Minding the gaps

The ongoing oil calamity off the Louisiana coast poses tremendous challenges, not only to containing and countering a significant environmental catastrophe but also to management of public health and care delivery in the region. As with any disaster or exceptional event—including those we have faced—the situation presents a dizzying mix of proven science, unknown factors and unique circumstances.

Sadly, the scope of this disaster is not unprecedented. In 1979, a Mexican drilling platform, the Ixtoc I, exploded in the southern Gulf. More than 3.5 million barrels of oil escaped in the 10 months it took to cap that leak, flowing at a rate greater than the Deepwater Horizon site, albeit at 160 feet versus a 5,000-foot depth. Similarly, the 1991 Kuwaiti oil well fires caused a significant amount of environmental pollution and as yet unknown long-term health consequences.

As HHS Secretary Kathleen Sebelius has said, the myriad efforts of local, state and federal governments will contribute to situational awareness and any subsequent, needed response. The efforts include enhanced environmental sampling (air, soil and water), BioSense and poison control monitoring, and activating elements of the U.S. Public Health Service Commissioned Corps, the National Disaster Medical System, and other federal and state assets to provide augmentative capabilities.

Determining the proper response is complicated by the extensive unknowns. While a common perception is of a large, black slick atop the water, reports of subsurface plumes, a film-causing ambient air suspension and dispersion by use of chemicals of varying toxicity cloud the operational picture. Although not unprecedented in volume or response, the current spill occurred at an exceptional depth under a unique ecosystem of water currents, flora and fauna.

The world of contingency planning relies heavily on the concept of “all hazards” response. This is an attempt to provide for the general case and agent- or situation-specific circumstances. Ideally, this approach includes public health considerations within the emergency responder population and those within a hard-to-define, proximate area of impact.

Even if the disaster-related health threats can be adequately identified, the extent of exposure is likely to remain a mystery. Variables such as prior exposures, susceptibility, whether personal protective equipment was used, if PPE was used correctly, and the effectiveness of available equipment against the specific threats remain largely undiscoverable. Further confounding factors include the applicability of standards developed by the Occupational Safety and Health Administration, National Institute for Occupational Safety and Health, and others for nonemergency environments to disaster scenarios. Can or should routine standards be applied in extraordinary circumstances? Responders to a disaster will often accept risks to self as a part of their response. To what extent does this selflessness contribute to subsequent medical conditions? An occupational culture of dedication to duty can itself be an unquantifiable health risk.

Moreover, post-disaster health consequences have not been extensively researched. For example, there have been 38 supertanker accidents during the past 50 years; only seven have been studied for human health effects. There has been some movement in this regard, such as the registration and subsequent monitoring of responders to the World Trade Center site. Creating a significant “exposure registry” would be a challenging task fraught with legal, privacy, insurance and other potential implications, but could prove invaluable in the long run.

In addition, balancing the functions of preparedness, response, mitigation and recovery across the diversity of potentially affected populations can be daunting. Toxic exposures can be relatively readily identified and the immediate effects monitored. Less apparent are the effects of social determinants of health. Workplace disruptions and unemployment are typically precursors of lower vaccination rates, degradation of healthy eating and decreased compliance with prevention and treatment regimens. Gross contact with pooled crude oil or exposure to toxic fumes provides a baseline marker for subsequent syndromic surveillance. Less evident are the long-term effects of the subtle atmospheric presence of oil evaporated off the sea surface, or even the extent and reach of these invisible clouds.

Finally, perhaps the greatest public health challenge is providing the appropriate level of access. Disaster response literature is replete with analysis of what has been termed the “worried well,” individuals not sickened by the event but who still present for treatment. These numbers are typically orders of magnitude greater than actual casualties and can overwhelm a treatment venue or system. Similar, and far more vexing, will be the emergence of stress-induced and psychosomatic conditions, verifiable physical illnesses but with no direct organic cause. This represents the medical planner's conundrum: ample access increases utilization, or, “If you build it they will come.” Differentiating among conditions with organic causes, stress-induced illnesses and the concerns of the “worried well,” and then matching them to appropriate treatment, is both an immediate and long-term task.

Perhaps building on the lessons of the World Trade Center collapse and severe acute respiratory syndrome, better known as SARS—both incidents with many unknowns but demanding rapid response—the initial health response to Deepwater Horizon has been positive. The trade center collapse exposed gaps in communication and coordination within our extensive health system. It is imperative that those gaps be closed via advanced planning and enhanced sharing of information. Far too many of our advances in response have been products of retrospective analysis. The ongoing disaster in the Gulf offers the opportunity to improve our capabilities in this arena. The long-term benefit of doing so is immeasurable.