Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do

Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do

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by Irwin Redlener

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This important book by one of our leading experts on disaster preparedness offers a compelling narrative about our nation’s inability to properly plan for large-scale disasters and proposes changes that can still be made to assure the safety of its citizens.

Five years after 9/11 and one year after Hurricane Katrina, it is painfully clear that the


This important book by one of our leading experts on disaster preparedness offers a compelling narrative about our nation’s inability to properly plan for large-scale disasters and proposes changes that can still be made to assure the safety of its citizens.

Five years after 9/11 and one year after Hurricane Katrina, it is painfully clear that the government’s emergency response capacity is plagued by incompetence and a paralyzing bureaucracy. Irwin Redlener, who founded and directs the National Center for Disaster Preparedness, brings his years of experience with disasters and health care crises, national and international, to an incisive analysis of why our health care system, our infrastructure, and our overall approach to disaster readiness have left the nation vulnerable, virtually unable to respond effectively to catastrophic events. He has had frank, and sometimes shocking, conversations about the failure of systems during and after disasters with a broad spectrum of people—from hospital workers and FEMA officials to Washington policy makers and military leaders. And he also analyzes the role of nongovernmental organizations, such as the American Red Cross in the aftermath of Katrina.

Redlener points out how a government with a track record of over-the-top cronyism and a stunning disregard for accountability has spent billions on “random acts of preparedness,” with very little to show for it—other than an ever-growing bureaucracy. As a doctor, Redlener is especially concerned about America’s increasingly dysfunctional and expensive health care system, incapable of handling a large-scale public health emergency, such as pandemic flu or widespread bioterrorism. And he also looks at the serious problem of a disengaged, uninformed citizenry—one of the most important obstacles to assuring optimal readiness for any major crisis.

Redlener describes five natural and man-made disaster scenarios as a way to imagine what we might face, what our current systems would and would not prepare us for, and what would constitute optimal planning—for government and the public—in each situation. To see what could be learned from others, he points up some of the more effective ways countries in Europe, Asia, and the Middle East have dealt with various disasters. And he concludes with a real prescription: a nine-point proposal for how America can be better prepared as well as an addendum of what citizens themselves can do.

An essential book for our time, Americans at Risk is a devastating and realistic account of where we stand today.

From the Hardcover edition.

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Knopf Doubleday Publishing Group
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Help on Hold, Lives at Stake

Almost a month to the day following the devastating landfall of Hurricane Katrina, I made my third of many trips to the Gulf region of Mississippi. I was there to meet with members of the Operation Assist medical relief team who had been working nonstop to treat the unending flow of displaced and disoriented people who needed medical care. Operation Assist is the collaboration singer-songwriter Paul Simon and I organized between the Children's Health Fund and Columbia University's Mailman School of Public Health to bring emergency relief to people who had survived the storm. On the way from the Biloxi-Gulfport airport, I asked to be driven by some areas that had been particularly hard-hit. I had been to these neighborhoods before but was anxious to see what progress had been made.

We drove down I-90, heading into D'Iberville, a community of some 7,500 citizens, with a Wal-Mart, a Winn-Dixie supermarket, and a couple of dollar stores. The weather was balmy and slightly overcast. It felt like a normal day in a typical small southern town—until we looked out the window. In some neighborhoods, whole blocks had been flattened. Storefronts had been ripped off the buildings and overhead signs were left dangling from one corner of the store or had been blown away entirely. There were about 1,830 homes in D'Iberville before Katrina came crashing through town. In Katrina's wake some 1,250 homes had sustained wind or water damage. Nearly 400 had been destroyed.

In 2000, the median income for residents of D'Iberville was about $34,000 a year, about 20 percent under the national average of about $42,000. People were more or less middle class and mostly white, with fewer than one in five residents African American or Vietnamese. Many families were living at or below the poverty level; few had substantial investments or savings—in other words, little or no financial safety net was readily available. The storm damage, the disruption of the social networks, and vastly diminished public services were taking a toll on the community.

On my first visit, just days after the storm, I was overwhelmed by the extent of the damage, and perplexed and infuriated by so little evidence of any organized governmental response—or even presence. Now, just four weeks later, it seemed that nothing much had changed.

I saw high in the still standing trees of a destroyed middle-class community what seemed to be some toys and children's shredded clothes. Sifting through the wreckage of what had been a home, a family was looking for something to salvage. A few crews of Central American workers were beginning to reconstruct a roof or a house here and there, but in general, time seemed to have stopped altogether.

In a low-income housing project, children surrounded us and clamored for the bottled water and granola bars we had brought. I asked a mother if FEMA (the Federal Emergency Management Agency) or the Red Cross had been there. She said, "Not here. We have to send somebody out every day to find the closest Red Cross center, where we can get water for the community. It's usually a ten- or fifteen-minute drive from here. And we still don't have electricity or fresh water." When I asked if the children were going to school, she said, "Some days."

