Fieldwork on the Gulf Coast

Fieldwork on the Gulf Coast

Certain events split time into “before” and “after,” shattering our collective sense of safety and well-being.

For future public health practitioners and millions of others, disaster hit home on August 29, 2005, when Hurricane Katrina made landfall at dawn in southern Louisiana. The storm carved a path of destruction for hundreds of miles up the Gulf Coast into Mississippi. Floodwalls failed and levees burst open. Vulnerable low-lying neighborhoods, the majority of them also low-income, succumbed to the rising waters.gulf house on stilts

The media went into overdrive, with alarming photos of crowded shelters, stranded victims, and floating bodies. A national sense of shame took shape, along with scores of theories of what must be—or could have been—done for efficient preparation, evacuation, and recovery.

“The impact of Hurricane Katrina forces us to examine the crucial role that public health can and must play in our society,” Dean Kenneth Warner said in an address to new students at the School of Public Health on September 1. “This disaster points to the need for planning and organization, for public health readiness, for human talent, effort, and compassion.”

Students answered the summons by sending insect spray and sunscreen to immediate responders and raising funds for New Orleans Charity Hospital. They attended special seminars and classes with a new point of reference for chaos. And they responded en masse when an opportunity for spring break hurricane-recovery fieldwork was announced through the school’s brand-new Office of Public Health Practice (see Findings article), which oversees a growing emphasis on internships and training.

That 40 SPH students would willingly forgo spring break relaxation to join the frontlines of disaster relief begins to reveal the rationale behind a dean’s office initiative aimed at “building the practice of public health.” Fieldwork provides training that’s hard to equal on campus, as examples below and at right show.

Student volunteers came from four of the five SPH departments and varied degree programs. All of them first completed mandatory preparedness training through the Public Health Action Support Team (PHAST), a student organization run out of the Office of Public Health Practice.

PHAST faculty advisor JoLynn Montgomery, a health department veteran with a “passion for infectious diseases and outbreak investigation,” had earned her MPH at New Orleans’ Tulane University School of Public Health and Tropical Medicine before coming to UM for a PhD in epidemiology (’00). She was familiar with the region, and she networked widely to set up weeklong PHAST assignments throughout the strained public health infrastructure. “Our students will be welcomed because they’re going to work on existing projects,” Montgomery said shortly before spring break. “Folks down there are getting tired of people coming in with their own agendas.”

After crash courses in everything from HIPAA confidentiality to psychosocial issues, PHAST students met a final time in late February and discussed their motivations for joining the expedition south. “I want to let people know we haven’t forgotten them,” said one. Others wanted to join in the rebuilding, to find out what keeps people from being prepared, and to see firsthand “how the government screwed up,” as one student put it.

“They’re going to learn that relief work is hard work,” Montgomery said, remembering the frustrations she felt in her early years in public health. As a coping technique, she says she started running marathons when working with children whose mothers had AIDS.

little house in New OrleansStudents were given plane tickets, lodging and meal allowances, and advice to check the Gulf Coast weather on-line before packing.

For a week starting February 26, the most battered neighborhoods of southern Louisiana and Mississippi served as the PHAST students’ classroom. Dozens of relief agency workers and their community partners became teachers, in addition to the Office of Public Health Practice advisors.

The plan was for “service learning” to top the syllabus—meaning, work assignments would prompt transformative lessons to unfold, intensifying the value of both the service and the learning and leading to a deeper form of civic engagement. That’s just how it worked in several projects clustered along the line of wrecked homes and blue-tarped roofs from New Orleans to Biloxi:

  • Sorting donated pharmaceuticals and painting medical exam rooms in a New Orleans clinic for the uninsured led to an impromptu case study: how a health infrastructure is challenged when its poor residents are displaced, along with the medical school students and faculty who treated them.

  • Conducting interviews about met and unmet needs of storm victims led to revelations beyond the questions asked. “Our project has been to talk to various service providers,” said health behavior and health education student Megan Hoelle, who was stationed in Biloxi. “I have been absolutely blown away by the monumental task these providers are facing as they try to help the residents return to some sort of normalcy.”

