[IP] Hurricane Katrina Analysis - CFR Global Health Program
Begin forwarded message:
From: AMBOLLC@xxxxxxx
Date: September 2, 2005 7:58:52 PM EDT
To: dave@xxxxxxxxxx
Subject: For IP, if you wish: Hurricane Katrina Analysis - CFR Global
Health Program
From: SRosenstein@xxxxxxx
Date: September 2, 2005 6:53:40 PM EDT
To: SRosenstein@xxxxxxx
Subject: Hurricane Katrina Analysis - CFR Global Health Program
Dear Friends and Colleagues,
As we head into Labor Day Weekend most of us are heartbroken by news
from
Louisiana, Mississippi, and Alabama. The Council on Foreign Relations
Global Health Program has been watching the situation closely, with a
special eye on possible disease situations. We would like to bring
some key
points to your attention. This transmission is going out on Friday,
September 2: It is possible that the situation will have changed
markedly
by the time some of you read this, as you may not be checking your e-
mail
until after the holiday.
We would first like to draw your attention to the extraordinary work
being
done by the staff of the New Orleans Times Picayune. You can see the
newspaper, which is currently only able to publish online, here:
http://www.nola.com/hurricane/katrina/
Friends on the Picayune staff tell us that the newspaper offices and
printing presses were overwhelmed in the flooding, forcing the entire
staff
to relocate to facilities at LSU in Baton Rouge. There, the exhausted
staff
has been living 4-6 to a room in the dorms, or on cots in the makeshift
newsroom, covering the demise of their fair city. If there is justice in
the world, these folks will win the Pulitzer Prize for Community Service
Journalism.
Meanwhile, the Global Health Program sees parallels between such
things as
the tsunami response, major epidemic outbreaks, refugee crises, and the
U.S. government response to Hurricane Katrina and her aftermath.
First, a lot of the early media coverage focused on repeating the same
stock footage over and over of lootings. The looters were nearly all
black,
and you could well imagine that many viewers were thinking, “How could
those people behave that way?” The image of black looters, harking to
riots in the past and “lawlessness”, may have sparked a temporary
downturn
in American concern. From that moment the call was not for rescue,
but for
“law and order”. We are only now returning to a serious rescue mode, in
light of public outcry regarding the estimated 20,000 people stranded
without food, water, medicine, or hygiene in the New Orleans Convention
Center. In our experience such shifts of external public opinion,
however
transient they may be, have enormous outcomes on the ground, where
minutes
may have life-and-death consequences.
Across the region we have some of the worst poverty in America, and
most of
that poverty has a black face. Mississippi, Alabama, and Louisiana:
these
are states that consistently, since the Civil War, have ranked in the
bottom five states in America for virtually every social achievement,
from
education and infant mortality to police corruption. Government, for
many
of the region’s poor, has had one of two faces: corruption or overt
neglect. New Orleans has had one of the highest murder rates in the
nation
for decades and a notoriously corrupt police force. In our experience
dealing with catastrophes and epidemics overseas, there is a DIRECT
correlation between the historic relationship between government and its
people, and the willingness of the populace to believe in and correctly
respond to government instructions. Of course tens of thousands of
people
failed to evacuate: why believe the government this time? And of course
those folks who are slowly starving and baking in New Orleans assume
that
government has abandoned them.
I found myself recalling the way the Chinese people responded to the
SARS
epidemic. Because they knew that their government had lied to them many
times in the past and had covered up cases in the capital, people turned
away from official government sources of information. Rumors spread like
wildfire via cell phone text messaging, spawning a mass exodus from
Beijing
of tens of thousands of people. The medical system in China is
notoriously
corrupt and the peasants stay away from hospitals unless it is a
matter of
life and death. When government told the masses to go to the
hospitals if
they had fevers, the Chinese refused. The SARS situation spiraled out of
control in large part because the people had long-standing, sound
reasons
for distrusting their government. Public health collapses if the bond of
trust between government and its people breaks, or never exists. I
saw the
same thing with plague in India in ’94.