This visit and every subsequent one to the Gulf reinforced what we have now learned: the emergency response to the hurricane's damage in the Gulf was woefully, painfully insufficient. And as bad as things were in Mississippi, the situation was even worse in neighboring Louisiana, where, even six months after the storm, the news remained disheartening, an endless stream of unanticipated consequences and unresolved problems. Well beyond the acute emergency phase of the initial response, the services and relief efforts seem to be struggling as much as ever in New Orleans and throughout Louisiana. Information is faulty and incomplete. Issues that should have been thought about long before the disaster struck have become intractable barriers to meeting the needs of people who have been through a hellish combination of natural violence and bureaucratic blunders.

Gregory Kutz, the Government Accountability Office auditor who led an investigation into use of federal funds for relief, testified on February 14, 2006, before the Senate Committee on Homeland Security and Governmental Affairs that funds wasted in the Katrina aftermath will certainly amount to millions of dollars, and "it could be tens or hundreds of millions of dollars." And an audit by the Department of Homeland Security (DHS), led by Inspector General Richard L. Skinner and released on April 14, 2006, reaffirmed the chaotic squandering of taxpayer funds. No example better typifies this waste than the FEMA-administered debit card program that gave evacuees cards with $2,000 balances intended to purchase emergency provisions. The debit cards came with no oversight and no guidelines. As a result, the cards were used to purchase frivolous items unrelated to evacuation needs including adult entertainment, gambling, a $450 tattoo, and a diamond engagement ring for $1,100. Moreover, qualification for the cards required very little verification. Consequently, 900,000 of the 2.5 million cards distributed went to people with fake addresses and duplicate or fake Social Security numbers. A total of $24 million worth of cards were given out, with little hope that the total will ever be accounted for.

The basic challenge was finding housing for the estimated 300,000 families whose homes Katrina wrecked. As I write, the hard-hit neighborhoods of New Orleans remain virtually unchanged since the day after the floodwaters retreated. The 300,000 homes destroyed or made uninhabitable represent at least $67 billion in losses. This devastation surpasses the combined damage from the four largest hurricanes in 2004 (Charley, Francis, Ivan, and Jeanne), which ruined 85,000 homes. There are still blocks and blocks of irreversibly damaged houses, their interior walls covered with black mold, and thousands of metric tons of debris and garbage still filling the streets. So much of the mess remains frozen in time that a thriving new business has emerged: entrepreneurs, like the Gray Line bus tour that charges $35 a head, have been taking gawking tourists to see what Mother Nature has wrought and human beings cannot seem to fix.

At the very time when the federal government has begun to cut off funds supporting displaced families being sheltered in hotels throughout—and beyond—Louisiana, thousands of FEMA-purchased mobile homes languish in fields and empty lots in Florida and Arkansas, undelivered and unused. This fact came out in a CNN interview with a FEMA official in Arkansas. The backdrop was the surreal image of a sea of 11,000 empty, brand new white mobile homes.

The reporter asked, "Why aren't these trailers being used to house evacuees in Louisiana? Why are they still here?" The FEMA official replied, "It's hard to find places to put them in Louisiana where the right hookups—like electricity and water—are available." Later in the interview, the FEMA official, referring to New Orleans, offered, "Mobile homes can't be put in floodplains."

The need for temporary housing is still greatest in the neighborhoods that have been evacuated. Workers are needed to clean up and rebuild New Orleans. And employees are needed to restart the businesses struggling to regain their footing. But for workers to return, their families have to have somewhere to live and to go back to school.

Only 2,700 of the 25,000 perfectly adequate trailers used for temporary housing and purchased for more than $850 million had been installed by mid-February, 2006; nearly half of them were sitting in mud in Hope, Arkansas, waiting to be shipped and put to use. Tax dollars are paying for this travesty of a recovery program in a part of the country that Congress is trying hard to forget. There was at least one major military base in Louisiana that might have been a good medium-term housing solution; ironically, it was closed in 1992 through the Base Realignment and Closure (BRAC) process. England Air Force Base in Alexandria, Louisiana, a few hours north of New Orleans, was temporarily used to house about two hundred evacuees. Although a mixed-use property, surely it could have been considered as a location for trailers or other temporary housing. Yet, through February 2006, the government spent $249 million commissioning four cruise ships to provide more than 8,000 cabins for this purpose. The cost of some $5,100 per month per cabin was six times the going rate to rent a two-bedroom apartment. I am still wondering how this makes sense.

