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Health Distress & Hurricane Katrina: Why Race and Age Matter

Catherine Morrisey Masters Candidate, Social Justice & Human Rights Arizona State University Tempe, Arizona

Abstract
This study focuses on the physical health status of New Orleans residents both before and after Hurricane Katrina. This paper strives to: (1) Understand the demographic details regarding New Orleans residents; (2) determine if there are significant racial, gender and age differences in health outcomes of New Orleans residents; and (3) to evaluate theoretical frameworks regarding disaster responses and health outcomes. The Displaced New Orleans Residents Pilot Study (DNOPS) survey collected data via telephone and paper mail in 2008 from a random sample of New Orleans residents and their household members. The data shows significant racial and age differences in health outcomes, and an increased risk to females health after the Hurricane. In a series of logistic analysis, race and age (ages 1-17 and ages 18-29) were determining factors in health outcomes both before and after the Hurricane. Women were at a higher risk of developing poor health outcomes after the Hurricane, though the rates were not high enough to be considered significant. The theoretical and methodological implications of these findings are discussed.

Introduction & Background Information


The winds of Hurricane Katrina hit New Orleans at 125 mph as it made landfall on August 29, 2005. As a category 3 storm, it managed to break the citys levee system within a matter of hours, causing massive flooding throughout the city. When survivors emerged after the hurricane, what remained of their city rested beneath 10-20 feet of standing water, and the damage went as far as 150 miles inland (Adeola 2009). Not surprisingly, the residents of New Orleans were displaced, some for over 12 months, and were dependent on outside aid from the local and federal government, non-profits, church groups and volunteers to stay alive (Adeola 2009). The extended displacement is partly blamed on the Federal government for being so slow to declare New Orleans and other highly impacted coastal communities a Federal disaster area. This would have freed up millions of dollars in funding to be allocated to various organizations with more immediate access to residents needing it the most. Local governments and the inability to reach citizens before and after the hurricane, as well as the lack of planning and natural disaster preparation, are also cited as issues that only intensified already complicated issues (Cooper 2007). Accusations that poverty played a role in who was able to evacuate from the city to safer regions of the state quickly surfaced. New Orleans had been notoriously poor for decades before Hurricane Katrina struck, and nearly 23% of the citys population received government assistance and fell below the national poverty line, a rate 10 percentage points higher than the national average (Sastry, 2009). Blacks in New Orleans struggled to overcome a poverty rate of 35%, which was the highest among large cities in the United States (Sastry 2009). New reports showed crowded highways filled with

residents fleeing the city before the storm struck, but for residents who did not have access to a car or other means of transportation, the options were to relocate to the Superdome or stay in ones own home. Most bodies recovered after the hurricane were those of residents who stayed in their own homes, not knowing the citys levee system would fail only hours after the storm hit (Adeola 2009). Bodies were also most likely to be found in attics of the citys old homes, suggesting residents sought out higher places as floodwaters increased. Health and Natural Disasters: A Literature Review Considerable amounts of literature exist documenting the health issues facing New Orleans residents after Hurricane Katrina. A vast majority of this literature, however, focuses on the psychological health of residents, and emphasizes the high rates of PTSD and depression following major natural disasters (American Psychological Association 1994; Freedy et al. 1992; Suar et al. 2002; Kumar et al. 2007; Schultz et al. 2005). Less emphasis is given to the ramifications of such events on ones physical health (for example: high blood pressure, malnourishment or obesity, or infant and maternal mortality). Citing the notion that survivors of natural disasters are impacted in ways that affect their abilities to cope and adapt, therefore disrupting their sense of safety and ability to control their surroundings, academic literature largely reasserts the conclusion that major disasters negatively impact ones psychological health. The National Co-morbidity Survey conducted by Kessler and colleagues (2006) found that, post-Katrina respondents had significantly higher estimated prevalence of mental illness than pre-Katrina subjects. In a government survey of 800 Katrina survivors PTSD increased from 16% in 2006 to 21% in 2007 (Kessler et al. 2006; Adeola

