Hurricane Katrina made landfall on the Gulf Coast on August 29, 2005, and within hours it became the largest natural disaster in U.S. history. The extent of the devastation was unprecedented and had an adverse impact on lives in Mississippi, Alabama, and Louisiana, said Stephen Johnson, administrator of the U.S. Environmental Protection Agency (EPA). In Mississippi, for example, one could drive for hours along the coast and see the destruction. Even 100–150 miles inland, there was significant damage from the hurricane that could be seen for weeks after the initial disaster.
It was the first time in the careers of many disaster responders in the United States that medical assistance from outside the local region was required, noted Lynn Goldman of the Johns Hopkins University’s Bloomberg School of Public Health. Given the unprecedented nature of this natural calamity, the first responders deserve a lot of praise; however, this is not likely to be the last major disaster, noted Goldman. Responders and public health officials need to learn from the event to apply this knowledge to future disasters. At the same time, they need to address the ongoing issues and concerns of the people who have been impacted by this disaster, Goldman asserted.
The public has high expectations for preparing and responding to disasters. Public health officials need to base their decisions on a strong scientific base. It is not enough to spend a lot of time, energy, and resources. These investments need to be done in a smart way—guided by evidence, said Goldman.
EPA’S RESPONSE TO HURRICANE KATRINA
Hurricane Katrina required an unprecedented response from many agencies. As a first responder, EPA traditionally focuses on hazardous materials and oil spills, but because of the size of the disaster, the immediate mission of all the responding agencies was to assist in the search and rescue efforts, noted Johnson. EPA mobilized over 60 watercraft to assist in the search and rescue efforts. Although these efforts were different from EPA’s primary responsibility, the EPA team was able to rescue approximately 800 people.
Following the search and rescue efforts, EPA resumed its primary responsibilities under the national response plan, said Johnson. One of its primary concerns during Hurricane Katrina was the floodwaters from the levee breaches. These floodwaters were covering a number of potential hazards, including the major sewer system for much of New Orleans—causing concern about fecal con-tamination—and many Superfund sites in the New Orleans area, noted Johnson. At the same time, EPA was concerned about the air quality in the region, another challenge for the agency. Although the EPA has stationary monitors throughout the country, most of the monitors in the Gulf Coast were damaged or destroyed during the initial disaster.
ENVIRONMENTAL HEALTH ISSUES IN NEW ORLEANS AND LOUISIANA
The affected area of Hurricane Katrina covered three states and 90,000 square miles. In the state of Louisiana alone, approximately 1.7 million people were affected by the storm and needed to be evacuated, noted Jimmy Guidry of the Louisiana Department of Health and Hospitals. This was a daunting task that required evacuating the most densely populated area of the state to unaffected regions both within the state and in other states around the country. The state of Louisiana evacuated approximately 1.5 million people before Hurricane Katrina made landfall. However, approximately 200,000 individuals (accurate numbers were difficult to attain) remained in the affected area as the disaster unfolded. Although some people chose to stay, others did not have an opportunity to evacuate because of unavailable resources, said Guidry.
After Hurricanes Katrina and Rita, the New Orleans Health Department faced many challenges in monitoring and assessing the environmental exposures and rebuilding the public health infrastructure. The city’s public health officials interpreted the exposure data for the general population and worked on protecting people’s safety as they returned to their homes, said Kevin Stephens, director of Health, New Orleans Health Department. A number of questions still need to be answered, including
What is the long-term risk associated with exposure?
What specific monitoring methodologies should be used?
What should be monitored, what are the biomarkers, and how often should monitoring occur?
What precautions should be taken to eliminate risks and adverse effects? If the risks cannot be eliminated, how can their effects be reduced?
What are the appropriate communication strategies and messages?
The last question is very important because public health officials need to reassure the public. False reassurance would serve no purpose and could impede the recovery process, cautioned Stephens.
FEDERAL RESPONSE TO SHORT- AND LONG-TERM ENVIRONMENTAL HEALTH CONCERNS IN THE GULF COAST REGION
According to Howard Frumkin of the National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry (NCEH/ ATSDR), the Department of Health and Human Services, the Department of Homeland Security including the Federal Emergency Management Administration, and the Department of Defense are the first agencies to respond to disasters requiring federal support. The state and local agencies also have important responsibilities that sometimes, but not always, overlap with federal agency responsibilities and can lead to a very complex set of challenges. The central challenges were communication among the agencies and responding to environmental health issues.
