The public health response to disasters in the 21st century: reflections on Hurricane Katrina.

Introduction

Ten years have passed since my last update on the public health response to disasters (Logue, 1996). When that article was written, the world was halfway through the International Decade for Natural Disaster Reduction (IDNDR). Despite increased national and international attention to disasters resulting from the IDNDR initiative, unforeseen adverse human health effects continued to occur during that period as a result both of natural and of human-made/technological disasters.

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Even more dramatic events have occurred in this country and throughout the world in the decade following the IDNDR. The September 11, 2001, attacks in the United States represented the worst terrorist events ever experienced on American soil. Four major hurricanes hit the southeast coast of the United States from August to September of 2004, causing major economic losses and many deaths (Shultz, Russell, & Espinel, 2005). The tsunami of December 26, 2004, ravaged large portions of East Africa and South Asia, and a major earthquake struck Pakistan and other areas of Asia in 2005. Both events killed thousands of individuals. Hurricane Katrina struck the Gulf Coast area of the United States during late August 2005 and caused one of the worst natural disasters ever experienced in this country.

Now it is again timely to provide an update on the public health response to disasters and to give more public health attention to this subject. This article comprehensively outlines some of the public health lessons learned as a result of Hurricane Katrina and looks at how public health providers can better prepare to respond to disasters in the future.

Public Health Advances

Many positive advances have occurred since 1996. In 1997, a comprehensive text was published on the topic (Noji, 1997). In 2001, the American Public Health Association published a useful guidebook (Landes-man, 2001) to help public health professionals and others effectively prepare for and respond to the health consequences of disasters. More recently, the 2005 issue of Epidemiologic Reviews gave a thorough review of the public health impacts of disasters. That review updated three earlier reviews (Bromet & Dew, 1995; Lechat, 1990; Logue, Melick, & Hansen, 1981).

Because of the September 11, 2001, terrorist events and other subsequent concerns about terrorism, the roles of public health in disasters and public health preparedness have certainly been recognized and highlighted (Novick, 2005). Although a great deal of the public attention to disasters and public health following September 11 focused on terrorism, the tsunami of December 26, 2004, was a reminder that natural and other human-generated disasters also continue to deserve attention (Lamberg, 2005).

In 1996, very little training was being offered by schools of public health on the public health consequences of disasters. Today, the importance of disasters as a public health problem is widely recognized, and every school of public health in the United States offers some training in this area (Noji, 2005).

Although the topic of disasters was not chosen as a key objective by the U.S. Department of Health and Human Services (DHHS) as part of its Healthy People 2000 initiative (1993), one objective is included in the updated Healthy People 2010 initiative (2000). The overarching goals of Healthy People 2010 are to increase quality and years of healthy life and to eliminate health disparities.

The Centers for Disease Control and Prevention (CDC) have for years provided strong and comprehensive continuing support to others on issues that relate to disasters and public health (Logue, 1996). This support continues today and has strengthened in new areas, such as federal-grant support to states and others related to public health preparedness and the national environmental public health tracking (EPHT) program (McGeehin, Qualters, & Niskar, 2004). CDC grants on preparedness have recently expanded in scope to have a focus on all-hazards preparedness. As part of the EPHT program, both CDC and the Council of State and Territorial Epidemiologists (CSTE) developed a set of public health indicators that provide information about a population's health status with respect to environmental factors (CSTE, 2004). CDC and CSTE also identified 11 indicator topics that serve as broad categories under which indicators are organized. The category of disasters is one of these topics.

Other significant programs have also been developed that have an important impact on all public health preparedness and response actions. These include the National Response Plan, the Emergency Management Assistance Compact, and the National Incident Management System.

The Challenge of Hurricane Katrina

So if America has experienced so many public health advances related to disaster preparedness since 1996, what went wrong with the Hurricane Katrina disaster? Also, what may have gone right with the public health response to this event? Furthermore, what lessons can be learned for the future, given all of these advances?

Lesson 1: Evacuation and Protection of Those Not Evacuating

Public health professionals should have a significant role both before and in the immediate aftermath of any disaster, either natural or human-made (including acts of terrorism). It is critical that, as part of this role, key public health leaders be clearly designated who are responsible for coordinating all necessary public health responses, including public health communications. The author makes this recommendation in light of "10 essential public health services" that are key to understanding the public health activities that should be undertaken in all communities (CDC, 1994). These 10 services are really an outgrowth of the three defined core functions of public health practice-assessment, assurance, and policy development (Institute of Medicine, 1988).

