Katrina to Corona: Surges Urge United States to Learn

As a nation, from time to time we face extraordinary events and challenges. A key current nemesis is the coronavirus disease 19 (COVID-19) pandemic. The COVID-19 pandemic, caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), presents monumental challenges on multiple fronts and on a global scale. Since the first report out of the Wuhan district in China in December 2019, the pandemic has resulted in nearly 75 million cases worldwide. The US Centers for Disease Control and Prevention had reported more than 16 million cases and more than 300 000 deaths domestically as of December 17, 2020, making the United States the most affected country.¹

When catastrophic events occur, public institutions, especially government agencies, find ways to mitigate injury and loss to their citizens. Preparation is key and involves anticipating the elements of disaster events and creating policies and protocols that incentivize action and funding to lessen the burden of the crisis. COVID-19 tracking data highlight important emerging population-vulnerability issues and the evolving public health response. However, these issues and impacts are not new but were influential during previous catastrophic events.

One such event was Katrina, a high-category hurricane that made landfall along the Louisiana and Mississippi coasts on the morning of August 29, 2005. Katrina packed sustained winds of 120 miles per hour; its physical destruction was followed by unprecedented threats to life and health.^2,3 Both Hurricane Katrina and the COVID-19 pandemic exposed significant structural, social, and health deficiencies that have prompted significant changes to public health and policy responses. Although one event was a geoclimatic catastrophe and the other an infectious disease epidemic, they have health, socioeconomic, and structural features in common. Katrina and COVID-19 present shared lessons in preparing for and responding to public health disasters. Exploring policy, legislative, and emergency response and health care management of previous catastrophic events can prepare governments, the health care system, and citizenry to respond to future disasters.

DISPROPORTIONATE EFFECTS OF CATASTROPHIC DAMAGE

Although differing in reach across time and space, Hurricane Katrina and the COVID-19 pandemic wreaked economic, social, and health havoc on a massive scale. Katrina, one of the costliest hurricanes to hit the United States, caused an estimated $200 billion in damage, mostly concentrated in the Gulf Coast region.⁴ Fortunately, the rest of the US economy was relatively stable and could support the region’s recovery. Moreover, even excluding in-kind donations, the Department of State received $126 million from 36 countries and international organizations; the United States government had never before received such large amounts of disaster assistance.⁵

Unlike Katrina, the economic damage from COVID-19 is not limited in geographic scope or duration; its legacy will be far flung and long term. Total 2020 COVID-19-associated hospitalizations in the United States could cost $17 billion, and as of May 8, 2020, Congress had approved $2.4 trillion in stimulus funding, with more to come.⁶ In fact, Achim Steiner, administrator of the United Nations Development Programme, anticipates a COVID-19-driven reduction in the Global Human Development Index—a measure of the world’s education, health, and living standards—for the first time since the concept was introduced in 1990, a trajectory that is likely to be sustained.⁷

Hurricane Katrina and the COVID-19 pandemic vividly demonstrate the exceptional susceptibility of minority and disadvantaged groups to adverse outcomes from catastrophic events. Hurricane Katrina cut a broad swath across the Gulf Coast, but its health and socioeconomic effects were arguably worst in the New Orleans, Louisiana, area. Some of Louisiana’s most vulnerable people (those who are impoverished, uninsured, chronically ill, and members of disadvantaged minority groups) are concentrated in the southeastern portion of the state. Katrina breached several levees protecting New Orleans, flooding the Orleans and adjoining St. Bernard and Jefferson parishes, and mostly affecting people who lacked transportation to escape the hurricane or navigate flooded terrain afterward. Populations of these parishes are predominantly Black, and affected individuals were also generally financially impoverished and often were members of single-parent (mostly women) households with children.⁸

Elderly and male individuals fared worse under Hurricane Katrina’s wrath, as 49% of the 971 Louisiana decedents were at least 75 years old and 53% were men. However, the impact on Blacks was especially severe. Although Blacks constitute only 33% of Louisiana’s population, 51% of decedents were Black and only 42% were White. This is partially explained by New Orleans parish adult mortality rates, with Blacks being 1.7 to 4.0 times more likely to die than Whites.² New Orleans’ population also suffers disproportionately from poor health and poor access to care. A survey of Houston, Texas, shelters showed that 41% of 680 Katrina evacuees reported chronic health conditions.⁹ Ninety-eight percent of these evacuees were from New Orleans, and 93% were Black. Also, 23% of Louisianans lacked health insurance, as compared with 54% of the Houston evacuees. These marginalized individuals were ill equipped to withstand the adverse health effects of societal disruption.

