and challenges in these conditions across the Gulf region. Other reports of the National Academies of Sciences, Engineering, and Medicine have been helpful for defining indicators of health and resilience (NASEM, 2012, 2015a,b, 2017, 2018, 2019a,b,c, 2020; NRC, 2006, 2011). Similarly, other scholarship suggests a range of variables that contribute to human health and community resilience, particularly in disaster contexts and in places with climate change-related exposures that typify the Gulf states (Chandra et al., 2011; Colten et al., 2012; Goldstein et al., 2011; NCVHS, 2017).

The literature describes a number of variables related to health and resilience, from local social capital among those associated with the community unit of analysis (Acosta and Chandra, 2013; Klinenberg, 2002); to poor or lacking interactions among and information from public health officials (Ferrar et al., 2013); to the overarching quality and resources characterizing health care providers, insurance, and related capacity across primary, mental and behavioral, and environmental health care needs (AHRQ, 2018; Chandra et al., 2011). Indeed, the extant scholarship provides a plethora of relevant variables. However, the committee also sought to categorize and understand the relationships among these variables to better highlight gaps and challenges in the specific context of the Gulf region.

To this end, the committee approached the task of operationalizing the concept of human health and community resilience in three fundamental ways. First, the committee sought explanation. We attempted to trace the relationships among the various factors that define current health and resilience conditions. We relied on scholarship in public health and resilience to trace the likely determinants of gaps and challenges, as well as the underlying social and environmental contextual factors that might explain those determinants more fundamentally. Each of these three general stages—from underlying historical context, to resulting and evolving determinants of health and resilience within that context, to the resulting manifested health and resilience conditions in the Gulf states—helps define a plausible set of relationships among the variables of interest. This chapter addresses these stages in reverse order, starting with current health and resilience conditions, then examining the social and environmental determinants of those conditions, and ending with a description of the fundamental structural context.

The committee makes an important disclaimer regarding this first approach. Our objective with this strategy is not to produce a conclusive and rigorous causal chain or to test the contribution of any one factor or group of factors to health and resilience outcomes. This causal chain provides a useful framework for reviewing the data for the relevant indicators of health resilience only, and the gaps and challenges demonstrated in the framework are further explored in Chapter 4. The committee does not assume that specific social and environmental factors will produce uniform outcomes across Gulf locations. Rather, we categorize the range of variables of interest in accordance with categories established in the current

scholarship on health determinants for purposes of clarity. The purpose of this approach, then, is to present a network of relationships among these variables that can explain, albeit partially, the current health conditions in the Gulf and that may be unique to the Gulf region. We emphasize that the absence of definitive causal relationships across all social and environmental contextual themes, determinants of health, and health indicators is not cause for limiting decision makers or other actors seeking to improve health and resilience in the Gulf.

Second, the committee sought measurement. While previous reports of the National Academies have identified key themes and issues related to health and resilience, the committee aimed to identify and quantify these conditions more rigorously and explicitly. The committee used the World Health Organization’s interpretation of the relationship between these themes (Figure 3-1). The goal of this approach was to identify the gaps in health and resilience in the Gulf and calculate the scale of challenges in the region. With normalized data for the entire Gulf region, across the Gulf states, and across subgroups within the states, we believe a review of the current values for the variables of interest will illuminate gaps and challenges more clearly. As part of this effort, the committee commissioned a paper that aggregates consistent and normalized health indicators as they are currently available in the public domain (see Appendix C). The discussion in this chapter refers throughout to the quantitative and qualitative data presented in that multidisciplinary paper.

U.S. Department of Health and Human Services’ (HHS’s) Healthy People initiative, have included attempts to normalize health data for areas across the country (NASEM, 2020). Other national sources are available from HHS (including Centers for Disease Control and Prevention [CDC] and the National Institutes of Health), the U.S. Census Bureau, and the Federal Emergency Management Agency (FEMA). On the whole, these data sources focus on a single health condition or issue; are infrequently longitudinal; often are not disaggregated by subgroup, such as race/ethnicity, age, or income; may be self-reported; and/or may not be accessible at a level of granularity that allows for geographic analysis (IOM, 2015b).

There are some international resiliency scales as well, such as the National Resilience Scale (NR-13) and the Children’s Revised Impact of Events Scale (CRIES), which surveys youth to determine the effects of events such as war (Kimhi and Eshel, 2019; Perrin et al., 2005), but these scales, too, are subject to the aforementioned limitations. These limitations constrain the assessment of current health and resilience everywhere, but particularly in the Gulf. The paucity of measures for national disaster resilience in databases focused on children and adolescents is especially problematic since it is during late childhood and adolescence when resiliency becomes a critical component of development.

