Journal of Epidemiology & Community Health (Vol. 60, pg. 2)  [Printer-friendly version]
January 15, 2006


The recent hurricanes in the Gulf of Mexico exposed the poverty of
U.S. public health infrastructure, weakened by years of budgetary

[Rachel's introduction: Worldwide, the keystone idea of public health
is prevention. But hurricanes Rita and Katrina revealed that, in the
U.S., decades of budget-cutting have left us with a public health
infrastructure that is frayed, overburdened, and unable to prevent
major harm from natural disasters, epidemics of infectious disease,
or the well-documented health burdens of poverty, social
exclusion, job-related insecurity and stress.]

By Nancy Milio*

Katrina and Rita, the unprecedented September hurricanes and massive
Gulf of Mexico surge, overpowered the levees of New Orleans and
flooded state coastlines. They also exposed the poverty of U.S. public
health infrastructure, weakened by years of budgetary neglect.

Tens of thousands of New Orleanians were trapped in the city. They
were mostly poor African Americans who had no cars and no access to
the limited numbers of buses that were available. Fifteen thousand
eventually made it to safety in the Astrodome stadium. Thousands more
sought refuge in an unattended convention centre, virtually unknown to
authorities. Here they attempted to survive in extreme heat, without
adequate sanitation, water or food for several days. The ill, elders,
and children suffered most; several died; a third had been injured by
the storm; 40% had chronic diseases; a third were without necessary
medications. Over half had no health insurance and many were not
eligible for Medicaid, the public health insurance for the poor,
because they did not fit the narrow categories of that programme --
for example, they were not parents of young children.[1] Worse, dozens
of elders were left unattended in nursing homes and medical
facilities. As a result, they died; this lead to criminal indictments
against culpable health personnel.

The hundreds of thousands of Americans, both citizens and "illegal"
residents trapped in coastal towns and cities were vulnerable to this
catastrophic disaster because of three failures of public policy:
poverty, growing again in recent years, and the dearth of public
measures to reduce it; the inadequacy of emergency planning and
resources despite years of warning; thirdly, the deterioration of
environmental regulation to protect coastal wetlands, land use, and
storm mitigation. The question now is whether these health damaging
wrongs will be made right.


In the USA policies that broadly sustain a healthful level of living
for people who cannot work or find jobs that pay more than poverty
level wages ($19,000 for a four person family), have been steadily
under funded in recent years and are to be cut further in coming
years. These include cash assistance, food stamps, health and child
care, housing subsidies, unemployment insurance, and the failure to
raise the minimum hourly wage, at $5.50, unchanged since 1997.


The linchpins in the national population's health are a handful of
separate federal agencies that support each state's health department
and 3000 local health departments. Among these are the Centers for
Disease Control and Prevention and Environmental Protection Agency
(EPA). Each has had cuts of 10%-20% annually, shrinking their efforts
in disease prevention, surveillance, community health centres,
maternal and child health, and environmental monitoring and regulatory
enforcement. Other cuts were made in the Food and Drug Administration
and Occupational Health and Safety by as much as 50%.

Although new funds were invested in public health after the September
11, 2001 terrorist attacks, they were narrowly focused, with billions
going to drug companies to induce them to produce medications to
thwart bioterrorism attacks, such as anthrax. At the same time, public
health authority for emergency preparedness was moved from the US
Public Health Service to the new huge, 170,000 employee, 23 agency
Department of Homeland Security (DHS). Public health preparedness thus
became more vulnerable to budget and personnel cuts. All DHS workers,
under new imposed work rules, can be moved from one agency to another,
resulting in diminished expertise. Many tasks were outsourced to
commercial firms with non-unionised workforces, making DHS oversight
and coordination difficult at best.[2]

Authoritative reports recently examined public health preparedness.
They found that future financing plans will be $100 billion short of
meeting needed improvements. Two thirds of the states' health
departments lacked funds and workforce expertise; lacking too was a
comprehensive national information network for communication and
coordination among local, state, federal efforts.

FEMA, the Federal Emergency Management Agency, was once the lead
independent federal agency for dealing with disasters, gaining a
reputation for quick and efficient aid to states and communities
during the 1990s. It too was enveloped in the DHS and vulnerable to
programme cuts and new leadership after September 11. During the
Katrina emergency it was widely acknowledged to have failed; the head,
a political appointee, resigned within days.

