Public Health Integration Into Public Safety in Post-Katrina New Orleans

Hurricane Katrina’s impact reshaped national preparedness doctrine. The ensuing catastrophe, including acute and chronic environmental exposures, complex population movements, and patient management crises, highlighted the need to improve integration between the public health, medical, and traditional public safety disciplines. Recent crises, including the COVID-19 pandemic, unfortunately continue to exemplify the need for this proactive system approach to optimizing preparedness. Against this backdrop, we examine current practice, specific successes, and areas of improvement that remain, all of which may help propel the preparedness enterprise toward an optimized state of integration. As leaders in New Orleans, Louisiana, emergency response agencies (2006–2018), we posit that post-Katrina preparedness strategies provide a pathway to improve proactive cross-disciplinary integration and all-hazards preparedness.

Public health and emergency management agencies use a “lessons-learned” approach to generate corrective action following an incident or exercise. Following the guidance provided by the Department of Homeland Security’s (DHS’s) Homeland Security Exercise and Evaluation Program, lessons are captured in a standardized process titled after-action reports,¹ which in turn inform the improvement and corrective action plans. In addition to lacking an integrated systems approach, numerous improvement areas were documented by public sector officials and other stakeholders (see the box on page 1491) in state and federal after-action reports, including, but not limited to, comprehensive evacuation planning, emergency operations center coordination and situational awareness to include public health and medical response, leadership training on plans and incident management systems, and tactical communications interoperability.²

BOX 1— State of Louisiana After-Action Report—Hurricane Katrina.

Governor’s Office of Homeland Security and Emergency Preparedness
Louisiana Department of Health and Hospitals (now known as Louisiana Department of Health [LDH])
Louisiana Office of Public Health (as part of Department of Health and Hospitals and now LDH)
Louisiana—Hospital Designated Regional Coordinators from all 9 regions
Louisiana Department of Social Services (now known as Louisiana Department of Child and Family Services)
Louisiana Department of Environmental Quality
Louisiana State Police
New Orleans Police Department
New Orleans Office of Homeland Security (now consolidated into Homeland Security and Emergency Preparedness)
New Orleans Office of Emergency Preparedness (now consolidated into Homeland Security and Emergency Preparedness)
New Orleans Fire Department
US Coast Guard—Sector New Orleans
American Red Cross—Southeast Louisiana Chapter (and other state chapters)
Acadian Ambulance Services

Note. This box contains a truncated list of participating state agencies, departments, and other stakeholders.

The inadequate evacuation planning before Hurricane Katrina necessitated a new strategy: the city-assisted evacuation (CAE) framework. Critical to the framework is its flexibility to shift quickly based on hurricane trajectory and intensity and resource constraints. Being continuously updated, the CAE framework accounts for current and future changes in population density, urban mobility, access and functional needs, pet and animal evacuation, and specific resource requirements, including mental health services. Thus, a successful CAE framework requires an intimate understanding of the area’s population and how best to align and mobilize resources to collective and individual needs. For example, advances in health care delivery, life-sustaining technologies, and a generally aging population (often with serious chronic conditions) results in increased resource requirements to identify, evacuate, and provide for individuals with access and functional needs.³

The New Orleans Access and Functional Needs database, initially created in a partnership between the city’s Office of Homeland Security and Emergency Preparedness, emergency medical services, and the health department, addresses these aspects and remains a cornerstone of the CAE framework. What began as a way to anticipate medical transportation requirements has matured into a program that includes site visits by city and state public health officials to health care and medical facilities, senior living centers, and even private homes to assess specific resource requirements. These include specialized transportation assets, medical apparatus, pharmaceuticals, and types of shelter space. These local data are routinely cross-walked with federally available data; one recent exercise resulted in the positive identification of 93% of electrically dependent New Orleanians using a home oxygen concentrator or ventilator, making the New Orleans Access and Functional Needs database an accurate, reliable preparedness tool.³ Although execution of the CAE framework has occurred only once (Hurricane Gustav, 2008), it remains a nationally recognized program.

