PRESIDENT'S ADDRESS: PUTTING “CLIMATE” BACK INTO THE “CLIMATOLOGICAL”

PROLOGUE: “HOUSTON, WE HAVE A PROBLEM.”

Hurricane Harvey began as a typical August tropical storm that rapidly intensified into a Category 4 hurricane before making landfall along the middle Texas coast (Figure 1). The hurricane stalled with its center near the Texas coast for four days, dropping historic amounts of rainfall over southeastern Texas. Large areas received three feet or more of rainfall—a thousand year or greater flood. During August 26–27, 2017, extreme rainfall totals inundated the Houston metropolitan area (1,2,3,4). Intense rain bands documented rates of 6.8 inches in one hour. The front eventually moved over the Beaumont/Port Arthur area by late August 28, 2017. The highest sustained winds on land were 110 mph with a total of 51 tornadoes reported. Over four days, up to 61 inches of rain fell on parts of Greater Houston (estimated 6.7 million residents) (Figure 2), and approximately 70% of Harris County/Houston was flooded to at least 18 inches. Hurricane Harvey produced the most significant amount of hurricane rainfall ever in U.S. history and was the first major hurricane since 2005 to make landfall.

Fig. 1.

Hurricane Harvey–August 25, 2017.

Fig. 2.

Street flooding during Hurricane Harvey.

During the storm, dams reached peak levels that led to flooding of downstream neighborhoods, resulting in >300,000 homes and 500,000 vehicles being flooded and 10,000 residents being rescued. The flood water that flowed through Houston's streets contained elevated levels of arsenic, lead, and E.coli (5). Chemical plants in southeast Texas and refinery sites released “excess emissions.” One of the 43 superfund sites, the San Jacinto River Waste Pits (SJRWP), had damage that resulted in the release of toxic chemicals. A damaged tank at the Valero Oil Refinery leaked more than 200,000 pounds of benzene, toluene, and other organic compounds.

While Hurricane Harvey was pounding Rockport, Texas, Ben Taub Hospital (BTH) was preparing for the worst. As a 450-bed county hospital and Level I trauma center, we had plans in place to maintain the facility. On Friday, August 25, 2017, Ride Out Team One (residents and faculty) arrived, expecting to stay for 72–96 hours. As the storm unleashed a torrent of rain on Saturday, August 26, 2017, a six-inch pipe suffered a 30-foot gash. Nearly six feet of water flooded into a basement room, almost swamping vital electrical and telecommunications equipment. If that equipment had been flooded, the hospital would have had to be evacuated. A team of hospital engineers was able to save the essential equipment. Disaster recovery and plumbing contractors were ready to get to Ben Taub Hospital and help with repairs as soon as the storm ended. However, the pharmacy and food services had to be moved from the basement of the hospital; this was the major reason that the administration debated activating an order to evacuate the hospital.

THE GREENBERG JOURNEY: REMEMBRANCE

On Monday, August 28, 2017, Ride Out Team Two replaced Ride Out Team One, during a lull in the storm. Most of the Baylor College of Medicine (BCM) house staff and faculty had to be driven through high water to BTH in pickup trucks (Figure 2). During this time, we attempted to evacuate a few patients to other local hospitals, but travel proved to be impossible. Nevertheless, BTH remained open for incoming patients throughout the hurricane.

As an attending physician on the medicine service, I planned to make it to BTH as part of Ride Out Team Two (Figure 3). We live on the 20th floor of a building that is separated from the hospital by about a mile of city park (Figure 4). The street that runs through the park has a golf course on one side and the Houston Zoo and an outdoor theater on the other side. I anticipated having to wade through street flooding and, therefore, dressed accordingly. My wife, Lisa, suggested I should not attempt this journey, but I said I needed to go.

Fig. 3.

Staffing during Hurricane Harvey at Ben Taub Hospital for Medicine Service.

Fig. 4.

My journey through Hermann Park during Hurricane Harvey.

