4

Reducing Risk and Improving Disaster Recovery

Many workshop participants shared examples from their experience assisting with disaster response recovery, and rebuilding efforts in the Gulf region. Their remarks illustrated some opportunities for preventing and mitigating health impacts of disasters and underscored the importance of having baseline information about the health of communities. This information, combined with a greater understanding of the broader, social factors that affect health and well-being, provides an important basis for effectively responding to disasters, assessing health effects and mitigation strategies, and improving the health equity and resilience of communities. Their comments also identified some possible avenues for research or capacity building that could contribute to recovery and resilience.

ASSESSING POSTDISASTER HEALTH IMPACTS

Jennifer Horney, an associate professor of epidemiology and biostatistics at the Texas A&M University Health Science Center School of Public Health and the Hazard Reduction & Recovery Center, has worked on a team of public health practitioners that has responded to several hurricanes, including Katrina. The team used the Community Assessment for Public Health Emergency Response (CASPER) rapid needs assessment toolkit to collect data on disaster impacts, determine public health needs, better understand resident perception of various risks, and help make decisions around evacuation.

In describing lessons learned from these experiences, Horney said it is difficult to measure the long-

term effects of disasters because there are few ongoing or nationally representative cohorts, and because the potential number of affected respondents is typically small. “Generalizing from one disaster to the other is difficult,” she added. In Texas, she said, “Port Isabel is not going to be the same as Galveston. And we cannot do a study in one of those places and expect it to carry it over to the other.”

Funding for disaster research is almost exclusively focused on case studies of single disasters, she noted, which has precluded the ability to monitor change over time. Although different studies may use certain common measurements, researchers like to ask their own questions, so “there’s little opportunity for us to look across studies.”

Another point is that the United States has an amalgam of public and private data systems, which makes it difficult to track injuries or cases of disease and determine whether they are attributable to a specific disaster. If a food-borne disease outbreak happens, for example, can researchers determine if it actually was associated with something that occurred after a disaster, or are postdisaster and routine public health surveillance linked in the ways that they need to be in order to uncover these types of events?

Horney described a few opportunities for developing better baseline information to assess recovery and resilience. Various projects are under way to create indices and metrics that measure the quality and completeness of disaster recovery. For instance, as part of the President’s Climate Action Plan, NOAA and other agencies are making new efforts to catalogue pilot-tested resources, indicators, and metrics. NOAA, for example, is developing a scorecard of existing resilience indices and metrics, including metrics for the quality and completeness of recovery (Dwyer and Horney, 2014; Horney et al., in press). The Department of Homeland Security is documenting existing resilience indices and measurements to better coordinate federal agency climate change adaptation and preparedness efforts. The U.S. Department of Housing and Urban Development, as part of the activities taking place in its Hurricane Sandy Project Management Office, has developed a Sandy Index of Indicators, which include indicators and data sources related to measuring housing recovery. The Federal Emergency Management Agency (FEMA), in partnership with the Coastal Hazards Center of Excellence at the University of North Carolina at Chapel Hill has developed a checklist of 79 recovery metrics, categorized by Recovery Support Function and Core Capability (Dwyer and Horney, 2014; Horney et al., in press).

A second opportunity is that new funding is becoming available for interdisciplinary research with a particular focus on vulnerability, sustainability, and resilience. In December 2014, the National Science Foundation (NSF) accepted applications for the second round of its interdisciplinary research program in hazards and disasters—known as Hazards SEES¹—which specifically requires real engagement of community stakeholders and partners.² In addition to requiring research that is integrated across disciplines, Hazards SEES research must also be broadly applicable and transferable, and substantively engage stakeholders and community partners “at the early phases of problem identification and definition.” This explicit recognition of the value of so-called ordinary knowledge may bring to light new research questions and planning policy frameworks that are important to address community resilience to future disasters.

Third is an opportunity for investigations based on the recent increase in openly available data, in part due to the Obama Administration’s Open Data Initiatives.³ Nearly 150,000 data sets are freely available at data.gov for research, application development, and other projects. For example, the Centers for Medicare and Medicaid Services have released data on spending, utilization, and quality through their Geographic Variation Public Use File⁴ that allow researchers and policy makers to evaluate geographic variation in the use and quality of health care services. Horney recently analyzed Medicare claims from 2008 to 2012 across the United States at a county level in conjunction with FEMA disaster declarations to look at increases in certain disease and injury outcomes associated with disasters, as well as changes in health system utilization. “We are seeing things like fewer home health visits or more missed rehabilitation care visits in the period after disasters.” This is county level data, she acknowledged, but such research is a start at examining the kinds of health impacts that may arise regardless of the type of disaster or where it happened—impacts that public health systems need to think about in advance to achieve resilience to future disasters, Horney said.