Availability, Accuracy, and Accessibility of State Health Data

An alternative to nationally comparable data is the data generated by the states themselves that could be normalized in some fashion. Unfortunately, the quality of granular health data within states, and especially the five Gulf states, is generally poor. Some common sources of statewide data are the respective state departments of public health, often through a center for health statistics; Medicaid agencies; hospital data; state departments of education; cancer registries; and law enforcement agencies. The Behavioral Risk Factor Surveillance System (BRFSS), established by CDC in 1984, is the world’s largest ongoing telephone health survey system, tracking health conditions and risk behaviors in the United States annually. It is a state-based system of health surveys that collects information on health risk behaviors, preventive health practices, and health care access related primarily to chronic disease and injury.

For Alabama, the BRFSS is the only available source of timely, accurate data on health-related behaviors. Used by the Alabama Department of Public Health, the BRFSS provides state-specific information about such issues as diabetes, health care access, alcohol use, hypertension, obesity, cancer screening, nutrition and physical activity, tobacco use, and more. Researchers and federal, state, and local health officials use this information to track health risks, identify emerging problems, prevent disease, and

improve treatment. Other states may have different measured public health concerns. Unfortunately, state data are often plagued by some of the same methodological constraints and limitations as those seen in national data, including nonstandard measurement across surveys, different measured objectives per agency, differing definitions, limited access to and engagement of diverse populations, lack of comprehensive measurements of the social determinants of health, inattention to a life-course model and equity, and the inability to perform subgroup analyses. Methodological problems and challenges persist with health data reporting, aggregation, normalizing, and presentation at the federal, state, and local levels (Commonwealth Fund Commission, 2022).

Resilience Measures

Resilience refers to the process of overcoming the negative effects of risk exposure, coping successfully with traumatic experiences, and avoiding the negative trajectories associated with risks (Garmezy et al., 1984; Luthar et al., 2000; Masten and Powell, 2003; Rutter, 1985; Werner, 1992). Key to the concept of resilience is the presence of both risks and promotive factors that either help bring about a positive outcome or reduce or help prevent a negative outcome. Health vulnerabilities are a key factor in the resilience literature, and certain demographic characteristics (including age, particularly youth and the elderly) are of key focus. Resilience theory focuses on risk exposure among adolescents and on understanding healthy development in spite of risk exposure and emphasizes strengths rather than deficits.

The promotive factors that can help youth avoid the negative effects of risks, such as disasters, may be either assets or resources (Beauvais and Oetting, 1999): assets are factors internal to the individual, such as competence, coping skills, and self-efficacy, while resources are external to the individual, such as parental support, adult mentoring, and community organizations that promote positive youth development. The concept of resources emphasizes the social environmental influences on adolescent health and development; helps place resilience theory in an ecological context; and moves away from conceptualizations of resilience as a static, individual trait (Sandler et al., 2003). It also emphasizes that external resources can be a focus of change to help adolescents face risks and prevent negative outcomes.

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¹ A handful of examples in the Gulf have surfaced, for example Communivax (https://www.communivax.org/local-teams).

mechanisms for the translation, distribution, and implementation of the findings of health and resilience research. Plans for the distribution of results need to include directly linking community members, researchers, and relevant policy makers and practitioners to close the loop between the data collection and the policy implications.

To improve and expand the evidence base for health and resilience practices and translate this evidence for practitioners and policy makers, a research agenda specific to disasters and public health emergencies is required in the Gulf. Similar work in other areas include the NASEM Collaborative on Disaster and the National Institutes of Health/National Institute of Environmental Health Sciences Disaster Research Response Program (DR2) Community of Practice.^2,3 Community-engaged partnerships can be used to develop research agendas in advance of a disaster that are relevant to—and prioritized by—community members and local practitioners and emergency public health stakeholders. Identifying urgent, new, and targeted research questions in advance of predictably recurrent events, such as tropical storms, allows communities and researchers to work with funders to develop funding opportunity announcements ahead of such events and expedite research after they occur.

Previous studies have urged the development of a coordinated disaster research agenda nationally (NASEM, 2012), and this is equally an imperative regionally in the Gulf. Other stakeholders include CDC; relevant funding agencies; state, local, tribal, and territorial (SLTT) public health agencies; academic researchers; and professional associations. Their involvement is essential to ensure resourcing, coordination, monitoring, and execution of public- and private-sector disaster resilience research.

In addition to the benefits of stronger, more sustainable relationships and collaborations with impacted communities, assessments of health and community resilience in the Gulf region would be improved through increased primary data collection for that specific purpose. Information used for the assessment of health and community resilience often relies on data developed for other purposes. This use of secondary data can limit both the application and translation of research to the specific circumstances or contexts of affected communities. An increased focus on primary data collection specifically for use in assessing health and community resilience in the Gulf region would be one way to help develop a more complete picture for funders, policy makers, and communities. These data would be most useful if granular enough to support geographic analysis across multiple sectors, including environmental, health, education, justice, economic, and political, mapped to the forms of capital—natural, built, social, financial, human, and political—that enhance resilience.

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² https://www.nationalacademies.org/our-work/the-action-collaborative-on-disaster-research#sectionPastEvents.