The truth is, we weren't prepared to prevent the flooding of New Orleans because we didn't make sure that the levees at the 17th Street Canal and Industrial Canal and along canals extending south from Lake Pontchartrain would stand up to a greater than category 3 hurricane. While the Bush administration's proposed FY 2004 budget included $297 million for civil works projects in the U.S. Army Corps of Engineers' New Orleans district, Congress approved only $40 million, of which $3 million was slated for New Orleans's East Bank Hurricane Levee Project. But the U.S. Army Corps of Engineers project manager, Al Naomi, reported that $11 million was needed. Congress ultimately approved $5.5 million, but because of the project's reduced budget, work on the levee system was halted for the first time in thirty-seven years. To correct this deficit, we should have mounted an organized emergency response but stunning governmental incompetence and lack of coordination got in the way on many levels. And we are unprepared to recover because everywhere you turn in the Gulf there are overwhelming needs, too few resources, unclear lines of authority and responsibility, and insufficient on-the-ground innovation and leadership.

In late January 2006, Senator Richard Burr of North Carolina asked me to meet with him at his office in the Dirksen Senate Office Building at the Capitol. This meeting was one of a series he had scheduled with experts to explore a range of ideas about what was needed to prepare specifically for a bioterror attack and, more generally, for disaster response. Dr. Robert Kadlec, a former White House expert on bioterrorism and counterintelligence, is staff director of the Senate Subcommittee on Bioterrorism. He had arranged the meeting and told me to be prepared for a frank and open discussion.

The conversation was focused and honest, and the senator listened carefully. One of my main points was how unprepared the U.S. health-care system was to respond to or recover from a major disaster. He responded knowledgeably on the topic and we spoke at length about the chronic fragility of the public health system.

In the senator's office were two other people: Jennifer Bryning, a very capable senior staff member, and Dr. Kathy Hebert. Dr. Hebert had started working in Burr's office as a special policy adviser just a few weeks earlier. Until that time she was in charge of the cardiology clinics at Charity Hospital in New Orleans. The venerable Charity was one of the nation's best-known health-care facilities for the poor. Because more than 25 percent of the New Orleans population was classified as poor, the need for a hospital that took all comers, regardless of income or insurance status, could not have been greater. More than half of the evacuees initially in shelters—some 270,000 people—did not have health insurance; for most of them, Charity Hospital had been their primary place for medical care. Charity took an enormous hit during and after Katrina and the floods that followed. Now the facility is shut down, its fate uncertain.

When the session ended, Kathy Hebert and I walked out to the outer office. As we stood there, in front of the receptionist's desk, Kathy said, "Irwin, thanks for coming. I'm sure this will be helpful. But, I am very worried about my patients." I asked what she meant.

"On August 28th, just before Katrina hit, I had hundreds of patients enrolled in my cardiology clinics at Charity. And my colleagues in other fields were caring for lots of people with cancer, kidney disease, and chronic mental health conditions. Once the storm hit, and Charity went out of commission," she said, "we lost track of heart patients that needed catheterization and other lifesaving procedures. We are now trying to make sure that the kidney patients can get to an alternative dialysis center and that the psych patients can get their medications."

So where are these patients, I asked, knowing that in New Orleans alone, no more than 100,000 of the city's former 480,000 residents had returned. The remainder were scattered in shelters or relocated all over Louisiana and throughout another thirty-five or forty host states.

Kathy responded, "Irwin, I have no idea where my patients are." I asked her what she thought could be happening to her cardiology patients, especially the ones that needed critical medications or procedures.

Dr. Hebert paused, looking at me. Her eyes filled with tears. The receptionist was trying not to look at us, but had been paying rapt attention to this intense conversation. "My patients?" she asked. "They're dying. I am just so afraid that they're showing up in whatever emergency rooms are open, out of meds and out of time."

I tried to come to grips with what this young doctor was actually saying. I know I mumbled something about my willingness to help sort this out—and I did speak with Louisiana health officials. I also asked our Operation Assist medical teams on the ground to keep an eye out for patients who had been at Charity. By March, some of Kathy's patients had shown up in the few medical facilities that were still open for business; others had been evacuated to nearby states and would be there for the long haul. But many were not found.

As I thought about what Kathy's situation really meant, I appreciated anew how badly things were going in the so-called recovery of the Gulf in Katrina's aftermath. At the time, Kathy Hebert could not have known the fates of thousands of evacuees with chronic illnesses who had been rushed from New Orleans and now found themselves in Texas, Florida, Tennessee, and dozens of other states. Like refugees fleeing war zones, these patients were arriving in their "temporary" communities without medical records or the ability to contact their physicians. On the receiving end of this exodus, Dr. Joe Mirro at the renowned St. Jude Children's Research Hospital in Memphis noted, "We received nearly 100 pediatric cancer patients from New Orleans. Our staff tried as best they could to figure out what medications these kids were on, scrambling to look up treatment protocols and find the doctors who had been caring for them before the evacuation. Sometimes we found the information we needed; most of the time we just did the best we could."

From the Hardcover edition.

Meet the Author

Dr. Irwin Redlener is the director of the National Center for Disaster Preparedness at Columbia University’s Mailman School of Public Health and president of the Children's Health Fund, which he cofounded with singer Paul Simon. He has three children and lives with his wife in New York City.

From the Hardcover edition.

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