Hurricanes Katrina and Rita: evacuee healthcare efforts remote from hurricane affected areas.

Abstract: Hurricanes Katrina and Rita produced the largest evacuation due to a natural disaster in United States history. Many people were evacuated or rescued from New Orleans and the Gulf Coast, resulting in a need for mass disaster shelters and medical care for months following the storms. The shelter healthcare system that was successfully developed in the Shreveport-Bossier City, Louisiana area was accomplished with little support from customary sources. This report is written after much discussion and introspection of community leaders involved "on the ground," who organized and provided medical services to evacuees of south Louisiana. Its purpose is to compile "lessons learned" in preparation for the next disaster recovery effort that might affect this or any other region of our country.

Key Words: Katrina, disaster, communication, preparation, response, Shreveport-Bossier

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Hurricanes Katrina and Rita in September of 2005 dealt a devastating blow to the Gulf Coast of Louisiana and Mississippi. In Louisiana, more than one million people were displaced from metropolitan areas like New Orleans and Lake Charles, as well as from many suburban and rural communities along the coast. The number of homes destroyed by these storms was ten times that of Hurricane Andrew in 1991 or the combination of the four Florida hurricanes of 2004. The evacuees of Louisiana predominantly headed north and west--finding temporary residence in hotels, in the houses of friends and family, and in temporary emergency shelters of various sizes.

A disaster is defined as "a relatively acute situation that adversely impacts the health and economic well-being of a community to an extent that exceeds the local coping capacity." (1) It is well-documented that in natural disasters such as earthquakes and hurricanes, the direct public health effects are immediate and often devastating. Most deaths and injuries occur during the first few hours following the event, and secondary public health effects are related to displacement of the affected population, destruction of public utilities, and disruption of basic health services. (1) This pattern was observed in the aftermaths of Hurricanes Katrina and Rita, which occasioned the first-ever evacuation of a major American city.

Many evacuated New Orleans and the Gulf Coast in the days preceding Katrina, and many others had to be rescued after the storm receded. Most who left their homes before Katrina hit left nearly all of their material possessions behind, expecting to return after the storm passed. Those evacuated after the devastation of the city usually left with little more than the clothes on their backs. Many came to unfamiliar locations and found themselves dependent on others to provide their most basic needs. The aftermath of Hurricanes Katrina and Rita revealed both the compassion and the collaboration of a nation that responded to meet the needs of the disaster victims and was specifically shown by the rapid and effective response of the medical community of Shreveport/Bossier, Louisiana, to the needs of these displaced persons.

It is noteworthy that the shelter healthcare system that developed in Shreveport-Bossier City, Louisiana (referred to hereafter as Shreveport/Bossier), was accomplished with little support from customary sources. Medical records of people were nonexistent, and many brought medications outside of their original bottles. There were incomplete and sometimes contradictory recommendations from state and federal health agencies. Lacking a single source for reliable public health recommendations, local practitioners often were required to make decisions about protection from disease outbreaks and public health services, such as vaccinations.

Following the acute disaster response phase of search and rescue, triage and management of injuries and chronic health conditions becomes the major medical focus, (1) and this held true in Shreveport/Bossier. Despite all the uncertainty in people's lives, the shelter health system became a place for many evacuees to catch up on healthcare maintenance. For example, a mobile clinic staffed by local pediatricians was used to provide pediatric services to each shelter, and this provided an opportunity to bring childhood vaccinations up to date.

This report is written from the perspective of lessons learned in the acute and postacute disaster recovery efforts of one Louisiana community. Shreveport/Bossier is a metropolitan area of approximately 300,000 people, nearly 200 miles from New Orleans. Together they form a moderate-sized city, separated by the Red River, in northwest Louisiana. They became a major evacuation site for people displaced from both hurricanes because of their location on the major northbound interstate from south Louisiana and the size and the resources of the metropolitan area (Fig.).

Learning comes from examining both success and failure. As is the case with everyone involved in helping people after Katrina and Rita, the Shreveport/Bossier community had abundant experience with both. This report is written after much discussion and introspection of community leaders involved "on the ground," who organized and provided medical services to evacuees of south Louisiana. Its purpose is to compile "lessons learned" in preparation for the next disaster recovery effort that might affect our country. This communication offers these lessons under three major concepts:

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* If a community system is already established, don't invent a new one.

* The spirit of volunteerism is alive in America--use it effectively.

* The key to effective disaster relief is good communication.