As I started through the park, I noticed that the street was flooded and there were no other people or moving vehicles. I was attempting to walk on the running path that lines one side of the street, because it was approximately 12 inches above street level. As I came to the halfway point, the water level had risen to my calves and the path had disappeared under the rising water. Suddenly, I stepped into an unexpected depression in the path. This caused me to trip and fall into water, covering my clothes. The weight of the added water made it impossible to stand, forcing me to crawl on my hands and feet until I found higher ground. I was able to reach a live oak tree where I attempted to clear my confused mind. In addition to thinking about the possibility of drowning, several questions came to mind (Table 1).

TABLE 1.

My Questions While Waiting to Be Rescued

•  If I drowned, what would be the social media headline? • How would Hurricane Harvey be different from Houston's previous flooding events? • What medical and mental health issues would face the Houston community? • Would FEMA respond to our needs—both immediately and over the long term? • Would we learn something new about the medical response and environmental effects? • How would Hurricane Harvey affect our medical students, residents, and faculty? • Should the ACCA devote renewed attention to the effects of “climate” on our collective health?

My answer to the first question would really depend on whether my headline or my wife's headline were used. My choice was: “Hurricane Harvey Claims Life of Prominent Ben Taub Hospital Chief of Medicine.” My wife's choice would be: “Deluded Doctor Drowns in Deluge.” The second question I asked myself was: “How would Hurricane Harvey be different from Houston's prior flooding events?” Houston has had several tropical storms and hurricanes that have resulted in significant flooding. In addition, the city had learned significant lessons when it participated in the rescue and recovery from Hurricane Katrina in New Orleans.

The deadliest, most costly tropical storm to hit the United States was Allison in June 2001 (Figure 5). It caused 21 deaths and $4.8 billion in damages to the Houston metropolitan area alone (6). Tropical Storm Allison sent a five-foot wall of water into most of the facilities in the Texas Medical Center, resulting in the closure or evacuation of three large private hospitals. Decades of research were destroyed in both medical schools in the Texas Medical Center. BCM suffered monetary research losses in the range of $200 million.

Fig. 5.

Tropical Storm Allison flooding the Texas Medical Center in June 2001.

Several lessons were learned from Tropical Storm Allison. Electrical switching gear was relocated from hospital basements to higher levels. When patient evacuations were necessary, receiving hospitals had to accommodate new patients, staff, and physicians into a new hospital structure. An Incident Command System was developed to centralize control of all hospital operations.

My personal losses during this tropical storm included new furniture that had just been moved into the basement of BCM, where the Associate Dean of Graduate Medical Education and the Graduate Medical Education offices were located. New furniture, books, pictures, and diplomas were ruined by the 12 inches of water that accumulated overnight.

Houston and Ben Taub Hospital were also indirectly involved with Hurricane Katrina, which devastated New Orleans in August 2005. Because of the severe flooding and breach of the levee system, over 350,000 New Orleanians and Gulf Coast residents had to flee their homes. Without sufficient temporary shelters, government officials in Texas were asked to provide shelter in the Houston Astrodome (7,8,9,10,11,12). Beginning September 1, 2005, an estimated 27,000 evacuees were temporarily housed for several days, and in many cases, for weeks (Figure 6). In addition, the George R. Brown Convention Center opened and registered an additional 28,000 evacuees.

Fig. 6.

Hurricane Katrina: Houston Astrodome Clinic, 2005.

Lessons learned from Tropical Storm Allison had been put into effect prior to Hurricane Katrina. A Catastrophic Medical Operations Center (CMOC) had been developed and found to be the integral component of the regional medical response. However, many of the local medical personnel within the Astrodome/Reliant Center Complex had not received training in disaster response or evacuee care. Six hours before the first buses arrived from New Orleans, patient examination rooms and specialty areas were built, including areas for labs, radiology, pharmacy, urgent care, and an infusion center. During the three-week response period, approximately 55,000 evacuees were treated. Hurricane-related injuries were mainly minor. Cases involved primary care, internal medicine, pediatrics, psychiatry, and geriatrics, but very little trauma. One month after Hurricane Katrina, the Harris County Hospital District saw a 15% increase in clinic visits.

WHAT MEDICAL AND MENTAL HEALTH ISSUES FACED THE HOUSTON COMMUNITY DURING HURRICANE HARVEY?