Prior to the Hurricane Katrina landfall in the gulf area, major evacuation steps were taken to move susceptible populations from potential high-risk areas. Despite these steps, many people did not or could not evacuate. In the first three or four days following impact, affected residents who had not evacuated the flooded areas required basic care, support, and protection, but most victims did not receive this support (Thomas, 2005). As a result, many people died unnecessarily, and those who did not die experienced undue hardships. Hurricane Katrina was responsible for more than 1,300 deaths (Manuel, 2006). The majority of these deaths happened in Louisiana, many in New Orleans.

Public health leadership and a public health presence were needed immediately upon impact of the disaster to help prevent disaster-related deaths and subsequent excess morbidity. Although it may not be the direct role of public health professionals to rescue victims from rooftops or to deliver food or clean water, it is their role to "monitor health status to identify and solve community health problems," to "diagnose and investigate health problems and health hazards in the community," to "inform, educate, and empower people about health issues," and to "mobilize community partnerships and action to identify and solve health problems" (the first four essential public health services). As a public health professional, I found myself dismayed that news reporters, such as CNN television news reporters Paula Zahn and Anderson Cooper, appeared to be the only professionals taking public health leadership roles in the first few days after the Hurricane Katrina landfall by making public statements about how the victims who had not evacuated needed immediate help. I expect these kinds of actions from leading public health professionals, who should be immediately engaged following any type of disaster with "mobilizing community partnerships and actions to identify and solve health problems."

Lesson 2: Other Public Health Follow-up

Many individuals and both government and nongovernment agencies were engaged in numerous positive follow-up actions in the days following Hurricane Katrina. CDC again took a leadership role in many follow-up actions. CDC informed its grantees funded under infectious-disease grants, environmental health grants, injury prevention grants, and terrorism and emergency preparedness grants that these grants could be used to help with Hurricane Katrina relief efforts (CDC, 2005a). Both CDC and state and local public health agencies participated in workforce deployments to affected communities. As an example, the Pennsylvania Department of Health's Bureau of Emergency Medical Services coordinated the deployment of emergency medical services from Pennsylvania to Louisiana shortly after the disaster impact. These same agencies, as well as other involved agencies, also provided written advisories and recommendations to the public and initiated indicated follow-up steps on a number of public health issues (CDC, 2005b). These issues included the prevention of environmental health conditions such as carbon monoxide poisoning, mosquito control, and the prevention of accidents and injuries for those returning to the affected areas; immunization efforts and other actions used to prevent the spread of infectious diseases; and surveillance efforts related to disease, the environment, accidents and injuries, and mental health (Manuel, 2006).

In the first few days following Hurricane Katrina, the U.S. Environmental Protection Agency (U.S. EPA) and DHHS created a task force to identify the overall environmental health issues that would have to be faced for New Orleans to be re-inhabited. The team arrived in Baton Rouge, Louisiana, on September 6 and established a base of operations. The work of this group was commendable and led to important public health recommendations (CDC, 2005c).

Lesson 3: Training in Public Health Preparedness

Since the events of September 11, we have had more training than ever before in public health preparedness. After the Hurricane Katrina disaster, however, the overall effectiveness of this training when natural disasters actually strike appears to be in doubt. For years, this country has been aware of the potential risks to New Orleans associated with hurricanes and flooding. Emergency planners were involved in 2004 with a hurricane simulation exercise called "Hurricane Pam" that involved a Category 3 Hurricane striking New Orleans and causing devastating death and destruction (Fournier & Bridis, 2005). The lessons of this planning, however, had little effect in protecting the residents of New Orleans who did not evacuate prior to Hurricane Katrina the following year. A large part of training in public health preparedness since the terrorist events of September 11 has focused on terrorism. Although many public health preparedness programs now focus on all hazards, equal attention must also be given to training that emphasizes natural disasters, such as flooding and hurricanes, and the types of public health responses that are needed for these events.

