/or staff across the department, utilizing regular venues for staff education (all- employee or divisional in-services, lunch-time seminars) or other regular meetings of executive leadership, managers and staff.

Health Equity and Community Engagement

By design, all LHDs were asked to integrate a community engagement component into their work and community engagement took various forms. Health departments conducting climate and health vulnerability assessments used a variety of data to identify vulnerability communities. Community-based organizations were essential

intermediaries who helped design and communicate the results of vulnerability assessments, and who channeled feedback from specific neighborhoods. Some projects catalyzed a coalition of community-based and governmental organizations that provide services to vulnerable populations. These coalitions explored ways to coordinate services and meet potentially increasing demand induced by climate change, as well as broader strategies to address climate change and its impact on health.

Participants used a variety of strategies and venues to educate and inform the public, community-based organizations, and partners about various aspects of climate and health, ranging from on-going workgroups (Philadelphia, New Orleans, Denver), community climate-health summits (Maricopa, Milwaukee), committee work integrated into larger community planning processes (Denver, Macomb), and neighborhood meetings (Minneapolis, New Orleans). Four LHDs (Multnomah, Minneapolis, Seattle/King and New Orleans) contracted with community-based organizations representing disadvantaged communities to inform, educate, and empower their constituencies.

Lessons Learned

The Learning Collaborative demonstrated that:

1. Local health departments can integrate climate change into on-going programs and routine processes even with limited resources

When given very modest resources, the LHD can rapidly become the recognized voice for climate and health in their jurisdiction. There are multiple entry points within LHDs into climate and health work. Emergency preparedness and environmental health are adaptation-oriented, but other programs aligned with chronic disease prevention, epidemiology and policy can readily incorporate mitigation. LHDs have skills that are easily transferable to work on climate change, for example analyzing and presenting data, community outreach and engagement, health risk communication, and serving as a convenor on health issues. The funding provided was minimal, but it provided a trigger for LHD engagement on climate change. The small grants were matched and exceeded by in-kind commitments that catalyzed significant activity within the LHD and across the jurisdiction, even in locations where no such prior work had occurred.

2. LHDs can foster more robust community engagement in vulnerable communities through a health and equity lens

LHDs are trusted and active partners in their jurisdictions, particularly in the vulnerable communities with whom they often work. LHDs can leverage existing formal and informal relationships with community partners to engage communities on the issue of climate change and health. The LHD's awareness of community concerns - particularly related to health inequities and the social determinants of health - provides a context and sensitivity for the discussion of climate and health that may allow LHDs to engage

with communities on this issue in a qualitatively different way than many other local government agencies.

3. In most jurisdictions, there are activities underway related to climate mitigation/adaptation/resilience. The to-date extremely limited engagement of LHDs in these processes means many health and equity missed opportunities.

The LHDs demonstrated an ability to rapidly engage with other agencies to inject a health and equity lens into jurisdictional climate activities. Over 50 of the U.S. largest cities participate in national (and international) initiatives on climate change sponsored by associations of mayors, cities, and nonprofit organizations (e.g. ICLEI).2 But in many jurisdictions, LHDs are not engaged in these activities. With even limited resources, LHDs can bring their expertise, skills, and community orientation into these processes as well as (and most importantly) a health and equity lens that we believe can enhance the benefits to disadvantaged communities of local government climate action planning.

4. Grant itself provides credibility & legitimization

Participants repeatedly stated that having the grant “legitimized” the work, and created a channel for buy-in within the health department and the jurisdiction. Leadership buy-in is critical and allows for more entrée to spread the work both inter- and intra- organizationally. The grant opened up opportunities for the LHD to be involved in ongoing processes it had previously either been ignorant of nor simply left out of, and to reach out to community partners on this important topic.

5. The visibility of the LC led to important discussions with other LHDs that created a "ripple effect" among non-LC LHDs to involve themselves in climate and health activities.

West Coast (Seattle/King, Multnomah, and Los Angeles) LC members have initiated outreach to other west coast LHDs through regional calls and conferences. In the Denver region, an informal collaboration of health officers in Front Range jurisdictions has prioritized climate change as a priority. LHDs in Ohio have asked Columbus staff if there will be opportunities to form an Ohio climate and health LC. Other LHDs appear to be very interested in the LC, but lack resources to initiate activities on their own. National organizations representing local health departments (e.g. NACCHO) have also registered an interest in the LC, including expression of interest in participating in any future LC by members of the NACCHO climate change workgroup. Center staff and LC participants had an opportunity to present on a climate and health panel at the NACCHO Annual Conference and shared preliminary learnings with the NACCHO Climate Change Workgroup.

6. Climate and health vulnerability assessment is an important basis for health department action.

A formal climate and health vulnerability provides evidence for action and offers excellent opportunities for engagement within the LHD, among governmental departments, and in the community. It can focus on individual risk factors (e.g. homebound) and social determinants of health, or on specific impacts (e.g. heat). The vulnerability assessment need not require a lot of resources beyond those available within the LHD's epidemiology programs and/or local universities. Vulnerability assessment appears to provide and important foundation, but is not sufficient to guide broad-based action that considers both adaptation and mitigation strategies, and is not a pre-requisite for LHD action on climate change.

7. The Learning Collaborative provided critical structure and a supportive process (beyond the small funding provided) that enabled the successes described above and in the attached LHD project descriptions.

CCCH was able to establish trust with the participating LHDs - especially through the in- person meetings and subsequent one-on-one calls - that fostered bi-directional learning and feedback. One-on-one consultative calls provided honest and non-judgmental dialogue about the project, progress, and challenges, and provided an opportunity for CCCH to prompt and encourage each LHD to move further into perhaps less comfortable territory - particularly related to health equity and community engagement. The one-on-one calls also provided specific technical assistance - e.g. data sources and methodologies, specific reports, and networking opportunities with others in and outside of the LC. Progress reports augmented a sense of project accountability. CCCH operated as a hub that made connections among LHDs facing similar challenges or doing related work. We recognize the outstanding talent among the LC participants, but also recognize that the overall success is a mutual product that has received national recognition.

The composition and experience of CCCH's staff is likely to have contributed to credible mentorship: a national leadership role with a broad network of public health contacts; expertise in establishing and managing public health programs, including those for climate adaptation and mitigation in local and state government; and, expertise in climate and health communications, policies, climate science and epidemiology, Health in All Policies, and health equity.

Challenges

General Challenges of Local Health Departments

To put the major accomplishments of the LC into context, it is useful to recognize the broader environment in which local health departments operate. Local health departments (roughly 2800) are part of a governmental public health infrastructure that includes state and federal agencies, including state health departments and the Centers for Disease Control and Prevention. The role and responsibilities of LHDs has grown over the last two decades, and a greater emphasis on community health, health

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inequities, and the social determinants of health has emerged. However, many local health departments experienced significant staff and resource reductions during the 2009 recession that have not been redressed despite economic recovery. According to evaluations by the Institutes of Medicine, the stable and sustained funding needed for the effective performance of the public health infrastructure remains unfulfilled.3 Increasingly, LHDs are faced with marshaling un-funded response to climate-related events (e.g., Zika, hurricanes, wildfires) that divert resources from other critical activities. Despite these challenges, local health departments continue to contribute to improving health status and form the backbone of the U.S. public health infrastructure.

Learning Collaborative Challenges

We identified several challenges, through 1:1 bimonthly meetings with each LHD, and through discussions on webinars and at in-person meetings.

• Communicating about climate change and health - to staff, policy makers, and the general public - is challenging. A high level of awareness of political polarization of this issue has led to fear of openly talking about climate change and self-censorship in which reference to climate change is omitted even from health messages about climate threats (extreme heat, mosquito-borne illness). Several LC participants found that this fear was unwarranted and that communities welcomed open discussion about climate change and health. Yet even in receptive environments, the integration of climate and health messaging into routine communications needs greater support. There is a pressing need to develop and implement effective climate and health communications that are field tested and evaluated in different public health programs.

• Managing success: Repeatedly, LC participants discovered an unanticipated interest - among both community partners and other agencies within the jurisdiction - in the health and equity impacts of climate change, as well as a latent demand for LHD input and leadership on this issue. This created a demand for LHD engagement that exceeds current capacity.

• Spread to multiple programs within LHDs: The LC focused on relatively large LHDs, in which it is often difficult to break down organizational and programmatic silos. LC participants with a primary focus on internal capacity building were more successful in spreading work on climate change across multiple programs than others with a focus on a more specific project (e.g. rainwater). High-level leadership commitment and engagement fostered greater spread, Many staff want to be more engaged but are uncertain how to do so given the relative dearth of precedents or models that integrate climate change into programs with siloed funding and mandates (e.g. nutrition education or restaurant inspection).

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address urgent needs - for example Zika case investigations (NOLA), preparing for a Papal visit (Philadelphia), or responding to a giant sinkhole (Macomb). Additionally, senior leaders in many LHD do not yet see climate change as an urgent priority on par with an infectious disease outbreak or gun violence.

• Direct peer-to-peer exchange, communication and sharing among LC participants was not as robust as we had hoped, likely due to the LHD’s limited resources, time, and internal competing demands. CCCH staff facilitated networking among various LHDs - often as follow-up to one-on-one consulting calls. Participants suggested that an additional in-person meeting at 5-6 months into the collaborative and/or participation of other more geographically neighboring LHDs would have helped strengthen sharing across departments.

• Broadening the focus to include mitigation: Most of the LC projects focused on climate adaptation, yet the greatest health co-benefits are in systems changes that lower carbon pollution, e.g. through active transportation and healthy food systems. More opportunities emerged for a mitigation component as LHDs became more conversant with the issue, strengthened their relationship with other climate-related agencies and engaged in more discussions with community members about climate change and health.

Significance

The Learning Collaborative has made a significant contribution to the advancement of the field, but there remain unmet challenges and needs for the individual participants and for spread to other local health departments.

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 clearly offer a venue in which it is feasible to integrate climate change and health, and thus both to find new opportunities to provide a health and equity lens in climate policy and programs, and to educate other jurisdiction staff about the links between climate change, health, equity and the co-benefits of climate action. LC participants also demonstrated an ability to integrate into many other types of intersectoral climate-related working groups within their jurisdictions.

Awareness and knowledge of the impacts of climate change on health and of the role of public health in addressing climate change is slowly increasing in LHDs across the nation; but very few LHD staff have had any training or professional development related to climate change. While those projects that focused on building internal capacity had a greater impact internally, many of the LHDs were able to raise awareness, engender interest, build executive leadership support, and identify potential roles for various parts of the LHD.

References

1. Roser-Renouf C, Maibach E, Li J. Adapting to the changing climate: An assessment of local health department preparations for climate change-related health threats, 2008-2012. PLoS ONE. 2016;11(3):e0151558. 2. America’s Pledge. America’s Pledge Phase 1 Report: States, Cities, and Businesses in the United States Are Stepping Up on Climate Action: Bloomberg Philantropies; 2017.https://www.bbhub.io/dotorg/sites/28/2017/11/AmericasPledgePhaseOneReportWeb.p df 3. Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century. Washington, DC: Institute fo Medicine of the National Academy of Sciences; 2003.https://www.ncbi.nlm.nih.gov/books/NBK221239/ 4. Dervin K, Rudolph L. Workshop Executive Summary Climate Change and Health Communications, October 2015. Oakland, CA: Center for Climate Change & Health; 2016.http://climatehealthconnect.org/wp- content/uploads/2016/06/ClimateChangeHealthCommunication2016.pdf

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I. BACKGROUND

From January 2016 to December 2017, the Center for Climate Change and Health (CCCH) organized and sponsored a learning collaborative on climate change and health for local, urban health departments in the United States. This report documents the activities of the collaborative and evaluates the 24-month effort in terms of its process and impact. The first chapter describes the background of the learning collaborative and the context of the evaluation. Chapter II pools this information to give a description and evaluation of cross-cutting themes, and Chapter III evaluates the CCCH in its role as convener. Chapter IV provides recommendations based on the synthesis of the preceding chapters. Chapter V provides a description and evaluation of the specific projects carried out by the learning collaborative participants.

Context and Goals

The Kresge Learning Collaborative for Local Health Departments

In May 2015 the Center for Climate Change and Health (CCCH) organized a "Learning Collaborative for Urban Health Departments" (LC) funded by the Kresge Foundation. CCH's broad goals for learning collaborative were to:

• Support LHDs to develop models that demonstrate a variety of ways in which urban local public health departments can develop, integrate, scale-up and replicate approaches that simultaneously address climate change, community health and vulnerable populations, and health equity.

• Demonstrate approaches that successfully incorporate climate change into local public health department program practice and/or enhance local public health department participation in on-going local and regional climate change mitigation, adaptation and resilience work (i.e. capacity building).

To support and incentivize participation, CCCH offered small grants of up to $30,000 for 18 months to 13 local health departments (Table 1). After one health department withdrew several months into the project, funding was reallocated and was sufficient to support 9 of the 12 remaining LHDs with an additional $10,000 for 6 months. This extended their participation to 24 months ($40,000 total). Eligibility was restricted to local health departments (LHDs) serving urban jurisdictions (cities or counties) with a population of 350,000 or more from diverse geographic areas across the United States. LHDs also were required to participate in bimonthly interactive consultation, bimonthly webinars, peer-to peer training, resource sharing, reflection, and two mandatory 2-day in-person meetings, and evaluation organized by the CCCH sponsor.

LHDs had broad discretion to choose the type of project as long as they addressed slowing or preparing for climate change (often referred to as mitigation or adaptation/resilience), or both. The proposed projects could address a specific program area in which the local public health department wanted to develop its capacity to address climate change, community health and health equity. Applicants could also have proposed a project that scaled up an earlier effort, and/or contributed to the broader work of LHDs on climate change, health and health equity by creating a replicable approach or activities.

Projects could incorporate climate change into a variety of public health programs, including, but not limited to: chronic disease, asthma, nutrition (healthy food access/food security), maternal/child/adolescent health, communicable and vector borne disease, public health nursing, community health education, public health preparedness/ emergency response, built environment, environmental health, health planning, Health in All Policies, and health equity. Projects could also demonstrate potential strategies for local health departments to explicitly incorporate health and health equity into local or regional efforts to address climate change.

Applicants were informed that projects that focused on increasing climate resilience in disproportionately impacted communities, and that showed potential for replication in other programs and local health departments were favored.

Outreach and Application Review

A request for applications (RFA)5 were posted on the website of the Center for Climate Change and Health in May 25, 2015 with due date of July 30, 2015 and award notification of September 15, 2015. An informational conference call was held on June 17th that was attended by potential applicants. Additional outreach was conducted by CCCH staff (KD), who personally contacted representatives of the National Association of County and City Health Officials (NACCHO) and Association of State and Territorial Health Officials (ASTHO), whose members include state and local health jurisdictions, and whose organizations had previously sponsored grant programs on climate and health. CCCH staff leveraged their existing relationships with these and other national associations, including the Centers for Disease Control, and spoke directly to several local health departments to encourage their applying.

Thirteen applications were received by the deadline. Each was screened and reviewed for completeness by CCCH administrative staff and the programmatic content was reviewed by three CCCH staff using criteria stated in the RFA (Table I-1). Written notes captured strengths, weaknesses, and concerns of each proposal, and an overall assessment of the likelihood the project would build capacity, engage communities, and address vulnerable populations/disadvantaged communities. The notes were discussed in a session with all three reviewers. Although individual criteria were assigned scores, the criteria functioned as a checklist and talking points for discussion among the

3 reviewers. Because the applicant pool was small and nearly equal to the number of anticipated awards (12), a dispensation was made to fund all 13 applicants with the

Table I-1. Application Review Criteria Review Criteria Max. Pts 1. About your department/agency (20 points)

Provide a brief description of any work that your local health department has done to date on any of the following: • Work that explicitly addresses climate change and health 4 • Work that explicitly addresses health equity and the social determinants of health 4 • Work on public health programs or activities with climate change co-benefits (e.g. that reduce greenhouse gas emissions or increase climate resilience and simultaneously 4 improve health) • Intersectoral work with other agencies that are engaged in work on climate change. 4 Work with community based organizations that currently or potentially work on climate • 4 change and health 2. Project Description (40 points)

Describe the proposed project including:

• What will the project do? 7 • What are the goals and desired outcomes? 7 With what agencies and/or community-based partners will you work to plan and • 7 implement this project? • Indicate if this is a new program area or will complement existing work. 6 How will this project help to build your LPHD’s capacity to address climate change, • 6 health, and equity? Describe how this project will involve and/or focus on health equity and • 7 vulnerable/disproportionately populations. 3. Project Implementation (40 points)

Describe your anticipated staffing needs

• Provide the name, title and qualifications of the project coordinator 6 • Name and title of any project team members 3 Describe the LPHD program or office in which this project will be based, and why it is well • 6 suited for initiating or expanding work on climate change. • Describe your community partners and how you will collaborate to implement the project. 6 • Describe how your organization and its partners are capable of carrying out the work of your proposed project, based on your past work/track record, history of collaboration, and 6 commitment to building capacity and relationships on climate change, health and health equity. Describe any foreseen potential challenges or risks and how you plan to overcome them. • 6 Please include how you will ensure the ability to expend funds on a timely basis. Provide a complete work plan with project goals, specific, attainable and relevant • 6 objectives and a timeline 4. Summary • What we like, what we don't, concerns, weaknesses, and strengths. • Is the project likely to lead to building capacity within the LHD, or could it do so? • Is there adequate community engagement described, OR engagement with other agencies? OR, good reason why not? • Does the project adequately address equity/vulnerable pops/disadvantaged communities?

5 proviso that concerns of CCCH staff be formally discussed and applicants revise their scopes of work to address those concerns. The concerns focused on the adequacy of engagement between the applicant and other programs within the local health department, the timing and nature of community engagement, and the ability to leverage a project with a narrow scope (clinical, epidemiologic surveillance) into one with wider impact.

Project Extensions

A budget reallocation in 2017 provided funds to extend LC for an additional 6 months for some of the participants as $10,000 supplements to their original grants. (The unused portion of a grant from a LHD that withdrew in 2017 provided some of the funds, but funds were not available to extend all 12 LHDs.) The extension requests were competitive, and in a 4-question form, applicants were asked to describe the additional program activities, how the extension would help internal build in the LHD, how the extension would deepen relationships on this issue with other agencies in your jurisdiction, and how the extension would deepen relationships with community-based organizations and build community capacity. Nine of the 12 health departments were granted an extension.

Description of the Applicants

Key attributes of the thirteen local health departments in the Kresge Learning Collaborative are summarized in Table I-2 and Figure I-1. The local health departments are geographically diverse and cover the coasts, upper and lower Midwest and the southwestern United States. In terms of population served, New Orleans was the smallest (365,000) and Los Angeles was the largest (10 million). In terms of number of employees, Minneapolis was the smallest (100) and Los Angeles was the largest (4,500). Six health departments were city agencies; six were counties agencies, and 3 were a combined city-county agency (Denver, Philadelphia, Tulsa). Annual budgets ranged from $14 million in Milwaukee to $893 million in Los Angeles. The lead program in 5 health departments was environmental health; in 4 health departments the emergency preparedness program was the lead; in 2 the projects were co-lead by both environmental health and emergency preparedness, and in 2 other departments the project was led by epidemiologist or a program in the Directors office. Six health departments proposed a community-engaged assessment and strategic planning process. Five health departments proposed a specific adaptation project such as rain water harvesting, improved epidemiologic surveillance, assessing home bound population heat vulnerability, mosquito surveillance, or interventions in faith-based communities. All 13 projects centered on climate change adaptation, but 3 had some element of climate change mitigation (Los Angeles, Columbus, Multnomah). All projects partnered with either municipal or county governmental agencies, community-based organizations, and academic institutions. Eleven health departments described their vulnerable populations in terms of low income people of color. Based on prior epidemiologic surveillance, the two Arizona health departments identified specific vulnerable populations as elderly, homeless, home-bound, substance abusers, mentally ill, and outdoor occupations. Five health departments reported that prior to the Kresge

Table I-2. Kresge Climate and Health Learning Collaborative Awardees, January 2016-June 30, 2017 1 2 3 4 Item City of Columbus, OH City and County of Denver, CO Los Angeles County, CA Macomb County, MI Population 835,000 663,862 10 million 860,112 Number of Cities 1 1 85 13 No. of Employees/FTEs 400 190 4,500 155 Annual Budget, millions $46 $37 $893 $21 5: Population health; clinical 7: Community Health; Public 5: Environmental Health; 6: Office of Emergency health; neighborhood health; Health Inspection; Denver Animal Maternal, Child Health; Preparedness; Medical family health; environmental Protection; the Office of Medical Communicable Disease Examiner; Planning and Number of health Examiner; Environmental Quality, Control and Prevention; Quality Assurance; Divisions/program the Executive Director’s Office, Chronic Disease and Environmental Health; s and the Office of Injury Prevention; Health Family Health Services; Sustainability Facilities Inspection; Health Promotion/Disease Control

Environmental Quality/Air, Water, Environmental Health/Office Joint Environmental Participant's and Climate, and Community Emergency Preparedness of Environmental Protection Health & Emergency Division/program Health Planning and Program and Sustainability (OEP&S) Preparedness Assessments Community-engaged faith community Create a freely available climate Interdepartmental assessment and strategic engagement; climate and health vulnerability mapping coordination; action plan Nature of Project conversations leading to tool at the Denver neighborhood planning to implement (Initial proposal) congregational and individual level, which provides a "Five Point Plan"; create actions for climate adaptation framework to target resources to framework for extreme and mitigation vulnerable communities heat response Climate Adaptation/Mitigat Mitigation/adaptation Adaptation: heat, air quality Adaptation: Extreme heat Adaptation: flooding ion and Mitigation action planning

1 2 3 4 City and County of Denver, Item City of Columbus, OH Los Angeles County, CA Macomb County, MI CO Partners Faith-based CBO, academic, CBO (Groundwork Denver County departments; Municipal governmental municipal government Rocky Mountain Climate academic; non-profit (Warren Sterling Heights), Organization); municipal organizations; community- State health and human (Ohio Interfaith Power and government agencies based organizations services agency; academic Light; Ohio State University (Community Planning and (U of Mich) School of Environment and Development, Mayor’s Office Sheriff’s Department (reverse Natural Resources; City of of Sustainability, Office of 911 system), the Departments Columbus Office of Economic Development, of Public Social Services, Environmental Stewardship) Public Works, Parks and Aging, Community and Senior Recreation Services, Parks and Recreation, and the Public Library (all of which operate cooling centers), cities, and the Los Angeles County Metropolitan Transportation Authority; Citizens for a Better Environment; Climate Resolve, TreePeople; UCLA, the University of Southern California, and Loyola Marymount; regional climate collaborative (Los Angeles Regional Collaborative for Climate Action and Sustainability) Vulnerable low-income people of color low income, people of color low-income people of color low income, people of color populations

53% White, 31% Latino, 10% 85.4% White (including 52% White; 48% Latino; 9% Race/Ethnicity 28% African-American Black, 4% Asian, 2% Native Arab), 8.6% Black or African Black; 14% Asian American American

1 2 3 4 Item City of Columbus, OH City and County of Denver, CO Los Angeles County, CA Macomb County, MI Health Climate education survey Annual greenhouse gas Strategic climate-health None department's prior with Ohio State University; inventories, collaboration on "Five Point Plan to climate change climate change seminar; Climate Action Plan Reduce the Health and health work education of medical Impacts of Climate residents on climate change Change"; 2013 with its Climate & Health Workshop Series; two Climate & Health Reports (2014); participates in inter-departmental County Climate Committee, Healthy Design Workgroup; Sustainable Solid Waste Working Group City/County 2007, 2014, Climate Action Plan Climate Action 2005, Get Green/Green with health department 2015 Community Climate None found for county, Plan, date, Memo sustainability plan; participation Action Plan Warren or Sterling Heights; update, and update expected 2016 with (Unincorporated LA Coastal Resiliency for health department OEP&S collaboration County); Mayors Macomb County (no health participation Sustainability plan department participation)

Denver Environmental Health is a Largest health department Greenspot web-based tool separate entity from Denver in the United States; only Comment for pledging institutional and Health, which provides clinical health department that Massive flooding in 2014 individual climate action services, outbreak investigations, has a full-time position for health promotion climate coordination

part time in-kind PI from two, part-time LHD project 2-part time staff one part-time, in-kind LHD LHD, and partner agencies; coordinators; external supervising 1 contracted PI + 4 LHD; contract to Staffing 50% time LHD education consultants for mapping and data staff person full 11 external community health coordinator months planner

5 6 7 8 Minneapolis, Hennepin Item Maricopa County, AZ City of Milwaukee, WI Co., MN Multnomah County, OR Population 3.8 million 599,642 407,000 766,135 14 (9> 100,000 pop; 1 Number of Cities Phoenix) 1 8 (Portland) No. of 100 Employees/FTEs 633 139 306 Annual Budget, $20 $63 millions $14 $50 5:Program Operations; 4: Disease Control and 4: Adolescent Health and 6: Equity, Planning, & Community Transformation; Environmental Health; Family Youth Development; Strategy; Community Community Health Action; and Community Health; Health Environmental Health; Epidemiology Services; Performance Improvement; Laboratories; Consumer Research and Evaluation; Environmental Health Number of Disease Control Environmental Health Policy and Community Services; Maternal, Child, & Divisions/program Programs; Family Health; HIV/STD/ s Adolescent Sexual Health Equity; Communicable Disease Services

Participant's Disease Control/Office of Division of Disease Control and Environmental Health PHP Division/program Epidemiology Environmental Health Services

community-engaged Community-engaged and Assess community needs planning process and informed community and capacity to provide heat- Plan, design, implement adaptation plan for resiliency/vulnerability Nature of Project related prevention services to rainwater harvesting systems to extreme heat and flooding indicator system for (Initial proposal) homebound individuals and supply the watering needs of two development of local climate launch multi-agency community gardens and engage resiliency policies intervention collaborative community on climate and health

5 6 7 8 Minneapolis, Item Maricopa County, AZ City of Milwaukee, WI Hennepin Co., MN Multnomah County, OR Climate Adaptation: extreme Adaptation: heat, wildfire, Adaptation/Mitigat Adaptation: extreme heat Adaptation/Mitigation: food heat flooding drought/flooding, air quality ion security and storm water management Partners CBO (Area Agency on CBOs (Community organizations Municipal CBO (Climate Justice Aging); Academic (Arizona Reflo, Alice’s Garden, Guest government, Collaborative of 6 organizations), State University); House, Milwaukee Water academic governmental agencies; County/state government Commons, Urban Ecology academic (Arizona Department of Center) and governmental (Sustainability Office, Health Services (ADHS) – agencies (Government agencies University of BRACE; Maricopa County Environmental Collaboration Minnesota Department of Human Office, Dept. of City Humphrey School of Services; City of Phoenix Development, Office of Public Affairs) Environmental Sustainability), and academia (University of Wisconsin-Milwaukee

Vulnerable low income, elder, low-income people of Homeless low income, people of color populations homebound color Large Somali, AIAN, 44.8% White, 40% Black, 17% and Hmong Race/Ethnicity 57% White, 31% Latino 79% White, 6% Asian, 6% Black, Latino, 4% Asian 1% Native American, 0.4% Pacific Islander Health Heat-related surveillance None MOUs with CBOs, department's prior CDC pilot, state climate change health department The Climate Preparation Strategy and health work (BRACE), GLIOSA, and Climate Action Plan; incorporated climate adaptation and preparedness into planning efforts of Metro Parks and regional transportation planning agency; Climate Equity Workgroup

5 6 7 8 Minneapolis, Item Maricopa County, AZ City of Milwaukee, WI Hennepin Co., MN Multnomah County, OR 2013 ReFresh Sustainability 2009, 2014 Climate Action Plan Plan, no participation by Health City/County, 2015 Climate City/County Department Preparation Strategy with health Climate Action 2013, public health department participation; Climate Plan, date, advisory committee Equity Section and update, and 2009, Phoenix Climate with some PHD Implementation Plan for 2015 health department Action Plan (done with members update of the Climate Action Plan participation ICLEI); 2013 Sustainability Report (no health department participation) 4 part-time, in-kind LHD staff; two-1% time LHD staff; external two-5% time LHD 1 in-kind, 5% LHD, 10% paid 25% time contracted project consultants (Reflo); staff and contract to LHD coordinator; stipends to 6 coordinator; 1 part-time, in- materials are 30% of costs academic CBOs Staffing kind university professor consultants advisor

CBOs are under contract of health department to carry out Comment community engagement; health

equity lens institutionalized in health department processes

9 10 11 12 13 Philadelphia City- Seattle-King Tulsa City-County, Item New Orleans, LA County, PA Pima County, AZ Co, WA OK Population 365,00 1.56 million 1 million 2 million 609,610 Number of Cities 1 1 2, (Tucson) 39 8 No. of 208 1,500 Employees/FTEs 353 370 350 Annual Budget, $39.5 $316 millions $130 (incl Beh health) $35 $29 9: Essential 7: AIDS Activities 6: Animal Care; Community 5: Preventive 5: Food Safety; Services; Healthy Coordination; Maternal, health Assurance; Strategic Services; Personal Health; Environment/Emerg Child, Family Health; Air Integration (Epidemiology/ Environmental Family Health; ency Prep; Healthy Management Services; Surveillance); Clinical Health; Community Health; Start New Orleans; Environmental Health Consultation; Clinical Services; Community Environmental Health Health Care for the Services; Disease Public Health Nursing Health; Number of Homeless; Ryan Control; Laboratory Emergency Divisions/program White Program; Services; Medical Medical; s Violence & Examiner Correctional Behavioral Health; Health and Family Health- WIC; Rehabilitation Hypertension Services Control; Youth Gang Prevention Healthy Environmental Public Disease Control/Public Participant's Environments & PCHD Climate Change Health Health Preparedness EH/PHP Division/program Emergency Program/Director's Office Division/Environment Program Preparedness al Health Services

Improve and enrich ED records Internal & asthma patient and for HRI cases; assess feasibility External Nature of Project "BRACE" lite provider educational Mosquito-vector and utility of real-time HRI Capacity (Initial proposal) adaptation planning and unhealthy air day surveillance surveillance; better understand Building and notification (registry) and design directed prevention "blueprint" strategies for vulnerable groups

9 10 11 12 13 Philadelphia City- Seattle-King Tulsa City-County, Item New Orleans, LA County, PA Pima County, AZ Co, WA OK Climate Adaptation: extreme Adaptation: heat-related Adaptation: Adaptation: vector- Adaptation/Mitigat heat flooding, asthma-respiratory Adaptation: extreme heat heat, air borne disease ion vector-borne illness pollution Partners Governmental, CBOs, hospitals; Emergency Health Care facilities; county and city City/county academic academic occupational; vulnerable governmental, governmental, populations (homeless, academic academic (New Orleans (Asociación de substance abuse, mental health, Redevelopment Puertorriqueños en elders) (King County (Oklahoma State Authority – Resilient Marcha; Clean Air departments; University Extension NOLA; Trust for Council; Energy Labor (OSHA, NIOSH, Arizona City of Seattle; Office; INCOG – Public Land; Coordinating Agency; Construction Training Alliance); Puget Sound regional planning Louisiana Public Physicians for Social Healthcare (University of Arizona Clean Air agency; Local city Health Institute; Responsibility; Emergency Department; UA Agency; municipalities; Tulsa Tulane University; American Lung College of Pharmacy; local Center for County; Parks Louisiana Association of PA, clinics; Arizona Pharmacy Health and departments; Department of Healthy Air Campaign; Association); Behavioral health Global Oklahoma State Health and Asthma Care Clinic; St. (Pima County Behavioral Health Environment Environmental Hospitals; Christopher's Hospital Services; Emergency responders (CHANGE), Science Graduate Department of for Children; National (Tucson Fire and Police); Tribal UW) College; Oklahoma Public Works & Nursing Centers government (Tohono O’odham Department of Sewerage and Consortium; Temple and Yaqui Nations); Elders (Pima Environmental Water Board; New University) Council on Aging, Physicians for Quality; Oklahoma Orleans Mosquito, Social Responsibility) State Department of Rodent & Termite Health; Oklahoma Control Board) Department of Agriculture, Food and Forestry)

9 10 11 12 13 Philadelphia City- Item New Orleans, LA County, PA Pima County, AZ Seattle-King Co, WA Tulsa City-County, OK homeless, substance Vulnerable low-income people of low-income people low-income people of low-income people of abuser, mentally ill, populations color of color color color elders, occupational 61% African American 36% Latino; 19% < FPL; 18% >65 years old; 23% non-English 42% Black; 27% 72% White, 10.3% Race/Ethnicity substantial part-time speakers; 19% foreign living in poverty Black, 11.2% Hispanic populations of students born and snow-birds Health None None Heat related • Development of goals None department's prior ER/hosp/death and actions for the climate change surveillance identifying 3 2015 King County and health work high risk groups: outdoor Strategic Climate workers; homeless, Action Plan substance abusers, and • Participation in the mental health; elderly King County’s Executive Action Group on Climate Change • Partnership with City of Seattle and the Puget Sound Clean Air Agency in Seattle’s Chinatown/Internationa l District, and neighborhood leaders to understand community networks, assets, and strategies used to deal with extreme heat and air pollution.

9 10 11 12 13 Philadelphia City- Item New Orleans, LA County, PA Pima County, AZ Seattle-King Co, WA Tulsa City-County, OK 2008, 2015 GreenWorks City/County Sustainability Plan; 2015 City of Tucson Climate Action Public health 2010 Tulsa City 2009, GreeNOLA; no Climate Change 2012, 2015 developed Plan, date, Department Sustainability Plan, no health department Committee (PSR with health department update, and responsible for health department participation representative, no health participation health department healthy foods and participation department) participation healthy homes (lead and energy efficiency) 1 part-time LHD 1 part-time, in-kind 20% in-kind LHD PI, 15% 2 part-time, in-kind 3-part time (5%-7%) coordinator project coordinator LHD data analyst; 30% LHD and contracts to LHD staff supervising two from LHD; time paid MPH intern community-based graduate interns (materials largest partners/consultants Staffing (vulnerability expense) assessment); two external consultants for adaptation planning

Only local health Air pollution control Joint entity of City of department in Comment agency is part of Tulsa and Tulsa Louisiana; Rockefeller Health department County governments Resilient City

Figure I-1.

Learning Collaborative, their health department did not engaged in climate change and health planning or other activity. Except for Macomb County, each jurisdiction municipal or county government had published a climate action or sustainability plan prior to start of the learning collaborative. Seven health departments reported having formally participated in their jurisdiction's (or major city within the jurisdiction) strategic plan for climate action or sustainability. In four jurisdictions (Maricopa, Milwaukee, Pima, Tulsa), the health department apparently did not play a role in the development of their jurisdiction's climate or sustainability plan. Most health departments directed the majority of their $30,000 to hiring staff or consultants. In two projects materials (Philadelphia, Milwaukee) were a large expense. Seven health departments provided part-time, in-kind staff (generally the principal investigator or project coordinator). Health department staff hired and paid on the grant ranged from 1% to 50% time. Three health departments had external contracts or consultancies with community-based organizations to help carry out community engagement (Macomb, Minneapolis, Multnomah, Seattle-King). In two health departments (Minneapolis and Seattle-King) community -based partners had long-standing and existing MOUs to facilitate community participation.

Prior Efforts

Since 2010, the federal National Center for Environmental Health at the Centers for Disease Control and Prevention (CDC) has engaged state and local health departments on climate change and health through cooperative agreements with ASTHO6, NAACHO7 (2010-2014), and 16 states and two cities in its Climate Ready States and Cities Initiative (CRSCI).8 From 2010 to 2012, ASTHO provided six states with up to $90,000 per year to build capacity to prepare for and respond to the health challenges of climate change (Table I-2, Figure I-1). In 2012, NACCHO funded six local health departments as demonstration sites. From 2012 to 216 the CDC has directly funding state health departments ($100,000-$237,000 per year) to implement its 5-step model for climate adaptation (Building Resilience Against Climate Effects, BRACE).9

The ASTHO and NACCHO grants and demonstrations carried out internal needs assessments, training and education of public health leadership and health professionals on climate change and health, strategic planning, and community/stakeholder engagement. These efforts as well as CDC's CRSCI almost exclusively addressed climate change adaptation rather than mitigation. Some ASTHO and CDC state projects passed through funding to local health jurisdictions to stimulate local activities (e.g., California, Oregon, Maryland). These capacity building programs did not describe themselves as learning collaboratives but did include some but not all the hallmarks of a learning collaborative such as in-person meetings; regular, ongoing convening by a sponsor; technical support; individual consultation; learning opportunities; peer-to-peer sharing and networking; and common communications channels. To our knowledge, no formal evaluation was conducted on the ASTHO and NACCHO programs, which ended by 2014. Evaluation is a pillar of the CDC BRACE model, but no formal evaluations have been published of the first full cohort of BRACE awardees (2012-2016).

Table I-3. ASTHO, NACCHO, and CDC-sponsored Climate and Health Capacity Building in State and Local Health Agencies, United States, 2010-2016 A. ASTHO Year(s) Jurisdiction Activities Climate Change Collaborative (multi-disciplinary team of 22 experts from 18 different organizations): ASHTO policy statement; input on state grants; survey of states/territories; 2008-15 Multiple contribute to 3rd National Assessment; outreach at national meetings of directors of public health preparedness and environmental health Internal needs assessment of California Department of Public Health, and external needs assessment of local health officers, health care organizations; identified strategies, goals, 2010-12 California and activities for both adaptation and mitigation; provided trainings to public health professionals; developed a climate vulnerability screening tool Educate senior leaders at Florida Department of Health; 6 regional educational workshops 2010-11 Florida and regional initiatives; survey of attitudes and needs of local health departments. Develop 5-year strategic plan for the Michigan Department of Community health via a 2010 Michigan needs assessment, identifying strategies (10 essential services of public health); and multi- stakeholder planning process. Educational trainings for health professionals. . Strategic plan development by Minnesota Department of Health via climate change work 2010 Minnesota group, needs assessment survey, training of health professionals, communications plans, and external outreach. New Hampshire Department of Health convened multisector stakeholders for needs New 2010-12 assessment (10 essential services of public health); priority setting for mobilizing Hampshire partnerships, education, funding for capacity building. 2012 Indiana No report available Created a forum for city departments to engage with academic institutions, community leaders and state health officials to exchange ideas and develop priority actions for 2012 Rhode Island addressing the health impacts of climate change in Providence, RI. (State does not have local health departments.) (Adaptation focused) Wisconsin Department of Natural Resources engaged several state agencies and local community partners in moving climate adaptation from discussion to implementation of local 2012 Wisconsin government adaptation priorities in La Crosse City/County. Community engagement; community-wide workshop of stakeholders; facilitated discussion and strategy sessions

B. NACCHO-Sponsored Demonstration Sites, 2012 County/State Activities Mercer County Climate Change Action Committee is a group of county emergency responders and community planning partners; The Climate Adaptation Plan identifies target groups affected, Mercer Co., IL analyzes risk factors, identify impacts, prioritizes impacts, develops strategies, and addresses barriers. The City of Austin developed and piloted a five-step strategy to integrate public health priorities into regional climate change policies and interventions: 1) perform a regional scan of environmental Travis Co, TX hazards 2) identify the scope of influence 3) perform a gap analysis, 4) build a coalition of stakeholders, and 5) prioritize recommendations for action Created and delivered presentations to over 180 stakeholders about the public health impacts of Thurston Co., WA climate change to help develop knowledge and capacity among health department staff and external partners. The Environmental Health Program (EHP) of the Hennepin County Human Services and Public Hennepin Co, MN Health Department (HSPHD) worked with licensed food and lodging establishments to identify sources of and means to reduce carbon dioxide (CO2) emissions through a survey. This three-part video series was created by the Orange County (FL) Health Department as an educational tool to teach health department staff, external partners, and the general public about Orange Co., FL the health effects of climate change in Central Florida. The training presentation was given to 82% of Orange County (FL) Health Department staff, accompanied by pre and post-training assessments to determine the knowledge gained by staff through the training. Completed an internal self-assessment process that focused on the 10 Essential Services of Public Imperial Co, CA Health; conducted staff training “Climate Change and Public Health: A Primer"; developed and strengthened collaborations with community members, organizations, and agencies.