MENTAL HEALTH IMPACTS OF DISASTERS

Psychiatrist and neuropathologist Richard Powers offered a ground-level account of the response to both Katrina and the DWH oil spill. “Katrina taught us a lot,” he said. As Medical Director for the Alabama Department of Mental Health, he received a call from the Alabama governor’s office very early after the hurricane “that there were a couple thousand folks from New Or-

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¹ For more details, see http://www.nsf.gov/funding/pgm_summ.jsp?pims_id=504804&org=NSF;http://www.nsf.gov/pubs/2014/nsf14581/nsf14581.htm.

² See http://www.nsf.gov/pubs/2014/nsf14581/nsf14581.htm.

³ See http://www.whitehouse.gov/open.

⁴ See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-GeographicVariation/GV_PUF.html.

leans sitting in the Birmingham-Jefferson civic center, and would we mind going down there and fixing that problem;” especially for persons with mental illness or intellectual disability. He had to troubleshoot a variety of unanticipated issues, such as how to convince doctors to write pharmaceutical prescriptions for patients for whom there were no medical records available. He and his team confronted a number of challenges, many of which could be planned for in advance, he said. For example, when an urban annihilation event impacts a major urban area such as New Orleans, we can make predictions about the flow of people that are leaving, and where they are likely to run out of gas, he said. Such planning would help health departments to better target their resources during disasters. The prescription of controlled substances, especially narcotics such as methadone pose a unique challenge. Treated individuals may go into withdrawal if unable to receive their maintenance dose or engage in drug-seeking behavior in their host location creating other problems.

The DWH oil spill was not a natural disaster but a slowly evolving industrial disaster, “so people had a chance to get very anxious about what is about to happen.” Maintaining mental health in the affected communities was a challenge, particularly with “different people coming in with their own different agendas,” Powers said, such as lawyers with their scare advertisements and the petroleum industry with their own perspective on the event. In contrast to natural disasters, the oil spill was caused by a preventable mistake, he said, which lent a different quality to those that suffered losses.

Then there were the “agenda scientists,” he said. These are scientists who show up to do research but who “already have in mind what they think they’re going to find” and then make unfiltered pronouncements on CNN. “That has a direct impact on the psyche of the population that you are trying to keep calm, because now they are hearing, ‘Scientists are saying this, or scientists are saying that.’” Statements to the media like “the seafood is poison” or the oil spill is “killing both the tourist and the fishing industry” made his job of maintaining mental health a real challenge, Powers said.

The research literature in PubMed includes few citations on mental health issues related to the DWH oil spill. But Powers believes that enough data exist to demonstrate an increased frequency of depression after the spill. Anxiety disorders certainly increased, and Powers is convinced that the rates of substance abuse also went up after the two disasters (Hurricane Katrina and the DWH oil spill). Galea et al. (2007) reported that 49 percent of New Orleans residents who were impacted by Hurricane Katrina met DSM⁵ criteria for anxiety or depression at six months after the event as opposed to 26 percent in adjacent areas that were not flooded. In the same group, 30 percent met criteria for posttraumatic stress disorder (PTSD) in comparison to 13 percent in the adjacent areas.

The mission of public mental health officers includes preventing suicide, reducing domestic violence, and creating a permissive environment for a community to talk about and seek help for mental health issues, he said. After Hurricane Katrina and the DWH oil spill, the Alabama health department sent out crisis support counselors through a program called Project Rebound.⁶ These counselors were local residents who went into their coastal communities and brought people back in for attention within the established mental health system, which the state then had to ensure was ready to care for them.

Such work legitimized the counselors’ standing within communities, Powers noted, so public health researchers were later able to tap them in assisting with CASPER studies. Thus, efforts like Project Rebound can be an avenue for promoting appropriate research in affected communities.

Powers reported that the BP leadership, including the medical leadership, was reasonable in providing support for Project Rebound. The response from the federal leadership was less helpful.

During the discussion sessions, Powers noted that the recent move toward a minimalistic, small-government approach in many states will mean losing people with technical expertise in disaster response and recovery, he said. For example, Alabama has no current medical director for its mental health department, because it eliminated that position. Down the road, state governments, which are ultimately tasked with dealing with disasters, “are going to lose their ability to have the people online to manage some of these things.”