2009). Within four months of the hurricane, at least seven residents had reportedly committed suicide, and the overall suicide rate of the city tripled within 10 months of Katrina (Nossiter 2005; Kessler et al. 2006; Saulny 2006). Literature also asserts that high rates of substance abuse, domestic violence, emotional problems, anxiety and depression, in addition to physical health problems, are common in survivors of natural disasters and terrorist attacks (Boscarino 2004). Academics suggest that New Orleans residents were exposed to more extensive trauma than other Gulf Coast communities affected by the Katrina, as the city was too poor to clean up the damage alone, yet faced numerous bureaucratic obstacles at the local and Federal level (Nossiter 2008). These additional obstacles not only prolonged the negative health outcomes of residents, but also intensified them, which explains the heightened rates of poor health from residents several months after the hurricane (Guay et al. 2006). Additionally, Colleagues at Tulane University developed an online survey used to measure the rates of PTSD amongst survivors of Hurricane Katrina. They determined that non-minority female residents, who knew someone who died in the storm, were important predictors in rates of PTSD (DeSalvo et al. 2007). The study has received criticism, however, for using a collection of responses that were not representative of New Orleans demographics, and which was not designed to adequately sample poor minority residents in the area who would not have had access to the internet before the storm, and certainly not after widespread property destruction (Adeola 2009). It has also been noted that communities of color experience the ramifications of natural disasters more intensely. Many disaster-affected regions show higher death rates amongst minority communities, as well as the elderly populations (Sharkey 2007;

Passerini 2000). When it comes to race, gender, age and income, New Orleans has long been called a city of segregation, so it is not surprising that different communities experienced different levels of trauma resulting from the storm. In one study, death rates of Black citizens were twice as high as those of White citizens, and the death rate among Black elderly citizens was 20% higher than those of White elderly citizens (Sharkey 2007, 489). It is therefore necessary to address the ramifications of such differences in New Orleans, especially on the overall health of a given population in comparison to overall health outcomes of other populations found within the same city. It has also been noted within disaster literature that cultural factors may influence the intensity of emotional distress experienced by some residents (Suar et al. 2002; Mills et al. 2007; Kessler et al. 2006; DeSalvo et al. 2007; Adeola 2009). The studies that do exist on this topic express contradictive findings, however. Mills et al. (2007) found a definitive correlation between Black citizens and the severity of Acute Stress Disorder (ASD), for example, while Kessler et al. (2006) concluded that non-Hispanic White citizens who were single and unemployed had the highest likelihood of developing a mental illness after a natural disaster. Other factors believed to impact negative psychological impacts of disasters include low income, parental status, large family size and educational attainment (Gibson 2009; Freedy 1992). Disaster literature overwhelmingly concentrates on the psychological ramifications of events like Hurricane Katrina on a given community or population, and is limited in its response to measure physical health issues of communities. This can, in part, be contributed to the fact that much of the research was done after the major event occurred, resulting in limited knowledge of residents health both before and after a

natural disaster. Comparative reviews of self-reported physical health in a given area are also extremely limited, and consequently impact the overall understanding of health and disaster impact. Due to this discrepancy, it is even more important to address and analyze the roles of race, gender and age in ones physical health status prior to and after a natural disaster.

Theoretical & Conceptual Frameworks


Because a vast amount of disaster literature focuses on the psychological implications of disaster regions, typical theoretical frameworks used to guide research focus on potential stressors, cognitive processing of the event and individual characteristics which can influence the ways in which people react to major events (Adeola 2009). This paper aims to address the physical health issues affecting New Orleans residents before and after Hurricane Katrina, and therefore uses a sociological theory to examine the role of race, gender and age in determining the health of residents surveyed. The Theory of Social Constructionism With its roots in the post-modernism era of Western history, the Theory of Social Constructionism examines common social categories constructed by society, and which can also be reconstructed by society, to determine its impact on a given population or community (Phelan 2001). Advanced over decades to address the inequalities between different groups of people including different races, genders, sexual orientations, income levels and age groups -- this theory asserts that as the social identity of a particular group forms, so too do disparities among identities already existing and those in development. These disparities can manifest themselves through ones health status,

educational attainment, relationship/marital status, access to different public and private resources, employability and employment status, and stereotypes (Saluny 2006). Special attention has also been paid to the ways in which race, gender and age are socially constructed within a given society. While all of these subjects have biological components to their existence and definitions, the Theory of Social Constructionism asserts that the ways in which society establishes understandings about, and practices for, these differences favor some members of society over others (Saluny 2006). It claims, for example, that women are paid less than men because sexist practices against women have dominated the business world, rather than suggesting that womens lower pay is best explained by lower educational attainment or less work experience than their male counterparts. This assertion that disparities in society result from social constructs is critical when attempting to evaluate the health status of individuals before and after a major natural disaster. The major hypotheses derived from the Theory of Social Constructionism include: (a): Race, gender and age are all significant factors in determining the health status of New Orleans residents who survived Hurricane Katrina, and selfreported health outcomes show young minority women (under 18 years of age) are the most likely to see significant differences; Health disparities existed before and after Hurricane Katrina in New Orleans, and young women of color were the most affected group in both instances.

