Category: Mass Death: Disasters, Pandemics, etc.

The Effects of Natural Disasters on Society

In the wake of a natural disaster, death is not uncommon. Although communicable diseases do occur after hurricanes, death is more so caused by blunt trauma, crush-related injuries, or drowning.1 For example, during Hurricane Katrina, three hundred eighty-seven victims drowned, two hundred forty-six people sustained trauma or injuries severe enough to cause their deaths, and two hundred twenty-six victims had no specific cause of death. For those who had injury-related causes of death, six died from heat exposure, four unintentionally from firearms, two from homicide, four from suicide, three from gas poisoning, and one from electrocution. In total, Hurricane Katrina caused nine hundred eighty-six unfortunate deaths.2

Though the number of immediate deaths caused by Hurricane Katrina is astonishing, even more people perished after she had finished running through her full course. However, if the hurricane itself is not fully responsible for the loss of life, it must be attributed to another factor. Although most people correctly believe that, following natural disasters, there is an increased risk of infectious disease outbreaks, they often believe that it is higher than it truly is. In large part, this misconception is due to exaggeration by the media. The media works to cause unnecessary panic, confusion, and sometimes health-related actions within the population.3

Another false belief is that dead bodies cause disease. Actually, the main cause of disease is population displacement because it leads to other issues such as contaminated water and overcrowding which results in increased contact with infected individuals. Water may become contaminated if a hurricane destroys the sanitation and sewage systems which is extremely hazardous. Contaminated water is especially hazardous after natural disasters because various illnesses can develop from exposure to it.1

According to the Centers for Disease Control and Prevention (CDC), the diseases which can spread after disasters like hurricanes are “cholera, diarrhea, Hepatitis A, Hepatitis E, leptospirosis, parasitic diseases (eg, amebiasis [Entamoeba histolytica], cryptosporidiosis, cyclosporiasis, and giardiasis), rotavirus, shigellosis, and typhoid fever.”4 The factors which could influence the risk of infection of disease include availability of clean water, sanitation and sewage systems, degree of crowding, pre-existing health conditions of the population, immunity to illness, and access to healthcare.1

Population displacement is problematic because it increases the risk of infectious disease outbreaks. Population displacement causes people to move around and crowd places which have taken the least amount of damage during a hurricane. Gastroenteritis, also known as the stomach flu, resulted heavily after Hurricane Katrina in over a thousand evacuees. In overcrowded settings, noroviruses like gastroenteritis are easily spread.5 Acute respiratory infections (ARI) are another major cause of illness and death among displaced populations because of close proximity to other individuals.

 

People tend to overcrowd certain areas causing population displacement

http://tinyurl.com/y2s7c6h9

 

Hurricane Katrina was not the only natural disaster to see an increase in the spread of infectious diseases. After Hurricane Mitch (1998), the occurrence of ARI increased by four times in Nicaragua.1 The condition of illnesses like tuberculosis can be worsened because of population displacement and reduced access to healthcare. Following Hurricane Katrina though, an emphasis was placed on finding new cases of tuberculosis and continue treatment of the known ones.3 Not only does population displacement allow communicable diseases to spread more easily, but it also causes sudden population influxes in certain areas which leads to unsanitary living conditions.

If people consume unsanitary water, they could contract any number of diseases, including meningitis, cholera, Salmonella, E. coli, and other diarrheal infections. Those directly affected by Hurricane Katrina suffered from diarrhea, tuberculosis, norovirus, Salmonella, cholera.1 In fact, the CDC received reports of the occurrence of diarrheal disease from groups of individuals in evacuation centers in Louisiana, Mississippi, Tennessee, and Texas.4 Hurricane Jeanne forced the people of Haiti to deal with meningitis and he people of Central America had to endure cholera as a result of Hurricane Mitch.6 It is clear that following hurricanes, clean water is difficult to find.

The flooding that results from the occurrence of a hurricane, has hazardous effects such as vector-borne diseases and mold. Standing water can lead to the accumulation of carriers of Malaria and the West Nile virus in the surrounding area.6 The flooding that occurred because of Hurricane Flora led to an outbreak of over seventy-five thousand cases of Malaria.5 Mold is another issue that results from flooding. Hurricane Katrina left eighty percent of New Orleans, Louisiana submerged in water.4 Therefore, it is not shocking that visible mold growth was found in forty-five percent of homes inspected after Hurricane Katrina. The indoor air levels of mold were elevated meaning there was more airborne mold, and more reason for concern about respiratory health.5

 

The extent of flooding after Hurricane Katrina

http://tinyurl.com/y5xdpv9u

 

Physical damage and health concerns are not the only danger presented to us by hurricanes. By not actively preparing for and dealing with hurricanes, we put everyone already potentially in danger into an even greater risk for trauma. Across cultures, natural disasters greatly affect distributions of people in many different ways. After massive storms like that of Hurricane Katrina, we often find legions of studies conducted to find all the ways in which a population is affected. It has been found that being exposed to disease as well as the innumerable ethical dilemmas that come with attempting to solve such a large-scale problem, can have severe and lasting impacts on the culture of the region affected.

Culture is defined through material and non-material things, and hurricanes often destroy these things and leave behind unparallelled destruction in their wake. Factors that can influence cultural and psychological well-being include time taken to return to normal life, the extent of damage done by the natural disaster, and effectiveness or ineffectiveness of help received. Often times these cultural effects are different between races of people, such as in New Orleans when Hurricane Katrina hit in 2005. You can see the disproportionate suffering is clearly attributed to the “economic and social stratification that was present in New Orleans before Hurricane Katrina that became magnified after the storm.”7

Culture is incredibly important when considering the normative experience of families in America. It is the moral backbone that our nation is founded on, the glue that holds societies together. Without culture, there would be no common connection between people in the same geographical area, or even connections between people of potentially similar upbringings or backgrounds. In the instances involving natural disasters, culture can be deeply affected through the devastation of homes and personal items, as well as the natural social order in towns and urban areas. Often natural disasters destroy deeply personal items that cannot be replaced, which impacts the owners of the personal items extremely upset or angry for losing such a deeply personal keepsake.

 

Hurricane Katrina brought tremendous loss upon people and left them forever changed

http://tinyurl.com/y4d3e6qf

 

The great losses suffered by the people of New Orleans “exacerbated the uses of substance dependence, psychiatric disorders, child molestation, domestic violence, and other relational difficulties.7 News coverage also highlighted the social stratification in New Orleans during the aftermath of Katrina, and served to differentiate the vulnerable African-American poor from the rest of the population through media coverage of welfare dependency, crime, and familial dysfunction rather than focusing on the real issues at hand- the lack of disaster relief coming in to New Orleans.8

The elderly and children are often disproportionately affected when considering the rest of the population in the area of displacement and damage to property. These losses were also seen to cause a spike in rates of PTSD and general psychic morbidity among the elderly affected.9 Following Hurricane Katrina, there was a rate of PTSD among children as high as 62.5% who remained in the affected area. There were also similar rates of comorbid disorders such as oppositional defiant disorder and separation anxiety disorder.9 The impact of national disasters culturally can be shown through the destruction of property, social order, and high rates of PTSD and other relational difficulties. National disasters also affect other areas of life as well.

Having a thorough and clear understanding of the numerical and social impacts of natural disasters, one must wonder what can we do to make a difference? To make a true and effective difference, we can look at what we have and have not been doing in the past and hold those that dropped the ball accountable. In order to find those accountable, we must answer the question, what is the responsibility of the government when it comes to its people?

Specifically, in relation to hurricanes and other natural disasters, the responsibilities of the government are delegated to a specific government agency known as FEMA. The mission statement of FEMA or the Federal Emergency Management Agency is “Helping people before, during, and after disasters” according to their official website.10 Founded in 1988 with the responsibility of coordinating relief efforts after the declaration of an emergency, “It is designed to bring an orderly and systemic means of federal natural disaster assistance for state and local governments in carrying out their responsibilities to aid citizens.”10 (FEMA Website). Essentially, it is the responsibility of FEMA to ensure that people are properly evacuated, resources and aid are administered effectively, and in the aftermath of the storm, those displaced are safely removed from the area.

 

FEMA workers helping with hurricane recovery

http://tinyurl.com/y6hqff8q

 

As we already know, in the aftermath of a storm the chances for an epidemic of airborne and waterborne illnesses increase exponentially. Hurricanes bring colossal surges of water that typically stand for days if not weeks in homes in roads inhabited by countless people. Along with this water comes a myriad of dangers and conditions that can only exacerbate already deplorable conditions. It is vital that agencies such as FEMA fulfill their duty in order to get people out of dangerous and or contaminated environments and with resources one would vitally need after such a storm.

