Medical Examiner

Sick City

The diseases that Katrina unleashed.

A population at risk

On Sunday night I ran into an old friend, a New Haven pediatrician named Jim Morgan. He was getting set to join nine local physicians headed for the Hurricane Katrina disaster area to do what they could. What are health-care professionals contending with on the Gulf Coast?

Infectious Disease: The biggest threats of infectious disease don’t come from dead or decaying bodies in the water or (to a large extent) spoiled food. They involve the failure of basic public-health services: sewage disposal and water purification. Since the hurricane hit New Orleans, there has been no clean water available for washing, cooking, or drinking. The floodwater drowning the city is contaminated with sewage. That means the victims of this disaster are at risk for enteric disease—intestinal illness.

E. coli: In its mildest form, diarrhea and cramping are often caused by bacteria like the common E. coli. These problems tend to resolve by themselves in a few days, though people weakened by malnutrition, exposure, or stress may have diminished fluid and other reserves and some will be at significant risk for serious effects.

Cholera: In serious cases, diarrhea can be so gushing and uncontrollable that a patient can pass in a few hours from perfect health to death by dehydration. This is caused by the germ Vibrio cholera. We rarely see cholera in the United States, because sewage systems and water supplies are of good quality. But ominously, a few isolated cases of cholera have been diagnosed in Louisiana and Florida within the last 15 years. Those cases were caused by inadequately cooked local seafood, not sewage. But they tell us that the germ is present locally. On Monday there were reports of an outbreak of a relatively mild cousin of cholera caused by the bacterium Vibrio vulnificus. We have to hope that, despite the breakdown of water purification from the flooding, cholera does not make a comeback

Dysentery: This occurs when enteric disease becomes more invasive and includes bloody, mucousy diarrhea with great cramping, and sometimes fever besides, caused by Salmonella, Shigella, and a few other bacteria. There have already been 20 suspected cases of this disease among hurricane victims in Biloxi, Miss. We can expect to see more.

Typhoid fever: This disease begins in the bowel but then invades and damages other organs of the body, which can easily lead to high fever, collapse, and death. It is caused by certain Salmonella infections. Typhoid fever is a risk when sewage control and water purification break down because there is always a source of typhoid in the environment, from a small number of ostensibly healthy people who once were infected and continue for the rest of their lives to shed the germ in their stool. (The famous carrier Mary Mallon, otherwise known as Typhoid Mary, infected about 50 people when she worked as a cook in New York City about 100 years ago.)

Treatment: Modern medicine deals pretty well with all these problems, sometimes by prescribing antibiotics and anti-diarrheals, but mostly by aggressively replacing lost fluids and salts. Patients are encouraged to drink water that is enriched with packets of oral replacement salts (athletic drinks like Gatorade are only a fair substitute for water plus ORS). If patients are not able to drink adequate amounts to meet their needs, fluids must be given intravenously.

The trouble in New Orleans has been that neither clean water, nor ORS packets, nor access to intravenous fluid rehydration have been available to victims in the devastated region. Medical personnel (like my friend) have been pouring in, but in some places there are not yet systems for setting up all the needed field hospitals and aid stations. There will be more deaths as a result.

Mental health: This is a big concern. I know that people are resilient, but frankly I cannot imagine how one can survive, without help, the experience of the storm, followed by days without food or water, homeless, surrounded by death, with family and friends missing. As other disasters have shown, help is not easy to come by (indeed, community mental-health needs are often so great and resources so limited that without a disaster help is hard to arrange). The Mississippi and Louisiana refugees pose a particular difficulty because they are scattered. I suspect we will need to prepare and train a set of people specifically to deal with this need: a sort of national mental-health corps.

Loss of medical care: One of the worst effects of the hurricane and its aftermath is the suffering of the frail and elderly. People with chronic disease are always closer to the ragged edge and more dependent on medical technology. No power means no air conditioning, no fans, no refrigeration to keep medications stable, and no open pharmacies. No transportation means no access to medical care. And for the people who reached them, some hospitals had no power, no water, no supplies. In the wake of Katrina, medical care was returned to the 19th century.

Immunization: To combat the exposure to viruses and bacteria from contaminated water, everyone who has been evacuated from the devastated area or who remains there or is coming down to help should be immunized immediately against hepatitis A and typhoid. Physically stressed people who are packed tightly in small areas are at great risk for passing illness back and forth. For that reason, any flood victims whose immunizations for measles-mumps-rubella, varicella, and tetanus have lapsed or are missing should be brought up to date with new shots, ideally with an added boost of diphtheria and whooping cough protection. It will be better to err in favor of over-immunizing, since there is no harm (beyond the risk of a slightly achy arm) in giving an extra shot to an already protected person. It is also imperative that children be brought up to date for these vaccines and also for protection against the most common form of meningitis, which is prevented by the HIB vaccine.