(b):

These hypotheses are tested in the following sections of this paper using the Displaced New Orleans Residents Pilot Study (DNORPS), which measures self-reported data regarding physical health of New Orleans residents one month prior to and after Hurricane Katrina.

Data & Methods


The data used throughout this study came from the DNORPS conducted in 2006, approximately one year after the hurricane struck. Researchers at the University of Michigan and the RAND Corporation conducted the study of 344 New Orleans residents via telephone, paper or in-person surveys. The purpose of the study was to assess the needs of the larger New Orleans community, and so assess the design and outcomes from fielding a survey of this population, such as identifying a sampling frame, tracking displaced residents, and assessing non-response patterns (Sastry 2009). Additionally, the design of DNORPS centered around stratified, area-based probability sample of pre-Katrina dwellings in the city of New Orleans to help provide insight on residents prior to the hurricane, a factor which is lacking in most literature already published on the topic (Sastry 2009). By utilizing area-based sampling, researchers were able to find and select dwelling units at random to participate in the study, decreasing the likelihood of too many cases coming from one particular region of the city. For sampling purposes, researchers divided New Orleans in three ways based on flood depth. The impact of flooding created a range of issues among New Orleans residents, as some individuals lost their entire homes, family members and churches while others are noted to have experienced far less despite living just miles away. Because flooding greatly impacted some regions of the city over others, it was important to researchers to control for how many individuals were surveyed from each region of New Orleans, as those who had seen severe flooding would understandably need considerably more resources in order to recover (Sastry 2009).

Researchers therefore divided the city three ways: first identified was the areas with no flooding, which came to represent about 29% of all dwelling units in New Orleans. These housing units saw most damage result from high winds, but homes remained habitable after the hurricane. Next to be identified were areas with less than four feet of flooding, which came to represent 20% of overall homes in New Orleans after the storm. These units sustained anywhere from minor to serious damage as a result of floodwaters. The last to be identified were areas with over four feet of flooding, which came to represent approximately 51% of total dwellings in New Orleans. These units had severe structural damage and were often deemed uninhabitable by modern living standards (Sastry 2009). <<SEE TABLE 1 IN APPENDIX >> Additionally, the questionnaire was structured so that individuals were asked to complete the survey for themselves and also for each member of their household. This is why 344 people were surveyed, but the survey represents 388 cases. The survey asked for general demographic information, as well as pre-Katrina and post-Katrina employment, marital and health status (Sastry 2009). The survey also asked people to share how they viewed their psychological health and quality of life before and after the hurricane. For the purpose of this paper, demographic information concerning race, gender and age will serve as independent variables, and ones physical health before and after Hurricane Katrina will serve as the dependent variables. These variables will be reviewed through logistic regression to determine if race, gender and age influence health outcomes before and after a natural disaster. Table 2 shows the breakdown of demographic information in relation to residents health. <<SEE TABLE 2 IN APPENDIX >>

It should be noted that some variables were recoded to help the logistic analysis. Questions regarding race originally allowed individuals to select from one of the following options: Caucasian, Black/African America, Hispanic, American Indian/Alaskan Native (AI/AN) and Asian. Very few individuals identified themselves as Hispanic, AI/AN or Asian and including these options in the logistic regression would have skewed the overall results. Race was therefore recoded to compare the health outcomes of Caucasians and racial minorities. Additionally, age was recoded so that common age groups could be identified. This variable was recoded so the following age groups would be recognized: ages under 18, ages 18-29, ages 30-49 and ages 50 and older. Health before and after Katrina was also recoded so that disparities between health could best be tested. Individuals who identified their health as excellent, very good or good were grouped together, while those who ranked their health as fair or poor were combined.

