Learning from disasters

A reflection on the EF-3 tornado that hit St. Louis on Friday.

Last Friday, an EF-3 tornado struck the city of St. Louis, where I live, and tornados struck other parts of the central US, including Kentucky and Wisconsin. The Missouri storm, which was the strongest to hit St. Louis since 2011, cut through the city at 55 mph, with winds up to 152 mph, destroying thousands of homes, injuring 38 people, and killing five. As of last Sunday, 23,000 homes and business were without power.

The heart of these events is always in the stories of the people who are most affected—stories of loss of loved ones, of homes destroyed, of the challenge of coping, as a community, in the near- and long-term. And, in particular, such stories are, here in St. Louis today, and always after such events, more acute in already economically precarious neighborhoods, including, today, neighborhoods like Fountain Park and the Greater Ville that have long faced a range of challenges before the storm struck, now made worse by the moment.

These stories are also to be found in the Washington University community, of which I am a part. The University suffered damage during the storm, and many members of our community have connections to parts of the city that were hardest hit. I have been hearing from colleagues who are without power, who are sleeping on friends’ sofas, whose homes are not habitable, and who must now contend with all the uncertainty that comes with trying to move forward in the face of loss.

So, in this moment, I wanted to reflect on disasters such as this one, on what we know about them, what we can learn from them. Readers of these essays will know that I have been writing about disasters—such as hurricanes, tornados, floods, wildfire, and manmade disasters like terrorist attacks—and their consequences for a long time. Over the course of this writing and thinking, I have come to think five points are of most salience with respect to disasters, worth remembering in the wake of events like Friday’s tornados. I will summarize them here, in the hope that they might be helpful to our local St. Louis community and to the broader national conversation about how we address such challenges.

First, disasters have profound implications for the mental and physical health of the populations they affect. The health consequences of disaster can include physical injury and death, posttraumatic stress disorder (PTSD), generalized anxiety, and depression. Disasters touch not just the populations directly affected, but also first responders, the families and communities of the injured, and the broader populations. It is important to remember the enormity of these effects, that disasters pose challenges to health at a scale that can be hard to fully grasp, and that addressing these challenges means taking steps that support the health of whole populations, not just individuals or small groups.

Second, the consequences of disasters are long-term, with economic and social effects that extend well into the future. The effects of disasters and mass traumatic events do not just ripple outward into the community, they ripple forward through time, shaping health years, even generations, after the precipitating event. Our team found, for example, that mental health patterns in Nimba County, Liberia, roughly matched the geographic area where a civil war had occurred in the region about 20 years before. This reflects the long-term challenge posed by disasters and the importance of putting in place structures that support recovery well into the future. This includes treatment for the physical and psychological consequences of disasters as well as investment in rebuilding the homes, neighborhoods, businesses, and schools that serve as the engine of economic and social wellbeing in communities.

Third, context matters. Communities that were doing poorly pre-disaster will likely experience a disproportionate burden of a disaster’s consequences. One of the striking characteristics of a tornado is how almost surgical it can be in its devastation. Some homes may be completely destroyed, while neighboring homes may be untouched. One block may be flattened while the next block may have escaped major damage. This disproportion calls to mind the health inequities that keep some groups sicker than others. Such divides are often particularly pronounced in cities, such as St. Louis, where a single street can be all that separates more well-off areas from those that lack much. When disaster strikes, it is often areas that were already doing poorly that suffer most. This may be because buildings in less privileged parts of town are not as well-made as in other areas, placing them at a disadvantage in cases of extreme weather. Or it could be because a lack of social services hampers recovery efforts. It is also often the case that those who live in disadvantaged areas are often sicker to begin with, or likelier to have been exposed to trauma, which can make them less able to bear the burden of injury and trauma that comes with disasters.

Fourth, the best form of defense against disasters is creating a healthier world. I always worry this sounds trite. But it is empirically true in the case of disasters. When we are dealing with events that may happen anywhere at any time, what choice do we have—if we are serious about preventing these consequences—but to make sure that we are ready to handle these events by being as healthy as possible to begin with? Building a healthier world means addressing the challenges that make populations vulnerable to disasters in the first place. It means ending the inequities that hold back the health of many and make them vulnerable when disaster strikes. It means investing in a robust social safety net to create more resilient communities. And it means pursuing an equitable distribution of the material resources that support better health for all. Creating a healthier world is not easy, and it is understandable that we may look for quicker fixes to the challenge of population-level vulnerability in the face of disasters. However, fixing a problem means addressing its roots and the root of poor health after disasters—as we are seeing so clearly in St. Louis—is the fact that we have not created a world that is as resilient, as healthy, as it could and should be.

Fifth, what happens after a disaster matters tremendously. We should invest in the structures that support mental and physical health when disasters occur. In study after study, we have found that what determines long-term mental health after disaster strikes is as much the disaster experience as it is the conditions that people live through after disasters. Being employed, having social supports, having stable housing, and schooling for children matter as much—if not more—than the disaster event itself. These factors are notable in that we can do something about them. We can provide jobs and social support for those who are affected by disasters, we can make sure the damage caused by a tornado or hurricane is not compounded by lack of resources or a sense of being abandoned by the wider community. Ensuring this, however, takes investment. It means making the political decision that health matters and shoring up the structures that support health when disasters strike. In this sense, disasters are a reminder to do what we should be doing already—creating a context where everyone can be healthy, where no one is excluded from the resources that generate health. This takes work and political will.

Even as we bear these five points in mind, we face the question: what can we do, as individuals, in a world where disasters happen all the time and can affect our friends, our neighbors, our communities, ourselves?

First, it feels appropriate that, as we continue to bear witness, we remember what it is that we do at heart—continuing to generate the knowledge and approaches that build a healthier world. This imperative is a large part of what drew me to WashU. We are building a new school of public health in Missouri—the heart of the country—specifically so we are positioned to generate the knowledge and data, and to pursue the practice, that make a difference where the work of public health is needed most. I have received many messages from members of our community over the last few days, and the common theme has been “How can we help? How can we use our resources to make the situation better for our neighbors?” These questions distill what public health is about. Our role is to make the science and evidence clear, to teach the next generation, and to be part of communities, so that when disaster strikes, we can engage from a place of solidarity, ready to leverage what we have to offer towards the better health of all.

Second, we should work to ensure that this is a country that invests in the resources that can anticipate, mitigate, and, when possible, prevent disasters. This runs counter to the current disinvestment we are seeing in many of the structures—including FEMA—that support resilience in the face of disaster. Insofar as we see a pulling back from the steps we should take at the local and national level to create these structures, it is our responsibility to do all we can to communicate why this is the wrong course to take, towards advancing better approaches.

Third, as individual citizens, there is always something we can do to help others, whether by volunteering our time, donating needed resources, or providing an informed perspective on the challenges populations are facing. Some opportunities for helping those affected by the recent tornados can be found here. Thank you to all who are doing so much to support communities in need at this time.

I write this essay in part from a place of personal reflection, as a member of a community that has been touched by challenge. However, I recognize that such challenges occur, domestically and globally, all the time. Today it is St. Louis, tomorrow it could be anywhere. Given this reality, it is up to all of us to keep doing what we are doing to work towards a healthier world, one that is built to prevent, when prevention is possible, the worst from occurring and, when it is not, to mitigate to the fullest extent possible the effects of disaster for as many as possible.

I am grateful to the contributions of members of the WashU community, whose personal reflections on recent events informed this essay.