In the documentary titled, “When The Levees Broke”, Spike Lee (2006) recounts the numerous tragedies suffered by those caught in the wrath of Hurricane Katrina.11 Survivors recount stories of going days in shelters without electricity, plumbing, or medication for the sick and elderly. These are the stories of people that evacuated to shelters and people that stayed home to brave the storm because they did not have the resources to evacuate or relocate alike. Specifically, in part three of the documentary a few children explain that their mother passed away from a lack of compressed oxygen while waiting days for aid.11 What this shows, is people clearly died as a direct result of not having access to the proper resources in the aftermath of the storm.

The failures of FEMA are not isolated simply to Hurricane Katrina, most recently in 2017, category 5 Hurricane Maria ravaged Puerto Rico in a storm that considered one of the worst to ever hit the Caribbean islands on record. Keeping FEMA’s mission statement in mind, as well as the fact the agency had 9 years to learn specifically from events in Katrina (as well as the numerous disaster in between), one would expect FEMA to have been fully staffed and trained with resources in place for Hurricane Maria. In the year and a half since the catastrophic storm, we have learned that over three thousand people died as a result of Hurricane Maria12, it took nearly a year for power to be restored to the entirety of Puerto Rico13, and twenty-thousand pallets of fresh bottled water sat spoiling in the hot sun waiting to be distributed as countless Puerto Ricans had no access to running water.14

While Hurricane Katrina was neither the first nor last hurricane to hit the US, we can learn from this and others in order to prepare in the most effective ways possible and ensure the least amount of loss of life as we can. There were increases in mortality of forty-seven percent15 and sixty-two percent16 increase were found in New Orleans and Puerto Rico respectively. What this demonstrates is the failures of our government have real life or death implications for hundreds of thousands if not millions of people. Studies found that in both Hurricanes Katrina and Maria there were extreme increases in overall mortality.

Every single day millions of people count on the idea that in the event of a natural disaster or emergency, they can depend on the government for information and resources. It is not simply the obligation but the stated duty of the federal government and FEMA to take care of its people in their most desperate times of need. Without the effective distribution and management of aid and resources by FEMA, countless people will find themselves in contaminated environments with little to no access to clean water or vital medications.

 

Jillian Araya

Tierra Faulkner

Elizabeth Allred

 

 

  1. Watson, John , Michelle Gayer, and Maire A. Connolly. “Epidemics after Natural

Disasters.”  Emerging Infectious Diseases  January 2007.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725828/.

  1. Brunkard, Joan, Gonza Namulanda, and Raoult Ratard. “Hurricane Katrina Deaths,

Louisiana, 2005.” Disaster Medicine and Public Health Preparedness 2, no. 04

(December 2008): 215-23. https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/hurricane-katrina-deaths-louisiana-2005/8A4BA6D478C4EB4C3308D7DD48DEB9AB.

  1. Kouadio, Isidore , Syed Aljunid, Taro Kamigaki, Karen Hammad, and Hitoshi Oshitani. “Infectious Diseases following Natural Disasters: Prevention and Control Measures.” Expert Review of Anti-infective Therapy  10 (January 10, 2014): 95-104. https://www.tandfonline.com/doi/abs/10.1586/eri.11.155.
  2. Ligon, B. Lee. “Infectious Diseases That Pose Specific Challenges After Natural Disasters: A Review.” Seminars in Pediatric Infectious Diseases  17, no. 1 (January 2006): 36-45. https://www.sciencedirect.com/science/article/pii/S1045187006000033.
  3. Ivers, Louise , and Edward T. Ryan. “Infectious Diseases of Severe Weather-related and Flood-related Natural Disasters.” Current Opinion in Infectious Diseases  19 (October 2006): 408-14. https://oce.ovid.com/article/00001432-200610000-00003/HTML.
  4. Spiegel, Paul , Phuoc Le, Mija-Tesse Ververs, and Peter Salama. “Occurrence and Overlap of Natural Disasters, Complex Emergencies and Epidemics during the past Decade (1995–2004).” Conflict and Health,  March 01, 2007. https://conflictandhealth.biomedcentral.com/articles/10.1186/1752-1505-1-2.
  5. Holiday, Bertha G. Hurricane Katrina: A Multicultural Disaster, (American Psychological Association), March 2006. apa.org/pi/oema/resources/communique/2006/03/katrina-special-section.pdf.
  6. Mann, Nicole and Victoria Pass, The Cultural Visualization of Hurricane Katrina (University of Rochester), 2011. www.rochester.edu/in_visible_culture/Issue_16/articles/mann and pass/mann_pass_intro.html.
  7. Jogia, J. et al, Culture and the Psychological Impacts of Natural Disasters: Implications for Disaster Management and Disaster Mental Health (The Built and Human Review volume 7), 2014. research.aston.ac.uk/portal/files/14837549/Culture_and_the_psychological_impacts_of_natural_disasters.pdf.
  8. About the Agency. (n.d.). Retrieved from https://www.fema.gov/about-agency
  9. Lee, S., Pollard, S., Nagin, R., Penn, S., Sharpton, A., Marsalis, W., Belafonte, H., … HBO Video (Firm). (2006). When the Levees Broke: A Requiem in Four Acts. New York: HBO Video.
  10. Fink, S. (2018, August 28). Nearly a Year After Hurricane Maria, Puerto Rico Revises Death Toll to 2,975. Retrieved from https://www.nytimes.com/2018/08/28/us/puerto-rico-hurricane-maria-deaths.html
  11. Sullivan, E. (2018, August 15). Nearly A Year After Maria, Puerto Rico Officials Claim Power Is Totally Restored. Retrieved from https://www.npr.org/2018/08/15/638739819/nearly-a-year-after-maria-puerto-rico-officials-claim-power-totally-restored
  12. Weir, B. (2018, September 20). 20,000 pallets of bottled water left in Puerto Rico. Retrieved from https://www.cnn.com/2018/09/12/us/puerto-rico-bottled-water-dump-weir/index.html
  13. Stephens, K. U., Grew, D., Chin, K., Kadetz, P., & Greenough, P. G. (07/2007). Excess mortality in the aftermath of hurricane katrina: A preliminary report. doi:10.1097/DMP.0b013e3180691856
  14. Kishore, N., M.P.H., Marqués, D., PhD, Mahmud, A., PhD., Kiang, M. V., M.P.H., Rodriguez, I., B.A., Fuller, Arlan,J.D., M.A., . . . Buckee, C. O., D.Phil. (2018). Mortality in puerto rico after hurricane maria. The New England Journal of Medicine, 379(2), 162-170. doi:http://dx.doi.org.libproxy.lib.unc.edu/10.1056/NEJMsa1803972

 

 

The Effect of Hurricanes on Epidemics of Airborne and Waterborne Illnesses

In the wake of a natural disaster, death is not uncommon. Although communicable diseases do occur after hurricanes, death is more so caused by blunt trauma, crush-related injuries, or drowning.[1] For example, during Hurricane Katrina, three hundred eighty-seven victims drowned, two hundred forty-six people sustained trauma or injuries severe enough to cause their deaths, and two hundred twenty-six victims had no specific cause of immediate death. For those who had injury-related causes of death though, six died from heat exposure, four unintentionally from firearms, two from homicide, four from suicide, three from gas poisoning, and one from electrocution. In total, Hurricane Katrina caused nine hundred eighty-six unfortunate deaths.[2]

Though the number of immediate deaths caused by Hurricane Katrina is astonishing, even more people perished after she had run her full course. Thus, it is clear that the hurricane itself is not fully responsible for the loss of life so there must be another factor at play. Not only are the effects of severe hurricanes and other natural disasters long-lasting, but also deadly. Diseases often spread among survivors leading to even more loss of life. Although most people correctly believe that, following natural disasters, there is an increased risk of infectious disease outbreaks, they often believe that that risk is higher than it truly is. In large part, this misconception is due to exaggeration by the media. Without specific evidence, the media reports about the imminent threat of disease which causes unnecessary panic, confusion, and sometimes health-related actions within the population.[3]

Another false belief is that dead bodies cause disease.[1] People worry that the bodies of those who have passed may infect those who have survived with disease. However, the main cause of disease is actually population displacement. Population displacement leads to other issues such as contaminated water and overcrowding which results in increased contact with infected individuals. Contaminated water is especially hazardous after natural disasters because various illnesses can develop from exposure to it.[1]

According to the Centers for Disease Control and Prevention (CDC), the diseases which can spread after disasters like hurricanes are “cholera, diarrhea, Hepatitis A, Hepatitis E, leptospirosis, parasitic diseases (eg, amebiasis [Entamoeba histolytica], cryptosporidiosis, cyclosporiasis, and giardiasis), rotavirus, shigellosis, and typhoid fever.”[4] The factors which could influence the risk of being infected by any one of these diseases include availability of clean water, damage to sanitation and sewage systems, degree of crowding, pre-existing health conditions of the population, immunity to illness, and access to healthcare.[1]

People tend to overcrowd certain areas causing population displacement

http://tinyurl.com/y2s7c6h9

Population displacement is problematic because it increases the risk of infectious disease outbreaks. Population displacement causes people to move physically and crowd places which have taken the least amount of damage during a hurricane. Gastroenteritis, also known as the stomach flu, resulted after Hurricane Katrina in over a thousand evacuees. In overcrowded settings, noroviruses like gastroenteritis are easily spread.[5] Acute respiratory infections (ARI) are another major cause of illness and death among displaced populations because of close proximity to other individuals. After Hurricane Mitch occurred in 1998, the number of observed cases of ARI increased by four times in Nicaragua.[1] The condition of illnesses like tuberculosis can also be worsened because of population displacement and reduced access to healthcare. Following Hurricane Katrina though, an emphasis was placed on finding new cases of tuberculosis and continuing treatment of the known ones.[3] It helps put minds at rest to know that even in a state of emergency, officials do everything they can to try to save as many lives as possible. Not only does population displacement allow communicable diseases to spread more easily, but it also causes sudden population influxes in certain areas which leads to unsanitary living conditions.

