Doctor’s Orders

When Hurricane Katrina made landfall on Aug. 29, 2005, Dr. Nicole Laurie was leading the public health preparedness program for RAND Corp. As disaster descended on the Gulf Coast, she established a rapid policy response group to assist affected communities and began documenting the consequences of one of the most devastating natural events in U.S. history. Today, Lurie is assistant secretary for preparedness and response at the Health and Human Services Department, a position created by Congress to address a critical need revealed during Katrina. She’s also a rear admiral in the U.S. Public Health Service. 

In an interview with Deputy Editor Katherine McIntire Peters, Lurie talks about what’s changed over the last decade, and what hasn’t.

Where were you when Katrina hit?

I was living in Washington. We had a pretty significant influx of people who came into the D.C. area and went to the D.C. Armory to get care. I remember showing up there with a stethoscope around my neck and someone asking, “Are you a doctor?” I said yes, and they said, “Could you go see these patients?” That was the extent of my credentialing.

What was the biggest concern, from a public health standpoint?

I think we all had a lot of questions about how coordinated a federal response might be. I understood pretty clearly from my previous work that the population on the Gulf Coast and New Orleans in particular was, from a public health perspective, a pretty needy population—a lot of people with a lot of chronic disease. People with lower levels of education in general than the American public. A lot of people who were uninsured and likely to have undiagnosed medical conditions. 

What were the needs?

There was not a good system of outpatient or primary care outside Charity Hospital in New Orleans at the time. There were lots of people with pretty serious complex chronic diseases, and a lot of people who were on dialysis or with untreated hypertension and diabetes.

Dialysis was such a problem because people who didn’t get dialysis on time ended up in emergency rooms and hospitals with some frequency. It’s bad for patients, but it’s also one of those things that causes additional unneeded surge in the health care system. So we’ve focused a lot on trying to do something about it.  

Since Katrina, what have been the most significant accomplishments?

One is that we can circle the area on a map, and we know who lives there. We know how many people, what languages they speak, and we know what their burden is with chronic disease. So we know not only who’s on dialysis, but we know that 40 percent of the population is diabetic, or overweight enough that it’s going to be hard to evacuate them, or whatever. That’s a huge advance, just taking advantage of all the information that’s out there and putting it together in an actionable way. 

We also have an organized system in government under the National Response Framework to be able to coordinate through FEMA with all the different parts of the federal government that have to do with any response. 

A big gap in Hurricane Katrina was in mental health—both the mental health of the population before the storm as well as people who developed mental health issues because of the effects of the storm. Importantly, mental health issues for responders really came to the fore, and we now have a pretty organized system of mental health response. 

We’ve also made a lot of advances in hospital preparedness. Most hospitals don’t have generators in the basement [anymore]—and they [all] have generators. They have to practice their evacuation plans every year. 

What about the challenges?

Some remaining issues and gaps I see are No. 1, people’s memories are short. There’s been a pretty significant decrease in funding for emergency preparedness. I think there was this notion that we could just buy a lot of stuff and put people through training and we’d be done. But people in the workforce turn over all the time. People need to train and practice and exercise in health care facilities and communities all over the country every single year. So those cuts are really making me very concerned that we’re back on the cusp of many of our infrastructure components being very vulnerable. 

The other thing, and I think you saw this with Hurricane Sandy or even H1N1 [flu outbreaks], is not only does every hospital need to be prepared, but it needs to be prepared as part of the community health system. It doesn’t do me any good as a hospital to be able to evacuate my patients if I don’t know where they’re going, if there’s not somebody to receive them. 

In Sandy you saw all these nursing homes needing to evacuate. Well, many of them didn’t have a plan. As a result you had lots of people in shelters all over the place and the National Disaster Medical System needing to do a lot of work to decompress hospitals and emergency rooms and take care of nursing home patients in other places because the community planning wasn’t as far advanced as it needed to be. 

These are private facilities with a range of competency levels—how do you address that? 

That’s exactly right. What makes it even harder is that many of these facilities compete with one another, so telling them they have to plan together and collaborate has been new. Having said that, what we’ve done is require the development of health care coalitions—organizations that include most of the health care facilities in the community, not just hospitals, but dialysis centers and nursing homes and surgery centers that need to prepare and work together in a disaster. 

For example, if you think about the Amtrak crash in Philadelphia [in May], there were about 200 people injured. The health care coalition stood up and said here’s how many beds each facility has and here’s how many patients each can take. It did what we call patient regulation—allocated the different patients around to different hospitals, so none had a disproportionate share of sick or injured people. The same thing happened after the Boston bombing. 

Another big advance from Katrina has been electronic records, so now people’s health care records go with them. During Katrina, I remember vividly from being at the [D.C. Armory] a lot of people didn’t know what their health issues were, what their medications were. Many facilities’ health care records were destroyed. 

That’s a huge development that makes care a lot safer for individuals.