After the flood. A strategic primary health care plan for homeless and migrant populations during an environmental disaster.

An environmental crisis, such as flood, can significantly affect health care delivery and services in a community. Environmental disasters can be particularly devastating to already vulnerable populations such as the homeless and migrants, who, because of social, political, and economic constraints, experience special health care needs. In 1993, after Iowa experienced the worst flood in its history, President Clinton declared the entire state a federal disaster area. Later, the Iowa Department of Public Health received a federal grant to evaluate the health care delivered during the flood and develop a strategic plan to enhance primary health care for the homeless and migrant populations during future environmental disasters. The plan was based on data obtained during and after the flood in three critical areas -- communication, health care delivery, and community. These areas were themes that emerged from a series of interviews with representatives from health care agencies and clients themselves. Each theme became the focus of specific, comprehensive recommendations and strategies to meet the daily challenges of the homeless and migrants, as well as to enhance the delivery of primary health care services in the future. Homelessness and the Iowa Flood On April 1, 1993, after days of unrelenting rain, the Mississippi River overflowed. As it ran south, the Mississippi flooded its tributaries, the Iowa and Raccoon Rivers, which overflowed in July. The Raccoon River flooded the water plant in the capital city of Des Moines, leaving more than 250,000 residents without water. Many bridges and highways across the state were impassable and closed. Most of the state was at a virtual standstill, and 6,000 residents were left homeless. The public transportation system sustained more than $5 million in damage. Total flood damage in Iowa exceeded $2.7 billion. The flood only accentuated the problem of homelessness, which, in Iowa, as in other areas of the United States, was growing at an alarming rate. In figures from the early 1990s, the number of homeless adults and children, representing various religious groups and ethnic backgrounds, was between 250,000 and four million nationally (1). The Iowa Coalition for the Homeless conducts a census every two years and reports that in 1992 and 1994, the homeless population was approximately 16,000 and 19,000, respectively (2). Included in the homeless census are migrant laborers, who, because of their transient lifestyle, lack permanent housing. The homeless and migrant populations share economic, political, and societal constraints (3). Access to health care for both groups is hampered by economic and political forces: the expanding need for health care for the indigent, bureaucratic guidelines for service, and the continuing tendency for certain health care workers to be insensitive and stereotype individual clients. Migrants, who often do not speak or understand English, tend to have a higher degree of social isolation. The homeless face a constant struggle for daily survival and often have histories of psychiatric disorders and substance abuse in addition to chronic health problems. The rigors of daily living and survival require tremendous coping abilities. Basic needs, such as food, shelter, and clothing, often go unmet. It is understandable, then, that health care is often a matter of low priority, despite the great risk of disease, the prevalence of mental illness, and the presence of chronic health conditions, such as diabetes, hypertension, and heart disease. Given the usual stresses of daily living for the homeless and migrant populations, the trauma of an environmental disaster can lead to crisis. The flood that devastated Iowa exacerbated preexisting health care problems and strained the overburdened health care system for the indigent. The waiting time for appointments increased to two to three weeks for routine concerns. Migrants who had arrived in Iowa for seasonal work found themselves without income, housing, or health care access. …