³ https://www.niehs.nih.gov/research/programs/disaster/community/index.cfm.

localized, specific information with which to improve their health and resilience. However, such assessments are unique to each community, and do not allow for a comparative understanding of gaps, challenges, and successes across states and the Gulf region. While there may certainly be places and circumstances in which the development of new instruments or tools is warranted, the overall research enterprise benefits if the instruments used to gather data advance a broader understanding. To that end, the greatest benefit can be derived if funders of research on health and community resilience in the Gulf region encourage grantees to make use of a common set of measures, and support investment in new measures only when the gap being filled and the value added by a new measure are clearly identified. Consequently, the committee’s data review is limited to data consistently reported across both the Gulf region and the nation.

INDICATORS OF HEALTH IN THE GULF

Data on the indicators of health in the Gulf and their limitations are summarized in the paper commissioned by the committee (see Appendix C). These data focus primarily on adults, as is the case for much of the data collected during disasters. When one looks at health indicators for specific social and demographic groups, disparities in the Gulf states become apparent that are not demonstrated by the aggregate values. The data indicate that African American and Native populations face worse health conditions in the Gulf than outside of the region, as do low-income households. This section highlights health indicators in the Gulf among adolescents, whose resilience is critical to building and maintaining sustainable, resilient communities. Unfortunately, as with adults in the Gulf, significant health differences are seen among adolescents in the Gulf region compared with the nation (Anderson et al., 2022; Wang et al., 2020).

Today’s adolescents struggle with a wide range of health care needs related to a variety of social, economic, and environmental factors. Adolescents in the southern United States generally have worse health status relative to their counterparts in other regions of the country (Anderson et al., 2022). Additionally, youth from poor, marginalized, rural, and educationally and economically disadvantaged backgrounds experience health inequities that yield poorer overall health compared with youth from better-resourced and more advantaged circumstances (Castro-Ramirez et al., 2021; Heard-Garris et al., 2018, 2021; Liu et al., 2019). The South remains the poorest region of the United States, with Louisiana and Mississippi having the highest poverty rates in the nation (Shrider et al., 2021; USDA, 2022), and teens in the Gulf states have higher rates of such health conditions as obesity, adverse reproductive health outcomes, and unmet mental health care needs (Feiss and Pangelinan, 2021; Thompson et al., 2018; Wang et al., 2020).

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⁴ Data from the 2019–2020 National Survey of Children’s Health interactive data query: Child and Family Health Measures; nationwide and each state for comparison; physical, oral health and functional status; overweight or obese. https://www.childhealthdata.org (accessed December 1, 2022).

(CDC, 2021). While the nation has experienced a decline in teen pregnancies and births, Southern states in the Gulf still have among the highest rates of these outcomes nationwide (HHS, 2022). According to the National Center for Health Statistics, Alabama had the fifth-highest teen birth rate in the country, with Louisiana and Mississippi having the highest (NCHS, 2020).

Forty-six percent of Americans will meet the criteria for a diagnosable mental health condition at some time in their life, and the onset of half of all lifetime cases occurs by age 14 (Kessler et al., 2005). Prior to the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor life outcomes in young people, with one-fifth of adolescents having a diagnosable mental health disorder (Ghandour et al., 2019; Perou et al., 2013). Increases in rates of behavioral problems, anxiety, depression, and suicide were a major concern for adolescents and young adults. In 2019, suicide became the second-leading cause of death for adolescents aged 15–19 (Statista, 2022). According to the 2019 Children’s of Alabama Community Health Needs Assessment and 2020–2022 Implementation Plan, mental health was one of the health issues for adolescents most frequently identified by health care professionals and educators across the state of Alabama (Children’s of Alabama, 2019). In the United States, injuries and deaths caused by firearms among adolescents and young adults surpassed those caused by motor vehicle crashes in 2020 for the first time in history (Goldstick et al., 2022).

With the onset of the COVID-19 pandemic, rates of mental health disorders in the United States increased; symptoms of depression and anxiety doubled for adolescents and young adults during the pandemic (Racine et al., 2021). Emergency room visits for suspected suicide were 50 percent higher for adolescent girls compared with the same period in early 2019 (Yard et al., 2021). The mental health conditions among young people were likely exacerbated by increased stressors and traumatic experiences related to the pandemic, including reduced connections and in-person interactions with friends, social supports, school supports, and community supports, as well as experiences with death and loss, increased race-related violence, political polarization, and gun violence (HHS, 2021). Adolescents most vulnerable to mental health challenges include those living in economically disadvantaged and immigrant households, those experiencing homelessness, those involved in child welfare or juvenile justice systems, those with disabilities, those from racially and ethnically minoritized groups, those identifying as LGBTQ+, and those in rural areas. A study by Reiss (2013) found that, compared with peers of higher socioeconomic status, children and adolescents from socioeconomically disadvantaged areas were two to three times more likely to develop mental health problems.