Perhaps the single most crucial difference between New York’s
response to
9/11 and New Orleans’ and the hurricane region’s response to the current
crisis is communication and its corollary, leadership. Though cell
phones
were disrupted and emergency responders in Lower Manhattan lost contact
during the morning of 9/11, the people of New York knew immediately what
was going on. We did not lose electricity citywide, TVs, radios. Mayor
Giuliani rose to the occasion brilliantly, making full use of every
press
conference and broadcast opportunity to honestly assess the situation,
telling New Yorkers what the government did, and did not, know. New
Yorkers were frightened, of course, but they knew what was going on and
they could see, minute by minute, what was being done in their behalf.
In contrast, none of the people now trapped in New Orleans or wandering
around in shock along the Mississippi/Alabama coastal communities
have any
idea what is going on. They have no electricity, and therefore no
television or radio. Information is entirely rumors. When reporters
interview them, these desperate souls are grilling the journalists for
news. This means that the comfort of observed leadership is completely
absent. No matter what the Mayor of New Orleans says, his people cannot
hear him. They do not see the vast destruction. I doubt more than a
handful
of the folks trapped inside New Orleans at this moment have any idea how
massive the damage to the Gulf Coast is.
Worse, there is real danger that the only overt sign of leadership
will be
military, in the form of anti-looting enforcement and armed personnel.
While bringing law and order to the situation is essential, the
absence of
obvious civilian leadership and information means many local refugees
will
view themselves as an occupied or policed population. Given overtones of
racism, this could be explosive.
Looking forward, based again on my years of covering Third World
disasters,
here are my concerns:
1.) The Mississippi Delta region is the natural ecological
home
of a long list of infectious microbial diseases. It is America’s
tropical region, more akin ecologically to Haiti or parts of
Africa
than to Boston or Los Angeles. The most massive Yellow Fever
epidemics in the Americas all swept, in the 19th Century, up the
Mississippi from the delta region. Malaria was not eradicated
from
the area until after World War II. Isolated cases of dengue
fever,
another mosquito-borne disease, have been spotted in the
region over
the last ten years. Not only are all the mosquitoes that
traditionally carry these microbes still thriving in the area,
but
the Aedes albopictus mosquito – a large, aggressive monster, was
introduced to the Americas from Asia about 15 years ago, and now
thrives in the Gulf area. (See:
http://www.cdc.gov/ncidod/dvbid/arbor/albopic_new.htm .) Most of
these troublesome mosquito species reproduce rapidly in
precisely the
conditions now present, post-hurricane. Some prefer massive
stands of
still, warm, polluted water: that would be New Orleans. Some,
such as
albopictus and Yellow Fever carrier Aedes aegypti (see:
http://www.cdc.gov/ncidod/dvbid/dengue/ae-aegypti-
feeding.htm ) like
small pools of unsalted water, such as fresh rainwater that
accumulates in tree stumps and debris. One of their favorite
breeding
sites is the dark, warm, water-filled cavity of an abandoned
tire,
for example. America’s commitment to mosquito control has been
declining steadily since we eradicated malaria, and even fear
of West
Nile Virus didn’t spawn a massive re-commitment to funding
mosquito
abatement programs. Worse, to my knowledge nobody has ever had
much
success in clearing mosquitoes from the sort of massive water-
soaked
ecology that now is New Orleans, nor the scale of water-pooling
debris found along the Gulf tri-state area. It is perhaps
ironic that
the only real experience with this scale of insect control for
the
last two decades has been in developing countries: the CDC and
State
health folks should be reaching out to PAHO and the insect
control
expertises of Africa and the Caribbean right now. If we cannot
manage
to get ahead of the insects, there could very well be a disease
crisis ahead.
2.) For years the CDC has warned about Vibrio cholerae
(http://www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm ),
Vibrio
vulnificus and other gastrointestinal organisms found in
shellfish
and some fish caught in the Gulf of Mexico. The old New Orleans
mantra has been that Tabasco kills ‘em, so chow down the raw
oysters
and forgettaboutit. But we would not be the least surprised to
see a
surge in algal blooms and their vibrio passengers over the
next two
weeks both inside New Orleans and along the Gulf. Consider
this: the
hurricane must have disrupted all of the coral reefs in the
region,
and killed millions of fish. All that rot is now floating
around in
the Gulf. It is food for algal blooms. The vibrio live in the
blooms.