Utilization of Established Community Systems

It is well-documented that in refugee situations clinical medical care is a priority issue. (2,3) Some evacuees require acute care for injuries, medical conditions, and diseases, while others require mental health support after the immediate crisis (2,4) When Shreveport/Bossier became a site for evacuation of people from the two storms, the early response was led by large community healthcare systems (Table). From the start, the medical care of this new, instant population was delivered by physicians, nurse practitioners, physician assistants, nurses, and other healthcare professionals at several large shelter medical clinics created across the sister cities. These shelter clinics delivered triage and acute care for new arrivals, provided ongoing medical care for acute and chronic health problems, monitored (and recorded) key public health sentinel markers to monitor for disease outbreaks, and provided public health services such as vaccinations. The shelter healthcare delivery system drew from the established networks already present in the community and was based in its three large health systems. The first-aid approach historically used by the American Red Cross in disaster relief situations was not adequate in this large scale disaster, which produced an overwhelming number of evacuees that not only needed acute care but also required longer term care for chronic conditions.

While these ambulatory care sites were created at each shelter site, the already established ambulatory care sites of the large health systems and the offices of groups of primary care physicians became established points of entry into the community healthcare system. Within 48 hours, a network of physician offices in the community assumed the care of evacuees regardless of health insurance status. The establishment of new systems to deliver healthcare to evacuees both in and outside large shelters was necessary because the healthcare needs of this large evacuation population exceeded the capacity of an already strained emergency room system.

The need for comprehensive pediatric care was recognized early. This led to the mobilization of the local pediatric community, who made use of an existing mobile clinic, staffed by local pediatricians, to meet the needs of all of the evacuee shelters. It moved between sites and was used to provide pediatric services to each shelter in rotation. They even developed the capability of accessing the state immunization database and provided the opportunity to bring childhood vaccinations up-to-date.

Pharmaceutical representatives became first responders in delivering samples to the shelters for immediate use of evacuee healthcare providers. A large independent for-profit pharmacy (Sterling) and a nonprofit "free" pharmacy (Interfaith Pharmacy) teamed in a leadership role to form a distribution system for medications needed by evacuees. A large wholesale pharmaceutical system (Morris Dickson) became the distribution outlet to supply medication to evacuees in every large shelter in Louisiana.

Within a couple of days, the National Association of Chain Drug Stores developed an agreement to participate in supplying medicine refills for victims of Katrina and then Rita. Every retail pharmacy in the community participated in this humanitarian effort, without established government guidance.

Dental services were established by local dentists, the Louisiana State University Health Sciences Center Oral Surgery Department, and volunteer dentists from other parts of the country, using offices in an already established indigent dental clinic. Community mental health professionals were available around the clock to aid in counseling victims and placement of people with more serious mental illness. A local privately-owned medical laboratory volunteered to provide lab services for the shelters, and a medical waste disposal company developed a system for medical waste disposal as a part of their service to the community.

This entire health system process developed with little or no input or guidance from state or local government or the Red Cross. The response was quick, effective, and done "on the fly"--a testament to the efficacy of well-established community networks and leadership.

The narrative of the establishment of a comprehensive health system was only a small part of the total story. Large churches adopted each of the large Red Cross shelters and helped fill the critical shortage of manpower. Many paid church leaders took on full-time roles to be on-site shelter managers with the blessings of the local American Red Cross Chapter. They also worked in the recovery effort to establish more permanent arrangements (housing and jobs) for people displaced to Shreveport/Bossier.

Security for evacuees and workers was quickly established by local law enforcement. The local Police forces established site and perimeter security. The local sheriffs departments assumed responsibilities for internal security. Louisiana National Guard capacity was initially mobilized to direct relief efforts in South Louisiana but were also deployed later to assist security efforts at the shelters.

Local Boy and Girl Scout units and other youth organizations organized meals, clothing drives, and monetary collections to assist with shelter operations and care of evacuees. The local food bank increased its capacity 10-fold overnight. A local church and the Salvation Army developed volunteer networks to convert previously empty buildings to distribution centers and to operate these centers to supply north and south Louisiana recovery efforts.

As emphasized in the Sphere Project report, (2) there is a huge advantage to using already-established community networks in a large-scale disaster. These can provide intellectual and financial resources, as well as a web of network connections for organization of disaster recovery efforts. Networks can also be rapidly mobilized, which is important in the early, time-critical phases of disaster response. This point alone explains the success of large, local community businesses and nonprofits early in our disaster recovery effort. In this effort, the collaboration of business and nonprofit sectors was more effective than the initial response of the government sector. This effectiveness might be explained by the well-established line of authority, flexibility, and quick decision-making capabilities of local business and nonprofit sectors.

Suggestions for Future Staging Areas and Sites of Evacuation Close to the Disaster

1. The most effective response requires a focus on large health systems as the primary resources of first response to the medical needs of evacuees in the community. The emergency department (both physician and nurse leadership) should be considered as "on point" in these circumstances.

2. Before a disaster, identify emergency response leadership teams with expertise in establishing medical clinics either before or at the time of the disaster. As each clinic is established, one or two members of this leadership team should be "retained" in a leadership role in the established clinic. This group must have a developed plan for services and a resource book before the disaster.

