Introduction
Hurricanes are among the most destructive natural hazards, causing injuries, fatalities, and acute illnesses that may be compounded by secondary hazards, health care disruptions, and loss of essential services.Reference Waddell, Jayaweera and Mirsaeidi 1 – 3 Although advances in preparedness, technology, and behavior can mitigate these impacts, ongoing urbanization and environmental degradation continue to increase population vulnerability.Reference Noji 4 In the United States (U.S.), hurricane impacts are typically quantified by mortality, while the burden of hurricane-related morbidity remains poorly understood even in developing nations like the U.S. This gap stems partly from a research focus on mortality rather than illness and injury, as well as the challenges of tracking affected individuals and attributing health outcomes directly to hurricane exposure.Reference Waddell, Jayaweera and Mirsaeidi 1
Much of the hurricane-related morbidity data has been obtained from hospital records, which limits understanding of the true extent of impact because hospital data will only reflect injuries or illnesses where professional care was sought or needed.Reference Waddell, Jayaweera and Mirsaeidi 1 An analysis of injury patterns following the Northridge, California earthquake showed that a majority of people who reportedly experienced an injury did not actually seek professional medical care, or they obtained care from private physicians or clinics which are not typically included in surveillance data.Reference Shoaf, Sareen and Nguyen 5 Besides gaps in knowledge on the scope and magnitude of hurricane-related morbidity, little is known about health care-seeking behavior that occurs after a natural disaster, which also limits our ability to record morbidity via hospital records. Additionally, hospital records may be unavailable or incomplete due to the disaster’s direct impact on facilities’ ability to collect such data, either due to power outages, physical damage to medical records, or staffing shortages that may impact administrative processes that produce medical records. Thus, examining only hospital records can vastly underestimate the health impacts of a given disaster.
The 20th anniversary of Hurricane Katrina provides an opportunity to reassess its health impacts and reflect on advances in disaster preparedness and response. When Katrina made landfall in Louisiana on August 29, 2005, it exposed the catastrophic consequences hurricanes can have in the United States and prompted major reforms across emergency management and health care systems. Katrina remains the costliest tropical cyclone in U.S. history, with damages estimated at $203 billion (2024 USD). 6 More than 80% of New Orleans flooded, over 90,000 square miles were declared disaster areas, and approximately 800,000 people were displaced, representing the largest U.S. population displacement since the Dust Bowl of the 1930s. 7 , Reference Diaz, Brisolara and Harrington 8 Public health and health care infrastructure were devastated as only three area hospitals continued operation through the hurricane.Reference Rudowitz, Rowland and Shartzer 9 Overall, 1,800 people died, and thousands of injuries were reported using hospital records.Reference Daley 10 , 11 Additional morbidity data were collected through an active surveillance system established by the Louisiana Department of Health and Hospitals, the Centers for Disease Control and Prevention, and emergency medical response teams.Reference Williams, Guarisco and Guillot 12
Although substantial investments have been made in emergency preparedness, health care system resilience, surveillance, and electronic health records since Hurricane Katrina, recent hurricanes demonstrate that disaster-related morbidity remains a major public health challenge. Following Hurricane Ian in 2022, disruptions in health care access, chronic disease management, injury treatment, and environmental exposures continued to contribute to substantial morbidity among affected populations.Reference Sodders, Stockdale and Baker 13 CDC reports about Hurricane Ian documented outbreaks of floodwater-related infections, including a marked increase in vibriosis cases following storm surge exposure, highlighting persistent health risks associated with hurricane-related flooding.Reference Sodders, Stockdale and Baker 13 More recently, Hurricane Helene in 2024 revealed vulnerabilities extending beyond local health care infrastructure when flooding of a major pharmaceutical manufacturing facility contributed to nationwide shortages of intravenous fluids and other critical medical supplies.Reference Cahan 14 These events highlight the continuing consequences of disrupted health care access and continuity of care. Here, we present previously unpublished data on Hurricane Katrina-related injuries, health care utilization, and medication needs, providing a unique perspective on how disaster response and preparedness have evolved over the past two decades while identifying persistent gaps that remain relevant today.
