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Our role was to assess as many of the shelters as possible, rapidly identify immediate and longer-term needs and problems, and develop a plan for a response that was fully coordinated with the local authorities, who, with their federal counterparts, commanded the needed resources. At the moment of Joyce's offer of help, I needed copies of the lists of doctors and nurses who were available for deployment. Joyce immediately addressed herself to the task with energy and intensity, grasping the piles of loose sheets and making her way to the copy machine.
Like the water in Lake Pontchartrain, which waited for a breach in a levee to unleash its power on the adjacent neighborhoods, a reservoir of potentially catastrophic communicable diseases lies ready to explode into an epidemic that can overwhelm a vulnerable population confined to overcrowded quarters. The early warning system for such outbreaks consists of health care providers who can detect unusual patterns in their clinical practice. But when the health-protection infrastructure of an entire geographic area is destroyed, ordinary symptoms begin to carry extraordinary meaning. Diarrhea containing blood might signify dysentery. Patients with cough might be harboring tuberculosis. In an overcrowded shelter, an untreated person with tuberculosis places the entire population at risk. One must be extremely vigilant, recognizing that every symptom in a displaced person, no matter how innocuous it would seem in normal practice, might be the leading edge of a destructive wave of infectious disease.
In a little over four days, our multidisciplinary and interagency teams assessed more than 200 shelters housing nearly 30,000 people. Amazingly, in a majority of cases, the basic public health needs were being met. There were inspiring stories of local communities rising up to provide for their unexpected guests; nearly all native Baton Rouge residents had someone new staying in their homes. Nearly every hotel housed displaced families, extended families, and pets. Nearly every large shelter had created a clinic, staffed by local doctors and nurses furnished with medicines and supplies, to provide medical care.
Coordination on the ground is imperative. The American Red Cross was caring for more than 50,000 displaced people. There were more than 9000 hospital beds in New Orleans that could no longer be used for sick patients. Many of the New Orleans health care and public health workers had also been displaced, but many wanted to help, perhaps believing that immersion in the care of others would assuage the pain of their own losses. The clinics in the larger shelters were improvised but were generally providing good medical support, given the limited resources available.
When Katrina hit, the immediate national response among health care professionals mirrored the response to the Asian tsunami last December: everyone wanted to help. But because Katrina had invaded U.S. shores, many well-intentioned clinicians and health care organizations simply self-deployed and traveled to Louisiana, where their arrival compounded the overall disorganization of the effort to provide health care to a population that did not normally have great access to care. They were writing prescriptions for medications that couldn't be filled, for diseases such as hypertension and diabetes. Lacking an assigned role within a properly planned framework, many found themselves sitting on their hands, doing nothing for which they had been trained.
I soon found myself saying, "We are here for the people of Louisiana" — a mantra that I repeated endlessly to the eager volunteers who arrived in uncoordinated fashion. I am fortunate to have been trained in emergency medicine, public health, and disaster response. But in the first days and weeks after this disaster, my clinical skills were my least useful qualities. I was helping to manage more than 100 doctors and nurses deployed on public health missions throughout the state, virtually all of whom had been waiting around to do something. Every one of them wanted and expected to save lives and alleviate suffering, but it was still logistically impossible for them to use their skills in the way they expected. Clearly, there was a disconnect between the aspirations of the army of volunteers and the actual needs of the victims of Hurricane Katrina.
In the immediate aftermath of a disaster involving large, displaced populations, doctors, as difficult as it might be to accept, are one of the least useful commodities. The first priorities, standards in the developing world, are security and safety for the population, then water, sanitation, food, and shelter. Once the humanitarian-aid staff is safe from danger, the most effective way to save lives is to ensure the availability of clean water, secure a place for bodily wastes away from the water supply, and then vaccinate every child younger than 15 against measles. Only after these needs have been addressed can curative care become operational.
Unfortunately, the skill set for such a response was not on the curriculum vitae of any of the health care workers who had shown up to volunteer. All the eager, superbly trained doctors and nurses who told me "I'm here to help" almost always meant that they were ready to deliver care in the same way they did at home. But the burden of the initial emergency response is on logistics, not on the provision of direct care. Indeed, attempts to provide direct care in a setting with no coordination or infrastructure can distract from the urgent mission of establishing basic human security and meeting immediate needs.
Through those early days of frantically assessing the safety and needs of the population and planning the medium-term response, Joyce was one of the most valuable members of our team. Without question, without complaint, she made copies, gave directions, and ferried people around in her car. Her only expectation was to help. She had dropped everything to volunteer; she had left her work, her daughter, and her grandchildren behind and, having missed the flight she planned to take, had driven alone across several states to Baton Rouge. At the end of her two-week session, she would return to her life, another of the many anonymous volunteers who responded to the crisis. Once back at home, she would resume her usual work — as a thoracic surgeon.
Source Information
Dr. Cranmer is a physician in the Division of International Health and Humanitarian Programs, Department of Emergency Medicine, Brigham and Women's Hospital, Boston.
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Related Letters:
Hurricane Katrina and Disaster Medical Care
Rathbun K. C., Cranmer H.
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N Engl J Med 2006;
354:772-773, Feb 16, 2006.
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