Furthermore, the public mental health system has become privatized, he said. But the private companies will not have a response infrastructure ready to go like a public system has, and they will not step up to do the job “unless you throw a lot of money at them.” In setting up a capable healthcare workforce to take care of traumatized people after disasters like Hurricane Katrina or the DWH oil spill, he said, the peer review literature says that the most effective mental health interventions are cognitive processing therapy and exposure therapy. However, both treatments are very time intensive. That raises important questions: How much of a workforce to deliver those therapies will be present and in reserve in a community? What kind of public health programs will agencies need to try to minimize morbidity?

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⁵ The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States.

⁶ See www.projectrebound.org for more information.

Finally, he encouraged the Gulf Research Program to engage the Veterans Health Administration and the Department of Defense, which are organizations with “tremendous experience with resiliency, trauma management, and toxicology.”

LINKING COMMUNITY RECOVERY AND RESILIENCE

Eight years ago, Angela Grajeda began working in the Gulf region as a member of the American Red Cross’s recovery team helping communities rebuild after Hurricane Katrina. Now she is disaster program manager for the charity’s south Mississippi chapter. Her experience includes working on a Red Cross pilot program working to strengthen the resilience of communities along the Gulf Coast in Mississippi and New Orleans, as well as in Miami.

In the aftermath of disasters, the “mental health concerns of the community are huge, but we also need to make sure that we are taking care of the responders,” she said. These are individuals on the front lines of disasters who see the dead bodies and other devastating impacts of a disaster, but their mental health issues are not routinely addressed. “Compassion fatigue” can also set in among recovery workers who often hold communities together during the recovery period. These workers can become overwhelmed by the many surrounding, tragic stories of loss, said Grajeda. “As they get fatigued in their work, the community network that you have built begins to crumble to some degree.”

Grajeda said it would be ideal to look at how to address these needs ahead of time. For instance, how can a standard be set within the response community that seeking help is acceptable? How can mental health services be made easily available to emergency response managers, so they do not have to leave their workplaces to seek help elsewhere? In addition, emotional fallout from disasters can often occur long after the disaster has passed. How can mental health support be better integrated into the daily life of vulnerable populations, such as children?

During the discussion, Leanne Truehart from the St. Tammany Parish chapter of the National Alliance on Mental Illness noted that a helpful resource is the American Psychiatry Association’s disaster psychiatry committee, which can offer phone support to local mental health providers.

Another often unanticipated effect, Grajeda said, is the stress caused by the influx of volunteer relief workers and emergency funds. Volunteers often rush to help after disasters, but they often do not understand the community and are not well organized. Thus, communities need to plan in advance for volunteer intake centers and for the influx of dollars, she said. A lack of an organized entry point “creates competition among those very resources that are doing the work, and then you get a disjointed recovery process.”

These and other issues have come up as part of the Red Cross’s pilot program to help communities plan for recovery. Many community residents have adapted to periodic natural disasters as a routine part of their lives, she said. Major disasters become part of “a community memory,” and communities “reset” themselves after each natural disaster knowing that whatever they do in response is also a means to prepare for the next event. In its pilot program, the Red Cross takes advantage of this time between disasters to help develop community networks and plans that can guide recovery from the next disaster. Focusing on needs identified by community residents, the program helps the community create a plan for recovery, as well as helps to put that plan into action, she said.

As a final point, Grajeda emphasized that in planning for recovery, it is important to know what a community’s vision is and what it is working toward. That knowledge will allow for recovery to progress more quickly.

During the discussion, Grajeda said that after a disaster, considerable delay tends to happen at the point after the immediate response to a crisis has been taken care of, when people start thinking about planning the recovery. Recognizing this gap, the Louisiana and Mississippi Regional Resilience Network, which she works with, is looking at how to take people who are immediately focused on the recovery phase and “implant” them within the response phase from the start. “One of the things we need to be looking at 10 years down the road is how do we allow the system to breathe properly?” Grajeda said. In a crisis, there is a need for an influx of workers and staff to come into a community to establish and offer a service, but most of those people later leave. The question is how to develop these capacities within the standing community so when a crisis is over, “There’s not a huge void left.”

HEALTH EQUITY AND RESILIENCE

The definition of public health has evolved, noted Eric Baumgartner, a public health physician who is the policy and program planning director for the Louisiana Public Health Institute. Public health has broadened beyond the historical focus on tactical interventions targeting immediate events such as infectious diseases or trauma towards a contemporary understanding that individual and collective health arises from the interplay among broader determinants of health. “Most of what impacts population health is in fact the interactions between people with their environment,” he said. That includes not just the natural and built environment but also the social environment, which influ-

ences “the ability of people in the context of family and neighborhood to achieve their potential [in] health and independence throughout the life continuum.”