Lesson 4: Eliminating Health Disparities

I want to underscore the point that one of the overarching goals of Healthy People 2010 is to eliminate health disparities (DHHS, 2000). The Institute of Medicine (IOM), as a follow-up to its 1988 report, The Future of Public Health, convened a committee to examine health issues in the 21st century. In 2003, the committee published The Future of the Public's Health in the 21st Century (IOM, 2003), which noted that "frequently, those who are most likely to be at social and economic disadvantage live in communities that are at higher risk of environmental contamination, face greater exposure to intentional and unintentional injuries, and are least likely to have access to good medical care." If the public health community is serious about eliminating health disparities, then it needs to do a better job at developing public health preparedness plans and follow-up that take into account those who are most vulnerable. Unfortunately, because many of the victims of Hurricane Katrina are poor and African-American, the importance being granted to the overarching goal of eliminating health disparities during times of serious societal upheaval appears open to debate (Broder, 2005).

Lesson 5: Re-Examining Health Programs

It is time to re-examine national, state, and local health programs that relate to disaster preparedness and response. This review should especially focus on the effectiveness of preparedness training, the adequacy of the program in treating this topic as a priority public health area, and the ability of existing programs to provide sufficient "public health response capability" during both the immediate-impact period and the recovery period following disasters.

At the national level, those who administer federal health grant programs and other health-related programs that deal with disasters should re-examine their programs so that major national environmental health hazards such as natural disasters are made a national priority As an example, the CDC EPHT program mentioned earlier has identified disasters as a priority indicator topic. It is noteworthy that Hurricane Katrina had a significant negative impact on both Tulane University, located in New Orleans, and the state of Louisiana, both CDC EPHT grantees. CDC and its EPHT grantees should consider focusing on disasters in the future as part of its national EPHT program. Also, as part of this re-examination, programs should evaluate the effectiveness of all preparedness plans and training in times of real disasters and modify those plans and training that fail to demonstrate effectiveness in the field. The evaluation should develop contingency plans for catastrophic disasters that can destroy local or regional public health infrastructure so that an effective public response will still occur.

National health initiatives, such as the Healthy People 2010 initiative, should expand the scope of these programs to include additional relevant objectives that relate to disasters and public health. Although there is one objective in Healthy People 2010 in this area, this objective was designed to be developmental in nature (DHHS, 2000). DHHS should consider expanding these initiatives in new ways, such as ensuring that there is a "public health presence" in the field immediately following impact and in the recovery period following disasters.

Although the work of the U.S. EPA/DHHS group mentioned under Lesson 2 was important, there is also a critical need to have such an important team ready and able to provide public health leadership and support both prior to the impact of a disaster, at the time of impact, and in the immediate aftermath of the impact. The vision may be similar to that of a military "strike team" that is poised to respond at a moment's notice in the field.

It is noteworthy that CDC already provides excellent guidance to state, local, and tribal health directors on response activities that should be initiated during the first 24 hours (the acute phase) of most emergencies and disasters (2005d). Although excellent guidance from this program already exists, better efforts are clearly needed to effectively implement this information for future national disasters and emergencies.

The creation of the federal Agency for Toxic Substances and Disease Registry (ATSDR) in the 1980s proved successful in helping the country deal with public health issues related to hazardous waste sites (Logue, 1996). Given that disasters represent a major national environmental hazard and a predictable recurring problem that adversely affects public health, it may be the right time to consider the creation of a special CDC center or other functional unit within DHHS that is exclusively dedicated to disasters and public health. Such a unit would be the primary focal point for the public health response to disasters at the national level. CDC's National Center for Environmental Health has for years taken a lead in initiatives related to the public health response to disasters (Noji, 1997), but most of these initiatives have focused on epidemiological approaches. A new center should be comprehensive in its organization and include all pertinent areas of public health (e.g., medicine, environmental health, epidemiology, communications, emergency response, and emergency medical services). The model used to design ATSDR in the past should again be considered because of the success of this agency.

Emergency management agencies are key agencies involved with disaster management. It is essential that all state and local health agencies re-examine their relationships with their corresponding state and local emergency management agencies to ensure that the connection with these agencies is strong and that direct linkages can be quickly established in times of real emergencies.

Finally, the federal health leadership should consider convening an expert panel to provide recommendations and scientific consensus on ways to improve the federal health response to disasters. The panel should include experts from the public health community, including schools of public health; representatives from local, state, and federal health agencies and emergency management agencies; representatives from the legislature; members of the public, including those who may have been victims of recent major disasters; and representatives of other interested groups such as the media.