Methods
We developed a survey to capture multiple dimensions of disaster response, including perceptions of health before and after the disaster, physical or mental illness and injury, as well as medication use and health care access. These primary data were collected using a modified 2-stage cluster sampling method in accordance with the Centers for Disease Control’s Community Assessment for Public Health Emergency Response (CASPER) method that has been used to study morbidity after other hurricane disasters.Reference Zane, Bayleyegn and Haywood 15 , 16 The 2-stage sampling method was used to account for the fact that many households were still not occupied 2 years after the event. For the first stage, census block data were utilized to identify 30 geographically distinct clusters. Once valid block groups were identified, 30 households were selected using a random number generator. For the second stage, we identified housing units that were occupied at the time of the study and selected seven occupied household addresses from each block group using a random number generator. Due to the age of the dataset and limitations in the archived field materials, the total number of eligible housing units within the sampling frame is no longer available. Household occupancy was also constantly changing, so it was not feasible to know the actual population size or total number of eligible housing units at any given time during the study period.Reference Kelley, Perman and Shoaf 17
A total of 210 face-to-face interviews were conducted by the research team in Orleans Parish, Louisiana, from October 2006 to October 2007. However, over 90% of interviews were completed in October 2007 due to staffing challenges. The response rate was 40%, calculated as the number of completed interviews to actual in-person contacts made. All interviews were completed during a single session in English only. No incentives were provided to participate in the survey.
Measures
Respondents were asked questions on demographic characteristics, evacuation behavior, hurricane-related damage, injuries and illnesses, health care-seeking behavior, and disaster preparedness levels. Questions were both open- and close-ended.
Injury and illness exposure
In order to determine the extent of possible injury or illness exposure, respondents were asked about their contact with flood water and damage to or near their home. Contact with flood water was measured with the dichotomous yes/no question, “Were you directly in contact with the water from the hurricane?” If respondents answered “yes,” they were asked, “If so, did you…” “wade in it (0-2 feet),” “wade in it (2-4 feet),” “wade in it (over 4 feet),” or “head was submerged.”
Damage to or around a respondent’s home was measured with several questions. The first asked, “Other than your own home, was there any damage in the area where you lived, that is, within five blocks in any direction, to major structures – such as buildings, homes, freeways, levees, dams, roads?” Answers were coded as “yes” or “no.” The next few questions measured damage specifically to the respondent’s property. First was a dichotomous yes/no measure, which asked, “Was the home you were living in damaged enough to need repairs as a result of the hurricane?” Second, respondents were asked, “Did you or anyone else in your home have any other personal property or belongings damaged in the hurricane?” Responses were coded as “yes” or “no.”
The last 2 questions asked about the damage that occurred and how the damage was caused. The first question asked, “Was most of the damage that occurred caused by …?” Responds could select from “wind,” “rain,” “storm surge/waves,” “flood water,” “flood debris,” “wind-borne,” “mold contamination,” or “other.” Anyone reporting “other” was asked to specify the cause. Respondents could select all responses that applied. Second, they were asked, “What kind of damage occurred as a result of the hurricane?” Provided responses were “entire building destroyed,” “floor damage,” “foundation damage,” “patio/porch damage,” “roof/ceiling damage,” “wall damage,” “contents,” “chimney damage,” “window breakage,” “garage damage,” “shingles, siding and/or other shutter damage,” or “other.” Anyone reporting “other” was asked to specify the damage. Respondents could select all responses that applied.
Injuries, illness and health care-seeking behavior
Respondents were asked about injuries and illness sustained during or after Hurricane Katrina. First, respondents were asked whether they had experienced any physical injuries with the measure, “Did/do you have any physical injuries-even minor ones such as cuts and bruises-as a result of the hurricane?” If the respondent said “yes,” they were asked the open-ended question, “Please describe [this physical/these physical injuries]?” For each injury mentioned, a series of questions were asked: “Did you seek medical care for this physical injury?” “Were you able to get medical care for this physical injury?” “Were you hospitalized for this physical injury?” “Were you given any medications for this physical injury?” “If not, why were you not given medication for this physical injury?” Respondents could select “medication not needed” or “medication not available.” Respondents could provide up to 6 different injuries for which the same 5 follow-up measures were asked.
Second, respondents were asked about emotional injuries with, “What about emotional injuries? Would you say that you suffered emotional injuries-even minor ones such as sadness-as a result of the hurricane?” Responses were dichotomous yes/no answers. As with the physical injuries, respondents were asked an open-ended question to describe the emotional injury. For each emotional injury, the same 5 follow-up questions were collected for up to 6 different emotional injuries. Lastly, respondents were asked about illness: “Did/do you have any illness/illnesses-even minor ones such as a cold-as a result of the hurricane?” Responses were coded as “yes” or “no.” As with the physical and emotional injuries, respondents were asked to describe the illness. For each illness, the same 5 follow-up questions were asked for up to 5 illnesses.