  • Sweeping and trash detail in New Orleans neighborhoods revealed compelling disparities. Cleanup progressed quickly along Mardi Gras parade routes in the upscale Garden District, while time seemed to stand horribly still in the rubble-strewn neighborhoods where floodwaters lifted modest houses off their slabs and dropped them askew to rot and mold.

The balance between service and learning wasn’t perfectly proportioned in every project, however. That made for interesting lessons, as well.

For example, working days were long and relentless for students in Bogalusa, Louisiana, more than 100 miles north of New Orleans and a world away from urban problems. Hurricane-generated tornadoes had ripped through this poor community in timber country. One SPH team specialized in grunt work to reopen Campfire USA’s daycamp, so that this summer 450 area children will have a nature experience that includes lessons in nonviolence. It will also include a brook that’s babbling again, now that the SPH team has cleared brush for a swampy field to drain. “It’s basic environmental health science,” explained health management and policy student Jawad Niazi. “Standing water breeds mosquitoes.”

Another SPH team sorted a small mountain of clothes to refurbish the Salvation Army store in Bogalusa. The backlog of donations had grown while staff there focused on distributing $360,000 in cash vouchers to help residents rebuild. “It was hard at times,” said HBHE student Amy Kranitz. “But at the end of the week, I felt proud of all we’d done for the people who depend on this store.”

Both Bogalusa teams met with civic leaders for perspective on the disaster’s impact on the community. And the PHAST team doing diabetes-education outreach among crowded refugee communities in Baton Rouge learned firsthand how health and mental health afflictions pile up in stressed populations. “The needs of this community seem endless,” observed environmental health sciences student Karen Zynda, “but so do the alliances and resources.”

Political lessons dominated other students’ experience, as they gained close exposure to disparities they’d previously encountered mainly in textbooks. One PHAST team left the region with a vivid sense of the social inequities and “racial ghosts” lurking behind New Orleans’ current crisis. When overworked staff in restaurants on Magazine Street proved rarely willing to participate in the Tobacco-Free Living interviews that an eight-person PHAST team had been assigned to conduct, the students regrouped and visited the site of the 17th Street Canal levee break. They attended a seminar with Dr. Kimberley Richards of the People’s Institute for Survival and Beyond, an antiracism training organization. And they sought out people in the community who wanted to talk. One government employee, who had walked through floodwaters to the Louisiana Superdome after Katrina hit, provided a local history lesson about a city that sacrificed low-income neighborhoods by deliberately dynamiting its own levees in 1927 in a futile attempt to redirect floodwaters—then in the ensuing years, had made its disadvantaged populations disenfranchised enough to raise questions about whether explosive noises heard before the levee break in 2005 were the sounds of history repeating itself.

The group-learning endeavor was particularly meaningful for Ellen Wan, a first-year epidemiology student who hadn’t been back to her hometown since Katrina hit (she spent the holiday between semesters in Philadelphia, where her parents had temporarily relocated).

“Finally I am able to verbalize the social anxiety I’ve always had about living and growing up in this area,” she said. Having never really understood the meaning of institutional racism before, she said she now saw how “the design of a policy, process or system disproportionately affects certain races or ethnic groups more negatively than others.

“This is why New Orleans was in bad shape before Katrina, and this is why the recovery efforts are so slow.”

PHAST studentsNews media love to “peg” a story, and they went into overdrive nationwide again when the six-month anniversary of Katrina coincided with New Orleans’ controversial decision to host Mardi Gras events.

The New York Times was running daily front-page features on the region, including one on March 1, above the fold, on the Find Family National Call Center. Mardi Gras may as well have been light-years away, judging by the solemn atmosphere inside the high-security Find Family HQ in Baton Rouge that day. Here, two PHAST students helped do background identification work separating the living from the dead.