C. CDC-Sponsored Climate Resilient State a & Cities Initiative, 2012-2016 State/City Activity 5-step adaptation model: 1) anticipating climate impacts and assessing vulnerabilities, 2) projecting All: BRACE the disease burden, 3) assessing public health interventions, 4) developing and implementing a Model climate and health adaptation plan, 5) evaluating impact and improving quality of activities Arizona Heat-related illness California Heat, sea level rise, wildfires; injuries, chronic disease; mental health; 10 LHD subgrants Florida Heat, tropical storms, extreme precipitation/drought Illinois Heat, asthma, flooding, vector-borne disease, mental health Maine Heat related outcomes, vector-borne disease Maryland Heat-related illness, infectious disease, extreme weather injuries; 4 county pilots Massachusetts Water, food, and vector borne diseases, heat stress, hazardous weather events, respiratory diseases Michigan Heat related disease, respiratory disease Minnesota Extreme heat events, vector borne disease New Hampshire Severe weather and heat injuries, respiratory illness, vector-borne disease New York Extreme weather, waterborne, food-borne, and vector disease New York City Heat-related morbidity and mortality, respiratory illness, water-borne and vector-borne disease Temperature related morbidity and mortality; extreme weather; air pollution; water, food, and vector North Carolina borne diseases Oregon Water and food borne diseases, extreme weather, ecosystems; 4 county projects Rhode Island Extreme weather, heat, sea level rise San Francisco Heat stress morbidity and mortality associated with air quality impacts; sea level rise Vermont Heat, vector-borne disease Wisconsin Extreme heat, changing precipitation patterns and flooding, drought, vector-borne diseases

Other Contextual Issues

The Kresge Learning Collaborative coincided with several notable events that may have influenced public perceptions and the urgency attached to climate change and health for the applicants, their management, and the communities with whom they interact. These include the 2015 Paris Climate Agreement,10 the 2015 encyclical of Pope Francis on our common home and human-induced climate change,11 the worsening Zika epidemic with sustained, local transmission in Florida in 2016,12 record breaking temperatures in many world and U.S. locations (2015-2016)13, and a rapid sequence of devastating hurricanes (fall 2017) in Houston (Hurricane Harvey), Florida (Hurricane Irma), and Puerto Rico (Hurricane Maria). Polarization and policy gridlock on the topic of climate change persisted in the U.S. Congress and many state legislatures. In the aftermath of the national elections in November 2016, many Obama era climate initiatives, including the Clean Power Plan, have stalled or have been reversed by the Trump administration.

Overview of the Learning Collaborative Process

The Climate and Health Learning Collaborative was conceived by CCCH as a convened, self-conscious group of local health departments with broad common goals to engage their health department, jurisdiction, and community on climate change and health through the lens of health equity. The goals would be realized by their organizing and conducting a local project and utilizing collective resources organized and provided by the collaborative organizers - the Center for Climate Change and Health. These collective resources included learning activities, networking and relationship building, common communications platforms, and information sharing. Opportunities for networking and information sharing included structured and non-structured venues, including face-to face annual meetings; bimonthly informational webinars on topics suggested by both local health departments and the CCH; bimonthly 1:1 personalized calls to share progress, accomplishments and challenges, and make referrals to collaborative other members with similar challenges or solutions. An overview of the timeline and processes of the learning collaborative are presented in Figure I-2.

After awards were made in September 2015, CCCH requested that awardees spend a few more weeks to further familiarize themselves and gather additional information, if necessary, about activities on climate change in their jurisdiction and among their partners (Table I-4). This information and refinements to the scopes of work were discussed in 1:1 meetings November 2015, after which, the scopes of work were finalized

CCCH Staffing of the Learning Collaborative

The CCCH staff of the LC was made up of the principal investigator (20% effort), a project coordinator (50%), and a senior scientist (33%). . There was no turnover in positions for the principal investigator (a public health physician with an MPH and the senior scientist (a PHD, MPH epidemiologist). Four interns, who were primarily involved with content development for the CCCH website, played incidental roles, although one.

Figure I-2. Overview of Learning Collaborative

Joint CCH & LHDs Application In-person Kick-off Meeting (7/1/2015) (1/13-14/2016)

Awards (9/15/2015) Projects 1:1 Calls Webinars Columbus, OH Feb 2016 Mar – Vulnerability assessment Denver, CO Apr Jun May – Communications Los Angeles Co., CA Aug July – Heat Environmental Macomb Co., MI Scan Oct Sept – Co-benefits Maricopa Co., AZ (9-10/2015) Dec Nov – Community engagement Milwaukee, WI Feb 2017 Jan 2017 – Evaluation Minneapolis, MN Apr Multnomah Co., OR Mar – Integration CC in LHD Jul programs First 1:1 Call New Orleans, LA Sep (11/2015) Philadelphia, PA Nov May – Community engagement Seattle-King Co., WA Key Informants Aug – Internal capacity building Tulsa, OK Nov

Finalized SOW (2016-May 2017) In-Person Meeting (5/2017) Evaluation

Table I-4. Background Information for First Learning Collaborative meeting

(Please note: these are questions we will explore with you in November-December in a telephone call to be scheduled later. We are not asking you to provide this information in writing. If you feel confident that you can answer these questions fairly accurately and thoroughly without gathering any more information than what you currently have, great! But if you do not feel confident about this, please take some time over the next 5-6 weeks to gather this information. We appreciate that many of you have provided some of this information in your applications).

1. Briefly describe current activities related to climate change and health within your health department. Please make sure to reach out to all programs in the health department to find out if any are doing work that is related to climate change and health.

2. What processes and structures are currently used in your health department to build staff capacity around emerging public health issues, and how will this project contribute to internal capacity-building on climate change and health?

3. Briefly describe what other government departments or agencies in your jurisdiction are doing related to climate change. For example, has your planning agency developed a Climate Action Plan, or has your emergency services agency developed climate-related contingency plans?

4. Briefly describe the work of key community-based organizations and not-for- profits (both your partners and others) in your community related to climate change, health equity, and environmental justice.

5. What are some of the things you think your team might best be able to contribute to the learning collaborative? Are there any resources on climate change and health that you would like to share with collaborative members?

6. What are some of the things your team would most like to get from the learning collaborative?

(recent MPH graduate with a focus in climate change and global health) was hired to replace the original project coordinator who retired in December 2016. Thus, staffing was stable and provided continuity to the LC. The LC activities were internally discussed and coordinated at regular CCCH biweekly staff meetings. Extra meetings were scheduled, as needed, for events (such as webinars, in-person meetings, 1:1 calls) and evaluation.

Communications

Group communications with the applicants was facilitated with a GoogleGroups listserve ([email protected]), which, through a monthly newsletter, posted administrative announcements, reminders of upcoming events (e.g., dates for progress reports, webinars), feedback questionnaires, and new resources, some of which were generated by LC participants A GoogleDrive, accessible to all the participants (but not the public), was the repository of the roster of participants and their contact information, brief descriptions of the projects, webinar slides, in-person meeting presentations of CCCH and LC LHDs, and other resources (journal articles, reports, interview guides, questionnaires, etc.). CCCH-LC staff planned, executed, and evaluated the webinars. Brief electronic questionnaires (using Survey Monkey) captured the utility of the content and process.

Evaluation

CCCH staff developed an evaluation plan in August 2016, the product of which is this report. The aim of the evaluation was to provide detailed documentation of the project, assess whether its goals were being met, distill lessons learned, and make recommendations for next steps. The evaluation was done by CCCH staff using existing project resources. It relied on administrative data generated in the course of the project (applications, scopes of works, 1:1 notes, feedback from the webinars, progress reports, etc.), which were supplemented with brief interviews of the participants and key informants, who included leadership of the health departments and officials from the jurisdiction's governmental agencies and community partners. The questions posed to LC participants were:

"As you think about your work on climate change and health over the last 2 years:

1. What are a few of the things you are most proud of? What do you feel you've been able to accomplish?

2. Do you think this project has had any impact on: • your department? If so, how? • your collaboration with other departments in your jurisdiction? • your community? If so, how? • your work with community partners? • your own work?

3. Are there any specific resources or project support activities that would have made it easier to do this work?"

Questions posed to key informants were:

1. From your perspective what do you see as the primary impact of the LC project? • Within your organization? • Do you think that the LC was visible to people in the external community? If so, was there was any sort of impact in the community? • Have you seen impacts across other organizations in your jurisdiction? 2. Are there specific things you think have been helpful about this project? • Has it impacted the way you do your work? 3. What could have been done to make this project more impactful? 4. How has this project shaped future climate work in your jurisdiction? How has it changed your thinking about climate and health? • How might that impact your future work? 5. Are there things you would like to see the LHD do in relation to climate change in the future to support your work on climate change and what would that look like? 6. What would you like to see in terms of next steps for climate and health work in your jurisdiction? • What is needed to support climate and health work in your jurisdiction

We also collected information from LC participants on their assessment of CCCH's role in conducting the learning collaborative as well as the usefulness of the components (webinars, 1:1s, the two in-person meetings, project communications, technical assistance, etc.) and their suggestions for improving the LC process (Chapter IV).

In-Person Meetings

CCCH hosted two, 2-day, in-person meetings in Oakland, California in January 2016 (kick-off) and May 2017 (final). The agendas of the meetings are presented in Figures I- 3 and I-4. Travel to the meeting was paid by CCCH apart from grant funds.

Kick-off Meeting

The kick-off meeting provided a setting in which the LHD participants and organizers learned about each other's health departments and their LC projects, networked, shared information, and, with a tone and expectations set by the organizers, strengthened commitment to the learning collaborative as a collective enterprise. There were 25 attendees, including 22 representatives of the 13 health departments, two community partners, and one representative of a national environmental health association. The format alternated between blocks of 10 minute didactic presentations by each LHD (using a template provided in advance by the CCCH) and capacity-building exercises. The template covered background on the jurisdiction and health department, project goals and objectives, key activities, incorporating equity, building LHD internal capacity, and project partners. A short question and answer followed each presentation. The

26 exercises included using the CCCH's Climate and Health Framework for Action, role plays on integrating climate change in the LHD's activities, climate and health communications, and strategies for community engagement. Dr. George Luber, Associate Director for Climate Change at CDC's National Center for Environmental Health, was a guest speaker, who described CDC's BRACE grant program that supports adaptation planning by state health departments. LHDs expressed what they wanted to get from participating in the collaborative (Table I-5) and their expectations of CCCH as conveners.

Preferences and content of the collaborative communications platform were discussed and decided (GoogleGroup listserve, GotoMeeting teleconferencing for webinars). Results of a pre-meeting survey to prioritize possible webinar topics were shared and voted on. A post meeting survey indicated that the participants regarded the meeting as highly successful in promoting mutual learning and interaction, and identifying ongoing sharing opportunities with their peers.

Final Meeting

The kick-off meeting occurred 17 months into the learning collaborative and was held to share information about each other's projects, provide feedback to the organizers on their role, and distill lessons learned – on internal LHD capacity-building, cross- jurisdictional collaboration, and community partner engagement. There were 21 attendees who represented of 12 local health departments. Like the kick-off meeting, the format alternated between blocks of 10 minute presentations by each LHD (using a template provided in advance by the CCCH), topical exercises, and discussions. The template covered background on the jurisdiction and health department, project goals and objectives, progress to date, incorporating equity, building LHD internal capacity, and community engagement, successes and challenges. A short question and answer followed each presentation. The exercises included a World Café rotation of small groups of self-selecting discussants, who engaged in 15 minute structured discussions (see questions on agenda Figure I-4) on how to integrate climate and health into different local health program areas: 1) maternal, child, and adolescent health; 2) health policy; 3) chronic disease and active living, 4) infectious vector borne disease, 5) environmental health, and 6) epidemiology, surveillance, community health assessment. The exercise generated scores of ideas, which are presented in Appendix A.

The evaluation of the LC organizers by LC participants was done in small groups using structured questions provided by the organizers, who left the room during the discussions. The themes of this evaluation will be presented in Chapter IV of this report.

Figure I-3 Climate Change and Health Learning Collaborative for Local Health Departments January 13-14, 2016

Day 1 - January 13, 2016 8:30-9:00 Check-In and Breakfast

9:00 - 9:20 Welcome and Context for the Learning Collaborative Kathy Dervin

9:20 -10:20 Introductions Kathy Dervin o No more than 90 seconds per person o Tell us something special: o about you as a person o that you/your team did at work o about your organization o about your city or county

10:20 -10:35 Break

10:35 - 11:05 Learning Collaborative Overview Neil Maizlish o What is a learning collaborative? o Our goals o What do participants want from the collaborative? o Areas of interest identified by survey

11:05: 12:00 A Public Health Framework for Climate Change, Linda Rudolph Health, and Equity o Overview o Mapping

12:00 - 12:20 CDC Climate and Health Program Resources George Luber

12:20-1:15 Lunch All

1:15-2:15 Local Health Department Presentations Participants (10 minutes presentation, 10 minutes discussion) o Seattle o Minneapolis o New Orleans

2:15-2:45 Logistics and Administrative Issues o Invoices o Travel expenses o Reporting o Calendar o Webinars o Resource sharing

2:45 - 3:00 Exercise

3:00-4:00 Local Health Department Presentations

(10 minutes presentation, 10 minutes discussion) o Philadelphia o Columbus o Tulsa

4:00 - 5:00 Networking

5:30 - 6:00 No-Host Bar All 6:00 - 8:00 PM Dinner

Day 2 - January 14, 2016 8:00-8:30 Breakfast All (if you need to reschedule your 1:1 calls, please come on the early side and talk to us during breakfast)

8:30-9:50 Local Health Department Presentations Group (10 minutes presentation, 10 minutes discussion) o Los Angeles o Pima o Maricopa o Denver

9:50-10:50 Communications Kathy o Overview o Discussion

10:50 - 11:00 Break All

11:00 - 12:00 Local Health Department Presentations Group (10 minutes presentation, 10 minutes discussion) o Macomb o Milwaukee o Multnomah

12:00 - 12:45 Lunch

12:45 - 2:00 Creating Strong Partnerships o Across LHD programs Linda o Across local agencies o With communities Kathy

Figure I-4 Climate and Health Learning Collaborative Final Meeting Agenda

Day 1 - Tuesday, May 16, 2017 Time Activity Lead/ Facilitator

8:30-9:00 Breakfast/Check-in

9:00-10:00 Introductions: Please be prepared to speak for TWO minutes Linda and tell us: • something interesting about you personally • something unexpected that happened in your project • something that you learned in your project that you found personally moving

10:00-11:00 Individual project presentations: Linda, • Philadelphia (10:00-10:20) Savannah • Tulsa (10:20-10:40) • New Orleans (10:40-11:00)

11:00-11:10 Break

11:10 - 11:45 Building and maintaining capacity with other agencies (large Linda, Neil group discussion)

11:45 - 12:45 Individual project presentations: Linda, • Macomb (11:45-12:05) Savannah • Maricopa (12:05- 12:25) • Milwaukee (12:25-12:45)

12:45-1:30 Lunch

1:30-2:30 Maintaining Relationships with Community Partners- how to stay Linda engaged with community partners? (large group discussion)

2:30-3:00 Logistics/Administrative Issues- evaluation status, final report, Neil, interviews, etc. (NM, SN presentation) Savannah

3:00- 4:30 World Café (6 stations, 1 facilitator per station)- Integration of 6 stations: climate change into other programs- small groups Linda, Neil, • How would you make a pitch to these other programs? Savannah, • What would the integration look like? Catherine, • Programs: Chronic Disease/PA, EH (restaurant/ non- Minna, restaurant inspections), Epi/surveillance/CHA, Zach WIC/nutrition/nutrition assistance, MCH, emergency prep, infectious/communicable disease/vector-borne disease, health policy

5:30 - 8:00 Dinner: PM • 5:30-6:15: Social Hour • 6:15-8:00 Dinner

Day 2 - Wednesday, May 17, 2017 Time Activity Lead/ Facilitator

8:00-8:30 Breakfast/Check-in

8:30-9:30 Individual project presentations: Linda, • Minneapolis (8:30-8:50) Savannah • Multnomah (8:50- 9:10) • King (9:10-9:30)

9:50-10:50 Evaluation- small group discussions guided by Center Neil, LHD- questions (4 groups-40 min and 20 min group discussion)- take facilitated notes on the poster board to capture the conversation small groups • Self-facilitated small groups w/o us in the room - don’t (40 min), stay with the people you came with- report • What did the Center do well? back/large • What could we have done to make their experience group better? And/or more productive? discussion • What did they find valuable vs. not valuable about being (20 min) a part of the collaborative? • Do you have ideas about what we could have done to increase collaboration? • What would you advise a local health department that has not previously been involved in climate change? Important things you wish you had known about engaging department and public in climate change and health? • Did this change your personal motivation or trajectory, your department’s priorities/trajectory?

10:50-11:00 Break

11:00-12:00 Center’s review of lessons learned/trends in collaborative (LN, Linda, Neil NM presentation and large group discussion)

12:00-1:00 Individual project presentations Linda • Denver (12:00-12:20) • Columbus (12:20-12:40) • Los Angeles (12:40-1:00)

1:00-1:30 Lunch

1:30-1:45 Resource review Linda

1:45 -2:30 Moving Forward and Wrap up Linda, Neil, Savannah

Table I-5. What the Learning Collaborative Participants Wanted to Get out of the Collaborative, First In-Person Meeting, January 2016 Area Item Peer contact What are other people doing Learn from their experience How we are doing compared to others Work with regional participants who share common issues Capacity building How to get more funding and resources Strengthen social cohesion Training materials for staff - climate change 101 Best practices/lessons learned in building capacity within LHD How to integrate climate communications into existing LHD programs How to integrate LHD work into City/County Climate Action, adaptation, or sustainability plan Discuss how to use our experience and stories to build a movement Engaging communities Working with low-income communities with daily survival and stakeholders concerns Expand circle of stakeholders Forming/working with cc coalitions Partnerships others are pursuing/building Maximizing the connection between community/government action Work with elected officials Work with faith-based organizations…

Chapter References

5. Rudolph L, Dervin K. The Climate Change and Public Health Learning Collaborative for Urban Health Departments Oakland, CA: Center for Climate Change and Health, Public Health Institute; 2015.http://climatehealthconnect.org/wp- content/uploads/2015/05/201505_CCCH_RFA.pdf 6. Association of State and Territorial Health Officials. Climate Change Capacity Building Grants. Arlington, VA: Association of State and Territorial Health Officials; 2016.http://www.astho.org/Climate-Change-Capacity-Building-Grants/ 7. National Association of County and City Health Officials. Climate Change Demonstration Sites. Washington, DC: National Association of County and City Health Officials; 2016.http://archived.naccho.org/topics/environmental/climatechange/ccdemosites.cfm 8. National Center for Environmental Health. Climate Ready States & Cities Initiative. Atlata, GA: Centers for Disease Control and Prevention; 2016.https://www.cdc.gov/climateandhealth/climate_ready.htm 9. Marinucci G, Luber G, Uejio C, Saha S, Hess J. Building Resilience against Climate Effects— A novel framework to facilitate climate readiness in public health agencies. Int J Environ Res Public Health. 2014;11:6433-6458.

10. UN Framework Convention on Climate Change. The Paris Agreement: United Nations; 2015.http://unfccc.int/paris_agreement/items/9485.php 11. Pope Francis. Encyclical Letter Laudato Si' of the Holy Father Francis on Care for Our Common Home. Rome, Italy: Vatican; 2015.http://w2.vatican.va/content/francesco/en/encyclicals/documents/papa- francesco_20150524_enciclica-laudato-si.html 12. Centers for Disease Control & Prevention. Zika Virus. Atlanta, GA: Centers for Disease Control & Prevention; 2016.https://www.cdc.gov/zika/ 13. NOAA National Centers for Environmental Information. State of the Climate in 2015. Bulletin of the American Meteorological Society. 2016;97(8): (Special Supplement).

II. PROJECTS SYNTHESIS

The 12 LHDs in the LC were a diverse cross-section by population served (365,000 to 10 million), annual budget ($14 - 893 million), staffing (100 to 4,500), governance (city: 3, county: 5, consolidated city/county: 4), and range of services (prevention, clinical, environmental). The LHDs were also diverse regarding their prior departmental and jurisdictional engagement on climate change and health equity, organizational structure, and proposed work within this collaborative. Most of the LHDs proposed some sort of vulnerability assessment or planning process, while a few proposed specific adaptation projects.

Local Health Department Integration

Examples of Climate Change Integrated into LHD Processes

• Macomb Department of Public Health (DPH) used the Mobilizing for Action through Planning and Partnerships (MAPP) process in its 2016 Community Health Needs Assessment (CHNA), designating climate change as a key “force of change”. • Maricopa and Tulsa integrated climate change into routine surveillance functions (heat-illness surveillance and mosquito and West Nile Virus surveillance, respectively). • Philadelphia placed climate change into work on asthma and air quality. • LHDs (New Orleans, Minneapolis, Philadelphia, Denver, and Multnomah) performed climate and health vulnerability assessments for extreme heat and other climate threats, in some cases adapting the CDC's BRACE model. LHDs incorporated indicators of social vulnerability to climate change impacts (Macomb, Multnomah, Denver, New Orleans, and Minneapolis). These vulnerability assessments were done considerably more rapidly and cheaply than more formal BRACE assessments, sometimes largely in partnership with local graduate students. • Philadelphia specifically analyzed geographical patterns of asthma incidence to prioritize clinical networks participating in their climate outreach and education programs. • Maricopa and Macomb utilized community-based surveys to assess vulnerability to heat and flooding, respectively, in high-risk and disadvantaged populations.

Significance

In each of these examples, LHDs demonstrated that climate change could relatively easily be integrated into activities or processes that most US LHDs know and/or engage in. The use of the MAPP process is widespread among LHDs across the U.S. CHNA’s

34 are required for LHDs to obtain initial accreditation form the Public Health Accreditation Board, and every 5 years thereafter to maintain accreditation. All LHDs conduct surveillance – most include vector surveillance and increasingly LHDs conduct syndromic surveillance amenable to use for heat illness.

LHDs demonstrated that it is feasible to conduct a credible climate and health vulnerability assessment using existing data, with very limited budget and personnel resources. Most of the data used in these assessments is readily accessible to almost all LHDs, including at least some information on regional or jurisdiction-specific climate projections.

Examples of Public Health Integrated into Jurisdictional Climate Change Processes

• Los Angeles, Seattle/King, Macomb, Minneapolis, Multnomah incorporated health and health equity concerns into existing climate action mitigation or adaptation plans, and identified specific roles for the LHD in jurisdictional climate processes.

• Denver integrated climate change into the LHD-led Health in All Policies interdepartmental workgroup, utilizing that group to provide feedback on their heat vulnerability tool, which in turn added a climate and health perspective to a neighborhood-level community development planning process.

• Philadelphia and Los Angeles took advantage of seasonal extreme heat planning led by other jurisdictional partners to coordinate or build a framework for LHD activities. In the case of Los Angeles, an extreme heat plan was one of 5 detailed action plans that list deliverables, objectives, staff leads, and deadlines.

• Philadelphia, New Orleans, and Los Angeles led new intersectoral committees or advisory groups on climate change and health, with representatives both from multiple LHD programs and sister agencies from within the jurisdiction (e.g. Office of Sustainability, Public Works, Parks & Recreation, Water Management, etc.). These groups have elevated the role of the LHD in jurisdictional efforts to address climate change - in some cases to a widely recognized leadership role. The just-released NOLA Climate Action Plan includes discussion of the co-benefits of climate action and the increased vulnerability of populations (including children, the elderly, and those experiencing poverty or homelessness) and specific neighborhoods to climate health impacts.

Significance

35 between climate change, health, equity and the co-benefits of climate action. LC participants also demonstrated an ability to integrate into many other types of intersectoral climate-related working groups within their jurisdictions.

Other Ways LHDs Integrated Climate Change into Public Health Practice

• The Philadelphia Health Department made a climate-health-clinical connection with clinic-and hospital-based clinicians caring for patients with asthma. The project incorporated climate change into educational materials for children with asthma and created a registry of patients to receive medical alerts on days with poor air quality (made worse by extreme heat). • New Orleans created a physician's guide (based on the CCCH Physicians Guide to Climate Change and Health - see page 15), which was used to train physicians in their Medical Reserve Corps. • Tulsa's mosquito surveillance program directed environmental inspectors to evaluate screening on windows and doors in low income neighborhoods, and subsequently alerted policy makers of the need to extend the existing screening ordinance to conform to a climate change related lengthening of the mosquito season.

Local Health Department Capacity Building

All participating LHDs engaged in some level of internal capacity building, but these efforts varied widely in intensity and success.

Los Angeles and Seattle/King County conducted intensive, pro-active, and systematic activities to build internal support for the integration of climate change into LHD programs and to increase internal capacity to do so. These efforts required considerable time and staff resources. Most of the LHDs conducted some sort of educational outreach to managers and/or staff across the department, utilizing regular venues for staff education (all-employee or divisional in-services, lunch-time seminars) or other regular meetings of executive leadership, managers and staff.

In Los Angeles, the intense internal effort may have reduced capacity to initiate community engagement efforts. How to do both internal and external engagement well and simultaneously remains a challenge with limited resources. The pre-LC efforts of Los Angeles County, which in conjunction with the School of Public Health at the University of California, Los Angeles developed a 7-week core climate and health curriculum for its staff, were shared with the LC participants, but not replicated. Nonetheless, modest steps were taken at nearly all LHDs to begin educating their workforces on climate change and health.

Significance

Awareness and knowledge of the impacts of climate change on health and of the role of public health in addressing climate change is still very low in most LHDs across the nation; very few LHD staff have had any training or professional development related to

36 climate change. While those projects that focused on building internal capacity clearly had a greater impact internally, many of the LHDs were able to raise awareness, engender interest, build executive leadership support, and identify potential roles for various parts of the LHD.

Health Equity and Community Engagement

By design, community engagement was a requirement of each LHD LC project and each LHD defined its primary community in the context of its project. Thus, community engagement took various forms. Community-based organizations were essential intermediaries who helped communicate the results of vulnerability assessments and receive feedback in Minneapolis, Multnomah, and New Orleans. A coalition of community-based and governmental organizations providing social services to the home-bound was convened by the Maricopa County Health Department, and identified potential solutions to closing gaps in services through improved coordination.

Educating jurisdictional partners and community-based organizations had several venues, including new and ongoing intra- -jurisdictional workgroups (Philadelphia, New Orleans, Denver), community climate-health summits (Maricopa, Milwaukee), committee work integrated into larger community planning process (Denver, Macomb,), and neighborhood meetings (Minneapolis, New Orleans). Multnomah, Minneapolis, Seattle/King and New Orleans leveraged existing memoranda of understanding and engaged in new contracts with community-based organizations representing disadvantaged communities to inform, educate, and empower their constituencies.

In Columbus, OH, a city with a long history of climate action, the LHD had difficulties extending an existing climate action pledge program to faith communities in low income African American and Latino neighborhoods.

Challenges

We identified several challenges, through 1:1 bimonthly meetings with each LHD, and through discussions on webinars and at in-person meetings.

• The integration of climate and health messaging into routine communications is a new activity that poses challenges, even in receptive environments. LHDs are struggling to figure out how to communicate climate change and health among their own staff, policy makers, and the general public. The possibility of push-back from climate deniers can lead LHDs to a type of self-censorship in which climate change is omitted even from health messages about climate threats (extreme heat, mosquito-borne illness). Building a broad-based coalition of partners who share a common concern (e.g. homebound services) appears to be one pathway to "Bridge Public Health and Climate" as was discovered by Maricopa County and Philadelphia.

• Some LHDs were unable to effect significant expansion of climate and health activities beyond a single program within the LHD, although these activities did

engage other agencies and/or community partners. For example, Tulsa (the LHD with the most conservative political context and least prior experience with climate change) introduced significant changes in its vector-borne disease program and worked with governmental partners to institute related changes in housing inspections. Some collateral interest was generated among program managers with responsibilities for data, outbreak management, land use, and food insecurity (e.g. the linking provision of shade from “food forests” and heat adaptation).

• Managing success: Repeatedly, LC participants discovered an unanticipated interest - especially among community partners - in the health and equity impacts of climate change, as well as a latent demand for LHD input and leadership on this issue. This created a demand for LHD engagement that exceeds current capacity. This was particularly the case in Philadelphia and New Orleans.

• Breaking down organizational silos within LHDs: Engaging a wide cross section of LHD programs is labor intensive and challenging for a small project on climate and health, even with leadership backing. Many program staff want to be more engaged but are uncertain given the dearth of precedents or models for program activities that integrate climate change. With funding from this project, Los Angeles appears to be the first LHD in the United States to develop detailed actions plans to implement a strategic climate and health plan across the department’s many programs.

• Limited time, staff resources and competing priorities: LHDs are constantly confronted by limited resources - resources that have often shrunk in recent years. Additionally, staff in fiscally stressed health agencies are constantly called upon to address urgent needs - for example Zika case investigations (NOLA), preparing for a Papal visit (Philadelphia), or responding to a giant sinkhole (Macomb).

• Direct-peer-to-peer exchange/communication/sharing among LC participants was not as robust as we had hoped, likely due to the lack of resources, time, and internal competing demands. CCCH staff facilitated networking among various LHDs - often as follow-up to one-on-one consulting calls - on specific topics. Participants suggested that an additional in-person meeting at 5-6 months into the collaborative and/or participation of other closer LHDs would have helped strengthen sharing across departments.

Lessons Learned

There are several important lessons learned that can now be generalized from our experience:

1. Local health departments can integrate climate change into on-going programs and routine processes.

When given modest resources, the LHD can rapidly become the recognized voice for climate and health in their jurisdiction. There are multiple entry points within LHDs into climate and health work. Emergency preparedness and environmental health are adaptation-oriented, but other programs aligned with chronic disease prevention, epidemiology and policy can readily incorporate mitigation. LHDs have skills that are easily transferable to work on climate change, for example using and presenting data, community outreach and engagement, and climate communications. However, most LHDs require assistance to actually move toward this integration.

2. LHDs can foster more robust community engagement in vulnerable communities through a health and equity lens

LHDs leverage existing formal and informal relationships with community partners. The LHD's awareness of health equity and the social determinants of health in the context of their own community (e.g. New Orleans and a history of racism) adds a sensitivity in community interactions that can frame the LHD community engagement in a qualitatively different way than many other local government agencies.

3. Explicit and proactive strategies will be required to institutionalize climate change as a focus within LHDs.

Build on lessons learned to encourage participants at the outset to consider how the project will lead to sustainable integration of climate, health, and equity into the LHD across programs, engagement with other jurisdictional agencies, and engagement with vulnerable communities.

4. In most jurisdictions, there are activities underway related to climate mitigation/adaptation/resilience, but with no or very limited engagement (or even awareness) on the part of the LHD.

The LHDs demonstrated an ability to rapidly engage with other agencies to inject a health and equity lens into jurisdictional climate activities. A large percentage of US cities participate in national (and international) initiatives on climate change sponsored by associations of mayors, cities, and nonprofit organizations (e.g. ICLEI). But in many jurisdictions, LHDs are not engaged in these activities. With even limited resources, LHDs can bring their expertise, skills, and community orientation into these processes as well as (and most importantly) a health and equity lens that we believe can enhance the benefits to disadvantaged communities of local government climate action planning.

5. A little money goes a long way, but some resources are absolutely required - at least until these practices become more widespread.

The grant provided financial (albeit small) and organizational support for staff to work on climate change and health, even in jurisdictions where no such work had happened to date. Small grants are matched and exceeded by in-kind commitments that catalyze significant activity within the LHD and across the jurisdiction. The newness of the topic, the lack of clear guidelines, and internal bureaucratic procedures contribute to a potentially long lead time to start. But once interest and skills are demonstrated to community and jurisdictional partners, or opportunity provided for internal engagement, momentum can build very rapidly (e.g. New Orleans, Denver, Minneapolis, Philadelphia, Maricopa, Los Angeles, and Seattle/King County).

6. Buy-in and legitimization

Participants repeatedly stated that having the grant “legitimized” the work, and created a channel for buy-in within the health department and the jurisdiction. Leadership buy-in is critical and allows for more entrée to spread the work - both inter- and intra- organizationally. The grant opened up opportunities for the LHD to be involved in ongoing processes it had previously either been ignorant of nor simply left out of, and to reach out to community partners on this important topic.

7. Climate and health vulnerability assessment is an important basis for health department action.

A formal climate and health vulnerability provides evidence for action and offers excellent opportunities for engagement within the LHD, among governmental departments, and in the community. It can focus on individual risk factors (e.g. homebound) and social determinants of health. The vulnerability assessment need not require a lot of resources beyond those available within the LHD's epidemiology programs and/or local universities. Vulnerability assessment appears to be provide important foundation, but is not sufficient to guide broad-based action that considers both adaptation and mitigation strategies.

8. Communicating about climate, health, and equity remains a significant challenge.

There is a pressing need to develop and implement communications strategies for a variety of public health programs. Our final report from communications workshop suggests that it would take a major effort to further develop effective climate and health communications. The current communications recommendations on climate and health do not adequately reflect public health values and best public health communications practices. Current climate and health recommendations (e.g. Maibach, Eco-America) are important and valuable but, based on our experience, overly simplistic. Even with practice on integrating climate change into public health messaging (during two separate webinar sessions), few of our LC participants actually implemented a communications strategy. A much greater effort - grounded in public health - is needed to create a prototype public health communications campaign with messages that are

40 relevant to various public health programs in different jurisdictional contexts and founded on clear policy and systems change goals.

9. The visibility of the LC led to important discussions with other LHDs that created a "ripple effect" among non-LC LHDs to involve themselves in climate and health activities.

West Coast (Seattle/King, Multnomah, and Los Angeles) LC members have initiated outreach to other west coast LHDs through regional conferences. In the Denver region, health officers in Front Range jurisdictions have prioritized climate change as an annual priority. LHDs in Ohio have asked Columbus staff if there will be opportunities to form an Ohio climate-health LC. Other LHDs appear to be very interested in the LC, but lack resources to initiate activities on their own. National organizations representing local health departments (e.g. NACCHO) have also registered an interest in the LC, including expression of interest in participating in any future LC by members of the NACCHO climate change workgroup. Center staff and LC participants had an opportunity to present on a climate and health panel at the NACCHO Annual Conference and shared preliminary learning with the NACCHO Climate Change Workgroup.

10. The Learning Collaborative provided critical structure and a supportive process (beyond the small funding provided) that enabled the successes described above and in the attached LHD project descriptions.

III. EVALUATION OF CCCH

Goals of the Learning Collaborative

The learning collaborative set out to 1) support LHDs to develop models that demonstrate a variety of ways in which urban local public health departments can develop, integrate, scale-up and replicate approaches that simultaneously address climate change, community health and vulnerable populations, and health equity, and 2) demonstrate approaches that successfully incorporate climate change into local public health department program practice and/or enhance local public health department participation in on-going local and regional climate change mitigation, adaptation and resilience work (i.e. capacity building).

From several lines of evidence that include deliverables provided by the LHDs, administrative data generated by the project, self-assessments of the participants, and key informant interviews (Chapter III), the LC as a whole unequivocally met its goals to expand the capacity of local health departments to a) address climate change, health and equity and b) engage in cross-sectoral collaboration, integration of climate change within LHD programs, and engage community actors, particularly vulnerable populations. Without the LC, it is likely that most of the participating LHDs would have continued a pattern of being ignored or having marginal involvement in their jurisdiction's climate action planning. The implications of this finding are huge: with relatively small investments and coordination, LHDs can rapidly become significant and welcomed health voices in their jurisdiction's climate planning activities, and, in some cases, actually catalyze climate action. In an era in which federal support for climate action is waning, this is a promising avenue to make progress.

The CCCH staff played a key and consistent role of encouraging each participant to address all the elements of the overall LC goals that were clearly delineated in the RFP. As illustrated in Chapter II, most LHDs faced challenges with simultaneously addressing internal program integration, climate and health communications, and community engagement. Especially in 1:1s, CCCH staff adopted a tone of "encouragement without criticism" in an honest appeal to try to address these key areas. The CCCH staff navigated the delicate balance between overreach (in light of the small subawards) and expectations to meaningfully address each of these areas. This tension was most apparent in projects that primarily focused on internal capacity building or technology (e.g. rain water harvesting, mosquito trapping). The LHDs responded favorably to CCCH entreaties and made additional efforts to address these underdeveloped areas of their projects.

Pima County - one of the original 13 LC LHDs - dropped out toward the end of the first year. The contract of the principal investigator, who served as project director and champion for this work, was discontinued. Following the unfortunate deaths of two hikers from Europe, the LHD decided to shift the focus of their heat illness prevention work to tourists, rather than the focus on outdoor workers, homeless populations, and people with substance abuse and mental illness that had been previously agreed to in

42 the contract scope of work. We had one conversation with new project staff, in which we encouraged not to entirely set aside the SOW. Shortly thereafter we received a letter to notify us that Pima LHD was terminating the project, followed by a conversation with the LHD Director in which he indicated that we were "too demanding" given the small amount of the contract and that the department has other priorities.

Process Evaluation

CCCH fulfilled its role as convener and administrator of the subawards, and carried out all the activities in its scope of work as scheduled. To encourage broad participation, we made a conscious decision to allow flexibility in project design and topic choice (within our broad goals). This contrasts to other approaches that impose a single model for a single aspect of climate change (e.g. BRACE and climate change adaptation). Given the diversity of LHDs and their uneven staring points, our approach was reasonable, and has inherent benefits and challenges. It provides examples of multiple entry points to engage on climate change, health, and equity – to other participating LC LHDs and to the wider public health community. As the LC sponsor, it creates challenges in managing diversity. For participants, it may limit internal LC collaboration, if an insufficient number of projects share a common topic (heat, flooding, etc.) or geography. Some of the suggestions by the LC participants (below) to improve the LC confirm these design issues and support several of our recommendations and next steps (Chapter V).

Building in a few months space between making award announcements and finalizing scopes of work allowed sufficient time for LHDs to gain approvals and to start together as a cohort in January 2016.

CCCH staff recognized that bimonthly 1:1 meetings were a labor-intensive, but necessary activity that established the sponsor's credibility, promoted mutual trust, and added value by being a sounding board and providing technical support. Less frequent 1:1s after the first year in an established cohort may be a resource-sparing alternative in future efforts.

The choice and prioritization of webinar topics emerged from an early survey of participants. The sequencing reflected the anticipated chronology of activities common to many projects. For example, at least half the projects proposed creating climate- health vulnerability maps as a first key step. However, participants whose projects did not focus on this topic or had already done this before the start of the LC found such webinars less useful. Over time, CCCH modified the 90-minute webinar format to include more LC participants as presenters and more opportunities for interactive discussion. This garnered positive feedback, but maintaining spontaneous interactions during discussion periods was often challenging. Delegating more responsibility to LC participants to lead discussions may be worthwhile considering in the design of future webinars along with other possible changes (see below).

The two, two-day in-person meetings were essential elements of the success of the LC. In-person contact was key ingredient to fostering personal relationships among LHD participants, and between the CCCH staff and participants. It also helped cement the identity of the collective enterprise and the sense of mission. In a project with a 2-year duration, an additional mid-point meeting would also be beneficial. The meeting formats struck a balance of didactic presentations of individual projects and group exercises tackling programmatic themes such as communications, community engagement, and

44 internal capacity building. Given the positive feedback (below), this format was a good choice.

LHDs Feedback on the Role of CCCH as the Learning Collaborative Sponsor

On several occasions throughout the LC we asked LHDs to provide feedback on the performance of the CCCH and what the CCCH could do to enhance their work:

Mid-project pre-webinar questionnaire (January 2017): What could we, the Center for Climate Change and Health, do to enhance your work in the remainder of the project?

Final meeting LHD-only discussion (May 2017): "What did the Center do well? What could we have done to make their experience better? And/or more productive? Do you have ideas about what we could have done to increase collaboration?

Final 1:1 (November 2017): Are there any specific resources or project support activities that would have made it easier to do this work?"

The responses are compiled in Table IV-1 and indicate that the participants concurred with CCCH's own evaluation of its structure and process for the LC. Of note, participants suggested regional and topic pairings for participants as a way to improve the design of the collaborative.