Water may become contaminated if a hurricane destroys the sanitation and sewage systems because then there is no way to clean the water. In crowded areas, the need for sanitation and sewage systems only increases. Bodily fluids and feces are likely to infiltrate the water and taint it. If people consume unsanitary water, they could contract any number of diseases, including meningitis, cholera, Salmonella, E. coli, and other diarrheal infections. Those directly affected by Hurricane Katrina suffered from diarrhea, tuberculosis, norovirus, Salmonella, cholera.[1] The CDC received reports of the occurrence of diarrheal disease from groups of individuals in evacuation centers in Louisiana, Mississippi, Tennessee, and Texas.[4] The diarrheal disease had spread across four different states allowing it to gain the status of an epidemic. Hurricane Jeanne forced the people of Haiti to deal with meningitis and the people of Central America had to endure cholera as a result of Hurricane Mitch.[6] The spread of disease across an entire country or region of the world certainly causes worry as infectious diseases can easily transform from small outbreaks to epidemics if the population and officials are not careful.

The flooding that results from hurricanes has hazardous effects such as increased risk of vector-borne diseases and mold. Standing water can lead to the accumulation of carriers of Malaria and the West Nile virus in surrounding areas.[6] The flooding that occurred because of Hurricane Flora led to an outbreak of over seventy-five thousand cases of Malaria.[5] Mold is another issue that results from flooding. Hurricane Katrina left eighty percent of New Orleans, Louisiana submerged in water.[4] Therefore, it is not shocking that visible mold growth was found in forty-five percent of homes inspected after Hurricane Katrina. The indoor air levels of mold were elevated which means there was more airborne mold, and therefore, more reason for concern about respiratory health.[5]

The extent of flooding after Hurricane Katrina

http://tinyurl.com/y5xdpv9u

Physical damage and health concerns are not the only dangers presented by hurricanes. By not actively preparing for how to deal with hurricanes, people put themselves at an even greater risk of trauma. Across cultures, natural disasters like hurricanes greatly affect distributions of people in different ways. After massive storms like Hurricane Katrina, legions of studies are often conducted to identify all the ways in which the population is affected. It has been found that being exposed to disease as well as the innumerable ethical dilemmas that come with attempting to solve such a large-scale problem, can have severe and lasting impacts on the culture of the region affected.

Culture is defined through material and non-material things, which hurricanes often destroy, leaving behind unparalleled destruction in their wake. Factors that can influence cultural and psychological well-being include time taken to return to normal life, the extent of damage done by the natural disaster, and effectiveness or ineffectiveness of help received. Oftentimes, these cultural effects vary between races of people. When Hurricane Katrina hit New Orleans in 2005, the disproportionate suffering was clearly attributed to the “economic and social stratification that was present in New Orleans before Hurricane Katrina that became magnified after the storm.”[7] The great losses suffered by the people of New Orleans “exacerbated the uses of substance dependence, psychiatric disorders, child molestation, domestic violence, and other relational difficulties.[7] News coverage highlighted the social stratification in New Orleans during the aftermath of Katrina and served to differentiate the vulnerable African-American poor from the rest of the population. The media mainly covered matters of welfare dependency, crime, and familial dysfunction rather than focusing on the real issues at hand like the lack of disaster relief coming into New Orleans.[8]

Culture is incredibly important when considering the normative experience of families in America. It is the moral backbone that our nation is founded on, the glue that holds societies together. Without culture, there would be no common connection between people in the same geographical area, or even connections between people of potentially similar upbringings or backgrounds. In instances involving natural disasters, culture can be deeply affected through the devastation of homes and personal items, as well as the natural social order in towns and urban areas. Often natural disasters destroy deeply personal items that cannot be replaced, which impacts the owners of the personal items. They may become extremely upset or angry because they have lost such a deeply personal keepsake. Hurricanes are not known to show anyone any mercy and will leave nothing but paths of destruction in their wake.

Hurricane Katrina brought tremendous loss upon people and left them forever changed

http://tinyurl.com/y4d3e6qf

The elderly and children are often disproportionately affected when considering the rest of the population in the area of displacement and damage to property. Displacement and property damage were actually seen to cause a spike in rates of PTSD and general psychic morbidity among the elderly affected.[9] Following Hurricane Katrina, there was a rate of PTSD among children as high as sixty-two percent of those who remained in the affected area. There were also similar rates of comorbid disorders such as oppositional defiant disorder and separation anxiety disorder.[9] The impact of national disasters culturally can be shown through the destruction of property, social order, and high rates of PTSD and other relational difficulties.

One must wonder whether or not it is possible to lessen the social impacts which inevitably follow natural disasters like hurricanes. The only way it would even be possible enact change is if individuals looked at what had and had not been done in the past and learned from those mistakes. Once those responsible for the mistakes are identified, they can be held accountable. People often rely on their governments, especially in times of crisis, because they expect their government to help them. However, the exact responsibilities of the government must be established for the government to be able to effectively help its citizens.

Specifically, in relation to hurricanes and other natural disasters, the responsibilities of the government are delegated to a specific government agency known as the Federal Emergency Management Agency or FEMA. The mission statement of FEMA is “helping people before, during, and after disasters”.[10] Founded in 1988 it holds the responsibility of coordinating relief efforts after the declaration of an emergency. According to FEMA’s official website, “it is designed to bring an orderly and systemic means of federal natural disaster assistance for state and local governments in carrying out their responsibilities to aid citizens.”[10] Essentially, it is the responsibility of FEMA to ensure that people are properly evacuated, resources and aid are administered effectively, and in the aftermath of the storm, those displaced are safely removed from the area.

FEMA workers helping with hurricane recovery

http://tinyurl.com/y6hqff8q

In the aftermath of a storm, the chances of an epidemic of airborne and waterborne illnesses increase exponentially. Hurricanes bring colossal surges of water that typically stand for days if not weeks in homes inhabited by countless people. Along with this water comes a myriad of dangers which only exacerbate already awful conditions. It is vital that agencies such as FEMA fulfill their duty to get people out of dangerous or contaminated environments with resources one would vitally need after a severe storm.

In the 2006 documentary When The Levees Broke, Spike Lee recounts the numerous tragedies suffered by those caught in the wrath of Hurricane Katrina.[11] Survivors recount stories of going days in shelters without electricity, plumbing, or medication for the sick and elderly. These are the stories of people who evacuated to shelters and people that stayed home to brave the storm because they did not have the resources to evacuate or relocate. Specifically, in part three of the documentary, a few children explain that their mother passed away from a lack of compressed oxygen while waiting days for aid.[11] This clearly shows that people died as a direct result of not having access to the proper resources after the storm.

The failures of FEMA are not isolated simply to Hurricane Katrina. Most recently in 2017, category 5 Hurricane Maria ravaged Puerto Rico. The storm was considered one of the worst ever recorded to hit the Caribbean islands. Keeping FEMA’s mission statement in mind, as well as the fact the agency had nine years to learn from events regarding Katrina (as well as the numerous disasters in between), one would expect FEMA to have been fully staffed and trained with resources in place for Hurricane Maria. In the year and a half since the catastrophic storm, there have been over three thousand deaths as a result of Hurricane Maria.[12] It also took nearly a year for power to be restored to the entirety of Puerto Rico,[13] and twenty-thousand pallets of fresh bottled water sat spoiling in the hot sun waiting to be distributed as countless Puerto Ricans had no access to running water.[14]

While Hurricane Katrina was neither the first nor last hurricane to hit the United States, lessons can certainly be learned from its occurrence in order to prepare in the most effective ways possible and ensure the least amount of loss of life. Following Hurricane Katrina and Hurricane Maria, there were increases in mortality by forty-seven percent[15] and sixty-two percent[16] in New Orleans and Puerto Rico, respectively. Both increases in overall mortality are certainly considered to be extreme. These statistics demonstrate that the failures of the government have real-life implications like death for hundreds of thousands if not millions of people.

