The Katrina public health debacle: lessons learned and lessons ignored.

Better planning for disaster relief is clearly important on a national basis, as the large loss of life in New Orleans following hurricane Katrina has made abundantly clear. Even apart from concerns resulting from manmade disasters, there are abundant ecological threats with the potential to damage large population centers. These range in cause and geography from the next earthquake in San Francisco, to the next hurricane in the Southeast, to the next volcanic eruption of Mount Saint Helens.

There has been widespread criticism of the role of FEMA, other federal agencies, state and local agencies, and of elected officials in the wake of Katrina; the criticism has often come from each of these groups regarding others, and all in turn have been subject to criticism by the public and the media. A disquieting op-ed piece by Michael Cook in the New York Times, for example, described FEMA as a "Bureaucratic Disaster Area" that "has neither the funds nor the will to actually do anything about the nuts and bolts of disasters." What is most disquieting of all, however, is that Cook wrote those words not in 2006, but rather in 1989, yet in large measure they still resonate today. (1)

It remains very much an open question whether even the fatally flawed response to hurricane Katrina will be sufficient to generate a national consensus to adopt more effective strategies to prepare for future national calamities of comparable magnitude. (2) I would submit that what is still needed is a fundamental change in our national approach to disaster planning, not just a reshuffling of personnel and organizational charts. Our ability to prepare for a sudden influx of casualties, whether civilian or military, has long been called in to question. (3)

The Katrina disaster demonstrated at least four areas of weakness that played out in succession, each compounding the problems of the preceding stages:

1. The lack of an effective evacuation plan for residents who were directly in harm's way left a huge population exposed to the risks of both the storm and its aftermath.

2. An inability to effectively deliver aid to those left within the zone of most concentrated destruction contributed to casualties in the days after the storm.

3. The ad hoc process of dispersal of people from the disaster area, both before and after the storm, led to a scattered local resource network (police, firefighters, doctors, nurses, clergy), which destroyed proximity to other members of their own units and from the community members they served.

4. The continued diaspora of much of the affected community, most notably the population of the flooded areas of New Orleans, made it much more difficult to engage in dialogue about if, where, or how their neighborhoods should be reconstructed.

I propose that we consider the possibility of using a fundamentally different approach to prepare for mass evacuations in the future, one built around the realignment of existing resources. The fundamental premise behind this approach is that it is substantially easier to transport people in an organized fashion from an unsafe area to a safe area, than it is to transport a broad range of resources on an ongoing basis to a devastated and perhaps still unsafe area.

I would suggest that bases no longer needed for military use should be fitted for use by communities that require evacuation. One could coordinate evacuation destinations by extended (9 digit) postal zip code, so that one might evacuate to the same location all those who reside in a neighborhood, along with all those providing core civic services to that neighborhood. As an example, one could evacuate together both the schoolchildren and the schoolteachers, both the parishioners and their clergy, both the patients and their community health workers, both the citizens and their local police officer.

In particular, plans are already in place to close an array of military bases nationwide, many of which already have housing and other facilities in place. (4) Such facilities could each be equipped in advance with nonperishable goods to handle thousands of evacuees: tanks of clean water, canned foods, medicines, clothing supplies, fully preprovisioned school buildings, hospitals, and so on.

The inventory for each evacuation site could also include a fleet of buses able to provide public transportation from a disaster area, then offer local transport support at the evacuation site, and finally, transport the population back once the danger had passed. Buses could offer evacuation assistance to those without access to a personal car, and who lack access to rail or other public transportation. Broad use of buses would also tend to diminish the use of personal cars, which routinely clog evacuation routes by their sheer numbers.

Use of staged evacuation sites would make it easier to evacuate those in harm's way well in advance of an impending hurricane or other anticipated disaster when evacuation is safest and simplest, with surface roads still open. In the case of those who fail to evacuate, or in instances when an unanticipated disaster strikes, air evacuation could readily supplement surface resources. Helicopters could transport personnel to just beyond the danger zone, to the nearest open civilian or military airstrip, from where they could be flown to their evacuation site. The process would be especially facile if the evacuation site were a former military base which already had an airstrip in place to receive evacuation flights.

An additional advantage of using closed bases as disaster relocation centers is that the local economy in many cases has generated a broad range of consumer businesses to support ancillary services (such as movies, shopping and other amenities) to the military base population. An episodic use of the base site by disaster evacuees could make use of this infrastructure as well, and help make the overall base environment community more homelike and less austere than the evacuation facility would be in isolation. This synergy between base and community could also help shield the local economy from some of the economic effects of base closure.