Discussion and Conclusions

Recurring natural and technological disasters will continue to adversely affect public health. About one disaster a week requires international external assistance somewhere in the world (Novick, 2005). In 1996, a review of the public health response to disasters (Logue, 1996) challenged public health professionals to reflect on progress in this area and to improve the level of response. At the beginning of this century, on September 11, 2001, terrorists attacked the United States and gave a wake-up call, again reminding all those involved with public health preparedness and response to be vigilant to the possibility of a human-made disaster.

The Hurricane Katrina disaster further reminded the public health community that despite the lessons learned from the September 11 attacks and other recent natural disasters in both the United States and other countries, the public health community still needs to improve its level of response. In a recent report by Trust for America's Health (2005), the federal government received a grade of "D" for its public health response to and performance in Hurricane Katrina. It is to be hoped that both federal health agencies and other public health partners will improve their performances in the future when disasters strike again.

In this review of the lessons learned from Hurricane Katrina, I give a "mixed" review to the public health response to disasters. As discussed in the sections on Public Health Advances and Lesson 2, the public health community has advanced greatly since 1996 and the close of the 1990s (the IDNDR) and has been able to effectively provide indicated follow-up public health support to affected communities. The issues discussed under Lesson 1 and Lesson 4, however, illustrate that there are deficiencies in the public health responses both prior to disaster impact, including with support related to evacuation strategies, and in the period immediately following impact when those who did not or could not evacuate require support. The deficiencies also apply to disaster preparedness plans (Lesson 3) that need to recognize the special needs of vulnerable populations, including the poor, the sick, the elderly, and those in institutions, both before disaster impact (e.g., evacuation needs) and immediately following disaster impact (e.g., rapid identification, protection, and treatment of vulnerable individuals). Finally, as discussed under Lesson 5, we should begin to improve our public health response to disasters by re-examining existing programs and implementing necessary changes.

Tropical hurricanes continue to be a major recurring natural disaster affecting the United States every year (Malilay, 1997; Shultz, Russell, & Espinel, 2005). Most deaths from hurricanes are due to drowning, particularly from storm surges. Mortality associated with hurricanes in the United States peaked at 6,000 in the hurricane of 1900 in Galveston and at 1,836 in the hurricane of 1928 in Lake Okeechobee, Florida (Malilay, 1997). The mortality patterns declined for decades following these two events. Hurricane Katrina reversed this trend by causing the third highest peak ever experienced in this country The first two hurricanes were Category 4 storms, and Hurricane Katrina was a Category 3 storm on the Saffir-Simpson scale. It is noteworthy that Hurricane Camille, which struck Mississippi and Louisiana in 1969, was a Category 5 storm that caused 256 deaths. It is possible that other hurricanes of less intensity could also cause major destruction. A good example is Hurricane Agnes, a Category 1 storm, which caused catastrophic flooding inland in Pennsylvania and other areas of the northeast in 1972. In addition to hurricanes, many other natural disasters such as earthquakes, floods, and tornadoes regularly affect the United States and result in both loss of life and excess morbidity for those exposed to these hazards (Noji, 1997; Noji, 2005).

An editorial in the 2005 issue of Epidemiologic Reviews noted that it was timely to have "Epidemiologic Approaches to Disasters" as the theme for that entire issue (Ibrahim, 2005). I echo that thought: It is timely to give more public health attention to disasters in general. I also believe that the public health community should be challenged again to action as a result of this new national tragedy.

Acknowledgments: The author thanks Arthur Frank, M.D., of the Drexel University School of Public Health, and Michelle S. Davis, Yasmin Dada-Jones, Ph.D., and Kandiah Sivarajah, Ph.D., of the Pennsylvania Department of Health, for their helpful review and comments. Thanks also go to Julie Miller, of the Pennsylvania Department of Health, for her valuable assistance in the preparation of the manuscript.

Corresponding Author: James N. Logue, Acting Director, Bureau of Epidemiology, and Director, Division of Environmental Health Epidemiology, Pennsylvania Department of Health, Room 933, Health and Welfare Building, 7th and Forster Streets, Harrisburg, PA 17120. E-mail: [e-mail].

Disclaimer: The views expressed in this article are solely those of the author 00and are not to be interpreted, in whole or in part, as constituting the opinions, interpretation, or position of the Commonwealth of Pennsylvania or the Pennsylvania Department of Health.

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James N. Logue, Dr.P.H., M.P.H.