Table IV-1. Feedback from LHDs Participating in the CCCH Role Topic Feedback Communications • Resources on GoogleDrive not formatted for easy access /Interaction • Difficult to track other jurisdictions’ projects • Pair-up collaborative members by like projects/similar topic areas, city/demographics Webinars • Clarify focus/takeaway of webinars • Include community partners in webinars • Prior information about content level/ knowledge base of webinars • Relevancy of webinar topics • Focused webinar for a subset of LHDs with similar interests In-person • Additional meeting mid-way through projects (or push back date of the initial kick-off meeting) Meetings • World Café takeaways for future work • More time for discussion- • Workshops/final meeting extended to another day to support greater ease of travel for those who have further to travel (hotel flight) • Rotating meeting location 1:1s • Helpful suggestions and guidance Resources • Help jurisdictions find additional funding opportunities after conclusion of LC Administration • Successful: * Financial administration * Reporting process * Prompt feedback/responsive * Great partnership! guidance, flexible and supportive * Set-up the projects/teams for success * Genuine interest- involvement from the Center Compiled from: Mid-project pre-webinar questionnaire (January 2017), Final meeting LHD-only discussion (May 2017); Final 1:1 (November 2017)

IV. RECOMMENDATIONS AND NEXT STEPS

The Learning Collaborative demonstrated significant interest and capability on the part of local health departments to engage meaningfully in climate change with a health and equity lens. The LC has built knowledge and practice among a small network of LHDs, and has provided insight into an initial set of emerging best practices and strategic approaches that we believe could be spread more intentionally. These include:

• Engagement of LHD senior leadership, program managers and interested staff, and formation of an LHD climate and health work group • Identification and outreach to agencies in other sectors engaged in work related to climate change within the LHD jurisdiction • Rapid climate and health vulnerability assessment using available data and drawing on extant community health and equity assessments • Identification and outreach to NGOs/CBOs engaged in work on climate change, health, environment, and social justice and equity • Engagement with disadvantaged communities and vulnerable populations • Identification of opportunities and strategies to work with local and regional agencies in other sectors to support policies with climate, health, and equity co- benefits • Integration of climate change in LHD communications • Development of a LHD climate and health action plan that incorporates elements of mitigation, adaptation, and resilience.

To build on the achievements and lessons learned to date, we envision the following as next steps for building LHD capacity and practice at the nexus of climate change, health, and equity:

1. Maintain the network of LHDs with which we have engaged to date and invite other LHDs to participate through webinars and a listserv.

2. Implement a second LHD learning collaborative, building on the lessons learned in the current project:

• More intentionally recruit specific LHDs based on criteria such as prior work on equity and Health in All Policies and/or regional awareness of climate impacts; • Provide more structure for LHD activities, with more intentional focus on the emerging best practices identified above; • Include funding for at least one local CBO as a requirement for participation; • Provide tools, technical assistance and peer-to-peer learning to support those activities, including learning from LHDs in the first LC; • Engage and contract with 4 regional public health institutes (members of the National Network of Public Health Institutes, of which the Public Health Institute’s CEO is currently the Board Chair) in states with a participating LHD to convene regional LHDs to (a) expand peer learning on climate change; (b) discuss strategies to spread climate and health work in LHDs; and (c) discuss the role of

and strategies for public health in partnering with other sectors and with communities to advance climate solutions with health and equity; • Explore potential avenues for institutionalization of LHD climate and health engagement, eal.g. Public Health Accreditation Board.

Additionally, we would be interested in exploring the feasibility and strategies to identify local/regional funders to support funding of additional LHDs in the LC and additional seed funding for state-based climate and health networks.

We note, in retrospect, that these practices mirror closely the approach that many local health departments have taken in expanding public health practice to heighten awareness and build capacity to address health inequities and the social determinants of health.

V. INDIVIDUAL HEALTH DEPARTMENTS

A. Philadelphia Department of Public Health

1. Background

With a staff of over 1200 and an annual budget of $130 million, the Philadelphia Department of Public Health (PDPH) serves 1.56 million residents of the City and County of Philadelphia, Pennsylvania. Philadelphia presents a sprawling, urban environment with a diverse population facing cultural, linguistic and economic barriers: 42% of residents are African American and 27% live in poverty. Philadelphia has the distinction of being the third ranked "asthma capitol" in the United States by the Asthma and Allergy Foundation of America. A large number of children diagnosed with asthma (36,000) attend Philadelphia public schools. Compared to bordering suburban counties, Philadelphia's children are more likely to visit an ER and have multiple visits throughout a year.

Prior Climate Change Activities of the Local Jurisdiction

The municipal government of Philadelphia has taken an active role in climate action planning since 2007, when it released its Local Action Plan for Climate Change14 as part of its commitment to the US Conference of Mayors and ICLEI’s Cities for Climate Protection Campaign. The PDPH Air Management Services Division played a leading role in developing the City's greenhouse gas inventory, and was a key member of the Sustainability Working Group, which evolved into the Mayor's Office of Sustainability (MOS) in 2009. The MOS developed a sustainability plan called Greenworks15 that explicitly acknowledged the threat of climate change and identified measures to mitigate carbon emissions with a focus on energy, environment, equity, economy, and community engagement. The PDPH is listed as a contributor to the 5-year plan and responsible for several goals to enhance healthy food accessibility. Greenworks16 was re-visioned in 2016 under Mayor Kinney. In 2012, the Office of Sustainability convened a Climate Adaptation Working Group (CAWG), which included the PDPH. The CAWG commissioned a citywide climate adaptation assessment, which was published in November 2015.17 Health effects mediated by extreme heat (heat stress, air pollution) were identified in the document as were PDPH's role in reducing risks.

Applicant and Proposal

The Public Health Preparedness Program (PHPP) represented the jurisdiction in the Learning Collaborative. The PHPP is one of several programs in the Disease Control Division of PDPH. The other divisions in the Department include the AIDS Activities Coordinating Office; Maternal, Child, Family Health; the fore mentioned Air Management Services; Environmental Health Services; Laboratory Services; Chronic Disease Prevention, and Medical Examiner.

Background and Prior Climate Change Activities of the Health Department

PDPH stated in its proposal that its previous focus has been managing the environmental consequences of climate change, rather than preparing the population for anticipated health effects. The historical role of the health department, particularly the Air Management Services Division, in developing the city's climate action plan and its adaptation assessment, was not mentioned in the proposal. It was noted that the Air Management Services Division is the local, lead air pollution control agency, which monitors air pollutants and enforces city, state and federal air quality standards. PDPH coordinates the multi-agency response to heat emergencies, including issuing public information statements and warnings and deploying mobile teams for in-home visits in response to calls received at the Philadelphia Corporation for Aging’s (PCA) Heatline. Both the Environmental Health Services Division and the Acute Communicable Disease Program at the Division of Disease Control address vector-borne diseases, including mosquito abatement, and issuing health alerts to healthcare providers regarding vector- borne diseases (e.g., West Nile Virus, chikungunya). Prior to the Learning Collaborative, there had not been a comprehensive department-wide hazard vulnerability assessment or planning project that explicitly linked climate change and health effects. To address this gap, a nascent climate and health planning activity, using the CDC BRACE framework, immediately preceded the learning collaborative. The PDPH internal planning group identified asthma exacerbations due to intense heat, increased pollen, and air pollution as a climate and health priority. Several long-standing departmental programs focused on asthma surveillance and in-home remediation and education about asthma triggers and environmental hazards such as lead and tobacco smoke. However, none of these previous efforts explicitly considered climate change or environmental threats outside of the home environment.

2. Description of applicant's proposal and goals (what)

The original proposal, "Philadelphia Asthma Readiness and Resilience Project", described a collaborative effort between asthma patients, caregivers, community based organizations, and the PDPH to educate patients and caregivers about how they can minimize risks for asthma attacks that may be triggered by environmental factors related to climate change.

Goals and Objectives

The overarching goal of the project was to improve health outcomes, including reduction of ER visits, among asthma patients that may be adversely impacted by environmental conditions related to climate change. The specific objectives from the October 2015 scope of work (January 2016 - June 2017) and project extension (July 2017 - Dec 2017) are presented in Table V-A1.

Table V-A1. Objectives of the Philadelphia Asthma Readiness and Resilience Project October 2015 Scope of Work (January 2016 - June 2017) 1. Identify populations with asthma most likely to be adversely affected by climate change risk factors such as allergens and air pollution (leveraging existing data in the community health needs assessment) 2. Design language/literacy appropriate outreach and educational materials to increase awareness of environmental factors that may trigger attacks and promote appropriate self-care among asthma patients. 3. Partner with organizations that conduct home visits for asthma patients to facilitate inclusion of PDPH’s climate change and asthma educational curriculum and outreach materials. 4. Seek partnerships with healthcare providers to facilitate distribution of PDPH’s educational and outreach materials in provider offices 5. Seek partnerships with community-based asthma programs (and other organizations, as appropriate) to facilitate distribution of PDPH’s outreach materials and conduct events to educate the community about climate change and health effects. 6. Enroll interested asthma patients/caregivers in one of PDPH’s broadcast notification systems (STREEM) to send them alerts when environmental conditions are likely to trigger asthma attacks (i.e., poor air quality days) and to provide tips for self-care. 7. Explore partnerships with other entities whose work may be complementary to or align with the goals of this program, such as PDPH’s Air Management Services or the Philadelphia Housing Authority Project Extension (July 2017 - December 2017) 1. Maintain the Climate Change and Health Advisory Group (meetings and support) 2. Develop and disseminate extreme heat educational materials

Staffing/Organizational Chart

The proposal had a seven member project team drawn from the PHPP, which included the Assistant Program Manager and principal investigator (in-kind) and the Vulnerable Populations Outreach Specialist (in-kind).

3. Description of applicant's proposed objectives and activities

Apparently in response to CCCH's request that LHDs reach out and explore climate and health activities in their jurisdiction as part of the processes of finalizing their scope of work, the PHPP made its first-ever direct contact with the Mayor's Office of Sustainability (MOS) in the fall 2015. The MOS was transitioning to a newly elected and supportive mayor. The PHPP started attending the interagency workgroup on climate change (CWGA), whose focus was not asthma. The PHPP became more aware of climate projections and other data already compiled by the MOS and decided to reorient their project to not only deal with significant concerns with asthma, but also better align

51 and integrate its activities as the health voice of climate adaptation in Philadelphia city government.

On March 2, 2016, in the first stakeholders meeting (that was originally planned to introduce the project to the asthma care community and patients), PPHP expanded their focus and re-visioned their project with the following objectives:

1. Identify key stakeholders and immediately form a Climate Change and Health Advisory Group (CCHAG). 2. Review the climate change projections for Philadelphia, identify potential health impacts, and estimate disease burden. 3. Identify the populations and communities most vulnerable to expected health impacts. 4. Collaborate with partners to devise mitigation and adaptation strategies, determine methods and mechanisms for effective community engagement, and develop consistent, language-and literacy appropriate risk communication messages. 5. Document projected health impacts, vulnerabilities, and proposed mitigation/adaptation strategies in a Climate and Health Adaptation Plan.

At this meeting, the PHPP introduced a "rapid BRACE" methodology which leveraged the existing climate information produced by several units of the PPHD and the MOS.18 There were 34 stakeholder organizations (Table V-A2), including those mentioned in the original proposal, but also included a larger municipal government contingent from the Mayor's Office of Sustainability, Office of Emergency Management, and Water Department. The discussion also jumpstarted a discussion on both adaptation and mitigations strategies and ways the PHPP could intermediate, such as gathering information from different city sources on options for low pollen trees to mitigate urban heat islands.

This meeting was pivotal in formally expanding the direction and scope of work. With apparent support from PDPH leadership, the CCHAG was established and became an ongoing official activity. As the expansion became apparent to both the PHPP and CCCH in the April 2015 1:1 call, the PHPP made a formal request to modify the original scope of work, which was enthusiastically approved by CCCH.

In 2016 and 2017, the CCHAG met a total of 6 times at 4 to 6 month intervals. The progression of topics in the CCHAG meetings was 1) general education on climate and health risks, focus on heat threats with an emphasis on heat illness, asthma, and air quality, and leveraging the BRACE framework to organize their plan of attack, 2) identification of adaptation strategies, and 3) climate change and health communication, 4) vector-borne disease, and 5) severe storms and their health impacts. The CCHAG also formed an Asthma Subcommittee.

PHPP also launched a separate Extreme Heat Workgroup with the Office of Emergency Management to review the City’s Excessive Heat Plan. The heat planning was

Table V-A2. Members of the Climate Change and Health Advisory Committee (March 2, 2016; June 29, 2016; October 2, 2016, January 31, 2017, July 27, 2017; November 30, 2017), Philadelphia Department of Public Health Community American Lung Association of PA, Healthy Air Campaign Based Asociación de Puertorriqueños en Marcha (APM)* Organization Clean Air Council The Franklin Institute Greater Philadelphia Coalition Against Hunger Health Promotion Council HACE Physicians for Social Responsibility JEVS At Home (home health services) Pennsylvania Horticultural Society Mom’s Clean Air Force Bicycle Coalition of Greater Philadelphia Overbrook Environmental Education Center PennEnvironment Philly Climate Works Sierra Club

Governmental Delaware Valley Regional Planning Commission Environmental Protection Agency Mayor’s Office of Sustainability Philadelphia City Planning Commission Philadelphia Department of Parks and Recreation Philadelphia Department of Public Health (Emergency Preparedness Program) Philadelphia Office of Emergency Management Philadelphia Water Department Phil. Dept. of Behavioral Health and Intellectual disability Services Public Health Management Corporation School District of Philadelphia* Southeastern PA Transportation Authority U.S. Forest Service

Academic Drexel University, Dornsife School of Public Health* Temple University (Center for Bioethics, Urban Health and Policy; College of Public Health) Pennsylvania Integrated Pest Management Program* Penn Institute for Urban Research

Healthcare & Asthma Care Clinic, St. Christopher's Hospital for Children* Home-based Temple University, Department of Nursing* Services Energy Coordinating Agency (low income home energy services)* National Nurse-led Care Consortium* Public Health Department Clinics* Philadelphia Corporation for Aging * Member of Asthma Subcommittee (meeting April 20, 2016; August 2, 2016, November 7, 2016)

53 conducted with a climate change lens, in consideration of the likelihood of more frequent, longer duration and higher intensity heat events.

The adaptation strategies were incorporated into and outline to inform an eventual Climate Change and Health Adaptation Plan.

PPHP participated in the three workgroups for the Extreme Heat Response Plan update: 1) Event Notification & Public Affairs/Messaging, 2) Alternate Safe Locations, and 3) Vulnerable Populations and Community Outreach, which was led by the LC coordinator. PPHP made significant contributions to the educational materials ("Stay Cool, Philadelphia"), the re-design of notifications, and the development of data-driven community outreach that used census tract maps with a heat vulnerability index.

A structure and process for developing longer term heat mitigation strategies were deferred to a future date, but, by the end of the project, appear to have aligned with citywide initiatives of LC partners including a heat planning project of MOS and follow- up to a community resilience training, sponsored by the PDPH, conducted by RAND, and attended by PDPH, the Franklin Institute, and other community partners.

The Asthma Subcommittee of the CCHAG met three times in 2016. This committee has become the locus of much of the original project proposal with the explicit objectives to:

• Identify populations with asthma/areas of the City most likely to be adversely affected by increasing allergens, air pollution, etc. • Design language/literacy appropriate outreach materials to increase awareness of environmental factors that may trigger attacks • Establish partnerships to facilitate distribution of PDPH’s educational and outreach materials/integrate PDPH program with existing programs • Enroll interested asthma patients/caregivers in one of PDPH’s broadcast notification systems (STREEM) to send them alerts when environmental conditions are likely to trigger asthma exacerbations.

The Asthma Subcommittee met on August 2, 2016 to explore impacts of climate change on pollen and to better understand the City’s plans for urban greening with participation from the Pennsylvania Horticultural Society and US Forest Service. The subcommittee met again on November 7, 2016 and discussed the PDPH's support (via dissemination of project materials) of City-wide programs to foster early childhood development (Free Library Read by 4th Campaign), academic performance and school attendance (School Ambassadors), healthy homes (Health Commissioner) and the US EPA Air Quality Flag Program, which an educational program that provides community alerts using flags and logos color-matched to the real-time US EPA Air Quality Index. Due to an unanticipated delay in processing approvals for the production of the educational materials, the Asthma subcommittee was not reconvened in 2017. However, many of the activities were pursued in the CCHAG.

Figure 2 summarizes the structure of the City of Philadelphia's climate change and health activities as of the December 31, 2017.

4. LHD capacity building

Prior to the launch of the Learning Collaborative in 2016, the PDPH's primary involvement in climate activities appeared to have been 1) assisting the city identify

FigureFigure V-A1. 2. Schematic Schematic of Philadelphiaof City of Philadelphi Departmenta Climateof Public andHealth Health Climate Activities, and Health 2007 Activities,- 2017 learning Collaborative

Mayor’s Office of Philadelphia Office of Emergency Community Sustainability Department of Health Management Partners*

Climate Action Plan, 2007 Air Disease Control/ “Greenworks” Sustainability Plan, Management Public Health 2009-2015, 2016- Services Preparedness Climate Adaptation Work Group (Assessment, 2015) Climate Change and Health Advisory Group, 2016- Other City and Regional Agencies: Parks & Rec, Water, Planning, Extreme Heat Adaptation Plan School District, Transportation Working Group

Asthma Partner projects Subcommittee

Initiated by Climate and Health Learning Collaborative * See table of partners carbon emitters and quantifying carbon emissions from data collected by the Air Services Management Division, 2) assisting the implementation of the city's emergency response plan for heat which also included Ambulatory Health Services and Environmental Health Services, and 3) promoting city programs for active transport, community gardens and healthy foods highlighted in the Greenworks sustainability plan through routine activities of the Chronic Disease Division. These capabilities remain intact, but the project has started a trajectory for greatly expanded capacity as the citywide lead agency for climate change and health. There are new standing advisory groups focused on health and climate change with significant participation from sister city agencies, nonprofit agencies contracted with the city to provide social services, leading academic institutions, health care providers serving economically

55 disadvantaged and people of color, and a broad base of other community-based organizations.

5. Disadvantaged populations and health equity

There are multiple mechanisms that the project has employed to address disadvantaged populations. Geographic information on asthma emergency room utilization was used to identify high incidence zip codes and medical care institutions serving high risk populations. Community-based organizations that represent asthma and heat vulnerable populations, some of whom are city contractors (low income, elderly, Spanish speaking, homeless) were members of the CCHAG, Asthma Subcommittee, and Extreme Heat Working Group. Adaptation strategies for extreme heat response from existing city efforts and scans of best practices from US and Canadian cities specified adaptation strategies for different disadvantaged populations. The CCHAC Asthma Subcommittee also became a locus to identify and support partners' projects that impact social determinants of health including early child development, housing/health homes, education, and economic development/training. This has a broad health equity benefits.

6. Integration of climate change into health department programs/communications

The PHPP has ensured that multiple PDPH divisions were represented at the CCHAG meetings, including Disease Control, Environmental Health Services, Ambulatory Health Services, Chronic Disease Prevention and Air Management. However, additional activities by these divisions on climate change and health outside of their participation in the CCHAG were not documented. Nonetheless, awareness of the PHPP climate change work has reached PDPH leadership and has been institutionalized as an objective in the Department’s strategic plan.

PHPP has used existing, routine tools to explicitly communicate climate change and health, such as the quarterly Health Bulletin,19 aimed at a general community audience. However, communicating climate change and health in some educational materials ("Asthma and Springtime Triggers") made no mention of the role of climate change in multiplying existing threats (i.e. increasing warmer temperatures and extended pollen season and potential asthma impacts.).

Of note, PDPH conducted three climate change and extreme heat workshops in summer 2017 with Climate Urban Systems Partnership, a National Science Foundation- funded project whose purpose was to improve local understanding of and engagement with climate change issues. PDPH has made a strong effort to provide community education about climate change and health as time and resources allow. Conducting community education with partners amplified the LC's impact by presenting broad- based content that included health, mitigation, energy conservation/efficiency, and equity. As an indicator of success, this model of community education has generated commitments to present 3 new workshops, focusing on climate change and severe storms, with the same partners in spring/summer 2018.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

A major challenge was significant staff changes (including new management role for the LC PI) and under-staffing. Competing priorities included three flu clinics for first responders, and staffing the Disaster Assistance Services Center for persons who evacuated from Puerto Rico and the U.S. Virgin Islands after Hurricane Maria.

Expanded project scope has bought both benefits and challenges. This is best summed in the words of the Project Coordinator Jessica Caum:

"It (is) a very positive sign that organizations that have been working on climate change for much longer than PDPH are now coming to us looking to partner on projects and asking us to present on health impacts. One year ago, we had no footprint and now we are viewed as the leader on climate change and health in Philadelphia. The major challenge continues to be limited staff resources . . ."

After a significant delay, materials for asthma patient education were printed and disseminated with the assistance of the partners in the Asthma Subcommittee. Nonetheless, the process of developing materials actively engaged partners and was an important means to solidify relationships. The materials have generated positive feedback and fill a void because prior to the project there was a lack of educational materials that integrated in-home, environmental and climate change-related asthma triggers.

The project significantly benefited from nearly a decade of climate change research and planning conducted by the Mayor's Office of Sustainability Office with participation from the PDPH's Air Management Services. In the meetings of the CCHAG, the PHPP was able to present to stakeholders a cogent summary of anticipated climate risks for Philadelphia and possible health impacts based in part on this prior research. This allowed the project to rapidly advance to the stage of identifying strategies for a heat and asthma adaptation plan. In the classic BRACE framework, identifying climate risks and their health implications, identifying vulnerable populations, and assessing the future health burden from climate change are a data- and labor- intensive effort spanning several years. Because of the availability of existing information, including that on adaptation strategies compiled by the BRACE program at CDC, the PHPP accomplished these steps in a few months. This was certainly an unanticipated opportunity that was seized by the PHPP.

The PHPP noted that information on climate change generated by other city agencies was difficult to access. In response, it established an internal website accessible to other city agencies to house resources and contact information for climate and health.

8. Assessment of meeting goals

Administrative Data

As of December 15, 2017, the PDPH has met all its scheduled objectives and deliverables outlined in in its scope of work as modified Table V-A1. The PHPP has attended each webinar and 1:1 call to date, and submitted its progress reports. It has also met the goals of the LC by developing, integrating, and scaling-up approaches that simultaneously address climate change, community health and vulnerable populations, and health equity. PDHP has also successfully incorporated climate change into local public health department program practice and enhanced local public health department participation in on-going local and regional climate change, adaptation and resilience work.

Self-Assessment

In the self-assessment 1:1, greatly increased capacity to work on climate change, health and equity was a predominant theme. Building and strengthening relationships with multiple governmental agencies and community-based organizations were notable accomplishments. The project also greatly expanded the program's understanding of: 1) the city, its demography, and specific communities; 2) how city government functions and ways to get things done; 3) how to do PHPP planning and provide services. With this increase in capacity and demands from partners, the PHPP was acutely aware of resource limitations.

Key Informant Interviews

We interviewed representatives from the Office of Sustainability and the Franklin Institute. The key informants credited the LC with expanding the network of government agencies and community-based organizations with whom they worked, and would not have come to their attention in the absence of the LC. The key informants also cited PHPP's unique contribution of a human health dimension to their previous climate change work, particularly the use of health data (e.g., asthma ER/hospitalization rates) and providing a broad-based approach to community education.

Section References

14. Sustainability Working Group. Local Action Plan for Climate Change. Philadelphia, PA: City of Philadelphia; 2007. 15. Office of Sustainability. Greenworks Philadelphia: 2015 Progress Report. Philadelphia, PA: City of Philadelphia; 2015.www.phila.gov/green 16. Office of Sustainability. Greenworks: A Vision for a Sustainable Philadelphia. Philadelphia, PA: Office of Sustainability, City of Philadelphia; 2016.https://beta.phila.gov/media/20161101174249/2016-Greenworks-Vision_Office-of- Sustainability.pdf 17. Mayor’s Office of Sustainability and ICF International. Growing Stronger: Toward a Climate- Ready Philadelphia. Philadelphia, PA: Mayor’s Office of Sustainability 2015.https://beta.phila.gov/media/20160504162056/Growing-Stronger-Toward-a-Climate- Ready-Philadelphia.pdf 18. Caum J, Ramirez M. Climate Change and Health Advisory Group Meeting Summary Report. June 29, 2016. Philadelphia: Philadelphia Department of Public Health, Division of Disease Control, Public Health Preparedness Program; 2016.

19. Philadelphia Department of Public Health. Climate Change in Philadelphia. Health Bulletin. 2016;9(1):Spring/Summer 2016.

B. Tulsa City-County Health Department

1. Background

With a staff of 350 and an annual budget of $32 million, the Tulsa City-County Health Department (TCCHD) serves 600,000 residents of the city and county of Tulsa, Oklahoma.20 TCCHD is accredited by the Public health Accreditation Board. TCCHD is governed by a nine person board made up of 5 members from the City of Tulsa and 4 from the Board of County Commissioners. The Department, in association with the Oklahoma State Department of Health, is responsible for meeting a variety of health- related needs of the County, including code enforcement of health service regulations; family planning services; dental and health clinics and referrals; maternal and child health services, immunizations for infants; and certain psychological services for adolescents. Tulsa County has 8 municipalities and is 70% White, 10% African American and 10% Latino. In 2015, approximately 16% of county residents had incomes below the federal poverty level. There is an 11 year gap in life expectancy between north and south Tulsa. Community health needs assessments21 and community health improvement plans (using the MAPP process) were conducted in 2013 and 2017.22, 23 These documents demonstrate a consistent priorities of stakeholders and residents for obesity and chronic disease prevention through behavioral risk factor reductions (physical inactivity, diet, alcohol, drug and tobacco use), access to health services, and higher educational attainment.

Prior Climate Change Activities of the Local Jurisdiction

Neither the State of Oklahoma nor the City or County of Tulsa have developed climate action plans, and State officials have been vocal in rejecting the scientific consensus that human-induced climate change is linked to fossil fuel burning.24 Nonetheless, Tulsa city, county, and regional agencies are engaged in planning activities that impact greenhouse gas emissions through energy efficiency and renewable energy programs25 and expansion of public transportation and active travel (walking and bicycling).26 City and County agencies receive funding from the Federal Emergency Management Agency, which requires updating of multi-hazard mitigation plans, which, for the City of Tulsa, includes extreme heat and extreme weather events.27 In 2016, the City of Tulsa received a 2-year grant from the Rockefeller Foundation as part of the 100 Resilient Cities Initiative,28 but Resilient Tulsa's initial assessment does not explicitly mention climate change. Different organizational units of the Tulsa Health Department (Health Officer, Emergency Planning, Environmental Health, Policy & Health Analytics) are participants and members of technical advisory committees of several of these jurisdictional planning activities.

Applicant and Proposal

The Environmental Health Services Department (EHSD) represented the jurisdiction in the Learning Collaborative. The EHSD is one of 5 program areas in the TCCHD, which include food safety, personal health, family health, and community Health. Within the

EHSD, departmental supervisors and the coordinator of the vector control program staffed the Learning Collaborative.

Background and Prior Climate Change Activities of the Health Department

The proposal stated that the Learning Collaborative would be the first official climate related activity of the TCCHD. No prior climate change activities of other TCCHD organizational units were mentioned in the proposal.

2. Description of applicant's proposal and goals (what)

TCCHD stated in its proposal that mosquitos of Aedes spp (the carrier of Chikungya, Dengue Fever, and Zika virus) were collaterally collected in a high percentage of traps used for routine monitoring of Culex spp, the primary vector of West Nile Virus. (In the first 9 months of 2016, Tulsa County registered 3 human cases of West Nile Virus.) The application cited the likelihood that warming temperatures and increased variability of precipitation in the Tulsa region might extend the overwintering range of Aedes spp and increase the potential for Aedes spp-borne diseases to become endemic over the next several years.

Goals and Objectives

TCCHD stated its long-term goal as enhancing its vector control program to further mosquito disease prevention throughout Tulsa County. The means of achieving this goal was through evaluating the variability of weather patterns and collecting vector data, which would enable TCCHD to forecast and create a prevention plan. The specific objectives from the October 2015 scope of work are presented in Table V-B1.

Table V-B1. Objectives of the Tulsa City-County Health Department, October 2015 1. Identify locations throughout Tulsa County by mosquito species and integrate this information with geologic features, and with assistance from THD/Pathways to Health/CHIP, integrate social/ economic data 2. Inspect up to 10 locations for trap use and maintain sites throughout mosquito collection season 3. Test new trapping techniques at selected sites 4. Monitor emerging mosquito-borne diseases using disease specific vector tests in collection samples 5. Conduct quarterly meetings with THD partner divisions, local and state government agencies regarding climate change and health 6. Review City of Tulsa's existing housing code for policy changes 7. Use social media to communicate and inform mosquito issues within Tulsa County, including hazards of mosquitoes to aid in prevention of mosquito breeding on private property and other climate and health issues 8. Use news outlets and media releases to inform public about mosquito concerns and other climate change impacts on health 9. Distribute flyers about mosquito prevention and climate change resiliency and add information on utility bills

Duration of Participation

TCCHD participated in the learning collaborative for 18 months (January 1, 2016 to June 30, 2017).

Staffing/Organizational Chart

Five staff were identified to implement the proposal. Three were supported by the Learning Collaborative and include the chief of the EHSD, a supervisor, and the program coordinator of the vector control program with 5%, 7%, and 7% level of effort, respectively. Two in-kind staff from TCCHD's Marketing and Creative Services department (its director and coordinator of marketing and public relations) were members of the project team. The application listed 8 municipalities in Tulsa County as local government participants. TCCHD said it expected to work with the following community partners:

• Oklahoma State University Extension Office and Environmental Science Graduate Program in order to utilize climate-based research • Oklahoma Department of Environmental Quality for climate change projections • Oklahoma Department of Health and Oklahoma Department of Agriculture, Food and Forestry for ongoing mosquito control activities.

3. Description of applicant's proposed objectives and activities

To discuss ways to strengthen the proposal, share the results of the environmental scan, and to gather information to finalize the scope of work, CCCH initiated two telephone calls with the project staff in the fall of 2015. In addition to the project lead from EHSD mentioned in the proposal, the Policy & Health Analytics manager for TCCHD officially joined the project team. The manager oversees program areas for epidemiology in acute disease investigation, community planning, maternal and child health and provided linkages to jurisdictional activities on built environment, health promotion/health living programs, and community health needs assessment.

As part of the environmental scan, the TCCHD project lead observed that climate change was not as heated a term as was expected in community settings. The sense of the project team was there was community consensus that climate change was happening, but that there was less consensus on human attribution (vs. natural causes). Leading community actors, including business-oriented Sustainable Tulsa, were already engaged on this issue. Activities that that promoted emergency preparedness and community resiliency were regarded favorably. Within TCCHD, the LC project team stated that climate change and resiliency would be a priority in their strategic planning process for 2016, in part, due to the LC grant activities and due to a supportive health department director.

Regarding objectives 1-4, project activities in 2016 mirrored the stated objectives. Maps were created of the 2015 distribution of Aedes spp trapping and locations of standing

62 water favoring mosquito breeding based on soil type and naturally occurring seasonal flooding. New trapping techniques were implemented to allow for monitoring of Aedes spp throughout Tulsa County. Trapping was varied to identify the optimum combination of time of day, trap type, position of trap, and type of attractant (CO2, pheromone). Weekly data collection was done at 50 traps, which included mosquito specimens and weather conditions at each trapping site. Maps were created that the number of trapped mosquitos and economic hardship quartile for each of Tulsa County's 45 zip codes. (The maps suggested a positive correlation, but, to date, TCCHD has not reported how this information was used or communicated to the impacted communities/ neighborhoods.) Antigen assays (VectorTest, www.vectortest.com) were applied to detect the presence of potential mosquito-borne viruses in trapped mosquitoes. Nearing mid-season, THD realized that the new traps did not collect nearly the sample size as the trapping methods utilized previously, however, the new traps did collect a much higher majority of the target species. With the close of the 2016 mosquito season, TCCHD analyzed trapping data to identify most efficient trap type, and reported identifying two Aedes species. However, an unexpected finding was albopictus being more abundant in traps than egypti, which is counter to general findings in Oklahoma.

As to objective 5, a kick-off meeting was conducted in March 2016 with 15 community partners quarterly meetings (Table V-B2, next page), all but Oklahoma State University were local, county, regional, and state government agencies. Several municipalities outside of Tulsa County also attended. In the meeting, climate correlations between mosquito population northern migration and milder winters was presented. Individual meetings with each partner municipal partners were done in-person initially and later by conference calls and emails due to labor-intensiveness of outreach.

Regarding objective 6, the project team worked with the City of Tulsa's code enforcement group to 1) adopt enhanced standards for screens on windows/doors that would require year-round placement and 2) to enforce citations for not meeting existing summer months screen requirements. Also, TCCHD assisted in enforcement of a new regulation that banned the sale of tires (notorious mosquito breeding receptacle) within 300 feet of residential properties.

Regarding objectives 7-9, from January to October 2016 (pre and post mosquito season), the mosquito control program staff conducted 28 television news interviews on 16 different dates regarding mosquito control and prevention, West Nile virus and Zika. The media outlets included major broadcast stations (ABC, CBS, NBC, Fox, and NPR) for which estimated news programming viewership ranged from approximately 7,000 to 90,000 persons. From January to August, TCCHD issued 12 Facebook posts, which generated 537 post clicks and 249 comments, and 11 Twitter tweets that generated 110 likes. (Project staff observed that Oklahomans were more predisposed to use Facebook than Twitter for social media.) Three webpages (mosquito control, WNV, and Zika) on the TCCHD website received over 4000 pageviews. TCCHD used a commercial search platform (TVEyes) to calculate the publicity value of their media contacts. None of the communications included a reference to climate change. TCCHD assisted local governments in public education by providing bullet points on utility bills.

Table V-B2. Community Partners of the Tulsa City-County Health Department Learning Collaborative, 2016-2017 Name of Type Organization Areas of collaboration Quarterly and Other Updates Govern- INCOG (Council Mapping, Census Maintained contact with throughout season, recommended zoning mental of Governments) information, Zoning code changes and plan review information (see attached "Retention Pond") Sand Springs Observation, maintenance Informed THD of larvacide use and additional locations where (City) crews, larvacide application, resources could be placed, helped with general public outreach code enforcement Jenks (City) Observation, outreach, code Informed THD of locations of high mosquito activity, presented enforcement information to city council regarding climate change and mosquito population expectation, added information to monthly utility bill Bixby (City) Observation, outreach, Trapped mosquitos using THD equipment, brought in samples to larvacide application, test, maintained data of larvacide applications, added information trapping to monthly water utility bill Glenpool (City) Minimal - Code enforcement City charter allows THD to perform any duty given within Tulsa County or City of Tulsa, maintained communication throughout season Broken Arrow Spray equipment, larvacide, Weekly communication, utilized traps in own jurisdiction, brought (City) code enforcement, trap samples to test to THD, informed THD of larvacide use, utility bill collections information, discussed concerns Skiatook (City) Minimal - Code enforcement Maintained communication throughout season to ensure problem areas addressed Oklahoma State Data, financial assistance Bi-weekly conference calls, assisted in purchase of larvacide to Department of be distributed throughout Tulsa County, shared health data and Health analytics to ensure areas with human virus detection could be monitored Oklahoma State Licensing, permitting Maintained contact as needed to ensure proper permitting and Department of licensing received for activities related to mosquito control Agriculture, Food and Forestry Academic Oklahoma State Data, Technical Bi-weekly conference calls to discuss mosquito capture rates and University species identification. Discussed technical information regarding trapping techniques * Additional Community Partners: Owasso, Collinsville, Sperry, Tulsa County

4. LHD capacity building

The project led to increased knowledge and technical skills in the TCCHD's vector control program. The integration of multiple data sources (economic hardship and mosquito collections) to assess potential human disease risks in small county geographies appears to be a new element of disease surveillance focused on health disparities. This aspect of the project is intertwined with the professional development (master's degree) of the project lead and ties to a significant academic partner, the Oklahoma State University. The project is likely to have enhanced the activities of environmental inspectors charged with enforcement of existing and new window screening requirements in the City of Tulsa. The project may have elevated mosquito habitat control as a concern in TCCHD's participation in land use planning and development.

5. Disadvantaged populations and health equity

The project team addressed disadvantaged populations and health equity by assuring that traps were widely deployed throughout Tulsa County (45 of 50 of its zip codes). The project team acknowledged that wealthier suburbs with greater access to political power have received preferential treatment in some complaint-driven county services Through data analysis TCCHD attempted to examine the relationship between the geographic association between economically disadvantaged populations and size and type of mosquito populations, although the publication of results appears to be part of the master's thesis of the program lead. Results of the analysis seem to have created a new focus to encourage regular housing inspectors with work related to mosquito control to dedicate a portion of their time to neighborhood “campaigning” on mosquito control and prevention.

Direct communication with community-based organizations representing disadvantaged communities and neighborhoods was not an activity undertaken by this project. TCCHD had much interaction with municipalities, and assisted with information placed on utility bills. But there was no apparent explicit effort to coordinate with municipalities on mosquito control and prevention activities in their disadvantaged populations.

6. Integration of climate change into health department programs/ communications

The project was represented by key personnel in the Environmental Health Services Division and the Policy & Health Analytics office, which has responsibilities for epidemiologic data analysis and communicable disease investigations. This appears to be a strategic alliance that broadens the access of climate change and health to health department management and other programs. Communicable disease statistics that are compiled and reported annually by Policy & Health Analytics29 do not yet report case counts of West Nile Virus, or activities of the vector control program. The Marketing and Creative Services department played a central role in media outreach and social media. Although there were multiple opportunities, there was no explicit integration of climate

65 change into public communications. In some settings "climate change" was not referenced directly and euphemistic phrases were used (e.g., “as the winters become more and more mild, this will be more of a problem.”). The settings and frequency in which this approach was employed was not documented.

To date, regular mechanisms such as "lunch and learn" sessions to inform and integrate program activities with other TCCHD programs do not appear to have been implemented.

The learning collaborative coincided with the 2016 Community Health Needs Assessment and 2017 Community Health Improvement Plan. The CHIP is led by TCCHD under the umbrella of a broad coalition of community-based organizations, businesses, and social services organizations. Although integration of climate change into these activities was discussed in one-on-one calls, "climate change" and vector control activities were not mentioned in these documents.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

As mentioned above, explicit mention of climate change appears to be a significant challenge. This occurred despite indications of a supportive health director, community interest in environmental issues from data collected in the development of the CHNA, and private discussions with opinion leaders that "climate change" was being acknowledged.

Because mosquito control and prevention is seasonal, maintaining interest of community partners beyond a season pattern is challenging: "As the weather cools, most of the thought regarding mosquitoes also cools."

Unanticipated opportunities

The emergence of Zika epidemic and documented local transmission in a Miami neighborhood elevated the interest in TCCHD mosquito control efforts, including traditional WNV surveillance. As stated by the LC lead:

"The emerging Zika virus crisis, while unfortunate, has been a platform used by THD to encourage new city zoning codes regarding storm water detention. The emerging disease threat has also assisted with the climate change messaging, showing tangible threats that are current and relevant."

Although the project was primarily aimed at climate change adaptation, the TCCHD built on positive relationships with local municipal partners to make operational changes that led to significantly decreased mileage and staff time in the more remote parts of Tulsa County. TCCHD also instituted new practices in the mosquito program that increased efficiency and decreased the amount of time each field employee had to spend on mosquito collection and sorting.

Several activities related to climate change and health, but were not part of the original scope of work were part of learning collaborative discussions. These include the TCCHD's promotion of food forests and other built environment interventions that increased health food and physical activity through active transportation and land use planning and low impact development to reduce mosquito habitat.

8. Assessment of meeting goals

Administrative Data

TCCHD met its goals in the improving the technical aspects of mosquito monitoring and modeled a process of improved government efficiency and internal collaboration between key units of the health department (vector control and epidemiology and communicable disease control). The project also allowed the mosquito control program to have a greater public visibility at a time of heightened concerns with the introduction of Zika virus in the United States. However, the broader goals of the LC to broadly integrate climate change within the health department and jurisdiction were not achieved within the learning collaborative timetable. Despite multiple opportunities, integrating climate and health messaging in vector-borne disease communication was not achieved.

Self-Assessment

We were not able to conduct a self-assessment interview with the LC participants. However, based on the final report narrative, the TCCDH stated that without the LC grant, they would not have been able to conduct any of the activities they accomplished in their scope of work. The participants also stated that while "every objective was met, while not always to the fullest extent of what THD was expected, THD did have success in some capacity in every category." TCCHD considered community partnership building as a major accomplishment. The TCCDH also credited the CCCH grant with creating "a sustainable program within vector control. THD is able to continue to utilize the traps, systems and procedures created without outside resources, making it a part of the regular workload."

Key Informant Interviews

Departmental managers were unanimous in their recognition that the project improved data sharing between the LHD, municipal jurisdictions, and the State health department; improved basic business processes; and strengthened relationships in partner agencies. The difficulties in explicitly communicating climate change were also reaffirmed in key informant interviews in the context of the conservative political environment. Nonetheless, key informants were optimistic that future related climate change and health work could extend to transportation planning for active travel and built environment to improve food security (food forests).

