THE POST KATRINARITA STORY: APPLYING LESSONS LEARNED TO PROTECT VULNERABLE FAMILIES AND CHILDREN

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THE POST- KATRINA/RITA STORYAPPLYING LESSONS
LEARNED TO PROTECT VULNERABLE FAMILIES AND
CHILDREN

• August 28, 2007
• Plenary Session
• 2007 CityMatCH
• Urban Maternal and Child Health
• Leadership Conference
• Denver, Colorado

GINA PAYTON LAGARDE, M.D., MBA Louisiana Child
Health Medical Director Maternal and Child
Health Program Office of Public Health
TIME Hurricane Katrina, The Story that Changed
America
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Objectives

• Illustrate the economic, psycho-social, and
  healthcare impacts of Hurricanes Katrina and Rita
  (Katrita)
• Outline storms aftermath challenges
• Discuss Louisiana Public Healths response, then
  and now
• Recommendations from lessons learned

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PRE-KATRINA"Laissez Les Bon
Temps Roulez"
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PRE-KATRINA
Louisiana Statistics
Source U.S. Census Bureau, 2005 American
Community Survey
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The Storms Impact
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The Wind Came
TIME Hurricane Katrina, The Story that Changed
America
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The Storm Surge Came
TIME Hurricane Katrina, The Story that Changed
America
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The Levees Broke
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and The Water Came
TIME Hurricane Katrina, The Story that Changed
America
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The Calvary Came, EVENTUALLY!
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Hurricanes Katrina
Rita EQUAL OPPORTUNITY DESTROYERS
(9) Region a LA Office of Public Health
administrative area made of a group of
parishes (64) Parish county a sub-division
of the state and/or an administrative area of
civil government (17) Ward voting district in
New Orleans
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Economic Impact
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Irreparable Property Destruction(London Ave.
Canal Levee Breech)
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Murphy Oil Spill (St. Bernard Parish)
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Loss of Communities
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The Costliest Storms

• Hurricane Katrina is the costliest and one of the
  deadliest natural disasters in U.S. history
• Hurricane Rita is the ninth costliest storm in
  U.S. history.
• Combined Damages gt 150 billion
• Loss of Homes gt 365,000 (LA.)
• Loss of Businesses gt81,000
• Loss of Jobs gt455,000 (LA.)
• Loss of Schools 1,500 gt700,000
  students/teachers
• Approximately 1,500 of 2000 primary schools and
  59 of 79 colleges and universities were located
  in the impacted parishes.

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Psycho-Social Impact
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Separation of Families

• Pre-Katrina
• 1 million people evacuated New Orleans
• 150,000 people (mostly poor, disabled) were
  unable to evacuate
• Many people chose not to evacuate (job, pet,
  inconvenient, rode out past storms successfully,
  etc.)
• 26,000 people were in the Superdome (shelter of
  last resort)
• 2 Weeks Post-Katrina
• Evacuees sheltered in over half the states
• gt 250,000 evacuees sheltered in Louisiana SNS
  (special needs shelters), ARC (Am. Red Cross)
  shelters, churches, community centers
• gt 90, 000 evacuees in Louisiana hotels and homes
• Thousands of people unaccounted for

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4 Weeks Post-Katrina
Diaspora of Displaced Survivors

• Biggest mass migration in US history
• 800,000 evacuees were registered in all 50
  states and in almost half the zip codes of the
  U.S.

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Loss of Lifeas of August 2, 2006, DMORT

• In Louisiana
• Hurricane Katrina Related Deaths gt 1,118
• Race 53 African American 39 Caucasian 8
  other
• Gender 53 males 47 females
• Age 65 over 60 yrs 4 under 21 yrs (12
  deaths)
• Parish 75 Orleans 18 St. Bernard 7 other
• Hurricane Rita Related Deaths 0
• From Louisiana 1,464 deaths
• Note Exams conducted by DMORT (Disaster Mortuary
  Operational Response Team), a component of the
  National Disaster Medical System (NDMS), which is
  a section of the U.S. Department of Homeland
  Securitys Federal Emergency Management Agency
  (FEMA) and are made up of volunteer professionals
  (doctors, dentists, forensic scientists, police
  officers, medical examiners, funeral home
  directors, medical investigators, other techs

