This post has been inspired by one of the references mentioned by Mary McKee in her recent article. The publication in question, Shelter From The Storm: Local Public Health Faces Katrina, describes the hurricane experience of five public health departments that responded to the crisis. It does a good job of capturing the issues involved in dealing with the aftermath of the disaster, through a series of interviews with public health officials in five cities - Pensacola, Houston, Birmingham, San Antonio, and Memphis.
The following essay aims to derive some general lessons from these events. This is driven by the scope of the response needed, the role played by oil-fuelled transport, and the likelihood of further natural disasters driven by climate change. The following ideas are in no particular order of importance.
“Gone With The Wind”
Healthcare lessons from the public health response to Hurricane Katrina.
1. The scope of the systems that were in place before Katrina struck were essentially adequate for the task. The difficulty, however, lay in the fact that the systems were designed to cope with disasters occurring within their respective state: they were generally inadequately prepared for out-of-state evacuees. This included problems with accessing medical records and (later) getting reimbursed for expenses.
The lesson: Planning for emergencies needs to be done on a regional basis (much as natural resource management works better when organised around distinct bioregions). This is especially true for facilities and agencies occupying border regions of states or countries, where there is a higher than average risk of large natural disasters (eg Gulf of Mexico or the Caribbean), or where the respective countries are small (eg Central America).
Their planning process was statewide, not regional, so a major role in assisting residents of (other states) was not one they had carefully rehearsed.
2. Several health departments had done scenario training, simulations or table-top exercises, but again generally based on in-state events: some were unprepared for large influxes of evacuees from areas quite distant from them. The lesson: Simulations are a useful training tool but are only a means to an end; they are also only as good as their content.
3. Don’t rely on the Federal Government for help - their response was delayed and inadequately small. The lesson: Look after yourself because the government won’t (or can’t).
FEMA came about two weeks after the evacuees…and followed its own protocols rather than integrating with local systems that already were in place.
4. Pharmaceutical supply was a major issue at several centres, as many patients arrived without their regular medications. The lesson: Stash a few days worth of essential medications to take with you in an emergency - there is no guarantee that there wll be any at your destination if you need to be evacuated, etc.
People should take more responsibility and rely less on the federal government.
5. In several locations the public health response succeeded in part due to informal relationships forged by key players before the disaster occurred. The lesson: Developing workable relationships within your community is essential for survival, no matter where you are or the size of your community.
6. Many local people volunteered their services to help out, but some agencies were unprepared for such offers and did not utilise their volunteers very well. The lesson: Disasters bring out the best in some people, even when you don’t expect it.
7. In at least two of the five cities profiled, local residents created friction about missing out on services that had been redirected to help evacuees. The lesson: Disasters may also bring out the worst of human nature.
The demand (from evacuees) would have been greater if gas shortages hadn’t kept many evacuees from making their way that far north (to Memphis).
8. Disease surveillance and food safety were two major areas of success - only one small outbreak of gastroenteritis occurred, and it was quickly contained. The lesson: Look for areas of leverage that give disproportionately large returns for the effort involved (mass immunisation was another successful example of this concept).
9. The Memphis case study explained that the number of evacuees received there would have been greater if gas shortages had not prevented car travel that far. It is also worth noting that many evacuees were moved by bus or plane. It is obvious then that mass transport after a large scale disaster is important.
Of note in this case is that it was predominately oil-fuelled. I presume that the transport of responders into impacted areas relied on similar methods, and also that rail transport would probably have been difficult due to hurricane damage. The lesson: Oil-fuelled transport was essential to the management of this disaster (and unless one rides a donkey, will probably continue to be so).
She’s not willing merely to trust federal co-ordination…disaster preparedness and response training… must occur across agencies and at the local level.
10. The response to Katrina needed to be maintained for several weeks (if not months) as evacuees could not return home. Several interviewees said that it was difficult (in terms of staffing and budgets) to continue caring for evacuees while also delivering their pre-Katrina services, and that a greater depth of trained workers and resources was needed. The lesson: Emergency planning must consider how to deal with the need for a possibly prolonged response (or even to more than one co-existing disaster).
11. Several aspects of the report highlight just how important it is for communities to be as self-reliant as possible. This includes developing a reserve of skills, manpower, materials and capital. Such relative independence from external help is likely to become even more important in the future as the weather and many other aspects of life become more unpredictable. The lesson: Identifying and developing local capabilities should begin now.
12. One of the interviewees said that health care workers must pay particular attention to be more prepared than average so that they “may assure their availability to serve during an emergency”. The lesson: Personal preparedness for all is important, but perhaps even more so for health care workers (so that they can respond without undue concern for the well-being of their own loved ones). I wonder even if we have an ethical duty and moral responsibility to be so prepared?
Clinical Issues
I wanted to list several specific clinical issues that were revealed in this report:
- There are likely to be unwell patients who require acute medical care (and perhaps even greater numbers than normal due to stress; lack of food, water and sleep; absence of usual medications; and unaccustomed physical exertion).
- It required a lot of resources to get the correct (regular) medications to the correct evacuee.
- Treating substance abuse patients on methadone etc was an unforeseen need.
- Accessing out-of-state medical records (including medications) was problematic.
- Writing medication prescriptions was very time-consuming in some areas (in others emergency dispensing powers were used).
- Many patients could not afford to buy new medications (in one area they were supplied with up to 10 prescriptions for free).
- Dealing with special-needs patients (eg the elderly, mentally ill, or physically disabled) required extra attention to be successful.
Some unanswered questions
How should we prepare for the public health response to such large scale natural disasters?
Will global warming make these sorts of events more common?
How might the response have been different if the disaster had been a nuclear or biological terrorist attack and (a) the evacuees were contaminated or infected and (b) there was a health risk for the responders?
How successful would the response be if an identical disaster occurred after peak oil?
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