3. After the initial mobilization, division of responsibilities among health systems brings accountability to the medical disaster relief efforts.

4. Utilize the local business and nonprofit entities as first responders. This includes engaging large businesses and nonprofits in a discussion about the division of responsibilities, and establishing agreements on multiple fronts before a disaster.

5. State and local governments should have established policies that aid the mobilization of volunteer effort through the local community. In a government proclamation of an emergency, volunteers should have the support of the government and protection from liability during their good faith efforts.

6. State and federal health agencies need to agree before a disaster on who has authority over health recommendations in the disaster area.

Utilization of Volunteerism

The degree of volunteerism and level of cooperation between usually competitive health systems in our community was unprecedented. The response of people outside the region wishing to help was equally astounding. What was missing and needed was a good system to manage the outpouring of support. There was at first no internet connection in the local shelters themselves, which would have enabled immediate management of a potentially large volunteer effort. Although we had a 211 system (an existing information and resource call line for people to access social services in the area), the capacity was limited and could not be "ramped up" quickly enough to use it to maximum effect under these disaster conditions.

In the case of healthcare workers, no system existed to separate medical personnel from the thousands of others volunteering without these skills. Early on, it was evident the capacities of the Red Cross and government organizations were also very limited in the area of volunteer management in a large disaster. For that reason, some medical personnel who were needed in this long-term healthcare effort were "turned away" by Red Cross volunteers managing the volunteer recruitment effort. This included both local healthcare professionals wishing to serve the shelter healthcare system and "out of state" physicians and nurses who were told they were not needed.

The medical leadership of the shelter healthcare system did immediately establish a web site at the university for volunteers to sign up. This was very helpful, but its presence and purpose had to be communicated to medical system personnel through a "word of mouth" system. In addition, concern over licensing verification of providers proved a barrier to more widespread media attention.

The immediate mobilization of appropriate talent is essential to a rapid and effective disaster relief strategy. On the basis of reports from physician and nurse volunteers who participated in healthcare delivery in shelters in Shreveport/Bossier, we think there is significant room for improvement. While we were scrambling in survival mode to care for the medical needs of evacuees, physicians and nurses all over the country were apparently scrambling to offer their services. The National American Red Cross was inundated in the early days of Katrina with potential volunteers. However, stories of physicians going to full-day classes on how to setup cots before using their skill and talent in a shelter do not reflect an ideal system.

The local American Red Cross understood the importance of empowering others in organizing the local shelters and assisting the medical efforts; as often, these efforts were the result of the connections of community leadership at the individual shelters. However, this help was not from any effort coordinated from the national level of American Red Cross or other large volunteer or governmental agencies. Instead, the outpouring of humanitarian aid in Shreveport-Bossier was facilitated largely by nonprofit, faith-based and business sectors.

Suggestions for the Effective Use of Volunteers in Evacuation Sites Close to a Disaster

1. Local disaster organizations in areas that are highly likely to be used as evacuation areas in Level 4 and 5 hurricanes, large earthquakes, or other major disasters should be prepared with a plan to effectively capture the talents of local community volunteers. Elements of this plan include a database of pre-identified volunteers that may be maintained nationally and locally, tested communications systems, a web based system to allow individuals with specific medical skills to sign up for services, a system to put leaders on alert quickly using a "first call" system, and preparations for mobilization of needed supplies.

2. Homeland Security must develop a better understanding of and a closer relationship with local nonprofit agencies that could respond to disasters in a volunteer capacity in their community. If Homeland Security is to be the agency that coordinates and supervises all the others, they must know the community and the human network resources

3. Disaster relief organizations like the Red Cross, Salvation Army, and Homeland Security must identify the specialized talents needed in the face of a large-scale relief effort. This should be done as preparation for any disaster relief effort. As it relates to medical services, the human resource skills might be different for hurricane victims than those of an earthquake or other major disaster. In the care of evacuees from the hurricanes, some of the more important talent needs were emergency room physicians, pediatricians, psychiatrists, family physicians, and mental health experts.

Utilization of Communication

Communication networks must be established immediately following a disaster on multiple fronts. A lesson learned in affected communities following Katrina and Rita was the need to plan for alternative communication networks. Of all the problems with federal and state response to the storms, the failure to provide effective communications was at the root of the problem because coordination is impossible without communication. The unprecedented damage to the basic infrastructure in south Louisiana and Mississippi exposed this planning weakness and hampered relief efforts. Reliable predisaster networks were often affected, even in areas untouched by the disaster because they often did not have the capacity to deal with the massively increased load during and after the disaster.

