Public Health at the End of the World

It is inconceivable that there is anyone in this country who is unaware of the events that have overtaken the communities where the Mississippi River empties into the Gulf of Mexico. Much of the response is being carried out by firemen, EMS (emergency medical services) personnel, and policemen, as well as the U.S. military, specifically including the U.S. Coast Guard. However, there is still much to be done on the public-health front. When all of the fires have been extinguished, all remaining survivors have been rescued, and the looters either imprisoned or chased away, what remains will be largely a public- health incident – on a scale that has not existed anywhere in the United States since the end of World War II.

The magnitude of this disaster is tremendous; one look at the aerial photos on any news site will show that. However, what the photos do not show is the inherent difficulties in keeping the population of a major city alive when all major sources of drinkable water have been contaminated by benzene and saltwater (not to mention other, and worse, contaminants). How can first responders and public officials provide food and shelter for tens of thousands of people – many of them ailing or injured or both? How do the thousands of first responders on the scene stay alive in the same life-threatening conditions?

Until the supply lines are completely set up, those working in a disaster area must sustain their operations with what they personally carried in on their backs, supplemented if possible by what they can scavenge on the scene. The first responders are vulnerable to many of the same hazards as those unfortunate citizens they are trying to help, and as a result could be considered a secondary drain on the almost always scarce resources available.

One of the major differences between the scale of Hurricane Katrina, and the flooding that followed, and other recent massive disasters is the almost total disruption of the infrastructure along the Gulf Coast and in the city of New Orleans. As horrible as the attacks of 11 September 2001 were, those involved in the post-attack response operation were able to go home at night to warm, clean, and dry beds. Some chose not to, of course, but in New Orleans tonight, and for many nights to come, that will not be an option.

Sanitation – the Key to Continued Survival

The states most immediately affected by the hurricane and follow-on flooding made early requests for assistance to their counterparts in other states. One of the more important things they asked for was people with sanitation experience. At first blush that wording might bring up images of staff members familiar with the business end of a scrubber, but in the public-health community sanitarians represent the pointy end of several important sticks.

The National Environmental Health Association defines environmental health and protection as protection “against environmental factors that may adversely impact human health or the ecological balances essential to long-term human health and environmental quality, whether in the natural or man-made environment.” With that definition in mind, it becomes obvious that the purviews of public-health sanitarians in a disaster of the Katrina scale are many and varied – and extremely important. It should be kept in mind that, in this context, long term starts early in the morning and continues through the completion of recovery and usually well beyond.

It also is important to understand that, although these issues come under the jurisdiction of the public-health community, many other agencies and disciplines will be working on the same issues and problems. However, the public-health community and its agencies will be working on the issues for months and perhaps years to come, whereas most of the other agencies involved will not be. Following is a brief summary of some, but by no means all, of the major public-health issues and problems the public-health community is working on in New Orleans and other communities along the Gulf Coast.

Hazardous Materials (HazMat). 

Many news outlets have carried photos of large areas of water covered with a rainbow sheen of petroleum products. These chemicals – most of which are in fact the leaching out of the accoutrements of daily life – are spilling from the submerged tanks of gas stations and chemical-production facilities, leaking from the thousands of cars, trucks, and other vehicles that are still underwater, or simply escaping from the millions of places where chemicals are stored in most modern households. Making them even more toxic is that all of these chemicals are now mixed in a sludge of bacteria and waste flushed out of the sewer system.

What does the public-health community have to do with HazMat? This is a question that even seasoned responders often do not know how to answer. Fire-based HazMat teams are the typical first responders of the HazMat world, but it is the public-health environmental-hazard community that tracks the long-range health effects of chemicals in the modern world. It is the job of public-health personnel to work on the human effects of the HazMat.

The Super Dome – a poured-concrete structure far enough away and well above the likely sources of flooding – initially seemed an inspired choice to shelter the masses of those New Orleans citizens who could not get far enough out of the city. What changed it from an ideal shelter to one that eventually had to be abandoned was infrastructure – or, more specifically, the loss of infrastructure.

Drinking Water Protection. 

Maintaining a continued supply of potable water and protecting the principal sources of clean water are always major public-health undertakings. As previously mentioned, the amount of chemicals washed into the standing water in and around the areas hit by Hurricane Katrina is staggering – however, the risks associated with the sewage that has contaminated the surface water in those areas is an even greater hazard.

Adding to the non-availability of enough clean water is the presence of bodies, both human and animal, also contaminating the environment, particularly in standing water. These bodies not only pose a major risk to physical health but also lead to mental health stress, as well as emotional distress, that affects survivors and rescuers alike.

Food Safety. 

In the day-to-day world, public-health professionals inspect food preparation facilities as part of the licensing and approval process. However, in the face of a major disaster such inspections often are set aside because of the greater necessity to manage the feeding of large masses of overwhelmed evacuees.

Disease Monitoring and Prevention. 

Another routine task assigned to public-health agencies is to track “reportable” diseases – i.e., those diseases that by law or regulation must be reported to the local or state Department of Health or Board of Health. Once such reporting has started, the public-health epidemiologists study the flow of the disease to identify both its origin and its spread. During any major natural disaster the same epidemiologic tools can be brought to bear on illnesses, such as dysentery, that are not usually reported to the health department.

In a disaster of Katrina’s scope the disease-monitoring staff can identify the causes and contributing factors involved in the spread of an illness such as the aforementioned dysentery, which – because of the inadequate hygienic facilities available – could quickly sweep through an evacuation center or decimate a team of rescuers. By isolating the cause and identifying the contributing factors, the spread of such illnesses can be checked.

Sustained Medical and Hospital Resources. 

One of the major focuses of the current response operation is on hospitals and their patients as well as the medical staff and their families. Many of the more alarming reports coming through the media on a daily basis for the last two weeks have been about hospitals that are being evacuated and/or are sending distress messages requesting assistance in maintaining power and basic food and water supplies as well as medical supplies and equipment.

As one of the main interfaces between the hospital community and the response community public-health personnel should be in position to assist in organizing and reporting a hospital’s surge capacity.

Naval/Military Support. 

One of the more encouraging reports received during the last week was that the Military Sealift Command’s Navy hospital ship USS Comfort was deployed on short notice to the Gulf of Mexico to aid in the efforts to respond to the Hurricane Katrina disaster. This is the same ship that proceeded at flank speed to New York City in the wake of the 11 September 2001 attack on the World Trade Center towers.

In short, although the nation’s public-health professionals will not be putting out fires or stopping the looting in New Orleans, their role in the response-and-recovery efforts following Hurricane Katrina will be, as in so many other major disasters, key to the continued good health and welfare of the hundreds of thousands of residents directly affected.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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