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Depression /Post Traumatic Stress Disorder

• Constant Reminders
• Debris destruction
• Unpopulated neighborhoods
• Empty schools/parks
• Media Coverage
• Loss of life/quality of life
• Loss of hope
• Long-term psychological effects unknown

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Healthcare Impact
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Healthcare Infrastructure Collapse

• LA Healthcare Market gt 50 impaired
• Loss of patients
• Loss of medical records
• Loss of gt 6,000 trained, experienced medical
  personnel
• Loss of healthcare facilities
• 141 (of 201) hospitals,
• Loss of public health units 4 OPH and 5 City of
  New Orleans health units
• Loss of Federally Qualified Health Units
• Loss of School-Based Health Centers
• Loss of medical, dental, and mental health
  services
• Loss of scientific research
• Disruption in medical education and residency
  training
• Loss of inventory (medical equipment and
  supplies)
• Loss of pharmacies and pharmacists
• Dramatic shift in payer mix w/o corresponding
  reimbursement

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New Orleans Charity
Hospital and Level 1
Trauma CenterMedical Center of Louisiana _at_ New
Orleans
Pre-Katrina
Post-Katrina
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Aftermath Challenges
Communication Challenges
Mental Health Challenges

• Surge Capacity Challenges
• Trained Workforce
• Volunteerism

Childrens Health Safety Challenges
Preparation/ Policy Challenges
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Challenge 1Communication

• Vulnerable Infrastructure collapsed -- no
  electricity, overwhelmed networks/radio
  frequencies, downed towers, etc.
• Unreliable Equipment -- land/cellular/satellite
  phones (800mhz) computers
• Logistics
• Reactive (Katrina) vs. Proactive (Rita)
• Coordination -- services, volunteers, local
  providers (overlooked), and new partners
  mid-stream
• Tracking sheltered evacuees, volunteers
• Documentation of services -- time constraints,
  forms/documents, medical records
• Miscommunication -- message/language,
  messenger/chain of communication (vertical vs.
  horizontal)
• Media Mayhem

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Challenge 2 Surge Capacity

• Surge Capacity is a systems ability to rapidly
  expand
• beyond normal services to meet the increased
  demand for
• qualified personnel, (medical) care, and (public
  health)
• services in the event of bioterrorism or other
  large-scale
• public health emergencies or disasters.
• Limited resources (pre- and post-Katrina)
  providers, equipment, supplies, trained
  personnel, space, etc.
• Healthcare infrastructure collapsed in southern
  Louisiana
• Access to medical services -- limited,
  unavailable
• Influx of patients overwhelmed intact healthcare
  systems statewide

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Challenge 3a Public Health
Workforce/Manpower

• Public Health Workforce
• Over-worked
• Double duty -- disaster operations routine
  public health operations
• Gaps in public health unit and programmatic
  services
• Fatigue -- long work hours prolonged special
  needs sheltering (3 mo)
• Under-staffed
• Aging workforce/retirements w/ -- w/o
  replacements
• Hiring freezes (cuts in funding)
• Essential vs. non-essential workers
• Variable provider medical skills level/training
• Primarily skilled in non-acute care
• Limited or no training/skills in pediatric care
  (esp. children w/ special needs),
  trauma/emergency medical/psychiatric care,
  intermediate level of care, etc.
• Limited to no medical practice experience in
  non-traditional settings (gyms, coliseums,
  hotels, bridges, tents, airport, etc)
• Victims of the storms

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Challenge 3b Volunteer
Workforce/Manpower

• Variable provider medical skills level/training
• Limited or no training/skills in pediatric care
  (esp. children w/ special needs),
  trauma/emergency medical/psychiatric care,
  intermediate level of care, etc.
• Limited to no medical practice experience in
  non-traditional settings (gyms, coliseums,
  hotels, bridges, tents, airport, etc)
• Under-utilized resources (i.e. local providers,
  allied health, students, retirees)
• Acute Influx of volunteers and donations
• Acute Exodus of volunteers (Hurricane Rita,
  personal missions accomplished)
• Volunteer Management
• Credential Verification
• Centralized
• Foreign medical providers
• Assignments
• Documentation/Debriefing
• Accountability/Liability
• Housing and Transportation
• Misconduct
• Sustainability

