EPIDEMIOLOGICAL ASPECTS OF HURRICANE CAMILLE

Morbidity in the Hurricane Shelter Populations of

Plaquemines Parish, Louisiana.

Adapted from presentation at the Epidemiology Session
Fifth Joint Meeting, Clinical Society and Commissioned Officers Association, Washington, D. C., April 3, 1970.

Kenneth C. Schneider, MD, MPH
Sr. Surgeon. USPHS

Tulane University School of
Public Health and Tropical Medicine
New Orleans, Louisiana

Epilogue: Remembering Hurricane Camille

THE STORM

On Sunday evening, August 17, 1969, a small, fierce hurricane skirted the mouth of the Mississippi River and, at 10 PM, thrust inland on the Mississippi Gulf Coast .

Camille, with an unusually compact eye of 5 miles diameter, was the most intense hurricane ever to enter the United States mainland. Winds exceeding 200 miles per hour, and an extremely low central pressure, combined to generate the highest tides ever recorded on the Gulf Coast. A wall of water, up to 30 feet high, surged through the populous Bay St. Louis - Pass Christian Area of Mississippi.

Houses that had withstood many previous storms were reduced to piles of rubble by the ravages of wind and water. In many cases, all that remained of homes and businesses were the concrete foundation slabs.

This was the unusual aspect of Hurricane Camille — widespread destruction of homes caused large numbers of refugees to remain homeless for long periods of time.
Of the 284 known deaths, only 5 occurred in Louisiana, 3 of these in Plaquemines Parish (County). This is the Parish that occupies both banks of the final 80 miles of the Mississippi River, just below New Orleans. Here, early evacuation of nearly all the residents of the southernmost low-lying areas undoubtedly averted hundreds of casualties. On the West Bank of the river, in the area south of Empire, an area of 11,000 population, destruction was virtually total. In this area alone, over 3000 homes were either completely destroyed or sustained major damage. Flood waters, up to 17 feet deep, persisted for nearly a week after the storm. In Buras, two high schools, later to be used as shelters, were flooded up to the second floor level.

During the first month after the storm, refugees, on the West Bank of Plaquemines Parish, accumulated nearly 30,000 person-days of exposure to the peculiar risks of life in the hurricane shelters.

MEDICAL RESPONSE

Initially as a volunteer, then under assignment with the State and Parish health departments, I provided physician services in the shelters during the first 6 weeks after the storm. The hurricane hit just as I was to begin a "rural health" rotation with the Louisiana State Health Department, part of my assignment as a Resident in General Preventive Medicine. The clinical experience was not very dramatic. Hurricane shelter medical practice was like busy general practice. Minor conditions, such as fire ant bites and skin infections, prevailed. As the days passed, there were fairly rapid changes in the assortment of conditions treated, Were these changes part of predictable trends? We expected epidemics, but with the work divided between many volunteer physicians and nurses, we weren't sure that we could even detect an epidemic early enough to take action.

Donations of medical supplies were often inappropriate. Physicians' samples, though welcomed, presented problems of sorting, storage and outdated drugs. Donated hearing aid batteries far exceeded needs (I think we might have been able to light up the Capitol dome!). Shoes were ill-fitting, often because donors forgot to tie them together in pairs.

The Tulane School of Public Health residency curriculum required me to document and evaluate my experience. The objectives of my hurricane shelter morbidity study were to:

Describe the shelter population
Identify persons who obtained medical services
Describe their complaints and the medical conditions treated.

Data was collected from Red Cross and Plaquemines Parish Health Department records. Medical information was tabulated retrospectively from patient records, which were maintained in the form of a line listing in each shelter.

THE SHELTERS

There were 6 racially segregated shelters, which served 4 relatively distinct populations. Three of the shelters were located in the northern part of the Parish, in Belle Chasse (just south of New Orleans). A fourth opened 3 days after the storm, in Port Sulphur. After flood waters had receded, and utilities were restored, 2 weeks after the storm, all of the refugees were transported to the 5th and 6th shelters, in Buras.

SHELTER	Maximum Population (approximate)	Opening Date	Closing Date	Days Open
US Naval Air Station, Belle Chasse	2000	16 August	20 August	4
Belle Chasse High School	1700	16 August	1 September	15
Scottville High School	800	16 August	1 September	15
Port Sulphur High School	105	20 August	31 August	11
Buras High School	400	1 September	11 November	71
Sunrise High School	126	1 September	November 30 +	90+

The largest shelter population subgroup consisted of whites, from all areas of the Parish, who were evacuated during the 24 hours before the storm, and occupied the Belle Chasse High School. As many as 1700 may have gathered there on the evening of the storm, but those who lived nearby returned home quite promptly. Others

exited during the next 2 weeks, as their homes were repaired. On September 1st, the 15th post-disaster day, the 400 remaining residents were transported to Buras High School. By now they represented a fairly stable population, of persons whose homes were destroyed or sustained major damage.

