Social and Environmental Justice as a Lens to Approach the Distribution of $105 Million of Directed Funding in Response to the Deepwater Horizon Oil Disaster

Introduction

Social and environmental injustices are well-recognized contributors to health disparities. ¹ We describe the Gulf Region Health Outreach program (GRHOP), an innovative approach to improving the health of Gulf coast communities affected by the Deepwater Horizon (DWH) Gulf oil spill ² in which social justice and environmental justice were central considerations. The primary goal of this ongoing program, now in its last year, is to help reinvigorate community and individual resilience shaken by the disaster through an integrated health model focusing on a partnership between Gulf Coast residents, environmental health specialists, community development, and physical and behavioral health providers.

GRHOP was developed based on ongoing activities by community organizations, supported by the Greater New Orleans Foundation, and by BP and the Plaintiffs' Steering Committee as part of the Deepwater Horizon Medical Benefits Class Action Settlement (Medical Settlement). GRHOP was established by Federal Court Judge Carl J. Barbier who awarded GRHOP $105 million of the $7.6 billion total. GRHOP is not involved in the direct compensation of victims of the DWH oil spill for specific injuries or losses. Instead, it represents a unique attempt by the American judicial system to impact broader community health issues not readily addressable through usual toxic tort mechanisms aimed at recompensing individuals following a disaster. Furthermore, GRHOP does so in large part through improving components of community health resilience. While community resources can be enhanced by tort compensation of directly affected individuals, evidence that standard adversarial litigation tactics and long drawn out periods before payment is received can have adverse psychosocial impacts on the involved individuals and their communities has been provided by Picou, a GRHOP project leader, and his colleagues. ³

GRHOP is a collaboration among the Alliance Institute, a community-based organization; the Louisiana Public Health Institute; and relevant components of Louisiana State University Health Sciences Center; Tulane University; University of South Alabama; University of Southern Mississippi; and University of West Florida (Fig. 1). The target beneficiaries are residents, especially the medically underserved, of 17 coastal counties and parishes in Alabama (Baldwin, Mobile), Florida (Escambia, Okaloosa Bay Santa Rosa, Walton), Louisiana (Cameron, Jefferson, Lafourche, Orleans, Plaquemines, St. Bernard, Terrebonne), and Mississippi (Hancock, Harrison, Jackson).

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FIG. 1.

GRHOP structure, projects, and goals. GRHOP, Gulf Region Health Outreach Program.

Specific goals of the GRHOP projects are to (1) build the capacity of primary care community health clinics in the region; (2) increase the mental and behavioral health expertise of health professionals in the targeted communities and increase awareness of mental and behavioral health issues across the GRHOP footprint; (3) increase the environmental health expertise of health professionals in the targeted communities and the health literacy of local communities; and (4) train and facilitate employment of community health workers who will help residents navigate the healthcare system and access needed care. GRHOP purposefully incorporates community involvement. One example is the Alliance Institute's involvement in the opening of the RFK Lafitte Medical Clinic in Jean Lafitte, Louisiana, which can serve as a healthcare home to 5000 families and creates jobs for local residents. ⁴

Objectives of GRHOP include informing residents in targeted communities about their own health and providing access to skilled frontline healthcare providers supported by networks of specialists knowledgeable in addressing physical, environmental, and behavioral and mental health needs, thereby improving the resilience of the targeted communities to future health challenges. The DWH Settlement Agreement also established a GRHOP Coordinating Committee consisting of the heads of all projects and three outsiders, including the chairperson, to ensure that the respective projects function in a cooperative and integrated manner.

Among Coordinating Committee determinations were that projects ideally should be sustainable beyond the 5-year GRHOP funding period. In addition, all projects should be carefully evaluated with subsequent publication of outcomes, a process that is now under way in the last year of GRHOP. Logic models were developed by each GRHOP component as a means to further join together resources with desired outcomes, to help integrate the activities of the components, and to serve as a basis for evaluation. In this article, we focus on the use of social and environmental justice concepts by GRHOP with a particular focus on approaches to mental and behavioral issues central to community resilience.

