When I heard that the folks who didn't evacuate were being told by Nagin and the FEMA people that they were on their own and not to expect city services, I gagged. Yea, maybe the evacuation went smoothly, but I knew there would be severely disadvantaged folks who couldn't, or wouldn't evacuate and would be at great risk. He seems to be saying, it's all your fault if you drown, don't blame us.

I am so glad to hear that there were committed care-givers and other rescue workers who still kept an ear out for those left behind, in spite of the fact that "the city's mandatory evacuation program had ended hours earlier."

My sister is a nurse at Tulane - she moved there after Katrina, specifically because she wanted to help out in a city she's always loved. I've been in touch with her on and off, and it's amazing what the conditions are there. Don't forget them - even though they have power and water, they are still working with a small crew and an expanding patient base. God bless them!

The United States will remain abnormally vulnerable to disasters, pandemics, and surge capacity events if if fails to to learn from its basic health care mistakes. We know all that we need to know to make changes, but we refuse to act.

Epidemiology - Since the time of John Snow and cholera (and the usual decades of delay implementing any advance), medicine has followed the principles of epidemiology - until recently. Increasing rates of disease always follow concentrations of people and this is clearly the pattern for TB, Hepatitis A, B, and C, and HIV/AIDS. Concentrations favor rapid spread during pandemics. In any real epidemic or pandemic, the last place you want to go is the concentrations of the exposed and infected people crowding into hospitals.

Profit vs Public Health Hospital performance can be contrasted with schools. Schools are paid by the attendance rates of students. School districts have learned to close for 2 or 3 days to stop the spread of infection. They actually make more money by closing. They can even close to contain highly infectious stomach viruses. One high school had an episode of students vomiting at the cafeteria and school was closed for 2 days for cleanup and prevention of spread. It worked. A nearby hospital had the same scenario and of course kept going. Numerous employees and patients became ill and infection spread to other city locations.

Profit vs Common Sense In a true pandemic, everything non-essential shuts down, people stay home, and the authorities must keep order, keep people in their homes, and deliver necessary food and goods to keep people at home (hard to do when some run out before the end of the month). The entire focus is stopping or slowing spread to allow resources to catch up. This is rarely possible. Only one town in Colorado managed this during the Spanish Flu (Barry - The Great Influenza).

Also studies have indicated that significant portions of hospital personnel are likely to fail to show up in pandemic situations. One of the reasons is that there is often no one to care for their families. They know that they may go and not be able to get away. They may also be risking their lives. The big issue is who will care for their family in these situations. Dedication is not the problem. Until someone shows interest in their top priority, the situation will not change. Until family situations are addressed, few are likely to show up when most needed.

Hospitals operate under business principles, which will tolerate operations that will spread disease and concentrate people. Schools operate closer to public health principles, and people are spared. We are a long way from the preparation that we need as a society. Another dissertation involves tolerating poor nurturing, child development, and education, which is why people will not be prepared to act in the most important determinant of outcomes - the individual decisions made. The first years are when you learn to trust authority, obey, and have a chance to do well in school to learn what must be learned to live in concentrations safely.

Policies That Concentrate - Currently 75% of physicians and even higher levels of health resources are packed into 3000 zip codes in 1% of the land area with only 35% of the population. Physicians and hospitals are in locations where people are not. Louisiana is a state with divisions into the highest concentrations of physicians and the lowest. This also follows inequities in income distributions. When the top concentrations of physicians and professionals in New Orleans were taken out, the entire state suffered.

For all of its criticism, FEMA did warn the nation of 200 billion dollar disasters related to concentrations of people in harm's way. Hurricanes for New Orleans and NYC as well as earthquakes for SF, LA, and Memphis/St.Louis. Not on the list was the Tampa-St. Petersburg area but this is the Gulf Coast Area with higher concentrations than New Orleans and also with few exits. Those in Florida also have a habit of paying attention to the authorities, another lesson learned when few paid attention even after Katrina.

Former Coast Guard officials have warned the nation that coastal areas are vulnerable in many ways, especially in the inability to address surge capacity events. The entry areas to emergency rooms are nearly impossible to access even to visit people at the hospital, much less when a crowd arrives in a short period of time. There are too few hospital/ER complexes and they are crowded together. Rapid response is limited for not only disasters, but even myocardial infarctions and strokes.

New cost saving measures also work against disaster preparation. Hospitals often have medical suppliers keep or "own" their inventory, much like Walmart. In other words, there are fewer stockpiles and health care depends on daily or hourly transportation. Interruptions and increased demands will be a challenge without sufficient preparation.

It is possible to prepare, but we have to be willing to implement the needed changes.

Robert C. Bowman, M.D., Professor

A.T. Still University School of Osteopathic Medicine in Arizona