Section References

20. Tulsa City-County Health Department. Financial Statements and Internal Control and Compliance Reports. Tulsa, OK: Tulsa City-County Health Department; 2015.https://www.sai.ok.gov/olps/uploads/2015_tulsa_citycounty_health_department_single_au dit_financial_statements_2hsa.pdf 21. Tulsa Health Department. Community Health Needs Assessment. Tulsa, OK: Tulsa Health Department; 2016.http://www.tulsa- health.org/sites/default/files/page_attachments/CHNA%20report_4_15_16-compressed.pdf 22. Tulsa Health Department. Pathways to Health. Tulsa, OK: Tulsa Health Department; 2013.http://brocknunn.com/pathwaypress/wp-content/uploads/2014/06/CHIP-full.pdf 23. Tulsa Health Department. Community Health Improvement Plan. Tulsa, OK: Tulsa Health Department; 2017.http://pathwaystohealthtulsa.org/wp-content/uploads/2017/01/2017-Tulsa- County-Community-Health-Improvement-Plan.pdf 24. Inhofe J. The Facts and Science of Climate Change. Washington, DC: U.S. Senate Committee on Environment and Public Works; Undated.https://www.epw.senate.gov/repwhitepapers/ClimateChange.pdf 25. City of Tulsa. City of Tulsa Sustainability Plan. Tulsa: City of Tulsa; 2011. 26. Indian Nations Council of Governments (INCOG). Connections: 2035 Regional Transportation Plan. Tulsa, OK: Indian Nations Council of Governments; 2012.http://www.incog.org/transportation/connections2035/documents/Connections2035Reg ionalTransportationPlan(9).pdf 27. City of Tulsa. Multi-Hazard Mitigation Plan Update - 2009. Tulsa, OK: City of Tulsa; 2009.https://www.cityoftulsa.org/media/1975/2009-hazardmitigationplan.pdf 28. Resilient Tulsa. 100 Resilient Cities Tulsa Initial Findings Report. Tulsa, OK: City of Tulsa; 2016.https://www.cityoftulsa.org/media/2901/100rcreport-11-21-16.pdf 29. Tulsa City-County Health Department. Tulsa County Health Profile 2015. Tulsa, OK: Tulsa City-County Health Department; 2015.http://www.tulsa- health.org/sites/default/files/page_attachments/_health-profile-2015-web.pdf

C. Macomb County Health Department

1. Background

With a staff of 155 and an annual budget of $21 million, the Macomb County Health Department (MCHD), Michigan serves 860,000 residents spread across 13 cities, of which Warren is the largest (approximately 134,000).30 MCHD is governed by an elected county executive and a 13-member board of supervisors and is one of three agencies that make up the Health and Community Services Agency. The county has a rich tradition of manufacturing, and continues to be a major manufacturing center. However, a shift in the economy during the 1990s produced a significant increase in service sector employment which current makes up approximately 45 percent of employment. Macomb Count is 82% White, and Blacks, Asians and Latinos each make up less than 5% of other race/ethnicities. Macomb County is home to a small, but growing Arab population. Approximately 11.7% live below the federal poverty level. The Health Department is made up of six main organizational units: office of emergency preparedness, medical examiner, planning and quality assurance, environmental health, family health services, and health promotion/disease control. 31

In 2014, Warren and other cities in southeast Michigan were devastated by flooding caused by a rainstorm that dropped 5 inches of rain in 3 hours. In Warren, over 18,000 homes were damaged and property losses were estimated at $1.2 billion. In partnership with the county emergency management agency and county executive, MCHD set up a call center to assist residents report damage and address concerns, of which mold, air quality, and mental health support were most prominent.

Prior Climate Change Activities of the Local Jurisdiction

In Macomb County, the City of Warren has a program called "Going Green", which is led by its major and an Environmental Advisory Committee. It promotes green initiatives throughout the city and advises the mayor on "energy efficiency issues in order to mitigate climate change." Macomb County has a climate adaptation plan – Resilient Macomb32 – but apparently does not a climate action or sustainability plan.33 The development of Resilient Macomb was led by the Land Information Access Association (LIAA), a Traverse City, Michigan non-profit partly funded by the Kresge foundation. The plan was completed in January 2016 as the Learning Collaborative was just starting. The plan included detailed maps for excessive heat, flooding, and social vulnerability. The Macomb County Health Department's Learning Collaborative activities were included in the Resilient Macomb's inventory of climate adaptation resources.

The Green Macomb initiative (http://green.macombgov.org/Green-Home) was created by the Macomb County Department of Planning & Economic Development to support tree canopy and other green infrastructure. The project is framed in terms of economic vitality, quality of life, and environmental well-being of the region, but climate change is not mentioned on their website. Likewise, Macomb County has a state-funded Green Schools program (http://greenschools.macombgov.org/GreenSchools-Home) which focuses on recycling, energy conservation, and environmental protection by students in

69 public and private elementary and secondary schools. Macomb County public works is participating in a "climate-smart" habitat restoration project along the Clinton River spillway, which provides a flood control channel to protect three major Macomb county cities. The project is partly funded by the National Wildlife Federation, which provides technical support for several related habitat restoration projects around the Great Lakes.34

Under the auspices of the county emergency management agency, Macomb County updated its hazard mitigation plan (2015-2020)35 which mentions heat and flooding, but future trends do not mention climate change.

Regional planning for transportation, infrastructure, and economic development is carried out by the Southeast Michigan Council of Governments (SEMCOG), of which Macomb County is a member. Many of its plans impact greenhouse gas mitigation (bicycle and pedestrian plans) and climate resiliency (green infrastructure, storm water management) but climate change is not mentioned in their planning documents (http://semcog.org/Plans-for-the-Region). Data and maps with possible use in vulnerability assessments are produced by SEMCOG.

Of note, Macomb Community College offers an associate degree program in renewable energy technology.

At the State level, under a former governor, Michigan developed a statewide Climate Action Plan in 2009 with collaboration from a several city mayors (but none from Macomb County). The plan has not been updated by the succeeding governor.

As previously mentioned in Table I-2, the State of Michigan Department of Health and Human Services (MDHHS) received capacity building planning grants from ASTHO in 2010 and from CDC in 2012 to 2016 as part of Building Resilience Against Climate Effects (BRACE). With this funding MDHHS established the Michigan Climate and Health Adaptation Program (MICHAP), which developed a strategic climate and health adaptation plan in 2010 and an update in 2016.36 The update identified Macomb County as a heat-vulnerable community. A significant community partner with MDHHS was LIAA, which contributed to the state's strategic plan on climate and health and developed training guide for local planners and decision makers.37 MICHAP/BRACE developed climate and health profile reports for Michigan counties38 in collaboration with the Great Lakes Integrated Science Assessments Program (GLISA) of the National Oceanic and Atmospheric Administration (NOAA). Macomb County Health Department has participated in MICHAP activities.

Applicant and Proposal

The Emergency Preparedness Program in the Environmental Health Division represented the jurisdiction in the Learning Collaborative. Other programs in this

70 division include food safety, waste water disposal, water quality, and shelter management.

Background and Prior Climate Change Activities of the Health Department

Overt climate change activities within the MCHD appears to have started with the grant for the Learning Collaborative. The application mentioned that MCHD participated in a 2-day planning exercise in 2016 in collaboration with the U.S. Department of Defense at the Selfridge National Guard Air Base. The exercise aimed to increase preparedness of military installations and their neighboring communities to climate change impacts by engaging, educating, and discussing planning with those communities.

2. Description of applicant's proposal and goals (what)

Goals and Objectives

Macomb County Health Department stated its goals to:

• Establish a climate change resiliency coalition • Develop a health assessment • Increase Macomb County Health Department staff’s knowledge about climate change.

A key aspect of implementing the assessment was using the framework of Mobilizing for Action through Planning and Partnerships (MAPP), a widely used, community-driven strategic planning process developed by the National Association of County and City Officials.39 Using the climate resiliency coalition as its community partner, the climate and health assessment was embedded by the MCHD Learning Collaborative staff in the larger concurrent MAPP process used by the MCHD to create its updated Community Health Needs Assessment (CHNA), as required by the Affordable Care Act.

Staffing/Organizational Chart

The project was led by the MCHD emergency preparedness program coordinator and a supervisor in the Environment Health Division whose efforts were part-time and in-kind. (The coordinator assumed the Division directorship midway through the project.) Four upper management staff (health officer, deputy health officer, medical director, environmental health director, and quality improvement and assurance manager) had part-time, in-kind support roles. The bulk of funding went to contracting with a community health planner. Some of this funding was reallocated for incentive gift cards to increase participation in the community assessment of flood victims.

Duration of Participation

MCHD participated in the learning collaborative for 18 months (January 1, 2016 to June 30, 2017).

3. Description of applicant's proposed objectives and activities

The objectives of the project are summarized in Table V-C1 (next page). Community partners in the resiliency coalition are listed in the Table V-C2. The MAPP process for the

Table V-C1. Objectives of the Macomb County Health Department, October 2015 1. Establish a climate change resiliency coalition that has representation from local, state, and federal government, academic, and community based partners 2. Utilizing the MAPP framework with Coalition members, effects of climate change will be addressed in the overall Macomb County Community Health Assessment 2.1 Identify existing data relevant to climate change projections, impacts, and vulnerability, including in consultation with Michigan BRACE 3. Involve both LHD staff and partners in the community coalition partners with conducting health assessment 4. Present information to Macomb County Health Department staff, stakeholders and the community to improve community resiliency and capacity to respond to climate change events 4.1 Utilize data MAPP assessment, and community input to create a climate change resilience strategic plan.

Table V-C2. Community Partners of the Macomb County Health Department Learning Collaborative, 2016-2017 Type Name of Organization Governmental Macomb County Emergency Management Macomb Planning and Economic Development Macomb County Community Services Agency Macomb County Community Mental Health Van Dyke Public Schools City of Warren Michigan Climate and Health Adaptation Program (Michigan Department of Health/BRACE) Selfridge Air National Guard Base

Healthcare MyCare FQHC Advantage FQHC St. John Health System

Academic University of Michigan School of Public Health Michigan State University Extension Office

Community-based Land Information Access Association Macomb Community Action

CHNA started in July 2015 and finished in December 2016 with the publication of the Macomb County Community Health Needs Assessment.40 The community coalition meetings kicked off in March 2016 and met multiple times in conjunction with the CHNA and the development of the climate and health strategic plan.

The CHNA MAPP assessment was made up of four separate assessments: the forces of change, community themes and strengths, community health status, and local public health. Climate change was incorporated as a force of change. In the prioritization of forces of change, the topic "Climate Change/Natural Resources, Green Initiatives, and Air pollution" received 10 votes among 24 other topics, tying in the number cast for the cost of education. The other priority topics (11-14 votes each) were growing aging population, growing immigrant population, violence, increased chronic disease, substance abuse, and cost of health care. Only the topics with the highest votes were ultimately considered for inclusion in the Community Health Improvement Plan (CHIP), which was schedule for release in 2017. In the draft CHIP (Jan. 2017), climate change goals appeared in a section related to health equity and was stated as "climate change capacity building and public education." Project staff suggested that many participants were reluctant to give climate change greater priority because specific goals and metrics had yet to be explicitly linked to programmatic activities like other public health programs.

Two key activities contributed to the development of the strategic plan (goal 4.1). First, was a survey of county 4000 households with a focus on Warren residential areas impacted by the flood of 2014. A 41-item questionnaire was administered door-to-door with the help of Medical Reserve Corp volunteers. The questionnaire covered residency during the 2014 floods, health and health changes after the flood event, household composition and socio-demographics, emergency preparedness, and county services. One question specifically addressed residents' view of climate change: "Overall, do you believe that we are experiencing Climate Change?" As of March 2017, 500 residents responded to the survey. Preliminary results suggest that two-thirds of respondents do not believe that climate change is occurring.

Second was compilation of data relevant to climate change projections, impacts, and vulnerability (Goal 2.1). This was largely achieved by using existing data and reports for climate projections produced by the MICHAP/BRACE/GLISA collaboration and vulnerability maps produced by coalition member Macomb Planning and Economic Development. As of this writing, the strategic plan was still in development.

4. LHD capacity building

Before the Learning Collaborative, climate change activities in Macomb County occurred with some awareness and modest participation by MCHD, mainly in response to initiatives taken by the State Health Department (BRACE) or LIAA (coastal adaptation resiliency). By piggy-backing on to the CHNA/MAPP process, MCHD "mainstreamed" discussions of climate change into a major public health activity and built a community

73 collation recognized by the Steering Committee of the MAPP/CHNA process. The Steering Committee's recommendation that the MCHD-led collation hold a community forum on climate change and health signals the recognition of MCHD's leadership role and the need for community education on this issue. The forum was held in September 2017, after MDPH's formal participation ended in the learning collaborative.

5. Disadvantaged populations and health equity

While the community survey focused on areas impacted by the 2014 floods, it is not apparent how project activities engaged disadvantaged populations and health equity. Macomb Community Action, a county governmental agency that provides supportive social services (including weatherization) for low income households, seniors and the disabled, was a collation member. Several progress reports acknowledged the need to expand and diversify the climate resiliency coalition, and outreach to faith-based organizations. MCHD mentioned that it had other initiatives in Warren including a grant from the State’s Building Healthy Communities Program to improve access to healthy food and safe places for physical activity in communities where people are disproportionately affected by poor health and have limited access to healthy lifestyle resources. However, there were no reports from the LC staff on how disadvantaged communities in Building Healthy Communities were related to their climate change activities. Moreover, the means by which information on vulnerability mapping (goal 2.1) will be incorporated into the strategic plan has not been reported.

6. Integration of climate change into health department programs/ communications

After the Learning Collaborative kick-off meeting in Oakland on January 2016, MCHD LC staff discussed climate change in internal management meetings of MCHD, apparently the first time climate change was formally discussed among management. Upper leadership received regular updates, but only in December 2016 did Division directors get a formal presentation on the project. Several opportunities to present the project to program managers and departmental staff were identified such as in-service day and "Lunch and Learn" but will not have occurred until the end of the project period.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

In the early stages of the project there seemed to be difficulty in communicating the project internally and "getting past the words 'climate change'." Some staff suggested it was less confusing or confrontational to substitute "climate variability." This seemed to signal internal differences in opinion within the health department:

"A very interesting thing was that when talking about Climate Change impacts specifically, Air Pollution and Water Quality for example, there was majority of

agreement that we are currently seeing impacts in our community. However, when we using the term 'Climate Change', the attitudes of staff were more critical and dismissive."

Over time, this resistance appears to have diminished and may be related to unanticipated opportunities. While the LC project was visible to upper management and the resiliency coalition, the visibility of the LC project does not appear to be as high. Formal mechanisms to present the project to staff and engage them in discussions of incorporating climate change and health into their programmatic areas was repeatedly delayed and had not taken place by the conclusion of the project in July 2017.

Other challenges included changes in senior staff (including the lead for this project who became a Division Director), unfilled positions for support staff, and a year-long emergency response to a sinkhole that has disrupted sewer services to 500,000 residents.

Unanticipated opportunities

Upper management received regular project updates at their management meetings. The promotion of the LC lead to Division Director may have strengthened the awareness of climate change and health and strengthened the linkage to the CHNA/MAPP process. One sign that the project influenced upper management is that the Health Officer regularly sent Division Directors articles on climate change.

8. Assessment of meeting goals

Administrative Data

Incorporating climate change discussions into the MAPP process was perhaps one of the most significant accomplishments of MCDH. We believe this may be the first effort of its kind among health departments using MAPP in the United States. The final product, however, provided limited visibility of climate change to one, albeit, important section of the Community Health Needs Assessment relating to health equity. Community partners were engaged in the MAPP process, but there was no indication beyond a community forum (held in September 2017) how the coalition would engage on climate change, health, and equity on an ongoing basis.

Self-Assessment

Based on the final progress report narrative, "our participation in this learning collaborative significantly enhanced our knowledge, capacity, partnerships, preparedness and resiliency for addressing future impacts of climate change in Macomb County. The collaborative provided the necessary tools and resources to be able to educate our coworkers, administration, and community partners. What made these presentations successful was the use of vulnerability mapping to show inequity in

75 our own community. We successfully brought community partners together in a coalition that represented local government, universities, environmental advocacy groups, and partners that directly serve the underrepresented community . . . This project has opened our eyes to the fact that most of the staff believe in climate change but tend not to feel comfortable talking about it."

Key Informant Interviews

We interviewed the Director of the Office of Emergency Management and faculty at Oakland University (who assisted in the development and execution of the community survey). A theme of the interviews was "opening up our eyes" to the health and mental health dimensions of climate change. This was achieved primarily through providing health data. The OEM director stated that because of this project, health data would play a more prominent role in their planning process.

Section References

30. Hackel M. Adopted Budget for Funds With Fiscal Years Ending December 31, 2016 and September 30, 2016. Mt. Clemens, MI: Macomb County Board of Commissioners; 2016.http://finance.macombgov.org/sites/default/files/content/government/finance/pdfs/FULL %202016%20ADOPTED%20BUDGET.pdf 31. Macomb County Health Department. Macomb County Health Department Plan of Organization. Mount Clemens, MI: Macomb County Health Department; 2017.http://health.macombgov.org/sites/default/files/content/government/health/pdfs/2017M CHDPlanofOrganization0215.pdf 32. Land Information Access Association. Resilient Macomb: Planning for Coastal Resilience in Macomb County, Michigan. Traverse City, MI: Land Information Access Association; 2016.http://www.liaa.org/media/projects/media/macomb_final_report_and_maps.pdf 33. Michigan Climate Action Network. Michigan Climate Plans. Traverse City, MI: Michigan Climate Action Network; 2017.https://d3n8a8pro7vhmx.cloudfront.net/miclimateaction/pages/109/attachments/origina l/1487791485/Michigan_Climate_Plans_4_pager.pdf?1487791485 34. Gregg RM, Hitt JL. The National Wildlife Federation’s Climate-Smart Restoration Partnership in the Great Lakes. Ann Arbor, MI: National Wildlife Federation, Great Lakes Regional Center; 2012.http://www.cakex.org/case-studies/national-wildlife- federation%E2%80%99s-climate-smart-restoration-partnership-great-lakes 35. Office of Emergency Management & Communications. Macomb County Hazard Mitigation Plan Mount Clemens, MI: Office of Emergency Management & Communications; 2016.http://oemc.macombgov.org/sites/default/files/content/government/oemc/pdfs/MCHaza rdMitigationPlan05192015.pdf 36. Cameron L, Ferguson A. Michigan Climate and Health Adaptation Program (MICHAP) Strategic Plan Update: 2016-2021. Lansing, MI: Michigan Department of Health and Human Services; 2016.http://www.michigan.gov/documents/mdch/MDCH_climate_change_strategicPlan_final _1-24-2011__343856_7.pdf 37. Land Information Access Association. Climate Health Adaptation Planning in Michigan: Training for Local Planners and Decision Makers. Traverse City, MI: Land Information Access Association,; 2016.http://liaa.org/downloads/health_planning_training_general.pdf

38. Cameron L, Ferguson A, Walker R, Brown D, Briley L. Michigan Climate and Health Profile Report, 2015: Building Resilience Against Climate Effects on Michigan’s Health. Lansing, MI: Michigan Department of Health and Human Services and Great Lakes Integrated Sciences Assessments Program; 2015.http://www.michigan.gov/documents/mdhhs/MI_Climate_and_Health_Profile_517517_ 7.pdf 39. National Association of County and City Health Officials (NACCHO). Mobilizing for Action through Planning and Partnerships (MAPP). Washington, DC: National Association of County and City Health Officials; 2017.http://www.naccho.org/programs/public-health- infrastructure/mapp 40. Macomb County Health Department Office of Health Planning. Macomb County Community Health Assessment. Mount Clemens, MI: Macomb County Health Department; 2016.http://health.macombgov.org/sites/default/files/content/government/health/pdfs/CHA01 1117.pdf

D. Columbus Public Health

1. Background

With a staff of 400 and an annual budget of $46 million, the City of Columbus, Ohio, department of public health, known as Columbus Public Health (CPH), serves approximately 835,000 residents. The department is governed by a 5-person Board of Health, with members appointed by the Mayor and approved by City Council. Demographically, 61.5% of the Columbus population is white, 28% is African-American, 5.6% of the population is Latino, and 4.1% is Asian. The city is often utilized as a test market because the demographics are similar to that of the entire United States. CPH is made up of five main organizational units: population health, clinical health, neighborhood health, family health, and environmental health. In recent years, the strategic priorities of the health department have been: reduce infant mortality, reduce overweight and obesity, reduce the spread of infectious diseases, improve access to health care, and implement departmental reorganization.

Prior Climate Change Activities of the Local Jurisdiction

The City of Columbus has had an active program for sustainability since 2005, when then Mayor Michael Coleman launched the Get Green Columbus initiative and issued the first in a series policy documents called Green Memos. The first Green Memo41 prioritized waste recycling, air pollution, water quality, green business development, and urban greening. The Health Commissioner was among 8 city department directors who comprised the Mayor's Environmental Policy Working Group, which was complemented by an advisory council made up of leaders from civic, neighborhood, and business groups.

In 2008, the City created GreenSpot,42 which is a registry of households, community groups, businesses, and neighborhoods who voluntarily pledge to take actions from a list of city-recommended options in categories, which include energy conservation, water conservation, and recycling. Participants get public recognition and awards. For example, neighborhoods that apply receive information about best practices for environmental and financial benefits, support from the city to develop neighborhood sustainability activities, and recognition in social media and street signs placed in their neighborhood. The City of Columbus received a grant from the Ohio Environmental Education Fund to expand the GreenSpot Kids program to schools. As of May 2017, GreenSpot had more than 15,500 participants.

In 2010 (also under Mayor Coleman's administration), a 5-year plan and update of the initial green memo was launched (Green Memo II).43 It continued the initial goals and specified 8 objectives and 38 action items for city departments and others, and initiated annual reporting of progress. Specific goals were set for greenhouse gas reduction in city operations as well as increase in energy efficiency in city facilities, and an expansion of active transportation and public transit. The city institutionalized the internal and external advisory groups as the Green Team, which included

78 representatives from CPH, and created the Mayor's Office of Environmental Stewardship with 2 staff persons.

The third Green memo, called the Columbus Green Community Plan44 (again under Mayor Coleman's administration), was issued in 2015 and is also a 5-year plan (2015- 2020) with 178 action steps and 9 goal areas. It characterized climate change as an "urgent priority" and created a separate chapter on climate change that briefly described health impacts of climate change. CHP staff participated in the development of this plan and were designated as liaisons to the Mayor’s Office of Environmental Stewardship and the Green Team Advisory group.

The commitment to greenhouse gas mitigation was renewed under incoming Mayor Andrew Ginther, who, in January 2016 committed Columbus to participating in the United Nations-sponsored Compact of Mayors.45 The compact sets a three year timeline (2019) for Columbus to produce a comprehensive climate action plan for carbon mitigation and a climate change adaptation plan that includes a vulnerability assessment.

Applicant and Proposal

The learning collaborative project, called "Faith Communities Impacting Climate Change", is based in the Office of Environmental Sustainability (OES), located within the Environmental Health Division. Other programs in this division include: food protection, healthy homes and schools, water and land protection, hazardous materials, vector and animal control, and environmental health licensing and support services.

Background and Prior Climate Change Activities of the Health Department

CPH leadership and staff in the Environmental Health Division have been members of the city's internal advisory sustainability committee and liaisons to the community-based advisory committee since 2005. The principal investigator for the Learning Collaborative has been the long-standing CPH staff liaison to the city's Green Team and directs activities of the OES. OES has worked with community partners on climate change education projects such as an all-day seminar attended by 80 representatives from businesses, health organizations and academia. Topics included climate change science, public attitudes about the issue, projected health impacts and potential economic policies to successfully address the impacts. OESP also has partnered with Columbus-area hospitals participating in the Healthier Hospitals Initiative46 to propose an education project to train medical residents on the health impacts of climate change.

In 2013-2014, OES and the Ohio State University’s School of Environment and Natural Resources conducted a pilot project that surveyed 420 Columbus residents about their knowledge and beliefs on climate change, and actions they would to support to address it. The project also developed and delivered a PowerPoint presentation on climate change in 19 community meetings throughout the Columbus area. The information helped inform the Mayor’s Office of Environmental Stewardship in its climate change

79 planning, and the survey results were highlighted in the Columbus Green Community Plan.44 According to the OES, the pilot project was a crucial stepping stone in the development of the Learning Collaborative proposal, which aimed to recruit new constituencies, engage them in specific actions to mitigate and adapt to climate change, and evaluate the environmental impact of those actions.

2. Description of applicant's proposal and goals (what)

Goals and Objectives

This project proposed by CPH examined the impact of providing climate change education to faith communities in Columbus, OH. The goal of the project was to use climate change information to secure commitments from both faith institutions and congregation members to engage in climate change adaptation and mitigation actions.

Staffing/Organizational Chart

The project was led by the OES director (10% in-kind), a half-time outreach/education coordinator, and had in-kind contributions from the Mayor's Office of Environmental Stewardship, and two staff of the main partner - Ohio Interfaith Power and Light (OhIPL). OhIPL is the Ohio affiliate of the national Interfaith Power and Light network47 and a project of the Ohio Council of Churches. OhIPL helps Ohio’s interfaith communities meet the challenges of climate change through action and advocacy and promotes energy conservation, energy efficiency and the use of renewable energy by houses of worship and their congregations.

3. Description of applicant's proposed objectives and activities

The activities of the project are summarized in Table V-D1 (next page). A key component of the project was to adapt an engagement strategy that OhIPL had been previously implemented in Cleveland and Cincinnati:

• Outreach to build relationships/collaborations with established organizations or persons of faith in African American/Hispanic religious communities • Listening and engaging faith leaders and persons of faith in one-on-one conversations and group conversations that focus on shared values, finding common purpose, and engagement • Soliciting Climate Action Responses, such as reducing carbon footprint and supporting energy efficiency and renewable energy measures • Identify African American/Hispanic faith communities to have one-on-one climate conversations.

Given OhIPL's experience in faith-based communities, the role of OhIPL was to assist CPH in facilitating climate conversation.

Table V-D1. Proposed Activities of Columbus Public Health Learning Collaborative, October 2015 1. Prepare presentation on climate change and health and conduct climate change conversations 2. Identify and contact potential partner congregations, including develop outreach materials; Initial interview with congregation officials 3. Identification of populations most vulnerable to climate change and integration of this information into city’s climate change action plan 4. Presentations to church congregations 5. Provide assistance to congregations to engage in climate action. Secure commitments of congregations to engage in climate change adaptation and mitigation measures Develop follow-up process to maintain contact with each congregation. 6.a, Identify/recommend possible improvements in city outreach/communications 6.b. Identify/recommend possible additional city climate adaptation and mitigation actions 6.c. Identify potential additions to GreenSpot program 7. Incorporate recommendations into city climate action plan 8. Engage other Columbus Public Health divisions/programs in climate change and health

Significant difficulties were encountered in implementing the proposed activities. A substantial delay occurred in hiring the project Outreach coordinator, who did not begin until April 2016 and worked 7 months before resigning to accept a full-time position at CPH.

Early outreach to describe the LC project was made with statewide and regional church organizations (Ohio Council of Churches and Catholic Diocese of Columbus), CPH staff who had worked with African American communities in Columbus on infant mortality reduction, and Latino community representatives. Over 1000 Columbus faith institutions were compiled from CPH historical lists, and influential contacts were identified from a long-standing 40 member Mayor's Religious Advisory Council. Despite this outreach, it proved difficult to recruit a significant number of individual congregations for climate conversations. In May 2016, a key staff person in the main partnering organization (OhIPL) was laid off, limiting the ability to conduct free-energy audits, although a city- sponsored substitute was found.

As part of the content of the climate conversations, a 20-slide PowerPoint presentation was developed that discussed basic science of global warming, local changes in extreme temperatures and precipitation, health impacts (heat and asthma), and actions individuals can take to mitigate and adapt to climate change (active transportation, tree planting, home energy efficiency). After several presentations, the materials were simplified to communicate to low literacy audiences.

Given project delays from the labor-intensiveness of identifying and recruiting congregations and lack of uptake by congregations, several mid-project course corrections involving new partners were explored. First was aimed at public elementary schools and those of the Columbus Catholic Diocese, whose teachers and students expressed an interest in learning about climate change. Another initiative was to establish a link with a community service program (ADVANCE) of the US Green Building Council, 48 which aimed to increase access to green building resources and expertise for new, underserved and underrepresented communities. Third was the recruitment of a neighborhood social justice organization called "Think, Make, Live." 49

As of March 2017, climate conversations were held in 5 congregations, GreenSpot Schools was kicked off at 1 school in the Columbus Catholic Diocese, and 1 church was identified as a site for an ADVANCE energy improvement plan.

4. LHD capacity building

Before the Learning Collaborative, the OES and CPH leadership had a long history of participation and integration in the city's sustainability and climate change programs. This project was an attempt to add a new, faith-based constituency centered in disadvantaged African American and Latino communities.

5. Disadvantaged populations and health equity

The City of Columbus has an Office of Minority Health, which quarterly convenes an advisory committee of 40 representatives from CPH and the state health department, academic institutions, local health care systems, and neighborhood health advisory committees. The focus of the OMH in 2016 appeared to be access to health services in race/ethnic and refugee communities. Although the LC did some initial outreach to the OMH, programmatic links were not created between the LC and the OMH. Mayor's Office of Diversity and Inclusion also promotes social equity and did not appear to play a role in the project.

The LC project mentioned that a vulnerability assessment was being developed as part of the city's new Climate Action Plan, but did not indicate the geographic overlap between the faith-based congregations of interest, climate risks, and existing social vulnerabilities in Columbus residents.

6. Integration of climate change into health department programs/ communications

The project staff acknowledged existing mechanisms to increase the awareness of the LC project and the City's Climate Action Plan among staff in CPH. For example, the Environmental Health Division often conducts an annual educational module for CPH professional staff on topics of environmental health. Forging closer links with CPH programs in communicable disease, epidemiology, and emergency preparedness were

82 expressed in one-on-one calls, but it appears that widespread dissemination of the LC project and integration with other CHP programs occurred during the project period. CPH did not appear to face barriers in communicating climate change and public health in City planning documents; however, climate change and health communications did not appear to be integrated into other CHP programs.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

As mentioned above, the LC project experienced significant administrative and programmatic challenges. The decentralized structure of faith-based organizations, which often relied on the volunteerism of congregants to organize meetings and events was recognized by LC staff as a significant barrier that could not be overcome by the dedicated efforts of staff. Follow-up of individual congregants to arrange and document personal commitments for action was also labor-intensive. This raises a question of whether the original model based on both individual and one-on-one climate conversations is scalable or applicable in this setting. In previous applications of primate conversations, the role of OhIPL was more visible to church leaders and congregants. In this implementation, its role was smaller than originally planned and was sidelined when its funding was lost.

The loss of the program director in March 2017 compounded these difficulties.

Unanticipated opportunities

CPH broadened the scope of the pre-project GreenSpot Kids program, which through grant funding, had developed curriculum and activities for elementary schools, but had not formally created a schools category in GreenSpot. The LC project appears to have contributed to the creation of GreenSpot Schools, especially in those run by the Columbus Catholic Diocese. The receptivity of this religious organization was probably influenced to some degree by the 2015 Papal Encyclical on climate change and environmental stewardship.

8. Assessment of meeting goals

Administrative Data

While CPH met many of the goals they set for the project, the project had a limited scale in the target community of faith-based organizations and their congregants in Columbus' disadvantaged low income and African American and Latino communities. In the context of the entire Learning Collaborative, the unfulfilled goals of CPH represent a possible cautionary lesson on the challenges of applying an education and change model that requires much one-on-one contact in diverse organizations with decentralized structures and members who are volunteers.

Self-Assessment

Based on the final report narrative, the LC coordinator concurred that unforeseen difficulties (mentioned above) limited the project in achieving its goals. The project, however, did respond by seeking new partners (ADVANCE, Greenspot Schools) and a new model (church renovation) to engage the faith-based communities.

Key Informant Interviews

We spoke to the coordinator of the City of Columbus Greenspot program and the regional director of the U.S. Green Building Council, which oversees the ADVANCE program. They acknowledged the importance of their partnership with the CDPH, and the challenges working in minority communities. Government agencies - whose representatives are not from minority groups - must be authentic partners, and it takes time to establish authenticity in the eyes of the underserved communities. The entry point of the project was not necessarily the entry point of community, which is more receptive to addressing immediate economic survival issues. The shortness of the project did not allow for a preliminary stage of community needs assessment, which would have also helped established trust between partners.

Section References

41. Coleman M. Get Green. Columbus, OH: Office of the Mayor; 2005.https://www.columbus.gov/uploadedFiles/Columbus/Programs/Get_Green/Documents _and_Principles/GetGreen%20Memo_SSa.pdf 42. Office of Environmental Stewardship. GreenSpot. Columbus, OH: City of Columbus; 2017.https://www.columbus.gov/greenspot/ 43. Coleman M. Get Green: Green Memo II. Columbus, OH: Office of the Mayor; 2010.https://www.columbus.gov/WorkArea/DownloadAsset.aspx?id=70868 44. Office of Environmental Stewardship. The Columbus Green Community Plan: Green Memo III. Columbus, OH: City of Columbus; 2016.https://www.columbus.gov/WorkArea/DownloadAsset.aspx?id=2147486721 45. Michael R. Bloomberg, C40 Cities Climate Leadership Group, ICLEI – Local Governments for Sustainability, United Cities and Local Governments, UN-Habitat. Compact of Mayors; 2017.https://www.compactofmayors.org/ 46. Healthier Hospitals Initiative. Healhier Hospitals Initiative. Reston, VA: Practice Greenhealth; 2017.http://healthierhospitals.org/ 47. Interfaith Power & Light. Interfaith Power & Light. San Francisco, CA: Interfaith Power & Light; 2017.http://www.interfaithpowerandlight.org/ 48. US Green Building Council. ADVANCE. Washington, DC: US Green Building Council; 2017.http://www.usgbc.org/articles/advocacy-and-community-service-usgbc-ohio#service 49. Think, Make, Live. Motivation to Empower Self Development, Community Engagement, and Social Justice. Columbus, OH: Think, Make, Live; 2017.http://www.thinkmakelive.org/

E. Minneapolis Department of Public Health

1. Background

With a staff of 100 and an annual budget of $20 million, the Minneapolis Health Department (MHD) serves 407,000 residents of the city of Minneapolis.50 The City Council serves as the Board of Health and is responsible for making final policy and programmatic decisions for the Minneapolis Health Department. MHD was accredited by the Public Health Accreditation Board in 2016.51 The Health Department is responsible for meeting a variety of health-related needs of the city, including environmental services, healthy homes and lead hazard control, chronic disease prevention, public health emergency preparedness, maternal and child health, healthy seniors, and youth development and healthy sexuality. The Department serves the needs of a diverse population; Minneapolis is 60% White, 18% African American, 11% Hispanic or Latino, and 6% Asian.52 Additionally, nearly 16% of Minneapolis residents reported a birth country other than the Unites States. In 2015, approximately 25.3% of City residents had incomes below the federal poverty line. There is an eight to thirteen year gap in life expectancy between the affluent suburbs of Minneapolis and the inner city neighborhoods.53 The 2012 Community Health Improvement Plan identified maternal and child health, nutrition, obesity and physical activity, social and emotional wellbeing, health care access, and social conditions that impacts health as the strategic health issues of focus.54 Similarly, the Community Health Assessment conducted by Bloomington Public Health, Minneapolis Department of Health, and Hennepin County Public Health Department defined nutrition, obesity and physical activity, social connectedness, and school readiness as key performance measures.55 These documents and others, including the Achieving Health Equity in Minneapolis Report, emphasize the shared priorities of diverse stakeholders and residents to address chronic disease, improve access to health and other services, and address social determinants of health.52

Prior Climate Change Activities of the Local Jurisdiction

In 2012, the Minneapolis City Council set bold goals for greenhouse gas emission (GHGE) reductions 15% by 2015 and 30% by 2025, and updated the goal to 80% by 2050 in April 2014. Emissions declined by more than 17% between 2006 and 2015.56 In 2013, the city released the Minneapolis Climate Action Plan, which described climate change as “a defining challenge of this century, and even this decade.” 57 The CAP strategies fall primarily into improving energy efficiency, increasing use of local renewable energy, reducing vehicle miles traveled and developing active transport infrastructure, and reducing the waste stream. Minneapolis is designated as a Climate Change Champion Community by the US Department of Energy.58 The city of Minneapolis has a fairly long history of engaging in sustainability and environmental initiatives and activities; the Environmental Coordinating Team was established in 1994, the Sustainability Program was established in 2003, followed by the adoption of Sustainability Indicators in 2005. In 2007, the city established the Climate Change grant program, which awards “small grants to groups interested in promoting concrete actions

85 among residents and businesses to reduce GHGE.” 59 The Minnesota Health Department conducted Climate and Health Vulnerability Assessments in 2014 and 2015. The 2015 assessment outlined 5 goals that will guide priorities and funding decisions for activities and programs to minimize the health impacts of climate change.60 The goals include identification and tracking of public health impacts of climate change, development of mitigation and adaptation strategies, identification of vulnerable populations, enhancement of planning and preparedness for emergency and disaster response and recovery, and increased public health system capacity to respond to and adapt to public health impacts of climate change.

Applicant and Proposal

The Minneapolis Health Department’s Public Health Emergency Preparedness Program officially represented the jurisdiction in the Learning Collaborative, however the Office of Sustainability has played a major role throughout the duration of the project. In addition to the Climate Change Preparedness program, the Public Health Emergency Preparedness Program supports Zika Virus, Ebola, and Extreme Heat and Cold Preparedness programs, and exercises and plans for city health department responses to special events, natural, and terrorism caused incidents.

Background and Prior Climate Change Activities of the Health Department

The Health Department has been involved in climate change work since 2005, and most recently has engaged numerous community engagement initiatives and pilot programs. MHD activities related to climate change generally sit in Environmental Services (ES), and tend to fall primarily into the following categories, urban greening, air quality, conversation, environmentally-friendly practices, and energy auditing and efficiency. MHD’s Environmental Services houses the Minneapolis Green Business Cost Share Program, which invests “in businesses that promote cleaner, healthier, and more efficient business practices.”61 The City offers awards up to $100,000 for investment in more sustainable and efficient technologies in dry cleaning, auto repair, printing and other manufacturing businesses. ES also houses the Energy Benchmarking Program for Public and Large Commercial Buildings, which provides information on energy usage for buildings over 25,000 square feet.

MHDs Prevention and Healthy Living program has been involved in numerous initiatives related to food access and healthy food systems, including community gardens and the Office of Sustainability’s Home Grown program, which “is a citywide initiative expanding the community’s ability to grow, process, distribute, eat and compost more healthy, sustainable, locally grown foods.”62 Environmental Services also supports to the Minneapolis Urban Forestry Project, which provides trees and planting services to businesses and non-profits in order to reduce energy costs, more effectively manage storm water, reduce carbon dioxide, and increase green space throughout the City. The Health Department Environmental Services program also monitors air quality, water quality, and environmental pollutants. While these programs do not explicitly make the connection to climate change, they do ultimately mitigate the impacts of climate change

86 or support the development of more resilient communities and a more resilient Minneapolis.

2. Description of applicant’s proposal and goals (what)

The original proposal submitted by the Minneapolis Health Department described a collaborative effort between the Health Department, the Office of Sustainability, University of Minnesota Humphrey School of Public Affairs, Macalester College, and various community-based organizations to initially conduct a climate and health vulnerability assessment, conduct a series of community dialogues, and develop a report that includes community-identified recommendations.

Goals and Objectives

The overarching goal of this project is to expand upon the limited climate change adaptation/resilience work conducted by the Health Department, increase awareness of climate change impacts for Health department staff and community members, and enable Health, Sustainability and other City Departments to begin planning for climate change impacts.

More specifically the goals of this project were to identify populations particularly vulnerable to the health impacts of climate change, engage community-based organizations and members in community dialogues, and elicit community-identified recommendations to support resiliency and ensure that health equity is addressed. The specific objectives from the October 2015 scope of work are presented in Table V-E1 (next page).

Duration of Participation

MHD participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

Staffing/ Organizational Chart

The proposal had a four-person project team drawn from the Health Department and Office of Sustainability. The team included the Preparedness Manager and principal investigator (.05 FTE), Preparedness Specialist (.05 FTE), and the Sustainability Program Coordinator.

