The Deepwater Horizon oil spill prompted the first use in history by the US government of the designation “Spill of National Significance,”1 connoting one
that, due to its severity, size, location, actual or potential impact on the public health and welfare or the environment, or the necessary response effort, is so complex that it requires extraordinary coordination of federal, state, local, and responsible party resources to contain and clean up the discharge.(p18)
In its 2011 report to the president, the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling recognized human health effects as the least-recognized consequence of the spill and also those most poorly addressed in existing law and policies.1 The report acknowledged the resilience of Gulf Coast communities and underscored 2 important areas of focus related to human health—an emphasis on both mental and physical health and a need for assistance to the affected communities already facing limited access to health care services as a result of Hurricanes Katrina and Rita.1 The Gulf Region Health Outreach Program (GRHOP) responds to these key considerations.
The GRHOP addresses the problem of health resilience through a multidisciplinary public health systems approach using community-based assets. The program is a set of integrated, 5-year projects to strengthen health care in 17 coastal counties and parishes in Alabama (Mobile, Baldwin), the Florida Panhandle (Escambia, Santa Rosa, Walton, Okaloosa, Bay), Louisiana (Orleans, Jefferson, St Bernard, Plaquemines, Lafourche, Terrebonne, Cameron), and Mississippi (Hancock, Harrison, Jackson). The target beneficiaries of the GRHOP are residents of these areas, especially uninsured and medically underserved populations. The GRHOP was developed jointly by BP and the Plaintiffs' Steering Committee as part of the Deepwater Horizon Medical Benefits Class Action Settlement, which was approved by the US District Court in New Orleans on January 11, 2013, and became effective on February 12, 2014. The GRHOP is overseen by the court and is funded with $105 million from the Medical Settlement.
In the context of the GRHOP, resilience relates to the capacity of individuals and communities to anticipate and respond to disasters, and sustainability is defined as the persistence beyond the 5-year funding period of knowledge, infrastructure, and programs derived from GRHOP support. The ultimate goal of the GRHOP is to inform residents of the targeted communities about their health and provide access, during the funding period and in the future, to skilled frontline health care providers supported by networks of specialists knowledgeable in addressing physical, environmental, behavioral, and mental health needs, thereby improving the resilience of the targeted communities to future health challenges.
The component projects include the Primary Care Capacity Project (PCCP), Mental and Behavioral Health Capacity Projects (MBHCPs), Environmental Health Capacity and Literacy Project, and Community Health Workers Training Project. The program also incorporates a Community Involvement project that oversees community participation with program activities and works in cooperation with project leaders to coordinate community involvement within and across all GRHOP projects.
The Table lists the GRHOP projects and organizations. The PCCP invests $46.7 million across all of the 17 Gulf Coast counties and parishes to expand access long term to integrated, high-quality, sustainable, community-based primary care with linkages to specialty mental and behavioral health services and environmental and occupational health services. The project is overseen by the Louisiana Public Health Institute and builds sustainable capacity of community health clinics through direct funding via cooperative agreements and delivering customized group and individual technical assistance. Clinics have used the funding for salary support for clinical providers and support staff, medical equipment, and electronic medical record systems/upgrades. The PCCP supports and advances health systems development through direct funding for health information exchanges, infrastructure investments, and technical assistance. It also builds strategic partnerships to improve health through funding state partners, partnership engagement activities, and technical assistance to nonclinical partners. For example, its Regional Care Collaborative supports the organization and facilitation of regular communications among PCCP community health centers, state partners, and GRHOP partners through developing communication tools, hosting periodic meetings and joint training and continuing education sessions, and encouraging other opportunities to interact and collaborate. In addition, the PCCP supports the Community-Centered Health Home Demonstration Project, which builds on the 3 established characteristics of a successful patient-centered medical home and provides a framework for primary care—and health care organizations in general—to address individual health needs while systematically addressing community conditions that affect individual health.
The MBHCP is implemented by a coalition of academic institutions in which the partners work independently of each other in their respective states and also collaborate on initiatives across the region. The $36 million project provides mental and behavioral health services to improve the overall well-being of the targeted communities. Using models of integrated mental and behavioral health care, the MBHCP works with the other projects to enhance the ability of community clinics to develop into high-quality “one-stop shops” that include integrated mental and behavioral health care. The project contributes longer-term capacity-building resources through the provision of supportive therapeutic and strength-based mental and behavioral health services for children and families, including requested services within schools and communities (eg, Mental Health First Aid). The MBHCP also provides training to better prepare primary care clinicians to treat mental and behavioral health conditions and to work collaboratively with mental and behavioral specialists. The structure of the MBHCP inherently provides a cross-disciplinary approach through its collaborative model. In Louisiana, the project operates through the Department of Psychiatry at Louisiana State University Health Sciences Center. Faculty members at the School of Social Work oversee the project at the University of Southern Mississippi and the University of West Florida in their respective states, and a faculty member in the Psychology Department at the University of South Alabama leads the work in Alabama. This cross-disciplinary structure provides diverse perspectives and models to addressing mental and behavioral health.
The Community Health Workers Training Project is led by the University of South Alabama's Coastal Resource and Resiliency Center. With $4 million in funding, the Center trains lay health workers across the region to provide outreach within their communities to encourage healthy lifestyles, improve health literacy, and help ensure access to needed health services. Selected community health workers are employed by health clinics and community-based organizations across the Gulf Coast, with their salary and benefits paid by the Environmental Health Capacity and Literacy Project. In addition to the basic training for community health workers, the project also delivers advanced training in the prevention and management of chronic diseases and volunteer training for peer health advocates. The project aims to develop a network of trained local residents who will help strengthen the health foundation of the community and serve as community resources for years to come.