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Challenge 4 Mental Health

• Mental Health
• Sheltering of psychiatric patients -- no
  available inpatient beds
• No federal funding to support interventional
  services for pre-existing mental illness
• Federal funding for crisis intervention only (4
  mo. only)
• Provider shortage
• Lack of infant and pediatric mental health
  services

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Challenge 5Child Health Safety

• No Comprehensive Pediatric Disaster Plan
• Limited pediatric-trained providers
• Poor coordination of services statewide
• Safety Issues
• Separation from family -- No Safe Havens
• Unsafe sheltering -- no cribs, no high chairs, no
  peds-friendly bathrooms, no toddler-friendly
  foods, etc.
• Unsafe transportation -- no car seats
• Medications -- no pediatric formulary
• Environmental hazards post-disaster lead, mold,
  carbon monoxide poisoning, etc.
• Evacuee Identity Protection/Privacy
• Inadequate/unavailable pediatric supplies --
  diapers, pedialyte, bottles, etc.
• Need for fun distractions -- childrens TV
  shows/tapes, toys, books, etc.
• Maternity issues sheltering postpartum and high
  risk prenatal No prenatal services in New
  Orleans

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Challenge 6Preparedness Policy

• Disaster plans and policies designed around
  intact infrastructures
• Exclusive Planning (silos, intra-agency)
• Inadequate Promotion of plans and policies
• Gaps in disaster plan(s)
• Governors Executive Orders during response phase
  and early recovery phase

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LA Public Health Response Then
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Traditional Public HealthRole in Disasters

• Coordination of Public Health and Sanitation
  Measures
• Provide services, equipment, staffing
• Special Needs Shelters
• Strategic National Stockpile Management
• Temporary Medical Operations Staging Area
  (T-MOSA)
• EMS (emergency medical services)/First Responders
• Search and Rescue Base of Operations (SARBOOs)
• Disease Surveillance and Tracking
• Inspection of food and drinking water
• Immunizations
• Laboratory testing

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LA Public Healths Response to KatritaThe
Safety Net The Calvary

• Public Health was forefront in all levels of
  essential services

• Direct Health Care Services

• Enabling
• Services

• Population-
• Based Services

• Infrastructure-Building Services

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Post-Katrina LA Public Health The Safety Net

• Direct Health Services
• Emergency Services
• Triage Medical Operations Staging Areas
  (T-MOSAs) gt70,000 triaged
• Search and Rescue Base of Operations (SARBOOs)
  after both storms
• Hospital Services temporary field hospital
  (Baton Rouge)
• Acute Primary Care -- evacuees, first
  responders, people statewide
• Temporary Clinics DMAT, police stations, tent
  cities, ARC shelters, EOC
• Strike teams OPH, USPHS and/or Volunteer
  physicians nurses, mental health providers,
  EMTs)
• Primary Care gt18,000 pts. seen / gt18,000
  scripts written
• Acute Mental Health Care (LA DHH-OMH OPH,
  SAMHSA)
• Pharmacy Services
• Strategic Natl Stockpile (SNS) Dispensing
• Retail pharmacy recruitment to provide emergency
  prescription medications

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SARBOO
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Post-KatrinaLA Public Health The Safety Net

• Enabling Services
• 8 OPH Special Needs Shelters served 13,000
  shelterees no loss of life or outbreak of major
  disease
• EMS transportation special needs shelterees,
  volunteers, strike teams no loss of life or
  EMS units
• Distribution of gt 1,000 donated car seats, cribs,
  high chairs
• Population-Based Services
• Mass immunizations mobile strike teams, public
  health units, shelters
• gt 14,589 Immunizations given to general public
• gt115,000 Tetanus vaccines given to emergency
  workers
• Disease Surveillance and tracking in shelters
  diarrhea in shelters coughs/respiratory
  illnesses skin infections common

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LA Public Health The Safety Net