Table V-E1. Objectives of the Minneapolis Climate and Health Project from October 2015 Scope of Work October 2015 Scope of Work (January 2016 - June 2017) 1. Select data for climate hazards, vulnerable populations, and vulnerable systems and infrastructures 2. Complete a literature review on climate change impacts in Minnesota, populations vulnerable to climate change, and vulnerability assessment methodologies using peer-reviewed research as well as white papers from federal, state and local agencies and organizations 3. Use geographical information systems and other risk assessment methodologies to assess the location and magnitude of climate change impacts, vulnerable populations and system vulnerabilities across Minneapolis. 4. Present vulnerability assessment findings to local health department staff, as well as other partners convened earlier in the project development 5. Develop community engagement plan, focusing resources on the areas identified as most vulnerable to climate change impacts 6. Host neighborhood-scale community meetings in the three communities with the greatest potential climate change impacts and/or vulnerability to increase awareness and develop community-led solutions. 7. Utilize key-informant interviews, meeting evaluation surveys, and other participant feedback to evaluate the vulnerability assessment and process of community engagement 8. Identify next steps for the City’s climate adaptation work. Project Extension (July 2017 - December 2017) 1. Host neighborhood-scale community meetings in the two communities with the greatest potential climate change impacts and/or vulnerability to increase awareness and develop community-led solutions 2. Host two emergency preparedness training sessions (ReadyCamp) 3. Host final dinner meeting with community particpants and key City leadership and staff to present recommendations

3. Description of applicant’s proposed objectives and activities

MHD’s proposed project was a three-phase project. The first phase was a vulnerability assessment in order to identify the populations and community assets and services most vulnerable to these impacts due to higher risk and lower resiliency. The second phase was described as the community engagement phase, in which the Health Department partnered with Macalester College to select communities of focus for the implementation of neighborhood based programs and developed engagement strategies. The basis of the engagement strategy was initially outlined as recruitment of community partners and the provision of stipends for participants. Given the available funding and staff time, the Health Department planned to engage three communities, based on indicators of vulnerability and resiliency- and proposed to partner with two community partners in each of the three communities, for a total of six community partners. The Health Department contracted with Macalester College to evaluate the

88 process and results of the community meetings, and as well as recommendations proposed by community members.

Phase 1: Vulnerability Assessment

MHD collaborated with graduate students in the Urban and Regional Planning program at the University of Minnesota Humphrey School of Public Affairs to conduct the place- based climate change vulnerability assessment using geographical information systems (GIS). Indicator selection was an iterative process and data sets were requested from government and non-government sources. Indicators were selected based on a thorough literature review of previous climate vulnerability assessments, Minneapolis City staff recommendations, and the utility of the data to fit the smaller geographic area of the City.

Within the climate vulnerability assessment there is a distinction between social vulnerability, defined as “characteristics of individuals or households, measured at the community scale”, and landscape vulnerability, defined as “characteristics of the built or unbuilt environment.”63 Initially, the assessment was designed to include the effects of two landscape vulnerability variables, extreme heat and flooding, and social vulnerability into one climate change vulnerability map, however, due to data limitations social vulnerability and extreme heat vulnerability were included on a combined place-based vulnerability map, and flooding vulnerability was included as a separate narrative overview of flood risk. Additionally, the students included a floodwater accumulation analysis and principle component analysis, which were not initially included in the vulnerability assessment scope.

Following the completion of the climate vulnerability assessment and the associated report, the University of Minnesota students presented the assessment findings at three separate meetings to Health Department staff, the Community Environmental Advisory Commission, and the Public Health Advisory Committee, respectively. Overall feedback was positive and the results were unsurprising to those who reviewed the maps and overall climate vulnerability assessment. The City staff held a meeting on July 25, 2016 to review the technical data included in the assessment.

Phase 2: Community Engagement

MHD partnered with Macalester College to design the Community Climate Conversations (community dialogues), they also relied on input from the Center for Earth Energy and Democracy (CEED) and the City of Seattle to gain insight on community engagement and meeting facilitation. Based on the results of the vulnerability assessment and input from the Macalester College partners, the Health Department selected Near North, Phillips, and Longfellow communities for the community engagement phase of the project. Near North and Phillips were selected based on their overall vulnerability score. Upon the suggestion of Macalester College consultant, Longfellow was included as a pseudo “control group” as it has high flooding vulnerability, but is an upper-middle class, predominantly white neighborhood. MHD

89 worked to draw on existing Memoranda of Understandings (MOUs) with community- based organizations (CBOs) in the three selected communities. See CBOs initially selected in the table below.

Table V-E2: Community Dialogue CBO Neighborhood Partners Neighborhood CBO Longfellow • Longfellow Community Council • Transition Longfellow Phillips • Pillsbury United Communities- Waite House • Little Earth Near North • Minneapolis Urban League • Lao Assistance Center

Meetings were held with individual organization leadership to secure support and participation, and discuss project expectations. Each CBO sent representatives to the all-day training on September 12, 2016, during which much of the time was allocated to planning the community dialogues, including recruitment strategies that would result in participation reflective of the community composition. Each CBO was awarded a $500 stipend to support planning and recruitment efforts, MHD provided meals, associated materials, and childcare, additionally, each participant was awarded a $50 gift card.

During winter 2016, community dialogues were held in Longfellow and Phillips, the Near North meeting was postponed (see delay outlined below in section 7). There were 18 participants at the Philips dialogue, and 23 at the Longfellow dialogue. Participants engaged in an asset mapping activity with the goal of identifying unique elements that support climate resiliency in their communities. Participants also discussed the climate change impacts most relevant for their neighborhood and community and strategies to mitigate or adapt to these impacts. Macalester helped conduct evaluations of the community dialogues and follow-up meetings were held between MHD and Macalester to discuss findings and next steps.

Phase 3: Evaluation and Plan Development

As described above, the final phase of the project included the evaluation of the community dialogues. The most consistent message from Community Partners and participants was the need for more information/ awareness/preparation for emergencies and natural disasters. The results were also presented at a City Council meeting in 2017 and a follow-up presentation is scheduled for 2018. The LC staff held discussions internally with other programs to determine avenues for continuing support for emergency preparedness engagement, which includes cost, timeline and potential funding sources of the recommendations.

4. LHD capacity building

The involvement of the Public Health Advisory Committee (PHAC) throughout this project in an advisory capacity will be an important source of support and advocacy in advancing the climate and health agenda forward in the health department and the city government. PHAC advises the Health Department and the City Council on policy and programmatic issues related to the health of Minneapolis residents. PHAC reviewed the climate vulnerability maps in the first phase of the project and will be asked to review the final recommendations put forward in the final assessment. Once they agree to and complete the review, PHAC can advise the City Council regarding policy decisions, which will ultimately impact future city funding for climate and health programming and shapes Minneapolis’ trajectory on climate action for health.

5. Disadvantaged populations and health equity

There are several mechanisms employed throughout the duration of this project that address disadvantaged populations and health equity. Two of the three communities (Phillips and Near North) were selected based on the overall place vulnerability score, which includes social and landscape vulnerability to heat. Indicators used to assess social vulnerability include elderly population (percent of population over 65 years), young children (percent of population under 5 years), poverty (percent of population living at or below the Federal poverty level), limited English (percent of population who speak English “less than well”), people of color (percent of the population not identifying as White, Not Hispanic), disability (percent of civilian noninstitutionalized population who report a disability), vehicle access (percent of households with no vehicle), renters (percent of households who are renters), and air conditioning (average percent of residential parcel units with central air conditioning). The inclusion of these indicators and the social vulnerability measure overall demonstrates a commitment to recognizing and addressing the social determinants of health that ultimately place certain communities at higher risk of the health impacts of climate change. MHDs partnerships with CBOs that serve low-income communities and communities of color and the facilitation of community dialogues in which the community participants lead the conversation and ultimately make recommendations for action reinforces MHD’s commitment to “health lives, health equity, and healthy environments” (Minneapolis Health Equity report, 2014).

6. Integration of climate change into health department programs/communications

The outcomes of this project, specifically the vulnerability assessment and ongoing engagement with community partners serves as a foundation to expand the efforts of the health department both internally and externally to prioritize programs that address the health impacts of climate change. Presenting final recommendations to City Council will ideally result in increased funding for the Health Department’s Climate and Health programming. The LC have hosted two brownbag lunches with staff, as well as set up viewing rooms for staff to come together and participate in a webinar series hosted by the Minnesota Department of Health on the health impacts of climate change. LC staff have not yet discussed with other programs how climate change would integrate directly

91 into their work. According to LC staff, limiting factors are categorical nature of funding streams and available staff time.

The MHD website includes a page dedicated to Climate Change Resiliency (http://www.minneapolismn.gov/health/preparedness/climate), on which there is a description of the MHD Learning Collaborative project, key project phases, and key partners.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

The main challenge encountered in MHD’s project was associated with the organization and execution of the community dialogue in the Near North community. The initial issue arose due to a staffing change at one of the partner CBOs (Urban League), one of the most enthusiastic community leaders left his agency. This delayed the community dialogue and left the Lao Assistance Center (LAC) as the sole community partner. MHD and LAC worked together to translate materials, fliers, and applications into Lao and Hmong, however a few weeks prior to the scheduled community dialogue LAC informed MHD that they would not be able to assist in translation and facilitation in the small group dialogues. Due to limitations in funding and translation services the dialogue was canceled. Fortunately, MHD connected with two other CBOs (Neighborhood Hub and Appetite for Change) who were very enthusiastic about hosting a climate and preparedness event in North Minneapolis. Neighborhood Hub had experience responding to the 2011 tornado that devastated North Minneapolis and brought their learnings from that tragedy. The Northside Preparedness Jam was hosted in September 2017, with a significant change in format compared to the previous two climate and health workshops. The event was hosted outside in a community event space; there were spoken word artists, musicians, and youth-led performances, as well as tables for organizations and the City to share information and resources with attendees.

MHD connected with one more community partner in Northeast Minneapolis to host a fourth community workshop in October 2017. This workshop was closer in format to the first two, but included storytelling and more small-group dialogue and fewer presentations.

The culminating event for the series of workshops was inspired by an event Macalester had hosted with the City of Saint Paul when they were doing similar work in 2014-2015. MHD hosted a dinner in November 2017 to bring together community partners, community participants, and City staff to share ideas, recommendations and opportunities for collaboration. The event was well attended by City staff but unfortunately did not get as many community partners or participants to attend. The discussion at the event helped highlight the particular interest of community in knowing more about City programs and resources, specifically engaging with communities that are not already connected to City communication channels.

While the community dialogues were considered successful, there was concern from several community partners regarding the amount of work required to facilitate a community dialogue for relatively little compensation.

The second challenge encountered in this project occurred with the “Community Learning Opportunity in the Age of Climate Change” on March 8, 2017. This event was held in conjunction with MHD’s annual meeting with and for CBOs, with which MHD has MOUs for Emergency Preparedness. Unfortunately, due to staff miscommunication invitations were sent to the community only one week prior to the event and the location was changed from previous years, therefore resulting in significantly decreased attendance; this year there were 10 attendees, previous years have had 75-100 attendees.

Unanticipated opportunities

On May 26 2016, Minneapolis announced that it had been selected to participant in the Rockefeller Foundation's 100 Resilient Cities final cohort. While the 100 Resilient Cities is not solely focused on climate change, it provides a timely and relevant opportunity to integrate the climate vulnerability assessment and the recommendations from community dialogues into Minneapolis’ Resilience Plan.

8. Assessment of meeting goals

Administrative Data

The Minneapolis LC collaborative met all of the major goals outlined in its scope of work and developed all of the promised deliverables. In partnership with graduate students at the Humphrey School of Public Affairs the project team developed a vulnerability assessment to heat and flooding, including 9 social vulnerability factors. The LC project team successfully co-hosted four community climate preparedness workshops with several of the most vulnerable communities in Minneapolis. These community workshops facilitated the developed of relationships with eight community partners, whom with the health department had not worked previously. Additionally, the project team fostered internal capacity building and intra and inter-departmental collaboration by engaging City staff from the Minneapolis Health Department, Sustainability, Community Planning and Economic Development, Public Works, Neighborhood and Community Relations, IT, and others in presentations and conversations about how to measure Minneapolis’ vulnerability to climate change and the associated health impacts, how respective department work will be impacted by climate change, and how departments and programs can connect with impacted communities.

Self-assessment Questionnaire

The grant enabled the Minneapolis project team to conduct meaningful community engagement and relationship building, ensuring that community workshops were led by community members and leaders. Additionally, the project team indicated that the grant facilitated greater communication and collaboration across City departments than had previously occurred. Throughout the duration of the grant period, the project was able to dedicate greater focus to adaptation and resilience efforts than they had previously.

Key Informant Interview

We interviewed the Executive Director of one of the partner community-based organizations and a high-ranking member of the health department leadership. The community partner stated that this project was the first instance in which her organization had been approached about climate change and lead to the development of relationships with other CBOs they had not worked with previously. Health department leadership indicated that the grant “allow[ed] us to do things we’d like to do,” moving projects and goals from aspirational to real by creating accountability, a timeline, and financial justification for critical work.

Section References

50. City of Minneapolis. City of Minneapolis Budget in Brief. Minneapolis, MN: City of Minneapolis; 2016.http://www.minneapolismn.gov/www/groups/public/@finance/documents/webcontent/w cmsp-173866.pdf 51. Minneapolis Health Department. Public Health Advisory Committee (PHAC). Minneapolis, MN: City of Minneapolis; 2017.http://www.minneapolismn.gov/health/phac/index.htm 52. Minneapolis Health Department. Achieving Health Equity in Minneapolis. Minneapolis, MN: Minneapolis Health Department; 2014.http://www.minneapolismn.gov/www/groups/public/@health/documents/webcontent/wc ms1p-133417.pdf 53. Commissioner’s Office. Advancing Health Equity on Minnesota: Report to the Legislature. Saint Paul, MN: Minnesota Department of Health; 2014.http://www.health.state.mn.us/divs/chs/healthequity/ahe_leg_report_020414.pdf 54. Hennepin County Human Services and Public Health, Minneapolis Department of Health, Bloomington Public Health. 2012 - 2015 Community Health Improvement Plan for Hennepin County Residents. Minneapolis, MN: Community Health Improvement Partnership; 2012.https://www.hennepin.us/-/media/hennepinus/your-government/projects- initiatives/documents/2012-2015-chip-plan-hennepin-res.pdf?la=en 55. Hennepin County Public Health, Minneapolis Department of Health, Bloomington Public Health. Community Health Assessment: To Identify Public Health Priorities. Minneapolis, MN: Community Health Improvement Partnership; 2016.https://www.hennepin.us/- /media/hennepinus/your-government/projects-initiatives/documents/chip-book.pdf?la=en 56. City of Minneapolis. City Sets Goal to Reduce Greenhouse Gas 80 Percent by 2050. Minneapolis, MBN: City of Minneapolis; 2014.http://www.ci.minneapolis.mn.us/news/WCMS1P-123878 57. Sustainability Office. Minneapolis Climate Action Plan. Minneapolis, MN: Minneapolis City Coordinator;

2013.http://www.minneapolismn.gov/www/groups/public/@citycoordinator/documents/webco ntent/wcms1p-113598.pdf 58. US Department of Energy. Climate Action Champions: Minneapolis, MN; 2015.https://energy.gov/policy/climate-action-champions-minneapolis-mn 59. Minneapolis Sustainability Office. History. Minneapolis, MN: City of Minneapolis; 2017.http://www.minneapolismn.gov/sustainability/history/index.htm 60. Climate & Health Program Environmmental Impacts Analysis Unit. Minnesota Climate and Health Profile Report. Saint Paul, MN: Minnesota Department of Health; 2015.http://www.health.state.mn.us/divs/climatechange/docs/mnprofile2015.pdf 61. Minneapolis Health Department. Minneapolis Green Business/Housing Cost Share Program. Minneapolis, MN: City of Minneapolis; 2018.http://www.minneapolismn.gov/environment/WCMS1P-105418 62. City of Minneapolis. Homegrown Minneapolis. City of Minneapolis, MN: City of Minneapolis; 2015.http://www.minneapolismn.gov/sustainability/homegrown/ 63. Sandkamp L, Martin K, Bailey C. Technical Report: Minneapolis Climate Change Vulnerability Assessment. Minneapolis, MN: Minneapolis Sustainability Office & Health Department and Humphrey School of Public Affairs, University of Minnesota; 2016.http://www.minneapolismn.gov/www/groups/public/@citycoordinator/documents/webco ntent/wcmsp-180497.pdf

F. Los Angeles County Department of Public Health

1. Background

With a staff of 4500 and an annual budget of $893 million, the Los Angeles County Department of Public Health (LACDPH) serves 10 million residents of the Los Angeles County.64 It is the largest local health department in the United States. County agencies and departments are overseen by a 5-member board of supervisors and an appointed chief executive officer. From 2006 to March 2017, LACDPH was an autonomous department, but, during the Learning Collaborative, it was merged into a Health Agency that included departments for health services and mental health. LACDPH was accredited by the Public Health Accreditation Board in March 2017.

LACDPH is organized into 3 large bureaus (Operations Support, Health Promotion, and Health Protection) and 2 offices (Office of Communications & Public Affairs, and Medical Director/Disease Control), and operates 14 community health centers and 39 programs. Within the bureaus, divisions include Environmental Health; Maternal, Child & Adolescent Health; Communicable Disease Control and Prevention; Chronic Disease and Injury Prevention; and Health Facilities Inspection. The Department serves the needs of a diverse population, which, in 2010, was 52% White, 48% Hispanic or Latino, 14% Asian, and 9% African American. In 2015, approximately 18% of county residents had incomes below the federal poverty line. Among the county's 88 cities, there was a 15 year difference in life expectancy in 2010.65 The 2015 Community Health Improvement Plan66 identified three priority areas (increase prevention and access to health services, creating healthy communities, and achieving equity) and 10 goals, of which reducing air toxics invoked a strategy of cross-sector collaboration to "reduce greenhouse gas emissions and protect the public from the repercussions of climate change." LACDPH appears to be unique among local health departments; since 2014 it has employed a full-time staff member dedicated to coordinate climate change and health activities.

Prior Climate Change Activities of the Local Jurisdiction

According to the California Governor's Office of Planning and Research, 84 of the county's 88 incorporated cities had initiatives or plans to address climate change in 2016,67 including the City of Los Angeles's Climate Action Report68 and Sustainability Plan.69 The mayor of Los Angeles (since 2013), Eric Garcetti, has a national profile on climate change. He co-founded the national Mayors National Climate Action Agenda and was a member of President Obama's State, Local, And Tribal Leaders Task Force on Climate Preparedness and Resilience.

Several departments in Los Angeles County (although not LACDPH) have had sustainability offices for some years; however, it was not until 2016 that Los Angeles County established Chief Sustainability Office within its Chief Executive Office, with the goal of developing a County Sustainability Plan. A Sustainability Council comprised of department directors and staff is assisting with the development of the Plan, which is

96 anticipated to provide a vision for sustainability for (a) County facilities and operations; (b) County unincorporated areas; and (c) the broader region, including the county’s 88 cities (http://green.lacounty.gov/wps/portal/green). The County inventoried greenhouse gases in 201070 and developed a climate action plan for unincorporated areas in 2015.71 (Unincorporated areas disproportionately represent disadvantaged populations.) In 2016, the County of Los Angeles published a strategic plan 72 that explicitly addressed the "serious threat of global climate change" and, through inter-departmental and cross- sector collaboration, seeks to "create and implement policies and programs to reduce the emission of greenhouse gases from all sectors of our community, ensure that community climate resilience is integrated into our programs and plans and inspire others to take action."

Several nongovernmental and community-based organizations are active on climate change in Los Angeles County and the greater Los Angeles region. These include Citizens for a Better Environment (CBE), the Natural Resources Defense Council (NRDC), Tree People, and Climate Resolve (cool roofs). Several work with city councils to implement ordinances and a few have worked with the LACDPH (NRDC).

A regional network of climate practitioners and decision-makers from academia, cities, LA County, regional agencies, non-profits, and businesses comprise the Los Angeles Regional Collaborative (LARC) for Climate Action and Sustainability (http://www.laregionalcollaborative.com/). LARC is a membership organization that fosters climate mitigation and adaptation work and includes public health as one of its sectors.

Applicant and Proposal

The Environmental Health Division, which employs the full-time Climate and Health Coordinator, and the Public Health Emergency Preparedness Program (which became a Division during the project) officially represented the jurisdiction in the Learning Collaborative.

Background and Prior Climate Change Activities of the Health Department

Formal activities on climate change and health were initiated in 2013 when LACDPH launched a Climate and Health Workshop series in collaboration with the school of public health at the University of California, Los Angeles. The series was created specifically for LACDPH staff, and covered the basic science of climate change, the impacts of climate change in the Los Angeles region, and how those impacts relate to DPH’s mission. In 2014, DPH released two Climate & Health Reports73, 74 outlining the health impacts of climate change in Los Angeles and the role of various government agencies in addressing climate change. The reports debuted a five-point framework (the Five Point Plan to Reduce the Health Impacts of Climate Change) for organizing intersectoral climate and health activities that encompassed public education, climate mitigation and adaptation, internal capacity building, and internal business operations of the health department (Appendix56). The follow-up to the reports was the creation of an

LACDPH-led, intersectoral Climate Committee, comprised of 6 additional County departments (Beaches and Harbors, Internal Services, Fire, Parks and Recreation, Public Works, and Regional Planning) and on-going collaboration with intra-jurisdictional workgroups for Healthy Design and Sustainable Solid Waste. In 2016, the Climate Committee, responding to recommendations in the 2015 County Climate Action Plan to meet 2020 GHG reduction goals, initiated the development of an urban heat island reduction plan.

Health equity, strongly emphasized in LACDPH’s goals, is one of six strategic priorities in its Strategic Plan 2013-2017, whose objectives include generating and disseminating data and reports on health equity, social determinants, and health disparities; providing input and guidance on policy and advocacy efforts regarding health equity and social determinants of health; engaging key partners in addressing the social determinants of health; and incorporating health equity into existing DPH efforts.

2. Description of applicant’s proposal and goals (what)

The original proposal submitted by the LACDPH supported a new internal initiative called the Climate & Health Initiative to engage its divisions and programs in defining and implementing activities to advance the Five-Point Plan to Reduce the Health Impacts of Climate Change.

Goals and Objectives

The goals of the Climate & Health Initiative were to 1) meet with all relevant division directors to discuss how their divisions’ activities relate to climate change; 2) launch an intradepartmental workgroup that identifies at least five actions that can be taken by divisions/programs to support DPH’s climate change goals; 3) develop plans to meet those five goals; and 4) as a pre-identified action, work to develop a DPH Extreme Heat Response Framework. The specific objectives from the October 2015 scope of work are presented in Table V-F1 (below).

Table V-F1. Objectives of the Los Angeles Climate and Health Project from October 2015 Scope of Work

1. Engage DPH divisions in implementing the Five Point Plan

1.1. Meet with division directors and program directors to determine current mitigation and resilience activities and steps for new ones 1.2. Establish an intradepartmental climate change workgroup with representatives from DPH divisions 1.3. Develop minimum of five action plans to meet stated goals 1.4. Hire web designer or graphic designer to engage DPH-wide interest and brand efforts

1.5. Determine system for sustaining staff interest in climate change mitigation and resilience efforts

2. Improve DPH’s preparedness for and response to extreme heat events

2.1. Use intradepartmental workgroup established in Activity 1.2 to develop list of measures for improving preparedness and response to extreme heat 2.2. Refine list of proposed measures based on feedback from other County departments and external partners; identify concrete deliverables 2.3. Develop Extreme Heat Response Framework in time for summer 2017 2.4. Begin implementing program activities (e.g. monitoring systems, mapping) to support implementation of the Extreme Heat Response Framework

Extension (July 1, 2017 - December 15, 2017) 1. Integrate climate messaging into existing communication pathways throughout DPH

Duration of Participation

LACDPH participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

Staffing/ Organizational Chart

The proposal had a three-person project team comprised of the full-time Climate and Health Coordinator in the Environmental Health Division, a part-time epidemiologist from the Public Health and Emergency Response Division, and an AmeriCorps intern in Governor Brown's Civic Spark program. Civic Spark, administered by the Local Government Commission, is a California initiative dedicated to building capacity for local governments to address climate change, and its interns are typically recent college graduates in environmental sciences.

3. Description of applicant’s proposed objectives and activities

The applicant proposed to create a structure (intradepartmental workgroup) and process for internal capacity building organized around the Five-Point program and to leverage this workgroup's activities to improve the emergency preparedness and response to extreme heat events. The activities centered on meeting with each of the LACDPH's division and program directors, establishing an intradepartmental workgroup, creating action plans, and identifying and linking existing activities (e.g., surveillance, public education and heat notification, transportation to cooling centers) to extreme heat prevention and response planning for the 2017 heat season.

In preparation for the meetings with division directors, the LC staff met with key climate and health champions in the department, compiled information about the Learning

Collaborative and LACDPH's climate and health prior activities into a briefing sheet, identified potential program linkages to climate change, distributed an introductory memo from the LACDPH (interim) Director to the Division chiefs encouraging their participation. The Division chief from the Environmental Health Division presented the project at an intradepartmental Leadership meeting.

In early 2016, the LC staff had meetings with 19 directors who were briefed on the Initiative and were engaged in discussions on how their divisions and programs were addressing climate change, how they could enhance those activities, and who they would like to nominate to participate in the Intradepartmental Workgroup. In June 2016, a 22-member Intradepartmental workgroup was established with representatives from the public information office, operations/facility management, chronic disease prevention and health promotion, environmental health and emergency preparedness, nursing, veterinary health, communicable disease control, health assessment and epidemiology, children’s medical services, and women’s health. In preparation for this meeting, the LC staff prepared an information sheet about the initiative, a logic model, and a list of objectives and conducted one-on-one phone calls with each candidate. The kick-off meeting included a small group brainstorming activity in which current and proposed activities were identified and categorized by areas of the Five Point Plan. A 12-month timeline for the workgroup was developed. At successive workgroup meetings goals and over 25 objectives were identified (using Bubble maps) and prioritized (using Control & Impact diagrams). Five goals and activities represented refinements to those in the original Five Point plan, and the universe from which 5 detailed action plans were to be developed as a deliverable for the Learning Collaborative.

The objectives for the Extreme Heat Response Framework were subsumed under the Five Point Plan goal to provide guidance to local government and community partners on climate preparedness. The proposed objectives included to provide services for vulnerable populations, expand the extreme heat alert system, increase the effectiveness of cooling centers, build LACDPH capacity around extreme heat response, and educate the general public on the health risks associated with extreme heat and provide guidance for individual preparedness. The 4 other goals included: 1) using existing information distribution pathways to educate and engage the public on climate change science, adaptation, and mitigation topics, 2) promoting tree planting and preserving mature trees in coordination with the DPH-led Tree Committee, 3) communicating with Los Angeles County Supervisorial Districts about the public health risks of climate change which are most pertinent to their constituents, and 4) promoting flexibility around alternative work schedules, alternative work stations, and telecommuting.

The prioritized set of 5 goals was presented to LACDPH management in December 2016 and approved in early 2017 (after the appointment of a new LACDPH director). For each of the five goals, an action plan was developed with refined goals, objectives and specific tasks. For example, the Five Point Plan Goal of "Inform" was translated by the intradepartmental workgroup as "Distribute information through existing pathways" and had eight specific tasks (e.g. letters of support from County Health Officer,

100 developing and coordinating key messages for staff and clients, provide technical support to staff, and evaluate communications activities). In total, the action plan is a 9- page document with 28 objectives and 80 specific tasks.

Although implementation of the entire action plan was not part of the scope of work, the project did provide several examples of implementation. Under Goal 4 "Build", a template was created for presentations to the Board of Supervisors on climate change and health that included district specific data on climate risks, health impacts, and recommendations. Under Goal 1 "Inform" the LC collaborated with internal communications specialists to publish "Climate Change and Health in LA County: Opportunities for Physician Intervention" (http://rx.ph.lacounty.gov/RxClimate1117) in LACDPH's digital newsletter RX4P for clinicians.

Community Partners

As an internal capacity building project, the Climate & Health Initiative primarily reached out to internal programs of the LACDPH. However, through the Extreme Heat Response Plan goals (to provide services to community members), several community organizations were identified to review heat safety brochures for distribution at LACDPH community clinics, District Offices, and outdoor events, such as the Parks After Dark. The Parks After Dark program revitalizes parks in neighborhoods with high crime rates and economic hardship and offers residents an opportunity to engage in physical activity and interact with County agencies at information booths. At six Parks After Dark evening events during July and August 2017, four LACPDH staff and two interns from the LC distributed leaflets (heat safety, urban heat island reduction, and a map of cooling center locations) and a brief verbal questionnaire on coping in hot weather and cooling center utilization. Approximately 120 residents responded to questionnaires and made 20 recommendations on what Los Angeles County could do to make it easier for residents to cope with heat.

4. LHD capacity building

The Climate & Health Initiative was a capacity building project for the LACDPH. New structures and processes were created to engage management, programs, and staff and to craft action plans for 5 goals in an overarching climate and health framework developed prior to the learning collaborative.

5. Disadvantaged populations and health equity

The LACDPH has a high sensitivity to disadvantaged populations and health equity. Populations vulnerable to extreme heat are acknowledged in some goals (inform), but health equity appears to be a more implicit than an explicit part of the action plan details. The Extreme Heat Response Framework clearly outlines strategies for addressing disparities faced by disadvantaged populations with regard to heat health impacts, including strategies such as “Strategy 1.2 - Partner with organizations serving

101 vulnerable persons to disseminate heat safety information and best practices” and “1.3 - Address inequalities faced by vulnerable populations.”

6. Integration of climate change into health department programs/communications

The intradepartmental work group institutionalizes climate and health activities in the LACDPH programs that participate. The initiative aims to expand membership of the work group, which has increased to more than 30 participants. The action plan goal to Inform describes the development of core messages and draft message maps have been developed.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges The retirement of a supportive and long-standing LACDPH director and health officer (Dr. Jonathan Fielding) created some organizational uncertainty and delays until a new, permanent director was hired in early 2017. Significant support was provided by the interim director and health officer and commitments to the project were reaffirmed by the new director (the interim health officer remains). A departmental reorganization (being merged into a new health agency) did not impact the project.

In a project that focuses on internal capacity building, the degree and timing of community involvement in action planning is a potential challenge. LACDPH programs have ongoing relationships with CBOs and clients. Community members provided feedback on the type and content of materials distributed at Parks After Dark events as well as ideas for what local government could do to help them adapt to extreme heat, but broader community engagement was not developed more deeply in the project.

Unanticipated opportunities

One important leverage point for resources was the incorporation of three consecutive CivicSpark (AmeriCorps) interns into project work. The continuity and quality of the interns substantially advanced the project and allowed the LHD staff to concentrate on the organizational development.

8. Assessment of meeting goals

Administrative Data

The LC collaborative met the major goals outlined in its scope of work (1.1-1.3, 1.5, and 2) and produced all the promised deliverables. The participation in the LC advanced capacity building on climate, health, and equity - especially in the areas of internal capacity building. One area that was not emphasized in the itemized objectives of scope of work, yet is a goal of the LC is community engagement. The project made a unique contribution in creating action plans, and may be the first (or among the first few)

102 health departments to translate high level goals and strategies of climate action plans into to practical implementation.

Self-assessment questionnaire

Before the grant, what existed was a high level strategy document and reports, but no process or structure to integrate climate change, health, and equity into LHD activities. With the grant, capacity was greatly expanded to the point where standing workgroups and staff are volunteering to do this work. A testimony to the durability of the effort was that the structure and process were so strongly institutionalized that it was seamlessly embraced by new health department leadership.

Key Informant Interview

We interviewed two policy analysts form two different Divisions with LACDPH. They were unanimous in praise for the LC to have brought programs heads together and fostered thinking of how to integrate CCH into programs.

Section References

64. Los Angeles County Department of Public Health. Annual Report, 2012-2013. Los Angeles, CA: Los Angeles County Department of Public Health; 2013.http://publichealth.lacounty.gov/docs/ar2012-2013.pdf 65. Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Life Expectancy in Los Angeles County: How Long Do We Live and Why? A Citioes and Communities Report. Los Angeles, CA: Los Angeles County Department of Public Health; 2010.http://www.publichealth.lacounty.gov/epi/docs/Life%20Expectancy%20Final_web.pdf 66. Los Angeles County Department of Public Health. Community Health Improvement Plan for Los Angeles County, 2015-2020. Los Angeles, CA: Los Angeles County Department of Public Health; 2015.http://publichealth.lacounty.gov/plan/docs/CHA_CHIP/CHIPforLACounty20152020_03. 2016_revised%20logo_121616.pdf 67. Governor’s Office of Planning and Research (OPR). California Jurisdictions Addressing Climate Change. Sacramento, CA: Governor’s Office of Planning and Research; 2016.https://www.opr.ca.gov/docs/2016_California_Jurisdictions_Addressing_Climate_Chan ge_Summary.pdf 68. City of Los Angeles. Climate Action Report: Updated 1990 Baseline and 2013 Emissions Inventory Summary. Los Angles, CA: City of Los Angeles; 2014.https://www.lamayor.org/sites/g/files/wph446/f/landing_pages/files/pLAn%20Climate% 20Action-final-highres.pdf 69. City of Los Angeles. Sustainable City pLAn 2nd Annual Report, 2016-2017. Los Angeles, CA: City of Los Angeles; 2017.http://plan.lamayor.org/wp- content/uploads/2017/03/sustainability_pLAn_year_two.pdf 70. ICF International. Los Angeles County Draft Municipal Greenhouse Gas Inventory. Irvine, CA: ICF International; 2010.http://file.lacounty.gov/SDSInter/green/204266_LACODraftMunicipalGreenhouseGasIn ventory.pdf

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71. Los Angeles County. Unincorporated Los Angeles County Community Climate Action Plan 2020: Department of Regional Planning, Los Angeles County; 2015.http://planning.lacounty.gov/assets/upl/project/ccap_final-august2015.pdf 72. County of Los Angeles. County of Los Angeles Strategic Plan, 2016-2021. Los Angeles, CA: County of Los Angeles; 2016.https://www.lacounty.gov/files/ST%20plan/2016- 2021%20County%20Strategic%20Plan%20Final.pdf 73. Rhoades EK, Contreras C, Garrett SK, Bakshi M, AJ B. Your Health and Climate Change in Los Angeles County: Report 1. Los Angeles, CA: Los Angeles County Department of Public Health; 2014.http://publichealth.lacounty.gov/eh/docs/climatechange/YourHealthandClimateChange. pdf 74. Rhoades EK, Contreras C, Garrett SK, Bakshi M, AJ B. Framework for Addressing Climate Change in Los Angeles County. Los Angeles, CA: Los Angeles County Department of Public Health; 2014.http://publichealth.lacounty.gov/eh/docs/climatechange/FrameworkforAddressingClima teChange.pdf

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G. Denver Department of Public Health and Environment

1. Background

With a staff of 190 and an annual budget of $37 million, Denver Department of Public Health and Environmental (DDPHE) serves 664,000 residents of the City and County of Denver. The City and County of Denver are governed by 13-member city council and a mayor, and the Director of DDPHE reports to the mayor's office. DDPHE is the lead agency for public health and is organized into 6 main divisions: community health, public health inspection; animal protection, the Office of Medical Examiner, environmental quality, and the Office of the Executive Director. DDPHE was accredited by the national Public Health Accreditation Board in 2017 as the local health department for Denver. DDPHE is a separate agency from Denver Public Health, which is part of Denver Health and Hospital Authority and operates community health clinics, registers births and deaths, provides enrollment services for the Affordable Care Act, provides tobacco control and other health promotion services, maintains vital statistics and other health data, and is responsible for emergency preparedness and response. DDPHE and Denver Public Health jointly produce Denver's community health needs assessments 75 and the community health improvement plan.76

The Department serves the needs of a diverse population, which, in 2010, was 53% White, 31% Latino, 10% Black, 4% Asian, and 2% Native American. In 2015, approximately 17.3% of county residents had incomes below the federal poverty line. Among the county's 106 neighborhoods, there was a 14 year difference in life expectancy in 2010,77 and the 2015 community health assessment documented health disparities by income and race for multiple health behaviors and outcomes.75 The community health needs assessment also identified the themes of equity, prevention, and the importance of place in determining health status. The 2015 Community Health Improvement Plan76 identified two priority areas: access to care, including behavioral health; healthy eating and active living (HEAL), including the built environment.

Prior Climate Change Activities of the Local Jurisdiction

Denver released its first Climate Action Plan in 2007,78 which was updated in 2015.79 DDPHE staff helped develop the city's greenhouse gas inventory. DDPHE leadership was on the Mayor's "Greenprint" advisory council in 2007 and played a lead role in the 2007 update. The Lancet Commission's statement80 on climate change and health (“tackling climate change could be the greatest global health opportunity of the 21st century") was featured prominently in the second report. In 2014, the City and County of Denver released its first climate adaptation plan.79 The plan identified increased temperature and urban heat island effects, extreme weather events, and reduced snowpack as the priority vulnerabilities. The plan proposed short and medium-term goals and activities to reduce vulnerabilities and assigned responsibility to specific city departments. DDPHE staff played a lead role in the drafting of the plan. The city has established an Office of Sustainability (which partners closely with DDPHE), which has created 2020 goals that span climate and health. Denver's mayors have been active

105 participants of national initiatives on climate change including Mayor’s Climate Protection Agreement of the U.S. Conference of Mayors and the Mayors National Climate Action Agenda (https://climatemayors.tumblr.com/).

Applicant and Proposal

DDPHE's Community Health Division and the Environmental Quality Division (Air, Water, Climate Program) officially represented the jurisdiction in the Learning Collaborative. The Community Health Division is the locus of several different programs that primarily focus on the built environment and healthy living. Program areas include Health in All Policies, health impact assessments, and Safe Routes to School.

Background and Prior Climate Change Activities of the Health Department

As described above, DDPHE has been an integral part of climate change activities in Denver city government and was a lead agency in crafting its climate action plans and adaptation plan. Equity and place are strong themes in the climate action plans, adaptation plan, and community health needs assessment. The Health in All Policies program developed a Neighborhood Equity Index based on socioeconomic factors, access to care, built environment, and mortality and morbidity data (http://www.denvergov.org/content/denvergov/en/environmental-health/community- health/health-in-all-policies.html). DDPHE's climate and health proposal (below) focused on geographically refined climate and health vulnerability assessment, which intersects several existing city neighborhood-level planning activities in which DDPHE has partnered with other city agencies. A 2014 Denver City Council budget priority made HIAs a standard component of all neighborhood plans, and, by 2017, three neighborhood HIAs had been completed (https://www.denvergov.org/content/denvergov/en/environmental-health/community- health/health-impact-assessment.html). Other partners and planning processes include Denver's Community Planning and Development Department (Neighborhood Planning Initiative), the City Office of Economic Development (Strong Neighborhoods), and Denver Public Health (community health needs assessment and community health improvement plan). Other plans include Denver Moves (transit, pedestrian, bicycle, trails) and the Parks and Recreation strategic plan.

2. Description of applicant’s proposal and goals (what)

The proposal submitted by DDPHE was called the Denver Neighborhood Climate and Health Vulnerability (DNCHV) Project.

Goals and Objectives

The aim of the DNCHV Project was create maps that utilize multiple climate and health datasets to assess neighborhood vulnerabilities, especially in regard to extreme heat. The overall goal was to enable DDPHE and partners to integrate and prioritize climate change into policies, plans, and interventions of city departments and those of the broader community. This approach was an explicit "Health in All Policies" strategy for

106 incorporating climate change into upstream determinants of health to increase community health and resilience. Table V-G1 lists the specific objectives of the project.

Table V-G1. Objectives of the Denver Neighborhood Climate and Health Vulnerability Project October 2015 Scope of Work (January 1, 2016 - June 30, 2017) 1. Create a robust dataset on health outcomes and climate change impacts 2. Assess possible data 3.1 Create an advisory group to develop the specifications for the mapping tool 3.2. Identify and convene at least 5 key community-based stakeholders to solicit input regarding development, indicators, and data for mapping tool 4. Develop mapping tool 5. Train users, including key community stakeholders 6. Integrating the climate change and health vulnerability information into interventions Extension (July 1, 2017 - December 15, 2017) 1. Convene at least two facilitated discussions with non-public health agencies regarding climate change 2. Develop customized products (e.g., information sheets) for non-public health agencies about climate change and agency-relevant topics

Duration of Participation

DDPHE participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

Staffing/Organizational Chart

The project team was led by the two managers in the Community Health and Environmental Quality Divisions, both contributing a part-time (0.4 FTE), in-kind effort. Several other DEH staff from impact assessment, site assessment, and the climate program were also on the project team. The bulk of funding was earmarked for a contractor (Four Twenty Seven, Berkeley, CA) to develop the heat and health vulnerability mapping tool.

3. Description of applicant’s proposed objectives and activities

The proposal described a three-phase approach to develop and disseminate a heat- health vulnerability mapping tool resolved at the level of neighborhood (e.g. census tract). The first phase was an environmental scan or literature review of similar, existing tools, in part to inform the project of the range of data that might be needed. The second phase was the creation of data layers for GIS mapping and the possible creation of an index that would combine and weight individual variables. The third phase was dissemination through a GIS portal to enable access to both city departments and the public, including community groups, and to incorporate this information into the plans and policies of different City departments.