Relative to their peers, youth who identify as LGBTQ+ are four times more likely to consider suicide, plan for suicide, or attempt suicide. Those who identify as transgender and racially diverse are at even greater risk for mental health concerns, suicide, and high-risk behaviors (e.g., substance

use, self-harm, and sexual risk taking) (Clay, 2018; Reisner et al., 2016; Thoma et al., 2019). The effect of the pandemic on youth likely varies among individuals, but underserved adolescents and young adults, especially those from Black, Indigenous, and people of color (BIPOC) and LGBTQ+ communities, are disproportionately at risk of experiencing increased social isolation, stress, and trauma related to preexisting social determinants of health exacerbated by the pandemic (Salerno et al., 2020). The pandemic’s exacerbation of mental health conditions for adolescents, and for the entire population, makes resiliency in the face of disaster even more challenging.

Adolescents in the Gulf region encounter many geographic and socioeconomic obstacles to receiving medical and mental health care. The Southern region remains the poorest region in the nation. According to the 2021 U.S. census, 15.3 percent of U.S. youth lived in poverty; however, 82.4 percent of all U.S. counties with child poverty rates of 40 percent or more were in the South (Creamer et al., 2022; U.S. Census, 2022a). Adolescents in the South often live in rural and resource-poor areas. In Alabama, for example, 55 of the state’s 67 counties are rural. Individuals living in rural areas typically have limited access to primary care physicians and shorter life expectancies (Alabama Public Health, 2007).

The vast majority of Alabama counties are also medically underserved areas with a significant lack of medical and mental health professionals.⁵ Children in these areas must travel farther for preventive and health services and have fewer options for health care coverage and insurance relative to their counterparts living in other areas. As noted in the commissioned paper, infant and child mortality are also critical factors showing disparities between Gulf states and other regions in the United States. Further, Gulf states that did not expand Medicaid include Alabama, Florida, Mississippi, and Texas; the only Gulf state that did implement Medicaid expansion was Louisiana.

HEALTH DISPARITIES

Although granular data for the Gulf states are not always available, aggregate data for a few groups across the states do exist, and those data point to stark differences between the health characteristics of specific groups and

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⁵ Determined using the Health Resources and Services Administration’s Health Professional Shortage Area tool (searching for dental and mental care in all counties in Alabama). https://data.hrsa.gov/tools/shortage-area/hpsa-find (accessed November 16, 2022).

those of their counterparts outside of the Gulf. Disparities and inequities by race, income, geography (e.g., rurality, coastal, other environmental hazard), and other demographic characteristics may be found, but there are also challenges with data on health disparities and tracking by race/ethnicity, income, and other class or social and demographic groupings. These challenges are particularly problematic with respect to the measurement of race.

DETERMINANTS OF HEALTH AND RESILIENCE IN THE GULF

The current state of individual, household, and community health across the Gulf not only is a challenge to regional resilience but also is symptomatic of gaps in other conditions, systems, and structures. In fact, a preponderance of scholarship over the past half-century has conclusively demonstrated that a range of social and environmental factors can shape health conditions and outcomes as much as if not more than personal or familial epigenetic composition (NASEM, 2016; NRC, 2001; Wilkinson and Marmot, 2003). Once loosely referred to as the social determinants of physical and mental health, the focus of this body of work has been on demonstrating how social structures (such as racism, sexism, and other group-based discrimination) and economic disparities (as reflected in educational attainment, income, and wealth) have shaped a range of biological, behavioral, psychological, and social precursors to disease and poor health (NIMHD, 2017).

In light of this body of work, the committee made a concerted effort to understand the current state of health and resilience in the Gulf through the lens of these social and environmental determinants. The past 2 decades have seen an explosion of frameworks and models for understanding health outcomes through that lens, impelled by the same impetus that motivated the work of this committee: to understand the drivers of health and the disparities therein and to inform guidance for addressing them. A brief review of the evolution of this work is particularly instructive for the committee’s work on the Gulf.

Broad improvements in life expectancies observed with urban planning that enhanced access to clean water, sanitation, and better living conditions have been far more commonly attributed to these environmental factors than to advances in medical care or access during the same period (Grundy, 2005). This perspective does not discount the role of direct medical care and personal epigenetics in health outcomes; rather, a social and environmental determinants approach is inclusive of these more immediate

determinants and allows for a broader view of the factors and pathways that shape health and resilience in the Gulf, as elsewhere.

Research on childhood lead exposure serves as an example of the deepening understanding of the powerful effect of social and environmental determinants on health. Initial work focused on simple associations between disadvantaged neighborhoods with greater lead exposure and anemia (Malik et al., 2022). Later, scholars explored the difference between short causal chains, such as that between lead exposure and anemia, and longer causal chains, such as that between childhood lead exposure and cognitive stunting, educational performance, graduation rates, and thus income (Searle et al., 2014). This work then evolved into studies of latent or later-term consequences, such as the effect of childhood lead exposure on adult health behaviors and mental health (Albores-Garcia et al., 2021). Recent research has even shown that childhood lead exposure may alter the personal epigenetics of the brain, leading to heightened risk for Alzheimer’s dementia (Eid and Zawia, 2016). This progression in scholarship is repeated across an array of social and environmental determinants of health, revealing their powerful influence.

