The previous panels demonstrated the importance of the human element in the functioning of critical infrastructure. The same observation applies in the area of public health, said Monica Schoch-Spana, senior associate with the Center for Biosecurity of the University of Pittsburgh Medical Center. The title of the final panel at the workshop—healthy populations and responsive institutions—captures this dependence on human resources. Public health, medical, and mental health institutions require well-trained people to help preserve the well-being of the population and meet their needs when they are ill or injured. The panelists included Paul Byers, Knox Andress, Joseph Donchess, and Garcia Bodley (Appendixes B and C).
Schoch-Spana reviewed the three questions the panelists had been asked to consider:
1. How have preexisting levels of health and illness in the Gulf Coast shaped the epidemiological outcomes of major disasters? What short- and long-term interventions in the health arena could enhance population resilience to future disasters?
2. What factors currently enable Gulf Coast health care facilities (from hospitals to long-term care facilities) to remain “online” in a disaster, maintain basic services, and respond to emergent health needs? How could the level of institutional resilience be improved?
3. What role does robust or intact medical, public health, and mental health infrastructure play in successful and prompt recovery from a major disaster in the Gulf Coast? How could or should the Gulf Coast enhance such infrastructure?
MEETING MEDICAL NEEDS AFTER A DISASTER: PAUL BYERS
Before Hurricane Katrina, the Mississippi State Department of Health felt that it was prepared for a hurricane. “Within a couple of days, it was glaringly obvious that we were not prepared to address many of the issues we were presented with,” said Paul Byers, acting state epidemiologist with the Mississippi State Department of Health.
The epidemiology of diseases on the Mississippi Gulf Coast resembles that of the rest of the United States. People have chronic medical problems, including diabetes, end-stage renal disease that requires dialysis, and coronary artery disease. After a disaster, people need specialized medical care, even if the capacity of primary care centers and hospitals has been drastically reduced. Furthermore, the medical care system in Mississippi has many holes. Many people in the state are not only uninsured but also have no medical home, and many places lack an adequate supply of primary care physicians.
Mississippi had several special medical needs shelters in place before Katrina, but these facilities did not meet the needs of many people after the storm. They did not have enough food, water, or medications, and many had no references to their original prescriptions, making proper medicine dosage difficult to maintain. Even where they had generators, they did not have gas to run them. The state also planned to partner with schools, community health centers, and other local institutions to provide sheltering for people with special medical needs, but the infrastructure was not in place to do that.
After the storm, the state built up its infrastructure, including a permanent special-needs shelter with trained staff and backup power and supplies, and it was better prepared when Hurricane Gustav hit in September 2008. But problems still occurred because many people who were evacuated from the Gulf Coast did not know what medications they were taking. An electronic health information exchange is needed, said Byers, so that health care providers can quickly access medications, diagnoses, special medical needs, and other information to provide the best possible care. “That takes a lot of money and a lot of effort.”
The Department of Health has the responsibility both to meet immediate medical needs in the first days to weeks after a medical or natural disaster and to meet long-term medical needs. To do so, said Byers, it needs to have partnerships with multiple entities to provide physical infrastructure and meet whatever needs exist. For example, the state now has special medical assessment teams that can be deployed to an area. A partnership with the University Medical Center in Jackson has resulted in portable facilities that can provide primary care and even surgery. Byers said that partnerships with the federal government are also necessary to access resources that transcend what is available locally.
DRAWING ON OUTSIDE RESOURCES: KNOX ANDRESS
Like Mississippi, Louisiana struggles with a wide variety of health needs. Ranked 49th in the nation in health outcomes, it has many people with chronic diseases such as diabetes and end-stage renal disease. “Folks are living longer, so how do you deal with [their] needs?” asked Knox Andress, the designated regional coordinator, Louisiana Region 7 Hospital Preparedness, Louisiana State University Health Sciences Center–Shreveport, and Louisiana Poison Center.
Considerable effort has been devoted to building sheltering and alternate care facility capacity. This has involved drawing on the resources of other states and other institutions. It also involves education to change the culture of preparedness. This education needs to be directed both toward health care providers and toward the people they serve. Particular populations need to be identified and then contacted to explain responses when a disaster occurs.