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The initial proposal included the possibility of using downscaled neighborhood projections of temperature (maximum and minimum, extreme heat days, heat waves, etc.) from climate models run by the Colorado-based National Center for Atmospheric Research. However, because this was neither technically or financially feasible, it was not pursued.

The best practices scan81 reviewed the published literature on historical and projected heat exposures for Denver and heat vulnerability indices and their supporting data. The recommended approach for mapping and index construction incorporated American Community Survey 5-year samples (2010-2014) for demographic variables and disability (vehicle access, linguistic and social isolation, elderly population, educational attainment, race, and ambulatory and cognitive disability), Denver Department of Parks data on tree canopy and impervious surfaces, and Colorado Department of Health data on the prevalence of ever-diagnosed diabetes. Thirteen variables were combined into a heat vulnerability index using factor analysis using a widely practiced method developed by Reid et al.82 A story map was created and posted on DDPHE's website that combines color-shaded, census tract maps with a brief narrative on the contributions of domains and indicators to heat vulnerability (https://www.denvergov.org/content/denvergov/en/environmental-health/community- health/HeatVulnerability.html)83 and links to Denver's climate adaptation plans and health impact assessment.

Discussions on incorporating information from the tool into plans and policies were held with the Department of Community Planning and Development and the Department of Public Works for their Ultra Urban Green Infrastructure program. The tool was discussed with the City's bicycle network planners to consider how heat vulnerability may impact future routing. Ways to extend the usefulness of the tool have been discussed, including linking the tool to case studies of how similar information has been successfully used in planning. Interesting, a common request from partners is for data layers rather than the specific tool.

Internal and Community Partners

The project team envisioned the primary users of the tool as city agencies involved in aspects of neighborhood planning. However, the project coincided with the formation of an interdepartmental work group in late 2016 that was an initiative of Health in All Policies program of the Community Health Division, whose manager was DDPHE's co- lead in the Learning Collaborative. (The idea was to consolidate multiple health initiatives and citywide planning processes in one workgroup.) Advising on the heat tool was incorporated into the work plan of this group, whose over time members are listed in Table V-G2. The workgroup facilitated also data acquisition in the case of tree canopy (Parks & Rec) and impervious surfaces (Public Works).

For external partners, a number of community partners who participated in community health assessment/improvement plans were mentioned as possibilities.

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Table V-G2: Partners in Denver Neighborhood Climate and Health Vulnerability Project Partner City Governmental Community Planning and Development Office of Economic Development Public Works Recreation & Parks Office of Sustainability Denver Public Health, Health Promotion Program Mayor's Office of Children's Affairs DDPHE Public Health Inspections

Community Trust for Public Lands Mile High Connects (SPARCC collaborative)

However, the Denver Office of the Trust for Public Lands, TPL – a national non-profit dedicated to creating public parks and other greenspace – emerged as key partner. One collaboration in mid-2017 was a conference that featured brief presentations by community representatives from the Westwood neighborhood, their local Councilperson, and two executive leaders of DEH to discuss their efforts at building resilience in the Westwood community. This was followed by a round robin of subgroup discussions of specific topics ("World Café"). The discussions, in part, examined successful efforts at building community resilience in Westwood that were potentially replicable to other city neighborhoods. This event was considered to be a prototype of several other events planned for 2018 by TPL, DDPHE, and the SPARCC collaborative (see below).

4. LHD capacity building

Participation in the Learning Collaborative and conducting the DNCHV Project built capacity for climate and health at DDPHE, particularly in the Divisions of Community Health and Environmental Quality, whose partnership and leadership roles were considerably strengthened. The funding allowed the development of a new tool that informs decision-making for plans, projects, and programs on the heat health impacts of climate change. The project may have enhanced the formation of the Interdepartmental Workgroup on Health by creating a sense of purpose around a concrete activity (heat tool development) of mutual interest. The project appears to have increased the dialogue on health and planning between multiple City agencies and strengthened relationships with other City agencies.

5. Disadvantaged populations and health equity

The tool was designed to incorporate vulnerable population characteristics and the index is a surrogate for cumulative health impacts of extreme heat in Denver's

109 vulnerable populations. The prioritization of specific neighborhoods as highly vulnerable addresses some aspects of health equity. Other programs within the Community Health Division have created a separate health equity index. The LHD states an intention to "pair" the extreme heat tool with the health equity index. However, this has yet to be implemented by the project's end.

6. Integration of climate change into health department programs/communications

The project presented multiple opportunities to engage climate change into different departmental programs and communications. The Community Health and Environmental Quality Divisions jointly managed the project and engaged several of their staff. Public Health Inspections Division became a member of the Interdepartmental Workgroup. DDPHE and Denver Public Health jointly produced the factsheet "The Health Impacts of Climate Change" as part of Denver Public Health and DDPHE’s joint Denver Vital Signs series April 2016), a bimonthly electronic newsletter for general, public dissemination on important public health topics. This appears as first- ever collaboration on climate change. However, several other divisions and programs may have not had similar levels of engagement. There were no mentions of engagement with the Office of the Medical Examiner or Animal Control, the former of which is responsible for investigating possible heat-related deaths. Pet health during heat emergencies is germane to the operation of DDPHE's animal shelter as well as education of the pet owning public.

The project grappled with the difficulties of communicating climate change and health and the need for easy-to-use and comprehensible messages for city and external partners. This was a concern in the development of the heat tool, but lessons learned from the heat tool development were not explicitly mentioned as informing department- wide messaging on climate and health.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

Initial delays arose from the City contracting process, but these did not substantially interfere with the project development. The project attempted to balance tool development and the needs of internal City users with the timing of input from community-based stakeholders. As of this writing, the nature of feedback on the heat tool from community-based organizations and environmental justice groups has not been completed.

Unanticipated opportunities

The project co-evolved with the formation of an interdepartmental workgroup on health, whose members acted in an advisory capacity to this project.

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In February 2017, a multi-sector collaborative "Mile High Connects", administered by the Denver Foundation, received a $1 million, 3-year SPARCC (Strong, Prosperous, And Resilient Communities Challenge) grant to ensure that the regional transit system fosters communities that oﬀer all residents the opportunity for a high quality of life. [SPARCC is a 3-year, $90 million, 6-city program funded by philanthropic foundations (including the Ford, Robert Wood Johnson, Kresge, and JPB Foundation and The California Endowment). It aims to support major, new infrastructure investments that lead to health equitable opportunities (https://www.sparcchub.org/about/)]. DDPHE has a member of the Community Health Division on the project team and continues to seek ways to collaborate and support this initiative.

Public health directors from several Front Range jurisdictions and their communications staff prioritized climate change in 2018. DDPHE is a charter member of this group and is the lead convener. This group may provide opportunities to develop climate and health messaging.

The project was able to present its work in several venues that sparked interest, networking, and sharing of materials. These included at Colorado Public Health Association for Public Health Week and the 2017 annual meeting of the American Public Health Association.

In his July 2017 State of the City address, the mayor of Denver announced a goal to move all city operations to 100% renewable energy. However, no timeline was stated, and DDPHE has made an internal goal to provide policy support and analysis to help establish a timeline that could provide an update at the 2018 State of the City address.

8. Assessment of meeting goals

Administrative Data

DDPHE has met its primary goal to develop a heat health tool and engage City partners in its development. Through an interdepartmental workgroup on health, DDPHE created a structure and process to promote the inclusion of health and information from the heat tool into the planning process of City departments. It has also regional collaboration among local health departments within its region. DDPHE operates in a supportive political environment in which its extreme heat tool includes an explicit climate change messaging. DDPHE has begun to engage community groups on climate change and health, primarily by collaborating and integrating the health voice in planning and development initiatives undertaken by local non-profits (TPL, SPARCC). Thus, the goal of recruiting 5 community groups to engage on heat vulnerability may have been met by having been recruited by or linked to community coalitions representing multiple community stakeholders. Fact sheets were still in progress at the end of 2017.

Self-assessment

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Participants noted a stark "before/after" comparison with the LC: "Two years ago I was not involved personally or professionally on climate change and health, and now there is a climate and health lens to my equity work." The project has fostered close collaboration between two divisions within DDPHE (Environmental Quality and Community Health) that did not exist before the LC, and has extended the network of organizations each has worked with. Previous work of the Environmental Quality Division focused on the technical aspects of environmental health (e.g. energy efficiency) and now there is an emphasis on the human health dimensions. The HVI tool provided a mechanism to engage multiple city agencies on health issues and connect on citywide cabinet discussions, such as heat island mitigation.

Key Informant Interviews

We interviewed managers of the two community organizations (TPL, SPARCC) most involved with DDPHE's work. Both were emphatic in the importance of the role DDPHE played in providing data on human health effects of extreme heat in form of maps. These data help "make the case" for engagement on climate change that goes beyond purely environmental concerns, which was their organizations' traditional framing. DDPHE's joining in community coalitions was regarded as a "new way of doing business" that broke down silos.

Section References

75. Denver Public Health and Denver Environmental Health. Health of Denver Report Community Health Assessment, 2014. Denver, CO: Denver Public Health and Denver Environmental Health; 2015.https://www.denvergov.org/content/dam/denvergov/Portals/746/documents/2014_CHA /Full%20Report-%20FINAL.pdf 76. Denver Public Health and Denver Environmental Health. Be Healthy Denver: Denver’s Community Health Improvement Plan 2013-2018. Denver, CO: Denver Public Health and Denver Environmental Health; 2014.https://www.denvergov.org/content/dam/denvergov/Portals/746/documents/Be%20He althy%20Denver%20Comm%20Report%20FINAL.pdf 77. Center on Society and Health, Virginia Commonwealth University. Denver Life Expectancy Methodology and Data Table. Richmond, VA: Virginia Commonwealth University; 2014.http://societyhealth.vcu.edu/media/society-health/pdf/LE-Map-Denver-Methods.pdf 78. Mayor’s Greenprint Denver Advisory Council. City of Denver Climate Action Plan. Denver, CO: City and County of Denver; 2007.https://www.denvergov.org/content/dam/denvergov/Portals/771/documents/EQ/Climat e1/DenverClimateActionPlan_2005_Original.pdf 79. Denver Environmental Health. City and County of Denver Climate Action Plan 2015 Denver, CO: City and County of Denver 2015.https://www.denvergov.org/content/dam/denvergov/Portals/771/documents/Climate/C AP%20-%20FINAL%20WEB.pdf 80. Lancet Commission on Climate Change and Health. Health and climate change: policy responses to protect public health. Lancet. 2015;386(10006):1861–1914.

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81. Four Twenty Seven. Public Health and Climate Data and Vulnerability Index Analysis and Development: Best Practice Scan: Evaluating Heat Vulnerability in Denver. Berkeley, CA: Four Tenty Seven; 2016. 82. Reid CE, Mann JK, Alfasso R, English PB, King GC, Lincoln RA, et al. Evaluation of a heat vulnerability index on abnormally hot days: an environmental public health tracking study. Env Health Persp. 2012;120:715-720. 83. Four Twenty Seven and Denver Environmental Health. Methods: Assessing Vulnerability to Extreme Heat in Denver, Colorado: Story map developed by The Denver Department of Environmental Health and Four Twenty Seven, Inc. Berkeley, CA and Denver, CO: Four Tenty Seven and Denver Environmental Health; 2016.http://427mt.com/wp- content/uploads/2016/12/Methods_DenverHeatVulnerabilityStoryMap_V1.pdf

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H. Maricopa County Department of Public Health

1. Background

With a staff of 633 and an annual budget of $63 million, the Maricopa County Department of Public Health (MCDPH) serves 4.1 million residents of Maricopa County, Arizona. Among its 27 cities, Phoenix is the largest with a population of 1.5 million. The County’s governing body is a 5-member Board of Supervisors, who appoint a county manager to administer county functions, including those of the public health department. MCDPH is the lead agency for public health and is organized into 5 main divisions: program operations, community transformation, community health action, performance improvement, and disease control. MCCDPH was accredited by the national Public Health Accreditation Board in 2016. Maricopa County Environmental Services is a separate department responsible for inspection of food establishments, public accommodations and trailer parks and for vector control.

The County is predominantly White (57%) and Latino (31%), and 6% of residents are Black. A decade's long national spotlight on immigration policy and policing was focused on Maricopa County's former sheriff, who was found by the U.S. Department of Justice to have engaged in discriminatory behavior and racial profiling in the Latino community. In 2015, approximately 16.3% of county residents had incomes below the federal poverty line. Among the 36 zip codes in the Phoenix area, there was a 14 year gap in life expectancy.84 Using the MAPP framework (Mobilizing for Action through Planning and Partnerships), Maricopa County's first-ever CHNA/Improvement Plan in 2015 documented numerous health disparities among racial/ethnic groups, and identified obesity, diabetes, cardiovascular disease, lung cancer, and access to care as strategic public health priorities.85 The CHNA stated that health equity was an essential component of the County's vision and values. The Arizona Advisory Board for the CDC- funded Racial and Ethnic Approaches to Community Health (REACH) participated in the CHNA, but MCCPH does not have a specific program or office on health equity. Neither climate change, heat, nor heat-related mortality and morbidity were mentioned in CHNA or the "Forces of Change" subassessment. (Maricopa's climate from fall to spring was mentioned as a community asset.)

Maricopa County is one of the largest urban centers in the United States to experience extreme heat. Annually, Phoenix experiences an average of 110 days with temperatures over 100°F and 19 days over 110°F. The United States Global Change Research Program projects that average daily temperatures in the Southwest will increase 2.5 to 8°F by 2100.86

Prior Climate Change Activities of the Local Jurisdiction

As of 2017, Maricopa County had not published a climate action plan, climate adaptation plan, nor does it sponsor an Office of Sustainability. However, in its 2015 Maricopa County Multi-jurisdictional Hazard Mitigation Plan,87 multiple climate change impacts on infrastructure and health were identified, and the likelihood of increased

114 intensity and duration of extreme heat days was acknowledged. The Department of Public Health Office of Preparedness and Response participated in the plan development and the MCDPH's heat death surveillance data were used in the report. The City of Phoenix carried out a greenhouse gas inventory in 2012 and a Sustainability Plan in 2013, which included measures for energy conservation and renewable energy generation on City facilities (e.g. senior center, transit centers, and waste water treatment plants.). Updates were issued in 2015.88, 89 A sustainability network of Arizona cities is convened by the Arizona State University Global Sustainability Program, and includes Maricopa County and a majority of its cities. It was previously mentioned that the State of Arizona Department of Health Services is a participant in CDC's BRACE program, which has included MCDPH in its activities, and published a statewide climate and health adaptation plan in 2017.90

Applicant and Proposal

MCDPH Disease Control Division's Office of Epidemiology officially represented the jurisdiction in the Learning Collaborative. The Office of Epidemiology (OE) is responsible for monitoring health trends and behavioral risk factors and conducts surveillance for heat-related illness. The OE operates as "consolidated" model supporting all the departments programs (family health, SNAP, obesity prevention, nutrition, asthma prevention, etc.).

Background and Prior Climate Change Activities of the Health Department

MCDPH Office of Epidemiology has been conducting surveillance of heat-associated morbidity and mortality since 2006. The Program has documented over 632 heat- related deaths from 2006 to 2013 and has analyzed risk factors that include: age over 75 years, African American and American Indian race, and lack of air conditioning. Heat monitoring activities recently added a component for syndromic heat surveillance. In 2105 a rapid epidemiologic assessment of households revealed that, while residential central air conditioning was highly prevalent (95%), the cost of electricity and equipment maintenance and failures diminished the actual availability of residential cooling. MCDPH states that it uses public health messaging to educate the public about the risks surrounding heat exposure, and partners with local organizations to promote public cooling and hydration stations in Maricopa County, which are open throughout the heat season.

2. Description of applicant’s proposal and goals (what)

Goals and Objectives

Maricopa County's homebound population was identified as a being exceptionally vulnerable population to extreme heat. The project stated three goals: a. assess Maricopa County’s capacity for providing community services that aim to mitigate climate change or assist citizens with adapting to extreme heat

115 b. assess the needs of homebound individuals during extreme heat events and determine their awareness and use of existing community services, and c. increase community awareness about existing services and connect homebound individuals to the most effective and appropriate interventions to meet their needs.

Table V-H1. Objectives of the Maricopa County Department of Public Health Learning Collaborative Project from October 2015 Scope of Work Scope of Work October 2015 (January 1, 2016 - June 30, 2017) Goal 1: Collaborate with community stakeholders to mitigate climate change and improve public health Objective 1.1 Complete an assessment of Maricopa County’s capacity to provide community services that aim to mitigate climate change and/or assist citizens with adapting to extreme heat.

Objective 1.2 Implement a local heat collaborative with community members and stakeholders, experts, policy makers

Objective 1.3 Disseminate methods, results, recommendations of heat prevention project Goal 2: Reduce the rate of heat-related morbidity and mortality among homebound individuals in Maricopa County, Arizona Objective 2.1 Assess awareness, use of services, and needs of homebound individuals during extreme heat events

Objective 2.2 Increase community awareness of (i) heat-related symptoms, (ii) methods for preparing for extreme heat events, and (iii) Maricopa County’s effective and appropriate heat prevention services for homebound individuals

Goal 3: Increase MCDPH’s awareness about and capacity to address the interplay between climate change, public health, and health equity 3.1 Convene MCDPH leadership/staff across divisions to share information about heat illness/current project and get input regarding heat-vulnerable communities, relevant services, and MCDPH relevant activities 3.2 Convene MCDPH leadership/staff across divisions/programs to present survey/data results and get input re climate resilience and prevention of heat illness, for incorporation into strategic plan

Project Extension (July 1, 2017 to December 15, 2017) 1. Implement action plan with input from key stakeholders and steering committee 2. Align climate change work into one of the existing health coalitions (Health Improvement Partnership of Maricopa County)

Duration of Participation

MCDPH participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

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Staffing/ Organizational Chart

The project team comprised a quarter-time coordinator (paid from LC funds) and three (part-time, in-kind) epidemiologists, and a supervising manager (part-time, in-kind) of the Epidemiology and Data Services Program. The role of the coordinator was to coordinate communication and meetings with community partners, manage data collection, monitor data for quality, facilitate assignments to public health staff, and implement interventions in the community. The role of the epidemiologists was to develop surveys, analyze data, interpret results, and disseminate key findings to stakeholders.

3. Description of applicant’s proposed objectives and activities

To carry out the first objective, the MCDPH proposed to develop a comprehensive list of governmental and community-based programs and services for county residents that target climate change, vulnerable populations, or preventive health. This universe of service providers was then used to identify services available to homebound populations and a recruitment tool for being included in a series of stakeholder meetings under the rubric of a "Heat Summit", later renamed as "Bridging Climate Change and Public Health." One key partner was identified in the proposal as the Phoenix Agency on Aging, which sponsors the Home-Delivered Meals program that monthly enters homes of 1000 elderly and disabled residents. The project proposed to deploy Home- Delivered Meals delivery personnel to also deliver surveys to their homebound clients with the goal to identify their needs for heat illness prevention, and link these needs to services provided by the stakeholders participating in the Heat Summits.

The delivery staff of the Home-Delivered Meals program delivered questions to 1300 clients, of whom, 472 returned questionnaires. In November 2016, preliminary results of the analysis were presented at the first, half-day stakeholder summit ("Bridging Climate Change and Public Health"), in which 45 of 90 invited organizations attended. Findings included a high prevalence of homebound having difficulties with utility bills for air conditioning and maintaining the units in working order, and the lack of services that could provide assistance. The summit had an agenda that included 1) exploring the linkages between public health, climate change, and vulnerable populations, 2) setting the stage for further action incorporating health equity, 3) exploring the challenges of resources, and 4) joining collaborative efforts to inform action on climate change. A group activity at the summit used the Climate and Health Framework developed by the Center for Climate Change and Health.91

In contrast to previous heat surveillance activities, the summit explicitly mentioned climate change, which had been approved by the MCDPH leadership prior to the summit. The apparent volume of positive feedback from participants allowed this approach to continue for a second convening of "Bridging Climate Change and Public Health", which took place in May 2017 and focused on implementation strategies. The follow-up was the convening of a subset of stakeholders to develop a formal Climate and Health Strategic Plan for Maricopa County. To this end, MCDPH convened three

117 strategic planning workshops with its planning stakeholders between August and October 2017. Five strategic directions were identified:

• Celebrating Success and Champions • Promoting Community Awareness and Public Education About Climate and Health • Fostering Environmental Action for a Healthier Community • Coordinating Research and Collaborative Efforts to Catalyze Change • Developing a Strategic and Targeted Communication Plan.

The initial proposal also included a subcontract with researchers at Arizona State University (also collaborating with the Arizona BRACE program) to place small, portable, real-time data logging devices (iButton, Maxim Integrated, San Jose, CA) in the homes of a sample of homebound residents to assess their perceived thermal comfort and actual ambient temperature. This part of the project was not pursued due to logistical delays working with multiple partners (which delayed the IRB review process), the cumulative cost of devices, and limited capacity to conduct both the homebound survey and iButton distribution and data collection during the heat season.

Internal and Community Partners

Table V-H2: Community Partners in the Maricopa County Public Health Department Learning Collaborative Sector Partner LHD (internal) Community engagement, policy, human services, air quality, preparedness, public health nursing, health improvement partnership

Governmental City of Phoenix Maricopa County Human Services Department Arizona State Department of health Services

Non-Profit Area Agency on Aging, Region One Southwest Network (homebound with behavioral health issues)

Academic Arizona State University

Business Selrico (vendor for Home-Delivered Meals program)

4. LHD capacity building

The project demonstrated increased capacity to move from limited interventions from heat surveillance to targeted interventions and coalition building in a specific vulnerable population and broader conversation about climate and health in a group of community

118 services providers. The MCPHD has a much expanded role as the convener of the coalition members developing the countywide Climate and Health Strategic Plan.

5. Disadvantaged populations and health equity

The project focused on a heat-vulnerable population (homebound), but did not appear to directly engage a broader group of vulnerable populations. Health equity was elevated in visibility during the summits, but it is unclear what additional actions have been taken to address health equity. Organizations that represent disadvantaged populations were included in the health summits.

6. Integration of climate change into health department programs/communications

The OE invited other units of the health department to be part of the summits (Office of Communication and Marketing (Public Information, Digital Content and Social Media, FindHelpPHX); Office of Community Health Innovations (Healthy Community Design); Office of Public Health Policy; Office of Preparedness and Response and within the Office of Epidemiology with Communicable Disease Unit.) However, it is unknown to the extent to which other programs in MCDPH assisted in organizing the summit or were responsible for follow-up within their programs. While the "Bridging" events are explicit in communicating a climate and health, it is not clear whether this new framing has propagated to other programs.

One of the most profound changes that occurred in the project was the explicitness of "climate change" language in public dialogue: "Most importantly, we no longer hesitate to use the terms climate change and health as these terms have been proven to be more acceptable in our community than anticipated."

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

LC staff simultaneously worked on LC projects and their regular assignments, which creates competing priorities. A change in staff also required extra time to transition the project to a new staff member.

The Homebound Survey had an unanticipated effect of generating a large call volume for housing and utility assistance. While the callers were referred, the MCDPH and its partners stated they were not able to develop a long-term plan to aid the homebound population with cooling system needs. Lack of key stakeholders from business community was cited as a limitation.

The delayed hiring of the project coordinator posed a challenge to maintain the project schedule. Working with multiple entities (Area Agency on Aging, the private vendor for

119 the Home-Delivered Meal Program) posed a challenge to the project to coordinate the IRB review of the iButton component of the project, which was ultimately postponed.

The political environment has not been conducive to the open discussion of climate change among actors in County government, which made this project a testing ground for the MCDPH. Prior to the project, the singular focus of the CDPH was on heat without linkage to climate change. It was unknown how the administration would react, given concerns that the Board of Supervisors had questioned the contract for the Learning Collaborative.

Unanticipated opportunities

The first summit appeared to generate tremendous momentum and the feedback was so overwhelming that it validated the risks taken by the MCDPH leadership in being publically explicit about climate change and health.

8. Assessment of meeting goals

Administrative Data

The project met its specific goals from the Scope of Work and exceeded expectations by creating a community coalition that is engaged climate and health planning for Maricopa County. Given the initial concerns that the political environment was not conducive to an open discussion of climate change, this is a major accomplishment. By design, the MCDPH had a principal focus to assess the cooling systems needs of the homebound population. Other vulnerable populations were not deeply engaged on this project. The Office of Epidemiology engaged other MCDPH programs on climate and health as part of the community coalition, but engagement of multiple programs within the health department was not significantly developed on its own.

Self-Assessment

From the final progress report narrative, the LHD acknowledged the importance of the LC to engage in new partnerships, enhance networking with community-based organizations, open conversations with professional organizations, learn about projects that are already taking place in the community, and learn about the need to work with vulnerable populations.

Key Informant Interview

We interviewed the MCDPH Program Operations Administrator (who was formerly the Public Information Officer) and a community-based organization. The MCDPH interviewee confirmed the challenging political environment in which the LC project operated. Several factors may have contributed to the success of the project: 1) use of a health frame and broad community engagement from notable community institutions (e.g. Arizona State University), 2) ongoing local media coverage of climate change,

120 particularly the impacts of heat, and 3) external funding (vs. internal funding from local tax dollars).

The community-based organization valued the MCDPH ability to inform the health dimension of climate change and the role of direct social services. The judicious use of health data helped make the case.

Section References

84. Center on Society and Health, Virginia Commonwealth University. Phoenix Life Expectancy Methodology and Data Table. Richmond, VA: Virginia Commonwealth University; 2014.http://societyhealth.vcu.edu/media/society-health/pdf/LE-Map-Phoenix-Methods.pdf 85. Maricopa County Department of Public Health. Maricopa County Community Health Assessment. Phoenix, AZ: Maricopa County Department of Public Health and the Arizona Department of Health Services; 2014.http://assets.thehcn.net/content/sites/arizona/MC_CHA2012.pdf 86. US Global Climate Research Program. Resources, Data, & Multimedia. GlobalChange.gov; 2015. http://www.globalchange.gov/browse 87. Department of Emergency Management, Maricopa County. Maricopa County Multi- jurisdictional Hazard Mitigation Plan Phoenix, AZ: Maricopa County; 2015.https://www.maricopa.gov/DocumentCenter/View/5118 88. City of Phoenix and Arizontal State University. 2015 Greenhouse Gas Emissions Reduction Report. Phoenix, AZ: City of Phoenix and Arizontal State University; 2016.https://www.phoenix.gov/oepsite/Documents/2015%20City%20of%20Phoenix%20GH G%20Summary%20Report.pdf 89. City of Phoenix. Sustainability Report, 2015-2016. Phoenix, AZ: City of Phoenix Office of Sustainability; 2016.https://www.phoenix.gov/sustainabilitysite/Documents/Final%20COP%202015- 16%20Sustainability%20Brochure%2003.27.17.pdf 90. Roach M, Barrett E, Brown HE, Dufour B, Hondula DM, Putnam H, et al. Arizona’s Climate and Health Adaptation Plan. A report prepared for the United States Centers for Disease Control and Prevention Climate-Ready States and Cities Initiative; 2017.http://www.azdhs.gov/documents/preparedness/epidemiology-disease- control/extreme-weather/pubs/arizona-climate-health-adaptation-plan.pdf 91. Rudolph L. Climate Change and Health: A Framework for Action. Oakland, CA: Public Health Institute; 2014.http://www.phi.org/resources/?resource=climate-change-and-health-a- framework-for-action

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I. Multnomah County Health Department

1. Background

With a staff of 306 and an annual budget of $50 million, the Multnomah County Department Health Department (MCHD) serves 790,000 residents of Multnomah County, Oregon. Among its 8 cities, Portland is the largest with a population of 690,000. The County’s governing body is a 5-member Board of Commissioners, whose chair is elected at-large and oversees county departments.

MCHD is the lead agency for public health and includes 7 main divisions: Public Health, Corrections Health, Integrated Clinical Services, Mental Health and Addiction Services, and Business Operations, Equity & Inclusion.92 MCHD has a health officer (who provides physician consultation, technical direction, and leadership to support public health activities and clinical services) and a director, who is the primary liaison to federal, state, and county elected officials and county department leadership.

The Public Health Division is guided by the Multnomah County Public Health Advisory Board. Major program areas of the Public Health Division include: 1) Maternal, Child & Family Health, 2) Environmental Health Services, responsible for inspecting licensed facilities, monitoring mosquitoes and other vectors, and assuring healthy environments, including tobacco-free environments, 3) HIV/STD and Adolescent Sexual Health Equity, 4) Communicable Disease Services, 5) Community Epidemiology Services, which supports data-driven policy and interventions through health and disease monitoring, evaluation, and research, 6) Equity, Planning and Strategy, advances the self-identified priorities of diverse community partners to reduce documented inequities through program, policy, and system improvements; and culturally specific programming.

In 2016, approximately 17.1% of county residents had incomes below the federal poverty line. The County is predominantly White (79%), 6% of residents are Black, and 6% are Asian. A 2014 MCHD report card documented health disparities across numerous health outcomes, particularly among the county's African American and Native American residents compared to whites.93 Using a modified MAPP process, a community health needs assessment (CHNA) was published in 2015, which reiterated findings of widespread health inequities and prioritized several health issues: access to health care, chronic disease, culturally competent services/data, mental health, and substance abuse.94 Climate change was not mentioned in the CHNA. However, a community-led community health improvement plan (CHIP) in 2016 did incorporate several goals related to climate change, including clean air policies in agency plans and climate communications.95

In 2015 and 2017, Multnomah County experienced record breaking summer heat (>105° F) and regionally transported wildfire smoke, which created unprecedented poor air quality that extended from summer to fall. Warming trends also increased the frequency and toxicity of algal blooms in Multnomah County rivers and lakes. Affordable housing, gentrification, in-migration of residents from neighboring high cost states and their possible connections to climate change are contentious community issues.96 In the

122 summer of 2016, MCHD implemented for the first time ever its extreme heat plan, which led to opening of cooling centers, extra water and medical staff at a large public event, and syndromic surveillance for heat-related illness. Emergency department data showed a sharp increase in visits for heat-related illness.

Prior Climate Change Activities of the Local Jurisdiction

The City of Portland and Multnomah County are among the jurisdictions with the longest history of climate action planning in the United States. In 1993, under the auspices of ICLEI (International Council of Local Environmental Initiatives), the City of Portland adopted its first climate action plan,97 which identified carbon reduction strategies for transportation, energy efficiency, renewable energy, recycling, and tree planting. In 2001, a climate action plan was jointly produced by the City of Portland and Multnomah County. It made specific reference to human health as a climate impact, but did not identify a role for the county health department. After biannual updates, in 2009, the city-County Climate Action Plan included participants from the MCHD Environmental Health Services (EHS) and the plan's scope expanded to include climate adaptation. Health impacts of climate change were featured prominently in messaging, but actions of the health sector were not included.

In 2013, with funding from CDC's BRACE program, a plan specifically devoted to climate change and public health Climate Change and Public Health Preparation Plan98 was produced by the MCDH. The plan followed the BRACE framework, incorporating a vulnerability assessment, potential interventions, and strategic planning objectives. The climate threats addressed were heat, air quality (respiratory illness and allergies), and vector borne disease. Nine strategic planning objectives, primarily focused on adaptation, were outlined using language adapted from the essential functions of public health.99 Sections of the document highlighted equity and climate justice in the context of jurisdictional commitments to equity. In 2014, the City of Portland and Multnomah County published a two-part plan focused on climate adaptation called "Climate Change Preparation Strategy." 100, 101 This was a cross- sector effort of 15 City and county departments in which MCHD played a leading role. It included a vulnerability assessment and the formulation of 12 major objectives for 2030 encompassing actions to reduce climate vulnerability and improve public health preparedness. Two goals were specifically related to health: 1) minimize health issues caused by extreme heat days, especially among the vulnerable, and 2) manage the increased risk of disease due to changes in vector populations. Specific county departments, including public health, were assigned roles for implementation. The strategy had an explicit equity component and examined ways in which health co- benefits could be maximized. In 2015, the City of Portland and Multnomah County released an updated version of its Climate Action Plan102 which incorporated 20 major objectives for carbon mitigation and adaptation. In addition to city and county agencies, including representatives from the MCHD, external advisors from an Equity Working Group made up of 6 community organizations participated in drafting the document. (The Coalition of Communities of Color, CCC, which was the primary community partner of MCHD's learning collaborative was a member of the equity working group.) Explicit

123 commitments were made in the plan to "address factors leading to health disparities such as barriers to active lifestyles and transportation, pollution exposure and unequal access to green space, healthy food and other natural resources." 102,p132

The MCHD also played a role in advising the Oregon Health Authority on the 2017 Climate and Health Resilience Plan,103 which identified resilience actions for local health departments.

In addition to the climate action plans, there are 10 other related planning processes in the City of Portland and Multnomah County, which include a comprehensive plan for Portland, city-county natural hazard mitigation, regional transportation, food action, economic development, urban forestry, and watershed management, and parks and recreation.

Applicant and Proposal

MCHD Environmental Health Services (EHS) officially represented the jurisdiction in the Learning Collaborative with its project titled "Healthy Environments Data Indicator Project (HEDIP)." EHS is part of the MCHD Community Health Services unit, and addresses health inequities in chronic diseases by improving the health and livability of the home and addressing environmental-related health concerns. Among its five priority areas are: housing education; tobacco prevention; environmental health education; consultation, advocacy, assessment, and engagement; and healthy homes. EHS has been the MCHD's locus of environmental health education and outreach related to global climate change, air quality, built environment, and housing. It brings a public health and environmental justice lens to projects and initiatives by providing data collection and analysis, research and technical consultation, risk communication, community engagement, stakeholder workgroup participation, and policy advocacy.

Background and Prior Climate Change Activities of the Health Department

MCHD EHS has been actively engaged in climate change and health activities since 2007, and the LC's first project coordinator represented the MCHD on the drafting committees of the climate action plans and updates from 2009 to 2015.98, 100-102, 104, 105 EHS was instrumental in weaving health concerns into these plans, as well as advocating for a focus on equity. EHS has worked with the regional land use and the transportation planning agency to incorporate climate adaptation and preparedness into their future projects and planning. EHS has a strong history of working with community- based organizations around climate change, place-based initiatives, and health. Many of these organizations are culturally specific, representing communities especially vulnerable to climate-based adverse health outcomes and environmental injustice. The HEDIP Project appears to be an outgrowth of EHS's work with several of these CBOs, which requested EHS to support their need to improve community data collection, analysis, and understanding of indicators and tools available.

2. Description of applicant’s proposal and goals (what)

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Goals and Objectives

As originally conceived the project had goals to facilitate community capacity to use MCHD's extensive data holdings, and, with their own experiences, allow community organizations to create neighborhood-scale climate and health profiles that would be the springboard for their own policy development and advocacy (Table V- I1).

Table V-I1. Goals and Activities of the Multnomah County Health Department Healthy Environments Data Indicator Project (HEDIP) Original Scope (January - May 2016) Goal 1: Empower MCEHS and state partners to address community climate change resilience and mitigation needs through shared climate change data inventory understanding and use. Goal 2: Leveraging MCEHS power as the local health authority, empower community voice in advocating for and participating in development of climate change resilience, adaptation, and mitigation strategies in the local policy arena. Goal 3: Contribute to the boarder work of LPHDs on climate change, health, and health equity by creating a replicable approach to climate change data capacity building. Revised Scope (May 2016 - July 2017) Goal 1. Improve communications and messaging, especially around qualitative and quantitative data, around climate resilience for use with community and decision 1a. Select initial list of climate resilience indicators 1b. Share proposed climate resilience indicators with MCHD leaders/staff in other divisions/programs for input 2. Develop indicator maps, review maps 3. Develop user-friendly accessible data platform and communication materials in partnership with Coalition of Communities of Color (CCC) 4. Distribute and evaluate framing and messaging

Goal 2: Improve climate resilience communications and messaging for use with community organizations and decision makers 1. In partnership with CCC, develop an outline of key climate, health and justice concepts based on national research and models 1b. Present curriculum to Climate Justice Coalition for feedback 1c. Revise curriculum, develop a toolkit, translate and give to CCC for pilots & evaluation.

Goal 3. Policy, System, and Environmental Change 1 Work with CCC to identify one key policy issue that can integrate health equity framing into content and analysis 2 Use climate resilience indicators and write issue brief/testimony in support of issue. 3. Inform policy through our Government Relations Office 4 Evaluate process with CCC and other stakeholders Extension (July 2017 - December 2017) Task 1. Convene an intra health department climate working group to share information in the HEDIP project and to identify opportunities for advancing climate & health work. Task 2. Hold a climate and health collaboration meeting for multiple county, city, and state

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agencies to share climate, health and climate justice data and discuss policy solutions Task 3. Participation in planning and recruitment of local health departments in the Northwest Climate Conference (October 2017) Task 4. Local health co-benefits of low-carbon transportation study: contribute to a study of the local health co-benefits of active transportation as a climate mitigation strategy The original proposal also formulated a goal to build the project's process into one that could be replicated by community organizations to other issues.

In the first few months of the project, there was an unexpected change in commitments of several of the six community-based organizations that were initially proposed to lead efforts in community engagement. The organizations raised concerns that the stipends were inadequate for the level of effort and that demands of multiple governmental agencies were exceeding their capacity and inefficient. There was also no consensus among the groups that a data-oriented project would provide useful information for their work. These issues necessitated a revision in the scope of work, which entailed working more closely with interjurisdictional partners and with a single community partner the Coalition of Communities of Color (CCC), who employed a full time staff person for climate justice.

The revised proposal (May 2016) retained the data focus and its link to policy, systems, and environmental change. However, it relied on a single CBO (CCC). It shifted the technical development of neighborhood scale data analysis from a CBO-led to an EHS- led process, but with extensive CCC input on communications and dissemination. It also re-scoped the policy action to one mutually agreed topic in which the climate resilience indicators would form the basis for an issue brief or legislative testimony. Portland State University was also a significant partner who provided technical services in constructing and mapping vulnerability indicators.

Staffing/Organizational Chart

The project proposal supported a 10% FTE EHS project coordinator from EHS staff, 15% FTE intern, and stipends for community organizations for participation and community engagement (~50% of budget). The grant was matched with 5% an in-kind EHS supervisor. The first project coordinator left for another position in county government in the first 6 months of the project and was replaced by a coordinator who led the project for the remaining 18 months. The second coordinator previously worked as a lead in the Oregon Health Authority's CDC-funded BRACE project.

Duration of Participation

MCHD participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

3. Description of applicant’s proposed objectives and activities

To carry out Goal 1 of the revised scope, and in partnership with CCC and Portland State University Urban Planning Department, the HEDIP created a climate and health

126 indicator tool that uses interactive story maps (http://multco.maps.arcgis.com/apps/MapJournal/index.html?appid=f6536b4fc7d946918 975da4cc0005578, 6/6/2017). The ArcGIS Online format juxtaposes a panel of brief narratives with census tract maps for 18 individual indicators from the literature- informed social vulnerability domains: a) demographics (<18 or >65 years old, people of color, linguistic isolation, educational attainment, social isolation, foreign born, single parent household), b) socioeconomic status (poverty, unemployment, household income, renters, housing cost burden), c) existing health burden (prevalence of asthma, diabetes, heart disease, disability), and d) air pollution from point sources. An overall climate vulnerability score based on these indicators is also presented. The 171 Multnomah County census tracts are ranked and color-coded by quintile of the indicator values. The indicators were reviewed with staff from other MCHD divisions and community organizations. A highlight was a January 2017 presentation to 4 climate and environmental justice organizations who incorporated the findings into their own education programs related to climate justice.

Goal 2 was implemented by CCC as curriculum for two, community-led climate and health workshops that embedded climate, health and justice concepts. The curriculum was outlined in September 2016 and piloted in December 2016 by the Coalition of Communities of Color (Climate and Environmental Justice 101 and 102).

To kick-off the implementation of Goal 3, EHS hosted a training workshop in September 2016, which focused on policy, system, and environmental changes for climate and health. The workshop was attended by CCC, 10 staff from multiple county offices including the Office of Sustainability, and staff from the Health Department’s Healthy Homes and Communities Program. Air quality emerged as a priority issue.

Goal 3's focus on policy, systems, and environmental change was implemented in part by EHS providing data and research to inform discussion about draft proposal introduced in the 2016 Oregon State legislature (Senate Bill 1574 "Healthy Climate Bill"). The bill was a priority of CCC. In addition to creating a carbon trading market to meet decadal carbon reduction goals, the draft bill proposed to direct a portion of state carbon auction revenues to projects that benefit disadvantaged communities. The climate vulnerability indicators and index were used to educate advocacy groups and policy makers on one such approach to identifying disadvantaged communities. The bill has been deliberated in several legislative sessions, and, at the end of the 2017, it was reintroduced with a large number of sponsors, signaling its priority for the 2018 session.