Yet even the relatively straightforward causal pathways between the material environment and health outcomes outlined above have given way to more nuanced and complex understandings of the dynamics that drive differences in health outcomes. These differences are neither simple (more money can purchase better environs and medical care) nor dichotomous (poverty leads to bad health, and lack of poverty allows good health). This scholarship has revealed that a wider array of social factors, such as education, racial marginalization, and lack of social support, equate to the death rate from leading pathophysiological causes of disease, such as heart attack, stroke, and lung cancer (Galea et al., 2011). It has also revealed influences from the home environment, community, and society on various health behaviors, from smoking and alcohol to violence and trauma (Bingenheimer et al., 2005; Pollack et al., 2005).

Exploring these linkages reveals the effect of these social determinants on stress and the resulting allostatic load, leading to adverse health outcomes (McEwen, 2022). Emerging research has pushed the envelope and brought full circle the understanding of the role of social determinants (class, status, social hierarchy, stress) in health, from regulation of stress hormones that affect inflammation and learning; to epigenetics that regulate which genes are expressed or not, influencing immune response; to the telomeres on the ends of chromosomes that protect against damage and are related to life expectancy (Evans et al., 2021; Price et al., 2013).

Finally, the effects of these determinants on health outcomes exist along a gradient, with individuals having greater wealth, education, and/or social status enjoying better health than those in the next group in the economic or social hierarchy and so on, rather than constituting a simple threshold preventing good health (Braveman and Gottlieb, 2014). This observation

suggests a graded relationship whereby differences along these determinants influence health outcomes throughout society and present opportunities to affect health outcomes for all, not just one group, a perspective that accords well with the committee’s mandate.

It is not lost on the committee that these differences in health outcomes are consequences along multifactorial and interacting pathways that are complex and not easily interrogated. Current scholarship has evolved along with these investigations into disparities, probing these causal pathways to reveal the larger conditions, structures, and systems that influence health. These explorations have led to the current frameworks cited above, and grounding this report, that explain social and environmental determinants of health. They encompass the identified structural influences highlighting a socioeconomic and political context that includes governance, macroeconomic, social, and public policies along with cultural and social values that can influence education, employment opportunities, and income and define social position and status, which in turn determine an individual’s material living environment and psychosocial stress, as well as health care quality and access (NASEM, 2016; WHO, 2010).

At the same time, these frameworks necessitate a look at the processes that shape the way public policies and practices are fashioned to create health disparities, which WHO states is a function of the distribution of money, power, and resources (WHO, 2008). Research on health equity has highlighted the historical and current structural roots of these health disparities along causal pathways and the institutional racism that has been codified into various public policies or operationalized in the private sector, from housing discrimination to investments in education (Braveman et al., 2022; Williams and Mohammad, 2009). These dynamics are very much relevant to the Gulf region, as they are to any other region of the United States, and can serve as a valuable way to understand health and resilience among and between populations within the Gulf and in comparison with the broader U.S. population. Given this strong evidence base for understanding the current state of health and resilience in the Gulf through the lens of these social and environmental determinants, the committee sought to review the currently available indicators for these factors.

INDICATORS OF HEALTH DETERMINANTS

It is important to consider several factors when using indicators of social and environmental determinants to make assessments, perform comparative analysis, and track progress. First, the various determinants discussed above often lie outside the typical health and health-related data collected within health systems. Several broad surveys of health data have attempted to include indicators for the social determinants of health as well

(e.g., Dover and Belon, 2019; RAND, 2018; WHO, 2008). Even Healthy People has included a set of determinant variables within the categories of economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context (although these are all measured at the national, aggregate level) (NASEM, 2019c; WHO, 2010). Yet in general, the determinants included in these summaries tend to focus on specific household or group characteristics, which leads to the holders of those characteristics being treated in a potentially negative or positive way that, in turn, leads to their disparate health outcomes. This observation accords with an approach to remedying health disparities that focuses on specifically marginalized or disadvantaged groups, as it considers social position (Penman-Aguilar et al., 2016).

More operationally accurate ways to construct an indicator for a health determinant, however, would be measurement of the context, not the characteristic. For example, measures of equitable employment opportunities, biases in the distribution of health care providers, and the quality and affordability of nutritious food would be more appropriate indicators of causal determinants than would group characteristics that fail to represent these contextual factors. As described above, understanding the structural determinants of health is critical as well, including biases in public policies, institutional racism, and quality of governance.

