Mental health providers worry about Harvey's legacy

At least 11,000 Houston residents sought shelter at the George R. Brown Convention Center this week after torrential rains forced them out of their homes.

For Dr. Sophia Banu, the convention center became her office.

The Baylor College of Medicine professor is an attending physician at Ben Taub Hospital and for the past three days, Banu and a team of as many as 10 mental health professionals have been on call to help provide psychiatric services to evacuees. A total of four to five professionals have been at the center to cover two, eight-hour shifts a day, seeing an average of two to three people an hour, depending on their condition.

"People who are on medications, or people who run out of medications take a little bit longer than if you do brief psychotherapy with someone who's having a panic attack or are anxious or nervous," Banu said.

Immediate support is warranted during a disaster, as anxiety and depression rises in people who have lost their homes, or are unsure whether a family member or friend is safe, she said.

More than 30 people have reportedly died and more than 30,000 have been evacuated from their homes as of Thursday afternoon after Hurricane Harvey hit land last weekend and produced up to 50 inches and rainfall.

Banu and her staff are helping victims schedule follow-up appointments for counseling at the hospital or at community clinics that may be easier for patients to reach.

She said providing follow-up care will be essential after Harvey. "There will be a huge need for mental healthcare moving forward," Banu said.

About a dozen area hospitals have been forced to close in some capacity due to flooding, according to Dr. Umair Shah, executive director of Harris County's public health department, who said most of those currently offline are smaller facilities while the area's largest health systems have remained operational.

The county's public health and disaster response efforts are being led by a catastrophic medical operations center established by the region's SouthEast Texas Regional Advisory Council, which is tasked with providing "technical assistance to the region for Preparedness, Trauma, Injury Prevention, Stroke, Cardiac and Pediatric services."

Shah said health officials get real-time updates to learn which hospitals are accepting patients. The command center also flags accessible routes for paramedics, and can track nursing homes and other long-term care facilities to identify areas that need help.

"Houston's Harris County is as prepared as any county in the country," Shah said.

Lessons from Katrina

Dr. David Engleking recalls taking part in emergency preparedness planning for southwestern Louisiana when he first joined Gulf Coast-based Christus Health system in 2009 as chief medical officer of St. Patrick Hospital in Lake Charles.

A few years had already passed since 2005's devastating storm season saw major hurricanes such as Katrina and Rita ravage coastal regions along Louisiana and Texas. More than 1,800 people were killed and more than a quarter-million people were displaced in the immediate aftermath of Hurricane Katrina.

But "the residual effects of that kind of thing last for a long time after the appearance of normalcy has been restored," said Engleking said, now chief medical officer for Christus' health insurance arm.

Some residents experienced skin and wound infections due to exposure to chemicals and bacteria found within contaminated water. Crowded shelters saw cases of diarrheal infections.

Those who returned home, found moldy environments that contributed to respiratory infections and tuberculosis.

Floodwaters washed away mosquito breeding sites, but that insect population later thrived in large pools of standing water. The result was a doubling of West Nile virus infections one year after Katrina, according to Dr. Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine in Houston.

"At the time of Katrina there was no dengue, chikungunya, or Zika in Louisiana," Hotez said. Zika cases had actually been declining this year compared with 2016. "But now we have all three here in Texas, so I think we have to worry about that as well."

A 2007 study published in the Journal of General Internal Medicine found more than 20% of the three-quarters of Katrina survivors who had one or more chronic conditions cut back or stopped their treatment after the storm.

But the quietest public health concern after Katrina was the massive toll it took on the mental health of survivors. The storm was devastating and deadly and aggravated post-traumatic stress disorder, especially for those already diagnosed with a behavioral health disorder.

"Needless to say, people with mental health diseases do not need any other provocation," Engleking said. "The minute you begin adding major stressors that add longer-term disruptors to their routine, their therapy often gets provided by the local police department and the county jail."

Indeed, an assessment of Katrina survivors conducted upon their return to New Orleans found nearly half showed signs of post-traumatic stress disorder, with the most vulnerable being low-income, young African-American mothers. Overall rates of mental illness increased a year after the storm, with 14% experiencing serious mental illness compared with 7% before the hurricane.

According to Dr. Maureen Lichtveld, professor and chair of environmental health sciences at Tulane University's School of Public Health and Tropical Medicine, local access to mental health services was already low before Katrina,

In the years after, efforts were made to put behavioral health resources closer to the affected communities to provide quicker response during a disaster.

Lichtveld said one of the ways the region surrounding New Orleans improved capacity to mental health services was to train and deploy members of the community as health workers to provide a kind of social network that helps victims deal with their anxieties.

"This is all about planning beforehand and knowing your gap so that others around you can help fill it," Lichtveld said.

The funding need

While the immediate focus is on search, rescue and recovery efforts, Shah is sure the proper infrastructure was in place to address the long-term, public health needs of residents. However, he acknowledged that the unprecedented amount of rain and flooding will challenge providers and will require outside help.

He said much will depend on emergency funding. And just how much federal support can be expected remains unclear.

Last weekend HHS Secretary Dr. Tom Price declared a public health emergency in Texas, which will free up some emergency funding immediately. The CMS also can grant healthcare providers more flexibility in meeting the health needs of Medicare and Medicaid beneficiaries, such as waiving certain documentation requirements.

President Donald Trump has reportedly pledged billions in emergency aid to Texas. But Republican congressional lawmakers are reportedly seeking to cut more than $870 million from the $2.3 billion remaining in the Federal Emergency Management Agency's disaster relief account to offset some of the costs of building the president's wall along the U.S.-Mexico border.

It is likely Congress will approve a disaster relief funding package given the level of devastation, estimated at more than $40 billion—the most expensive natural disaster in history.

Hotez said he remained cautiously optimistic about federal aid.

"I've learned to lower my expectations as to what I can expect from the federal government," Hotez said. "From everything that I have seen we've been on our own."