The true extent of the American tragedy that is Hurricane Katrina is still unfolding almost 12 months after the event and its implications may be far more reaching. Hurricane Katrina, which briefly became a Category 5 hurricane in the Gulf of Mexico, began as a storm in the western Atlantic. Katrina made landfall on Monday, 29 August 2005 at 6.30 p.m. in Florida as a Category 1 hurricane, turned north, gained strength and made landfall again at 7.10 a.m. in southeast Louisiana as a Category 4 hurricane and rapidly attenuated over land to a Category 3 hurricane. New Orleans is below sea level as a consequence of subsidence and because of elevation of the Mississippi river due to altered flow. The storm brought a nearly 4 m storm surge east of the eye, where the winds blew south to the south shore of Lake Pontchartrain, and gusts of 344 km/h at the storm's peak at ∼1.00 p.m. Levees protecting the city from adjacent Lake Pontchartrain failed, inundating 80% of the city to a depth of up to 8 m. Further east in the Gulf Coast, a storm surge of 10.4 m was recorded at Bay St Louis, Mississippi [ 1, 2].
What followed was horrifying and discouraging. Poor residents and the immobilized were left stranded in squalor. Essential services failed. Heroic rescues were undertaken with wholly inadequate follow-up and resettlement [ 3]. Emergency response was feeble. It was only after the military intervened that the situation began, slowly, to improve. New Orleans and much of the Gulf Coast to the east is still a depleted, devitalized, largely uninhabitable wreck. Less than a month later, on 24 September, Hurricane Rita followed. A much stronger storm in magnitude, Rita caused further displacement and disruption in Texas, where evacuation measures, undertaken in near-ideal conditions, were shown to be completely inadequate.
Floods usually conceal more than they reveal. Hurricane Katrina was an exception. It revealed truths about disaster response in the United States that had been concealed. Now, months later, one may assess the response and recovery to the disaster, evaluate how the country handled the challenge and determine what lessons were, or could have been, learned.
Katrina revealed that natural disasters and public health crises are as much threats to national security as intentional assaults. An entire region that played a vital role in the American economy and a unique role in the country's culture ground to a halt. During Katrina and Rita, ∼19% of the nation's oil refining capacity and 25% of its oil producing capacity became unavailable [ 4]. The country temporarily lost 13% of its natural gas capacity. Together, the storms destroyed 113 offshore oil and gas platforms. The Port of New Orleans, the major cargo transportation hub of the southeast, was closed to operations. Commodities were not shipped or accessible, including, in one of those statistics that are revealing beyond their triviality, 27% of the nation's coffee beans [ 5]. Consequences of this magnitude are beyond the reach of conventional terrorist acts.
Katrina revealed the close interconnection between the natural environment and human health risk. The capacity of wetlands in the Gulf Region to absorb precipitation and to buffer the effects of such storms has been massively degraded in recent years by local development. This has been known for a very long time [ 6], but development yielded short-term economic gain while mitigation was expensive. Katrina also revealed that understanding the threat and the circumstances that enable it means nothing if no concrete preparations are taken. The disaster that struck New Orleans, specifically, was not only foreseeable but also understood to be inevitable. Emergency managers had participated in a tabletop exercise that followed essentially an identical scenario just 13 months before, called ‘Hurricane Pam’ [ 7]. Had their conclusions and recommendations been acted upon, the actual event may have turned out differently. Although the levees would still have failed, perhaps those responsible for safeguarding the people would not have done so.
Katrina revealed that the federal agency designed to protect all Americans was incompetent. The Federal Emergency Management Agency (FEMA) reached its peak under President Clinton, when it enjoyed Cabinet-level rank. Post 9-11 FEMA was subordinated within the Department of Homeland Security (DHS), a department highly focused on terrorism and intentional homeland threats. The wisdom of combining the two was always in doubt. The logical solution is to move FEMA out of DHS but so far there has been no political will to do so and FEMA is so reduced and depleted as an agency that it probably could not now operate at a Cabinet level even were it to have the authority [ 5, 8].