The well known key ingredients for effective planning include clear
goals and a strategy based on defined responsibilities of all major
stakeholders; mechanisms for decision making, coordination and
communications -- and resources: money, people, supplies, expertise.
It also requires the use of reliable information, preferably science

The science data before Katrina were clear. They were summarised and
published by an investigative reporter in May 2005 after reviewing
years' worth of government and academic reports:

A slow-moving Category 4 [140 miles/hour] or 5 [170 miles/hours]
hurricane...could generate a 20 foot surge that would easily overwhelm
the levees of New Orleans....the geographical "bowl" of the City would
fill up with the waters of the lake, leaving those unable to evacuate
with little option but to cluster on rooftops....The water itself
would become a festering stew of sewage, gasoline, refinery chemical,
and debris...New Orleans could furnish perhaps the largest natural
catastrophe ever experienced on U.S. soil.[3]

Just before the Bush Administration in 2001, FEMA had been offering
disaster mitigation grants to states to help repair the flood
protection levees of New Orleans. These were eliminated. FEMA had
cited a hurricane strike on the city as one of three worst most
probable natural disasters that could occur in the USA. At the same
time, the Army Corps of Engineers, whose job is to protect flood prone
land, asked Congress for $430 million to shore up the levees.
Louisiana Congressional officials sought $14 billion to revive the
coastal wetlands, but got only $ 0.57 billion. By 2004, the
Administration instead had cut funding by 80%, and what was available
was often spent on less than necessary water projects in Louisiana to
support industry, with limited regard for environmental damage while
destroying millions of acres of storm blocking wetlands.[4]


The health risks raised by the disregard of poverty by policymakers
and the inadequacy of public health and safety preparedness agencies
were multiplied by the decline in environmental protection. Beyond
continuous budget cuts in recent years, the EPA became newly headed by
political rather than professional appointees. It redefined regulatory
terms such that "wetlands" -- which were not to be used for economic
development -- became open to commercial purposes in the Gulf region,
weakening the shoreline buffer against storm surges. In line with the
Administration's policy to lighten government regulation of business,
it focused on re-writing rules protecting drinking water and air;
asbestos and mercury elimination, and as most widely known, global
climate change.

As a case in point, an environmental official in the White House, a
former Petroleum Institute lobbyist, edited an EPA climate change
report so as to raise uncertainties about whether global warming is
occurring and downplaying potential damage. (He soon resigned and went
to work for the giant oil firm Exxon-Mobil.)

Katrina and Rita revealed another facet of climate change that
policymakers are not acknowledging. Over 2 million evacuees mandated
to leave Houston, Texas during Rita were caught in gridlock on the
expressways because there were too many cars. People in New Orleans
were caught in town because they had no cars. What they shared with
all Americans is a dependence on cars -- the mark of "freedom" to move
"whenever and wherever". That devotion adds to U.S. oil dependence,
which makes a large contribution to imprisoning the world's population
under a thickening blanket of water warming greenhouse gases,
intensifying hurricanes.


The Administration's answer to auto-oil dependence is to promote more
of the same. The Governor of Louisiana wants billions to build more
highways for the next evacuation. The Department of Interior is
planning to expand energy development on public lands, including the
pristine Alaska National Wildlife Reserve and the nation's coastal
waters, ending a 25 year moratorium. The new Energy Act provides many
billions mainly to promote fossil fuel industries.

With a projected $150-200 billion needed to restore New Orleans and
surround -- which has one of the highest poverty rates in the country
-- the majority Republican Party's Study Group proposed to cut the
2005-2006 budget further to pay the disaster's costs, producing $370
billion in "savings" over five years. These cuts involve the services
and protections that were already deficient and helped create the
vulnerabilities of New Orleans and the coastal poor, including health
and education programmes, home care, energy conservation; water
quality and wastewater infrastructure; high speed rail development and
new public transit; neighbourhood investment and minority business
development, legal services for the poor and local emergency worker

In the new century, U.S. leaders' commitment has been to "free market"
solutions to public issues. This wake up moment could be more
healthfully used to restore financing to reduce poverty to at least
European levels; to rebuild adequate public health and safety
capacity, and to enable tools to protect environments, moving toward a
new energy future, for example, a national intercity rail system,
linking small and large cities, spurring rural development, new
transportation options, conservation, energy efficiency technologies
and buildings, new energy sources and new good jobs, training and
education, discouraging sprawl and energy expensive houses.


1. Center on Budget and Policy Priorities. Katrina evacuees
ineligible for Medicaid. 26 Sep 2005.

2. Government Accountability Office. Federal agencies face
challenges in implementing initiatives to improve public health
infrastructure. Jun 2005.

3. Moody C. Frail disaster preparation. Am Prospect 2005;5:23.

4. Editorial. New York Times 2005; Sep 13.

5. Republican Study Group. Budget Options for 2005-06. 22 Sep 2005.

Correspondence: Professor N Milio Carrington Hall, number 7460,
University of North Carolina, Chapel Hill, NC 27599-7460, USA;