As the view has evolved beyond the control of infectious diseases, the public health sector has recognized that many health conditions are mediated by social factors that may call for interventions outside the traditional scope of public health practice. For example, clinicians and health insurers increasingly recognize that clinical care visits alone may not control a diabetic patient’s blood sugar levels; instead, what matters most are the things that happen in that person’s daily life between medical appointments, such as access to nutritious food and safe places to walk or exercise. “That’s a very complex thing to deal with,” Baumgartner said, noting that success stories in community health are commonly led by sectors other than public health, such as urban planning, housing, and transportation.

Many people working in health-related disciplines have come to see the world through the lens of health equity,⁷ which is built upon social justice, he said. Achieving health equity will take deliberate consensus across different sectors and structural change in communities including formal policy changes and shifting cultural norms. Health equity also contributes to resilience because it is “the enduring, underlying nest” or base from which a community could prepare for and rebound from a hurricane or other disaster, he said. Efforts are needed to better connect and align discussions of health equity and community resilience, he said.

With the growing understanding that many factors influence a community’s health, more and more cities across the United States are creating interactive Web-based platforms for “democratized data”⁸ that have been “translated into informational products that communities can consume,” Baumgartner said. In partnership with the Gulf Region Health Outreach Program (GRHOP), the Louisiana Public Health Institute, with funding from the Baton Rouge Area Foundation, is working with central coast communities to build such platforms, which can provide information about major health determinants such as household income and education level as well as data on the environment, economy, education, and transportation issues.

Democratized data platforms could help inform people’s decisions on matters such as whom to elect, how resources should be allocated, and how to deal with economic shocks or hurricanes. In addition, because of the development of open, interactive websites, “There have never been more affordable, easier, actionable ways to democratize data in informational products.”

Information availability and access can also be critical during disasters, Baumgartner observed. Hurricane Katrina affected New Orleans residents differently depending on who they were and what neighborhood they lived in. Many did not leave their neighborhoods because they had unmitigated chronic diseases and did not trust they would be able to get their prescription drugs or medical help if they sought refuge elsewhere. At the same time, many people who fled New Orleans during Katrina “didn’t come back because they didn’t know if their service providers were back,” he said. And, for many that did return, there was no official record about the health services they received while displaced. There are many opportunities to think about how improved access and availability of health information can contribute to health equity and resilience, he said.

Baumgartner summed up his talk with the message that the perspective of health equity can be very instructive, especially in the current era of an unprecedented alignment of health care financing, health care delivery, and public health. Furthermore, when disruptive events such as Hurricane Katrina happen to vulnerable communities, “It does spark a renaissance of civic engagement” that can help drive new policies and allocations of resources to give communities a better chance of moving toward health equity and greater resiliency.

ACCESS AND USE OF HEALTH INFORMATION

Linda McCauley, Emory University, commented that with many communities increasingly engaged in understanding, collecting, and mapping environmental monitoring data, her dream for the next decade is to see communities access and get engaged in their health data so “they get the entire picture that crosses the environmental and health side.”

Eric Baumgartner, Louisiana Public Health Institute, discussed the need to recognize the ongoing “sea change” in the availability of information that can inform complex activities, including community resilience. It is currently possible to electronically obtain health data at the enterprise level (across a health care organization) for a healthcare provider, whereas in the past that information could only be accessed through on-site audits. What still lies ahead is the challenge of getting systems-level data on the services that a patient receives from a multitude of entities, he said. At the same time, health

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⁷ Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment. http://www.cdc.gov/chronicdisease/healthequity.

⁸ Enabling community actors to access data and to use it to build community capacity to effect social change (Treuhaft, 2006).

data collected at the level of small areas—rather than at a large geographic scale—remain scarce, and a deliberate effort is needed to fill that gap to analyze where health disparities really lie. With individual and population health being the sum result of the interplay of factors across various domains of daily life of residents in their natural, built, and social environments, seeing the big “ecological view” will require aggregating and juxtaposing data from different parts of the community picture, not just health care. The emerging digital information interfaces are starting to make that possible, which will help communities plan and act, he said.

Maureen Lichtveld of Tulane University added to the conversation about democratizing data by noting, “It is one thing to put out the data, it is another thing to make the community truly a partner by being able to interpret the data in a way that the data should be interpreted.” While public health experts can talk all they want about engaging communities, she said, it will not happen “if we do not provide all communities with the tools to truly partner.”