• Infrastructure-Building Services
• Needs Assessments USPHS, Volunteer physicians
• Coordination of Volunteer providers and services
• Information Exchange/Communication
• Centralized Organizational Infrastructure
• 9 Centralized state public health regional
  administrative offices
• Centralized Emergency Operations
• Information Technology
• OPH and DHH Intranet services for info. exchange
• HelpThemNow.net volunteer interest registration
• KatrinaHealth.net pharmacy web-based database
  for medication and allergy information on
  evacuees
• Katrina Missing and Find Family National Call
  Center links on DHH website (www.dhh.state.la.us)
• LINKS Immunization database w/ over 37,000
  accessible patient records
• Credentialed Volunteer Providers database
• Surveillance and tracking of disease

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LA Public Health Response Now
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LA Public Health
NowCenter for Community Preparedness

• Pre-Event Planning, Preparedness (training
  education), Promotion, Policy/Legislation
• Pandemic Flu Preparations
• All Hazards Plans
• COOP (Continuity of Operations Plans)
• MOUS
• GOHSEP (Governors Office of Homeland Security
  and Emergency Response)
• Communication
• NIMS (National Incident Management System)
• ICS (Incident Command System)
• HAM and Switchboard Operations
• Mobile Communication Operations
• Electronic Tracking of shelterees/evacuees w/
  bracelets

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LA Public Health Now
Center for Community Preparedness

• Workforce Development
• Trainings (medical and non-medical personnel)
• Medical Skills training, BDLS, ADLS
• FEMA NIMS
• Volunteerism
• ESAR-VHP (Emergency Systems for Advanced
  Registration of Volunteer Health Professionals)
• Volunteer Summit (ARC, Medical Reserve Corp,
  Citizen Corp, LA Serve Commission, Louisiana
  Campus Compact, Volunteer Reception Centers,
  Louisiana Voluntary Organizations Active in
  Disaster, faith-base community, non-profits,
  civic organizations)
• Child Health and Safety
• Medical training of OPH staff
• Pediatric Supplies
• Pediatric Formulary
• Other

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Key Components for Effective Disaster
Preparation and Response

• Disaster Plans
• All Hazards
• Comprehensive (incl. pediatric needs)
• Flexible Inter-operable
• Standardized message, language
• Practiced and Promoted
• Include all entities that will have a role in
  execution of plans (local providers, elected
  officials, educators, business leaders,
  faith-based leaders, national program leaders,
  board/professional certification reps, etc.)
• Communication
• Create system that is seamless, flexible,
  coordinated, and interoperable
• Expand Information Technology capabilities
• Mobile communication command centers
• Alternatives to hi-tech equipment -- HAM radios,
  bullhorns, courier system (Keep It Simple)
  Redundancy
• Tracking mechanism

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Key Components for Effective Disaster
Preparation and Response

• Manpower/Workforce
• Flexible -- Provide medical services to all age
  groups in traditional non-traditional settings
• Accessible pre-credentialed, pre-registered
  national database
• Trained in existing plans, trauma and emergency
  medical care
• Mental Health Services
• Counseling for public health employees
• Crisis intervention AND Treatment (newly
  diagnosed pre-existing illness)
• Infant and child mental health services trained
  providers
• Available immediately through at least one year
  post-disaster

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Key Components for Effective Disaster
Preparation and Response

• Policy/Legislation
• Must be flexible maximize services
• Disaster plan implementation, execution,
  accountability, funding
• Sustained Federal and State Funding of Public
  Health
• For all 4 levels of service (direct care,
  enabling, population-based, and infrastructure
  building)
• For nationwide assessments of wireless
  communication network capabilities and
  information technology development capabilities
• For development/maintenance of accessible and
  compatible communication and information systems
• For national databases
• For mandatory standardized disaster plan
  preparations, practice/training, promotion

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• To achieve a better level of preparedness for
  future events, appropriate planning, training,
  communication, and staffing are required, along
  with improved policies and sustained funding.

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Contact Information

• GINA PAYTON LAGARDE, M.D., MBA
• Louisiana Child Health Medical Director
• Address Office of Public Health
• MCH Program
• 1450 L A Road
• Metairie, Louisiana
• Phone [phone] (work)
• Fax [phone]
• Email glagarde_at_dhh.la.gov