The other major population subgroup, initially numbering 500 to 700, consisted of blacks, mostly from the southern part of the Parish, who were evacuated quite early— many, on the day before the storm. They occupied Scottville High School, also in Belle Chasse. They exited at a somewhat slower rate than did the whites. Again, they formed a stable population, numbering about 110, after the move to Sunrise High School, in Buras.

A third, and only temporarily the largest subgroup, consisted of blacks who left their homes late on the day of the storm — some, even as the storm was gaining force. Finding the Scottville shelter crowded, 2000 overflowed into the Naval Air Station, Belle Chasse. Most were able to return to nearby homes immediately, but a few went on to occupy the Scottville shelter, helping to account for the increase in the Scottville population during the first 3 days after the storm.

A fourth small group, of whites, was housed in the Port Sulphur High School, beginning on the third post-disaster day.

	SHELTER OCCUPANCY, Person-days; PDD = Post-disaster Day
SHELTER POPULATIONS (Predominant Race)	1st Week PDD 0-7	2nd Week PDD 8-14	3rd Week PDD 15-21	4th Week PDD 22-28	1st Month PDD 0-28
Belle Chasse-Buras High Schools (White)	10750	4250	2735	2651	20386
Scottville-Sunrise High Schools (Black)	4624	2220	889	815	8548
Port Sulphur High School (White)	440	556	0	0	996
Belle Chasse Naval Air Station (Black)*	na	na	na	na	na
TOTAL	15814	7026	3624	3466	29930
Post-Disaster Day (PDD) #0 = August 17, 1969 -- Note that first week includes 8 days; *na = occupancy not available

CHARACTERISTICS OF WHITE AND BLACK SHELTER POPULATIONS

I will confine most of my remarks to the two major subgroups of shelter residents, one white and the other black. They allow some comparisons because both occupied the separate shelters in Belle Chasse at the same time, both moved down to Buras on the same day, and both formed relatively stable populations during the 3rd and 4th weeks after the storm.

There were other similarities between the groups.

Food was served cafeteria style, using the high school equipment. Meals, as may be expected, were monotonous but balanced and adequate in quantity. Infant formula was dispensed from special “formula rooms.”
Their sleeping accommodations consisted of canvas army cots without mattresses, arranged in classrooms. Cribs for infants were scarce, and mothers often stood watch over sleeping children. Relatives tended to seek out the same room, but unrelated families often occupied classrooms together.
The degree of crowding was about the same in each group — at worst, an average of 33 and 29 persons per room in the white and black groups respectively. By the 14th post-disaster day (PDD), these averages had decreased to 10 and 12 persons per room respectively. Salvaged household goods and other personal belongings were placed in makeshift receptacles and stored under cots and along the perimeters of rooms. There was no air conditioning. Daytime temperature highs varied between 86o and 91o F, and evening temperatures dipped as low as 66o F. Pets were not allowed in the building, but many dogs were tied up just outside their owners’ windows.
Toilet and hand washing facilities, and general sanitation, were adequate. There was a lack of organized recreation for both groups. Outside windows were not screened.
In each shelter, a medical aid station, staffed around the clock by one or more registered nurses, was maintained. Physicians made daily visits and were available on call for emergencies.

The groups differed in the major attribute of race. There was the impression of another difference between the groups. Whites appeared to be more actively engaged in recovery of losses, through salvage operations or hasty insurance claims. They stored a greater number of bulky objects such as appliances, and also had more pets. It was not unusual, during the first two weeks, to find blacks who had not yet visited their damaged properties.

Again, no actual measurements were taken but blacks appeared to have less geographic mobility than whites. They appeared less able to visit their homes during the first two weeks after the storm. This may have been due to the fact that they owned fewer automobiles, or fewer insured homes, or had fewer valuable belongings worth salvaging. They may have been simply reluctant to apply for permits to pass the police barricades.

In any event, after both populations moved to the two shelters in Buras, access to home appeared no longer to be a differentiating factor.

DEMAND FOR MEDICAL AID

At least one nurse was on duty at each shelter at all times. The Plaquemines Parish Health Officer provided most of the physician services, holding sick call each morning that was announced over the school loudspeakers. First aid equipment on hand was adequate for the traumatic injuries that arose. Experience with previous storms had taught the Parish Health Department staff to expect a broader range of illnesses.

Individual patient records were not universally implemented. Instead, each shift of nurses kept a running log of cases on a standard (now obsolete) American Red Cross form ARC 2077A. This form included, in addition to identifying and demographic information, and space for complaints, treatment, and often a diagnosis or physical findings. Each shelter also developed supplemental lists of persons with certain chronic conditions, such as diabetes, epilepsy, heart disease and pregnency, and individual records were often manitained in these cases.

As indicated by the figure to the left, demand was greatest during the 3rd to 9th days after the storm. During this time, about 200 people were treated daily. After the move to Buras, the number treated averaged about 80 per day. (Click on images for enlarged view).

The figure to the right illustrates the overall rates (per 100 shelter occupants) of new visits and revisits for medical treatment of any kind.