A wide range of environmental health issues surfaced in the aftermath of the hurricane, and even though public health concerns are important to all in government, they are not the only concern, noted Frumkin. NCEH/ATSDR had to confront a number of crosscutting social and organizational challenges in trying to address health, safety, and environmental problems following Hurricanes Katrina and Rita. In the lifesaving phase of the response, some immediate decisions had to be made to identify and address life-threatening environmental hazards. Medium-term decisions included controlling hazards so that people could reenter the city. Finally, long-term questions include ensuring environmental health in reconstruction.
PROTECTING WORKERS DURING RECOVERY AND REBUILDING
Workers are the common denominator in all disasters, whether natural disasters, accidents, or terrorist events. They are the first responders who have to go to the scene to perform rescue and recovery operations, said Max Kiefer of the National Institute of Occupational Safety and Health (NIOSH). During the aftermath of Hurricane Katrina, providing occupational safety and health services
was a challenge because of the steady influx into the region of documented and undocumented workers due to work availability.
One of the largest post-Katrina challenges for NIOSH was that the workers coming into the region were performing tasks that they may not have been trained to perform, noted Keifer. The approaches for ensuring safety were different depending on the responsibility of the job. There were workers in the field who were responsible for debris removal, levee infrastructure, and industrial rebuilding as well as environmental cleanup. NIOSH was concerned about the workers’ exposure to the sediment, heat, noise, mold, and other environmental harms. Workers helping with residential refurbishment who were removing mold or debris were potentially encountering other substances, such as asbestos or lead, in some of these dwellings, said Keifer. At times they may not have been protected, as in the remediation of mold-contaminated environments.
RAPID RESPONSE ASSESSMENT
Coordinated effort and prioritization of health risks are critical, and they can become challenging when a relatively rapid response is needed but there is virtually no time to prepare for it, noted Kellogg Schwab of the Johns Hopkins University’s Bloomberg School of Public Health. This was true for Hurricane Katrina, with a disaster area that covered 90,000 square miles, creating community-wide and regional issues. Communication is a critical component of public health assessment, and with the size of the hurricane-affected area, it was one of the largest hurdles to overcome, said Schwab. Despite the many challenges to conducting health risk assessment, Schwab noted some positive outcomes. For example, Harvard University and Johns Hopkins University, teaming up with the Centers for Disease Control and Prevention (CDC), set up a toll-free hotline in Mississippi to provide the public with direct access to public health professionals who could provide information regarding the Mississippi Public Health Department’s response. Callers could also leave voicemail requesting a response for nonemergency issues.
On the basis of his experience in the region, Schwab highlighted some areas for further discussion:
Enhancing communication to assist in rapid health assessment,
Involving the public health community in articulating health issues,
Preparing assessors prior to an event and assisting them in adapting to changing situations,
Developing simple and meaningful target goals,
Developing effective strategies to provide targeted and timely results, and
Providing concise and accurate public health information and advice.
Schwab noted that additional work is needed to ensure effective communica-
tion strategies and prepare responders for health assessment. Although the next large disaster may be different from Hurricane Katrina, the same concepts of public health, infrastructure, and basic needs will still be present.
COMMUNITY INVOLVEMENT IN RESPONSE TO DISASTERS
The research community has amassed an extensive research database on medical ethics for patients; however, these principles may not be transferable to community-based research. Dianne Quigley of Syracuse University asserted that researchers also need to look beyond the Belmont principles to more communal ethical frameworks, such as virtue and communitarian ethics, the ethics of care, and postmodern ethics, which deals with power issues, otherness, and cultural diversity. Quigley singled out some ethical harms in community research:
Irrelevance to community needs and exploitation of community members,
Lack of comprehension by the community,
Exclusion of community contextual knowledge, and
Exploitation of community data.
To truly affect health, researchers and practitioners must address social and economic factors by working with the community, noted Sandral Hullett of the Jefferson (Alabama) Health System. She paraphrased Eugene Fidell, saying, “If the problem exists in the community, the solution can be found in the community.” That means that sometimes we in the health professions need to ask the communities what they want. She asserted that the knowledge, expertise, and resources of the involved communities are often key to successful research.