Katrina revealed how large and resilient the American economy has become overall. The evidence for this is how quickly the country has returned to economic growth and business as usual, despite the destruction of a region once economically important [ 9]. Katrina devastated ≥223 000 km [ 2] of the United States, an area almost as large as Britain. Yet, with one exception, the economy of the country barely registered an effect, even on psychologically volatile indicators such as stock market indices. It is projected that Katrina, as such, will only reduce growth in GDP for the United States by about one half of 1%. Although the southeast region served by New Orleans is very large geographically, it constitutes only 1% of the total American economy [ 10]. The lower Mississippi region adds little of its own economic value to GDP, other than tourism and as a source of energy. The exception noted above, of course, was the price of oil, as reflected in the prices of gasoline and refined petroleum products.
Katrina revealed how marginal the Gulf Region had become to the American economy, despite the wealth that passes through it. New Orleans itself was a poor city—it probably still is, although the returning citizens obviously have sufficient resources to allow them to return—and its neighbours in Mississippi and Alabama are not rich, either. The region is economically significant mainly for tourism, transshipment of cargo, oil and gas and for redistribution of wealth (in the form of legalized gambling). Reconstruction efforts may even fuel an economic expansion in the rest of the economy, although precious little prosperity resulting from it is likely to be seen in the devastated Gulf itself anytime soon. Astonishingly, the compounded effect of the war in Iraq, the high price of crude oil and the direct effects of Hurricane Katrina did not set back growth in the American economy, although it may have kept stock market prices level to the end of 2005.
Katrina revealed the great divide that remains between people living next to one another but differing in the clustered characteristics of race, poverty, immobility and ill-health [ 11, 12]. Those who lacked the resources, who could not fend for themselves, who were left behind, who happened to be sick were almost all African–American, and therefore so were the ones who died. Relatively, well off residents near the shore of Lake Pontchartrain also sustained many deaths [ 2]. However, the brunt of the storm was clearly borne by the poor and dispossessed. That this was not intentional does not make it any more acceptable.
Honour in this dishonourable story came from the role of rescue, medical, public health and occupational health professionals. Rescuers took personal risks to save the stranded citizens of New Orleans. Public health agencies quickly identified and documented the risks of water contamination [ 13], warned of risks from carbon monoxide from portable generators [ 14], identified dermatitis and wound infections as major health risks [ 15] and identified outbreaks of norovirus-induced gastroenteritis [ 16]. Occupational health clinics and occupational health physicians and nurses treated the injured, from wherever they came [ 17]. Occupational health professionals returned critical personnel to work as soon as it was possible, to hasten economic recovery and rebuilding. Occupational Safety and Health Administration professionals warned against hazards in the floodwaters and the destroyed, abandoned houses but supplies for personal protection were nowhere to be found. The American College of Occupational and Environmental Health served as a clearing-house for information and provided almost 200 participants with web-supported telephone training on Katrina-related hazards and measures to get workers back on the job safely.
It was not enough. No human effort could have been by then. But what can we, as a medical speciality, do better next time? The occupational health physician is not, as such, a specialist in emergency medicine, an expert in emergency management and incident command or a safety engineer, although many do have special expertise in these areas because of personal interest, prior training or military experience. The occupational health physician is, however, uniquely prepared to work with management and technical personnel at the plant, enterprise or corporate level. We can assist in preparing for plausible incidents, planning for an effective response, identifying resources that will be required, and advising on their deployment.
The occupational physician has critical roles to play in disaster preparedness and emergency management. Our role in disaster preparedness is distinct from those of safety engineering and risk managers. Our role in emergency management is distinct from those of emergency medicine and emergency management personnel. Our roles in both are complementary, sometimes overlapping and predicated on the value that we bring to the table as physicians familiar with facilities. We have the means to protect workers in harm's way and from the many hazards already so familiar from our daily work. Katrina demonstrates that occupational health professionals can translate experience of the ordinary to play an integral role in dealing with the extraordinary.