Analytic Strategy
Content analysis was performed on all open-ended questions. Variables from the open-ended question were exported from SPSS Statistics 17.0 into a Microsoft Excel spreadsheet for data management. 18 , 19 Once the coding was finished in Excel, the data were imported back into SPSS.
All descriptive statistics were calculated using SPSS and SAS. 20 With each frequency distribution, measures of central tendency (mean, median and mode) and dispersion (range and standard deviation) were obtained as appropriate. To test for associations between all variables of interest, bivariate analysis was performed. Pearson’s chi-square test was utilized to test for associations between categorical variables. For any cells with expected counts less than 5, the statistical test of association was not performed. Due to the sample size, an alpha level of 0.05 was used to determine statistical significance.
Results
Sample Characteristics
Table 1 presents the distribution of select demographic characteristics for the study sample. For respondents reporting one race/ethnicity, the composition of the sample had a similar distribution of Whites (35.7%), Native Hawaiian/Other Pacific Islander (0%), and Hispanic/Latinos (3.8%) as population projections for the 2006-2008 American Community Survey (ACS) for Orleans Parish, Louisiana. American Indians/Alaskan Native (1.9%) and Other races (5.8%) were over-represented in the sample, while Blacks or African Americans (46.1%) and Asians (0%) were under-represented. However, the vast majority of people reporting 2 or more races (10.4% compared to 0.9% in the ACS) also reported being Black or African American. Regarding other characteristics, survey respondents as a whole had less education and income, had a higher unemployment rate, were older, and overrepresented women and homeowners compared to ACS projections.
Selected demographic characteristics of the survey sample (N = 210)
Table 1. Long description
The table contains two columns: Variable and Frequency, n (%).
* Race/ethnicity: Black or African American 98 (47.8%), White 54 (26.3%), Other race 8 (3.9%), Two or more races 45 (22.0%), Hispanic or Latino origin 8 (3.8%).
* Age of respondent: 18 to 29 years 34 (16.3%), 30 to 39 years 20 (9.6%), 40 to 49 years 42 (20.2%), 50 to 59 years 54 (26.0%), 60 to 69 years 32 (15.4%), 70 to 85 years 26 (12.5%). Mean age is 50.1 with a standard deviation of 17.0.
* Educational attainment: Less than high school 30 (14.7%), High school 107 (52.5%), Associate degree 9 (4.4%), Bachelor’s degree 29 (14.2%), Graduate or professional degree 21 (10.3%), Other 8 (3.9%).
* Annual household income: Less than $5,000 29 (17.0%), $5,000 to $10,000 24 (14.0%), $10,000 to $15,000 15 (8.8%), $15,000 to $20,000 11 (6.4%), $20,000 to $50,000 45 (26.3%), $50,000 to $100,000 35 (20.5%), $100,000 or greater 12 (7.0%).
* Employment status: Full-time 76 (36.5%), Part-time 19 (9.1%), Unemployed 34 (16.3%), Retired 42 (20.2%), Other 37 (17.8%).
* Marital status: Married 72 (34.5%).
* Gender of respondent: Female 127 (60.5%).
* Owner-occupied Residence: 138 (68.7%).
* Prior physical or mental health problem: 70 (33.7%).
* Taking medication: 97 (46.6%).
Notes: N = 210 for the sample. The actual N for each variable depends on the frequency of missing data. The race/ethnicity variable was structured in accordance with the 2006–2008 American Community Survey, with a select all that apply format. No one reported being Native Hawaiian or other Pacific Islander. Only one respondent reported Asian race/ethnicity, and this respondent also reported another race and is thus reflected in the “Two or more races” row.
Environmental Exposures
During Hurricane Katrina, respondents were exposed to a myriad of environmental factors, such as contaminated flood water and physical damage (Table 2). Approximately one quarter (26.4%) of respondents reported contact with water from the hurricane. Of those who reported contact, over half waded in water over 4 feet deep or had their head submerged. Almost all survey respondents reported damage within 5 blocks of their household (95.7%), and enough damage to their home to need repairs (96.2%). About 4 in 5 people (81.7%) had their belongings damaged as well.