Any one closed base would be used on only rare occasions for evacuation from any particular area, and typically for only a brief period of time. A coastal community on track to be hit by a storm might be evacuated 2 to 3 days before anticipated landfall, and the evacuees returned once the weather cleared, if the storm in fact did not do much damage and the intervening roads remained passable. Many similar evacuations could therefore use the same sites sequentially, such as during a hurricane season that saw sequential hurricanes threaten first Texas, then the Florida panhandle, and then Mississippi.

The infrastructure to support fixed evacuation sites might or might not be more costly than a single lengthy aid operation under the current approach for a single disaster, such as Katrina. There would be some expense associated with keeping the military facilities open rather than shuttering them, and further expense in equipping these bases for their new purpose. Fixed evacuation sites would however almost certainly be far less expensive when the cost of the fixed site is averaged over the multiple disaster relief efforts for which each site would certainly be used over the years.

The cost of equipping such bases would, I suspect, not be larger than the cost of delivering aid in the recent ad hoc fashion. In the Katrina relief effort, over a hundred million dollars was spent just for poorly coordinated efforts to deliver ice cubes to those lacking refrigeration. (5) Temporary housing in the form of trailers is inferior in structural stability to fixed housing even for those fortunate enough to get a trailer, (6,7) and yet months after Katrina, thousands of trailers have languished far from those who need them. (8,9) A more organized relief approach such as proposed here is likely to yield a more economical, more effective and more holistic response to the needs of a devastated community.

The large number of military bases subject to closure is one of the strengths of this plan. Equipping multiple bases would enable a modular response, activating either a single site or multiple sites depending upon the magnitude of the population requiring evacuation. Use of multiple sites would make it likely that wherever in the country a disaster struck, an evacuation site would be relatively close by and fully intact, even if the closest evacuation site had itself suffered some damage.

References

1. Cook ML. FEMA: Bureaucratic disaster area. New York Times. November 1, 1989; A:29.

2. Rosenbaum S. US health policy in the aftermath of Hurricane Katrina. JAMA 2006;295:437-440.

3. Nusbaum NJ. Casualties abroad and at home. J Community Health 1994;19:1-5.

4. United States Government Accountability Office. Military base closures: Updated status of prior base realignments and closures. 2005; GAO-05-138.

5. Shane S, Lipton E. Stumbling storm-aid effort put tons of ice on trips to nowhere. New York Times. October 2, 2005.

6. Lipton E. Trailers, vital after hurricane, now pose own risks on gulf. New York Times. March 16, 2006 2006:1. Available at: http://docs.newsbank.com/openurl?ctx_ver=z39.88-2004&rft_id=info:sid/iw.newsbank.com:AWNB:NYTB&rft_val_format=info:ofi/fmt:kev:mtx:ctx&rft_dat=11064ECB15900500&svc_dat=InfoWeb:aggregated4&req_dat=0FD3D1C913B1A06F. Accessed May 2, 2006.

7. Hurwitz J. Inside the Box. The Times-Picayune. April 23. 2006. Available at: http://www.nola.com/search/index.ssf?/base/news-14/1145777415261150.xml?nola.

8. Bush President George W. Press Conference of the President March 21, 2006. Available at: http://www.whitehouse.gov/news/releases/2006/03/20060321-4.html. Accessed March 23, 2006.

9. Jimenez J. The Shreveport Times. May 2, 2006. Available at: http://www.shreveporttimes.com/apps/pbcs.dll/article?AID=/20060502/NEWS01/605020323. Accessed May 2, 2006.

Neil J. Nusbaum, JD, MD

From the Department of Medicine, University of Illinois College of Medicine at Rockford, Rockford, IL.

Reprint requests to Neil J. Nusbaum, JD, MD, Professor and Chair, Department of Medicine, University of Illinois College of Medicine at Rockford, 1601 Parkview Avenue, Rockford, IL 61107. Email: [e-mail]

The author's research receives support from Grant Number 5 P20 MD 524-2, from the National Center of Minority Health and Health Disparities, National Institutes of Health. The contents of this publication are solely the responsibility of the author and do not necessarily represent the official views of the National Institutes of Health.

Accepted May 1, 2006.