Preparedness and response are different activities but are interrelated. Resources consumed in educating and preparing citizens for emergencies directly translate into saving lives and money in responding to a disaster. Man-made and natural disasters in recent years have reinforced the need of shared responsibility across government and society (throughout all segments of the population) for sustainable risk-mitigating activities. This concept is described as a culture of preparedness, where individuals, communities, private industry, nonprofit entities, and all levels of government share responsibility and play a crucial role in preparing for emergencies.1 There is a barrier, however, that restricts the realization of this national goal.

The fact that the United States suffers from major health disparities hardly qualifies as news. Too many Americans cannot get adequate healthcare and this situation is often linked to geographical, economic, cultural, and racial factors. These disparities in access to care, quality of care, and health status are often the subject of political debate, particularly in election years like this. What I have learned through my experiences in the US Army, and what is generally not known, is the extent to which health disparities have become a barrier to a culture of preparedness. If we are going to be ready to respond to a future disaster, be it natural or of human origin, we must work to reduce health disparities as part of any preparedness effort.

People who do not have adequate healthcare tend to be sicker (often with chronic illnesses like diabetes and unmanaged hypertension) and less physically mobile. When disaster strikes, they require more assistance from healthcare personnel and others, including family members, who are themselves facing their own stressful situations. More frequent chronic illnesses tend to force them to depend on constant treatment through networks of doctors, hospitals, clinics, and pharmacies that are disrupted or destroyed during disasters. Because they are also more likely to be economically poorer (and not to own a car), they are often less able to evacuate from disaster areas on short notice. All of this means that the medically underserved have challenges in mobility and independence and require an elevated level of attention during a disaster response. These disparities that produce ongoing, special healthcare needs create a barrier to developing a culture of preparedness.

Hurricane Katrina and its impact on Louisiana and Mississippi clearly illustrated this problem. As the Kaiser Family Foundation noted in its report on healthcare in New Orleans and Louisiana before and after Katrina, the city and state had a strained and vulnerable "two-tier" healthcare system with 25% of the population in poverty and 20% lacking health insurance.2 When Katrina hit in August 2005, it destroyed many health facilities and closed down Charity Hospital, the largest healthcare institution for the poor in New Orleans. The Charity Hospital system in New Orleans was not effective in eliminating health disparities. However, many poor people in Louisiana and the gulf coast counties of Mississippi, who were just able to hang on with the existing healthcare system, lost all access to healthcare resources during and after the storm. Doctors' offices, pharmacies, and clinics were closed or destroyed and healthcare personnel dispersed because of the evacuation. This meant that rescue and recovery workers, in addition to their usual tasks, had to devote a good deal of time and resources to helping individuals who were weakened not only by the direct effects of the hurricane and flooding but also by disrupted inpatient and outpatient medical treatment.

All this became evident to me as I as the commander of the Joint Task Force (JTF-Katrina) experienced and responded to the disaster of Katrina. How you survive a disaster is directly proportional to what you were doing before it. In New Orleans, there are large pockets of poverty and the situation is worse than that in many other cities. The available jobs are largely for low-skilled and low-wage labor, such as in the tourist industry, which generally pays low wages and does not provide health insurance. If you are poor and struggling beforehand, as many people were and are in New Orleans, you are likely to be in an even worse situation afterward. I saw that at the Superdome and the Convention Center, on that first Friday-people with limited means and no margin for safety, without adequate food, water, and medication. At one point, two mothers thrust their dehydrated babies into my arms as I walked down the street. We got them medical care from a coast guard ship.

Unfortunately, progress in restoring health services has been slow. In the aftermath of Katrina, the people with chronic illnesses and injuries in New Orleans and the Gulf areas of Louisiana and Mississippi were in dire need of healthcare services; however, access to services was unattainable.2 So many people ended up in a vicious cycle where a history of inadequate access to healthcare led to more health problems when Katrina hit and the widespread social disruption caused by Katrina then, in turn, created an even less effective access to care, and, consequently, even greater health problems for these populations afterward.3 Also, death rates in New Orleans were documented as 47% higher in the first 6 months of 2006 compared with death rates before Katrina.4

Katrina was not the only catastrophe for the poor of New Orleans. The event has been used as an opportunity to close the doors of Charity Hospital, which since 1736, maintained a mission of treating the indigent and educating healthcare professionals. As the region's only Level 1 trauma center and major center for research, 75% of medical professionals in Louisiana were trained at Charity.5 We have embarrassing rates of health disparities in the nation. Can we afford to reduce the availability of healthcare services to those who need it the most while policy makers debate payment structures? Does this policy debate over payment for services justify delays in improving the health of our nation, which in turn would facilitate a movement for being better prepared for disasters? Would elevating health disparities as a risk to national security expedite eliminating this problem?

The United States needs to develop a culture of preparedness. I am very fortunate myself, because the culture of preparedness was a part of my early life. Many of us who grew up in poverty tried to prepare ourselves for those times when our lives would be even more difficult. I carried those lessons with me for the rest of my life and they helped me do what I did during the post-Katrina disorder in New Orleans and other parts of Louisiana. I remembered during Katrina that, as a 12-year-old boy who suffered a horrible head injury during a baseball game, my life was saved through care received at Charity Hospital.

The purpose of a culture of preparedness is to save lives and money before the disaster. The elements of this cross all domains of society and government. Part of this certainly involves educating people to become more self-reliant and self-sufficient-especially if they are poor. A mindset of passivity and dependence-waiting for someone to come along and help-simply creates victims during disasters like Katrina, when government falters and individuals and families must take care of themselves (or no one will).

However, the government must take the lead in creating the conditions for the culture of preparedness. Agency representatives cannot be trading business cards at the scene of a disaster. Political leaders must become greater advocates of preparedness. They must know the players in disaster response and how to access resources. Business leaders must also be proactive and understand the corporate savings in preparedness. In case disasters cross national boundaries, US diplomats must have support agreements with other nations and have realistic rules for accepting support from outside the United States.

In all of this, there is no more important area to address than healthcare. All of the above-mentioned groups must come together with healthcare and public health agencies and policy makers and work strenuously to reduce health disparities in this nation. The health of a community before any crisis has a direct correlation to the magnitude of the health crisis after the event. Disaster preparedness must include a major reduction in medical disparities, including providing everyone access to basic health services through a medical "home" with continuity of care. For the poor and underserved, primary care is essential along with therapy, monitoring and personal health education to eliminate or reduce the damage caused by chronic illnesses. Health educators must also empower and encourage each individual to take charge of and responsibility for their own health by improving his or her lifestyle, particularly with respect to patterns of diet and exercise and the avoidance of tobacco products.

To a significant extent, the battle for a culture of preparedness requires a simultaneous battle against health disparities. Disaster preparedness and health equity go together. If our nation can create greater medical equality, we will be in a much better position to respond in the future when, inevitably, the next Katrina strikes.

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