The link between environmental justice and behavioral health has been noted by Evans and Kantrowitz in their comprehensive 2002 review of the role of environmental factors in mediating the impact of low socioeconomic status on health. ⁵ They stressed the multifactorial environmental problems, ranging from air pollution to poor housing quality to noise that linked poverty with poor health outcomes. Others have also noted the difficulty in disentangling poverty and other stressors from racism as causal factors, as well as general misconceptions regarding the interplay of social and environmental impacts. ⁶

Gulf Coast Communities and the Dwh Oil Spill

The Gulf Coast contains economically important port, petroleum, tourism, and fishing industries colocated with significant natural environmental features. This location also exposes the population to both natural and technological disasters. The DWH oil spill occurred on April 20, 2010. It compounded effects of earlier hurricanes and impacted ongoing hurricane recovery processes throughout the region, 5 years after this largest marine oil spill in history, ⁷ communities and residents directly and indirectly impacted by this massive disaster are still struggling to comprehend and resolve its yet incompletely understood consequences to the Gulf waters, wildlife, wetlands, local communities, industries, business, household economics, and, most importantly, the people of the Gulf Coast.

The ensuing cleanup, involving the release of 2.1 million gallons of oil dispersant and over 50,000 cleanup workers, was also historic in scope. ⁸ There have been few similar disasters, the closest in impact in the United States being that of the Exxon Valdez. As pointed out by a group, including J. Steven Picou, a GRHOP project leader who studied the Valdez disaster and Jennifer Langhinrichsen-Rohling, also a GRHOP project leader, the two oil spills are in many ways similar in community and psychosocial impact, ⁹ but climate, socioeconomic, and cultural differences warranted a very different response.

Social and Environmental Disparities in Grhop Communities

It is well recognized that differences in community conditions powerfully predict the behavioral and social well-being of local residents and that achieving social justice is a prerequisite for eliminating health disparities. ¹⁰ Social justice encompasses the distribution of wealth, power, and opportunities within a community. Furthermore, social justice has a role through all stages of disasters—preparedness, response, mitigation, and recovery—with social vulnerabilities becoming even more apparent. For example, following Hurricane Katrina, poorer communities situated on marginal lands were the slowest to recover, due to limited insurance policies, increased poverty, and contractors focused on more affluent neighborhoods. Social vulnerability influenced outcomes at various stages of the Hurricane Katrina catastrophe, including mitigation, preparation, evacuation, storm impacts, and recovery. Achieving community resilience requires addressing underlying issues of social justice and other inequalities. ¹¹

Environmental justice can be viewed as the nexus between social justice and environmental hazards. The premise of environmental justice is that some communities bear a disproportionate burden of environmental risk. ¹² Environmental justice represents a community-driven process of accountability by engaging vulnerable members to formulate public policy and environmental decision making. ¹³

Communities along the Gulf Coast have a high percent of racial and ethnic minorities. With their high allostatic load of stressors—increased poverty leading to socioeconomically disadvantaged populations, vast health disparities, and repeated disaster exposure, they meet the definition of environmental justice communities. ¹⁴ Three truisms relevant to environmental justice are evident in the specific communities served by GRHOP: (1) there are more environmental hazards in disadvantaged communities, ¹⁵ (2) there are more individuals with poor health in disadvantaged communities, and (3) because of their poor health individuals from disadvantaged communities are more susceptible to environmental hazards. ¹⁶

To document whether environmental and social justice issues were of particular importance to the communities designated for assistance under the GRHOP, we utilized the CDC Comparative County Database to evaluate the general extent of health disparities in the 17 GRHOP counties and parishes. ¹⁷ This database attempts to avoid many of the problems inherent in county comparisons of health data by grouping similar counties together using demographic and other features, including social and environmental justice factors such as poverty, educational opportunities, stressed housing, access to healthy food, and environmental pollution.

Relevant health statistics for which data are sufficiently robust is put into one of three categories: better when the county is in the top 25% for that indicator; moderate when it ranks between the 25th and 75th percentile, and worse when in the worst 25th percentile. Based on the CDC Comparative County Database, we found that the counties and parishes in the GRHOP tend to have poorer health statistics despite social justice and environmental indicators being incorporated in determining comparability. Of the 716 health indicator rankings, 114 were in the better category and 262 were in the worse category (p < 0.001). For the 17 individual counties, 12 had more health indicators in the worse column, while only 4 had more indicators in the better column, with 1 tie (p = 0.04).