Several of the medical issues faced during Hurricane Katrina would also arise during Hurricane Harvey, including provision of adequate shelters for disabled individuals, increased treatment for psychiatric needs, as well as dealing with infectious disease issues. During Hurricane Harvey, the total population of vulnerable persons in the Houston–Galveston metropolitan area was over one million people (Figure 7). The surrounding counties had a total shelter capacity of approximately 92,000 people (13). Thus, Harris County could only meet 18% of the shelter demand for these highly vulnerable populations, and the Houston–Galveston metropolitan area could only shelter 36% of its population (Figures 8 and 9).

Fig. 7.

Hurricane Harvey affected all of Harris County.

Fig. 8.

Shelter demands during Hurricane Harvey.

Fig. 9.

Shelter demands during Hurricane Harvey.

The majority of clients served by home health affiliates were older adults who had more than one chronic illness (14). A survey of home health services found that three-fourths of the agencies reported disruptions in home visits for at least one week. In most cases, staff members were physically unable to reach their clients. Most agencies reported having had an emergency preparedness plan. Most clients were called in advance, and many agencies had moved visits up before the storm arrived. Some agencies transferred clients to local hospitals and emergency centers. Agencies also instructed their clients to call 211—a nationwide service designed to operate during a disaster. Surprisingly, there was little transferring of clients to other agencies due to lack of collaborative effort (15,16,17).

The BCM/Menniger Department of Psychiatry provided psychiatric services for almost two weeks at the convention center shelter. Approximately 60 clinicians staffed the shelter which housed ∼10,000 persons: 229 individuals were assessed at least once and 34 individuals had > 2 visits. Over 90% of those seen had preexisting health concerns. The most common psychiatric diagnoses were bipolar disorders, depression disorders, anxiety disorders, and substance use disorders. Posttraumatic stress disorder (PTSD) was preexisting in only 13% of interviewed patients at the shelter (18,19,20,21). The majority of the psychiatrists' efforts were providing distress tolerance skills; identifying individuals in need of further evaluation; and helping to obtain food, clothing, and medical care and access to the Federal Emergency Management Agency (FEMA) (14).

Tuberculosis control activities after Hurricane Harvey demonstrated the ability of public health agencies at the local, county, and state levels to provide continued treatment (22). Of a total of 282 active cases from 17 affected health departments, 280 were accounted for within a week after the storm began. Ninety-seven percent of monitored cases did not miss any medication doses. The infrastructure and preparedness worked.

Mold exposure was common during Hurricanes Katrina and Rita. Because of possible invasive infection in immunocompromised persons, interviews were conducted in the Houston area among a sample of immunosuppressed residents (post-transplantation or receiving immunosuppressive medications). Following Hurricane Harvey, half of the surveyed residents had participated in cleanup activities and had not worn recommended respiratory protection. Nevertheless, published studies from MD Anderson Cancer Center found no evidence of significantly increased rates or the emergence of unusual molds in the first 12 months after Hurricane Harvey (23,24,25).

New research has focused on the potential utility of social media and online social networks in disaster recovery (26). A recently published study investigated the role of WeChat in improving resilience among Houston's Chinese American community during and after Hurricane Harvey. A cell phone-based social messaging community used WeChat to form groups that would disseminate disaster relief information and coordinate rescue and recovery activities.

WOULD FEMA RESPOND TO OUR NEEDS?

President Jimmy Carter developed FEMA as an outgrowth of the Agency of Homeland Security. For FEMA to be called in, the governor of the affected state must declare a state of emergency. The annual budget of FEMA is approximately $14 billion. As part of its mission, FEMA manages the National Flood Insurance Program (NFIP) (27).

Congress established the National Flood Insurance Program in 1968. This program provides subsidized coverage in flood-prone areas. From a voluntary program, it quickly led to mandatory coverage for homeowner loans backed by federal mortgages in flood-prone areas. Lower insurance premiums were given to communities that exceeded the minimum flood ordinance requirement. This program is managed through the NFIP's Community Rating System.