3.) One word: sewage. The longer the region goes without
proper
systems for control of human waste, the greater the
probability of
transmission not only of cholera, but a long list of dysentery
and
gastrointestinal agents. Evacuating every human being from New
Orleans will, of course, help, but there will remain potential
disaster all along the tri-state coastline. Members of the
Infectious
Diseases Society of America, which has mobilized scientists and
physicians nationwide in readiness to respond should an outbreak
occur, have compiled this list of possible organisms to be
concerned
about at this time:
Enteric:
Typhoid (depends on likelihood of carriers- fairly plausible)
Cholera
Enterohemorrhagic E coli
Enterotoxogenic E coli
Enteroinvasive E coli
Campylobacter
Shigella
Vibrio parahemolyticus and vulnificus (including
contamination of
gulf shellfish)
Clostridium perfringens
Bacillus cereus
Salmonella
Staphylococcal intoxication
Rotavirus
Norovirus
Giardia
Cryptosporidium
Cyclosporidium
Other enteric-spread:
Hepatitis A
Hepatitis E
Polio (very high herd immunity)
Coxsackie and other Enteroviruses
Rabies
Leptospirosis
Botulism
Vector borne:
West Nile Virus (likely to be highly problematic)
Eastern Equine Encephalitis
St. Louis Encephalitis
LaCross Encephalitis
Dengue fever (real risk)
Malaria
Typhus fever (remote likelihood, last outbreak 1921)
Murine Typhus (not often major)
Trench (Quintana) fever
Relapsing fever (Borrelia recurrentis)
Plague (unlikely, non-endemic area)
Respiratory and close contact:
Meningiococcus
Tuberculosis
Measles, mumps (herd immunity likely very high)
Pertussis (herd immunity modestly high among high-risk age
groups)
4.) Pharmaceutical supplies are a bewildering problem: why
has
nobody broke into pharmacies around New Orleans to get essential
supplies for the refugees, and hospitals? We have dead
diabetics, and
probably epileptics seizing, CVD patients in need of nitro, and
children who could benefit from proper antibiotics.
5.) One past hurricane in the region produced so much
debris that
the cleared garbage filled an abandoned coal mine. We have
never in
history tried to dispose of this much waste. It is hoped that
before
any officials rush off thinking of how to burn or dump a few
hundred
thousand boats, houses and buildings, some careful
consideration is
given to recycling that material for construction of future
levees,
dams, and foundations. Looking at aerial images of the
coastline one
sees an entire forest worth of lumber, and the world’s largest
cement
quarry. No doubt tens of thousands of the now-unemployed of the
region could be hired for a reclamation effort that would be
rational
in scale and intent. It would be horrible if all that debris were
simply dumped or burned without any thought to its utility.
6.) The mental health of hundreds of thousands of people
must now
be a priority. Uprooted, homeless, jobless, rootless and in many
cases grieving for lost loved ones: These people will all
suffer for
a very long time. A key to their recovery is, again, a lesson
from
9/11: information. Whether they are “housed” in the Houston
Astrodome, are in tents in Biloxi or end up a diaspora of Gulf
refugees flung all across America, these people will for
months be
starving for information about their homes and communities.
The poor
will not be logging onto computers somewhere to read bulletins
from
FEMA. These people will rely primarily on broadcast
information, and
it is essential that the leaders of the three states and key
mayors
create reliable information sources for people to turn to. The
Times
Picayune online will, of course, be the primary go-to site for
middle
class Gulf refugees and expatriates, but to what outlet will a
million poor folks turn? Knowing what is going on “back home” is
essential to mental health recovery. We have been in disasters in
poor countries where wild rumors flowed among the poor for
months,
each one sparking a fresh round of anxiety and fear. If
government
cannot inform, there is no government.