Findings
The results of the logistic regression performed in Stata software are represented in tables 3 to 5. Additionally, hypotheses (a) and (b) were tested and these tables represent their findings. Table 3 specifically examines the role of race in overall physical health prior to and after Hurricane Katrina. As Table 3 suggests, race has the hypothesized effect, directly predicting the physical health of New Orleans residents before and after Hurricane Katrina. Racial minorities (African Americans, Hispanics, AI/AN and Asians) are more likely to have fair or poor health before (b = 1.49, P < .05) and after (b = 1.656, P <0.001) Hurricane Katrina. While race proves to be a determining factor before the hurricane, the analysis does also show the negative health

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outcomes resulting from natural disasters. This provides important information regarding health of low-income, racially divided communities and the challenges they face to address health issues, as well as the added health risks associated with major disasters. <<SEE TABLE 3 IN APPENDIX >> Table 4 represents the findings of how gender influences health of New Orleans residents. Analysis of the logistic regression suggests that gender did not directly influence the physical health of residents before or after Hurricane Katrina. Hypotheses (a) is disproven in the first regression, which shows the overall irrelevance of gender on health before Katrina (b = .8588, P = 0.694). The second part of the hypotheses (b) is also disproven, as findings from the regression show that health after Katrina was not influenced by ones gender (b = 1.0989, P = .483). While these findings are far from statistical significance, it should be noted that the probability of gender influencing ones health increasing for New Orleans residents after the storm. Exponentiated betas show a dramatic increase from before and after Katrina, and are worthy of consideration when understanding the role of gender in disaster response and health management. <<SEE TABLE 4 IN APPENDIX >> Using age as a variable can seem problematic when comparing the health outcomes of individuals. It is biologically natural for age groups to experience different health problems, as well as the length of time these issues occur, the perceived threats of health circumstances, access to medical professionals and a number of other factors. Because some health issues are going to be unavoidable occurrences for people within a given age range, the purpose of using this variable in logistic regression was to serve as a control. By evaluating the health of four different age groups within New Orleans, it is

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possible to see if there are any overwhelming numbers facing some age groups and not others (for example, high rates of poor health among young adults who are generally understood to be relatively healthy when compared to other census data). Table 5 shows that age is a determining factor in ones health both before and after Katrina, which is not entirely unsurprising based on what was just discussed. What is interesting, however, is that individuals ages 18-29 were most likely to have age influence fair or poor health before the hurricane (b = 4.8779, P <0.001). After Hurricane Katrina, youth under the age of 18 were more likely to see their health as fair or poor (b = 2.4175, P < .001). <<SEE TABLE 5 IN APPENDIX >> These findings uphold the second part of the original hypotheses (b), which state younger residents have additional health issues facing them after natural disasters. The first part of the original hypotheses (a), is somewhat correct while the findings do suggest that health is greatly influenced by age, young residents under the age of 18 were less likely than young adults (ages 18-29) to experience fair to poor health on account of age alone.

Conclusions
The information collected from the DNORPS show the impact of a natural disaster like Hurricane Katrina on the health of local residents. What the logistic regression also reveals, however, is that there were major health disparities existing in New Orleans prior to the hurricane, and younger residents of color were more likely to experience mediocre to poor health. Because the data show what life was like prior to Hurricane Katrina, theoretical frameworks regarding social constructs of race, gender and age can be reevaluated to help explain the health disparities that existed for younger people of color. Both race and age proved to be contributing factors to poor health in

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New Orleans, and health was worsened after Katrina. Due to the high rates of poor health prior to the hurricane, however, it cannot be concluded that Katrina is the sole force behind the citys disparities. Given the demographic information of residents and the theoretical understandings of race and age, it can be asserted that New Orleans residents facing poor health before Katrina likely endured decades of under or unemployment, poor educational attainment, discriminatory protocol by government and businesses, and other issues commonly associated with low-income communities, like substance abuse and high crime rates. It is also important to discuss how gender proved to be insignificant in determining ones health in this particular study, especially given the way sociological literature discussing social constructs tend to assert that women face complex health problems due to the ways in which gender is understood by mainstream society (Phelan 2001; Roemer 2008; Marbley 2008; Jenkins 2009; Coffey 2010). The study suggests that gender is influential to health in post-disaster areas, but contradict the theoretical notions regarding gender constructs. Because there was a considerable increase seen in the exponentiated betas of the gender data, it should be noted that this study is limited in its ability to determine exactly what factors influenced that increase (inability to access resources, gender-based violence, psychological distress, etc). Other limitations of this study include the role of mental health in ones overall health and the way in which the survey was distributed and answered. Disaster response literature is filled with examples of mental health concerns which arise in post-disaster regions (see: Literation Review). The findings in the DNORPS contradict these findings, however. Residents were asked a series of questions to address potential mental health

