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The traditional focus on infectious disease in displaced populations is well supported. Because disaster shelters often lack potable (or any) water, are often crowded and unclean, and may house a population with limited knowledge about health, the risks of airborne and waterborne transmission of disease are increased. Educating sheltered evacuees — particularly children — about strict personal hygiene can aid in preventing outbreaks. Ideally, facilities with adequate numbers of toilets and enough water for washing and bathing should be sought; in places where the shelters themselves are damaged — as many were in the Biloxi and Gulfport areas of Mississippi — evacuees may need to travel greater distances for shelter or wait wherever possible until better facilities can be found.
Epidemics of vector-borne disease have occurred after other hurricanes.2 Although there may be essentially no risk of malaria transmission on the Gulf coast, the presence of vast stands of stagnant water in any locale may increase the risk of other vector-borne diseases, particularly the viral encephalitides. The decision to initiate expensive spraying campaigns should always be based on solid knowledge of vector breeding and endemic disease. West Nile virus, St. Louis encephalitis, and even dengue have native ties to the Mississippi delta.3 There have been confirmed deaths from skin infections caused by Vibrio vulnificus, and wounds sustained during such disasters can result in infections that appear in the early days of shelter living.4 In the United States, tetanus is primarily a disease of the nonimmune elderly, so supplies for tetanus prophylaxis should always be kept on hand.
As shelters become stabilized and consolidated, surveillance based on syndromic case definitions should be implemented to identify potential disease transmission and to follow disease and injury trends. All data, whether collected by the Centers for Disease Control and Prevention (CDC), the state departments of health, the American Red Cross, or other nongovernmental organizations that sponsor shelters, must be coordinated if they are to be as useful as possible. Shelters are critical surveillance sites; however, since shelters are not staffed by physicians or public health experts, a simple, easy-to-use reporting mechanism that identifies sentinel symptoms (such as diarrhea, fever, acute respiratory infection, and hemoptysis) should be implemented as quickly as possible. In Mississippi, within 14 days after Katrina hit, the Red Cross and the state health department provided simple case definitions and set up a toll-free number for shelter staff members to report illnesses. As of September 22, 2005, only isolated cases of presumed chicken pox (in Mississippi), gastroenteritis (in Mississippi and Louisiana), and lice and scabies (in Louisiana) have been identified, but the threat of transmission is ever present.
Immunizations for vaccine-preventable diseases are required in these situations. Given the relatively low immunization rates in Louisiana, measles could become a problem.5 In addition, the influenza season is rapidly approaching, and crowded and elderly populations are at increased risk. In general, data on immunization coverage can be obtained at the time of registration in a shelter and should guide health care programming.
On the Gulf coast, environmental factors including stifling heat and humidity put the population at risk for dehydration and serious heat-related illness. Many people survived for days outdoors in sweltering heat, only to be evacuated to shelters without electricity and air conditioning. Floodwater laced with toxic chemicals, human waste, fire ants, rats, and water moccasins posed a distinct health risk for those attempting to escape to higher ground. The long-term effects of the environmental contamination will need to be evaluated, monitored, and alleviated.
The biggest health issue, however, was and will continue to be the inability of the displaced population to manage their chronic diseases. It remains uncertain how such a disruption of ongoing care will affect the long-term health of the population. Persons whose health depends on immediate medical care — hemodialysis, seizure prophylaxis, medications for diabetes or cardiac disease, or treatment regimens for HIV infection or tuberculosis — were and are at risk for potentially lethal exacerbations of disease. Those with special needs — hospice patients, the mentally and physically disabled, the elderly, and persons in detox programs — continue to endure life-or-death challenges beyond that of evacuation. Planning agencies are already struggling to build the sustainable procurement and distribution apparatus to address such long-term needs.
The economically disadvantaged often have multiple medical conditions that may be in advanced stages.4 For the largely black population of New Orleans whose access to health care was limited before Katrina and who already bear a comparatively heavy burden of chronic disease, the situation is especially critical. As we have learned from previous disasters, a strong infrastructure is required to withstand such an onslaught. Katrina disproportionately affected the poorest residents of New Orleans, who did not have the health reserve or the access to care needed to absorb the blow of a breakdown of the local public health system. In the long run, the destruction of the public health and medical care infrastructure has the potential to be more devastating to the health of the population than the event itself.
The immediate response efforts are only the beginning. Katrina, more than previous disasters, exposed the inequities facing our disenfranchised populations and laid bare the hard realities of the current state of health care for the poor. We are now faced with a tremendous social challenge: the physical displacement of hundreds of thousands of our most vulnerable and underserved citizens. If this crisis fails to redefine America's relationship to this population — if we revert to our accustomed passive avoidance — then the television cameras will document the same distressing scenes the next time a disaster strikes. The challenge for the health sector in the rebuilding effort will be no less than raising the level of care and easing the burden of disease for the entire population.
Source Information
Dr. Greenough is an assistant professor of emergency medicine at Brigham and Women's Hospital and Harvard Medical School, Boston, and an assistant professor of international health at the Johns Hopkins Bloomberg School of Public Health, Baltimore. Dr. Kirsch is an assistant professor of emergency medicine at the Johns Hopkins University School of Medicine, Baltimore, and the medical advisor for the American Red Cross, Washington, D.C.
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