Health system climate resilience plans and urban resilience: an exploratory study

Introduction

Although climate change has been recognized as a threat to human health for decades (1), the roles of health care providers in mitigating and adapting to these threats has only recently begun receiving widespread attention. In terms of mitigation, the healthcare sector in the United States is itself estimated to be responsible for around 10% of the country’s emissions (2), indicating emission reduction efforts needs to become a greater priority in these organizations. In terms of resilience, forecasts for higher-intensity storms and weather extremes suggest that health systems have increasingly important roles to play in preparing and supporting both their operations and communities during these events.

On Friday, April 22^nd, 2022, the U.S. White House and the U.S. Department of Human Health & Services (HHS) created a Health Sector Climate Pledge. Many organizations of different types from across the health sector signed onto this pledge, which has three main requirements. The first is that the organization agrees to reduce emissions by at least 50% by no later than 2030 and reaches net zero emissions by 2050 (3). The second is that each organization appoints an executive lead to oversee this work. Third, and most relevant to this article, is the development and release of a climate resilience plan that addresses (I) continuous operations, and (II) anticipating the needs of groups within the communities served who may experience disproportionate risks of climate-related harm.

Although the Health Sector Climate Pledge is relatively new, there is a longer history of this type of work within urban planning profession from which health systems can draw. Conversely, the role of urban resilience planning in supporting human health is also expanding (4). One area in particular, the smart cities paradigm, may help bridge the work of health systems with urban planners. Smart cities use modern technological solutions to reduce pollution and greenhouse gas emissions, produce clean and efficient energy, and provide a heightened standard of living for all residents (5).

Smart city plans overlap many of the same activities as health system resilience plans. Both involve pledges to reduce emissions and provide sustainable services to all members of their respective communities. Because smart city plans have been around much longer, in some cases dating back to early 1990s, they may offer helpful perspectives to the more recent climate resilience plans stemming from the HHS pledge. Furthermore, cases where health system climate resilience plans involve communities that are already part of smart city plans, harmonization across the two planning approaches could provide a shared planning “language” that strengthens their collective impact. The smart cities framework is an analysis tool to help assess the changes cities are undergoing to improve and become more resilient. The most important section of the framework for this brief is the assessment of climate initiatives, where smart cities are analyzed by the following categories: management, infrastructure, materials, energy, water, waste, and pollution. The smart cities framework is suitable for analyzing health system resilience plans because it provides a robust means for gathering and comparing actions by multiple organizations to enhance community resilience to climate change.

The purpose of the present study is to examine the climate resilience plans that are starting to emerge from health systems who signed the HHS pledge, using a smart cities framework. Our goal in this exploratory research is to look for ways in which the two approaches may be most effectively harmonized. We hope that this can fill the current knowledge gap in the analysis of health system climate resilience plans and the parameters to analyze them by.

Methods

Health systems were identified using the list of pledge signatories from the White House website which was accessed on January 23^rd, 2024. To locate resilience plans, we first completed Google searches to identify the corporate website of each health system on the HHS list. We then scanned the home page and “about us” pages, to determine whether a link to a sustainability page was included. If there was no link from either page, we searched within the corporate website using home page’s search function and the following keywords: “sustainability”, “resilience”, and “resilience plan”. These keywords were selected because health systems primarily put the resilience plans on their sustainability pages. Also, since the plans were intended to be resilience plans, “resilience” and “resilience plan” were used as keywords. We then manually searched each of the resulting links, until we either found a resilience plan or exhausted the relevant results.

We considered each search for a resilience plan to be successful if we were able to locate a report containing, minimally, the following elements: (I) an indication of a specific set of communities and/or geographic area of focus for the plan, (II) an assessment of one or more specific environmental vulnerabilities, and (III) specific recommendations and/or priorities for action. If the website description did not include all three elements, we considered the plan to be not yet “publicly disclosed”.

Our next step was to analyze each of the plans we had identified against the smart cities framework. In this step we examined whether each plan contained coverage of the following eight elements: management, infrastructure, materials, energy, water, waste, pollution, and community resilience. The first seven of these elements were based on results from a recent review of tools frequently used in smart city analyses (6). The last element, community resilience, was added to help grasp the extent to which the health system resilience plans attempted to solve climate issues within the context of their local communities. All reports were independently manually coded by three of the study authors (E.S., D.H.K., A.N.P.). Codings were then compared across authors, and discrepancies were reconciled through consensus. The approach to coding is described below.