Every single day millions of people count on the idea that in the event of a natural disaster or emergency, they can depend on the government for information and resources. It is not simply the obligation but the stated duty of the federal government and FEMA to take care of its people in their most desperate times of need. Without the effective distribution and management of aid and resources by FEMA, countless people will find themselves in contaminated environments with little to no access to necessities such as clean water and life-saving medications.

 

Jillian Araya

Tierra Faulkner

Elizabeth Allred

 

[1] Watson, John  T., Michelle Gayer, and Maire A. Connolly. “Epidemics after Natural Disasters.”  Emerging Infectious Diseases  January 2007. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725828/.

[2] Brunkard, Joan,  Gonza Namulanda, and Raoult Ratard. “Hurricane Katrina Deaths, Louisiana, 2005.” Disaster Medicine and Public Health Preparedness 2, no. 04 (December 2008): 215-23. https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/hurricane-katrina-deaths-louisiana-2005/8A4BA6D478C4EB4C3308D7DD48DEB9A.

3 Kouadio, Isidore  K., Syed Aljunid, Taro Kamigaki, Karen Hammad, and Hitoshi Oshitani. “Infectious Diseases following Natural Disasters: Prevention and Control Measures.” Expert Review of Anti-infective Therapy  10 (January 10, 2014): 95-104. https://www.tandfonline.com/doi/abs/10.1586/eri.11.155.

5 Ivers, Louise  C., and Edward T. Ryan. “Infectious Diseases of Severe Weather-related and Flood-related Natural Disasters.” Current Opinion in Infectious Diseases  19 (October 2006): 408-14. https://oce.ovid.com/article/00001432-200610000-00003/HTML.

4 Ligon, B. Lee.  “Infectious Diseases That Pose Specific Challenges After Natural Disasters: A Review.” Seminars in Pediatric Infectious Diseases  17, no. 1 (January 2006): 36-45. https://www.sciencedirect.com/science/article/pii/S1045187006000033.

6 Spiegel, Paul  B., Phuoc Le, Mija-Tesse Ververs, and Peter Salama. “Occurrence and Overlap of Natural Disasters, Complex Emergencies and Epidemics during the past Decade (1995–2004).” Conflict and Health,  March 01, 2007. https://conflictandhealth.biomedcentral.com/articles/10.1186/1752-1505-1-2.

7 Holiday, Bertha G. Hurricane Katrina: A Multicultural Disaster, (American Psychological Association), March 2006. www.apa.org/pi/oema/resources/communique/2006/03/katrina-special-section.pdf.

8 Mann, Nicole and Victoria Pass, The Cultural Visualization of Hurricane Katrina (University of Rochester), 2011. http://www.rochester.edu/in_visible_culture/Issue_16/articles/mann%20and%20pass/mann_pass_intro.html.

9 Jogia, J. et al, Culture and the Psychological Impacts of Natural Disasters: Implications for Disaster Management and Disaster Mental Health (The Built and Human Review volume 7), 2014. https://research.aston.ac.uk/portal/files/14837549/Culture_and_the_psychological_impacts_of_natural_disasters.pdf

10 About the Agency. (n.d.). Retrieved from https://www.fema.gov/about-agency

11 Lee, S., Pollard, S., Nagin, R., Penn, S., Sharpton, A., Marsalis, W., Belafonte, H., … HBO Video (Firm). (2006). When the Levees Broke: A Requiem in Four Acts. New York: HBO Video.

12 Fink, S. (2018, August 28). Nearly a Year After Hurricane Maria, Puerto Rico Revises Death Toll to 2,975. Retrieved from https://www.nytimes.com/2018/08/28/us/puerto-rico-hurricane-maria-deaths.html

13 Sullivan, E. (2018, August 15). Nearly A Year After Maria, Puerto Rico Officials Claim Power Is Totally Restored. Retrieved from https://www.npr.org/2018/08/15/638739819/nearly-a-year-after-maria-puerto-rico-officials-claim-power-totally-restored

14 Weir, B. (2018, September 20). 20,000 pallets of bottled water left in Puerto Rico. Retrieved from https://www.cnn.com/2018/09/12/us/puerto-rico-bottled-water-dump-weir/index.html

15 Stephens, K. U., Grew, D., Chin, K., Kadetz, P., & Greenough, P. G. (07/2007). Excess mortality in the aftermath of hurricane katrina: A preliminary report. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18388597

16 Kishore, N., M.P.H., Marqués, D., PhD, Mahmud, A., PhD., Kiang, M. V., M.P.H., Rodriguez, I., B.A., Fuller, Arlan,J.D., M.A., . . . Buckee, C. O., D.Phil. (2018). Mortality in puerto rico after hurricane maria. The New England Journal of Medicine, 379(2), 162-170. Doi: http://dx.doi.org.libproxy.lib.unc.edu/10.1056/NEJMsa1803972

HIV/AIDS in the United States

The HIV/AIDS epidemic broke out in the 1980s and continues to impact individuals across the world today. In fact, Ross et al. noted that individuals diagnosed with HIV respond in ways similar to Kübler-Ross’s death and dying because HIV/AIDs was and is to an extent today still a diagnosis that is a threat to one’s life [1]. The immense HIV/AIDs epidemic can be better understood when looked at from the perspective of the patients who are infected and how society responded to these individuals. With this in mind, understanding the origin, transmission, and possible treatments of HIV/AIDs provides background as to nature of the disease and the prognosis that individuals face. Secondly, the prevalence of socioeconomic and minority disparities in HIV diagnosis and treatment contribute to the treatment of these individual patients. Lastly, an ethical perspective can be applied to early HIV testing methods, confidentiality surrounding patient diagnosis and care, and the stigma produced by religious beliefs to help explain the effects of these measures on the treatment of individual patients.

In the 1980s, the world began to see the initial signs of an epidemic. Early in the decade, reports increased of seemingly random and rare infectious diseases across the world, but it was not till the end of 1981 when the first case of HIV was medically diagnosed. These rare infectious diseases became more prevalent due to HIV/AIDS weakening individual’s immune systems. In the beginning, HIV was only understood to be viral, deadly, and highly contagious. Society quickly became aware of this new life-threatening illness and because little was known about the virus panic began to set in. Furthermore, with little information on the transmission of HIV, the rate of infected individuals began to grow exponentially. There were nearly 500 documented cases in 23 states within a year.  By 1993, there was estimated to be around 2.5 million documented cases of HIV/AIDs around the world. Then in 1995, AIDs became the leading cause of Death for Americans for ages 25 to 44 [2] .

Understanding the transmission of the virus was the first step in slowing down the increasing infection rate. Among new cases, there was a higher prevalence of diagnosis in homosexual and needle drug using communities. This clear correlation lead scientists to determine that HIV was spread through blood or bodily fluids [3]. Unprotected sex or sharing needles are two ways that individuals would directly come in contact with bodily fluids and thus increase their chance of being exposed to HIV [2]. Another possibility of transmission includes women who have HIV and them passing it to their baby either during pregnancy or through breast milk [3]. Learning how the virus was transmitted, allowed scientists to isolate the pathogen and perform further studies.

The impact of this virus on a patient’s body was crucial to the understanding the intensity of this epidemic and potentially developing a cure. The virus that causes HIV/AIDs infects the body’s T cells. More specifically, it infects CD4 cells that are responsible for the body’s immune response. These cells are critical in the body’s ability to fight off infection [3]. A lower CD4 count is correlated with a higher probability of infection. Although Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDs) are caused by the same virus, it is important to note that there is a distinction between them. An individual is diagnosed with HIV once the virus can be detected in their system. Without treatment, HIV progresses into the final stage of the disease called AIDS. AIDS is when the body is no longer able to fend off outside diseases and infections. Medically, this is characterized by a patient having one or more infections and a T cell count of less than 200. To compare, a healthy immune system has anywhere from 500 to 1600 T cells [3]. Once the origin of the virus was understood, scientists were able to work on treatments and potential cures to aid individuals living with this terminal illness.

Today, roughly 1.1 million people in the US alone have HIV, and an estimated 162,500 are unaware of their condition [3]. Due to the widespread impact of HIV/AIDS, an effective treatment or potentially a cure is crucial. In 1987, one of the first antiviral drugs called zidovudine (AZT) was approved to successfully treat HIV. Now over 25 antiviral drugs have been developed and approved to prevent transmission and spread of HIV and its progression to AIDS [4].

