By Dr. S. Atyia Martin, Adjunct Faculty, Master of Homeland Security program, Northeastern University Director, Office of Public Health Preparedness at the Boston Public Health Commission (BPHC)
The potential for poor outcomes after disasters in cities is incredibly high due to complex infrastructure, higher density of people, and large numbers of socially vulnerable populations (Galea, Freudenberg, & Vlahov, 2005; Pelling, 2003). A disaster strains the limited capability and capacity of some populations to effectively respond and recover. Their circumstances reduce their ability to prepare for, cope with, and adapt to the impact of emergencies. Socially vulnerable people have existing social circumstances generally associated with age, gender, race, family composition, medical illness, disability, literacy, English language proficiency, and social isolation (CDC, 2010).
Each category of social vulnerability presents challenges for people. However, it is the interaction of these social factors that intensifies vulnerability. This overlap exponentially increases the level of exposure to risk and suffering such as injury, death, illness, and difficult recoveries (Morrow, 1999).
The literature review indicated that vulnerabilities exist based upon pre-incident social circumstances. Some of the literature also provided insight into the post-incident outcomes from disaster exposure that socially vulnerable people are more likely to face because of their existing social circumstances. The initial categories used to identify pre-incident variables included age, race, income, household composition, family composition, housing type, disease/illness, access, language and literacy, non- residents, gender, and disability (Cutter & Emrich, 2006; Kailes & Enders, 2007; U.S. Centers for Disease Control and Prevention, 2010). These categories helped to guide the literature review to compile a list of 63 social vulnerability attributes relevant to cities.
Categories for post-incident outcomes included exposure to injury, death, illness,property damage, losing loved ones, losing a business, or limited access to recovery services (Isaranuwatchai, Coyte, McKenzie, & Noh, 2013). These outcomes were extracted from a literature review and provide an organizational structure that can capture the multiple categories of vulnerability in to which a person can fall (see Figure 1 for a full list).
Each of the 63 social attributes or factors was researched to identify in the literature the related social characteristics that (1) increase vulnerability or (2) often coincide with the 63 social factors. Understanding the co-occurrence of socially vulnerable characteristics was an inductive process. The result of the literature review and link analysis is the Social Determinants of Vulnerability Framework.
FINDINGS AND RESULTS
There were seven pre-incident social factors that seemed to be driving social vulnerability based on the number of links to other pre-incident factors. These seven social conditions are directly or indirectly connected to the six post-incident outcomes that perpetuate social vulnerability. A key concept to keep in mind is that people in any one category are not necessarily vulnerable. Based on this analysis, it is primarily the presence of social isolation in conjunction with any of the other social factors that most significantly increases vulnerability.
PRE-INCIDENT SOCIAL FACTORS
Pre-incident social conditions represent the existing social vulnerability of people in cities. The social characteristics that had ten or more associated social factors became part of the framework: chronic and acute medical illness, people of color, low-to-no income, children, older adults, people with disabilities, and social isolation. These seven social factors, outlined below, appear in the Resultant Social Determinants of Vulnerability Framework.
Chronic and Acute Medical Illness. The most socially vulnerable people with chronic or acute medical illnesses were low-to-no income older adults with a disability.
People of Color. People of color were linked to ten other social factors. People of color who are most vulnerable are socially isolated and low-to-no income. Furthermore, people of color with those characteristics are more likely to experience displacement after an emergency.
Low-to-No Income. People with no-to-low income were also linked to all other social conditions in the Social Determinants of Vulnerability Framework. This indicates that low-to-no-income is a characteristic that consistently compounds risk.
Children. Although children had many social characteristics associated with it (12), it had the least that were linked to other social factors in the Framework. The children who seemed to be most vulnerable were socially isolated, low-income, with limited English proficiency, and were people of color. It should be noted that children are particularly vulnerable because in addition to their own circumstances, they are also impacted by the circumstances of the adults providing for their care (Shi & Stevens, 2010).
Older Adults. Older adults were most vulnerable when they were socially isolated, low-to-no income, and had a disability. There were a total of 16 factors of social vulnerability associated with older adults.
People with Disabilities. The most vulnerable people with disabilities were older adults.
Social Isolation. Social isolation refers to a lack of engagement in social ties, institutional connections, or community participation (Pantell, Rehkopf, Jutte, Syme, Balmes, & Adler, 2013; Seeman, 1996). Social isolation had the largest number of links to other factors of vulnerability. Based on the literature and the results of this analysis, social isolation is the most consistent contributor to social vulnerability.
This constant exposure to stressors deteriorates physical and cognitive health resulting in a comparatively higher longer term impact. The types of exposures people experience in their lives before an emergency that increase the impact of stressful events include: illness directly or to a loved one; social isolation; limited opportunity to make their own decisions (low-decision latitude); and threat or violence (Gustafsson et al., 2014). The results of this research indicate that many of the same stressors people are exposed to before an emergency that increase poor physical and cognitive health outcomes are the same as the stressors socially vulnerable people are likely to face after an emergency.
Post-incident outcomes represent the types of impacts from an emergency or disaster people may experience. There were a total of eight post-incident consequences were directly or indirectly related to all of the pre-incident social factors in the Framework. However, they were most outcomes from the literature. Six of the eight had at least one link to pre-incident social conditions: access to post- incident services; displacement; injury, illness, and death; loss of employment; property damage; and domestic violence. These significantly related to three of them: social isolation, low-to-no income (had the most links to post-incident outcomes), and people of color.
Social isolation is the product of a lack of social justice and social capital which are both important aspects of resilience (Chandra et al., 2011). Social justice, social equity, and social capital are related concepts. Social justice means the institutions serving the community enable them to contribute to decisions about their community and prevent inequality. Social equity means people get what is right for them. Social capital is the relationships people have with each other, their community, and institutions.
Practical approaches to improving community preparedness include connecting socially vulnerable people with others in their communities as well as government and community organizations that provide services meant to improve their well-being and quality of life. This is one of the reasons involving public health preparedness is key to successful emergency preparedness efforts: Every day, urban public health focuses on connect vulnerable populations with resources to promote their overall health and well-being. All of the previously mentioned actions represent increased efforts to move towards social equity in urban emergency management and are key elements of long-term vulnerability reduction. Thus, social justice and social capital are fostered to reduce the negative public health impact of social vulnerability and overall risk before, during, and after emergencies (Durant, 2011).
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