A second act that encouraged initiation of a disaster proclamation was the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988. With a presidential disaster declaration, communities would be eligible for financial and physical assistance through FEMA. FEMA's responsibilities involve disaster relief and disaster mitigation (Figure 10). The Hazard Mitigation Grant Program gives grants to states and local governments to mitigate disaster damage by planning and implementation programs. While these programs have resulted in increased community preparation, they have unfortunately supported overdevelopment in highly vulnerable coastal areas. Dr. Pilkey believed that: “Without these government subsidies, especially those granted by the Stafford Act, there would be far fewer, and far less expensive, houses along the coast” (28). The NFIP has paid out ∼$9 billion to properties that have suffered repeated damage. By 2012, the NFIP's accumulated debt was estimated to be $30 billion.

Fig. 10.

FEMA response during Hurricane Harvey.

At the request of FEMA, the National Academy of Sciences, National Academy of Engineering, and National Academy of Medicine appointed a committee to hold workshops to gain understanding of the causes and impacts of urban flooding in selected metropolitan areas (27). The metropolitan areas included Baltimore, Chicago, Houston, and Phoenix. The committee explored the causes, impacts, and actions necessary for managing urban flooding. It produced a consensus report that identified commonalities and variances among the case study metropolitan areas, estimated the size or importance of flooding in these urban areas, and researched causes and actions of urban flooding to existing federal resources or policies.

The NIH Disaster Research Response Program (DR2) was developed by the National Institute of Environmental Health Sciences (NIEHS) in collaboration with the National Library of Medicine. The goal of DR2 is to promote and coordinate disaster research using publically accessible data collection tools, multi-stakeholder exercises, and a network of trained research responders. DR2 activities include questionnaire development, training materials, protocols that have been required for human subjects, and subject matter experts (https://dr2.nlm.nih.gov). The NIEHS completed workshops in Los Angeles (2014), Houston (2015), and Boston (2016). The Houston workshop focused on preparedness gaps in the Houston Ship Channel that links the Gulf of Mexico to Houston.

After Hurricane Harvey moved through the Houston area, toxicologists with the Environmental Defense Fund detected high concentrations of the carcinogen, benzene, in the Manchester community in southeast Houston, near the Houston Ship Channel (29). This community is made up of low-income people who have been exposed to environmental and health risks for decades.

The Center for Precision Environmental Health Post Harvey Research Project was activated within one week of Hurricane Harvey (Figure 11). Wristbands developed by Oregon State University were handed out to people living or working in homes that were flooded. The bands detect volatile and semi-volatile chemicals from air and water (30). They were collected after seven days of use. In addition, biosamples and heath questionnaires were collected. Silicone wristbands developed at Oregon State University are low-cost, shelf-stable, and easy to store passive sampling devices (Figure 12) (31). These bands can test for 1,529 chemicals, but not metals, inorganic gases, or molds. After Hurricane Harvey, a team of Baylor College of Medicine scientists deployed wristbands in three areas around Houston that had experienced flooding. Preliminary results have recently been presented at a one-day symposium at BCM.

Fig. 11.

Hurricane Harvey survey.

Fig. 12.

Wristbands used to detect volatile chemicals during Hurricane Harvey.

Polycyclic aromatic hydrocarbons (PANs) are environmental toxicants that have been linked to cancer as well as diseases of the skin, liver, and immune system. Baseline samples were obtained in December 2016 from household dust in 25 homes in southeast Houston. In September 2017, after Hurricane Harvey, soil samples from the front yards of the same homes were collected. Wipes and soil samples were analyzed for the presences of PANs. This pilot study is limited in conclusions, but demonstrated a wide range of PANs, covering soil samples in southeast Houston near areas of high potential hydrocarbon exposure.

HOW WOULD HURRICANE HARVEY AFFECT OUR MEDICAL STUDENTS, RESIDENTS, AND FACULTY?

Many lessons were learned on how to provide excellent care during a disaster where the hospital was the locus of acute patient care (Figure 13). Our medicine residents, who were in the ride out teams, and those in the recovery teams were essential caregivers. The key person who provided invaluable leadership was our chief resident, Dr. Naseem Alavian. She was present throughout the ride out and recovery team time periods. She stayed in contact with our house staff in the hospital, as well as with our residents who were stranded at home. She was the primary liaison between the command and control centers at the hospital and provided daily briefings to the house staff.