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symptoms, including screens for suicidal ideation, anxiousness and depression, and hopelessness. Logistic regression performed on these questions did not show that a single mental health issues screened for was significant in the overall health of individuals. This is surprising given the amount of literature which suggests otherwise, and further research is recommended to better understand the ways in which New Orleans residents understand health (since the findings suggest they do not seem to consider psychological health a component of overall health). Questions regarding mental health linger in the limitations of this research. As discussed previously, those answering the survey were asked to complete one for him or herself, and one for each household member. Given how complicated it can be to track displaced families, this was likely the best solution for researchers conducting this pilot study. It is important to address, however, that those who responded may not have known the information being asked when it came to other household members. It may have been difficult to detect psychological distress in a young child, for example, or stigmatization may have played a role in what adult household members willingly shared with one another. Without a full understanding of how individuals interpreted the questions asked on the survey, it is difficult to understand how residents identified some health concerns and not others. It is therefore recommended that additional health research conducted in New Orleans and other post-disaster zones allow for more comprehensive understandings of how health is conceptualized within a given community. Because this study shows a contrast in mental health and physical health findings, it can also be asserted that race, gender and age may influence the cultural understanding of health, and what is or is not

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allowed to be part of ones overall well-being. Because disaster response is so heavily dependent on state and Federal governments in the United States and Europe, it would also be helpful for researchers in these regions to evaluate the role of these agencies in facilitating or prohibiting positive health outcomes. The data collected in the DNORPS is incredibly unique and helpful because it gauges the health circumstances of New Orleans residents both before and after Hurricane Katrina, which allows a base against which numbers and analyses can be compared. Future research will prove more helpful if this approach is taken so that the role of natural and manmade disasters can be fully understood in terms of health impacts. Additional insight on this will be critical in order to expand the overall work and understanding of health in disaster-affected regions of the United States and world.

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Appendix
Table 1. Stratification and Sampling for the DNORPS (n=344)

Population Flooding Stratum 0 feet < 4 feet > 4 feet Total Count 122,073 94,470 268,131 484,674 % 25 20 55 100

Dwellings Count 61,411 42,313 107,522 211,246 % 29 20 51 100

Sampled Named 93 59 70 222 Unnamed 31 21 70 122 Total 124 80 140 344 % 36 23 41 100

Table 2. Demographic Information of New Orleans Residents After Hurricane Katrina (n=388).

Variable Gender Male Female Age Age <17 years Ages 18-29 Ages 30-49 Age >50 Health Before Katrina Excellent / Very Good / Good Fair / Poor Health After Katrina Excellent / Very Good / Good Fair / Poor

Participants (n= 388)


Mean (SD) %

White (n= 141)


Mean (SD) %

.56 (.49) 168 220 95 (24%) 55 (14%) 110 (28%) 128 (33%) .85 (.27) 355 33 .21 (.40) 303 81

141 66 75 23 14 48 56

Non-white (n= 247) Mean (SD) % 247 102 145 72 41 62 72

132 9 121 20

223 24 182 61

Table 3. DNORPS Logistic Regression of Race and Physical Health (n=388)

Health Before Katrina Race


(White=0, Racial Minorities=1)

Coefficient .8370978

Std. Err. .4237275

z 1.98

P> |z| 0.048

b^eStdX 1.4965

Health After Katrina Race

1.04585

.2997606

3.49

0.000

1.6567

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Table 4. DNORPS Logistic Regression of Gender and Physical Health (n=388)

Health Before Katrina Gender


(Male=0, Female=1)

Coefficient -0.152234 .1900277

Std. Err. .3868292 .2707834

z -0.39 0.70

P> |z| 0.694 0.483

b^eStdX .8588 1.0989

Health After Katrina Gender

Table 5. DNORPS Logistic Regression of Age and Physical Health (n=388)

Health Before Katrina Age


(Under 18=0, 18-29=1, 30-49=2, 50 & older=3)

Coefficient 1.357071

Std. Err. .30407012

z 4.46

P>|z| 0.000

b^eStdX 4.8779

Health After Katrina Age

.7557657

.1369422

5.52

0.000

2.4175

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