By Marysel Pagán Santana, DrPH, MS, Senior Program Manager in Puerto Rico, Migrant Clinicians Network
What is Community Mobilization, and How is MCN Using It?
Community mobilization is a strategy that employs a cross-sectoral, community-based, participatory approach to address health, social, or environmental issues, empowering individuals and groups to take action to facilitate change, including policy change. This model has been utilized by the Centers for Disease Control and Prevention and World Health Organization to successfully tackle specific diseases or community health concerns in the US and internationally. MCN’s model utilizes community mobilization to meaningfully prepare for a disaster by reaching out to and accounting for the more vulnerable populations that are frequently not sufficiently consulted in disaster planning. After Hurricane Maria in 2017, community health centers served as a lifeline and became a central hub of immediate aid and continue to play a critical role in long-term recovery. Building on this role to foster the community’s ability to prepare and respond to future events is critical given the population’s susceptibility to hazards and impacts of climate change. The overarching goal of this project is to build capacity among health centers to employ a community mobilization framework for emergency preparedness in order to improve health outcomes of vulnerable populations before, during, and after a disaster.
Since the first Intergovernmental Panel on Climate Change report in 1992, climate experts have warned of the implications of the climate crisis and how it will affect seasonal weather events across the globe.1 Now, we are living through it, with more common extreme weather events, including more intense hurricanes, heat waves, wildfires, floods, and droughts. Hurricanes Irma, Maria, Michael, and Dorian destroyed communities in the Bahamas, Florida, and Puerto Rico, during the 2017, 2018 and 2019 hurricane seasons, a lived experience of the increasing intensity of hurricanes.2,3 In 2018, California faced the “deadliest and most destructive wildfire season on record”, with a total of 7,639 fires, according to the California Department of Forestry and Fire Protection (CalFire), although this year’s fire season, as of mid-September, had burned a record 3.2 million acres, a much higher number than in 2018, and with several months of fire season to go before the winter rains.4 In addition to extreme weather patterns, environmental changes such as deforestation, urban growth, rising ocean temperatures, and the spread of infectious diseases complicate our ability to cope with disaster. Together, the climate crisis coupled with environmental degradation could multiply the impact of the COVID-19 pandemic we are currently experiencing.5 Regardless of which disaster or combination of disasters one faces, it is crucial to note that the effects of the event are not universal, as historically marginalized populations experience the highest levels of negative impacts, including acute and chronic health consequences and mortality. Without consideration of these differences, a natural disaster could turn into a humanitarian disaster. The impact of such disasters on vulnerable populations is evident in the reports from recent events from Puerto Rico6,7 to California.8 And yet, communities can create their own emergency response blueprints to reverse some of these disparities through community mobilization.
Puerto Rico is a case study of disaster-amplified health disparities and community efforts to reduce them. This fall marks the three-year anniversary of Hurricane Maria, and the systemic inequities that were exposed during the hurricane are still evident across Puerto Rico. This deadly Category 5 hurricane highlighted income inequality, lack of access to health care services including chronic disease treatment, poor access to safe housing, and food insecurity. The storm and its ramifications most strongly affected the 22 municipalities that were directly hit, 12 of which report over 50 percent of their inhabitants living below the federal poverty rate (equivalent to $26,200 for a family of four). In addition to living through the direct impact of the hurricane, rural and/or low-income communities experienced poorer emergency response. The emergency response teams’ poor coordination affected victim recovery and ability to receive assistance. These factors in conjunction with high rates of chronic diseases such as asthma, diabetes, and hypertension escalated the situation from a natural disaster to a humanitarian disaster. The absence of basic resources, lack of knowledge of community needs and obstacles, and the working language and culture of the government were all key in the emergency response, or lack thereof, at the state and federal level. However, this disaster also brought about the establishment of local networks, frequently led by community health centers, that directed their efforts to the response and protection of vulnerable communities. The roots of these newly formed networks were strengthened after the earthquakes experienced in the southeast region of Puerto Rico in 2019 and 2020,9 and again with COVID-19.