Fig. 13.

Recovery efforts by medical students after Hurricane Harvey.

Other lessons learned from Hurricane Harvey and previous flooding events included mandating appropriate sleep for residents in the ride out teams, the need to work in teams, the need for frequent communication, and frequent evaluation of patients. During the recovery phase, residents and faculty may need more time to recover emotionally and reflect on what happened to them personally. Providing onsite counseling is necessary to support staff, students, and faculty.

Although BCM was closed for two days, many of its medical students volunteered at the Baylor outpatient clinic locations and helped coordinate a blood drive. Over 180 medical students were part of a volunteer corps and provided support to 45 faculty, staff, and students whose homes were flooded. A Hurricane Harvey Relief Fund created by BCM raised $1 million from which over 600 individual staff and faculty received funds to help in their recovery. Group counseling sessions were also provided during the first two weeks of September.

HOW WELL ARE MEDICAL SCHOOLS EXPOSING STUDENTS TO CLIMATE CHANGE ISSUES?

Based on data recently provided by the Association of American Medical Colleges (AAMC), only a minority of medical schools devote more than a few hours in their curriculum on climate change and human health. Except for emergency medicine residencies, little education is devoted to disaster management and control. Recent papers have tried to make the case for expanding teaching efforts on climate change and human health (32). They have outlined the following arguments for teaching climate change in medical education:

1. Today's students and residents have an increasing stake in developing a response to the impacts of climate change.

2. The scope of the health effects of climate change is unprecedented.

3. Physicians, nurses, and administrators have a responsibility to lead efforts to reduce health care's environmental footprint.

4. Our health care system is responsible for providing medical care to large segments of vulnerable patients experiencing health care impacts of climate change.

5. Inclusion of climate change issues into undergraduate medical education curricula would improve critical thinking, enhance participation in global health, embrace multidisciplinary perspectives, and increase public health literacy.

SHOULD THE ACCA DEVOTE RENEWED ATTENTION TO THE EFFECTS OF CLIMATE ON OUR COLLECTIVE HEALTH?

One of the American Clinical and Climatological Association's (ACCA) early members and president, Edwin Solly, MD, was a staunch advocate for teaching medical students about climate and its effects on human health (Figure 14). His Handbook on Medical Climatology outlined the curricular issues that medical schools could use to cover the subject (33). Donald A. B. Lindberg, MD, director of the National Library of Medicine, was asked by Dr. F. M. Abboud, president of the ACCA in 2008, to present a symposium at its annual meeting on climate change (34,35,36,37). At this meeting, Dr. Lindberg gave an impassioned plea for this organization to become involved in discussing climate change as a public policy issue. He wrote:

This paper seeks to answer those questions in order to inform the Association's possible study of the effects of global climate change on human health, an issue that is arguably comparable to what the founders faced. Recent governmental reports suggest that the medical and health care communities have not yet become engaged. If the ACCA does not, then who will?

Fig. 14.

S. Edwin Solly of the ACCA.

Dr. Lindberg, who died in August 2019, advocated for the ACCA to become more involved in this important issue (Figure 15). I propose several ways that the ACCA might become more involved and would pose these ideas as the basis for a more in-depth discussion by the ACCA membership (Table 2).

Fig. 15.

Donald A. B. Lindberg, MD—National Library of Medicine and member of the ACCA.

TABLE 2.

Possible Ways to Include Climate-Related Health Issues into ACCA Meetings

•Sponsor symposium on climate health every other year.

•Sponsor a student/resident presentation on one aspect of climate and population health to be given at our meeting and published in the Transactions.

•Sponsor invited lecture by nationally/internationally recognized expert on global health (to be named S. Edwin Solly Lectureship).

•Join the Global Health Consortium on Climate & Health Education (Columbia University).

•Other ideas?

