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An unparalleled catastrophe like the hurricane that struck New Orleans and the Gulf Coast last month has enormous implications for every sector of society-from government and the economy to social services and health care. For pediatricians, questions overwhelmingly concern the impact of the disaster on the provision of health care: What happened to the system? What happened to the victims and health-care personnel trying to care for them? And what lessons can be learned-for next time?
Scope of the disaster. In New Orleans and all along the Gulf Coast, hundreds are dead and thousands more traumatized by the horrendous days they endured until help arrived. Clinicians like Hemant Vankawala, MD, an emergency medicine physician who volunteered to work at Louis Armstrong New Orleans International Airport once it was turned into a triage center, wrote in an e-mail: "We didn't practice medicine ... we did the most basic triage providing morphine and a blanket to septic and critical patients and allowing them to die." Any physician who encountered Katrina's survivors, wrote Dr. Vankawala, "will never think of America the same way ... will never look at your family the same way ... It will forever change the way you practice medicine."
Katrina revealed what is usually hidden from view: The desperately poor, the underclass of our society, mostly-although not entirely-African American. There they were on our television screens: thousands and thousands of people, mothers and fathers and children, the elderly and the disabled, too poor or sick or disconnected to evacuate New Orleans before the flood waters overwhelmed them.
Response. The federal government, unbearably slow in responding to the emergency as it unfolded, is now on a faster track to relief and reconstruction. Billions of dollars have been appropriated and billions more will flow into a massive relief and reconstruction effort. Qualified evacuees will regain access to Medicaid and the states' children's health insurance plan (SCHIP). States whose health-care systems are strained by large numbers of survivors have been promised federal assistance. The speech that President George W. Bush gave in an eerily deserted Jackson Square, in front of brilliantly lit St. Louis Cathedral, laid out a program reminiscent of the New Deal in the scope of remedies proposed: urban enterprise zones, $5,000 personal accounts for education and retraining, an urban homesteading program. Presumably, somewhere in the program's fine print, is a plan to rebuild the health-care system. What kind of a system will it be?
Lessons learned. Health care for the poorest residents of New Orleans was inadequate long before Katrina exposed their plight. A survey of survivors by the Kaiser Family Foundation and the Harvard School of Public Health found that four in every 10 evacuees were physically disabled or had a chronic illness such as heart disease, diabetes, or high blood pressure. Half had no health insurance, and 66% used hospital or clinic-the destroyed Charity Hospital and University Hospital of New Orleans-as their primary source of care.
Ironically, those who survived the ordeal may be getting better medical care now: Health-care workers at an Atlanta clinic, for example, have reported seeing as many as six undiagnosed cases of hypertension and four cases of previously undetected diabetes each day among the evacuees they are assisting. One lesson that Katrina has taught appears to be that the existing health-care system has never worked for poor families like these. Rebuilding in the old mold will not suffice; new, fundamentally different approaches are needed. Pediatricians, with their tradition of advocacy for children and families, should be at the fore supplying those ideas.