7.) America, and this government, is going to witness an
enormous
political backlash from these events, stemming primarily from the
African American community, if steps are not boldly taken to
demonstrate less judgment, and greater assistance, for the
black poor
of the region. Cries of racism will be heard. In every
disaster we
have been engaged in we have witnessed a similar sense by the
victims
of disasters that they were being singled out, and ignored by
their
government, because of their ethnicity, religion or race. The
onus is
on government to prove them wrong.
8.) Much more thought needs to be given immediately to the
needs
of medical and psychiatric responders located just outside of the
region. The patient flow they are now receiving is minuscule
compared
to the tidal wave coming their way, whether they are in Baton
Rouge,
Jacksonville or Houston. FEMA and HHS need to get a massive and
steady flow of supplies their way, and coordinate tertiary
care needs
according to the skills base in each hospital. If it hasn’t
already,
HRSA needs to issue clear waivers immediately for Medicaid
coverage
for the poor, so that no hospital in the region, private or
public,
has an excuse for turning people away.
Finally, we would like to share with you (see below) a letter that
went out
to physicians and scientists nationwide today, from the Infectious
Diseases
Society of America (IDSA). If you cut through the acronyms and jargon
you
can see the point: they are mobilizing.
Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations
58 E. 68th St.
NY, NY 10021
(212) 434-9794 or (212) 434-9749
lgarrett@xxxxxxx
www.lauriegarrett.com
Research Associate, Scott Rosenstein, SRosenstein@xxxxxxx
Dear Colleague,
All of us have been shocked and dismayed by the devastating effects of
Hurricane Katrina. We sympathize with those affected and would like to
provide assistance and relief both as individuals and as a Society.
Over the last 48 hours, IDSA and HIVMA leaders and staff have been in
contact with infectious diseases physicians in the affected areas, with
staff from the Centers for Disease Control and Prevention (CDC) and the
National Institutes of Allergy and Infectious Diseases (NIAID), with
local
health officials, and with others in order to determine how our
Society and
members can be of greatest help in this rapidly evolving situation.
Sections of the IDSA and HIVMA websites (www.idsociety.org and
www.hivma.org) have been set aside to provide current information
regarding
opportunities as we learn of them and to provide information on relevant
infectious diseases in this situation.
1. Physicians to provide primary care are needed in all of the
affected
areas. The websites provide links to the medical societies of the three
affected states who are seeking volunteer physicians, as well as to the
Federal Emergency Management Agency (FEMA), which is also seeking
volunteers. Volunteers should not report directly to the affected areas
unless directed by a voluntary agency. Self-dispatched volunteers can
put
themselves and others in harms' way and hamper rescue efforts.
2. As the situation evolves, we expect that there will be an
increasing
need to provide infectious disease patient consultations. IDSA has
offered
the expertise of its members to help in this regard. To do so, Health
and
Human Services Secretary Mike Leavitt has asked NIAID and IDSA to
coordinate provision of a telephone/e-mail ID consult service. NIAID
will
be the clearinghouse for calls from consulting physicians, who will
then be
linked to ID consultants. If you are interested in participating in this
activity, please provide your contact information on the IDSA website.
3. We are evaluating the potential use of the Emerging Infections
Network in the affected areas to identify outbreaks of infection
early in
their course.
4. HIVMA is working to ensure that persons with HIV/AIDS from the
hurricane-affected areas have access to HIV medications and medical care
financed through public programs like Medicaid and the Ryan White
CARE Act,
without burdensome eligibility or residency requirements. HIVMA will
also
be posting information about state and local policies that have been
implemented to further these goals.
We will provide additional information regarding relief activities on
the
website as it becomes available. Your comments and suggestions are
welcome,
as is first-hand information regarding infectious disease and public
health
experiences in the affected areas.
Best regards,
Walter E. Stamm, MD
IDSA President
_____________________________
Scott A. Rosenstein, MA, MPH
Research Associate, Global Health
Council on Foreign Relations
58 East 68th St.
New York, NY 10021
http://www.cfr.org
phone: (212) 434-9749
fax: (212) 434-9827
email: srosenstein@xxxxxxx
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