Figure 1 demonstrates that taking effective HIV treatment can increase HIV positive individual’s life expectancy from 32 years to 71 years. [5]

The root of every successful HIV treatment is to preserve the patient’s immune system. This is done by stopping the rapid replication of the HIV virus within a patient’s T-cells [2]. The virus can be suppressed by combination antiretroviral therapy (cART) that contains three active drugs from two or more different drug classes [4]. Using treatment as prevention approach can significantly decrease the rate of newly infected individuals and as a whole control the HIV epidemic. This system involves frequent universal testing and initiating ART drugs early after diagnosis. Treatment at any stage of the HIV infection significantly decreases the rate of viral load across the population of individuals living with HIV [6].

In addition, drugs were created in order to protect individuals that were seen as a high risk to exposure to the virus [4].  A drug called Pre-exposure prophylaxis (PrEP) is a daily dose of HIV medications to prevent them from getting infected [3]. Post-exposure prophylaxis (PEP) is an antiretroviral medicine to prevent people from becoming infected after being potentially exposed to HIV. PrEP should be used 72 hours after a recent possible exposure. For all these medications, the treatment is only effective when used exactly as instructed and taken at specific times [2]. The development of these drugs in society have allowed individuals with HIV to live long healthy lives. Furthermore, they have allowed people who do not have HIV to engage in healthy sexual relationships with HIV + people. Although these drugs are available today, universal access to them is not guaranteed.

Unfortunately, there is a correlation in HIV/AIDs diagnosis in those affected and socioeconomic and minority disparities. HIV has frequently been a disease associated with social and economic inequality due to the high proportion of individuals with a lower socioeconomic status having tested HIV positive [7]. For instance, experts claim that “some African American and Hispanic/Latino communities experience high rates of sexually transmitted infections, poverty,  and incarceration as well as low levels of socioeconomic status and education” [8]. This statement attributes that the main disparity between minority groups is due to different socioeconomic status and education. Additionally, it has been confirmed that the individual risk behaviors associated with contracting HIV such as having unprotected sex or multiple sexual partners do not justify the differing percentages of HIV infection in various ethnic groups [8]. This large variation can be attributed to the difference in the social and structural environments in which risk behaviors occur [xx]. Unfortunately, those with constricted economic opportunities are more likely to engage in riskier sexual practices in order to survive making these individuals more at risk for becoming HIV positive [7].

In Figure 2 above, the relationship between HIV prevalence and income is demonstrated indicating a trend. This trend concludes that as an individual’s income decreases HIV prevalence increases [9].

With limited resources, individuals with lower socioeconomic status have limited health care and transportation which contribute to the high percentage of women who are HIV positive [7]. With increased rates of poverty, many individuals are less educated causing them to potentially engage in unsafe sexual habits without the knowledge of how to prevent contracting various diseases [8].

Additionally, due to the association of HIV with different minority groups, many HIV positive individuals who are of racial minorities are challenged with various types of HIV stigma which contribute to increase psychological distress within these individuals [8]. This disease continues to be one of the most “stigmatizing illnesses in the United States” due to “attitudes within and about racial minority communities are typically disparaging of HIV” [8].  In some extreme instances, employers who obtained the knowledge that job applicant had HIV would not hire them due to the belief that they were somehow incompetent and would not be able to fully complete the expectations required of the occupation [7]. This prevents individuals who have HIV from obtaining a job; thereby, worsening their economic situation further which may force them to return to unsafe sexual practices which would continue to spread the disease even further. These stigmas surrounding HIV can be lessened with increased awareness regarding HIV to the public. Another suggestion to improve the treatment of those with HIV is to implement methods to advance viral suppression among minority groups such as African Americans and Hispanics. For example, providing more accessible resources would diminish viral suppression and the likelihood of HIV transmission [8].

Additionally, lower education has been associated with increased HIV; therefore, scholars strive to reduce this by implementing school-based programs that have been proven to reduce risky sexual behavior and prevent HIV in numerous areas [7]. Hopefully, these measures will not only help reduce unfair treatment of those with HIV but also the prevalence of the disease itself due to the fact that “four of the eleven counties in the lowest unemployment quartile had the lowest unemployment rate” implying that as unemployment increases the persistence of HIV increases as well [9].

The large disparities between socioeconomic groups and the association of HIV positive individuals have created a cultural gap due to the different ways in which people from various social classes think [10]. In essence, class plays a huge role in the development of specific cultures. Culture can be de defined as “the values, rules, norms, religions, scientific theories, and symbols that can be identified in a society”; therefore, socioeconomic divisions strongly influence a society’s culture and must be considered when analyzing different cultures [11]. When there are large disparities in the prevalence of a disease between socioeconomic groups, assumptions begin to arise between the two social classes conveying a sense of resentment or dislike [13]. In order to reduce the stigma associated with HIV positive individuals, one must consider how the culture of that particular society influences the way in which different social classes not only interact but also think. HIV needs to be made more aware of in communities which would help reduce the cultural connotation implied when discovering that an individual has aids. Additionally, there continues to be a disparity in the availability of HIV testing resources that contribute to the growth of stigmatization within certain underprivileged socioeconomic groups.

Due to the stigmatization of the disease, in part related to the socioeconomic divisions, many people avoid being tested due to the lack of resources that are available within certain socioeconomic groups and due to the psychological factors associated with the diagnosis. However, slightly less than half of those infected with HIV are unaware of their status, so early HIV testing has become increasingly more important in our society today, even if it may cause damage to one’s social relationships [13]. Current legislation in Connecticut and New York requires mandatory testing for HIV in newborns, which indirectly reveals the mother’s status with respect to the disease [14]. This legislation brings forward an ethical debate over whether testing should be mandatory at birth due to the severity of the disease. Even though mandatory testing is a part of the law, it is still a breach of the individual’s informed consent because children may be tested without the parents’ knowledge or consent. Testing after birth provides the parents with knowledge about the baby’s HIV status, allowing them to immediately begin treatment to help their children live healthier and longer lives if their child is HIV positive. However, there is no universal cure for the disease and the knowledge that a child is HIV positive can be burdensome on the parents, who may not wish to care for or may not have the resources to properly care for a child with a terminal illness. Recommended testing for pregnant women would resolve the majority of these issues. If HIV testing were to become a routine part of prenatal care, women would not be required to specifically consent to the HIV test, but they would still be informed that the test would be conducted [15]. Early diagnosis of the disease leads to a better response to treatment and a reduced chance of transmission to others [13]. Thus, the parents and the child could benefit from prenatal testing instead of testing after birth. Also, if tests were performed prenatally, the parents of the child would be able to decide if they wanted to go through with or terminate the pregnancy. Many ethical issues can be raised in relation to recommended testing for HIV. If the screenings become frequent and routine, the woman may not realize she has the autonomy to opt out [15]. Additionally, routine testing raises issues of confidentiality over the baby’s and mother’s HIV status, which could result in social or marital isolation due to the stigmatization of the disease. However, due to the severity of the disease, many the US Public Health Service (USPHS) and many physicians recommend that prenatal testing for HIV become a routine part of prenatal screening [15].

Figure 3 shows that mothers who discussed HIV testing with their prenatal care doctor, were more likely to receive testing before or after birth [16].

The psychological factors associated with the disease result from the stigma surrounding the disease that affects the individual. Stigma surrounding HIV has existed since the initial outbreak when the disease became known as “gay-related immune deficiency” because members of the gay community made up the majority of those infected with HIV [18]. Not only is the gay community affected by the disease, but many other marginalized social groups that face the greatest discrimination are greatly affected by the disease. Many scholars believe religion is the driver of the marginalization of these communities affected by HIV [18]. This raises the question – can religion ethically be used as a morally sound basis for discrimination toward those infected with HIV? After the initial outbreak, many religious leaders immediately identified HIV with the gay community and took the position that God was punishing them for their sins associated with being homosexual [19]. Even though there was significant evidence that the disease could be spread by heterosexuals, many religions saw the disease as a way to marginalize homosexuals and to communicate that being homosexual was a sin according to God [19]. These religious leaders used the moral principle of fidelity to demonstrate how their hatred toward the gay community stemmed from their faith in God. However, these leaders lacked the moral principle of veracity because they denied that heterosexuals were also affected by the disease, even though there was sufficient evidence to support this fact. Even though these religious leaders adhered to some of the basic moral principles, they lack support from ethical principles like nonmaleficence, which suggests that one should inflict the least amount of harm possible. The religious leaders and their followers created a stigma for HIV/AIDS that continues to cause harm to marginalized communities. Many people refuse to get tested because of the social implications that become associated with the individual who has the disease and others keep their diagnosis a secret in fear of becoming a social outcast.