The disparity of the impact, response, and recovery at the community level is not a new phenomenon in the United States.10, 11 A few striking examples include Hurricane Katrina in 2005, and, more recently, the Camp Fire in 2018, which burned down Paradise, a small city nestled in the forested foothills of Northern California, with a large population of elderly, disabled, and poor residents -- many struggling with a combination of the three. Paradise residents who are older, have preexisting conditions, or low incomes are more likely both to be affected by the fire and to have sustained negative impacts of the fire, even almost two years later. The recovery process has not been the same for these individuals, as the economic impacts of the fire forced many of them to permanently migrate to other cities or states, instead of returning and rebuilding.12, 13
Each of these disasters shows a common thread of disparity within our most marginalized and vulnerable communities. This year, as we approach the two-year anniversary of the Camp Fire and the three-year anniversary of Hurricane Maria, we once again face discouraging autumn forecasts. On one hand, the National Hurricane Center predicts that this season has an 85 percent chance of an above-normal season, with 19 to 25 storms, 7 to 11 hurricanes, and three to six strong, intense hurricanes.14 On the other hand, the monthly wildfire forecasts predict a normal or above normal season within California and other western regions.15 After an unusual mid-August lightning storm, dozens of fires burning across Northern California confirmed that the fire season was well underway. As the fires burned along the Pacific Coast into September, out in the Atlantic, Tropical Storm Rene gathered force, the earliest storm to begin with the letter R on record – indicating a higher frequency of storms through September than ever recorded.
This year, the projections pose a more serious threat to public health, due to COVID-19 and the current social climate of the United States. The pandemic brings with it a plethora of health and economic complications that further highlight social disparities and marginalize vulnerable populations including Black, Latino, and immigrant communities.16 Social inequity within the United States plays an unfortunate role in the preparation for and response to natural disasters, as factors like race, ethnicity, and immigration status determine how a community is supported.17 Considering the projections of the climate crisis, it is crucial to consider factors such as structural racism, xenophobia, and poverty when administering risk assessments and emergency preparedness plans. It is imperative to recognize that the existing framework for the national response to disasters is just that: a framework. In order to ensure equity among disaster preparedness plans, one must consider the systemic barriers that communities face, as well as their language, culture, needs, and local resources.
A model that has proven helpful in ensuring equitable disaster preparedness is the community mobilization model. Local community efforts have been the backbone of the response to recent emergencies in Puerto Rico. This was particularly evident during Maria, when community health centers took services directly to the homes of patients when most of the population was isolated.18, 19 It was present when different organizations connected to assist during the 2019-2020 earthquakes.20 It is once again a dominant response now to the public health emergency related to COVID-19. The current emergency presents an opportunity to use community mobilization in response, specifically with food insecurity in vulnerable communities. Community health centers, community leaders, and government agencies identified food insecurity as an effect of the pandemic, due to unemployment and the closure of local food stores. Health centers in collaboration with community leaders can identify those families in need to facilitate distribution or to direct distributors to the most vulnerable communities using information from or previous experience with the health center. The result can be the mass distribution of food that in turn promotes local agriculture and healthy eating.21 Corporación de Servicios Médicos and Hospital General Castañer, two MCN partners in Puerto Rico, have put this food security initiative in action. These two centers have been working with their partners to deliver food to the vulnerable populations in their communities near the north and central region of the island. This not only addresses part of the food insecurity problem but could influence the health of these populations by distributing foods such as fresh fruits and vegetables, which are frequently out of their economic reach or not available. This is just one example of how community mobilization – localized and collaborative efforts supported by pre-disaster organization between community leaders and members – can reduce post-disaster disparities. And community mobilization can do much more.
In the context of emergency preparedness, there are various components of community mobilization that are adapted to fit the needs of the community it is serving, which helps to ensure a more equitable response to disasters. Community leadership management, identification and mapping of local resources, analysis of strengths, opportunities, weaknesses, and threats (SWOT), and other components come together to empower the local community while establishing a disaster response plan that is sensitive to the dynamics and needs of the community it serves. Similarly, this model identifies systemic barriers to emergency preparedness and response in order to minimize their impact in this context. The community mobilization model encourages local communities to play a role in the development of their own emergency management plans, while government agencies instead play a supportive role in order to address the barriers identified by the community.