Changes in standards and regulations can help health care systems respond to a disaster. For example, changes to the Stafford Act could allow all health care facilities, regardless of whether they are for profit or not for profit, to get federal assistance when their buildings are damaged, said Andress. Coalitions among organizations can identify common needs and areas of overlap. And better data and communications structure can provide more real-time information in the aftermath of a disaster. For example, an at-risk registry in Louisiana provides information on people with special needs who might need to be evacuated.
ASSISTANCE FOR NURSING HOMES: JOSEPH DONCHESS
The summer before Katrina, the approach of Hurricane Ivan toward New Orleans triggered a widespread evacuation, including the evacuation of many nursing homes. At the time, Highway 10 was under construction, and it took 48 hours for some busloads of nursing home residents to get to Baton Rouge. “We had several losses of life of elderly patients on buses trying to get to their sheltering sites,” said Joseph Donchess, executive director of the Louisiana Nursing Home Association.
The warning that Katrina was going to be a major event came two and a half days before landfall. The Louisiana Nursing Home Association immediately began calling not only its member facilities but also its nonmember facilities and impressing upon them the urgency to leave. But by then, many could not get buses to move their residents. The nursing homes had to hope they could shelter in place without harm.
“In fact, the storm did pass without great event,” said Donchess. “Unfortunately the levees began to break, and it was a flooding situation. That’s where we found ourselves after Hurricane Katrina.”
Elderly patients can be traumatized when they are moved from one location to another, said Donchess. Changing their routines can have both psychological and physiological consequences. “I heard the story of an elderly priest who lived in Our Lady of Wisdom Nursing Home who was very vibrant and very active. When he had to move for Katrina to Texas and was gone for 6 months, he very quickly lost his lust for life, so to speak, and he became sicker as the days went by. He died within 6 months.”
During Katrina, many nursing home patients were separated from their caregivers. “Nursing homes were literally forced to take their patients to the New Orleans Airport and simply drop them off. They ended up in Chicago, Salt Lake City, and other parts around the country.” Many people in nursing homes cannot communicate effectively, so they cannot provide information about themselves to new caregivers. Today, about 85 percent of the association’s nursing homes can transfer updated documents daily to a source outside the nursing home in case those documents are needed.
The staffs of nursing homes also have many needs during and after disasters. Many nursing home staff members are single mothers who were worried about their children during Katrina. Many needed mental health services in the aftermath of the storm.
After Katrina the Louisiana Nursing Home Association worked with the governor on a law that would ensure that nursing homes receive assistance during and after a disaster. With the new law, they can turn to the state for assistance, though they are still primarily responsible for the safety of their residents. Nursing homes have also worked with other organizations to receive grants for large generators, which would make it easier for the elderly to shelter in place. The association has a good relationship with the Public Service Commission, which would help ensure that hospitals, nursing homes, and other health care facilities receive priority attention if they lose power during a storm.
THE NEED FOR BEHAVIORAL HEALTH SERVICES: GARCIA BODLEY
Most emergency preparedness services have focused on medical needs, but behavioral health services, including mental health and substance abuse services, are also needed, according to Garcia Bodley, program director for the Louisiana Spirit Coastal Recovery Counseling Program. Her office has recently undergone changes to combine medical and behavior health services, though securing the necessary resources has been a challenge.
Disasters can increase the number of people who need such behavioral health services. An estimated 80 percent of the people who experience a disaster or some other trauma do not need intensive services, but the other 20 percent do. “That’s our role,” said Bodley, “to help people have the psychological and physical capability to bounce back after this type of experience.”
The Louisiana Spirit Program is a crisis counseling program modeled after a federal program. Interventions include immediate crisis counseling services for people who are not accustomed to seeking mental health services. “We are careful about how we present our services—it is crisis counseling in terms of helping people to get an opportunity to express what’s going on and to share their stories,” said Bodley. Services for behavioral health providers are also important, including some form of alternative staffing or emotional support.
The program also works with local providers, because they are the ones who know and are responsible for services in their communities. It has links to more intensive providers of mental health services should an individual need more counseling or substance abuse services. Partnerships with faith-based and other community-based organizations also can be invaluable. Bodley noted that the Gulf oil spill has created an intensified need for domestic violence and substance abuse services, and increased numbers of suicides remains a concern.