The health professional’s duty to keep patient information about HIV diagnosis secret has created some ethical dilemmas about confidentiality. Currently, HIPAA (Health Insurance Portability and Accountability Act of 1996) governs the rules about HIV testing and treatment confidentiality [19]. However, there are issues with HIV-infected patients refusing to disclose their condition to their partners, and health professionals are legally required to refrain from intervening. In one example, a 37-year-old man infected with HIV was having unprotected sex with his 17-year-old girlfriend. When a clinic worker attempted to convince him to tell his girlfriend, the man responded that telling her would destroy his dream of getting married and having children [19]. Under the ethical principles of beneficence and nonmaleficence, the health professional should have been able to inform the man’s girlfriend of his condition so that she and her potential children would not be affected by the severe disease. Unfortunately, health professionals are not always able to act strictly on ethical principles because of certain laws and regulations.

Through the progression of our scholarly analysis, it becomes evident that HIV/AIDS is a complex disease. A consideration of the scientific, social, and ethical factors surrounding the disease allows us to gain a complex understanding of the HIV/AIDS epidemic as it pertains to the individual. Although HIV/AIDS is a terminal diagnosis that an individual face, the initial outbreak, and resulting repercussions impact society as a whole. Furthermore, these effects and implications of the disease are still prevalent in our society today. In the future, it will require widespread support in order to reduce the number of transmissions and stigmatizations associated with infected individuals.

Sabrina Deweerdt

Elena Wilson

Hannah Weisbecker

 

[1] Schweitzer, Ana-Maria. Mizwa, Michael. Ross, Michael. “Psychosocial Aspects of HIV/AIDS: Adults,” In HIV Curriculum for Health Professional, 334-349. Baylor College of Medicine, 2010.

[2] Public Health. “HIV and AIDS: an origin story.” https://www.publichealth.org/public-awareness/hiv-aids/origin-story/

[3] NIDA. “Drug Use and Viral Infections (HIV, Hepatitis).” National Institute on Drug Abuse, April 23 2018, https://www.drugabuse.gov/publications/drugfacts/drug-use-viral- infections-hiv-hepatitis

[2] Public Health. “HIV and AIDS: an origin story.” https://www.publichealth.org/public-awareness/hiv-aids/origin-story/

[3] NIDA. “Drug Use and Viral Infections (HIV, Hepatitis).” National Institute on Drug Abuse, April 23 2018, https://www.drugabuse.gov/publications/drugfacts/drug-use-viral- infections-hiv-hepatitis

[3] Ibid.

[3] Ibid.

[3] Ibid.

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[5] The Center for Disease Control.Web. HIV Medicines Help People with HIV Live Longer (Average Years of Life). January 2019. https://www.cdc.gov/hiv/library/infographics/index.html.

[2] Public Health. “HIV and AIDS: an origin story.” https://www.publichealth.org/public-awareness/hiv-aids/origin-story/

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[6] Wilson, David P. 2012. “HIV Treatment as Prevention: Natural Experiments Highlight Limits of Antiretroviral Treatment as HIV Prevention.” PLoS Medicine 9 (7) (07): e1001231. doi:http://dx.doi.org/10.1371/journal.pmed.1001231.

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[6] Wilson, David P. 2012. “HIV Treatment as Prevention: Natural Experiments Highlight Limits of Antiretroviral Treatment as HIV Prevention.” PLoS Medicine 9 (7) (07): e1001231. doi:http://dx.doi.org/10.1371/journal.pmed.1001231.

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[8] McCree, Donna H. et al. “An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities” Sage, [no. 4]. https://www.jstor.org/stable/44297663.

[8] Ibid.

[8] Ibid.

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[9] CDC Study Reports Poverty Among Minorities Doubles HIV Infection Rate. Figure 2. July 18, 2018. Web. Conference Report. http://www.natap.org/2010/IAS/IAS_04.htm

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[8] McCree, Donna H. et al. “An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities” Sage, [no. 4]. https://www.jstor.org/stable/44297663.

[8] Ibid.

[8] Ibid.

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[8] McCree, Donna H. et al. “An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities” Sage, [no. 4]. https://www.jstor.org/stable/44297663.

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[9] Fede, Ana L. et al. “Spatial Visualization of Multivariate Datasets: An Analysis of STD and HIV/AIDS Diagnosis Rates and Socioeconomic Context Using Ring Maps” Sage, [no. 3]. https://www.jstor.org/stable/41639311

[10] “Social Class as a Culture” Association for Psychological Science. https://www.psychologicalscience.org/news/releases/social-class-as-culture.html

[11] Gabrenya, W. K., “Culture and Social Class” Research Skills for Psychology Majors: Everything You Need to Know to Get Started. http://my.fit.edu/~gabrenya/social/readings/ses.pdf

[12] “HIV/AIDs and Socioeconomic Status” American Psychological Association. https://www.apa.org/pi/ses/resources/publications/hiv-aids

[13] Evangeli, Michael, Kirsten Pady, and Abigail L. Wroe. “Which Psychological Factors Are Related to HIV Testing? A Quantitative Systematic Review of Global Studies.” AIDS and Behavior 20, no. 4 (2015): 880-918. doi:10.1007/s10461-015-1246-0.

[14] Wolf, Leslie E., and Bernard Lo. “Comprehensive, Up-to-date Information on HIV/AIDS Treatment and Prevention from the University of California San Francisco.” Ethical Dimensions of HIV/AIDS. (2001). http://hivinsite.ucsf.edu/InSite?page=kb-08-01-05#S3.2X.

[15] Hlongwa, P. “Current Ethical Issues in HIV/AIDS Research and HIV/AIDS Care.” Oral Diseases 22 (2016): 61-65. doi:10.1111/odi.12391.

[13] Evangeli, Michael, Kirsten Pady, and Abigail L. Wroe. “Which Psychological Factors Are Related to HIV Testing? A Quantitative Systematic Review of Global Studies.” AIDS and Behavior 20, no. 4 (2015): 880-918. doi:10.1007/s10461-015-1246-0.

[15] Hlongwa, P. “Current Ethical Issues in HIV/AIDS Research and HIV/AIDS Care.” Oral Diseases 22 (2016): 61-65. doi:10.1111/odi.12391.

[15] Ibid.

[16] The Center for Disease Control. Figure 1. May 21, 1999. Web. Prenatal Discussion of HIV Testing and Maternal HIV Testing — 14 States, 1996-1997. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4819a4.htm.

[17] Courtenay–Quirk, Cari, Richard J. Wolitski, Jeffrey T. Parsons, and Cynthia A. Gómez. “Is HIV/AIDS Stigma Dividing the Gay Community? Perceptions of HIV–positive Men Who Have Sex With Men.” AIDS Education and Prevention 18, no. 1 (2006): 56-67. doi:10.1521/aeap.2006.18.1.56.

[18] Blevins, John B., Mohamed F. Jalloh, and David A. Robinson. “Faith and Global Health Practice in Ebola and HIV Emergencies.” American Journal of Public Health 109, no. 3 (2019): 379-84. doi:10.2105/ajph.2018.304870.

[19] Heimer, Carol A. “‘Wicked’ Ethics: Compliance Work and the Practice of Ethics in HIV Research.” Social Science & Medicine 98 (2013): 371-78. doi:10.1016/j.socscimed.2012.10.030.

[19] Ibid.

[19] Ibid.

[19] Ibid.

 

The West African Ebola Virus Epidemic

According to the Center for Disease Control, the West African Ebola virus is a rare and deadly disease that most commonly affects humans and other primates. This disease comes from a virus within the genus Ebolavirus and is commonly referred to as simply Ebola or EVD (Ebola Virus Disease) [1]. Ebola is a type of hemorrhagic fever virus that affects the blood’s ability to clot correctly. This can lead to internal bleeding while blood leaks from the small blood vessels in the body. It can also cause tissue damage or inflammation.[2] Two principal organs that this disease attacks are the liver and the spleen. [3]

Ebola was first identified in 1976 during two synchronic outbreaks: one in the Democratic Republic of the Congo (DRC) and the other in what is now South Sudan. [5] Since 1976, the DRC and Uganda have suffered several large outbreaks. [6] In recent years, the disease has gained a reputation as one of the most deadly and feared diseases. EVD has caused several massive outbreaks within the continent of Africa and has created global panic.[5] Throughout these outbreaks, the average fatality rate has hovered around 50%; although, it has varied between 25% and 90%, depending on the outbreak.[2] As of April 2019, Ebola has caused at least 13,000 deaths worldwide, and experts have said that the total death number could actually be much higher as this number reflects mainly reported cases of Ebola only. Over 90% of these deaths occurred within the continent of Africa.[5]

The longest and most fatal Ebola epidemic started in 2014. This outbreak resulted in 28,652 cases and 11,325 casualties, more than all others combined.[5] Guinea, Liberia, and Sierra Leone were the countries at the center of that particular outbreak. The 2014 to 2016 crisis was the most widespread epidemic of Ebola that the world has seen yet; the majority of the cases were seen in African nations, but cases were also seen in several European countries and eleven diagnosed cases were treated in the United States. Many of the cases in the U.S. and Europe were in health care or aid workers.  In August 2014, the World Health Organization (WHO) declared the outbreak to be a Public Health Emergency of International Concern (PHEIC), prompting an international attempt to quell the spread of the disease. [7]

The Ebola virus can appear anywhere within two to twenty-one days after contact with an infected source; however, the average amount of time before symptoms show is anywhere between eight and ten days. When symptoms do emerge, they may mimic the symptoms of common illnesses such as influenza or malaria. Ebola suffers may experience fever, severe headache, muscle pain or weakness, vomiting, diarrhea, abdominal pain, or unexplained hemorrhages such as bleeding and bruising. [8]

Treatment for Ebola remains very basic. Historically, it consists of providing the patient with intravenous (IV) fluids, electrolytes, and sufficient oxygen. Many patients with Ebola are treated in isolation or quarantine. [9] Experimental drugs began to be developed during the 2014-2016 outbreak and garnered national attention. One organization, WHO, became sidetracked due to an expert meeting regarding the new experimental drugs. Because of this, proven methods of infection control were not facilitated in a timely matter, thus causing more long-term damage.[10] These experimental drugs were used primarily in high-income countries rather than being distributed to all infected regions. The prioritization of medicine for certain people based on their location and wealth is perhaps unethical, especially with a lethal disease like Ebola.