Piecemeal advances have been made in collecting these indicators, such as indices representing housing discrimination at the community level and a multifactorial index representing relative socioeconomic disadvantage (Fede et al., 2011; Mendez et al., 2011). Unfortunately, many of these indicators are not collected routinely or systematically; in other cases, the only metrics available for measuring them may be poor proxies. Even Healthy People uses voter participation to represent civic engagement; yet, it describes a wide variety of forms of civic engagement that are not well measured (NASEM, 2019c). Moreover, voter turnout would be an inappropriate indicator for the important contextual determinant of inclusive or representative governance.

Additionally, as with the case of Healthy People, individual indicators are often measured at the national, aggregate level. Even when available at the subnational level, the measurements often fall along census tracts or by district or municipal boundaries. These various levels of analysis can be appropriate and useful, given that health determinants operate at multiple levels, an important consideration for analysis (Penman-Aguilar et al., 2016). Yet these nongranular metrics can fail to take account of the dynamics operating at the neighborhood level, impeding decision making. Until measures of contextual and structural determinants are available at multiple actionable levels, assessment and tracking of health and resilience in the Gulf will remain a challenging endeavor necessitating reliance on demographic and aggregate proxy metrics. Demographic disparities reflect

the gaps in—and challenges to—health and resilience that the committee sought to identify for the Gulf region.

Social Determinants

A review of the general demographic composition of the Gulf states from the most recent U.S. census reveals variables that may explain some of the observed health outcomes in the region. In age distribution, the averages among the Gulf states closely mirror the averages of the United Sates in general. These proportions hold true for individual states as well, with the exception of Florida and Texas. Florida has a greater proportion of people over 65, at 20.5 percent, compared with the U.S. average of 16 percent, along with a smaller percentage of youth under 18 (19.9 percent vs. the U.S. average of 22.4 percent). Conversely, Texas has a smaller proportion of people over 65, at 12.5 percent, and a larger percentage of youth, at 34.8 percent. These differences may drive interstate disparities in absolute mortality rates and vulnerability to health hazards, and reflect different family and household compositions.

The average racial and ethnic profile of the Gulf states shows a substantial difference from the U.S. average; wide variations are observed as well among the Gulf states themselves (see Appendix C). Most prominently, the Gulf states, representing the South, have double the proportion of individuals identifying as Black or African American, at 24.4 percent, compared with the U.S. average of 14.3 percent (see Figure 3-3). Mississippi and Louisiana have the greatest proportions of this population—36.6 percent and 31.4 percent, respectively—followed by Alabama, at 26.6 percent. While Florida and Texas hew closer to the U.S. average for this population, they have a far greater proportion of Hispanic- or Latino-identifying individuals—at 26.5 and 39.3 percent, respectively—compared with the U.S. average of 18.2 percent.

Income and wealth, important drivers of health, show significant differences within the Gulf states (Figure 3-4; see Appendix C). Apart from Texas, median household income is nearly 18 percent lower among the Gulf states, at $54,175, compared with the U.S. average of $64,994, with Alabama

at a regional low of only $46,511 (almost 30 percent lower than the U.S. average) (see Appendix C). These differences are seen across gender, even in Texas, where both male and female full-time year-round workers earn about 20 percent less than the U.S. average for their counterparts.

This disparity in income between the Gulf states and the U.S. average is mirrored in the rates of poverty across age groups. Among those under age 18, poverty in the Gulf states averages 23.0 percent, compared with the U.S. average of 17.5 percent. As with Black or African American populations, Mississippi and Louisiana again have the highest proportions of youth poverty, at 27.6 and 26.3 percent, respectively (see Appendix C). On this indicator, Florida and Texas are closer to but still higher than the U.S. average, at 17.5 percent. In the common working age group 18–64, poverty rates follow a similar pattern: 15.1 percent across the Gulf states, and 18.2 percent and 17.4 percent, respectively, in Mississippi and Louisiana, compared with the U.S. average of 12.1 percent. And while poverty rates often flatten out among the elderly, this disparity in poverty is sustained even for those over age 65, for whom the average poverty rate is 11.2 percent, compared with the U.S. average of 9.3 percent. These stark, widely distributed, and sustained disparities affect health outcomes and resilience in the Gulf region.

While differences in employment rates are not as great, they show a similar disparity, with all Gulf states except Texas having a lower rate of employment compared with the U.S. average of 59.6 percent. The rate in Mississippi is lowest, at 52.7 percent, followed closely by Alabama, Louisiana, and Florida at 54, 54.9, and 55 percent, respectively (see Appendix C). These smaller differences can be deceptive, however, as they provide no indication of the quality, security, employer-provided benefits, and earnings of that employment, which are better determinants of health.

Educational attainment remains a poor proxy for educational opportunity and affordability. Still, the extant data on this indicator also reveals disparities between the Gulf states and the U.S. average: the percentage of the population in the Gulf states earning a college degree averages 35.6 percent, compared with the U.S. average of 41.5 percent (see Appendix C). Once again, as with racial makeup and income and earnings, Mississippi and Louisiana have the lowest averages on this indicator, at 32.9 and 31.3 percent, respectively. These disparities are even more pronounced at the bachelor’s and graduate or professional degrees.