Among the indicators that were particularly found in the worse column versus the better column were adult diabetes (11 vs 2); male life expectancy (11 vs 0); and female life expectancy (9 vs 1). Depending on the specific metric, the data used by the CDC for this comparison were gathered between 2005 and 2013, mostly before the 2011 DWH disaster. The male and female life expectancy indicators were from 2010, immediately before the spill. Accordingly, these data support our contention that the DWH disaster affected communities that were particularly vulnerable due to pre-existing health disparities.

Studies by GRHOP participants, as well as others, showed that the compounding effect of the DWH oil spill in communities recovering from previous hurricanes included increased mental health problems such as anxiety, depression, and posttraumatic stress, ¹⁸ which also explained many of the reported physical health problems. ¹⁹ Of note, these mental health problems are more apparent in individuals more heavily impacted by the oil spill, as studies of entire coastal populations revealed only modest effects on overall mental health and substance abuse. ²⁰

In a postdisaster environment, understanding and addressing behavioral health factors that directly and indirectly influence disaster recovery are crucial. ²¹ Provision of behavioral health services following disasters is an important recovery method that promotes resilience in individuals and communities by reducing symptoms and emphasizing inherent human strengths. ²² In view of the unique and profound aspects of this event, touching all aspects of life, systems level recovery is necessary.

Systems Level Recovery

The GRHOP approach recognized that recovery needs related to community well-being must be addressed at multiple levels, including individual, group, and community. In essence, we extended Bronfenbrenner's bioecological systems model from systems theory to disaster recovery. Bronfenbrenner's model asserts that multiple interactions between persons and their environment influence relationships from the macro-, meso-, and microsystems. These are conceptualized as “nested” systems, requiring multiple levels of programming. Simply stated, the context of the environment in its broadest sense, including such social factors as poverty and hopelessness, strongly influences behavioral health and performance. ²³ Response and services across macro-, meso-, and microlevels inform the development of disaster preparedness and intervention strategies that are sensitive to the unique needs of communities, individuals, and groups and effectively build resilience.

Much of disaster behavioral health response is confined to addressing only one dimension, despite evidence that successful recovery is influenced by many individual- and community-level factors. Traditional recovery often is siloed by funding sources and governmental regulatory requirements. In contrast, funding aimed at increasing long-term capacity, which has the ability to sustainably impact individuals and the local environment, is often lacking. GRHOP was strategically designed to involve multisystemic programming at the macrolevel (community), mesolevel (group), and microlevel (individual) to address health disparities and advance social justice. Specifically, GRHOP macrolevel community activities include primary care capacity investments, sustainable model development, and increased behavioral health access. ²⁴

One of the many GHROP macro examples is the LPHI efforts, through technical support and financial investments, in assisting community clinics to reach Federally Qualified Health Center (FQHC) status, thereby improving their opportunities for external support and sustainability. Meso group activities include community outreach, family and school supportive services, referral networks, and trainings and workforce development. ²⁵ One example is a collaborative effort between the University of South Alabama and Tulane University, in which close to 100 Community Health Workers were trained, many of whom were placed in local community health clinics. ²⁶

This GRHOP training example also contributes to the macrogoals by helping to position clinics for the transition to population health outcomes, as well as the microgoal of worker placement. Finally, microlevels (individual) include direct services, placement of community health workers, and consultation to professionals and community members. As one example, the Mental and Behavioral Health Cooperative Program (MBHCP), a collaboration of GRHOP components of the Louisiana State University Health Sciences Center and Universities of Mississippi, South Alabama, and West Florida, has provided direct mental health services at FQHCs and community clinics in designated counties/parishes. ²⁷ These GRHOP microactivities contribute to the mesolevel goals by training mental health professionals and macroactivities through helping clinics achieve and maintain their FQHC status and through improved billing capacity leading to sustainability of services.