Migrant Clinicians Network is in the second year of our project funded by the Bristol-Myers Squibb Foundation to integrate the community mobilization model into the emergency preparedness plans of vulnerable communities within Puerto Rico. In this project, community health centers and their community outreach staff, community health workers, and health educators team up with local leadership to establish an integrated emergency management plan. This opens a platform for communities to discuss and establish next steps, identify local resources, and involve the “Centro de Salud” -- the local health center -- which provides support to chronic disease patients and other vulnerable populations while serving as the community’s main link to government agencies. In the first year and a half of this project, we noticed that in addition to achieving our primary goal of improved community emergency response, the dynamic between community health centers and the community they serve improved greatly. There was a noticeable growth in mutual trust and communication, particularly when recognizing the barriers and needs of the community. This paved the way for improvements in community programs that help ensure the overall health and wellbeing of citizens, including the implementation of a mobile clinic program, and a community network with a rapid response framework for disaster support. The mobile clinic was made possible after the center build a deeper relationship with the community, creating bridges and strengthening the trust with community leaders. This served the community when earthquakes struck in early 2020, as community leaders kept in direct communication, and carried out the resource mapping and needs assessments during this emergency. The newly built network was then activated, using the mapping and assessments to facilitate the arrival of clinical support and supplies. In Puerto Rico, community mobilization has created a master roadmap that they have carried out effectively to help the most marginalized in their communities when disaster has struck. For the many communities that may be threatened by disasters in the coming years, such community mobilization may be a key to ensure a rapid and equitable response, and to bolster health justice at the local level.
Contact Marysel Pagán Santana, DrPH, MS, Senior Program Manager in Puerto Rico, about community mobilization in Puerto Rico: firstname.lastname@example.org.
Carlos E. Rodríguez-Díaz, “Maria in Puerto Rico: Natural Disaster in a Colonial Archipelago”, American Journal of Public Health 108, no. 1 (January 1, 2018): pp. 30-32. Available at: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304198
Gustavo A. García-López. Environmental Justice. Jun 2018.101-108.http://doi.org/10.1089/env.2017.0045 Available at: https://www.liebertpub.com/doi/abs/10.1089/env.2017.0045
Roman J. Hurricane Maria: A Preventable Humanitarian and Health Care Crisis Unveiling the Puerto Rican Dilemma. Ann Am Thorac Soc. 2018;15(3):293-295. doi:10.1513/AnnalsATS.201710-792OI
After the Fire: Vulnerable Communities Respond and Rebuild. Center for American Progress. 25 July 2019. Available at: https://www.americanprogress.org/issues/green/reports/2019/07/25/472738/fire-vulnerable-communities-respond-rebuild/
Bristol-Myers Squibb Foundation: https://www.bms.com/about-us/responsibility/bristol-myers-squibb-foundation.html
1 Climate Change: The IPCC 1990 and 1992 Assessments. International Panel on Climate Change. World Meteorological Organization/United Nations Environment Programme. June 1992. Available at: https://www.ipcc.ch/report/climate-change-the-ipcc-1990-and-1992-assessments/.
2 Kossin JP, Knapp KR, Olander TL, CS Velden. Global increase in major tropical cyclone exceedance probability over the past four decades. Proceedings of the National Academy of Sciences Jun 2020, 117 (22) 11975-11980; DOI: 10.1073/pnas.1920849117. Available at: https://www.pnas.org/content/117/22/11975.
3 Melillo, JM, Richmond TC, and GW Yohe, Eds. 2014: Climate Change Impacts in the United States: The Third National Climate Assessment. U.S. Global Change Research Program, 841 pp. doi:10.7930/J0Z31WJ2
4 2018 Incident Archive. CalFire. Accessed 11 August 2020. Available at: https://www.fire.ca.gov/incidents/2018.