Lichtveld mentioned two experiments where that is starting to happen. By using Public Participatory Geographic Information Systems, a community organization in New Orleans has mapped the loss of street lights and traffic lights, and community violence. She and colleagues also are working with the Louisiana Public Health Institute on a unique community-based participatory research training project for community members.

An important piece of how health systems data might help governments or other organizations do a better job is the scale of time and the issue of whether data can be generated in closer to real time, noted Lynn Goldman of George Washington University. Goldman has observed that government delays in making decisions about how to deploy resources—whether in health care, social services, money, or workers—are a source of considerable strain in communities. Some of that delay comes from problems intrinsic to the government process, but some of it has to do with the data, she speculated, noting that this could be a question for potential research into “how to make government work the way we all think it ought to work.”

Finally, Alexandra Nolen, University of Texas Medical Branch, pointed out that over the next three decades, entirely new ways of accessing and using health information are going to develop. “The question becomes not only how do we think about how we could use that information, but how do we intentionally shape the health information data system to better serve planning and response processes?”

HEALTH NEEDS OF COASTAL POPULATIONS

During the discussion, Richard Powers underscored the need to better understand coastal communities. “We have rural health initiatives, but not coastal health initiatives,” he said. “Yet coastal populations are different in many ways. How can we bring a greater attention to these issues, particularly among federal agencies, such as the National Institute of Mental Health and the National Institute of Aging?” Many segments of the coastal populations have a unique life cycle and health care risks. Little is known about the health of workers in the coastal maritime industries such as fishing, the coastal tourism industries such as uninsured seasonal workers in the hospitality industry, and the natural resource extraction industries such as the oil platform workers. The coastal populations are exposed to periodic disasters, and these citizens live with the persistent risk for disaster during the increasingly violent hurricane seasons.

In Powers’ view, along the Gulf coast there are few major academic centers with schools of public health to advocate for research on these populations and conduct the research, if funded. The reliance on outside experts has many problems. Local communities are unlikely to participate in research conducted by unfamiliar organizations. The local academic leadership often views these intrusions as academic opportunism, because the interest of outside organizations rarely extends past the funding life of the grant. Powers suggested that the Gulf Research Program should focus on developing local academic resources and professionals who could engage in ongoing research on medical and environmental issues that affect the coastal citizens.

BREAKOUT DISCUSSION SUMMARY

Summarized below are responses generated by two breakout discussion groups charged with developing suggestions for (1) research and monitoring opportunities that could reduce long term impacts of disasters and strengthen community resilience or (2) opportunities to improve understanding of baseline community health status.

Breakout question: What are some potential opportunities for research and monitoring to reduce long term impacts of disasters and strengthen resilience?

As a summary of the breakout discussion, Bernard Goldstein, University of Pittsburgh, presented the list, below, to all workshop participants. This list summarizes items suggested by individual and multiple participants during the breakout discussion and should not be seen as the consensus recommendations of the workshop participants; nor are they necessarily actions that the Gulf Research Program should undertake:

• Improve understanding of the long-term impacts of disasters and the effectiveness of in-

• terventions to reduce these impacts. This information could guide strategic and collaborative investment in long-term, community interventions (by non-profits and philanthropy organizations); support integrative planning at the community level before disasters; improve capacity to predict and mitigate health impacts.