In addition to initial selective treatment, the failure of pharmaceutical companies to seek and develop a drug for Ebola may be due to them seeing no profitability for preventing and treating the disease.[11] Is the lack of aid to a poorer country a selfish one, or one that comes from having the responsibility to care for one’s own before being able to help others? If a country is technologically advanced enough to develop means of aid for poorer countries and does not, then it perhaps becomes an injustice to the country in need of aid. However, when Ebola spread to the United States, the pressure to find a cure intensified. The inequality in how an illness is treated due to this outsider perspective prevents much aid in being carried out in the first place. Without adequate treatment, those infected with Ebola have a much more difficult time recovering.

Questions of medical ethics and how to treat an individual when they pose a potential threat to the public health creates a challenge of how should an organization respond in order to fight Ebola while maintaining a balance between the safety of the public and the rights of an individual.  https://www.bmj.com/content/350/bmj.h2105.full [10]

The ability to recover from Ebola is dependent on a series of different factors. These include the strength of a patient’s immune system, good and supportive clinical care, and the resources that a patient has available to them. EVD survivors have been shown to have antibodies to protect against the virus in the future present in their bodies up to ten years after they have recovered.[8] However, recovery comes with many challenges also. Even after recovery, survivors may experience side effects such as fatigue, muscle pain, eye or vision problems, and stomach issues. These survivors also face social challenges as re-entering the community after surviving the illness can be overwhelming and EVD survivors must face the stigma surrounding the disease as the return to their community.[1]

It is still unknown where the disease comes from, although scientists believe that it is animal-borne. [3] The main source of this animal to human transmission is determined to have been in contact with the blood, tissue, or bodily fluids of bats. Some species of bats, such as three types of fruit bats, that are eaten in African countries have now been found to be symptomless carriers of the disease. These three fruit bat types are Hypsignathus monstrosus, Epomops franqueti, and Myonycteris torquata[3]

Fruit bats hang in trees. These animals are thought to be the main source of transmission from animals to humans. https://www.animalwised.com/fruit-bats-as-pets-guidelines-and-tips-1406.html. [12]

Most specifically, Ebola can be transmitted from human to human through contact with the bodily fluids of an infected person or corpse. This transmission can be caused by contact through broken skin, mucous membranes in the eyes, nose, or mouth, or through sexual contact. This can also happen through contact with objects that have been contaminated such as needles and syringes.[1]

To protect others from the transmission of Ebola, quarantines are often imposed. These quarantines were seen both in the affected African countries and in the United States for healthcare and aid workers returning from overseas. Volunteers and workers, many of whom were from Doctors Without Borders and the WHO, were put in isolation for 21 days after returning from Africa. The officials who instituted these quarantines stated that it was to protect the citizens in their states from contracting the virus and to help monitor the aid workers until the virus could no longer be present. [13]

A health care worker, who is surrounded by quarantine fences and treatment tents, carries a child with a suspected EVD case. http://time.com/3502002/ebola-liberia-sierra-leone-doctors-nurses/. [14]

The process of quarantine was very controversial both in the U.S. and abroad. Critics argued that it was unethical and not based on scientific results. They argued that the disease was hard to spread because it can only be transmitted through bodily fluid contact, not the air.[13] Dealing with the outbreak required a lot of difficult choices, which spurred some ethical implications. The treatment of the Ebola and the use of quarantine seem like a matter which has a relatively easy solution to implement. However, the course of action the CDC and WHO took sheds light on how when a region is unprepared for a sudden outbreak, questionable decisions can be made.

One large proponent to the inefficient treatment of Ebola is the diagnosis of patients that potentially carry the virus and how they were quarantined. In the first case of quarantine for Ebola in the United States, four close family members were ordered to stay within their small apartment. One of whom was Thomas Eric Duncan. Within two days, Duncan was mistakenly discharged from the hospital and by the time he was readmitted he had come in contact with as many as 100 people, two of whom were nurses that became infected and later on recovered through treatment.[15] Later on, 177 individuals would be quarantined and the CDC would revise their recommendation on how to deal with incoming individuals that arrived from West Africa. From a pliant countermeasure in dealing with the spread of Ebola to a stricter one, a decision of how to balance had to be made. While considering to what extent should a person be isolated and treated on illness, it is important to not only view what the individual experiences but also how will quarantine affect the people around them.

The case of Duncan’s quarantine is a relatively small one, yet still managed to impact a lot of people. What happens when there are many more people infected and it is more difficult to keep track and quarantine them? One strategy of quarantine is through a defensive, militaristic means which was instituted to a degree with the Ebola outbreak. Such a method of quarantine is a utilitarian one, where decreasing the risk of spreading the disease takes precedence over an individual’s rights to leave a country. Here is where problems arise between both sides. On one side, the individuals that are not ill are protected from any potential risk of infection outside the country. On another, those that wish to seek medical aid internationally become unable to as they are forcibly quarantined for the “greater good”. Although the treatment of Ebola carrying individuals is still prioritized, it appears that when forcibly quarantined, that individual’s rights to free travel become inhibited in favor of protecting others.[16]

In many affected African countries during the 2014 to 2016 outbreak, officials decided to quarantine entire villages after an Ebola infection; this was an attempt to stop the disease from spreading to other areas. Many healthy villagers in these quarantined areas were put at a higher risk of contracting the disease and many villages started suffering from food and supplies insecurity. These issues got so severe at times that many isolated villagers threatened to break out of the quarantine that had been imposed on them [13].

Another way that health care workers attempted to stop the transmission of Ebola during the major outbreaks was through strict infected-body disposal guidelines. Throughout the beginning of this particular EVD epidemic, burial practices in western Africa played a major role in disease transmission.[17] Burial ceremonies involved washing and touching the deceased, which caused funeral guests to contract the Ebola virus if the dead had been infected. West Africa is home to a multitude of cultures and religions, including Christianity and Islam, where many people attribute disease to supernatural, if not religious, causes.

Islam practice dictates that family members of the same gender as the deceased must cleanse a dead body before it is buried. According to the World Health Organization (WHO), 20% of Ebola infections during the 2014-2016 outbreak occurred during burials of deceased Ebola patients.[18] When family and community members perform religious practices that involve directly touching or washing a body, they are still exposed to high levels of the Ebola virus and could it to others.

On the other hand, various sects of Christianity can obscure the etiology of Ebola; one verse from the Book of Deuteronomy claims that God inflicts disease, fever, and inflammation as a punishment for transgressions.[18] Some communities in West Africa have even ascribed Ebola to God’s retribution for adultery and homosexuality.[18]

Because of the large influence of religion and supernatural beliefs, many West Africans continue to accept the advice of spiritual healers and religious figures in lieu of medical aid. WHO estimates that 70-80% of people in West Africa engage in traditional medicine.[18] Without proper medical training, these healers often spread false information; consequently, many people affected by an Ebola outbreak fall victim to quackery, such as taking salt baths and salt drinks in order to prevent getting Ebola. Ironically, the lack of widespread medical education has also affected traditional healers in previous outbreaks; a Guinean government official once had to deter traditional healers from trying to cure Ebola.[18]

Through a public health approach, one step that has minimized the spread of Ebola is through education: teaching traditional healers how to treat patients without contracting Ebola and debunking myths about the disease is far more effective than eliminating their role in society. For example, the WHO is now teaching how to hold dignified burials for Muslim and Christian patients victimized by Ebola.[18] We believe that launching awareness campaigns about Ebola would respect cultural and religious practices in West Africa. At the same time, it fosters trust between health officials and affected communities.