The COVID-19 pandemic threatens to rend the very fabric of global society for an indeterminate time, but not all populations or communities are equally affected. Although incomplete, data on race and ethnicity show that the pandemic has disproportionately infected, and led to greater mortality among, populations with health disparities such as Blacks, Hispanics, and other minority groups.^10,11 According to an analysis of supplementary data, most of the 10 647 decedents in 16 public health jurisdictions were 65 years or older and had underlying medical conditions; 34.9% of Hispanic and 29.5% of non-White decedents were younger than 65 years, as compared with only 13.2% of non-Hispanic White decedents.¹²

Sequist’s comparison of the Navajo Nation and the small, densely populated town of Chelsea, Massachusetts, highlights ethnicity-linked COVID-19 pandemic disparities between these distinct communities of color and their broader populations. Fifty-three percent of COVID-19-related deaths occurred among the Navajo of New Mexico, despite this group representing only 11% of the broader population. In Chelsea, where two thirds of residents identify as Hispanic, more than 7000 cases among a population of 100 000 have been reported. Chelsea Hispanics have experienced the highest mortality rate in the nation, more than three times that of neighboring Boston.¹³

The reasons for disparities in COVID-19 pandemic outcomes among Blacks, Hispanics, and South Asians are not well established. Even among highly educated medical professionals, the mortality rate among minority group members has been extraordinary. Minority medical professionals, along with other minority workers, disproportionately serve front-facing industries, and they also support and are responsible for extended families and communities. Such communities are often burdened by high population density, which joins chronic disease, limited health literacy, and marginal financial and health insurance status as mortality-exacerbating dynamics.^14,15 As with Hurricane Katrina, difficulty in accessing care, deferred care of emergent conditions, and a deep-rooted mistrust of the public health and medical system are additional factors. In particular, highly complex combinations of comorbidities such as hypertension, diabetes mellitus, and chronic obstructive pulmonary disease are more frequent among marginalized groups than among Whites and are associated with worse outcomes.¹³

NONIMPLEMENTATION OF INFORMED DISASTER PREPARATIONS

The New Orleans basin and its sedimentary foundations and continuing subsidence are prime for flooding and have long been recognized as such. The US Geological Survey estimates that New Orleans, currently 3 meters below sea level and sinking at a rate of 1 centimeter per year, will descend an additional meter by 2100.¹⁶ Hurricane Katrina’s catastrophic flooding effects were anticipated. On November 2, 2005, Peter Nicholson, chair of the University of Hawaii’s Department of Graduate Engineering, informed the US Senate Committee on Homeland Security and Governmental Affairs on Hurricane Katrina that his department had found dozens of preexisting areas of soil instability and actual breaches in the levee system that likely contributed to its failure. He recommended that Congress enact a national levee inspection and safety program modeled after the National Dam Safety Program.¹⁷ Meanwhile, residents need to decide whether they can safely continue living in this area or whether they need to relocate, an especially difficult choice for marginalized individuals.

The US military and government leverage advanced simulated scenarios (gaming) to manage geography, population, resources, and technical and administrative expertise to achieve minimum-damage outcomes in combat and in disaster situations, such as weather events. For example, from May 24, 2004, through August 24, 2005, the Federal Emergency Management Agency conducted a multiagency emergency planning scenario for a hypothetical geo-climatic disaster, Hurricane Pam. Seven hurricane-specific and four general-disaster recommendations resulted.¹⁸ Similarly, the US Naval War College’s September 2019 urban outbreak pandemic exercise yielded 16 defensive recommendations to manage a COVID-19 pandemic–like situation.¹⁹

Dozens of additional modeling teams now offer support to policy and response directors by predicting COVID-19 trajectories through infectious disease and statistical modeling.²⁰ Notably, the Centers for Disease Control and Prevention and the Office of the Assistant Secretary for Preparedness and Response have developed five COVID-19 pandemic planning scenarios to evaluate the potential effects of various mitigation strategies and help inform public health planning.¹

DISPARITIES REVEALED BY KATRINA AND COVID-19

Inadequacies in the three principal social determinants of health—physical environments, social environments, and (inadequate) health services and health literacy—result in health disparities that amplify morbidity and mortality in catastrophes.²¹ According to Stephen M. Griffin of the Tulane University School of Law, Hurricane Katrina and the current COVID-19 catastrophe highlight policy disasters in the United States that can be traced back to federalism, “a fundamental aspect of American government, whereby the states are not merely regional representatives of the federal government, but are granted independent powers and responsibilities.” He argues, instead, that the federal government should be the first responder and coordinator in a major crisis.²²

In fact, an effective response strategy establishes basic protections from catastrophe that can neutralize disadvantageous socioeconomic and health disparities and protect marginalized groups from harm. According to both Griffin’s recommendations and those stemming from the aforementioned scenario exercises, there is a need for, among other components, expert central planning to direct, coordinate, and support regional authorities.^18,19 Unfortunately, with Hurricane Katrina, discrepancies among national, regional, and local perspectives delayed reinforcement of the levee system as well as timely evacuation assistance to marginalized groups. Also, in part because of conflicting information from authorities, the marginalized population in the New Orleans basin largely did not anticipate—and lacked the resources and support to escape or withstand—the resulting flood.²³