Exposure to flood water and physical damage among survey respondents (N = 210)
Table 2. Long description
The table is divided into two columns: Variables and Frequency, n (%).
* Water contact:
- Direct contact with water: 55 (26.4%).
- Wade in it 0–2 feet: 10 (19.6%).
- Wade in it 2–4 feet: 12 (23.5%).
- Wade in it over 4 feet: 22 (43.1%).
- Head was submerged: 7 (13.7%).
* Damage:
- Damage within 5 blocks of household: 199 (95.7%).
- Home damaged enough to need repairs: 201 (96.2%).
- Belongings damaged: 170 (81.7%).
* Cause of damage:
- Wind: 152 (75.6%).
- Flood water: 135 (67.5%).
- Mold contamination: 133 (66.8%).
- Rain: 114 (57.9%).
- Wind-borne debris: 81 (41.8%).
- Floating flood debris: 78 (40.2%).
- Storm surge: 55 (28.2%).
- Other: 24 (12.3%).
* Type of damage:
- Roof/ceiling: 162 (84.4%).
- Contents: 141 (73.4%).
- Walls: 139 (72.4%).
- Floor: 130 (68.1%).
- Shingles, siding, shutters: 127 (66.5%).
- Fence/exterior wall: 120 (62.5%).
- Windows: 103 (53.9%).
- Patio/porch: 80 (42.1%).
- Garage: 45 (24.1%).
- Other: 43 (22.6%).
- Entire building: 39 (19.8%).
- Chimney: 32 (17.1%).
Notes: N = 210 for the sample. The actual N for each variable depends on the frequency of missing data. Percentage for the causes of damage and type of damage variable does not add up to 100% because respondents were allowed to select more than one option.
Respondents were asked to report the types of damage and possible causes of it. They were allowed to report more than one type of damage or cause. Over 80% of respondents reported damage to the roof/ceiling (84.4%), followed by the house contents (73.4%), walls (72.4%), floor (68.1%), garage (66.5%), shingles/siding/shutters (66.5%), fence/exterior wall (62.5%), windows (53.9%), patio (42.1%), other damage (22.6%), entire building (19.8%), and chimney (17.1%). If “other” was reported, respondents were asked to specify the type, which included damage to landscaping and sheds in their yard. Respondents were also asked to report the possible cause of damage. The most common cause of damage reported was wind (75.6%), followed by flood water (67.5%), mold contamination (66.8%), rain (57.9), wind-borne debris (41.8%), floating flood debris (40.2%), storm surge (28.2%), and other (12.3%). If “other” was reported, respondents were asked to specify the cause. This included damage caused by rescue crews, animals (i.e., rats, termites, etc.), and fallen trees.
Health Status
Of the respondents interviewed, 19% reported excellent health prior to Hurricane Katrina, 23% very good, 28% good, 23.5% fair, and 6.5% poor health. Although the majority reported good to excellent health status, 34% of respondents reported some type of prior physical or mental problem. During the hurricane, the health status of some residents was compromised, resulting in a change in overall health status after the hurricane. Specifically, 4.5% reported much better health now compared to before Katrina, 7.5% better health, 53% about the same health, 30% worse, and 5% much worse. There was a statistically significant association between health status before and after the hurricane (P < 0.001). Among participants who reported “good,” “very good,” or “excellent” health before the hurricane, 78% reported their health was “about the same,” “better,” or “much better” after the hurricane. Among participants who reported their health was “fair” or “poor” before the hurricane, 65% reported their health was “worse” or “much worse” after the hurricane.
Reported Injuries and Illnesses
Of those interviewed, 17% (N = 36) reported a physical injury, and 85% (N = 179) an emotional injury. Common physical injuries included cuts, bruises, infections, pain, rashes, and fractures. Common emotional injuries included sadness, depression, anxiety, stress, anger, insomnia/nightmares, loneliness, and a sense of loss. Respondents were also asked to report illnesses experienced. In total, 32% (N = 67) reported some type of illness. Common illnesses included respiratory problems such as colds and coughs, allergies, and illnesses related to the immune or nervous systems. It should be noted that responses were coded as reported; therefore, a few respondents considered certain conditions as injuries instead of illnesses and vice versa (Table 3).
Distribution of reported injuries and illnesses in the survey sample
Table 3. Long description
The table contains two columns: Variables and Frequency, n (%).