Volunteers who are not wearing full protective gear bury a victim of Ebola https://static.independent.co.uk/s3fs-public/thumbnails/image/2014/10/08/09/ebola-1.jpg?w968.[19]

During the 2014 crisis, governmental and health care agency workers dressed in airtight suits to protect themselves collected the dead and worked to dispose of them. These workers collected the bodies from both confirmed and suspected EVD cases from the region where they passed away and transported them to the disposal sites. Some agencies buried the dead at protected mass grave sites and some cremated the bodies. In each of the affected areas, there was a widely published phone number that people would call to report deaths and bodies, a disposal team would respond to the call and take the body. Each team traveled in several utility vehicles, one for the body, one for the majority of the team including the leader, scout, sprayer, and several other workers, and finally a truck carrying police to manage the often angry villagers.[17]

A disposal team carries away an infected body as a loved one grieves and protests. https://www.pbs.org/newshour/world/bringing-safer-burial-rituals-ebola-countries. [20]

When the team arrived on site, they would begin by donning personal protective equipment (PPE) and surveying the scene. The sprayer would then enter the home/location of the deceased and spray the area and the body with hypochlorite solution (strong bleach) before the rest of the team entered. After the body was inside the body bag, the sprayer would again spray the body and the inside and outside of the bag and the team would transport it to the truck. Teams would often collect several bodies in the area before transporting them to the disposal site. If the deceased was being buried, workers were supposed to make sure that they were buried more than two meters deep however, as the number of dead increased the burials became rushed and sometimes sloppy. The majority of the dead were buried in unmarked graves. These sites were often protected by high wire fences, orange tape, armed guards, and heavy concrete walls, while some remained unprotected especially in quarantined areas.[17]

Health care workers bury the body of an Ebola victim in an unmarked grave at a protected mass grave site. https://www.ipinst.org/2016/06/ebola-outbreak-liberia-sierra-leone. [21]

Although the 2014-2016 Ebola outbreak ended, there is another in the Congo spreading at a fast rate. The current Ebola outbreak is estimated to have 406 cases and 676 deaths. [22]Again, this goes back to how foreign countries decide to help those unable to set up protocols and methods in preventing outbreaks that are known to be preventable to a certain extent. But should a country rely on another when it is not in a time of need? This question needs to be answered based on context and how likely a certain disease or problem is to present itself. Overall, the balance among quarantine, prevention, and treatment is not only a matter of whether it is ethical to do certain things, but also a problem of resources.

Maeve Taylor

Tommy Tran

Raymond Chen

[1] Centers for Disease Control and Prevention, “What is Ebola Virus Disease?,” September 2018. https://www.cdc.gov/vhf/ebola/about.html. Accessed 3 April 2019.

[2] Johns Hopkins Medicine, “Ebola.” https://www.hopkinsmedicine.org/ebola/about-the-ebola-virus.html. Accessed 2 April 2019.

[3] Leroy, Eric M., Brice Kumulungui, Xavier Pourrut, Pierre Rouquet, and et al. “Fruit Bats as Reservoirs of Ebola Virus.” Nature 438, no. 7068 (Dec 01, 2005): 575-6. http://libproxy.lib.unc.edu/login?url=https://search.proquest.com/docview/204560186?accountid=14244. Accessed 4 April 2019.

[4] News24, “Ebola in DRC now infecting newborn babies, UN says,” 2018. https://www.news24.com/Africa/News/ebola-in-drc-now-infecting-newborn-babies-un-says-20181123. Accessed 7 April 2019.

[5] Centers for Disease Control and Prevention, “Years of Ebola Virus Disease Outbreaks,” April 2019.https://www.cdc.gov/vhf/ebola/history/chronology.html. Accessed 7 April 2019.

[6] Centers for Disease Control and Prevention, “Ebola Virus Disease Distribution Map: Cases of Ebola Virus Disease in Africa Since 1976,” December 2017. https://www.cdc.gov/vhf/ebola/history/distribution-map.html. Accessed April 7 2019.

[7] Briand, Sylvie, Eric  Bertherat, Paul  Cox, Pierre  Formenty, Marie-Paule  Kieny, Joel Myhr, Cathy  Roth, Nahoko  Shindo, and Christopher  Dye. “The International Ebola Emergency.” The New England Journal of Medicine 371, no. 13 (September 25, 2014): 1180–82. https://doi.org/DOI: 10.1056/NEJMp1409858. Accessed 5 April 2019.

[8] Centers for Disease Control and Prevention, “Signs and Symptoms,” May 2018. https://www.cdc.gov/vhf/ebola/symptoms/index.html. Accessed 3 April 2019.

[9] Davis, Charles Patrick. “What Is the Medical Treatment for Ebola Hemorrhagic Fever?” Edited by Jerry R. Balentine. Ebola Hemorrhagic Fever (Ebola Virus Disease). MedicineNet. https://www.medicinenet.com/ebola_hemorrhagic_fever_ebola_hf/article.htm#ebola_hemorrhagic_fever_ebola_virus_disease_facts. Accessed 7 April 2019.

[10] Gericke, C. A. “Ebola and Ethics: Autopsy of a Failure.” BMJ 350, no. Apr 23 10 (2015). https://www.bmj.com/content/350/bmj.h2105.full.

[11] Dawson, Angus J. “Ebola: What It Tells Us about Medical Ethics.” Journal of Medical Ethics 41, no. 1 (2014): 107-10. https://jme.bmj.com/content/41/1/107.full.

[12] Johorey, Janhvi, “Fruit Bats as Pets: Guidelines and Tips,” June 2018. https://www.animalwised.com/fruit-bats-as-pets-guidelines-and-tips-1406.html. Accessed 7 April 2019.

[13] Drazen, Jeffrey M., Kanapathipillai Rupa, Edward W. Campion, Eric J. Rubin, Scott M. Hammer, Stephen Morrissey, and Lindsey R. Baden. “Ebola and Quarantine.” The New England Journal of Medicine 371, no. 21 (Nov 20, 2014): 2029-2030. doi:http://dx.doi.org/10.1056/NEJMe1413139. http://libproxy.lib.unc.edu/login?url=https://search.proquest.com/docview/1626693014?accountid=14244. Accessed 7 April 2019.

[14] Bajekal, Naina & Aryn Baker, “Ebola Health Care Workers Face Hard Choices,” Time, 13 October 2014. http://time.com/3502002/ebola-liberia-sierra-leone-doctors-nurses/. Accessed 6 April 2019.

[15] Rothstein, Mark A. “From SARS to Ebola: Legal and Ethical Considerations for Modern Quarantine.” SSRN Electronic Journal, 2014, 227-73. https://heinonline.org/HOL/Page?collection=journals&handle=hein.journals/inhealr12&id=231&men_tab=srchresults.

[16] Koch, Tom. “Ebola, Quarantine, and the Scale of Ethics.” Disaster Medicine and Public Health Preparedness 10, no. 04 (2015): 654-61. https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/ebola-quarantine-and-the-scale-of-ethics/76590E290DE79E6661381D4C821D726B/core-reader.

[17] Cordner, Stephen, Heinrich Bouwer, and Morris Tidball-Binz. “The Ebola Epidemic in Liberia and Managing the dead—A Future Role for Humanitarian Forensic Action?” Forensic Science International (Online) 279, (10, 2017): 302-309. doi:http://dx.doi.org/10.1016/j.forsciint.2017.04.010. http://libproxy.lib.unc.edu/login?url=https://search.proquest.com/docview/1945849310?accountid=14244. Accessed 6 April 2019.

[18] Manguvo, Angellar, and Benford Mafuvadze. “The Impact of Traditional and Religious Practices on the Spread of Ebola in West Africa: Time for a Strategic Shift.” The Pan African Medical Journal, September 22, 2015. Accessed April 8, 2019. doi:10.3897/bdj.4.e7720.figure2f.

[19] https://static.independent.co.uk/s3fs-public/thumbnails/image/2014/10/08/09/ebola-1.jpg?w968. Accessed 6 April 2019.

[20] Epatko, Larisa, “Bringing safer burial rituals to Ebola outbreak countries,” PBS News Hour, 14 October 2014. https://www.pbs.org/newshour/world/bringing-safer-burial-rituals-ebola-countries. Accessed 7 April 2019.

[21] Quinn. Maureen, “Governance and Health in Post-Conflict Countries: The Ebola Outbreak in Liberia and Sierra Leone,” International Peace Institution, June 2016.  https://www.ipinst.org/2016/06/ebola-outbreak-liberia-sierra-leone. Accessed 7 April 2019.

[22] Hermitanio, Maui. “Ebola Outbreak In Congo Spreading At Its Fastest Rate, WHO Says.” Tech Times. April 03, 2019. Accessed April 04, 2019. https://www.techtimes.com/articles/240793/20190403/ebola-outbreak-in-congo-spreading-at-its-fastest-rate-who-says.htm.

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