As with many indicators, representative metrics on the quality of housing, a hallmark health determinant, are lacking. Nonetheless, median gross monthly rents as a representation of local purchasing power and such market factors as desirability are lower across the Gulf states, except Texas and Florida, at a median of $955, compared with the U.S. median of $1,096, dropping to $789 in Mississippi, $811 in Alabama, and $876 in Louisiana (see Appendix C). The percentage of households without internet shows a similar disparity: 14.6 percent for the United States overall, compared with 18.7 percent across the Gulf states and a high of 23.9 percent in Mississippi.

Latinos fluctuate across the Gulf states on this metric, yet always share a disparity with their White counterparts.

While these metrics are limited, the literature provides evidence showing how health care coverage, access, and quality are compromised in the Gulf states, including the disparities seen within the states. Three of the five states considered in this report (Alabama, Mississippi, and Texas) rank among the bottom ten states for physician density (active physicians per 100,000 population) and in all cases, they are concentrated predominantly in or around urban areas, compounding the deficit of physician coverage for rural and disadvantaged populations (American Association of Medical Colleges, 2021; Machado et al., 2021).

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) reports that four of the five states considered in this report (Alabama, Florida, Mississippi, and Texas) are among the 12 states that have not expanded Medicaid coverage, with high rates of uninsured who would be newly eligible for coverage; Mississippi and Alabama lead this group with 54.2 and 48.2 percent of uninsured, respectively, being potentially eligible for coverage (Rudich et al., 2022). ASPE goes on to report in a brief that three of the five Gulf states considered in this report (Alabama, Florida, and Mississippi) have the highest combination of a high proportion of both Black individuals in the population and uninsured Black individuals, with the other two states (Louisiana and Texas) close behind (see Figure 3-5) (ASPE, 2022). The limited uniform state-specific study of these coverage and quality metrics prevents deeper analysis.

effects (EPA, 2017). For example, the rate of hospitalizations from heat stress has been found to be higher in the Gulf states compared with the United States overall (see Appendix C), and projected temperature increases will presumably exacerbate this health hazard (see Figure 3-11) (First Street Foundation, 2022).

In summary, Gulf communities have experienced environmental health hazards over the past century due to industrial pollution. However, these same areas are likely to experience further environmental hazards from the effects of climate change.

CONTEXTUAL CAUSES OF HEALTH AND RESILIENCE CONDITIONS IN THE GULF

The literature on the role of nonphysiological determinants of health outcomes, such as the social and environmental conditions described above, is consistent and conclusive. Evidence of the significant effects of these

determinants on physical and mental health is overwhelming. Although the causal pathways from these factors to health outcomes is complex and often contextual, that they are as relevant as genetic factors is no longer a subject for debate. Consequently, policies and interventions aimed at improving the state of these determinants—conditions over which health care providers and public health professionals typically have no authority—could be expected to improve health indicators.

Adding to this complexity is a newer body of work exploring the underlying contextual factors that define patterns in the determinants of health (Braveman and Gottlieb, 2014). This work finds that fundamental socioeconomic, political, and sectoral conditions not only inform similarities across health determinants but also, in many cases, inform health outcomes directly. These influences—located upstream of the social and environmental health determinants discussed previously—tend to consist of historical conditions that are variably defined and difficult to measure quantitatively, particularly in places like the Gulf where data on health and its determinants are already limited.

Although more qualitative, these contextual causes are real, and their influence on social and environmental determinants of health and, in turn, their contributions to health outcomes are documented. Thus the committee cannot overlook these causes and their significance for explaining variations in health outcomes between the Gulf and other U.S. regions, as well as disparities in health and resilience across subgroups within the Gulf. They are discussed in this section along three dimensions that mirror in part the resilience categories established in previous reports of the National Academies: socioeconomic, political, and sectoral (NASEM 2016, 2019a).

Socioeconomic and Political Context

Conditions experienced by people in the Gulf vary across demographic groups in three significant ways (see Appendix C). The first and most historically documented of these is the legacy of racism going back to the region’s European colonization, encompassing the displacement of Native nations and transport of enslaved Africans; state-sanctioned racial stratification and segregation after the Civil War; and ongoing disproportionate racial profiles of policy makers in the three branches of government in all five Gulf states. That this racism, particularly anti-Black and anti-Native, has informed social relations and economic opportunity in the Gulf region cannot be denied.