Because air quality emerged as the key policy issue for CCC and Multnomah County governmental stakeholders, in collaboration with the MCHD Community Epidemiology, EHS engaged in geographic cancer risk assessment of toxic air pollutants of major greenhouse gas emitters in the proximity to neighborhoods that ranked highly in the project Climate Vulnerability Index. The analysis showed that despite being disproportionately represented near point sources of pollution, climate vulnerable neighborhoods were at lower overall cancer risk from air pollution than more advantaged neighborhoods, and that all residents of Multnomah County generally had low risks. Transportation-related pollution (i.e. mobile source) and residential wood

127 smoke burning overshadowed point sources.106 This information was shared by EHS with advocacy organizations and informed the development of the policy brief and neighborhood profiles. The air toxics risk analyses were also used by EHS in analyzing 30 state legislative bills dealing with air quality and climate change for the Multnomah County governmental relations office.

Though not completed by the end of the LC, progress was made on tasks outlined in the project extension. The in-kind HEDIP supervisor garnered management support and identified climate contacts for each of the program units of the MCHD, and set a date for a first meeting.

Interjurisdictional integration of climate change and health was significantly advanced with a formal agreement between MCHD and the County Office of Sustainability to co- convene an interagency group of staff to discuss climate and health issues related to implementation of the County’s Climate Action Plan. After this meeting, a countywide climate leadership group was established in December 2017 that will coordinate climate mitigation and adaptation activities across departments. This appears to be substantively different than MCHD's previous role as a consultant in the City of Portland and Multnomah County's periodic updates of climate mitigation and adaptation plans. This new interdepartmental group, led by the Office of Sustainability, replaces a loose “sustainability liaison” structure. The HEDIP vulnerability maps were presented at these meetings and other county departments (transportation, emergency management) have begun to incorporate this information into their planning.

EHS's assisted Oregon Health Authority and the University of Wisconsin gather data to implement a transportation and health impacts model (ITHIM) to assess the physical activity co-benefits of active transportation in the preferred scenario of the regional transportation plan update (Metro). Preliminary results are scheduled to be present to partners in January 2018.

Internal and Community Partners

The principal partners in the HEDIP project are listed in the following table.

Table V-H2: Community Partners in the Multnomah County Public Health Department Learning Collaborative Sector Partner LHD (internal) Maternal Child & Family Health, Community Epidemiology Services, and Communicable Disease Governmental County Office of Sustainability Non-Profit Coalition of Communities of Color and their partners Academic Portland State University (Vulnerability Assessment) University of Wisconsin (transportation-health impact model)

By design, the principal community partner was the Coalition of Communities of Color (CCC). Formed in 2001, CCC is an alliance of culturally-specific community-based organizations from African, African American, Asian, Latino, Native American, Pacific

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Islander, and Slavic communities. The CCC supports collective racial justice to improve outcomes for communities of color through policy analysis and advocacy, culturally- appropriate data and research, and leadership development. CCC recent research includes the "Unsettling Profile" series of racial and health disparities reports that focus on racial/ethnic populations within Multnomah County. CCC policy analysis and advocacy has a statewide reach and has focused on educational justice and community and economic development with emphasis areas in anti-displacement and environmental justice. CCC's environmental and climate activities were rebranded in 2016 as REDEFINE: The CCC's Initiative for Climate and Environmental Justice (http://www.coalitioncommunitiescolor.org/cedresoucepage).

In December 2015, CCC was one of several Portland-area community-based organizations (CBO) who received a grant from the Kresge Foundation to implement a 3-year climate resilience plan for the Portland metro region.107 The grant focused on CBO-led organizing and advocacy to shape public processes related to climate resilience through education (not lobbying) and community mobilization. The priority areas included cross-cultural climate action capacity building, housing justice, transportation justice, green infrastructure, and disaster resilience. Specific advocacy was aimed at ballot initiatives and budget processes for funding active transportation, transit infrastructure, and transit youth passes, and the repeal of statewide ban on inclusionary zoning to promote affordable housing. A policy emphasis was making the national case for anti-displacement as a pillar of climate resilience. While City and County governmental agencies and data from their vulnerability assessments of disadvantaged communities were mentioned in grant, MCHD was not specifically named as a partner. Under the grant, the Portland Bureau of Emergency Management contracted with the grantees to conduct emergency preparedness trainings in disadvantaged neighborhoods.

4. LHD capacity building

The project demonstrated increased capacity to create data tools and work with community-based organizations to reach a statewide audience. Strengthening relationships with community partners and CCC in particular are among the major accomplishments of the project. The project coordinator indicated that a sign of success is "CCC regularly calls on MCHD to advise on data and policy issues." Strengthening the MCHD's relationship with the County Office of Sustainability provides a channel for health and equity content in governmental climate action planning.

Prior to the grant, static maps in reports were used to communicate climate vulnerability. The project developed interactive maps, which also incorporated specific community and governmental concerns of air toxics from point sources of greenhouse gas emissions and pollution. The use of data and analysis also helped bring clarity to the contributions of point sources vs. mobile sources of pollution.

Although the EHS has been part of the official City of Portland and Multnomah County climate action planning process since 2007, it appears not to have had an active role in

129 its implementation. The LC created an opportunity for MCHD to engage with the Office of Sustainability to assess the prevailing model of interdepartmental participation based on "sustainability liaisons." This led to the mutual recognition that an interdepartmental workgroup, convened by the Office of Sustainability and co-convened by EHS, may be a more effective model. Steps are being taken to institutionalize this approach.

5. Disadvantaged populations and health equity

Through CCC, disadvantaged populations, health equity, and environmental justice were dominant themes in in shaping the project. Mapping was a tool to identify populations and neighborhoods with climate vulnerable populations. CCC played a major consultative role in the construction of the mapping tool, development of the curriculum for climate education, and statewide policy advocacy on carbon mitigation and investments in disadvantaged communities.

6. Integration of climate change into health department programs/communications

Prior to the LC, the EHS was designed to represent the MCHD in interjurisdictional climate activities. EHS identified internal partners as Vector Control, the Healthy Retail Initiative, the Racial and Ethnic Approaches to Community Health (REACH) Initiative, and Public Health Preparedness. While the list of indicators for the mapping tool was shared for feedback with various divisions and Community Epidemiology assisted with the cancer risk analysis of air toxics, integration with other health department programs was not apparent.

During the project extension, efforts got underway to more broadly inform supervisors and other MCHD management, and this initiative may culminate after the LC ends.

Indicator mapping and the development of a curriculum for climate education were the HEDIP's main venues to promote climate communications. While the information in the mapping tool appears to have been shared with other government agencies and CCC and its partners, neither the mapping tool nor the curriculum have been publically disseminated (e.g. posted at https://multco.us/sustainability/public-health-and-climatechange) and remain a draft. The mapping tool also does not include links to the City- County climate action plans, related MCHP programs, and other resources.

There was no description of how the climate and health equity curriculum piloted by CCC was going to be deployed within the health department or in community settings.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges and Unanticipated Opportunities The defining challenge occurred early in the project with change in project coordinator and the change in commitments from community-based organizations. The focus on a single CBO, whose policy advocacy had both a local and statewide reach, represented an unanticipated opportunity and challenge. Through the climate vulnerability indicators

130 and epidemiologic analyses of local impacts of air pollution, EHS supported CCC's statewide legislative education, which, indirectly led to Portland State University's extending the climate vulnerability mapping tool as a statewide application.

There appears to be a challenge in aligning community priorities with those given in the County's 2013 Climate Change and Public Health Preparation Plan, and the 2014 Climate Change Preparation Strategy. While air quality was common to these plans and the HEDIP, there was no explicit mapping or projections for heat, urban heat islands, or vector-borne illness in the HEDIP. A major locus community interest (as described in the concurrent Kresge-funded grant) appeared to be active transportation, increased transit access, parks, and neighborhood emergency preparedness. The project extension allowed EHS to quantify the health co-benefits of active transportation to support this alignment.

8. Assessment of meeting goals

Administrative Data

The project met specific goals from the revised Scope of Work/Project Extension and met the LC's overall goal of significant community engagement and focus on vulnerable populations. It was less successful in integrating climate change and health in a broad swath of MCHD programs outside of EHS and in messaging on climate change. Although the project's focus was not interjurisdictional engagement (which had been long-standing), the project may have catalyzed a re-evaluation and restructuring of the prevailing model of interdepartmental engagement on climate action planning.

Self-Assessment

From the final progress report narrative, the LC's representatives acknowledged the importance of the LC to engage in community partnerships at the top of the ladder of engagement, where power is more equitably shared between the LHD and community organizations, and CBOs lead the effort. Other major accomplishments related to indicator mapping and the analysis of air toxics to better inform policy.

Key Informant Interview

We interviewed the environmental justice manager from the Coalition of Communities of Color and a senior analyst at the County Office of Sustainability. The interviews both emphasized the importance of the LC project strengthening their partnerships with the LHD. Both also emphasized the role of the LHD in projecting health into climate change framing and the utility of data on climate change and health that they were able to use in their work.

Section References

92. Multnomah County. Health Department. FY 2017 Adopted Budget. Portland, OR: Multnomah County; 2017.https://multco.us/file/54363/download

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93. Multnomah County Health Department. 2014 Report Card on Racial and Ethnic Disparities. Portland, OR: Multnomah County Health Department; 2014. 94. Multnomah County Health Department, Coalition of Communities of Color, Willamette HC. Multnomah County Health Department Public Health Division Community Health Assessment. Portland, OR: Multnomah County Health Department; 2015.https://multco.us/file/47115/download 95. Oregon Health Equity Alliance. Multnomah County - OHEA Community Health Improvement Plan (CHIP). Portland, OR: Multnomah County Health Department and Oregon Health Equity Alliance; 2016.http://www.oregonhealthequity.org/wp- content/uploads/2016/07/Multco-OHEA-CHIP-Sept-30-2016_Working_Updated-Nov-11.pdf 96. OPAL Environmental Justice. History. Portland, OR: OPAL Environmental Justice; 2018.http://www.opalpdx.org/history/ 97. City of Portland. Global Warming Reduction Strategy. Portland, OR: City of Portland; 1993.https://www.portlandoregon.gov/bps/article/112110 98. Multnomah County Health Department. Climate Change and Public Health Preparation Plan. Portland, OR: Multnomah County Health Department; 2013.https://multco.us/file/8243/download 99. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate Change: The Public Health Response. Am J Public Health. 2008;98:435-445. 100. City of Portland and Multnomah County. Climate Change Preparation Strategy: Risk and Vulnerability Assessment. Portland, OR: City of Portland and Multnomah County; 2014.https://multco.us/file/36550/download 101. City of Portland and Multnomah County. Climate Change Preparation Strategy. Portland, OR: City of Portland and Multnomah County; 2014.https://www.portlandoregon.gov/bps/article/503193 102. City of Portland and Multnomah County. Climate Action Plan: Local Strategies to Address Climate Change. Portland, OR: City of Portland and Multnomah County; 2015.https://multco.us/file/42548/download 103. Climate and Health Program. Oregon Climate and Health Resilience Plan. Portland, OR: Oregon Health Authority, Public Health Division; 2017.https://apps.state.or.us/Forms/Served/le8267a.pdf 104. Association of State and Territorial Health Officials. Climate Change & State Public Health: Charting New Waters. Arlington, VA: Association of State and Territorial Health Officials; 2010.http://practice.sph.umich.edu/micphp/files/GrandRounds/ClimateChange/Marinucci_Sli des.pdf 105. City of Portland and Multnomah County. Climate Action Plan. Portland, OR: City of Portland and Multnomah County; 2009.https://multco.us/file/33916/download 106. Haggerty B. Health Risks From Greenhouse Gas Co-pollutants in Environmental Justice Communities. Presented at the Northwest Climate Conference, October 10, 2017, Tacoma, WA. Portland, OR: Multnomah County Health Department; 2017. 107. Native American Youth & Family Center, Coalition of Communities of Color, Oregon OEJ. Tyee Khunamokwst “Leading Together”: Cross Cultural Climate Justice Leaders. Portland, OR: Native American Youth & Family Center, Coalition of Communities of Color, OPAL Environmental Justice Oregon; 2015.https://static1.squarespace.com/static/5501f6d4e4b0ee23fb3097ff/t/571e5e492eeb816 4565faac4/1461608489635/Final+Implementation+Plan_NAYA.pdf.

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J. New Orleans Health Department

1. Background

The New Orleans Health Department (NOHD) is the only local health department in the state of Louisiana, serving 365,000 New Orleans residents. NOHD has an annual budget of $39.5 million and has 90 full-time staff.108 The health department includes nine essential service programs including, Healthy Environment and Emergency Preparedness; Healthy Start New Orleans; Health Care for the Homeless; Ryan White Program; Violence and Behavioral Health; Family Health-WIC; Fit NOLA; Community Health Assessment; and Health Equity.

New Orleans’ strategic location near the mouth of the Mississippi River and the edge of the Gulf of Mexico established its significance as a place of commerce, as well as its geographical challenges. Situated on spongy delta soils, partly below sea level with high rates of annual rainfall, New Orleans’ relationship with water has been a defining characteristic of its development. Over the past several years, the city has seen very clearly the worsening impacts of climate change, including increased extreme temperatures and increased vector populations.109 The health department’s work has largely concentrated on responding to these health impacts and promoting general preparedness. This has included education on mosquito control, providing response services during extreme heat events to homeless populations, conducting outreach for hurricane preparedness, and informing citizens about flood preparedness.

NOHD serves a diverse population of approximately 33% White, 5.2% Latino, 60% African America, 4% Asian. According to the 2010 census, 27% of county residents had incomes below the federal poverty line.110 New Orleans also contends with significant health disparities; in 2013 there was a 25 year difference in life expectancy between different neighborhoods.111 In order to ensure that all citizens are able to live, learn, work, and play in equitable environments NOHD is committed to integrating and Health in All Policies framework across the city. The Department is also working to address social determinants of health through programs like “Best Babies Zone” and “Fit NOLA” which target their programming to historically disadvantaged neighborhoods. The Emergency Preparedness program was already heavily invested in vulnerable populations, working with city partner to provide health services to homeless individuals and coordinate evacuation of disabled residents during emergencies.

In the aftermath of Hurricane Katrina, the Louisiana Disaster Recovery Foundation released a report entitled GreeNOLA: A Strategy for a Sustainable New Orleans in 2008, outlining strategies to rebuild the city in a more sustainable way.112 In July 2017, the City of New Orleans published a Climate Action Strategy, including a 50% cut in GHG emissions by 2030.113 Prior to this LC project, the New Orleans Health Department (NOHD) had no explicit engagement on climate change, although its activities (e.g. mosquito control, flood warning) are climate-related. Following the current administration’s decision to withdraw from the Paris Accord, the New Orleans mayor began speaking explicitly about climate change and the importance of climate action,

133 this in turn has supported increased and more explicit reference to climate change in NOHD communications and materials as described in detail below.114 Additionally, the City is in the process of developing a resilience strategy though Rockefeller Foundation 100 Resilient Cities Campaign.115 This effort has brought together representatives from the private sector, academic institutions, social entrepreneurs, the coroner, city officials, and more to develop a comprehensive strategy that considers the needs of all New Orleanians.

Applicant and Proposal

The NOHD Healthy Environments & Emergency Preparedness program officially represented the department in the Learning Collaborative project. NOHD proposed to collaborate with a number of other department programs, as well as other city agencies and community-based organizations.

Background and Prior Climate Change Activities of the Health Department

Previous efforts to address climate change have focused largely on water-based projects such as improved levee structure, rehabilitation of the bayous and mitigating the hazards associated with saltwater intrusion. Very few of these projects have included insight from the New Orleans Health Department.

2. Description of applicant’s proposal and goals

The initial project proposal outlined a multi-stage project in which the project team would engage with other NOHD programs and external partners to identify New Orleans specific climate and health impacts and develop strategies to address these impacts. The preliminary step in this project was to host a kick-off event to bring together NOHD and community partners to discuss climate change and health in New Orleans and begin to engage potential project partners. The second critical project task was to conduct a climate and health vulnerability assessment over the first year of the grant period. Following the completion of the vulnerability assessment, NOHD proposal described a community engagement component in which a wide variety of community stakeholders would be brought together to explore how climate change will impact the health of New Orleanians, resulting in the production of an adaptation plan.

Goals and Objectives

The primary goal of the NOHD LC project was to create a comprehensive understanding of how climate change will impacts New Orleans and what the department and partners can do to mitigate the resulting health impacts upon New Orleans citizens. The sub-goals outlined to achieve the overarching goal are to conduct a climate and health vulnerability assessment for the city of New Orleans, develop climate and health adaptation strategies, and adapt to thrive.

Duration of Participation

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NOHD participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

Staffing/Organizational Chart

The project proposal included an in-kind part-time project manager and stipend support for three graduate interns. Throughout the duration of the project several other NOHD staff have supported certain project elements. NOHD also contracted with the Gulf Coast Center for Law and Policy (GCLP) to facilitate community workshops.

Table XX. Objectives of the New Orleans Climate and Health Project Scope of Work October 2015 Scope of Work (January 2016 – June 2017) 1. Determine/locate current climate projections for New Orleans 2. Determine partners for climate change and health project 2.1. Locate organizations working on this topics and determine role for each partner 2.2. Provide opportunities for partner/community organizations to provide input to climate vulnerability assessment and maps 2.3. Provide opportunities for internal NOHD partners to provide input to climate vulnerability assessment and maps 3. Determine health impacts of climate projections 3.1. Examine health outcomes associated with the projected scenarios 3.2. Identify known risk factors for the associated health outcomes 3.3. Acquire information on health outcomes and associated risk factors for New Orleans by census block or tracts or zip codes 4. Create Geographic Information System 4.1. Input this information in a GIS map to create an overlay analysis of risk factors which identifies communities and places that are vulnerable to disease or injury linked to climate-related exposure 5. Determine priority climate and health adaptive strategies 5.1. Meet with community partner and community members to share results of climate vulnerability assessment and maps 5.2. Meet with internal NOHD leadership/partners to share results and discuss climate and health adaptation strategies 5.3. Determine appropriate adaptive strategies with input from community partners and community members 5.4. Prioritize adaptive strategies with input from community partners and community members 6. Select immediate interventions to reduce impact of health outcomes 7. Draft long term mitigation strategies to address each of the projected health outcomes 8. Integrate climate change considerations into public health programming and policies 8.1. Conduct a training for NOHD staff on climate change and public health 8.2. Review results of climate vulnerability assessment with NOHD staff and Louisiana Department of Health and Hospitals

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9. Create an adaptation plan that outlines external and internal strategies to reduce health impact of the projected adaptation plan 9.1. Draft, review, and publish adaptation plan created by NOHD with community input 10. Include climate change projection modeling in all annual planning and strategy development. 10.1. Annually incorporate plans for the health outcomes associated with the climate projection models 11. Develop materials to support the interventions identified 11.1. Develop communication materials to distribute to vulnerable populations 12. Target health outcome response 12.1. Utilize GIS maps to target response to health outcomes to the most vulnerable populations Project Extension (July 2017- December 2017) 1. Write or update emergency operation plans based on community input 2. Identify volunteers and neighborhood leaders that are interested in assisting with response and community outreach 2.1. Train volunteers and neighborhood leaders on climate change, health impacts and response protocols 2.2. Conduct community outreach on climate change and emergency operations plans 3. Determine little waste/climate impact resources for emergency resources for emergency response 3.1. Procure supplies and resources for response to be used in extreme events 4. Incorporate climate change and health work into health equity framework and other NOHD programs 4.1. Conduct meetings with Fit NOLA partners on how climate change can be incorporated into nutritional and physical fitness programs

3. Description of applicant’s proposed objectives and activities

Climate and Health Vulnerability Assessment

The NOHD project team began work on the climate and health vulnerability assessment early on in the grant period. NOHD used the Centers for Disease Control and Prevention (CDC) BRACE framework to examine the climate change projections for New Orleans and associated health impacts focusing on the risk factors of heat, vectors, and air quality. The first phase of the climate and health vulnerability assessment involved collecting and organizing data on New Orleans climate history and trends. Once collected, the data was compared to potential scenarios based on climate change projection models. In order to determine which climate prediction models to use, NOHD consulted with local and state climatologist, also considering best practices from the CDC’s Climate Ready States and Cities Initiative, and analyzing data available for New Orleans. Following completion of this stage, the health analysis portion of the vulnerability assessment began, including a consideration of both the direct and indirect

136 health outcomes as well as the risk factors association with each of the identifies climatic changes. Once this information was determined, project staff began collecting data on where these risk factors are most prevalent in the New Orleans area, by census blocks. Two interns assisted in identified and collecting data from numerous sources, compiling into a Geographic Information System (GIS) in order to produce a series of vulnerability maps, which were then used to create an overlay analysis of risk factors, identifying the neighborhoods most vulnerable to morbidity and mortality linked to each identify climate-related health outcome. The project team encountered several challenges in collecting all of the desired health data, particularly air quality and vector data. While the NOHD project team met with a number of organizations working on air quality in Orleans Parish, none of them were collecting smaller tract-level data. Similarly, the Louisiana Department of Environmental Quality has air-monitoring stations in each parish, but there is only 1 per parish preventing the project team from including data at a smaller scale than the parish level. The New Orleans Mosquito Control Board was also unwilling to share their vector data with the NOHD team. Despite these challenges, the NOHD team was able to produce a robust climate and health vulnerability assessment outlined and discussed at length in their New Orleans Health Department Climate Change & Health Report.109

NOHD Staff Education

The NOHD project team hosted a climate and health training for all NOHD staff. The presentation covered the basics of climate change, how it will impact New Orleans, the health impacts, and how it impacts each Health Department program. Staff were then asked to brainstorm ways that their programs can include climate change information or projects into their current activities. Over 75 NOHD staff participated in the climate and health training.

The NOHD project team also shared the results of the climate and health vulnerability assessment with NOHD staff at an Environmental Health Tracking advisory board meeting, during which they also presented on the status of their extreme heat work.

Community Engagement and Education

Following the completion of the climate and health vulnerability assessment, NOHD partnered with the Gulf Coast Center for Law & Policy (GCCLP) to host three community meetings with several of the most vulnerable communities, as identified by climate and health vulnerability assessment. The goals of the meeting, as outlined by NOHD and GCCLP were to:

1. Map participant’s knowledge of CNOs extreme weather response protocols. 2. Communicate impacts of climate change on health broadly and specific to the GNO area. 3. Identify community health service needs. Cultivate and prioritize community action steps that address the intersection of climate and health. 4. Strengthen participant’s ability for increased civic participation.

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5. Collect and deliver community recommendations to address the impact of climate change on health in at-risk communities in New Orleans.

Following the completion of the three community meetings, GCCLP drafted a summary report with key recommendations for the city, including:

1. Build trust. One of the common themes that came up across the community meetings was residents’ lack of trust in the City’s ability (and willingness) to protect their health and well-being. Hurricane Katrina left residents weary of where the City’s interests lay both during emergencies (e.g. how and when the decision to mandate an evacuation is made) and after (e.g. who and what get prioritized during reconstruction) 2. Invest in community cohesion. The City should support neighborhood groups and networks with physical, financial, and educational resources. For example, with support from the City these groups could be encourages to undertake projects like neighborhood trash pickup days, which could help reduce available mosquito breeding sites. Strengthened community networks also better equip communities to endure extreme weather events.

While these meetings were not as well attended as NOHD and GCCLP has hoped, the community discussions and resulting summary report were critical in shaping elements of the NOHD’s Climate Adaptation Plan and the future priorities of the Healthy Environments and Emergency Preparedness program.

In addition to this series of community meetings, NOHD project staff developed a series of informational pamphlets for the public including: Climate Change and Extreme Heat, Climate Change and Mosquitoes, and Climate Change and Air Quality. All of which include an explanation of climate change and health, at-risk populations, and strategies to reduce risk.

Adaptation Plan & Other Planning Documents

NOHD project team drafted a health department Climate Adaptation Plan explicitly addressing the climate and health impacts in New Orleans. The plan outlined the identified adaptation strategies and the role of the health department in implementing said strategies. NOHD was also involved in drafting the New Orleans Climate Adaptation Plan (CAP) and ensuring that the health impacts of climate change were included in the plan.113 New Orleans CAP also addressed the health co-benefits of climate mitigation strategies, such as active transportation.

Climate change and health were also include in the New Orleans Community Health Improvement Plan.116 Reducing the “impact of climate change on the health of New Orleans communities and vulnerable populations is included under in the second goal of the plan, “Create social and Physical Environments that Promote Good Health for All.”113

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Staffing changes delayed the completion of the integration of climate change impacts into the Emergency Preparedness plans, however the project team indicated that this will be completed during the second extension period (January-June 2018).

4. LHD capacity building

The NOHD LC staff have established this program as a leading health voice on climate change, and have brought many partners to the table through this climate and health workgroup, which has met quarterly during the project period. Internal collaborators include: Medical Reserve Corps, Fit NOLA, Healthy Start, NOLAReady, Community Health Improvement Program, and Mosquito & Termite Control Board.

The NOHD project team also hosted an all staff training on climate change and health for the department. During which they discussed the health impacts of climate change in New Orleans, and facilitated brainstorming sessions with other program staff to identify potential areas for integration of climate change into their respective programs.

NOHD have also worked to directly integrate strategies to reduce their carbon footprint in their emergency responses. The Emergency Response program identified, establish procurement agreements, and purchased biodegradable and reusable supplies that can be used in emergency settings, including shelters. They have also collaborated with a local sustainable farmer to pick up organic waste from emergency shelters and compost it offsite, therefore reducing the amount of organic waste sent to local landfills. The NOHD team has also worked with the sanitation department to recycle more paper within the NOHD offices and develop an internal departmental policy to reduce carbon emissions.

5. Disadvantaged populations and health equity

NOHD’s partnership with the Gulf Coast Center for Law & Policy (GCCLP) clearly demonstrated their commitment to engaging with disadvantaged communities and striving for greater health equity across New Orleans. GCCLP is “a non-profit, public interest law firm and justice center with a mission to build, serve and advocate for structural shifts that promote equity in law, society and community” (https://www.gcclp.org/). Based on the vulnerability assessment and in consultation with GCCLP, NOHD supported three community workshops during which GCCLP facilitators engaged with community participants around climate change, climate justice, and health. As described previously, the recommendations crafted during these dialogues were included in NOHD’s Climate Adaptation Plan.

Additionally, during the vulnerability assessment process the NOHD project team pulled a number of hospitalizations data sets from the state surveillance system. This data was used in the Climate and Health Report, but also revealed some glaring differences between asthma rates in black and white people within New Orleans. The NOHD team has used this data to pull together a number of stakeholders in the community looking at

139 asthma to try to address the root causes of this disparity, which NOHD and partners believe to be related to housing conditions and accessibility.

6. Integration of climate change into health department programs/communications

As described above the NOHD project team integrated a climate change section into the 2016 Health Equity Framework, the 2016 Community Health Improvement Plan, and the 2016 Community Health Needs Assessment. They also developed a health department Climate Adaptation Plan and were instrumental in ensuring that the New Orleans CAP explicitly includes the health impacts of climate change.

The NOHD project team developed a series of informational climate and health pamphlets, a Physician’s Guide to Climate Change and Health, and a Patient’s Guide to Climate Change and Health. Additionally, the NOHD project has partnered closely with NOLAReady to integrate climate change messaging into existing NOLAReady informational and educational materials.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges

Throughout the course of this project, NOHD has had four directors and multiple staffing changes on our Healthy Environments and Emergency Preparedness teams which have been the primary teams working on the climate change and health project. Due to constant changes in the health department leadership, there have been a number of priority changes both within the NOHD LC team and external partners. While these changes did not drastically change the focus of the LC project, they did cause a number of delays throughout the duration of the project. The changes and limitations of staffing, while challenging, enabled the NOHD team to partner with other organizations to complete the vulnerability mapping and host community conversations.

Additionally, the city of New Orleans has experiences several extreme weather and vector-related emergencies, including a tornado, extreme flooding, and Zika monitoring and response. While this impeded the completion of explicit climate change work in several instances, it enabled the NOHD LC to further justify the importance of climate and health work in the department.

Finally, there are no strong sources of air quality data at the sub-parish level in New Orleans and the New Orleans Mosquito Control Board was unwilling to share their mosquito data with the NOHD LC team, as they do not want those maps available to the public.

Unanticipated opportunities

8. Assessment of meeting goals

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Administrative Data

The New Orleans LC team met all of the major goals outlined in its scope of work and developed all of the described deliverables. In partnership with several graduate students and other City agencies, NOHD completed the climate and health vulnerability assessment, which was incorporated in to the NOHD Climate Change & Health Report. NOHD collaborated with GCCLP to complete a series of community meetings across three different neighborhoods in New Orleans, from which they gathered a series of community recommendations for the health department. NOHD had completed a health department climate adaptation plan that includes the community recommendations and also provided input and critical health impact information to the New Orleans Climate Action Plan.113 Additionally, NOHD LC team has created a pamphlet series on climate change and health, a Physician’s Guide to Climate Change and Health, as well as a Patient’s Guide to Climate Change and Health.

Self-assessment

The NOHD project lead indicated that this biggest impact of the LC project was that they were “given a seat at the climate change table.” The grant funding and the existence of a national climate and health learning collaborative gave additional credence to climate change and health work happening in the health department. Additionally, through their partnership with GCCLP, NOHD was able to connect with numerous community organizations that they had not previously worked with, expanding their external network of partners.

Key Informant Interviews

We interviewed the Public Engagement Officer in the Office of Homeland Security and Emergency Preparedness and a Program Manager in the Office of Sustainability. The Public Engagement Officer indicated that the partnership with NOHD enabled the Office of Homeland Security and Emergency Preparedness to more effectively integrate public health messaging into their emergency preparedness materials, NOLAReady, as well as begin to craft and disseminate messaging on non-emergency issues (e.g. air quality). The Office of Sustainability manager stated that collaboration with NOHD on the LC project significantly elevated the visibility of the health department in their office, and fostered a greater understanding of NOHD’s access to critical data, community engagement strategies, and the capacity to addressing climate change impacts through a public health lens.

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Section References

108. Finance Department. Comprehensive Annual Financial Report. New Orleans, LA: City of New Orleans; 2016.https://www.nola.gov/accounting/files/comprehensive-annual-financial- report/city-of-no-financial-statement-audit-2016-color/ 109. New Orleans Health Department. Climate Change & Health Report. New Orleans, LA: New Orleans Health Department; 2017. 110. US Census Bureau. US Census QuickFacts: New Orleans, Louisiana; 2017.https://www.census.gov/quickfacts/fact/table/neworleanscitylouisiana/INC110216 111. Robert Wood Johnson Foundation Commission to Build a Healthier America. Metro Map: New Orleans, Louisiana - Infographic; 2013.https://www.rwjf.org/en/library/infographics/new- orleans-map.html 112. Nance E, Fisher W, Schwartz J, Quinn D. GreeNOLA: A Strategy for a Sustainable New Orleans. New Orleans, LA: Louisiana Disaster Recovery Foundation; 2008.https://www.nola.gov/getattachment/bece551e-5cf8-421c-ac27- 48db26194c40/Appendix-Ch-13-GreeNOLA-A-Strategy-for-a-Sustainab/ 113. City of New Orleans. Climate Action for a Resilient New Orleans. New Orleans, LA: City of New Orleans; 2017.https://www.nola.gov/nola/media/Climate-Action/Climate-Action-for-a- Resilient-New-Orleans.pdf 114. The New Orleans Advocate. Mitch Landrieu Condemns U.S. Withdrawal from Paris Accord: ‘One of New Orleans’ Most Urgent Threats Is Climate Change’. New Orleans, LA: The New Orleans Advocate; 2017.http://www.theadvocate.com/new_orleans/news/article_df611fb6-4718-11e7-a6df- 97c30b536e0a.html 115. 100 Resilient Cities. New Orleans Resilience Challenge; 2017.http://www.100resilientcities.org/cities/new-orleans/ 116. New Orleans Health Department. New Orleans Community Health Improvement Plan. New Orleans, LA: New Orleans Health Department; 2016.http://www.nola.gov/nola/media/Health- Department/Publications/CHIP_Second-Revision_-2016-2017_FINAL_112016.pdf

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K. City of Milwaukee Health Department

1. Background

The City of Milwaukee Health Department (MHD) has an annual budget of $14 million, 139 staff, and is responsible for the health of 599,642 people in the City of Milwaukee and surrounding areas.117 The health department houses four divisions; Disease Control and Environmental Health; Family and Community Health; Health Laboratories; and Consumer Environmental Health. MHD serves a diverse city population of 44.8% White, 40% African American, 3.5% Asian, and 17.3% Hispanic.117 The mission of the MHD is to ensure that services are available to enhance the health of individuals and families, promote healthy neighborhoods, and safeguard the health of the Milwaukee Community.118 Milwaukee is a worldwide leader on water conservation, previously named an innovating city to the United Nations Global Cities Program.119 The city rests on the second largest lake of the system of Great Lakes that represent one fifth of the entire freshwater supply on the planet.120 As such, Milwaukee and surrounding areas have an important responsibility in the stewardship and protection of this crucial freshwater resource, which has been and will continue to be impacted by climate change.

Prior Climate Change Activities of the Local Jurisdiction

Given Milwaukee’s proximity to the Great Lakes system, the City is an established steward of this water system and strives to address the impacts of climate change on freshwater resources, food systems, and vulnerable populations. The City of Milwaukee Office of Environmental Sustainability (now Environmental Collaboration Office) published the City’s first sustainability plan in July 2013, entitled ReFresh Milwaukee, which set “specific goals and targets for individuals, organizations, businesses and the City to achieve in eight priority Issue Areas (Buildings, Energy, Food Systems, Human Capital, Land and Urban Ecosystems, Mobility, resources Recovery, and Water).” 121 In alignment with the goals of ReFresh Milwaukee, in July 2014, the City passed ordinances and zoning changes that removed obstacles to establishing community gardens by “developing new real estate disposition strategies, repurposing residential properties to non-residential uses, expanding urban agriculture uses on vacant lots, and establishing micro-business ventures in the local food supply chain.”122 Wisconsin was awarded a Building Resilience Against Climate Effects (BRACE) grant in 2016; the Health Department is an active participant in the BRACE Scientific Advisory Workgroup. MHD collaborated with the Wisconsin State Health Department and was active in the development and implementation of the Heat Vulnerability Index for the City.123 This was expressly developed to address the social determinants of health and health equity by identifying and mapping cooling centers within Milwaukee where individuals can go during extreme heat events.

Applicant and Proposal

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The City of Milwaukee Health Department’s Division of Disease Control and Environmental Health officially represented MHD throughout the duration of this project.

Background and Prior Climate Change Activities of the Health Department

Prior to the LC climate and health project, MHD was not directly involved in any climate change activities outside of their participation in the BRACE Scientific Advisory Workgroup described above.

2. Description of applicant’s proposal and goals

The original proposal submitted by the Milwaukee Health Department outlined a multi- pronged project that was designed to simultaneously address climate change adaption and promote community health and health equity. This would occur through sustainably improving food security, decreasing storm-water runoff, while mitigating climate change by decreasing the carbon emissions associated with transportation of food and water treatment and transmission. The core component of the initial proposal was to partner with Reflo, Sustainable Water Solutions (Reflo) in the design and implementation of rainwater harvesting systems in two sites, Alice’s Garden and Guest House of Milwaukee. This project component was complemented by proposed community and MHD staff outreach and climate and health education sessions.

Goals and Objectives

The overarching goal of this project was to make the City of Milwaukee more self- sufficient, connected, and resilient, allowing for better adaptation to climate change. The sub-goals included collaboratively working with project partners to plan sustainable water harvesting systems, increasing knowledge and awareness of climate change and adaptation/resilience strategies among the public, developing a resource guide that promotes replication of water harvesting systems in the City and other urban areas, and increasing awareness of climate change and health and climate resilience strategies among MHD staff.

Duration of Participation

MHD participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

Staffing/Organizational Chart

The proposal had a two-person project team drawn from the health department. The Emergency Preparedness Coordinator (.01FTE) was responsible for managing the project, recruiting staff participation, and developing project plans in coordination with community partner. The project team also included an Emergency Response Planning Coordinator (.01FTE) who was responsible for general project support activities.

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Table V-K1. Objectives of the Milwaukee Climate and Health Project from October 2015 Scope of Work October 2015 Scope of Work (January 2016 – June 2017) 1. Collaboratively work with clients, contractors, consultants, and other project partners to plan sustainable water harvesting system to meet a significant proportion of watering needs at the Guest House and Alice’s Garden sites. 2. Phased implementation of systems for capture, storage, reuse of rainwater at Alice’s Garden and Guest House. 3. Increase knowledge and awareness of climate change and adaptation/resilience strategies among public 3.1. Promote projects through MHD website and social media sites 3.2. Host at least six learning events at project sites and other venues, including information on climate change and health, and health co-benefits of climate resilience strategies 4. Create a resource guide that facilitates replication of water harvesting systems for use in the City of Milwaukee and other urban areas, including information about climate change and health, the value of green infrastructure/water harvesting as a climate change and health resilience strategy, co-benefits of green infrastructure/water harvesting, rainwater harvesting planning guidance, and information on community and agency processes/collaboration for design/planning/implementation of these systems. 5. Increase awareness of climate change and health and climate resilience strategies among MHD staff 5.1. Convene at least two informational meetings for MHD staff about project, including information about climate change and health Project Extension (July 2017 - December 2017) 1. Host a Climate Change and Health Symposium to enhance regional awareness of climate change and health.

3. Description of applicant’s proposed objectives and activities

As described above, MHD proposed a multi-pronged project with the overarching goal to make the City of Milwaukee more self-sufficient, connected, and resilient, allowing for better adaptation to climate change.

Rainwater Harvesting Projects

MHD collaborated with Reflo, a nonprofit organization and leader in sustainable water use, green infrastructure and water management in urban environments. Reflo roots its projects in “strong client relationships and community partnerships [while] providing cost effective and sustainable solutions for rainwater and greywater use.”124 At the outset of the grant period MHD outlined two project sites for rainwater harvesting systems, Alice’s Garden and Guest House of Milwaukee. Alice’s Garden is a two-acre, urban,

145 community garden in Milwaukee that supports and encourages families and organizations to reclaim and nourish cultural and family traditions connected to land and food. Guest House of Milwaukee is the city’s largest male homeless shelter. The organization also converted five unused properties into a 1 acre farm across the street from the shelter, which is used for training and outreach for the men in the Guest House program.

In December 2016, Reflo and the Alice’s Garden Water Working Group finalized the conceptual plan to convert an adjacent former alley into a bioswale to treat rainwater prior to storage for use in irrigating crops. Alice’s Garden also proposed an existing collection structure located on the south end of the property to serve as the focal point for the project. After treatment through the bioswales, the water, as planned, will pump the harvested rainwater through a system of filters before it being used to irrigate the gardens. In Winter 2016, the Alice’s Garden project was awarded $65,500 (of the total $120,000 project value) from the Milwaukee Metropolitan Sewerage District and the Fund for Lake Michigan to be spent between 2017 and 2018. Full construction will begin in spring, 2018.

While there was initially significant momentum around the Guest House rainwater harvesting project, the project was postponed due to concerns vocalized by several aldermen regarding land use. The grant funds were allocated to an interactive climate and water systems education model, Enviroscape, described in greater detail below. Reflo continues to work towards greater community and political support for the Guest House project, but it is not expected to be built until 2018 or later.

Rainwater Harvesting Resource Guide

In partnership with Reflo and others, MHD co-developed a Rainwater Harvesting Resource Guide that is meant to facilitate the replication of water harvesting systems across Milwaukee and in other urban areas. The resource guide includes case studies to demonstrate techniques for various size projects as well as general information about the value of green infrastructure and water harvesting. The guide also includes specific review of the climate and health co-benefits of rainwater harvesting, including “increased access to healthy, fresh foods,” “reduce your carbon footprint,” “protect freshwater resources,” and “promote urban greening.” This resource guide will be available on the MHD website and the Reflo website in January 2018.

Community Engagement and Education

The MHD team, in collaboration with Reflo, ECO, and other partners hosted six community educational sessions. Several of the events relied heavily on the use of Enviroscape, an interactive table-top model designed to demonstrate an array of climate impacts on local environments, specifically extreme precipitation, runoff and sewerage overflow. MHD found that the Enviroscape model resonated with diverse audiences and plans to purchase one for use in future educational sessions.