Three primary features of participatory research include collaboration, mutual education, and acting on results developed from community-relevant research questions. Participatory research is based on mutually respectful partnerships between researchers and communities. The community needs to feel that it is a part of the process, that it is not being used or taken advantage of because of its hardships. Partnerships can be strengthened by joint development of research agreements regarding design, implementation, analysis, and dissemination of the results. That may be a lot to ask, noted Hullett, although if one is committed to making it work, it will. One of the most important things is disseminating the results of participatory research, thus letting the community know that it is part of the process. The results of participatory research have local applicability and are transferable to other similar communities as well.
Monique Harden of Advocates for Environmental Human Rights reiterated the importance of the community and the protection of the community. She noted that in many communities the environmental regulatory system has failed. Hur-
ricane Katrina has exposed failings not only from an environmental regulatory standpoint but also in social, economic, and racial issues. She asserted the need to advance and defend the human right to a healthy and safe environment.
RESEARCH TO ADDRESS GAPS IN ENVIRONMENTAL HEALTH ASSESSMENTS DURING A DISASTER
During a disaster, the first task is to respond to the immediate, emergent needs of the people in the affected area, the people in areas that are indirectly affected, and the people responding, said Gilbert Omenn of the School of Public Health at the University of Michigan. This will always be the first task, although we should also be prepared to address risks as they unfold. When responding to an event, a determination needs to be made whether the priority should be given to acute health conditions or to long-term health consequences of exposure. According to Paul Lioy of the Environmental and Occupational Health Sciences Institute at Rutgers University, scientists can apply some lessons learned from the terrorist attacks of 9/11 to the response to Hurricane Katrina. The 9/11 event can be divided into four exposure categories: (1) within the first hours, (2) within the first 3 days, (3) over the next 12 days, and (4) the time after the first 3 categories, said Lioy.
In any disaster, there are numerous unknowns about the extent of environmental exposures, and Hurricane Katrina was no exception, noted Thomas Burke of the Johns Hopkins University’s Bloomberg School of Public Health. There were concerns about toxic agents, mold, physical hazards, and the multiple pathways of exposure. For some of these harms, there may be unique pathways of exposure that are not a part of the risk assessment process. Thus, scientists may be addressing perhaps the most complex exposure pathways or a combination of agents, which complicates the public health response and risk communication. In order to provide accurate information, scientists need to understand the affected community to know the potential routes of exposures. This information will also serve to guide research and public health actions, noted Burke.
If public health looks at the continuum from environmental contamination to disease, there are many questions that arise during a disaster response. Maureen Lichveldt of the Tulane University School of Public Health noted that for science to embark on research that matters, it needs to yield a demonstrable return on investment in terms of prevention. The research needs to engage the end users, whether it is called community participatory research or collaborative research. It should cut across more than one disease or condition, and it has to inform new environmental policies. She suggested that scientists need to take an exploratory approach to defining and researching the types of susceptibilities. This research will address the real risk to real people—not the things that scientists would like to know, but the things that public health must know to be able to advance preven-
tion. Finally, while research needs to be informed by bench science, it has to be flexible to answer questions from the trenches as disasters unfold.
STRATEGIES FOR THE FUTURE
The workshop was held to address a number of goals. Among the primary reasons for this meeting was not only to convey compassion for the people of New Orleans and the Gulf Coast, but also to ensure their safety and well-being as they reinhabit their homes, noted Goldman. Second, the workshop began a scientific dialogue to understand the impacts of Hurricane Katrina on people’s health. Third, it discussed how the public health community can use the dialogue in preparation for future events. The workshop did not consist of lessons learned during the response, but rather was an examination of the science needed to inform the ongoing response to disasters of this magnitude, asserted Goldman.
One of the first steps in the response was to ensure environmental safety and well-being as the requirements for safe homes and neighborhoods. The area needs to have a strong environmental infrastructure, which includes safe drinking water, sanitation, and removal of trash and waste at the street, neighborhood, and regional levels, observed Goldman. In the long term, there is a need for reconstituting the communities in the region—knitting back together communities to provide social support. This will require commitment to schools and services and the preservation of cultural, racial, and socioeconomic diversity, noted Goldman.
During the meeting, a number of major themes were discussed that cut across scientific disciplines. Many of these themes warrant future discussion, including the need for research, scientific leadership, and environmental management. Goldman concluded by stating that there is a need for health studies, whether they are cross-sectional, case controlled, or longitudinal. Public health needs to look at disasters systematically to ensure that the affected communities are involved and can fully participate in the recovery