Nearly 2,000 names were still on Louisiana’s list of people missing or unaccounted for since hurricanes Katrina and Rita, down from a post-storm high of 12,000, according to the Times. With a widely publicized toll-free number, Find Family center was seeking matches between volunteered information and numerous databases, using forensic results, an eight-page Victim Identification Pro-gram form refined after September 11th, and other tools.

It’s as much like the TV hit CSI as it sounds, according to SPH students Fatema Mamou and Christiana Shoushtari, who worked at the dental records desk. They were gathering information from callers and helping public health dentist Douglas Cross answer inquiries about the missing based on salvaged dental records. Neither student had ever done this sort of work before, but they proved adept enough to be appreciated by staff who were fatigued but not deterred by long hours and hard circumstances.

Dr. Cross lost his New Orleans house, his office, and most of his clientele to the hurricane’s devastation and subsequent displacement. He has devoted himself to Find Family ever since. The missing people that dental records identify are only the dead. But connections among the living are still being made, and Mamou and Shoushtari joined in the clapping every time a bell rang out to signify that Find Family center had reunited friends or family.

“In epidemiology, we look at factors related to diseases,” said Mamou, a student in hospital and molecular epidemiology. “Here we find old age and poverty are huge risk factors. There’s a lot for epidemiologists to learn from disasters.”

Research supports Mamou’s observations. Poor people the world over are classically subjected to flood vulnerability because they live in the bottomlands, explained Columbia University geophysicist John Mutter in the March 14 New York Times. The devastation in the Lower Ninth Ward fits the model. “What’s really different about Katrina,” according to Mutter, “is that this disaster selected for the old,” with nearly two-thirds of identified victims being over the age of 60.

Shoushtari, also an SPH epidemiology student, said she successfully used the lessons in interviewing that PHAST students received from SPH lecturer Gregory Button (see Findings article). “He taught us to pause and give the person we were talking to time, and to not be afraid to repeatedly say, ‘Is there anything else?’” Using this technique, Shoushtari was able to zero in on the identity of an elderly victim 15 minutes into her telephone conversation with a relative. The dental desk sent the lead to a state database desk across the room. All were optimistic that one more name would soon be removed from the list of missing, and one more fate resolved.

Askew house in New OrleansPHAST students boarded their plane home grimy from a Saturday morning cleanup in New Orleans with Katrina Krewe. Colored T-shirts were souvenirs from various work crews, and one briefcase bulged with Biloxi service-provider interviews awaiting transcription. Reflections and new plans abounded, in addition to images captured for the long haul—with cameras or just eyes.

Health management and policy student Shawn Kimmel said that he became convinced during the trip that the current U.S. framework for emergency response “is inadequate, and based on a command and control top-down mode of response that doesn’t allow communities to use resources effectively.” On the communal “PHAST Break” blog set up for students, he posted this challenge:

“What can the PHAST students of the School of Public Health do now to begin to build sustainable working relationships upon our one-week experience in the Gulf Coast?”

These same questions concern Associate Dean for Practice Matthew Boulton, who is eager to expand partnerships the PHAST team established on the Gulf Coast and even develop new ones. On the frontburner is a commitment to create surveys on stress for struggling New Orleans clinics.

“The School of Public Health began a transformation when it started this office,” Boulton says, noting that collaboration between academic institutions and the practice community can yield tremendous benefits via applied research. At a PHAST debriefing meeting after the trip, he recalled how his own “call to service” had derailed his intended career as an academic clinician in a university hospital and led him instead to spend seven years working in public health clinics in Detroit–Wayne County.

“The only thing we knew sending you down there was that you’d experience public health practice,” Boulton told PHAST students. “It’s up to you to decide what to do now.”

Some students said they planned to ask professors if they could write real grants for Gulf Coast groups “instead of fake ones” for class assignments. They also talked about raising funds and awareness about the area’s needs. Many students felt frustrated as they tried to resume their courseload while still processing their experiences, still thinking of thousands of families living in flimsy white trailers disparagingly known as “FEMA mansions,” with the next hurricane season fast approaching and no real solutions for the area in sight.

“My heart feels burdened by what I saw,” said epidemiology student Flojaune Griffin.

