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(Please refer to the formatted PDF of this letter and its
attachment submitted via the web).

Dear Secretary Rodriguez and Chairman Nichols: 

This letter is being sent on behalf of two regional alliances of
Public Health Department representatives from across the State of
California, actively advancing chronic disease prevention and
health equity through a health in all policies approach.  We
welcome the opportunity to comment on the recent documents released
by the CalEPA/ARB regarding the identification of disadvantaged
communities for the purpose of prioritizing investment of the
Greenhouse Gas Reduction Funds per SB 535.   We understand that the
implementation of this legislation is progressing under rapid
timelines and appreciate the Air Resources Board’s commitment to
nonetheless provide thoughtful deliberation to address public
feedback.

As public health professionals engaged in efforts to reduce the
stark disparities in health that exist across California, an
important focus of our work is identifying and improving conditions
in health disadvantaged communities.  Evidence suggests that social
factors, which include income, unemployment, education and rent
burden, are the most significant drivers of health and wellbeing
(US Burden of Disease Collaborators. The state of US health,
1990-2010: burden of diseases, injuries, and risk factors. JAMA.
2013 Aug 14; 310(6):591-608.) We are concerned that neither Method
1 (overall CalEnviroScreen (CES) score) nor the other alternate
methods presented in the recently released methodology report,
“Approaches to Identifying Disadvantaged Communities”, adequately
identify populations that are highly disadvantaged based on these
social factors, collectively referred to as the social determinants
of health.  

The importance of employing a methodology that adequately
identifies and weights disadvantage based on the social
determinants of health is further elevated given the importance
community stakeholders place on income, unemployment, education and
rent burden in defining the common needs of disadvantaged
communities.  In Table 3 “Common Needs of Disadvantaged Communities
(As Identified by Community Advocates)” of the August 22, 2014
document  “Investments to Benefit Disadvantaged Communities,” the
bulk of the needs given are economic—improved jobs to increase
family income, better workforce preparation, reduced housing and
energy costs and improved transportation access.  The needs that
are not economic are couched in economic terms—health harms like
asthma and obesity are “suffered disproportionately by low-income
residents/ communities.”  

Stakeholders understand what the scientific evidence clearly
demonstrates; that social determinants are the largest contributor
to health and quality of life.  The Public Health Alliance of
Southern California, with technical assistance from the California
Department of Public Health (CDPH), has conducted an analysis to
determine whether communities identified as disadvantaged based on
a high (top 15%) overall CES score are also the most disadvantaged
(top 15%) in terms of poverty. Our analysis suggests that only
56.5% of these most impoverished (top 15%) census tracts would be
identified as disadvantaged based on their top 15% overall CES
Score (please see analysis (a) Poverty in the attachment below,
“Poverty, Population Characteristics and CES 2.0”). Further, only
52.5% of census tracts identified as disadvantaged based on the
overall CES score fell into the top 15% of census tracts based on
poverty level.  Both of these results suggest deficiencies in how
the tool is being used to identify socioeconomic vulnerability and,
hence, public health disadvantage.

A second analysis (see Attachment below, analysis (b) “Population
Characteristics”) also suggests a relatively poor statistical
correlation between pollution-burden and population
characteristics, as currently measured, among census tracts in CES
2.0.  Only 61.8% of the census tracts with a top 15% population
characteristic score are also in the top 15% in terms of their
overall CalEnviroScreen Score.  This poor statistical correlation
can be seen visually in Figure 2 of "Approaches to Identifying
Disadvantaged Communities” report where the scatterplot diagram for
method 1, overall CalEnviroScreen Score does not show a linear
clustering (i.e., pollution burden scores tracking equally with
population characteristic scores) but rather a diffuse cloud, with
many communities that score high on one criteria but not on
another. 

The fundamental approach utilized in CalEnviroScreen (CES), to
incorporate both pollution burden and social determinant criteria
into a single score through multiplication, creates a number of
methodological concerns.  First, the multipliers don’t always
reflect identified biologic or risk interactions between pollution
and population characteristic factors.   Additionally, the
assignment of weights such that an equal 10 point scale is given to
both the pollution burden and population characteristics means that
the primary (social) determinants of health are undervalued based
on their proportional contribution to health outcomes, and that
pollution burden is disproportionately over-weighted.  Finally, the
population characteristic score includes health outcomes strongly
associated with environmental exposures while omitting critical
chronic disease health outcomes that contribute to the majority of
healthcare expenditures (Galea S, Tracy M, Hoggatt KJ, DiMaggio C,
Karpati A. Estimated deaths attributable to social factors in the
United States. Am J Public Health. 2011;101:1456-1465.)
 

This analysis is not meant to suggest that pollution burden should
be discarded as a measure of disadvantage.  Instead, it suggests
that pollution burden and population characteristic data are
independent and should be weighted according to their share of
attributable mortality and morbidity in the United States. 

Our two Alliances are currently developing an evidence-based method
for identifying health disadvantaged communities.  This is a
deliberate process undergoing scientific review, and as such is not
expected to be completed prior to ARB’s September decision point. 
Given that, we understand that our index will not be considered as
a qualifying option in this first year’s criteria. However, we want
to ensure that in future years, an evidence-based health
disadvantage metric is included into the methodology for defining
disadvantaged communities.

In the development of future year’s disadvantaged community
identification methodology and allocation protocols, we would
suggest the formation of a working group that includes
representatives from public health and low-income communities to
provide input on the implementation of SB 535, ranging from
continued refinement in the identification of disadvantaged
communities, to SB 535 guidance document updates, and the
evaluation of the effectiveness of awarded projects in addressing
disadvantage.  This will provide critical input needed to both
effectively achieve greenhouse gas targets and maximize benefits to
disadvantaged communities.

For the purposes of this year’s allocation only, we ask CalEPA/ ARB
to consider the use of a one-time temporary measure that weights
the current CES indicators based on the relative magnitudes of
their demonstrated impacts on health and well-being as reflected in
the research literature. 

Thank you for your consideration of our comments.  There is a
tremendous opportunity to effectively address climate change and to
create transformative change in disadvantaged communities across
California.  We welcome the opportunity to partner with CalEPA/ARB
now and in the future to ensure that we meet or exceed greenhouse
gas targets while optimizing the greatest evidence-based
co-benefits for disadvantaged communities.

Sincerely, 
 

Susan Harrington M.S., R.D.
Director, County of Riverside Department of Public Health
Co-Chair, Public Health Alliance of Southern California 

Cheryl Barrit, M.P.I.A .
Preventive Health Bureau Manager
Long Beach Department of Health and Human Services
Co-Chair, Public Health Alliance of Southern California

Tracy Delaney, Ph.D., R.D.
Executive Director, Public Health Alliance of Southern California

Chuck McKenty, Ph.D.
Alameda County Department of Public Heatlh
Co-Chair of BARHII

Michael Stacey, MD
Solano County Public Health Department
Co-Chair of BARHII

Sandi Galvez, MSW
BARHII Executive Director