The Environmental Health Capacity and Literacy Project has received $15 million in funding and is led by a faculty member in the Department of Global Environmental Health Sciences at the Tulane University School of Public Health and Tropical Medicine. The project enhances the future capacity of environmental health scientists by integrating environmental health science into high school curricula and by exposing high school students to environmental health research through close interaction with Tulane faculty, postdoctoral fellows, and graduate students. The project also supports job placements for GRHOP community health workers and trains them to identify environmental health needs and to direct community members to the appropriate local health resources for services and care. Working with the Association of Occupational and Environmental Clinics, the Environmental Health Capacity and Literacy Project trains primary care professionals in community clinics supported by the PCCP to evaluate individuals with environmental health complaints, offer peer consultations with an environmental health expert, and assist with referrals of individuals to an occupational and environmental health specialist.
The Alliance Institute works in cooperation with the GRHOP project leaders to coordinate community involvement and outreach efforts across the programs. As Alliance Institute subcontracts with local community-based organizations to assist with these efforts in their local communities, it also uses this opportunity to increase the capacity of subgrantees to more effectively work with their target communities to address issues related to access to health care and overall community quality of health.
The implementation of the GRHOP is coordinated by the GRHOP Coordinating Committee, consisting of representatives from each of the organizations responsible for the GRHOP projects, as well as 3 independent members (not affiliated with a GRHOP project). The Committee evaluates the implementation of the projects, ensures that benchmarks are met, enhances the integration of the projects, and recommends adjustments to achieve the mission of the program.
The GRHOP, Resilience, and Public Health
Resilience is a long-sought goal of public health and affiliated programs.3 Providing systematic approaches to prevent shocks to the health of an individual or a population is effectively the goal of routine public health measures such as vaccination for infectious diseases and the prevention of pollution. Decreasing the vulnerability of populations to disasters has been identified as an important public health goal.4–7 Health vulnerabilities affect the impact of disasters and should shape the design of resilience-based approaches.8 These vulnerabilities have been evident in the US Gulf Region as communities have faced interdependent challenges including lack of preparedness against natural disasters and the impact of those disasters on physical and mental health, as well as persistent health disparities and historical environmental contamination exacerbated by the aftermath of Hurricanes Katrina and Rita and the Deepwater Horizon oil spill.
While progress has been made, the solutions to date have often employed program designs that typically do not promote communication and collaboration among partners, usually lacked a community-engaged approach, and generally failed to produce sustainable, systemic solutions.9 Moreover, strategies aimed at the resilience of infrastructures often ignore the role of humans and of communities.10 Achieving improvements in public health outcomes requires multidisciplinary approaches and increased understanding of adaptive systems, redundancy, vulnerability and the interdependency of health, and environmental and economic well-being11—all of which are central to resilience and sustainability.
The GRHOP serves as a model for a population-based approach to address population health in the aftermath of an oil spill. The GRHOP projects are designed interdependently to sustainably strengthen local capacity to advance the knowledge, programs, and infrastructure that will lessen the impact of future natural or technological disasters, promoting long-term community health resilience. Its incorporation of core competencies in environmental and human health, as well as integration with community needs and activities, exemplifies the overall integrated cross-systems approach that characterizes the GRHOP.
1. National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (US). Deep Water: The Gulf Oil Disaster and the Future of Offshore Drilling. Washington, DC. digital.library.unt.edu/ark:/67531/metadc123527/. Published January 2011. Accessed April 5, 2017.
2. 40 CFR 300.5 [Title 40. Protection of Environment; Chapter I. Environmental Protection Agency; Subchapter J. Superfund, Emergency Planning, and Community Right-to-Know Programs, Part 300 National Oil And Hazardous Substances Pollution Contingency Plan, Subpart A Introduction]. http://www.gpo.gov
/fdsys/pkg/CFR-2001-title40-vol24/pdf/CFR-2001-title40-vol24-sec300-5.pdf. Accessed July 13, 2017.
3. Ebi KL, Semenza JC. Community-based adaptation to the health impacts of climate change. Am J Prev Med. 2008;35:501–507.
4. Keim ME. Building human resilience: the role of public health preparedness and response as an adaptation to climate change. Am J Prev Med. 2008;35:508–515.
5. Jan S, Lurie N. Disaster resilience and people with functional needs. N Engl J Med. 2012;367:2272–2273.
6. Lurie N, Manolio T, Patterson AP, Collins F, Frieden T. Research as a part of public health emergency response. N Engl J Med. 2013;368:1251–1255.
7. Ebi KL. Resilience to the health risks of extreme weather events in a changing climate in the United States. Int J Environ Res Public Health. 2011;8:4582–4595.
8. Redwood-Campbell L, Abrahams J. Primary health care and disasters-the current state of the literature: what we know, gaps and next steps. Prehosp Disaster Med. 2011;26,184–191.
9. The National Academies Press. Disaster Resilience: A National Imperative 1-198. Washington, DC: The National Academies Press; 2012.
10. Haimes YY. Strategic preparedness for recovery from catastrophic risks to communities and infrastructure systems of systems. Risk Anal. 2012;32:1834–1845.
11. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health 1-192. Washington, DC: The National Academies Press; 2012.