  • Potential opportunities: Assess the impact of disaster-related policies and programs on communities. This might include mapping policy processes against the actual needs of populations; identifying unintended outcomes; and comparing the impact of different approaches. Qualitative and quantitative assessments would help to demonstrate impact and to make the case for the return on investment (for future investment by philanthropy organizations), identify areas in need of improvement/additional research and provide guidance for future disaster response and recovery. Specific areas to assess:
  • Claims processes (e.g., The Gulf Coast Claims Facility): What are the impacts on the health and well being of residents? Are there opportunities for improvement or other models that could be used?
  • The Vessels of Opportunity program in the Gulf: How did this impact the clean-up effort and communities? How does this compare with the impacts of the fishing vessel response program developed in Alaska?
  • Mental health interventions: What has or has not worked well during and after disasters? What policies and capacity need to be in place before a disaster strikes? How can these approaches be integrated into “all hazards” preparedness?
  • What approaches have “co-benefits” (i.e., they support preparedness and response, but also are good for public health in the absence of disasters). o What factors support sustained attention and focus on resilience? Can approaches with “co-benefits” help to maintain capacity over time? What can we learn from looking at the period between Hurricane Katrina and the DWH?
  • What are the benefits of response activities that involve communities in planning and execution?
• Develop a framework for resilience that will allow researchers to compare impacts—across affected communities and across disaster types. The framework should include social, environmental, economic, and health factors and enable researchers to understand how the recovery and resilience of communities is influenced by pre-existing conditions, such as health and social equity, public understanding of risk, and the built environment, and by pre- and postdisaster interventions.
• Develop models that better capture the harms of disasters for communities. What are the impacts and risks? There are tools and methods for assessing impacts of certain activities, such as those used by the World Bank the and International Monetary Fund to identify potential impacts (including health), evaluating safeguards currently in place, and identifying gaps. This type of assessment is not currently done for oil spills, but why couldn’t a process be developed that could apply these tools before a disaster occurs? This could help guide understanding of what questions should be asked before a disaster occurs. Potential opportunities:
• • A model could be developed and tested against what happened during the DWH and Exxon Valdez spills, then refined based on experiences during future disasters. Such a model could help to define the risks, benefits, and a community’s rate of return from risky activities such as deep water drilling.
  • Put together a team that could respond to and learn from disasters. They would be equipped with a plan for how to study the economic, social, environmental, and health impacts of disasters. One possible model is the Natural Hazards Center at University of Colorado Boulder, but it would need to involve communities. Research is needed to propose models/approaches.
  • The University of Delaware has a Disaster Research Center; The Natural Hazards Research and Information Center at University of Colorado Boulder has archives on the social, economic impacts of disasters. Both of these centers are resources for developing capacity to respond to disasters.
• Develop community capacity:
• • Develop a “reciprocal” disaster response network that allows the exchange of tools, expertise, and information about disaster response and recovery. o Fund non-profits to do integrative planning before disasters, to ensure community needs are identified and can be acted on quickly.
  • Evaluate existing curricula that have been developed around resilience and disaster preparedness topics—what are some opportunities to expand on this work to educate and train a broader community?
  • Support development of training for response workers and others working with communities (e.g., teachers, law enforcement, supervisors) focused on stress management. Improve understanding of who is potentially affected. During the oil spill many people provided support functions (bringing gear, food, etc.) for clean-up work and were potentially exposed to stress and contaminated materials.

• Focus on the incident command structure. Make sure that this structure is robust and that health and resilience issues are on the agenda.

Breakout question: How can the Gulf Research Program improve understanding of baseline health and well-being to improve the recovery and resilience of communities?

As a summary of the breakout discussion, Bernard Goldstein, University of Pittsburgh, presented the list, below, to all workshop participants. This list summarizes items suggested by individual and multiple participants during the breakout discussion and should not be seen as the consensus recommendations of the workshop participants; nor are they necessarily actions that the Gulf Research Program should undertake:

• Develop community risk and resilience profiles: Characterize communities based on the mix of assets and vulnerabilities; information can be used to target combinations of risks versus single issues (e.g., mobility-challenged).
• Identify relevant data sources outside of traditional public health (i.e., beyond standard data collected for health -such as maternal and child health and chronic disease—to housing, neighborhood walkability, nature exposure etc.).
• Capture data at a more granular level: County-level data are often insufficient, how to move to a more granular level, such as census tract data?
• Build upon existing surveys (e.g., Pregnancy Risk Assessment Monitoring System [PRAMS], housing, education): What questions could be added to these tools and how could you validate any new question?
• Strengthen robustness of results through cross validation. Look across resources that use different ways of collecting and looking at information (e.g., the Affordable Care Act required community benefit surveys, Robert Wood Johnson Foundation county level surveys).
• Develop critical network metrics that help us understand resilience, for example, what factors contribute to adaptive capacity? How do we understand how individuals are nested within networks?
• Develop and validate recovery/inter-disaster indicators that can be used to monitor recovery; what interventions need to be deployed and evaluated. (Partner with those working on this after Hurricane Sandy.)
• Develop methods and approaches that would be least burdensome, so that data can be collected during disasters.
• • Explore the use of new technologies to quickly get information that can establish a baseline (e.g., crowd sourcing, and self-reporting data: what is valid what is not; how to use this data). Are there opportunities to use these and other developing technologies to collect data after a disaster to develop a better understanding of community needs and to assess effectiveness of response and recovery?
• Support retrospective studies and modeling to guide thinking about approaches to preparedness, response, and recovery. Does this change by region? By disaster type?