THE GREENBERG JOURNEY: RESCUE

It is difficult to know how long I sat propped up next to a tree watching Hurricane Harvey's flood waters flow past. As the rain began to pour again after a brief hiatus, I saw a white truck slowly plowing through the rushing water on what had been a street. The driver waved to me to make my way to his truck (Figure 16). I summoned what strength I had and slowly walked in knee-high water to the opened front door of the truck. The driver helped me up into the front seat. He asked where I wanted to go but told me he couldn't get to Ben Taub Hospital because the flooded streets were impassable. I asked him to take me back through the park to my apartment building. I quietly entered our apartment and went to the bathroom to remove my waterlogged shoes and clothes. My wife, Lisa, did not have to say anything; I knew I would hear about my “journey” at some strategic future time.

Fig. 16.

“Rescue” from Hermann Park during Hurricane Harvey.

The following day I was able to make it to Ben Taub Hospital, as the waters had receded. My chief resident, Dr. Alavian, met me at her office and debriefed me on our situation. Everything was under control. The faculty, residents, students, and staff had performed extremely well.

EPILOGUE: RESILIENCE ↔ RECOVERY ↔ THE FUTURE

Most Houstonians recovered in the six months following Hurricane Harvey. Resilience and recovery were paramount in the communities' daily behavior. Although some trauma-exposed people developed mental health problems, many people continued to function well after the disaster (42,43,44,45). Individuals who had adequate training and preparation appeared to be most resilient (38,39,40). Social support from families, colleagues, and managers appeared to be protective against PTSD. Coping styles were also important. Among those involved in disaster recovery and relief efforts, a sense of fulfilment and meaning is commonly observed. These individuals report both personal and professional benefit. Disaster response work can often be viewed as rewarding. Participants often feel that they have made a contribution; they feel more connected to the community; and they report an increased sense of purpose and stronger professional competency (41,42,43,44).

The Harris County Flood Control District has a total annual budget of $150 million and >350 full-time employees. Most of these resources are primarily used to redirect or expedite the flood water to reduce flooding. These projects include widening ditches; building side lot swales; and replacing inlets, sewer lines, and driveway culverts. Larger projects are conducted in collaboration with the U.S. Army Corp of Engineers. A $550 million budget for Project Brays has been approved to widen 21 miles of Brays Bayou, replace or modify 30 bridges, and build four detention basins that will store 3.5 billion gallons of storm water. This project was projected to be completed by 2021. However, it is not clear whether these plans will alter future flooding in the Houston metropolitan area.

Within the next 20–30 years, our ability to save coastal beaches will likely be lost. Even if we had the will to significantly reduce the production of carbon dioxide immediately, it would not alter the rate of sea level rise in the twenty-first century. However, conceding the shoreline to nature is currently unpopular. Therefore, the United States must try to do what the Dutch did in the Netherlands and stave off the inevitable loss of coastal communities. We must adopt a strategy that is based on “living with water” and flooding some areas while protecting others (or adaptation).

The social and environmental determinants of health—clean air, safe drinking water, food, and shelter—are affected by climate change. Some reports have estimated that between 2030 and 2050 there will be approximately 250,000 additional deaths each year from climate change-associated malnutrition, malaria, diarrhea, and heat stress (45). Reductions in greenhouse gases may result in improved levels, especially through reduced air pollution. The debate over whether significant reductions in greenhouse gas emissions in the next few years will prevent more severe climate change 20 to 50 years from now does not alter what we can do now. While we debate the best mitigation strategies for long-term efforts, we need to decide on adaptation as a short-term, halfway measure.

DISCUSSION

Lane, Sacramento: I just wanted to thank you for that. We have had disasters of fires in California last year and they end, and we haven't yet thought long term about how to prevent them from happening again, so thank you for bringing that up.

Greenberg, Houston: Somebody else could give the talk on fires, earthquakes, or flooding. It's a big problem.

Konstan, Boston: That was really a terrific talk. I enjoyed it a lot and learned an enormous amount. Can you speak to the cardiovascular risks of an event like this?

Greenberg, Houston: Yes, that's a good question. Trying to get data on things like this was difficult. There a blip in ischemic events. There's better data that I've seen on air pollution issues affecting cardiovascular disorders than on acute flooding. We did not see a blip in epidemics that we could document. That may be because they are happening all the time. Other people have reported a major effect of air pollution on long- and short-term cardiovascular disease, as well as lung function.

