Left behind: the legacy of hurricane Katrina

Hurricane Katrina puts the health effects of poverty and race in plain view

The sinking of the Titanic, during which women in first class cabins were more likely to survive than those booked into cheaper decks, has been used to illustrate the effects of income and social class on health (T LaVeist, personal communication, 2005). In the aftermath of hurricane Katrina, Americans have been shocked and shamed to realise that they still don't have enough lifeboats for all of our citizens. Live images of uncollected corpses and families clinging to rooftops made vivid what decades of statistics could not: that being poor in America, and especially being poor and black in a poor southern state, is still hazardous to your health.

This may truly be a “teachable moment” about the impact of poverty and race on health. The gap in health between white and black Americans has been estimated to cause 84 000 excess deaths a year in the United States, a virtual Katrina every week.1 Because the victims gradually succumb to various diseases such as diabetes, cardiovascular disease, alcohol and drug abuse, cancer, and HIV infection, they rarely capture the public's attention in the way the victims of Katrina have. As a result, health inequality has persisted despite decades of important health gains, economic growth, and progress on racial issues in the United States.

It would be a mistake, however, to assume that the problems highlighted by hurricane Katrina are a unique legacy of southern racism or a problem affecting black Americans or America alone. The same factors that placed the poorest residents of New Orleans in harm's way—unemployment, poverty, neglect of communities, and alienation—contribute to health disparities for poor children and adults and those from minority groups throughout the United States,2 in the United Kingdom,3 and in other Western countries.4 5 But the aftermath of hurricane Katrina provides clear lessons about what changes in policy government and private agencies must make to tackle health inequalities.6

Fund prevention, not rescue. The recent UN International Strategy for Disaster Reduction notes the need to “invest to prevent,”7 yet a comprehensive plan for protecting the Gulf Coast languished for years because it seemed too expensive to implement: the costs of hurricane Katrina to the US treasury are now expected to rise as high as $200 billion. Pressure on healthcare budgets for the poor continues to squeeze services for primary care and prevention owing to soaring costs for emergency visits and for admissions to hospital and long term care, many of which might be preventable with better functioning systems of ongoing care. Nowhere are the high costs of deferring investment in health more evident than in a poor state such as Louisiana, which ranks 48th among 50 states in levels of health insurance, 45th in public health spending, 50th in overall health and second in the costs to the federal government of caring for its older and disabled citizens.8 9

Strengthen the infrastructure for public health. The individual heroism evident among those who responded to the emergency in Louisiana and Mississippi and in health workers who struggle every day to meet the needs of poor communities cannot make up for a frayed infrastructure. Recent reports have called attention to the neglect of the public health infrastructure in the United States and the United Kingdom.10 11 Strengthening this infrastructure will depend on improving the workforce, information systems, and organisation both locally and nationally.

Adopt policies that support responsible choices. Democracies cannot completely protect their citizens from the freedom to make bad choices. Yet hurricane Katrina's effects vividly illustrate how the choices available to us differ depending on where we live and how much money we have. Many who “chose” to stay in the path of the storm had no cars with which to escape, no faith that their property would be protected, and no insurance to cover their losses. Similarly, promoting personal responsibility as the solution to health problems such as obesity will not work if we do not reduce the barriers to exercise and healthy diets in poor urban communities, where parks and supermarkets are less common than fast food chains and stores selling alcohol. The problem is particularly acute in the US, where efforts to intervene early against chronic diseases such as hypertension and diabetes are hampered by a system that continues to leave 45 million citizens without health insurance.

Improve communication about critical threats to health. The failure of basic communication after the hurricane fed a downward spiral of the early recovery efforts. The lack of an authoritative source of information fostered confusion and rumours which exacerbated the chaos and sense of panic. Similar challenges hinder efforts to confront health problems in poor and ethnic minority communities, where a legacy of distrust of government and medical establishments provides fertile ground for misunderstanding, myths, and conspiracy theories about health issues. Rebuilding trust will require actively including the community in any planning and research which affects them, improving cross cultural training of health workers, and tapping into the informal information networks in these communities.

Build strategies that foster accountability. A variety of investigations will eventually sort out the failings and scattered successes of the preparations for and response to hurricane Katrina. And, although our ability to measure health disparities is improving, we still need better mechanisms to promote accountability for reducing them. Public and private healthcare organisations and both local and national governments will need to negotiate their shared responsibility for a problem that has many sources and no single solution.

Strengthen communities. It now seems that many of the most horrific stories to come out of New Orleans—roving gangs of rapists, snipers firing on helicopters—were exaggerated or untrue. But the perception of crime and disorder which impeded the response to hurricane Katrina also undermines efforts to attack health disparities. Problems of drugs and alcohol misuse and attendant crime and violence take direct tolls on health and lower the priority given by government and other organisations to health issues. The healthcare sector alone cannot tackle problems which require support from good schools, businesses, religious institutions, other community organisations, and law enforcement agencies.3 12

In the rush to rebuild in the southern states, Americans should pause to think more deeply about what it would take to create more equitable and healthier communities in New Orleans and throughout the affected areas. It is essential that these lessons are heeded in any plans for recovery. It is even more important that we and others apply these lessons to help the many other individuals and communities with poor health who continue to languish out of the public eye.