In this regard, there should be a thorough review of communication strategies in staging areas. This may be the most important concern in any disaster relief effort, and Katrina/Rita revealed some real deficiencies. In Shreveport/Bossier, the telecommunication companies were able to quickly take steps to increase cell phone capacity for the area, although the ability to connect to organizers was at times greatly slowed. But areas closer to the disaster were more profoundly affected. Communication needs for the "shelter health system" were met through the use of cell phones. As volunteers worked at shelters or signed up to help, their cell numbers were collected and the growing list was carried by medical leadership and posted in the medical triage areas. Regular medical leadership meetings and the university medical internet web site also were used for communications.

In addition, the importance of face-to-face meetings and briefings cannot be overstated. Even with an adequate communication system utilizing telecommunications, email, and web sites, there is a need for face-to-face meetings. In Shreveport/Bossier, the team of healthcare leaders met once or twice a week for late dinners to allow key people to be involved in shared decision-making. This allowed everyone to be "on the same page" and to share learning among large shelter operations.

In addition, daily meetings at each evacuee site, attended by local managers, Red Cross officials, police, and medical leaders, helped solve problems and coordinate efforts. The coordination of medical efforts with the ongoing efforts by other personnel, including the distribution of information to local disaster relief partners and agencies, was important to effective disaster relief.

Suggestions for Effective Communication Close to the Disaster Area

1. Before a disaster, communities must develop leadership cohorts involving local government, non profit, healthcare, and business leadership that have immediate access to resource directories and understand local responsibilities and chain of command.

2. On national as well as local and state levels, a task force of communication experts, including media and telecommunication expertise, should be established to explore communication issues related to large-scale disasters and alternative communication strategies. The exploration of possibilities would include consideration of media strategies, landlocked telephone lines, cell phones, text messaging, satellite phones, 800 and 888 numbers, battery powered radios (with appropriate arrangements for recharging), and email or web sites.

The review of both the successes and failures of evacuee healthcare efforts in a moderate-sized Louisiana metropolitan area, remote from the immediate destruction of the major hurricanes of September 2005, is an important exercise. This disaster caused the first modern full scale evacuation of a major U.S. city, and differed from most previous U.S. disasters to date in that there were large numbers of people seeking refuge long distances from their homes. Peter Drucker said, "The best way to predict the future is to create it." Lessons learned in Shreveport/Bossier could be instructive in preparing for the next large-scale disaster to face our country. Learning from this experience could help in planning for other types of disasters, including earthquakes, terrorism, or weather-related disasters.

Acknowledgments

The authors would like to recognize Terry Strain, PA-C, Doug Boudreaux, PharmD, Susan Cash, RN, and Sarah Kindall, RN, and all of the medical professionals who donated their time and talents during the disaster and helped in developing this manuscript.

References

1. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health 1997;18:283-312.

2. Humanitarian Charter and Minimum Standards in Disaster Response. The Sphere Project Handbook, 2004 revised edition. Chapter 5: Minimum Standards in Health Services. Available at: http://www.sphercproject.org/handbook/index.htm.

3. Nieburg P, Waldman RJ, Krumm DM. Hurricane Katrina. Evacuated populations-lessons from foreign refugee crises. N Engl J Med 2005;353:1547-1549.

4. Holman W. A market doubles-overnight. Baton Rouge hospitals face unprecedented planning and logistical challenges. Mod Healthc 2005;35:32.

Phillip A. Rozeman, MD, FACC, FSCAI, and Edward J. Mayeaux, Jr., MD, DABFP, FAAFP 

From the Willis-Knighton Health System, Northwest Louisiana Red Cross, and Louisiana State University Health Sciences Center, Shreveport, LA.

Reprint requests to Edward J. Mayeaux, Jr., MD, FAAFP, Professor of Family Medicine, Professor of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, PO Box 33932, 1501 Kings Highway, Shreveport, LA 71130-3932. Email: [e-mail]

Accepted July 11, 2006.

RELATED ARTICLE: Key Points

* Effective management of evacuee healthcare efforts depend on a thorough understanding of the capacity and networks available with established community health systems, pharmacies, medical clinics, and medical support services.

* The spirit of volunteerism in America is an ingrained part of our heritage but must be used wisely and effectively. In a large scale disaster and evacuation, capacity for service (especially healthcare) should be captured and utilized.

* Effective communication is the key to managing disaster recovery--especially evacuee healthcare efforts. Existing daily communication sources can be overwhelmed as a result of a disaster, and emergency plans must be in place beforehand.

Table. Major hospital systems in Shreveport, Louisiana

                                           No. of
Hospital             Address               beds    No. of employees

Louisiana State      1501 Kings Highway    450     4445 -- full-time
  University Health  Shreveport, LA 71130          1309 -- part-time
  Sciences Center
Willis Knighton      2600 Greenwood Road   787     4800
  Health System      Shreveport, LA 71103
Christus Schumpert   One Saint Mary Place  931     3,750
  Health System      Shreveport, LA 71101          600 -- volunteers

Data from Shreveport Chamber of Commerce and individual health systems.