Wolf, Boston: There's certainly a well-documented increase in cardiovascular events following earthquakes.

Greenberg, Houston: Yes.

Wolf, Boston: It's been well documented. … I'm not sure whether it's been documented after hurricanes or not, but I'd bet that it does occur.

Greenberg, Houston: It's hard to do. It partially has to do with your baseline data. It's well documented with certain infectious diseases like flu for instance. There's a secondary blip after influenza when there's an outbreak, but that may not have anything to do with climate change.

Wolf, Boston: I would bet that there's Takotsubo's cardiomyopathy after this.

Harrison, Nashville: I really enjoyed your talk as well. I would just like to reflect on something. When I was a small child, my family used to take vacations to South Padre Island. I remember that South Padre in the 50s and 60s was pretty much abandoned. There were a few tiny motels and little restaurants, but they were just miles of empty beaches. If you go there now, you see these very expensive high-rise condominiums just wall to wall all up and down the beaches. In the 50s and 60s, people had better sense than to build expensive housing along the U.S. coast. Somehow we've become very cavalier about spending money building these costly condominiums in harm's way. You touched on this in your presentation, but I think we're putting ourselves in great difficulty with this development.

Greenberg, Houston: I think you are absolutely right, and society is going to have to decide how we subsidize disaster relief, renovation, and mitigation. Houston is a perfect example. There is no zoning, and people have built in places they shouldn't be building. The urban footprint is changing the ability to have run-off water. All sorts of issues beyond just “climate change” are exacerbating what you see. Who should pay for rebuilding that high rise in South Padre if something should happen? I think insurance programs need to be reassessed so the financial burden is more on the individual than the federal government.

Hochberg, Baltimore: I have had the great pleasure of taking over for Phil Mackowiak after he retired as chief of medicine at the VA in Baltimore. We have disaster drills relatively frequently—maybe quarterly—for not only our facility in Baltimore but also for the other health care system facilities located on the eastern shore in northeast Maryland. I wondered if the VA in Houston and the other VAs in Texas were involved in your multi-medical school planning groups and what they could have offered to you in terms of disaster responses, from the training that's done.

Greenberg, Houston: Yes, they did. The Michael E. DeBakey VAMC in Houston did take some individuals for training at the residency level and at the student level with Hurricane Katrina, when they came over from Tulane. If you are referring to the Baylor plan, it included us, since the VAMC is a part of Baylor. How we would distribute students to the VA was part of the overall plan.

Hochberg, Baltimore: And what about prospectively, in terms of disaster response?

Greenberg, Houston: We have had many disasters that have been studied and used in our frequent flooding mitigation plans.

Hochberg, Baltimore: So I guess we're fortunate in that we do the drilling without having the disasters.

Greenberg, Houston: We just got through with Imelda and before Imelda there were a few others. I just gave you some of the big ones, but there are several in the past few years.

Ballantyne, Houston: Steve, that was a great talk, but speaking about the VA medical center, when we had Tropical Storm Allison, Andy Schafer was our chairman of medicine. The VA medical center was untouched, because it had planned for hurricanes and floods. About 2 million biosamples were saved. The government does well at planning for disasters. Your comment about VA medical centers being models in terms of really designing hospitals to withstand all of these things is worth noting.

Greenberg, Houston: We were lucky to have, compared to some others, a relatively newly built VA.

McInnis, Ann Arbor: Thank you very much for a great talk. I'm interested in your perspective on rebuilding in areas that are wiped out. Potentially, there is money to be made by going in and building much better buildings, dikes, etc., rather than abandoning these areas. From a climate perspective, how do we balance rebuilding or letting nature take its course?

Greenberg, Houston: You have asked a crucial question that everybody is trying to answer. Many people feel we are going to lose the shoreline of this country, as well as other countries within the next 30–40 years. Would that be stop if we stopped all building now and moved inland? That's a debated issue. Other people feel we can, like the Dutch and others have done, mitigate the effects by engineering barriers, green spaces, and the like. I don't know the answer, but it's an important and very costly question. We need to decide what works and what doesn't. You're absolutely right. Trying to decide who pays for these disasters, and if we should be paying for them at all, is critical.