The daily rate of visits for medical aid in the white shelter population (shown at the left) is seen to climb quite steadily during the first two weeks. If revisits for the same or related complaint are subtracted from total visits, the "new visit" rate, shown in the right part of each graph, averaged about 10 per hundred during the 2nd two weeks. In the black shelter population (at the right), the rate of visits to the medical aid stations was much greater. Subtracting the revisits, there was a peak of about 30 new visits per hundred during the third week after the storm. Nearly one-third of the entire shelter population appeared for treatment on the 19th day!

The cause for each recorded visit was coded utilizing a simple key that classified the reasons into one of six major categories that included 19 sub-classes as well as 6 qualifiers ( revisit for same or related condition, refill only, referred to outside physician or hospital, drug or medication reaction, "complications of," and "severe" injuries requiring suturs, splinting, etc). The reasons were then aggregated logically as shown in the following table:

REASONS FOR VISITS TO MEDICAL AID STATIONS, FIRST MONTH (PDD 0-28)
CONDITION	Belle Chasse-Buras (White)		Scottville-Sunrise (Black)
CONDITION	New Visits	Revisits	New Visits	Revisits
Acute Open Injuries	378	38	100	6
Acute Closed Injuries	56	4	12	2
Skin & Wound Infections	170	71	131	61
ENT & Resp Infections	251	23	198	119
Diarrhea	82	15	14	19
Non-Diarrhea Digestive	90	5	42	1
Headache, Nerves, etc.	131	17	91	6
Chronic Non-Diabetic	53	32	51	22
Diabetic Conditions	20	70	21	6
Allergic and Non-Inf Skin	68	2	31	1
Obstetric Conditions	10	3	2	7
Tetanus Shot Only	43	0	3	0
Birth Control Rx Only	14	0	3	0
Other Miscellaneous	173	28	72	7
No Diagnosis or Rx Recorded	174	46	28	8

Four conditions were judged to be of greatest epidemiological significance:

Open injuries
Ear, nose, throat and respiratory infections
Skin and wound infections
Diarrhea.

PATTERNS OF INJURIES AND ILLNESSES

Taken together, these four sets of diagnoses accounted for over 50% of all the conditions encountered. Injuries, especially common during the first two weeks, were generally minor abrasions, nail punctures and glass cuts. They were usually sustained during salvage or repair activities while visiting damaged properties. Respiratory infections increased during the second week. There were a good number of skin infections that appeared to follow skin injuries.

Visits for Selected Conditions, 2nd 2 Weeks

During the 3rd and 4th weeks, injuries were fairly common, and skin infections had become quite uncommon. Some 20 stool samples from patients with diarrhea were negative for enteric pathogens. Beta-hemolytic streptococci were recovered in only 12 of 180 throat cultures. These charts reflect the overall demand for medical aid for the four conditions during the frrst 2 weeks (to the left) and the second 2 weeks (to the right).

A comparison of the rates of these four conditions between the white and black shelter populations reveals an interesting difference in their patterns of occurrence.

In the white shelter population (displayed to the left), respiratory infections appeared in two waves, with peaks around the llth and 24th days. Injuries exhibited two levels of occurrence. During the first 2 weeks after the storm, injuries occurred in about 1.5% of the population each day. During the 2nd two weeks, they reached a plateau at about twice that level. Remember that the move to Buras brought the population right into the area of destruction. Skin and wound infections were distributed rather evenly in the white population. Diarrhea incidence was greatest during the second and third weeks.

The black population (chart on the left) had quite a different pattern of illness. Initially, the respiratory infection rate increased in the same manner as in the whites, but the epidemic continued, to peak later, at about the l?th day. A. normal, rather than a bimodal distribution, was assumed. Open injuries occurred at a very low rate during the first two weeks. After the move to Buras, injuries increased greatly, up to about 8 daily per 100 shelter occupants. By the end of the 3rd week they had fallen off, but already the cumulative rate of injuries equaled that of the white population. (Perhaps the blacks made up for their lack of access to their properties, engaging in somewhat more frantic salvage operations, once they were transported to Buras). Skin and wound infections in blacks occurred at about twice the rate of that in the white population, and tended to be grouped earlier. Diarrhea was rare, with most cases appearing during the 3rd week.

Finally, there was an interesting difference in the pattern of so-called "functional" complaints between the two groups. Functional complaints are defined as non-diarrheal gastrointestinal complaints, nervousness, insomnia, headache, psychiatric diagnoses, and the like. As illustrated in the graph to the left, the black population {the broken line} considerably exceeded the white population in the cumulative rate of these conditions. This difference was almost entirely due to an excess of functional complaints in blacks, during the second and third weeks. One might speculate whether these differing patterns result from differences in the stresses experienced by each group.

In summary, there was a progressive increase in the utilization of medical services in both shelter populations during the first two weeks after the storm. There were differences in their patterns of incidence of respiratory infections, open injuries, and functional conditions. Factors other than race may have accounted for these differences. Geographic mobility and access to damaged homes appeared to correlate positively with the incidence of open injuries.

Epilogue: Remembering Hurricane Camille

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