Community-Based Participation and Social Capital

A crucial component of effective disaster response programming is a successful outreach effort with invested community members, community stakeholders, and leaders. Community participation throughout GRHOP is essential to addressing environmental justice through building trust, bidirectional collaboration, and cultural respect for communities and their individual residents. ²⁸ Participation is also central to building community social capital—the existence of shared norms among members of a group that permit cooperation, a sense of belonging, and trusted networks. ²⁹ Social capital represents a community's capacity for effective coping and action, and is central to community resilience following disasters. ³⁰

The multidimensional nature of social capital theory makes it particularly useful in understanding and responding to the manifold impacts of natural ³¹ and technological disasters. ³² Hobfoll et al. developed five intervention principles to promote social capital following disasters; these include promotion of sense of safety; calming; sense of self- and collective efficacy; connectedness; and hope. To operationalize these interventions, community participation must be at the core, where community members can serve as experts on the ecology of the culture, place, and unique attributes of the disaster. ³³

In keeping with the understanding that community engagement is most effective when investment is made in the front-end process of developing relationships with community groups, ³⁴ GRHOP collaborators were selected in large part because of their previous involvement and adherence to community-based participatory principles. In addition, proposals from clinics considered by GRHOP required approval of the respective boards. Federally Qualified Health Centers (FQHCs), whose programs were the recipients of much of the GRHOP funding, are required to be governed by a board in which the majority of the members are patients of the FQHC and who reasonably represent the race, ethnicity, and sex of the individuals served by the clinic.

The Health Resources and Services Administration (HRSA) also recommends that Board composition reflects other demographic characteristics such as socioeconomic status. The Alliance Institute was responsible for vetting and recommending to the GRHOP Board other geographically based community organizations that worked along with GRHOP components in relevant community activities. For example, in Alabama the organization Boat People SOS partnered with Bayou Clinic in Bayou La Batre' to help the clinic provide translators for its Vietnamese population, which in Bayou La Batre’ is close to 30% of the total population.

Responding to the significant negative economic and behavioral health consequences for the Vietnamese American Gulf Coast communities of the DWH disaster requires that community organizing should begin with becoming familiar with personal history and immigration experiences; local Vietnamese health-related customs (i.e., attitudes toward mental health, home health remedies, and indigenous healthcare practices), and availability of Vietnamese-speaking advocacy or social service organizations to assist victims of disasters. ³⁵ However, we recognize the many challenges of working in the community, including those for a service-based organization such as GRHOP. ³⁶

Despite our collective experience in this area, we faced a new challenge as project efforts were triggered by the particular circumstance of an environmental tort. Even with its structure based in a judicial decision supporting community resilience, decreased social capital and subsequent issues of community distrust required enhanced sensitivity to representation of local residents, while ensuring not to place an undue burden on them through yet additional response and advocacy efforts. ³⁷ Despite these challenges, we hope similar efforts toward community resilience and environmental justice will be repeated if there are future examples of judicial decisions in environmental torts.

Discussion

The Gulf waters and its vast ecosystems, the human coastal residents and their communities, have survived and adapted to disruptive natural and man-made extreme events generation upon generation. The DWH oil spill represents a sentinel event in that the scope and more importantly the danger are much darker than just oil leaking from the ocean floor. Loss and recovery due to natural events are accepted by residents of the Gulf Coast. Recovery markers are often defined by the replacement of equipment (boats and businesses): and life returns to normal as the traditional economy and lifestyle resumes. The DWH oil spill is noteworthy in that the environmental insult imposes potentially persistent and recurring threats of sufficient magnitude such that residents questioned if life as they knew it would ever again be possible for themselves, their families, and communities. Disaster management and recovery efforts need to understand this viewpoint as it is entwined with the long-lasting resilience and behavioral health of communities. ³⁸

For Gulf coast residents, unresolved environmental issues introduce a significant degree of ambiguity about the impact of the DWH disaster. GRHOP-related studies show that this ambiguity is associated with a chronic stress burden that has a detrimental effect on the recovery of the population most impacted. ³⁹ Community leaders and health professionals report the presence of elevated stress levels and associated mental and behavioral health conditions of anxiety, posttraumatic stress disorder, and depression, as well as a variety of other health effects; consistent with other large-scale technological and natural disasters throughout the world. ⁴⁰