“I know we’ll all take this experience into our careers in different ways,” said Sumeet Goel, an epidemiology student who will enter medical school in the fall. “If we can’t help New Orleans, we can help other places.”

Chinwe Okehi changed her career plans and will enter a one-year nursing program after receiving her MPH in health management and policy. She hopes to return to New Orleans, where she knows she can fill a need. She said that while she and future physician Goel worked side-by-side at the St. Thomas clinic, they came to agreement on one principle: “You have to be an idealist and be able to imagine the impossible. However, you must also be a realist and be able to recognize incremental progress.”

In the hard-hit Lower Ninth Ward of New Orleans that nearly all PHAST students visited, some in literally the last hours before they boarded the plane home, “progress” began harshly two days after the students left when bulldozers moved in. In the first demolitions of flooded homes since Hurricane Katrina, the area is being cleared of debris (12.5 million cubic yards of it, the Army Corps of Engineers predicts), along with human remains found in some of the houses.

The cleanup is scheduled to take a year. Many PHAST students will be real-world practitioners by then. Their energy and new ideas will fuel many reaches of public health.

Members of the inaugural PHAST team seemed all to agree that they came back from spring break with a solemn responsibility to “bear witness” and carry on for someone they’d met, like the man cleaning his parents’ water-damaged home between his tours of duty in Iraq; the woman who salvaged only dishes and family photos from the home she had saved for years to buy; and the young man in dingy jeans who dozed for hours in a temporary church clinic, unaware of the toddler climbing on and off his lap, until he silenced the room by shouting in response to an intake nurse’s question, “Of course I feel frustrated!”

Even amid the lingering consequences of the most concentrated public health crisis this country has recently encountered, HBHE student Ericka Bolinger said she could discern encouraging signs. “I want to bottle what fuels these people and bring it to everyone I know. I can only call it humanity—the most important component of ‘community’ and, for me, the reason there is hope.”

By Mary Beth Lewis, web editor for SPH, who spent several days on the Gulf Coast with the SPH students. Photos are by Lewis and SPH students and staff.

Send correspondence about this or any Findings article to the editor at sph.findings@umich.edu. You will be contacted if your letter is considered for publication.

How SPH Students Helped

Bogalusa, Louisiana:
--Salvation Army: Restocked store transitioning back from relief to retail; consulted with community leaders on needs assessment.

--Campfire USA: Removed brush and environmental hazards, restored drainage, and rebuilt structures at tornado-wracked daycamp that teaches nature education and nonviolence.

Biloxi, Mississippi:
--Hands On Network: Completed daily crew assignments supporting social service professionals, assisting in clinics, and working on mold education.

--Delta State University Institute for Community-Based Research: Conducted and transcribed qualitative interviews with service providers (national, local, faith-based, governmental, etc.) on their hurricane relief challenges, successes, collaborations, and recommendations.

Baton Rouge, Louisiana:
--
American Diabetes Association: Conducted outreach education and recruited staff support for summer camp after merger with New Orleans chapter negatively affected funding.

--Find Family National Call Center (since renamed Louisiana Family Assistance): Supported lone dentist working to make matches and close missing-person reports using identifying information from dental records.

New Orleans, Louisiana:
--
Bucket Brigade: Analyzed environmental data on post-storm toxicity in St. Bernard Parish; produced community education flier entitled “ABC’s of the Murphy Oil Spill” for neighborhood distribution; volunteered in off-hours at soup kitchen.

--St. Thomas Clinic: Renovated exam rooms in water-damaged and displacement-stressed clinic for the uninsured; sorted donated pharmaceuticals (many asthma-related, as the region deals with the growing problem of “Katrina cough”).

--Tobacco-Free Living: Interviewed restaurateurs on smoke-free atti tudes; consulted with Louisiana Public Health Institute on data analysis and larger local issues resulting from the storm.

--Bring New Orleans Back: Completed various assignments with volunteer group called Katrina Krewe to promote cleaner public areas.

Map of how PHAST students helped


Larger version of map (new window)