Type of physical injury:
* Injury unspecified: 10 (27.8%)
* Cut(s): 9 (25.0%)
* Infection: 7 (19.4%)
* Pain: 4 (11.1%)
* Rash: 4 (11.1%)
* Fracture/break: 4 (11.1%)
* Other: 4 (11.1%)
* Bruises: 3 (8.3%)
* Fall-related: 2 (5.6%)
Type of emotional injury:
* Sadness: 67 (37.4%)
* Depression: 67 (37.4%)
* Anxiety: 40 (22.3%)
* Other emotion: 37 (20.7%)
* Stress: 22 (12.3%)
* Anger: 16 (8.9%)
* Loss: 15 (8.4%)
* Insomnia/nightmares: 13 (7.3%)
* Loneliness: 12 (6.7%)
* Psychosomatic response: 8 (4.5%)
* Loss of control: 8 (4.5%)
* Fear: 7 (3.9%)
* Frustration: 6 (3.4%)
Type of illness:
* Respiratory/cough/cold/sinus: 36 (52.9%)
* Other problem/condition: 16 (23.5%)
* Allergies: 12 (17.6%)
* Immune system related: 8 (11.8%)
* Nervous system related: 8 (11.8%)
* Cardiovascular condition: 6 (8.8%)
* Integumentary/skin: 6 (8.8%)
Health Care-Seeking Behavior
Of those injured or ill, 64% sought care for physical injury, 21% for emotional injury and 63% for illness (Table 4). Ninety-one percent of respondents who sought care were able to obtain it for their physical injury, 89% for their emotional injury, and 100% for reported illnesses. Of those who obtained care, respondents with physical injury or illness reported more hospitalization (24% and 14%, respectively) and provision of medication (86% and 88%, respectively) than for reported emotional injuries (9% hospitalization and 70% medication). All respondents who needed medication for physical or emotional injury were able to obtain it. However, 5% of people who obtained care and needed medication were unavailable to access it for reported illnesses.
Reported health care-seeking behavior among survey respondents
Table 4. Long description
The table consists of two columns: Variables and Frequency, n (%). It is divided into three main sections:
1. Physical injury:
- Sought care: 23 (63.9%)
- Obtained care: 21 (91.3%)
- Hospitalized for injury: 5 (23.8%)
- Provided medication: 18 (85.7%)
- Medication unavailable: 0 (0.0%)
2. Emotional injury:
- Sought care: 37 (20.7%)
- Obtained care: 33 (89.2%)
- Hospitalized for injury: 3 (9.1%)
- Provided medication: 23 (69.7%)
- Medication unavailable: 0.0 (0.0%)
3. Illness:
- Sought care: 43 (63.2%)
- Obtained care: 43 (100.0%)
- Hospitalized for illness: 6 (14.0%)
- Provided medication: 38 (88.4%)
- Medication unavailable: 2 (4.7%)
Notes indicate categories are not mutually exclusive. Denominators for ‘sought care’ are 36 for physical, 179 for emotional, and 68 for illness. Subsequent percentages use the preceding row’s count as the denominator.
Notes: The categories (physical injuries, emotional injuries, and illnesses) are not mutually exclusive. Participants were able to report more than one injury. The percentages in this table were calculated to show if a participant, for example, sought care for any of their reported injuries in the given category. There were 36 total participants with reported physical injuries, 179 with emotional injuries, and 68 with illnesses. These participant counts were used as the denominators for the “sought care” rows. The number of participants who sought care was used as the denominator for the percentage of participants who obtained care. The number of participants who obtained care was used as the denominator for the percentage of participants who were hospitalized, provided medication, or for whom medication was unavailable.
Nearly half of participants reported taking at least one medication prior to Hurricane Katrina (47%, n = 97). When asked to describe the types of medications they took, 42% (n = 41) could not name the exact medication that they were prescribed. Nearly all of the medication-using participants could name the disease or symptoms for which they were taking the medication (e.g., diabetes, blood pressure, pain, for transplant), while a small minority could only name the affected organ. A few participants (n = 4) did not know the type of medication or the purpose of the medication they were given: “too many to list - can’t even remember the names!”; “I don’t know what it was. Called the drug store and they give it to me.”
