Officials in Houston are just beginning to grapple with the health and environmental risks that lurk in the waters dumped by Hurricane Harvey, a stew of toxic chemicals, sewage, debris and waste that still floods much of the city.
Flooded sewers are stoking fears of cholera, typhoid and other infectious diseases. Runoff from the city’s sprawling petroleum and chemicals complex contains any number of hazardous compounds. Lead, arsenic and other toxic and carcinogenic elements may be leaching from some two dozen Superfund sites in the Houston area…
“Harris County, home to Houston, hosts more than two dozen current and former toxic waste sites designated under the federal Superfund program. The sites contain what the Environmental Protection Agency calls legacy contamination: lead, arsenic, polychlorinated biphenyls, benzene and other toxic and carcinogenic compounds from industrial activities many years ago… (A)

Houston was already affected by inequality and healthcare disparities. The Manchester neighborhood in Houston is what Samson described as a “classic environmental justice” area – a Latino neighborhood on the Houston shipping channel where petrochemical plants surround houses and most people speak Spanish.
“Barium is ubiquitous in the area because of refineries, as well as arsenic and mercury,” said Sansom. “All of that is going to be in potential of coming into contact with humans. There’s sort of the complex chemical mixture.”
Wildlife can also become a sudden danger. Standing water left after the flood recedes will leave an ideal breeding ground for mosquitoes – which were already a pest in Houston..
Zika captures the most headlines of any mosquito-spread diseases, but it’s far from the only one. The same Houston-endemic mosquitoes transmit dengue and chikungunya, infections characterized by fever. Other mosquito species spread West Nile virus, which can be dangerous for the elderly and health compromised.
Flood waters have also delivered fire ants to front doors, and Sansom warned flooded houses can become a home for venomous snakes such as water moccasins.
Water-borne and person-to-person infections can also easily spread after a disaster. Overwhelmed sewer systems bring people into contact with disease-spreading bacteria. Stomach illnesses are common following floods, public health officials said… (B)

“Authorities warned of the danger posed by the plant in Crosby, about 30 miles northeast of Houston. The French company operating the plant said explosions were possible, and William “Brock” Long, administrator of the Federal Emergency Management Agency, called the potential for a chemical plume “incredibly dangerous.”
Still, officials offered differing accounts regarding what occurred at the Crosby plant, which makes organic peroxides for use in items such as counter tops and pipes. The plant’s operators, which had earlier Thursday reported explosions, later said they believe at least one valve “popped” there, though they noted it was impossible to know for sure since all employees had left the site. (C)

“In the aftermath (of Katrina), a coalition of hospitals, emergency medical services, fire departments and community leaders undertook intensive efforts to fortify the city’s medical system. This led to such physical changes in the sprawling medical center as submarine doors that can be closed to wall off parts of a tunnel system that runs beneath the blocks-long area. Outside berms were built for protection should a gully off Brays Bayou overflow its banks, and strategically located flood gates that can rise three feet were installed. Hospitals that had emergency electricity generators in the basement moved them higher.
Such fortifications were tested as never before in recent days.
Based on protocols written over the intervening years, hospitals stationed extra staff members in their facilities so stranded workers could rotate in shifts. Other systems lessened the risk of running out of crucial supplies.
And unlike after Hurricane Katrina, in which no one knew where some New Orleans patients had been moved and some arrived at distant hospitals without medical records, a regional Catastrophic Medical Operations Center coordinated transfers and kept track of which hospitals had beds available for specific types of care…” (D)

A. A Sea of Health and Environmental Hazards in Houston’s Floodwaters, By HIROKO TABUCHI and SHEILA KAPLAN, https://www.nytimes.com/2017/08/31/us/houston-contaminated-floodwaters.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
B. Sewage, debris, mosquitoes: flood waters increase health risk for Harvey victims, https://www.theguardian.com/us-news/2017/aug/30/health-implications-texas-floods-hurrican-harvey
C. Chemicals ignite at flooded plant in Texas as Harvey’s devastation lingers, by Alex Horton and Mark Berman, https://www.washingtonpost.com/news/post-nation/wp/2017/08/31/harveys-wrath-moves-across-the-louisiana-texas-border-as-water-recedes-in-houston/?utm_term=.8973b6e86b6b
D. Some hospitals evacuated, but Houston’s medical world mostly withstands Harvey, https://www.washingtonpost.com/national/health-science/some-hospitals-evacuated-but-houstons-vaunted-medical-world-mostly-withstands-harvey/2017/08/30/2e9e5a2c-8d90-11e7-84c0-02cc069f2c37_story.html?utm_term=.70679d68f226
E. Here’s how to deal with those clumps of floating fire ants in Houston, by Megan Farokhmanesh, https://www.theverge.com/2017/8/29/16221842/hurricane-harvey-houston-fire-ants