Each plan was coded on a single-point scale for each element, reflecting presence or absence, using the following definitions. Due to the exploratory nature of this study, we used a single-point scale for each element since we primarily want to assess which categories are mentioned the most amongst plans. Management was coded as present if the report identified a specific leader or team as managing the health systems’ climate transition and publication of their resilience plans. Infrastructure was coded if the plan mentioned any physical changes to the health system site or local community. For the health system, examples included installing green rooftops or onsite solar panels. For the community, examples included new local farms or transportation to/from the health system.

The Materials category was coded if the report described sourcing supplies from climate friendly or local vendors or decreasing use of environmentally harmful materials and chemicals. Energy was coded if the report described energy sourcing and/or efficiency. Water was coded if the report mentioned decreasing excessive water usage, providing cleaner water/water reclamation for the community, or both. Waste was coded if the report described efforts to improve disposal practices. Finally, community resilience was coded if the plan described specific activities being undertaken within one or more specific communities.

Results

Of the 88 hospitals and health systems signing the HHS pledge in the first two rounds, we were able to locate a total of 35 resilience plans. Findings for smart cities components are illustrated by the dark gray bars in Figure 1. The most frequently cited category was pollution, appearing in all the 35 plans (100%). Conversely, the least frequently cited element was materials (66%), followed by management (71%), water (71%), and community resilience (74%). Since one of the primary goals of these plans was to emphasize community resilience, we conducted a secondary analysis of the plans that included this element. These results, as represented by the light gray bars in Figure 1, had a higher relative proportion of coverage from the smart cities elements.

Figure 1 Proportions of topics in resilience plans and all plans.

Discussion

With the initial target release dates for climate resilience plans having passed, there are several observations we can make. The first is that health system leaders may be experiencing barriers to the creation and dissemination of these plans. We base this conclusion on the relatively low number of plans that appear to have been released so far: just 35 out of the 88 health systems who signed on to the pledge during the initial periods it was open, or approximately 40% of the total. For many of the health systems in our study, plans were difficult to find, often involving many custom steps to locate. For a few health systems, there was an email prompt on the bottom of the sustainability page, where one could request more information, instead of having the plan readily available.

Even for the 35 plans we were able to locate, only 26 included descriptions of how they plan to help mitigate harm within their immediate communities. The rest focused only on decarbonization efforts within the health systems themselves, suggesting that only about a one third of pledge signatories (30%) have publicly released plans so far.

In examining climate resilience plans using the smart cities framework, we observed wide variability in terms of conceptual overlap across the plans. The area where we saw the most overlap was the reduction of pollution, with all the plans mentioning it. This was expected, since the HHS pledge emphasized reducing carbon emissions, and setting a pollution reduction timeline for health systems. Alongside pollution, most plans mentioned energy and infrastructure changes, mostly as a method to lower their emissions. Alongside lowering emissions, infrastructure played an interesting role in many plans, being used as a method of benefiting both the environment and community. Common ways this was done was through the creation of public greenspaces and local farms.

The area where we saw the greatest amount of opportunity was in management designations. Only 62% of the plans included a description of management leads or teams that have been tasked with leading the health systems’ climate goals. This gap was surprising to us, given the pledge’s emphasis on designating an executive-level lead.

Implications for policy & practice

There are some important limitations we should acknowledge before discussing policy and practice implications. As an analysis of emerging data regarding health system resilience plans, results are limited to the health systems participating in the HHS pledge who publicly released resiliency plans. Given the relative recency of this work, there are no longitudinal data are available yet to evaluate the impact of developing these plans.

Although resilience planning is currently a relatively new activity among health systems, we anticipate that as health-related impacts of climate change continue to become more apparent, more health systems will be incorporating a climate lens into their community impact planning. Based on our exploratory analysis, we believe the smart cities framework may offer useful guidance in categorizing potential approaches to strengthening community resilience. The smart cities framework may also offer a common language through which community health leaders in health systems can approach collaborations with urban and community sustainability directors. By collaborating across sectors, communities may be better positioned to jointly identify planning and readiness gaps, as well as redundancies in activity, promoting greater efficiency throughout the resilience planning process.

Acknowledgments

The authors would like to thank Winslow Dresser and Kristen Kaufman from Healthcare Without Harm for their very helpful input during this research work.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-145/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-145/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Research protocol was submitted to the IRB of the tail author (A.N.G.), where it was determined not to involve “human subjects” as defined by the Common Rule, and did not require IRB oversight.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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