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Table V-K2. Community Engagement & Education Sessions Location Content Attendees Elementary school Session included a rain barrel demonstration, storm 15 water runoff discussion, and a rain garden demonstration. All three presentations incorporated climate change and health into the content. Green Schools MHD staff used Enviroscape model to demonstrate 100 Consortium and discuss the connections between storm water Conference runoff, climate change, and health. Chill on the Hill MHD staff used Enviroscape model to demonstrate 130 and discuss the connections between storm water runoff, climate change, and health. Rock the Green MHD staff used Enviroscape model to demonstrate 33 Sustainability and discuss the connections between storm water Festival runoff, climate change, and health. Refresh MHD staff engaged community members in 30 Milwaukee discussions around climate change and health in and the specific impacts in Milwaukee. Milwaukee Heat MHD presented the LC project at the Heat Task Force 30 Task Force Meeting, including updates on rainwater harvesting Meeting projects, resource guides, community engagement, the Climate and Health Symposium, and next steps.

MHD Staff Education

The MHD project team invited all health department staff to participate in the climate and health lunch and learn programs hosted in May 2017. Unfortunately, only 11 staff participated in the lunch and learn session; however, the facilitators reported that there was engaging discussion regarding climate and health’s place in different department divisions.

Climate and Health Symposium

MHD hosted the first ever Climate and Health Symposium in Milwaukee in November 2017. Over 550 individuals from a variety of organizations were invited to the symposium, and approximately 90 people attended the event. The primary purpose of the event was to reframe climate change as a public health and equity issue, drawing on speakers from LHD, Wisconsin BRACE, and Center staff to illustrate the breadth and depth of the climate and health nexus. The symposium served as a venue for external partners to connect and begin to brainstorm strategies to incorporate climate change into existing programs. Additionally, the Commissioner of Health was supportive of the event and presented introductory remarks at the symposium. The Mayor also participated in the events, further demonstrating his commitment to climate mitigation

147 and adaptation efforts. MHD staff indicated that the symposium stimulated a series of conversations regarding potential collaboration and strategies for climate and health integration into jurisdiction activities.

4. LHD capacity building

The LC project facilitated the development of new and meaningful partnerships with other City departments including the Environmental Collaboration Office (ECO) and the Milwaukee Metropolitan Sewerage District. These partnerships enhanced MHD’s capacity to address climate change and make a broader impact in the community, through shared resources and partnership on several of the community educational sessions. Their partnership with ECO allowed them to participate in the Green Schools Consortium Conference, during which they interacted with over 100 students and school faculty.

MHD’s learning collaborative project was able to increase departmental knowledge and capacity of climate and health through engagement in the community educational events, the Climate & Health Symposium, and a series of lunch and learn programs with staff. Informing staff of the local climate and health impacts as well as sharing the work and initiatives of other Learning Collaborative participants prompted staff to begin brainstorming ways in which their programs could begin to integrate climate and health into existing programs and communications.

5. Disadvantaged populations and health equity

MHD’s partnership with Reflo and the selection of the project sites reflects MHD’s commitment to serve disadvantaged populations and further health equity in Milwaukee. This project demonstrated the feasibility of implementing projects that elegantly address multiple concerns in disadvantaged communities through a single solution that also integrates community education about climate, health, and equity. Throughout the design, planning, and implementation stages, Reflo included community partners and members in the dialogue and employs community-hiring practices as much as possible. Additionally, the Alice’s Garden site served as a location for several educational skills- building sessions, which reach local community members as well as staff of other local community based groups. MHD and Reflo are currently in discussion regarding the new project site to incorporate programming in underserved areas of the city. Some of the potential projects include rainwater-harvesting projects in several school gardens and a partnership with the non-profit Victory Gardens, which establishes raised beds and/or orchards in vacant lots, among others. Throughout this selection process, MHD and Reflo have maintained the commitment to work with and invest in historically undeserved communities, ensuring that disadvantaged populations have access to community gardens, green space, and spaces for community gathering.

6. Integration of climate change into health department programs/communications

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The educational sessions hosted for MHD staff served as a critical starting point for conversations regarding the integration of climate change into existing health departments divisions and programs. The MHD project team plans to continue these conversations with colleagues into the future, while simultaneously drawing upon collaborative efforts with Reflo and ECO. Climate change and health information will be included on the MHD website in early 2018 and the Rainwater Harvesting Resource Guide includes explicit discussion of climate and health co-benefits.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan

Challenges The major challenge encountered by MHD was staffing and capacity. When MHD was initially awarded the grant they had a full time intern whose primary focus was the LC climate and health project. Following the completion of the internship, MHD staff had to take on additional work in addition to their other duties. Additionally, the Division of Disease Control and Environmental Health went through a reorganization, which also took time away from MHD’s lead on the project. However, this allowed partners to step in and take a more active role in the project.

As described above, MHD project staff did not have the attendance they had anticipated at the health department lunch and learn sessions. However, MHD has indicated that there are several avenues that they will be pursuing in the future to more effectively engage health department staff and external partners. One example of this is to work more effectively with their environmental health regulators and retail food facilities to reduce food waste being sent to the landfill or increase donation of safe surplus food to local hunger relief agencies.

Unanticipated opportunities

The partnership with Reflo has led to a number of unanticipated opportunities for MHD. In summer 2018, MHD plans to pursue a grant opportunity with Reflo. The goal will be to create a Milwaukee Community Map that includes information on a variety of topics related to climate change and health such as heat vulnerability, cooling centers, urban greening initiatives, available resources, and stories about what organizations have done to address climate change. This resource would be an interactive map that would allow community members and organizations to learn more about the climate impacts in Milwaukee, strategies in place to address the impacts, and how individuals can get involved.

8. Assessment of meeting goals

Administrative Data

The Milwaukee LC collaborative met all of the major goals outlined in its scope of work and completed all of the promised deliverables. In collaboration with Reflo, MHD completed the rainwater-harvesting project at Alice’s Garden, which provided ample

149 opportunity for community education and engagement around climate change and health. MHD has also been able to support Reflo in identifying other potential sites for rainwater harvesting systems, including several schools and community gardens. MHD also conducted more than six public education sessions at various community events, project sites, and other public venues, often in partnership with key collaborators including Reflo and ECO. Similarly, MHD successfully delivered two climate and health lunch and learn programs to MHD staff. While these programs were not as highly attended as the project team had hoped for, they served to stimulate progressive brainstorming and conversation around climate and health in other MHD divisions. MHD also successfully hosted the first ever Climate and Health Symposium in Milwaukee, with over 90 people in attendance. Attendees represented a variety of organizations including other local health departments, healthcare organizations, academic faculty and staff, local non-profit organizations and community groups.

Self-assessment

The MHD project team indicated that the LC project significantly elevated the visibility and importance of climate and health work in Milwaukee. As described above, the LC project paved the way for meaningful partnerships with community-based groups and other city agencies. MHD stated that the Health Commissioner’s and the Mayor’s public participation in the Climate and Health Symposium is one of the most significant successes of the LC project and is indicative of the direction in which the City will move in relation to climate change and health work. With further work from MHD and collaborators, the health department and the City of Milwaukee as a whole will be able to build upon the current momentum and continue to support climate adaptation and mitigation strategies that support health and equity across the city.

Key Informant Interviews

We interviewed a Division Director and the Director of the Environmental Collaboration Office. Interviewees indicated that the LC project allowed MHD to develop stronger and more meaningful collaborative relationships with non-profits and other City agencies, therefore amplifying the importance of understanding and addressing climate change through a health and equity lens. There was consensus that MHD needs to remain engaged in the climate change discussion, that the health voice is critical in building community and political consensus around climate adaptation and mitigation strategies.

Section References

117. US Census Bureau. US Census QuickFacts: Milwaukee, Wisconsin; 2014.https://web.archive.org/web/20140207151149/http://quickfacts.census.gov/qfd/states/5 5/5553000.html 118. Milwaukee Health Department. Vision, Mission, and Organization. Milwaukee, WI: Milwaukee Health Department; 2017.http://city.milwaukee.gov/Health/Vision-Mission- Organization#.Wl47HJOplE4

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119. UN Global Compact Cities Programme. Milwaukee. Geneva, Switzerland: UN Global Compact Cities Programme; 2010.http://citiesprogramme.org/cities/milwaukee/ 120. US Environmental Protection Agency. Lake Michigan. Washington, DC: US Environmental Protection Agency; 2017.https://www.epa.gov/greatlakes/lake-michigan 121. City of Milwaukee. ReFresh Milwaukee: City of Milwaukee Sustainability Plan Milwaukee, WI: City of Milwaukee; 2013.http://city.milwaukee.gov/ReFreshMKE_PlanFinal_Web.pdf 122. Office of Environmental Sustainability. Office of Environmental Sustainability Newsletter. Milwaukee, WI: City of Milwaukee; 2013.http://city.milwaukee.gov/ImageLibrary/Groups/cityGreenTeam/PDF/OESNewsletter_Is sue5_Aug2013.pdf 123. Bureau of Environmental and Occupational Health. Milwaukee Heat Vulnerability Index, BRACE Program. Madison, WI: Wisconsin Department of Health Services; 2014.https://www.dhs.wisconsin.gov/publications/p0/p00882a.pdf 124. Reflo Sustainable Water Solutions. Our Mission. Milwaukee, WI: Reflo Sustainable Water Solutions; 2013.http://refloh2o.com/our-mission/

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L. Seattle-King County Public Health

1. Background

King County, Washington is the 14th most populous county in the U.S., with 1.93 million people.125 Covering 2,134 square miles, King County is home to two tribal nations, 39 cities, 130 special purpose districts, and over 150 spoken languages. It is also home to one of the most diverse zip codes126 and one of the most diverse school districts in the nation,127 with 23% percent of residents speaking a language other than English and 19% born in another country.128

With a staff of 1,500 and an annual budget of $316 million, Public Health, Seattle & King County (PHSKC) houses five divisions: Preventive Services, Environmental Health Services; Community Health Services; Emergency Medical Services; and Correctional Health and Rehabilitation Services.129 Although deemed one of the healthiest counties nationally, there are significant disparities in level of education, life expectancy, years of health life, and causes of death across geographic and racial groups.130 PHSKC’s mission is to identify and promote conditions under which all people can live within healthy communities and achieve optimum health. Public Health’s mission is supported by the overarching Equity and Social Justice commitment made by King County government, supporting incorporation of equity considerations into all of PHSKC’s work with the recognition that King County communities and residents’ quality of life depends on the ability of everyone to contribute.

King County is situated in the unique geography and climate of the Pacific Northwest and the Puget Sound Region. In 2009 and 2013, the University of Washington’s Climate Impacts Group released reports131 describing the serious health impacts that climate change will have on Puget Sound residents. These reports indicate that climate change in Washington will likely lead to larger numbers of heat-related injuries and deaths, and that the greater Seattle area in particular can expect substantial mortality during future heat events. The reports document other adverse effects, including more severe and frequent weather events, increased vector, water, and food borne diseases, increased allergies and asthma, and increased social impacts that will affect the public’s health.

Applicant and Proposal

The Environmental Health Services Division and the Preparedness Section officially represented Public Health Seattle & King County in the Climate and Health Learning Collaborative project.

Background and Prior Climate Change Activities of the Health Department

Seattle and King County have a well-established history of engaging on climate change, health, and equity, initiating the 2015 King County Strategic Climate Action Plan (SCAP)132 and the 2015 King County Executive Climate Leadership Team, and the King County-Cities Climate Collaboration (K4C). The Public Health - Seattle-King County Department (PHSKC) has supported these efforts by providing limited information

152 related to climate and health, such as how PHSKC could support SCAP outcomes. Though PHSKC was recognizing a need to delineate a clear role for the organization, staff had some examples of partnerships to address climate and health issues, such as engaging with the City of Seattle and the Puget Sound Clean Air Agency in Seattle’s Chinatown/ International District to understand community networks, assets, and strategies used to cope with extreme heat and air pollution.133 Soon after the contribution to the SCAP, Environmental Health and Preparedness formed the Climate Health Action Team (CHAT) and began working in earnest to develop their climate change and health expertise, which was greatly enhanced through participation in the Climate and Health Learning Collaborative.

Critical to Public Health’s climate change work are strategies to eliminate and reduce health inequities across all segments of the population. In 2005, in response to Hurricane Katrina, Public Health’ Preparedness Section created the Vulnerable Populations Action Team (VPAT), now known as the Community Resilience + Equity program (CR+E). This model works in tandem with community-based organizations so that no one population is disproportionately impacted in an emergency. For the past ten years, CR+E has collaborated with hundreds of community and faith based organizations on business continuity planning, establishing communication systems, and building community resilience. Environmental Health and the Preparedness Section have a history of working collaboratively to approach climate change and have initiated CHAT (Climate Health Action Team), a multidisciplinary Public Health team, to address climate change impacts and Public Health’s role, which has prepared Public Health to apply for this capacity building grant opportunity. Examples of activities that are catalysts to their joint work include: • Development of goals and actions for the 2015 King County Strategic Climate Action Plan transmitted in June 2015 to the King County Council. • Participation in the King County’s Climate Leadership Team facilitated by the Executive Office to ensure coordination of goals for climate change efforts among County Departments and local jurisdictions. • Partnership with City of Seattle and the Puget Sound Clean Air Agency in Seattle’s Chinatown/International District to conduct interviews with neighborhood leaders to understand existing community networks, assets, and strategies used to deal with extreme heat and air pollution.

2. Description of applicant’s proposal and goals (what)

The initial proposal outlined a multi-stage project rooted in equity and social justice. In order to facilitate the accomplishment of this underpinning goal throughout the project process and within all report products, the PHSKC planned to work closely with two community-based partners including them in their multidisciplinary planning group, the Climate Health Action Team (CHAT).

Goals and Objectives

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The overarching goal of the PHSKC Learning Collaborative project was to integrate climate and health considerations throughout Public Health, acknowledging the intersections of climate change, health and equity, and reflecting the, concerns and priorities of Public Health, their partners, and the local community. The sub-goals identified to reach the overarching goal involved the development of an internal and external engagement process, development of an agency climate change and health blueprint, and dissemination of the blueprint broadly to raise awareness and increase understanding of climate change and health.

Duration of Participation

PHSKC participated in the learning collaborative for 24 months (January 1, 2016 to December 15, 2017).

Staffing/ Organizational Chart

Staffing support included part-time in-kind efforts from two program managers. The proposal also included two University of Washington Community Oriented Public Health Practice MPH students to help support key grant deliverables.

Table V-E1. Objectives of the King Climate and Health Project Scope of Work October 2015 Scope of Work (January 2016 – June 2017) 1. Implement an engagement process with both internal (King County agencies’ leadership and staff) and external (community based organization and community leaders) stakeholders that solicits input and creates ownership 1.1. Integrate two subject matter experts (SME) or community based organizations (CBO) into the Climate Health Action Team (CHAT) structure and regular planning meetings 1.2. Conduct key information interviews of agency leadership and environmental justice CBOs 1.3. Survey development and implementation- agency staff and community partners 1.4. Conduct a literature review and review of existing data (e.g. health indicators) on climate change and health within the agency 2. Draft, vet, and finalize an agency climate change and health framework that incorporates stakeholders’ feedback 2.1. Compile findings from Objective 1 to inform agency framework approach 2.2. Engage SME/CBOs with the CHAT development of the draft framework 2.3. Re-engage internal and external key informants to vet draft framework 2.4. Finalize framework /strategic plan and obtain agency approval/authorization 3. Raise awareness and increase understanding about climate change and health, and to share the framework broadly with organizational and community partners 3.1. Develop a communication strategy for identifying key messages, and broadly disseminating project findings and information 3.2. Identify and translate key messages from Objective 1 findings and Objective 2 framework

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3.3. Develop materials to share project findings, framework, and next steps to agency staff and community partners 3.4. Deliver project findings (including framework) alongside evidence-based climate change/health information into replicable presentation or briefing for Public Health staff 3.5. Deliver project findings (including framework) alongside evidence-based climate change/health information into replicable presentation or briefing for community partners 3.6. Improve training based on feedback from internal and external audiences 3.7. Share or make training available to local, state, regional, and national Public Health partners Project Extension (July 2017- December 2017) 1. Development of health-focused decision-making tool for use when developing local climate-related plans and actions 2. Development of curriculum for PHSKC staff on climate change impacts on human health, how to communicate about climate change, and how programs and projects will be impacted

3. Description of applicant’s proposed objectives and activities

Climate Health Action Team (CHAT)

The Climate Health Action Team is composed of staff from Preparedness, Communications, Chronic Disease & Injury Prevention, and Environmental Health Services. Throughout the duration of this project the CHAT team engaged with King County’s Climate Core Team and two climate justice advisors: Puget Sound Sage and Got Green. CHAT was critical in the development of interview and focus group guides, surveys and provided feedback on the first draft of the Blueprint. In the second extension period CHAT will develop materials to disseminate the findings of the Blueprint to share with diverse stakeholders. Additionally, the CHAT climate and health training subcommittee will review and edit the training curriculum based on the diverse teams that will be trained across King County agencies.

Interviews & Survey – Internal and External

In order to inform the development of the climate change and health framework (Blueprint for Addressing Climate Change and Health 134, and assess the baseline understanding and perceptions of climate change and health within PHSKC, the project team interviewed 19 individuals on the Public Health’s Executive Team.

The PHSKC project team also conducted interviews with the leaders and staff of community based organizations from areas that serve at-risk communities, and conducted two focus groups at community-based gatherings, with approximately 20 participants each. The interviews and focus groups informed the development of online surveys, which were distributed to secure input and perspective from a wider audience. One survey was developed to gather input from internal stakeholders, the PHSKC staff,

155 and one survey was developed to gather perspective from an external audience, community stakeholders.

Several key themes emerged from the internal and external engagement process: • Knowledge: Overall, community members and PHSKC staff are aware of and concerned about climate change and believe it poses current and future risks to the health of residents, especially to certain groups at higher risk. However, there is a general lack of knowledge about expected and specific impacts to health • Priority: For community leaders, the priority of climate change and its impacts on health was generally lower than other issues. The most significant health issue of concern was the affordability and the quality of housing for the community. • Roles and Actions: There was belief that PHSKC should take action and play a leadership role in climate change impacts on health. Additionally, the PHSKC role in climate change needs to be strongly based on data and evidence and integrated into existing functions, programs and strengths, such as communication systems, connection to community, and role in policy development. • Equity: There is a need to maintain a cross-cutting approach to climate change work, similar to the county’s commitment and approach to Equity and Social Justice, focusing on social determinants of health, at-risk populations, health in all policies, and increasing preparedness and resiliency. • Collaboration: Community representation and engagement are essential; and often do not feel connected to or included in county agency decision-making and processes.

The interviews, focus groups, and surveys were critical in the development of the Blueprint for Addressing Climate Change and Health, described below.

Blueprint for Addressing Climate Change and Health

Through continuous engagement with the CHAT team and other internal and external partners, the PHSKC project team developed a Blueprint for Addressing Climate Change and Health, Public Health- Seattle & King County. The central goal of the Blueprint is to “build organizational capacity to address climate change and health with equity as an overarching consideration” (Blueprint, PHSKC). The Blueprint outlines essential Public Health functions and strategies to increase internal capacity, identify gaps and existing opportunities, and determine points for climate change integration into existing public health programs and areas of expertise. The Blueprint provides an overview of climate change and climate resilience, followed by a more in-depth review of climate impacts in the Puget Sound Region. The Blueprint outlines four guiding principles for PHSKC to use when planning and implementing climate change work:

1. Lead with Environmental Justice and Racial Equity: In order to prepare King County communities for the impacts of climate change, structural inequities that create and exacerbate climate vulnerability, and other vulnerabilities, must be addressed

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2. Promote a Health in All Policies approach: This approach is used across sectors to systematically take into account the health implications of decisions, seek synergies, and avoid harmful health impacts, in order to improve population health and health equity. 3. Use systems-thinking: Planning for adaptation and mitigation of climate change is complex and requires multiple, interdependent systems and organization to work together toward common goals. 4. Engage community in an inclusive, equitable way: Beginning with community ensures that the issues impacting them are identified and prioritized and that the community becomes the decision-maker rather than the sounding board, as climate science should be combined with community experience and expertise.

The Blueprint also includes key strategies rooted in the six core functions of public health.

Core Functions Key Strategies 1. Leadership and 1.1 Build climate and health literacy among Public Health and Organizational other King County agency leaders and employees Capacity 1.2 Build capacity to integrate climate change into Public Health and King County programs 1.3 Develop Public Health leadership at the local, regional and national levels 2. Assessment, 2.1 Prioritize and track key climate and health indicators and data Surveillance and 2.2 Expand the use of surveillance of climate related health effects Research to provide timely information for Public Health action 2.3 Encourage and participate in practical and applicable research related to climate and health 3. Listen and 3.1 Collaborate with partners through ongoing opportunities for Educate information sharing that guides climate and health message development 3.2 Collaborate with partners to develop key messaging that addresses identified gaps in climate and health knowledge 3.3 Disseminate and exchange climate and health information with communities 4. Community 4.1 Engage in climate and health planning that maximizes Partnership community ownership and promotes problem solving and Development collective action and Capacity 4.2 Emphasize community resilience in Public Health partnerships Building that integrates climate change adaptation and mitigation and all-hazards preparedness 5. Preparedness 5.1 Build capacity to effectively prepare for and respond to and Response climate-related health emergencies 5.2 Incorporate climate projections into hazard mitigation and public health preparedness planning 6. Policy, Planning 6.1 Include climate and health considerations in policies and plans and Advocacy at the local, regional and national level

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6.2 Advocate for climate-related policies and planning that promote equity and improve health

The Blueprint has been presented to and reviewed by the Public Health Executive Team and the King County Climate Leadership Team. CHAT is in the process of developing materials in alignment with the Blueprint that can be used in the dissemination of the findings and recommendations to diverse stakeholders.

4. LHD capacity building

The PHSKC project team built health department capacity around climate change and health in several critical ways. The Climate Health Action Team includes staff from Preparedness, Communications, Chronic Disease & Injury Prevention, and Environmental Health Services, and has been described by project staff as a cohesive group committed to continuing climate and health work rooted in equity and social justice. Engagement with the Public Health Executive Team over the past two years has served to elevate the issue of climate change across the department, facilitating greater understanding of the health impacts of climate change, climate related-health impacts across department divisions, and potential points for integration of climate change programming into existing programs. The project team has presented to the Executive Team on numerous occasions to share project updates and the Blueprint document. While there is some leadership support, PHSKC is experiencing considerable funding challenges in a variety of programming; climate and health work may not rise to the top of the priority list in the next biennial budget cycle of 2019-2020.

5. Disadvantaged populations and health equity

The PHSKC project team included equity and social justice considerations at nearly every step of the project over the past two years. Knowing that certain populations are and will continue to be disproportionately impacted by climate change, CHAT and the PHSKC project team built community engagement directly into the project process. Climate Justice Partners, Puget Sound Sage, and Got Green, were invited to and included in all CHAT meetings, helped develop and review project materials, such as interview guides and surveys, and provided feedback on the Blueprint to ensure community priorities were accurately represented in the document.

Additionally, a primary focus of the Blueprint is on building community resilience through climate resilience, and PHSKC will implement climate solutions and strategies that promote equity and improve health outcomes. As described above, the Blueprint also includes four guiding principles for PHSKC to use when planning and implementing climate change work; 1) lead with environmental justice and racial equity, 2) promote health in all policies, 3) use systems-thinking, and 4) engage community in an inclusive and equitable way. PHSKC’s continuous engagement with community groups through

158 built-in processes that prioritize community-led solutions will ensure that climate change work in King County continues with an equity and justice framework.

6. Integration of climate change into health department programs/communications

The Climate Health Action Team typically met 1-2 times per month to share project updates, work on shared deliverables, and discuss climate and heath work within PHSKC. CHAT consistently had representation from 3 PHSKC divisions and would provide meeting notes to those that were unable to attend meetings. While the PHSKC project team would like to see greater representation from PHSKC divisions, CHAT has evolved into a cohesive and productive work team. Once the final Blueprint document is completed and shared across PHSKC, this will provide further basis and impetus to integrate climate change into other health department programs and communications.

CHAT also plans to develop a budget request and justification for the department, and possible the Climate Leadership Team, to consider during the next biennium budget, which if accepted would significant enhance PHSKC’s ability to proactively and consistently engage in climate and health work across the department. Although it is a difficult time to receive new funds not designated for specific work (e.g. grants, contracts), bringing a proposal will at least continue to elevate the need to address climate change and health.

7. Significant challenges, unanticipated opportunities, and changes to proposed plan Challenges

The project experienced delays in scheduling interviews due to scheduling conflicts, however the PHSKC project team was able to conduct all of the interviews. Some PHSKC leadership initially held opinions that climate change, while important, was not one of the pressing issues that the public health department needed to respond to in the immediate term. There were also concerns from PHSKC leadership that climate information was not previously translated well for particular vulnerable communities or those outside mainstream circles. The PHSKC worked to address these concerns by actively engaging with climate justice groups, Puget Sound Sage and Got Green, as well as numerous other community-based groups through focus groups and surveys to determine community perceptions and priorities. In March 2017, one of the community partners (Got Green) withdrew due to capacity limitations.

Unanticipated opportunities

Continuous engagement with the Climate Leadership Team (CLT) and the preliminary drafts of the Blueprint resulted in additional funding from the CLT to adapt the PHSKC Climate & Health trainings to county-wide trainings. The PHSKC project team was so successful in demonstrating the climate and health connection to existing public health programs and other county agencies that the CLT unanimously voted to fund Public Health’s request to facilitate cross-departmental trainings and discussion groups, with the hope that some clear actions will move forward on behalf on the groups.

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8. Assessment of meeting goals

Administrative Data

The PHSKC LC team met all of the major goals outlined in its scope of work and developed all of the described deliverables. The project team continuously engaged CHAT in the development of the Blueprint, interviewed and surveyed internal and external partners to assess climate and health knowledge, priority actions, and PHSKC action, and developed a curriculum for PHSKC staff.

Self-assessment Questionnaire

The PHSKC project team indicated that participating in the Learning Collaborative, along with the financial support provided, helped legitimize public health engagement on climate change and contributed to other King County stakeholders and PHSKC leadership’s recognition that public health is an important partner in this work. Additionally, this project galvanized CHAT as a cohesive group committed to continuing to work on climate change and health. The momentum this project generated afforded PHSKC a seat at some of the larger climate resilience tables, including the 100 Resilient Cities project.

Key Informant Interview

We interviewed the King County Climate Engagement Specialist and the Division Director for Environmental Public Health Services. Interviewees indicated that this project elevated the issue of climate change, particularly with the Public Health Executive Team, clearly demonstrating the critical connections between climate change, health, and existing PHSKC divisions. The respondents also described the challenges of effectively engaging in this work, particularly conveying the urgency of this work, at a funding level that did not allow for a full-time staff person dedicated to climate and health work.

Section References

125. US Census Bureau. Community Facts: King County, Washington. Washington, DC: US Census Bureau; 2010.https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk 126. AOL News. America’s Most Diverse ZIP Code Shows the Way; 2010.http://www.aolnews.com/2010/03/25/opinion-americas-most-diverse-zip-code-shows- the-way/ 127. The New York Times. Remade in America. Diversity in the Classroom. New York, NY: The New York Times.http://projects.nytimes.com/immigration/enrollment 128. Seattle Times. Seattle’s Rainier Valley, One of America’s Dynamic Neighborhoods. Real Estate Section. Seattle, WA: The Seattle Times;

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2010.https://www.seattletimes.com/opinion/seattles-rainier-valley-one-of-americas-dynamic- neighborhoods/ 129. King County City Council. King County Adopted Budget: Public Health. King County, WA; 2017.http://www.kingcounty.gov/~/media/Council/documents/Budget/2017-18/2017-2018- Adopted-Budget-Book.ashx?la=en 130. King County Hospitals for a Healthier Community. King Country Community Health Needs Assessment. Seattle, WA: King County Hospitals for a Healthier Community; 2016.https://www.kingcounty.gov/depts/health/data/community-health- indicators/~/media/depts/health/data/documents/2015-2016-Joint-CHNA-Report- Summary.ashx 131. Climate Impacts Group. Washington Climate Change Impacts Assessment and State of Knowledge Report - Climate Change Impacts and Adaptation in Washington State: Technical Summaries for Decision Makers. Seattle, WA: University of Washington; 2009. 132. King County. King County Strategic Climate Action Plan. Seattle, WA: King County; 2015.http://your.kingcounty.gov/dnrp/climate/documents/2015_King_County_SCAP- Full_Plan.pdf 133. City of Seattle. City Designing Support for Extreme Heat Events. Seattle, WA: Seattle.gov Greenspace Blog; 2015.http://greenspace.seattle.gov/2015/11/city-designing-support-for- extreme-heat-events/#sthash.1EuMso0S.dpbs 134. Climate and Health Action Team. Blueprint for Addressing Climate Change and Health, Public Health - Seattle & King County (Draft). Seattle, WA: Public Health – Seattle & King County; 2017.

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Appendix A. Integrating Climate and Health into Local Health Department Programs, Final Meeting "World Café" Program Area What Would the Integration Look Like and How Would you Pitch It to the Other Programs? Maternal, Child Health • WIC: discuss locally sourced food, transportation, emissions, farmers markets at clinics • Public Health Nursing (PHN) → home visiting home assessment for heat, vectors, adaptation, energy cost → no heat → co-sleeping risks, pregnancy support services **referral to Environmental Health (EH) • Best-Beginning Program/Children First Program • Child care center program: PHN visits/assessments ■ CEU’s for child care providers • Lead testing/home visits, referrals to weatherization program • Public Health Childcare Consultations ■ Curriculum on nutrition, physical activity, climate change ■ Referral and school garden • Surveillance (collaborative and Epi) on low birth weight, pre-term births, link to displacement • Healthy Start - outreach to HUD ■ Speak/educate about climate change and health ■ Ed materials, etc. ■ Impetus: Zika- EH draft, HS disseminated *** Pitch: Long-term health effects, especially for infants and kids ■ Zika and VB disease ■ Air quality • Asthma homecare is situated in MCH for some jurisdictions ■ Interested in housing quality, which is also a climate change vulnerability *** Pitch - you’re already working on cc/health issues, going to get worse → primary prevention ■ code enforcement and individual care: getting stories → assessments, policy change • make sure they know what you’re doing, your capabilities • Child refugee health/behavioral health ■ Psychological first aid - extreme events, natural disasters

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• Sports/recreation- outreach/education/standard operating procedures for air quality, heat waves • Immunizations → educational opportunity • Pediatrics/Obstetrics education on climate change and /health (e.g., Zika education) ■ Air quality, heat, extreme weather, Zika • Outreach → healthcare for the homeless • MCH in Community Health Clinics → education, assessments ■ Unnecessary testing, medical waste, and cost sharing • Challenges ■ Conflicting messages → HEAL and air quality ■ Need to link data back to climate change to give more accurate guidance ■ What is the value add to including climate change in programs without funding • Climate change program could find funding to support integration ■ Unstable funding for programs → how to sustain integrated efforts ■ Many programs are grant funded- very prescribed program focus and deliverables ■ Ensuring logical/effective processes and referrals between programs • e.g. home visit assessments to weatherization ■ Information/materials sharing • Tension around relationship guarding, information vetting; but not enough capacity to fully integrate - maybe offer to do first draft • Approach ■ How does climate change impact kids and families so I can advocate for change/policy change? Tell me your impacts—issues of asthma, obesity, air quality, for example ■ Integrate efforts at funding opportunities

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Appendix A. Integrating Climate and Health into Local Health Department Programs (continued) Program Area What Would the Integration Look Like and How Would you Pitch It to the Other Programs? Health Policy ■ Outside Agencies • Housing and rainwater • Public works- utility shutoff ■ Heat • Public trail closure at certain temp • Epi data to support • Schools/recess/and temperature ■ Schools and Parks/Recreation ■ Plans for big events ■ Board of Commissioners ■ State Policy • Legislative affairs unit • Bill review/public comment period ■ Health Policy Office (AZ) ■ Antiquated Policies (OK) *** Pitch: • Comprehensive plan • Piggyback on things already being done • Help people see health angle of actions (e.g. bike lanes) • Save $ • “It’s all about the kids” • Hot button issue/political opportunity du jour • Scope and scale of issue and whether policy can address • States have a role in addressing climate change ■ What would it look like? • Be more proactive in engaging in policy decisions

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• Competition (e.g. fewest ozone days) • Policy platform • See Boulder (Streamlines approval) • Clear generic statements before policy becomes an issue ■ No fossil fuels for transportation by 2050 • Localized solutions • Employee incentives- transit passes, car pool (but also extend to temps) • Internal policies and procedures • Staff climate education • Add health lens to climate policy efforts • Health impact assessment for climate related actions/industry decisions • Translate research to policy ■ Attention to food safety and security ■ Challenges • Staff capacity • Political perceptions/actual political enviro • Management blessing • Resilience policies are cross-sectional • Funding • Competing priorities • Uniform policy would limit innovation

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Appendix A. Integrating Climate and Health into Local Health Department Programs (continued) Program Area What Would the Integration Look Like and How Would you Pitch It to the Other Programs? Chronic Disease/ ■ Diabetes/asthma clinics focus Physical Activity/ • Talk to patients regarding relevant information Nutrition • Link to strategies to impact environment ■ Heat • Air quality • Domestic violence • Crime ■ Food prices - insecurity- affordable fruit/vegetables - produce to preschools • Local food (sustainability goal) ■ Active transportation/safe places for physical activity ■ Driving short distances • Air quality • GHG • Physical activity ■ Action groups - asthma coalition, obesity coalition • Staff education modules/ppt • FitNOLA ■ Need a tool for programs to integrate information ■ Worksite wellness • Active transport subsidy • Community garden ■ Social media - “get healthy”, “move”- integrate heat into campaign (e.g. “Active Philly”) • Be active in high heat • Indoor activity • Bike safety ■ Air Quality Index - what to do?

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■ Heat/AQ messaging- DM, asthma, CVD—give the connecting message!!! ■ Joint advocacy for policy: reduce VMT/parks/transit • Meat consumption → meatless Mondays • Meat - ag practices to grow corn for meat vs. growing food ■ Thinking about individual behavior change/message vs. more upstream intervention ■ Prevention co-benefits • Primary and secondary → upstream interventions • Primary, secondary messages with different stakeholders ■ Integrate messaging with vulnerable populations • Adaptation and mitigation as primary prevention ■ Mental health and chronic disease • Injury prevention ■ Drowning • Heat vs exercise ■ Package info from PH/clients to tell personal stories for elected/policy—stories make it personal • E.g. DM-heat-what happens to clients? ■ Connections to planning, schools (Catholic Diocese) • Advocacy for health environments and climate co-benefits ■ Algal blooms increasing, brain parasite H2O ■ De-icing earlier ■ Policy conversation electric vehicles vs. active transport: role of chronic disease to push AT as primary climate strategy ■ Farm to school: increase equity ■ Asthma: focus on decreasing asthma and reduce UHI via physical changes in city • Chronic disease doing bike ■ Take UHI into account • Heat → athletic events ■ School playgrounds - heat

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Appendix A. Integrating Climate and Health into Local Health Department Programs (continued) Program Area What Would the Integration Look Like and How Would you Pitch It to the Other Programs? Infectious/ ■ Zika in the news today- good hook, going into new areas Vector-Borne Disease ■ Vector people know that climate affects vectors/ disease • Show more mosquitoes growing, more people affected • Do lots of data collection even if not reported/ widely shared • Some departments are struggling with funding ■ Communicable disease investigators (RN, Epi, reportable disease) • Already talking to people • Opportunity for messaging ■ Connect with the public- mosquito prevalence connection to cc- earlier discussion with public (Tulsa) ■ Using vector/disease dept.- voice to influence policy/advocacy platform • Upfront regarding what can be advanced ■ NOLA mosquito/vector control dept. has funding • Working with PH department ■ Struggles with dept. not releasing data- “don’t want people to be scared/ attract undue attention ■ Convincing people this is a big issue even though not dying from specific (global) diseases now ■ Include talk regarding climate change in pamphlets/reading that they already distribute • Food security and food safety ■ Talking to agriculture regarding climate change ■ People are worried about the immediate effects of other issues and of cc • Need to give info to food workers/migrant workers ■ Expand resources on helping people start gardens to include info on vectors, disease, water • Connections to water dept.- warnings in bill/info ■ Look at data (vector dept.) to find patterns • Use to make changes/monitor • Mosquito data- sensitive • Opportunity to broaden scope of data

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• Public land survey data/info • Giving data to epi and sharing with public • Making message consistent across vector/mosquito control and DPH ■ Specific funding requires specific messaging ■ Upstream vs. downstream messaging around treatment vs. training of families to prevent ■ Infectious disease and flooding • Vectors- ticks, new and emerging viruses ■ Vector issues seen as far away/localized elsewhere ■ Issue of immediacy • Disease spread based on environmental change- clear to people who work within the field • Important to plan 5-10 years out, including analysis on very localized pop density • Understanding changes in water flow (dams-predictable) • Projections of v-b diseases alongside climate projections → question of capability ■ Challenge regarding getting localized data • Encourage partnership with local research institutes- look past 2050 (next gen)

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Appendix A. Integrating Climate and Health into Local Health Department Programs (continued) Program Area What Would the Integration Look Like and How Would you Pitch It to the Other Programs? Environmental Health ■ Internal practices • Reduce HD carbon footprint by consolidating inspections/reducing VMT of EH ■ Relevant program areas within EH with potential for cc integration- key strategy is to find the linkages and make a strong connection → then share the resources • Food inspections • Food waste diversion • Food-borne illnesses and food safety • Air quality • Anti-idling efforts- post signage about air pollution, health and cc • Burn day permitting- wildfire risk mitigation ■ Opportunity to talk with people about air quality/ cc/ ozone alert day • Hazardous waste • Lead and housing inspections • Expand lead abatement efforts/housing inspections to include heat/cooling systems- to address other cc vulnerabilities like extreme heat/weather, vectors, mold, etc. • Look at the shared vulnerable populations- those exposed to lead are also more likely to be the same populations that are also more vulnerable to the health impacts of cc • Water quality/use • Re-use • Waste-water treatment • EH can partner with a CBO to provide information to low-income populations with solutions to help reduce water use and save money (e.g. 2L soda bottle full of rocks results in a low- flow toilet) • SLR and storm water infrastructure- this is a near term threat to health and equity- more strategies for adaptation- increasing storm water capacity- improving infrastructure • Food systems- reducing meat consumption • This may require partnership with another group/agency to • Confined Agricultural Feed Operations (CAFO) - the associated environmental impacts/contamination/health impacts/QOL

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■ Manure pits- need to be regulated to trap the methane- then there is the potential to trap this methane and put towards more sustainable energy solutions • Own/Operate land fill in some jurisdiction • Frame methane capture as a $ opportunity ■ Dual role of EH- regulated and non-regulated • Non-regulated are already largely on board with the cc issues- need to get regulated on board and involved where they can be particularly impactful- have them take on the educator role more fully *** Pitch- natural extension of your current- need to integrate cc into your programming for future health and sustainability- key leverage point as EH are regulators/code enforcement/ have the ability to push for changes in the code to support adaptation/mitigation strategies • Need to assess the newest, most efficient technologies/standards they should be supporting in terms of energy systems/cooling systems/housing code etc. ■ Green and Healthy Homes • Need to ensure the HD is not the barrier to improved methods/adaptation/mitigation strategies • Need to think about the rights of businesses to infringe on the health/ rights of individuals/communities

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Appendix A. Integrating Climate and Health into Local Health Department Programs (continued) Program Area What Would the Integration Look Like and How Would you Pitch It to the Other Programs? Epidemiology/ ■ Basic usefulness of epidemiology- increase visibility of epi’s role Surveillance/ ■ Have grant money and links to other modeling efforts Community Health • Grant writing for new money and provide data Assessment ■ Epi needed to predict disease occurrence in new setting ■ Linking health impacts (asthma) ■ Reframing existing indicators as climate indicators ■ Epi program surveillance/ monitoring role (essential PH function) • Need epi data to respond to community ■ Extend existing data collection • Need baseline to know how things have progressed ■ Academic cutting edge topic ■ Use epi for better policy and operations • Epi data can be persuasive in communications ■ Feedback between mitigation efforts and health impacts/ co-benefits/political support ■ Looks like reporting/packaging with CC frame • Expanded tracking and reporting • Creating climate change data tracking ■ Liaison role of established epi division to collaborate with other data centers (programs) • Horizontal integration ■ New epi person/intern • Climate, Health, Equity in all Policies epi function • Grand rounds on climate change • Joint presentations ■ Responsiveness to request for CCCH information