Katrina's wake disperses medical challenges well beyond Gulf coast

Physicians and public health officials across the country are trying to help people displaced by Hurricane Katrina reconstruct some semblance of a medical home.

At press time, more than 88,000 evacuees were living in 443 shelters in 18 states, and hundreds of thousands more were staying with friends and relatives -- making the effort to address their acute and ongoing health care needs an undertaking of national scope and one unlike recoveries related to any previous disaster.

"Under most hurricane scenarios, folks may or may not be evacuated, and they then return to pick up the pieces," said Charles Woernle, MD, MPH, assistant state health officer for disease control and prevention at the Alabama Dept. of Public Health. "There has never been destruction on such a massive scale before. They're going to be displaced for a long time." Alabama was directly impacted by the hurricane and is a refuge for thousands of people who have resettled there from other states.

Many physicians already have begun to experience the difficulties involved. For example, George Benavidez, MD, a family and emergency physician in Corpus Christi, Texas, volunteered to care for displaced people in Baton Rouge, La., immediately after the storm hit. When he returned, he brought 80 of them back to his hometown, adding to the nearly 2,000 already there. "We had to do something," he said. "These people understand that they're not going home any time soon, and we're going to take care of them."

One crucial challenge he and other physicians now face is getting those who have chronic diseases back on their regular medications. Most of these patients know the broad category of medicines they were taking, but few remember the exact names. Even fewer are aware of the dosages. Often it takes detective work.

"When we see a sack of prescription bottles, there's a sigh of relief," said J. Edward Hill, MD, AMA president and a family physician in Tupelo, Miss. He has been volunteering at the local safety net clinic, which has had to expand its hours from a couple evenings a week to seven days a week of extended hours to meet the new level of need.

Making adjustments, taking steps

On the public health side, numerous states have temporarily relaxed proof-of-vaccination rules for school entry. The goal is to get children back into the classroom quickly, and the expectation is that most youngsters already have met their home state requirements. Health officials are confident that parents can provide evidence in the next few months -- by accessing a state's immunization registry or getting vaccinated locally.

"These people are our guests, and some are potential future citizens of our state," said Joe Thompson, MD, MPH, chief health officer for the Arkansas Dept. of Health. "We have to allow the children to enroll in school." He estimates that more than 50,000 evacuees have settled in his state. This number is second only to Texas, which has taken in about a quarter of a million.

Steps also are being taken to reduce the chance of an infectious disease outbreak in shelters -- a very real concern. Already clusters of diarrheal and upper respiratory illnesses have occurred. Thus, in addition to promoting regular hand washing, the Centers for Disease Control and Prevention is recommending that shelter residents get shots against measles, mumps, rubella, varicella, hepatitis A and influenza.

"We're immunizing on the side of caution," said CDC Director Julie Gerberding, MD, MPH. "We're making sure that the immunizations of children are up to date. When the flu vaccine is available, we'll offer that as well. The last thing they need is a flu outbreak."

Access worries

Access-to-care issues are another important concern. In response, several insurance companies eased restrictions on out-of-network care at least through September, though this timeline could be extended. Also, the Centers for Medicare & Medicaid Services issued a statement ensuring that physicians who provide care to evacuees in good faith, but who do not comply with the normal requirements of the programs, will be paid and exempt from sanctions for noncompliance. Many doctors also have volunteered to provide free care.

Some physicians are among the displaced. Some have started practicing in their new locations. The Ochsner Clinic Foundation started advertising that patients from its main campus in New Orleans can see their usual doctors at the clinic's Baton Rouge location. "As a physician, I have to follow the patients, and they have moved," said Michael Wasserman, MD, one of Ochsner's pediatricians who usually practices in New Orleans but is now in Baton Rouge.

Others are staying with friends or relatives, filling out insurance forms and looking for ways to return home. But those intent on going back worry that, even if they rebuild their homes and practices, things could be altered forever.

"My practice is destroyed," said Floyd Buras, MD, a New Orleans pediatrician staying in Baton Rouge. His home sustained damage, and his office was underwater. "I want to go back with two or three trailers and hold clinics in them until I can rebuild ... but there's nobody living there. I have to rebuild my practice from scratch."

And weeks after the hurricane, experts say health worries are far from over. In fact, new ones will emerge. Some of the worst injuries occur after people return home to salvage what's left. Many are also expecting the trauma to cause significant and widespread mental health issues.

"They lost everything they had," Dr. Hill said. "We're beginning to see some depression, and we expect we'll see a lot more."