Discussion
Findings from this analysis expand the understanding of the physical and mental impacts of Hurricane Katrina on the health of residents in Orleans Parish. Prior to the hurricane, respondents reported, as a whole, good to excellent health. However, almost 1 in 5 experienced a self-reported physical injury and 4 in 5 residents experienced a self-reported emotional injury as a direct result of Katrina. Common physical injuries included cuts, bruises, and infections; common emotional injuries included sadness, depression, and anxiety. Moreover, a third of respondents reportedly experienced illness, which included respiratory problems, infections, and allergies. Over a third of those interviewed reported worse or much worse health after the hurricane, possibly because of the impact on health and the inability of some residents to obtain the health care they needed. Participants who noted fair or poor health prior to the hurricane more often experienced worse health after the hurricane, suggesting that Hurricane Katrina widened health disparities among vulnerable populations. These findings align with previous reports of a doubling of serious mental and physical health illness in low-income parents after Hurricane Katrina.Reference Rhodes, Chan and Paxson 21
Surveillance statistics from hospital admissions in greater New Orleans immediately after Hurricane Katrina showed lacerations/abrasions (27%), sprains/strains/dislocations (17%), and bruises/contusions (10%) to be the most frequent diagnoses in residents.Reference Sullivent, West and Noe 22 In this analysis, these types of injuries were among the most frequently reported, but at lower frequencies of occurrence. Interestingly, the majority of the survey respondents reported experiencing injuries, but many did not specify the type. It would be expected that every injury reported in a hospital admission would have a diagnosis; therefore, this may account for the lower proportions in this study.
Facility-based surveillance statistics in New Orleans between September 8-25 and September 25-October 15, 2005 also showed about half of all visits were for illnesses and a quarter for injury.Reference Williams, Guarisco and Guillot 12 Although specific injury diagnoses were not reported, illnesses included cough, respiratory problems, fever, and rash illnesses as frequent diagnoses.Reference Williams, Guarisco and Guillot 12 , Reference Lopez, Bergeron and Ratard 23 In this analysis, about a third of respondents reported illnesses and less than a quarter reported an injury, which were proportionally similar in their distribution in the survey sample. In line with hospital records, respiratory problems, fever, and rash were among the most frequently mentioned illnesses.
While comparisons with earlier hurricanes remain informative, more recent disasters suggest that many patterns observed after Hurricane Katrina persist today. Following Hurricane Ian in 2022, reports continued to describe injuries related to flooding, storm debris, falls, and environmental exposures, as well as worsening of chronic medical conditions among vulnerable populations.Reference Sodders, Stockdale and Baker 13 CDC surveillance also documented a substantial increase in floodwater-associated Vibrio infections after Hurricane Ian, with 38 cases and 11 deaths linked to storm-related exposure.Reference Sodders, Stockdale and Baker 13 Similar to findings from Katrina, morbidity extended well beyond acute traumatic injury and included infectious, respiratory, and chronic disease-related conditions.Reference Bushong and Welch 24 , 25 Together, these observations suggest that despite advances in forecasting, emergency communication, and response infrastructure, the overall spectrum of hurricane-related morbidity has changed relatively little over the past two decades.
Much more research has been performed on the emotional injuries or psychological sequelae related to hurricanes. However, a majority of this work involves measuring these impacts with an instrument or professional diagnosis and not directly with respondent reports.Reference Acierno, Ruggiero and Galea 26 , Reference Miller, Fitch and Swilley-Martinez 27 A study by Galea et al. found 31% of those surveyed after Hurricane Katrina had evidence of a mood or anxiety disorder at the time of the interview using the Kessler Psychological Distress Scale-6, and 16% had post-traumatic stress disorder using a separate screener based on the Trauma Screening Questionnaire.Reference Galea, Nandi and Vlahov 28 Although the magnitude of psychological injury is not comparable due to differences in measurement, the most frequently mentioned types of emotional illness were mood and anxiety disorders.
We report rare data about post-disaster health care-seeking behavior. About two-thirds of respondents reportedly sought care for physical injury and illness, but only 1 in 5 did so for emotional injury. Research by Shoaf et al. found only 10% of those who reported an injury after the Northridge earthquake sought care.Reference Shoaf, Sareen and Nguyen 5 Similarly, a study after the 2007 Southern California wildfires found almost one-third of displaced people reportedly needed health care at some point during the evacuation, and almost one-third of those, or 8% of the total, stated they had unmet health care needs.Reference Jenkins, Hsu and Sauer 29 With advancements in telehealth, it may be easier to track health care-seeking behaviors after natural disasters in the future because it removes physical distance as a barrier to seeking care. During the 2025 Southern California wildfire, telehealth use spiked dramatically, suggesting its important role in addressing morbidity in future disaster situations.Reference Casey, Gu and Schwarz 30 However, telehealth has challenges related to access to care during disasters, including stable internet connections that may be disrupted in a disaster situation.