The situation has been the same with the COVID-19 pandemic. Disagreement among international authorities and among US federal executive and advisory personnel as to the existence and nature of the COVID-19 threat contributed to inadequate and erroneous information and to disparate and fluctuating US instructions to, and support of, regional authorities.²⁴

The public, confused by conflicting messages, did not universally embrace or adopt even minimum protective measures. Much of the US health care system is now heavily stressed, necessitating guidance from the Centers for Disease Control and Prevention on interfacility patient and resource coordination and avoidance of a shift to crisis-care standards.¹ Tragically, with the COVID-19 pandemic as with Hurricane Katrina, the most vulnerable US citizens have again been the least protected and the most severely affected.

MORE HEALTH POLICIES NEEDED FOR MARGINALIZED GROUPS

Hurricane Katrina hit hardest in areas with high numbers of uninsured individuals that also ranked poorly on national health outcome measures. Medicaid is one avenue that improves outcome performance and enhances care access for low-income populations. However, federal and Gulf Coast state authorities initially limited Medicaid to elderly individuals and pregnant women. Some very-low-income parents and disabled individuals were also eligible, but others were not. Low-income individuals without children were not eligible. Fortunately, after Hurricane Katrina, the Centers for Medicare and Medicaid Services played a large role in increasing access to care, at least in Louisiana. In fiscal year 2006, upward Centers for Medicare and Medicaid Services adjustments moved Louisiana’s federal medical assistance percentage calculation to 69.79%, meaning that Louisiana would have to cover only roughly 30% of Medicaid costs going forward.²⁴

The COVID-19 pandemic has resulted in similar policy adjustments. The Families-First Coronavirus Response Act, as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, authorized a 6.2-percentage-point increase in federal medical assistance percentage calculations to help states respond to the pandemic.²⁵ The CARES Act also provides federal funding for states to cover COVID-19 testing for uninsured populations.²⁵ However, to encourage states to take full advantage of this support, the Centers for Medicare and Medicaid Services must emphasize that the percentage-point increase also applies to Medicaid disproportionate-share hospital expenditures. These Medicare and Medicaid payments improved care access for the most vulnerable in the aftermath of Hurricane Katrina and have improved access during the COVID-19 pandemic. Additional prevention today can further reduce the adverse impact of catastrophes on the most vulnerable—and on state health care budgets—tomorrow.

SUMMARY

Despite Katrina’s high international profile, its global footprint was narrow and its duration predictably limited, so other parts of the United States and the international community could rally to the Gulf Coast’s assistance. In contrast, the COVID-19 catastrophe is global in extent, with an indefinite and unpredictable duration and stunningly high mortality, and thus a Katrina-like rescue will not be coming. Tragically, both catastrophes disproportionately harmed and continue to harm vulnerable populations in social, historical, and political environments wherein health disparities are already prevalent, as in the United States.²⁶

A nation is only as healthy as its sickest communities. These catastrophes affirm the importance of three basic tools in mitigating disaster harm among disadvantaged groups suffering socioeconomic health disparities. First, disadvantaged and minority populations should receive at least minimum insurance coverage to ensure regular preventive and prompt health engagement. Second, greater investment in health literacy and promotion, a key Healthy People 2020 goal, should be consistently pursued as a cost-efficient method to decrease health care costs and improve health.

Finally, we recommend a process to communicate pending, active, and completed disaster mitigation strategy exercises to top national decision-makers in real time to facilitate timely and consistent disparity-resolving policy planning and legislative action. Our federal agencies, academic institutions, and the private sector frequently engage in “what-if” scenarios and conduct postevent analyses to plot strong national structural, socioeconomic, and health solutions to disasters. Such preparation can yield broad societal benefits, including decreasing the health care system’s crisis response burden, because it informs prompt, effective disaster protection, especially for the most vulnerable.²⁷

CONCLUSION

True success in disaster management is evidenced by salutary outcomes among society’s most vulnerable groups. Hurricane Katrina and the COVID-19 pandemic demonstrate the continuing need for effective planning and execution in protecting our most vulnerable citizens. Structural disadvantages make marginalized populations vulnerable to event-driven dislocation and morbidity and mortality. These effectively isolated populations may not receive the most factual and relevant information during a disaster. Our recommendations may represent a new way of thinking for authorities for whom the health disparity crisis has not traditionally appeared high on the radar.

Leveraging all available tools and skills to neutralize health disparities and enhance communication of simulation-derived disaster management strategies will help improve the fates of our most vulnerable citizens and of our entire nation.