How this phenomenon has played out in each state and in the local jurisdictions within them varies significantly, however. For example, by some indicators, such as racial integration, the states of Texas (3rd) and Florida (16th) rank in the highest quartile of U.S. states, while Alabama (28th), Mississippi (34th), and Louisiana (45th) continue to be among the most racially segregated states (McCann, 2022). Cities and counties

or parishes within these states provide a more nuanced picture. Several places in the Gulf display high racial segregation based solely on spatial distributions; examples include Irving (8th most segregated out of the Gulf’s 119 cities with populations of at least 200,000) and Houston (24th) in Texas; Montgomery (51st) in Alabama; Miami (9th) and Tampa (33rd) in Florida; and New Orleans (23rd) and Baton Rouge (30th) in Louisiana (Othering and Belonging Institute, 2022). Ultimately, the study of race and ethnicity in the Gulf states requires a deep understanding of regional histories and localized demographic patterns. Nonetheless, the overarching pattern of race informing determinants of health is evident.

Second, a similar pattern can be seen in the category of contextual indicators—income disparities. In the case of this indicator, Florida and Texas display worse Gini coefficients than those of Alabama, Louisiana, and Mississippi—that is, the difference in average income between the top 1 percent and bottom 99 percent of households is larger (Economic Policy Institute, 2016). Several cities in the region show even greater disparities because of their wealth concentration and diminished middle class; for example, Montgomery (222nd), Tampa (242nd), Jackson (253rd), Houston (264th), and New Orleans (266th) rank particularly low among 274 U.S. cities with regard to economic inclusion (Urban Institute, 2020).

Finally, the third category of contextual indicators involves these same demographic disparities within policy-making bodes in the Gulf states. Currently, the governors of all five states are non-Hispanic Whites, and all the state legislatures are composed of a disproportionate share of non-Hispanic White policy makers relative to the non-Hispanic White share of each state’s population (NCSL, 2020). For example, Texas’s 2020 legislature was 64 percent non-Hispanic White compared with the group’s 40.3 percent share of the state’s total population (NCSL, 2020; U.S. Census Bureau, 2022d). This pattern is repeated in the other four states as well: Louisiana (74 percent of legislators were non-Hispanic White versus 57.9 percent of the state population was non-Hispanic White in 2020); Alabama (77 percent versus 64.9 percent); Mississippi (71 versus 56 percent); and Florida (68 versus 52.7 percent) (NCSL, 2020; U.S. Census Bureau, 2022d).

Racism affects health equity as it undergirds the unequal distribution of the indicators discussed above (RWJF, 2017). Racism also affects health throughout the life course by directly affecting adolescents and young adults through various mechanisms, affecting their brains and bodies, their parents’ ability to protect and nurture them, and a neighborhood’s ability to help them thrive, all of which lead to health disparities (Heard-Garris, 2021).

According to Collins (2004, p. S13),

communities as a result of structural policies that create unequal distribution of assets and opportunities. Critical as well is measuring the higher levels of stress felt in these communities and rooted in the constant, lifelong effects of bias, discrimination, and stereotyping (Sapolsky, 2018). This framework needs to be included universally in research designed to explore health inequities and community health. An example is the “expanded” set of adverse childhood experiences (ACEs), which includes adverse community environments and adverse cultural exposures (Cronholm et al., 2015).

Given that individuals can have multiple marginalized identities, research grounded in intersectionality increasingly underscores multiple marginalizing social categories that intersect to amplify health inequities (Khan et al., 2017). In short, research on race and racism needs to include measurements of social determinants of health, ACEs broadly defined, and their intersectionality to get at the root of the effects of environmental and genetic factors.

There is insufficient data for research on effective interventions and best practices for promoting resiliency and addressing racism as a social determinant of health, an ACE, and a source of chronic stress among children and adolescents (Svetaz et al., 2018). While research has advanced to identify and understand some effects of racism, significant gaps persist in evidence-based interventions for dismantling and mitigating its effects, including the resultant health disparities and adverse effects on child and adolescent development (Miller et al., 2018).

Careful consideration of the anthropological, ecological, economic, historical, and social contributors to the complex milieu that constitutes the social determinants of health is necessary to frame health status and outcomes authentically. The collection of clinical data disaggregated by race and ethnicity will continue to be important to help characterize the differential lived experiences of individuals, especially children and adolescents, who represent the most rapidly diversifying segment of the U.S. population. Acknowledging that social determinants often contribute to the deleterious health outcomes disproportionately borne by communities of color is a critical operational framework. Essential as well in framing an equity lens for emerging and senior investigators and future explorations is an interdisciplinary approach that rigorously acknowledges the long-standing effects of intergenerationally transmitted trauma and ACEs and the role of structural racism in conferring risk and resilience (Coyne-Beasley and Svetaz, in press).

Unfortunately, health care providers often underestimate the pervasiveness of racism in U.S. culture and its effects (both overt and subconscious) on the care they provide. Racism has been built and maintained within the very fabric of the U.S. health care system and often manifests as implicit bias (Bailey et al., 2017; IOM, 2003). A recent article by Ko (2020, p. 1089) summarizes the problem by stating “The persistent segregation of communities by race, combined with our lack of diversity in medicine, will continue to result in chronically underserved minority populations.”