FW: [IP] Hurricane Katrina Analysis - CFR Global Health Program

Some notion of the extent of the problem.

-----Original Message-----
From: David Farber <dave@farber.net>
Date: Saturday, Sep 3, 2005 6:08 am
Subject: [IP] Hurricane Katrina Analysis - CFR Global Health Program

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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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