The success of the CAE framework is linked to systems-level integration of public health preparedness efforts and improved multisector coordination. In the National Response Framework, Public Health and Medical Services are categorized as Emergency Support Function-8. After Katrina, local Emergency Support Function-8 authorities became (and remained) engaged across a range of readiness activities—from weekly citywide preparedness meetings with public safety agencies to comprehensive inclusion in event and incident action plans for mass gatherings (e.g., Mardi Gras celebrations). State-level Emergency Support Function-8–specific strategies included establishing a designated regional coordinator for hospitals and emergency medical services for each of the state’s nine preparedness regions. Designated regional coordinators coordinate and share sector-specific situational awareness, resource requirements, and operational strategies with emergency operations centers.

Since Katrina, designated regional coordinators and hospitals maintain radio interoperability—the ability to communicate on a single system—with emergency operation centers and all of public safety on Louisiana’s network, which is the largest state interoperable radio system in the United States.⁴ The influences of the integrated designated regional coordinators are amplified by the federal Hospital Preparedness Program’s health care coalitions. Further, an elaborate, well-rehearsed timeline was developed to coordinate the simultaneous evacuation of otherwise distinct groups: the general population, those with access and functional needs, and hospital-based patient census.⁵ Situational awareness platforms in the emergency operations center now integrate hospital response, the New Orleans Access and Functional Needs database, transportation, and sheltering dashboards.

Our industrialized built environment often exacerbates natural disaster impacts. Katrina caused environmental contaminations, including oil spills and toxic industrial chemical releases; thus, an organic collaboration emerged between officials strategically planning for hurricanes and hazardous materials (hazmat) incidents, exemplifying multisector, all-hazard integration. From 2014 through 2017, New Orleans partnered with the DHS Office of Health Affairs (reorganized as the Countering Weapons of Mass Destruction Office) to conduct the Chemical Defense Demonstration Project. This project improved knowledge of the risk of chemical exposure and led to targeted response system enhancements (e.g., advanced hazmat training for emergency medical services and public health personnel, increased decontamination capability, specific medical countermeasure investments aligned to the greatest threats, and adaptation of evacuation and family reunification plans originally developed for hurricanes). Further, the New Orleans Access and Functional Needs database has the potential to inform the hazmat response of specialized resource requirements based on the prevalence of pulmonary illnesses and other potential health concerns that may compound the impact of a hazmat incident.

Katrina strengthened public–private sector relationships, especially through the creation of a tiered reentry protocol used during mandatory evacuations.⁵ Following mandatory evacuations, this tiered system prioritizes reentry of critical infrastructure and supporting agencies (e.g., water, power, hospitals, medical clinics, pharmacies, grocery stores, banks). Subsequently, the general population returns to a safer, functioning community. Public engagement detailing the reentry protocol and registration requirements dovetailed to other all-hazards initiatives. The city harnessed hurricane threat momentum to create an extensive occupational and residential closed point of distribution network within the Cities Readiness Initiative, which serves as the local planning initiative for medical countermeasure distribution of the Strategic National Stockpile.⁵ During responses to certain biological threats (e.g., Anthrax, the 2009 H1N1 influenza pandemic), these confidential partnerships, which also include hospitals, would operate in concert with city-operated public distribution points to accelerate the distribution of the Strategic National Stockpile medical countermeasure to the population at risk. Annual exercises further strengthen these partnerships.

A deliberate focus should remain on conceptualizing and sustaining an integrated systems approach while strengthening and further integrating threat-specific subject matter expertise into the preparedness and response infrastructure, including environmental health and exposure assessment strike teams.^6,7 The COVID-19 pandemic, documenting the first time all states and territories are under simultaneous major disaster declarations, continues to test the system, which is better tuned to natural disasters such as hurricanes, and highlights the need to improve systematic integration across sectors for full threat and response visibility. For example, much of the modeling and scientific data used to inform nonpharmaceutical interventions and other decision making is generated by academia and public health professionals. Yet, many of these entities were not fully integrated into preparedness systems before, thereby requiring them to pivot into this role in the middle of disaster. Louisiana’s response to COVID-19 has used the gains made since 2005, using academia, designated regional coordinators, and established partnerships to improve situational awareness, medical surge, and resource allocation.

Despite significant emergency-related improvements aimed at enhancing collaboration and coordination between public health, medical, and public safety disciplines, nationwide gaps persist in terms of public health preparedness being adequately funded and integrated into the public safety enterprise. This is the optimal time to transition a reactive system into one that is truly proactive.