More extensive research exists on mental health care service seeking after a disaster. Research from Wang et al. showed only 16% of their survey respondents used mental health services since Hurricane Katrina, which is consistent with the findings of this study.Reference Wang, Gruber and Powers 31 Others have examined various types of disasters and mental health service utilization after a disaster, with rates ranging from 2% to 38% reporting service utilization.Reference Van der Velden, Grievink and Kleber 32 Researchers, such as Boscarino et al., have hypothesized that service utilization rates remain relatively low because respondents do not think they have a problem; they want to solve the problem on their own; they lack access to services; they have financial problems; and/or they have a fear of treatment.Reference Boscarino, Hoffman and Kirchner 33
Medication continuity has received considerably less attention in disaster research than injuries, fatalities, or health care utilization, despite its importance for individuals with chronic diseases. One of the more noteworthy and understudied findings from this analysis was the prevalence of medication use before Hurricane Katrina and participants’ limited ability to identify the medications they were taking. Nearly half of respondents reported using at least one medication before the disaster, and more than 40% could not name the specific medication prescribed. Many Hurricane Katrina survivors arrived at shelters without medication bottles, prescription records, or detailed knowledge of their medication regimens, making it difficult for clinicians to accurately reconstruct treatment histories and maintain continuity of care. 34 , 35
At the time of Hurricane Katrina, Walgreens was one of the few major pharmacy chains that maintained enterprise-wide electronic prescription records, allowing pharmacists and clinicians to retrieve medication histories for displaced Hurricane Katrina survivors and refill medications when local records were inaccessible. 36 , Reference Carol 37 In the past 20 years, major advancements have been made to ensure that survivors can access their prescription medications during disaster situations. Today, nearly all large pharmacy chains, pharmacy benefit managers (PBMs), and health systems maintain electronic prescription records, and e-prescribing is the norm in the U.S. 34 This allows pharmacists and clinicians to reconstruct medication histories far more easily than during Katrina. Many states permit pharmacists to provide emergency refills, often up to a 30-day supply, during declared emergencies.Reference Ready 38 After Katrina, the Department of Health and Human Services created systems to facilitate medication recovery, including the Emergency Prescription Assistance Program (EPAP), which provides access to prescription medications and certain medical supplies for uninsured disaster survivors during federally declared disasters. 39
While substantial progress has been made since Hurricane Katrina to improve access to prescriptions and electronic health records, less attention has been paid to the vulnerability of the prescription drug supply chain itself. Recent work by Shahzad, Nogueira, and colleagues demonstrated that nearly two-thirds of drug production facilities operating in the United States between 2019 and 2024 were located in counties that experienced at least one weather-related disaster declaration.Reference Shahzad, Nogueira and Wagner 40 Hurricanes were the most common disaster affecting counties with active pharmaceutical facilities. Notably, Hurricane Helene in 2024 caused a nationwide intravenous fluid shortage after flooding disrupted production at a facility responsible for approximately 60% of the U.S. supply.Reference Cahan 14 Similar supply-chain disruptions were observed after Hurricane Maria in Puerto Rico. 41 These findings suggest that medication availability still remains a critical vulnerability during disasters. Future studies should consider how natural disasters affect the medical supply chain alongside prescription access, and treatment interruptions as important outcomes alongside traditional measures of injury and illness.