These conditions and effects are strongly contributed to by the lack of resolution of issues and concerns, including the possibility of longer term health effects, such as cancer, that are atypical concerns following a natural disaster. ⁴¹ Environmental stress is of particular importance to individuals and communities on the Gulf Coast. Past studies of environmental stress provide a foundation for the concept that place matters, both in terms of geographic and psychosocial definitions. ⁴²

GRHOP differs from other disaster recovery components because of its funding source and due to specific features built into its design, including its organizational structure, its partnership between public health, environmental health, and mental health, the amount and duration of the funding and, perhaps most importantly, on the GRHOP being goal driven rather than dictated by a list of activities put into a predetermined budget. The Federal Court Judge established the broad goals of the program, how much funding is available for how long, and the counties and parishes within four states where the money should be spent. Importantly, the GRHOP was free to use funding to meet goals by engaging community organizations, including community-based FQHCs with more flexibility than provided by the usual grant funding mechanism. Furthermore, through the coordinating process, each of the GRHOP projects was encouraged and empowered to work collaboratively, such that common goals led project management rather than a top-down management structure or style.

Another aspect of GRHOP that differs from many of the management approaches to health issues in disadvantaged communities is its focus on activities that produce sustainable benefits to the communities lasting beyond its 5-year duration. The methods of providing these services are paramount because deleterious health and behavioral health effects of the oil spill can take a lengthy period of time to become evident. Having DWH Medical Settlement funds set aside to respond to overall community health issues, without the need for personal litigation, is a unique approach to promoting health and resilience in communities suffering from health disparities due to broader pre-existing social and environmental justice issues.

Sustainability is central to addressing community health issues and is a feature of approaches aimed at achieving social and environmental justice. Agyeman and Evans ⁴³ have developed the concept of “just sustainability” to describe the nexus between sustainability and environmental justice, and have applied these concepts to fishing communities similar to those affected by the DWH oil spill. ⁴⁴ The GRHOP funding source was not sustainable in that the terms of the legal settlement specified a 5-year period. The Coordinating Committee addressed sustainability by aiming for projects that could be continued after 5 years. Thus, purchasing a dental chair in a clinic serving an area with limited dental care resources was considered sustainable as it would still be operational after GRHOP had ended, as would improvements in clinic IT technology and improved methods to understand oil spill disaster impacts and response. ⁴⁵

For example, the MBHCP quad state group, in collaboration with community residents, has developed a Gulf Coast Resilience coalition, aimed at facilitating preparedness and response to future disasters. ⁴⁶ Similarly, projects aimed at providing high school students from disadvantaged communities with summer environmental research projects, or increasing the environmental health knowledge of local science teachers, are seen as investments in a sustainable future. However, to be competitive, a request for funding for a clinic social worker not only required demonstration of need but also a business plan to show that resources for the social worker would be available after the cessation of GRHOP funding. Unfortunately, Medicaid expansion, as enabled by the Affordable Care Act, has not been enacted in Mississippi, Alabama, and Florida and was not implemented in Louisiana until July 2016. These ongoing policy and political decisions have significantly complicated the community capacity sustainability outlook. ⁴⁷

Conclusion

The GRHOP approach is based on a central tenet of environmental justice that the stress caused by racism and other social justice issues extends well beyond measurable disparities in pollution levels. ⁴⁸ Unique to technological disasters is the prolonged recovery due to chronic stressors affecting community health. ⁴⁹ Greatly complicating the DWH longer term disaster response is its direct and indirect impact on communities with significant health disparities related to long-standing social and environmental injustices. The GRHOP is an innovative approach to address longer term health issues through coordinated establishment and enhancement of FQHCs and community clinics; integrated health and behavioral health services; and increased environmental health capacity, all of which can facilitate healing and resolution. However, it is recognized that continued challenges, for example, the recent 5-year anniversary of the DWH disaster, remembrances, anxiety and uncertainty about the long-term impact, and recently discovered information related to environmental consequences (including oil found on rocks), can also inhibit the recovery process, as does the looming threat of yet another oil spill. ⁵⁰ The true value of the GRHOP approach will be the longer term impact of increased access to healthcare and integrated behavioral healthcare across the life span, thus contributing to the will and ability of individuals, families, and communities to adapt to new realities and to preserve their communities.