5 Coronavirus and Climate Change. C-Change: Center for Climate, Health, and The Global Environment. Harvard T.H. Chan School of Public Health. Webpage. Accessed 11 August 2020. Available at: https://www.hsph.harvard.edu/c-change/subtopics/coronavirus-and-climate-change/
6 Datos del huracán María. El Instituto de Estadísticas de Puerto Rico. Webpage. Accessed 11 August 2020. Available at: https://estadisticas.pr/en/datos-del-huracan-maria
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8 Meyers T. Which California Communities are Most Vulnerable to Wildfires? Direct Relief. 30 July 2019. Accessed 11 August 2020. Available at: https://www.directrelief.org/2019/07/which-california-communities-are-most-vulnerable-to-wildfires/
9 Madaras L. In the Field: Community Mobilization during Emergencies in Puerto Rico. Clinician-to-Clinician: A Forum for Health Justice. Migrant Clinicians Network. 25 March 2020. Accessed 11 August 2020. Available at: https://www.migrantclinician.org/blog/2020/mar/field-community-mobilization-during-emergencies-puerto-rico.html
10 Willison CE, Singer PM, Creary MS, et al. Quantifying inequities in US federal response to hurricane disaster in Texas and Florida compared with Puerto Rico. BMJ Global Health 2019;4:e001191.
11 Howell J, Elliott JR. Damages Done: The Longitudinal Impacts of Natural Hazards on Wealth Inequality in the United States. Social Problems. Volume 66, Issue 3, August 2019, Pages 448–467, https://doi.org/10.1093/socpro/spy016
12 Sellers FS. Forced from Paradise. Washington Post. 23 July 2019. Available at: https://www.washingtonpost.com/graphics/2019/national/paradise-fire-displaced-residents/
13 United States: California wildfires: urban expansion and the risk of displacement. 2019 Global Report on Internal Displacement. Internal Displacement Monitoring Centre. Available at: https://www.internal-displacement.org/publications/united-states-california-wildfires-urban-expansion-and-the-risk-of-displacement
14 National Oceanic and Atmospheric Administration. 'Extremely active' hurricane season possible for Atlantic Basin. Press Release. 6 August 2020. Accessed 19 August 2020. Available at: https://www.noaa.gov/media-release/extremely-active-hurricane-season-possible-for-atlantic-basin
15 National Significant Wildland Fire Potential Outlook: Predictive Services National Interagency Fire Center. 1 August 2020. Accessed 12 August 2020. Available at: https://www.predictiveservices.nifc.gov/outlooks/monthly_seasonal_outlook.pdf
16 Hooper MW, Napoles AM, and EJ Perez-Stable. Viewpoint: COVID-19 and Racial/Ethnic Disparities. JAMA. 11 May 2020. Accessed 19 August 2020. Available at: https://jamanetwork.com/journals/jama/article-abstract/2766098
17 Mayer B. A Review of the Literature on Community Resilience and Disaster Recovery. Curr Envir Health Rpt 6, 167–173 (2019). https://doi.org/10.1007/s40572-019-00239-3
18 Galvan A. Discussing the Damage to Health Facilities in Puerto Rico. Clinician-to-Clinician: A Forum for Health Justice. Migrant Clinicians Network. 23 October 2017. Accessed 12 August 2020. Available at: https://www.migrantclinician.org/blog/2017/oct/discussing-damage-to-hospitals-in-puerto-rico.html
19 Galvan A. From the Field: Puerto Rico Health Center Providing Services, Needs Medication. Clinician-to-Clinician: A Forum for Health Justice. Migrant Clinicians Network. 17 October 2017. Accessed 12 August 2020. Available at: https://www.migrantclinician.org/blog/2017/oct/from-the-field-puerto-rico-health-center-providing-services-needs-medication.html
20 Pagan Santana M. Earthquakes in Puerto Rico: Learning from communities and supporting their work. Clinician-to-Clinician: A Forum for Health Justice. Migrant Clinicians Network. 16 January 2020. Accessed 12 August 2020. Available at: https://www.migrantclinician.org/blog/2020/jan/earthquakes-puerto-rico-learning-communities-and-supporting-their-work.html
21 Food Bank of Puerto Rico, partners distribute $1M in food, vouchers, gift cards. 2 June 2020. Accessed 12 August 2020. Available at: https://newsismybusiness.com/food-bank-of-puerto-rico-partners-distribute-1m-in-food-vouchers-gift-cards/
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