Hurricane Katrina Analysis - CFR Global Health Program

[David Farber <dave () farber net>]

Begin forwarded message:

From: AMBOLLC () aol com
Date: September 2, 2005 7:58:52 PM EDT
To: dave () farber net
Subject: For IP, if you wish: Hurricane Katrina Analysis - CFR Global  
Health Program




From: SRosenstein () cfr org
Date: September 2, 2005 6:53:40 PM EDT
To: SRosenstein () cfr org
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 () cfr org
www.lauriegarrett.com
Research Associate, Scott Rosenstein, SRosenstein () cfr org



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 () cfr org




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