The Katrina disaster and its lessons.

Disasters by their nature are unexpected events that catch most of organized society in a crisis. Despite previously prepared protocols for interventions, the nature of disasters creates and brings to the surface the underlying dysfunctions that existed prior to the event in any local and national governments. Most recently, the hurricanes that tormented the southern coast of the USA and the subsequent flooding of New Orleans are only now being recognized as a focus for much needed mental health intervention. What existed there and the governmental response was reminiscent of those that occur in third world countries but, surprisingly, this was rather existing in a portion of one of the most highly developed and wealthy nations in the world. What happened in New Orleans is a good example of response to disasters in general. While much of the USA was preparing for an upcoming end of summer holiday, New Orleans was preparing for an all city evacuation before the forecasted hurricane, dubbed Katrina, would sweep through the Gulf of Mexico and hit land. Some people opted to leave their cars behind and evacuate to either a large convention center or the Superdome sports arena. Others drove in ravaging traffic jams for hours to reach safety away from the path of the hurricane. Others jammed the airport to fill flights to safer cities. When the hurricane's winds subsided, some people went back home, others were relieved and knew the decision to stay boarded up in their homes was correct. Yet, within hours, one of the levees holding water along a side canal from the Mississippi River broke, and water poured over its brim and onto the land far below the canal water level. Houses were flooded to their rooftops and whole communities were covered in water. People who could not get out of their attics fast as the water rose perished in the floods. Others died because they could not swim in the deep current or because they stayed for days on a rooftop without aid. While the world watched TV newscasts of this event, rescue was slow and the TV viewers were helpless to respond to the people interviewed pleading for help and to the doctors in the convention center and streets saying that massive help was needed and little had arrived. The overcrowded convention center and Superdome were not adequately supplied with drinking water or food. The Red Cross set up shelters, but they were not enough. The Federal Emergency Management Agency (FEMA) slowly became aware that their response efforts were not adequate. The local government of New Orleans, despite setting up a command center in a downtown New Orleans hotel ballroom, remained dysfunctional and lacked essential communication with both the state and federal governments. Each blamed the other and yet competed to do better. Meanwhile people continued to die on rooftops and not receive food and water. A vast number of survivors lost their homes, that became rubble or, if remained once the water level receded, were covered inside with mold. All belongings were unsalvageable. Insurance agents began coming to New Orleans to minimize the liability of their companies, leaving many homeowners vulnerable. The FEMA promised in public what they could not give in private. Although checks could come in the mail to pay bills, no mail could be delivered. Bills still came for electricity and telephone, although these services were not restored or the houses they corresponded to no longer existed. Although slow, the FEMA did find temporary housing for most and financially enabled many to begin to rebuild at least partially. The entire city medical care system was destroyed. The hospitals were closed. Patients could not find their doctors, as offices were closed and many of the doctors themselves lost their homes. Jobs were lost and employees were lost to the employers even if the business could be reopened. Medical records were lost in the rubble and floods, and many patients who showed up in clinics only knew the color of their pills, not what they were. Pharmacies were closed and if re-opening had to discard their supplies because the medications had spoiled in the heat and new deliveries were not coming quickly. Laboratories were also not available to process blood tests, and delivery trucks were unavailable to send the samples elsewhere. Aside from the clear victims and survivors, the first responders need mention. The police and firemen, and local citizens who rescued survivors and for weeks pulled the deceased out of flooded homes, all were in need of support. Some in extreme cases went unnoticed until they suicided. Many of the responders were also victims, as they lost homes and relatives as well. They were housed on cruise ships in the harbor and hotels that were not damaged, but lost much of their possessions. Once the remaining occupants obtained food, water, clothing and temporary shelter, the symptoms that emerged were insomnia, anxiety, panic and depression. Still the people from New Orleans, the first responders both local and coming from afar, as well as those people who indirectly were affected by daily TV news reports, become continuously tearful with reminders. Much of the above description is reminiscent of countless other natural or man-made disaster responses, with disorganization of those in command and competition among aid organizations. Two months after the disaster, when the basic needs were met for many, mental health issues came into the forefront. The new specialty of disaster psychiatry has recently gained recognition, after the September 11, 2001 terrorist attacks on New York City and Washington. However, in New Orleans, just as in many developing countries, religious support was the mainstay for hope and peace. Very few mental health professionals in New Orleans were trained in the evidence-based and now acceptable treatments of choice. Education about the need for early treatment, and identification of the most vulnerable for serious psychiatric consequences is needed, so that guidelines can be established and rumors about popular untested or even known harmful treatments can be quelled.