British Medical Journal
October 22, 2005


Hurricane Katrina puts the health effects of poverty and race in plain

By David Atkins and Ernest M. Moy

The sinking of the Titanic, during which women in first class cabins
were more likely to survive than those booked into cheaper decks, has
been used to illustrate the effects of income and social class on
health. In the aftermath of hurricane Katrina, Americans have been
shocked and shamed to realise that they still don't have enough
lifeboats for all of our citizens. Live images of uncollected corpses
and families clinging to rooftops made vivid what decades of
statistics could not: that being poor in America, and especially being
poor and black in a poor southern state, is still hazardous to your

This may truly be a "teachable moment" about the impact of poverty and
race on health. The gap in health between white and black Americans
has been estimated to cause 84,000 excess deaths a year in the United
States, a virtual Katrina every week.[1] Because the victims gradually
succumb to various diseases such as diabetes, cardiovascular disease,
alcohol and drug abuse, cancer, and HIV infection, they rarely capture
the public's attention in the way the victims of Katrina have. As a
result, health inequality has persisted despite decades of important
health gains, economic growth, and progress on racial issues in the
United States.

It would be a mistake, however, to assume that the problems
highlighted by hurricane Katrina are a unique legacy of southern
racism or a problem affecting black Americans or America alone. The
same factors that placed the poorest residents of New Orleans in
harm's way -- unemployment, poverty, neglect of communities, and
alienation -- contribute to health disparities for poor children and
adults and those from minority groups throughout the United States,[2]
in the United Kingdom,[3] and in other Western countries.[4,5] But the
aftermath of hurricane Katrina provides clear lessons about what
changes in policy government and private agencies must make to tackle
health inequalities.[6]

Fund prevention, not rescue. The recent UN International Strategy for
Disaster Reduction notes the need to "invest to prevent,"[7] yet a
comprehensive plan for protecting the Gulf Coast languished for years
because it seemed too expensive to implement: the costs of hurricane
Katrina to the US treasury are now expected to rise as high as $200
billion. Pressure on healthcare budgets for the poor continues to
squeeze services for primary care and prevention owing to soaring
costs for emergency visits and for admissions to hospital and long
term care, many of which might be preventable with better functioning
systems of ongoing care. Nowhere are the high costs of deferring
investment in health more evident than in a poor state such as
Louisiana, which ranks 48th among 50 states in levels of health
insurance, 45th in public health spending, 50th in overall health and
second in the costs to the federal government of caring for its older
and disabled citizens.[8,9]

Strengthen the infrastructure for public health. The individual
heroism evident among those who responded to the emergency in
Louisiana and Mississippi and in health workers who struggle every day
to meet the needs of poor communities cannot make up for a frayed
infrastructure. Recent reports have called attention to the neglect of
the public health infrastructure in the United States and the United
Kingdom.[10,11] Strengthening this infrastructure will depend on
improving the workforce, information systems, and organisation both
locally and nationally.

Adopt policies that support responsible choices. Democracies cannot
completely protect their citizens from the freedom to make bad
choices. Yet hurricane Katrina's effects vividly illustrate how the
choices available to us differ depending on where we live and how much
money we have. Many who "chose" to stay in the path of the storm had
no cars with which to escape, no faith that their property would be
protected, and no insurance to cover their losses. Similarly,
promoting personal responsibility as the solution to health problems
such as obesity will not work if we do not reduce the barriers to
exercise and healthy diets in poor urban communities, where parks and
supermarkets are less common than fast food chains and stores selling
alcohol. The problem is particularly acute in the US, where efforts to
intervene early against chronic diseases such as hypertension and
diabetes are hampered by a system that continues to leave 45 million
citizens without health insurance.

Improve communication about critical threats to health. The failure of
basic communication after the hurricane fed a downward spiral of the
early recovery efforts. The lack of an authoritative source of
information fostered confusion and rumours which exacerbated the chaos
and sense of panic. Similar challenges hinder efforts to confront
health problems in poor and ethnic minority communities, where a
legacy of distrust of government and medical establishments provides
fertile ground for misunderstanding, myths, and conspiracy theories
about health issues. Rebuilding trust will require actively including
the community in any planning and research which affects them,
improving cross cultural training of health workers, and tapping into
the informal information networks in these communities.

Build strategies that foster accountability. A variety of
investigations will eventually sort out the failings and scattered
successes of the preparations for and response to hurricane Katrina.
And, although our ability to measure health disparities is improving,
we still need better mechanisms to promote accountability for reducing
them. Public and private healthcare organisations and both local and
national governments will need to negotiate their shared
responsibility for a problem that has many sources and no single

Strengthen communities. It now seems that many of the most horrific
stories to come out of New Orleans -- roving gangs of rapists, snipers
firing on helicopters -- were exaggerated or untrue. But the
perception of crime and disorder which impeded the response to
hurricane Katrina also undermines efforts to attack health
disparities. Problems of drugs and alcohol misuse and attendant crime
and violence take direct tolls on health and lower the priority given
by government and other organisations to health issues. The healthcare
sector alone cannot tackle problems which require support from good
schools, businesses, religious institutions, other community
organisations, and law enforcement agencies.[3,12]

In the rush to rebuild in the southern states, Americans should pause
to think more deeply about what it would take to create more equitable
and healthier communities in New Orleans and throughout the affected
areas. It is essential that these lessons are heeded in any plans for
recovery. It is even more important that we and others apply these
lessons to help the many other individuals and communities with poor
health who continue to languish out of the public eye.


David Atkins, chief medical officer, Center for Outcome and
Effectiveness Agency for Healthcare Research and Quality, Rockville,
MD 20850, USA (

Ernest M Moy, senior service fellow, Center for Quality Improvement
and Patient Safety Agency for Healthcare Research and Quality,
Rockville, MD 20850, USA

Declaration of competing interests: DA and EMM are employed by the
Agency for Healthcare Research and Quality, a government research
agency which produces an annual report on healthcare disparities in
the US. The views expressed are solely those of the authors and do not
reflect the official position or policy of the Agency for Healthcare
Research and Quality or the US Department of Health and Human


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[2] National healthcare disparities report. Rockville, MD: Agency
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[3] Acheson D. Report of the independent inquiry into inequalities in
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[4] Blendon RJ, Schoen C, DesRoches CM, Osborn R, Scoles KL, Zapert K.
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[5] Beiser M, Stewart M. Reducing health disparities: a priority for
Canada (preface). Can J Public Health 2005;96(Suppl 2): S4-5.

[6] Payne AW. At risk before the storm struck. Washington Post 2005
Sep 13: HE01.

[7] Secretariat of the International Strategy for Disaster Reduction.
Invest to prevent. 2005.

[8] United Health Foundation. America's health: state health rankings
2004. 2005.

[9] Center for Medicare and Medicaid Services. Health care financing
review: Medicare and Medicaid statistical supplement, 2003.

[10] Committee on Assuring the Health of the Public in the 21st
Century, Institute of Medicine, Board on Health Promotion and Disease
Prevention. The future of the public's health in the 21st century.
Washington, DC: National Academy Press, 2003.

[11] Wanless D. Securing good health for the whole population: final
report. London: Stationery Office, 2004.

[12] Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment:
confronting racial and ethnic disparities in health care. Washington,
DC: National Academy Press, 2003.

Copyright 2005 BMJ Publishing Group Ltd