Exposure to environmental hazards during natural disasters is a growing topic of concern, largely due to their impact on infection as well as long-term cancer risk.Reference Galea, Nandi and Vlahov 28 Approximately one quarter of respondents reported contact with water from the hurricane, and almost all reported damage within 5 blocks of their household. About 4 in 5 people interviewed had personal property damage. This included damage to roof/ceiling, house contents, walls, floor, garage, shingles/siding/shutters, fence/exterior wall, windows, patio, and other damage. Research from Tropical Storm Allison found 32% of respondents had floodwater in their home and 35% had damage to their home.Reference Jenkins, Hsu and Sauer 29 A field survey after Hurricane Ivan found three-fourths of the homes in the study area were damaged.Reference Casey, Gu and Schwarz 30 Respondents were asked to report on the possible causes of damage and to describe its type. They were allowed to report more than one type of cause or damage. The most common cause of damage reported was wind, followed by flood water, mold contamination, and rain.Reference Bayleyegn, Wolkin and Oberst 42 Bayleyegn et al found similar results, with wind, flood water, and fallen trees identified as the main causes of damage.Reference Casey, Gu and Schwarz 30
Hurricane Katrina prompted extensive reforms in emergency management, public health preparedness, and health information infrastructure, including strengthening of FEMA, expansion of interoperable emergency response systems, broader adoption of electronic health records, and increased use of rapid community-based assessment methods such as CASPER. Nevertheless, recent disasters suggest that important vulnerabilities remain. Hurricane Ian demonstrated the ongoing challenges of maintaining continuity of care for medically vulnerable populations, while Hurricane Helene revealed the susceptibility of national pharmaceutical supply chains to weather-related disruptions. Compared with Katrina, health care systems today are better equipped to maintain communications, coordinate patient transfers, and restore services after a disaster. However, disruptions to medication access, chronic disease management, behavioral health services, and medical supply chains continue to produce substantial morbidity. Thus, the primary lesson from Katrina may not be that these challenges have been solved, but rather that they have evolved in form while remaining significant public health concerns.
Limitations
There are several limitations of this analysis. First, the timing of the survey may have affected recall, as respondents were interviewed over a year after the hurricane. However, the types and proportions of environmental exposures, injuries and illness, and health care-seeking behavior are congruent with other studies from Hurricane Katrina or other disasters, lending credibility that these results are indicative of respondents’ experiences. Moreover, if residents were not home when the team surveyed the area, they may have been missed from data collection. Because no follow-up data were collected from Katrina survivors after the original survey period, these findings should be interpreted as a historical assessment of post-disaster morbidity rather than evidence of current health conditions among survivors.
Second, sample representativeness may be an issue. Since accurate population estimates were unavailable during the data collecting period, it is not possible to know if the sample is representative of the population present after Hurricane Katrina. In addition, portions of households in each sampling cluster were inaccessible to the survey team, thus certain types of people may be unrepresented.
Direct comparisons across disasters should be interpreted cautiously, as morbidity patterns are influenced by local context, including demographic composition, baseline health status, infrastructure resilience, health care capacity, and underlying social and structural vulnerabilities. Nevertheless, recurring themes across recent hurricanes suggest that disruptions to health care access, medication availability, and chronic disease management remain common challenges.
Conclusions
We are entering an era where more severe hurricanes are anticipated due to climate change. These previously unpublished findings shed light on subclinical morbidity that is difficult to document using morbidity from hospital records alone. These include poor mental health and injuries for which survivors did not seek health care. This study reports high medication use and the lack of patients’ ability to identify their medications reinforce the importance of electronic medical health records in managing health in a post-disaster zone. Over the past 20 years, there have been significant efforts to document the long-term health effects of hurricanes on health care delivery and morbidity, which all impact mortality among populations who survive these natural disasters.Reference Nogueira, Sahar and Efstathiou 43 In addition, the challenges to identifying medical histories and medication usage among Hurricane Katrina survivors spurred the adoption of electronic health records to document and provide quick access to patient information.Reference Gettinger 44 , Reference Brown, Fischetti and Graham 45 Since this report’s findings support that hurricane-related morbidity is generally underestimated, developing real-time technology to report injuries of any severity could help us better understand the true extent of these disasters.
Acknowledgments and AI disclosure
We thank Joseph Perman, MPP, for his contribution to this research. The authors used Microsoft Copilot (GPT-5) to assist with editorial tasks, including language refinement, manuscript organization, and literature search support on July 26, 2026. This software is only available through institutional subscription. No modifications to the tool were made by the researchers. The authors critically reviewed and edited all AI-generated content and assume full responsibility for the accuracy, integrity, and originality of the final manuscript. All scientific interpretations, analyses, and conclusions were developed, reviewed, and verified by the authors.
Author contribution
K.S. contributed to the study conception and design. K.S. contributed to data acquisition. J.O. and R.C. contributed to statistical analysis. K.S. wrote the first draft of the manuscript. J.O., R.C., and K.W. assisted in revisions. All authors reviewed the final version of the manuscript.
Funding statement
NSF, award CMMI-0555148. NIH, project P30CA042014-36.
Ethical approval
University of California, Los Angeles IRB#11-002423.
Open access