“In addition to the catastrophic flooding from Hurricane Harvey, Houston residents have one more thing to worry about: floating colonies of fire ants.
Fire ants have waxy bodies that allow them to repel water. Should a colony find itself waterlogged, ants will protect their queen by forming a mass around her, as well as eggs, larvae, and pupae (ants that are in between larvae and adults). As the ants float, they rotate, so that the underwater ants will get to the top and vice versa..…
The ants, in fact, aren’t harmless, she says. People who come in contact with the colonies will get at least a few itchy, probably painful pustules. But how your skin reacts can differ from swelling to life-threatening allergic reactions. “Once they hit you, you’re a solid surface so they’re gonna crawl on you,” …. “When the first one stings, they emit a pheromone that causes a chain reaction that tells everybody else to sting, so you’re going to experience quite a few stings.”… (E)

“In the immediate emergency there’s concern around drowning, and especially for folks who are in motor vehicles where there is severe flooding, blunt trauma, fire-related injuries,” said Marisa Raphael, deputy commissioner of the Office of Emergency Preparedness and Response at the New York City Health Department.
Vulnerable populations, like the homeless, the elderly and the chronically ill, are especially at risk during and in the aftermath of a disaster…
Here’s a rundown of some of the public health concerns Texas faces in the days, weeks and months to come.
1. Inadequate access to medical care and prescriptions
2. Tight quarters promote the spread of infectious disease
3. Contaminated water can cause disease and infection
4. Rescue workers face risks associated with mold
5. Standing water may cause mosquito-borne infectious disease
6. Uncertainty takes a psychological toll
In the face of physical threats, it’s easy to underestimate the mental health toll that a disaster can take on a community. “Medical systems can deal with physical stuff quite well,” Jackson said, while noting the relative complexity of treating psychological maladies compared with an acute physical problem, like a broken leg.” (A)

“The muddy floodwaters now soaking through drywall, carpeting, mattresses and furniture in Houston will pose a massive cleanup challenge with potential public health consequences.
It’s not known yet what kinds or how much sewage, chemicals and waterborne germs are mixed in the water. For now, health officials are more concerned about drownings, carbon monoxide poisoning from generators and hygiene at shelters. In the months and years to come, their worries will turn to the effects of trauma from Hurricane Harvey on mental health.
At a shelter set up inside Houston’s George R. Brown Convention Center, Dr. David Persse is building a clinic of doctors and nurses and trying to prevent the spread of viruses or having to send people to hospitals already stretched thin. (B)

“The majority of people who die during floods drown: About 75 percent of the fatalities are drownings, per the World Health Organization. Two feet of rapid floodwater will sweep away an SUV. Just six inches of water, if it moves quickly enough, can knock over an adult, according to the National Weather Service….
Short term: Infectious disease
A flood contains more than rain. Sewage systems spill their guts. And the water can dredge up things more disturbing, if less infectious, than human waste. In New Orleans in 2005, the flooding from Hurricane Katrina exhumed corpses, sending coffins afloat through neighborhoods….
Short term: Power outages
Short term: Drug access
Short and long term: Mosquitoes
Long term: Mental health
Long term: Mold..
“All of those forces,” he explained Monday, “combine to make the Gulf Coast especially susceptible to infectious and tropical disease.” (C)

“With mosquito-borne illnesses specifically, it appears that there may be a delayed effect. In the short term, after a hurricane, there should actually be a lower risk of contracting these viruses, because the water likely washed away the existing breeding sites.
“But then over time, as the floodwaters recede, you’re left with pockets of water which are good for breeding both Culex mosquitoes and Aedes mosquitoes,” says Peter Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine in Texas. Culex mosquitoes carry West Nile, as well as St. Louis encephalitis and Japanese encephalitis. Aedes aegypti are the primary carriers for Zika, as well as dengue, chikungunya, and yellow fever.y means introducing a new ecosystem of fungal growth that will change the health of the population in ways we are only beginning to understand. The same infrastructure and geography that have kept this water from dissipating created a uniquely prolonged period for fungal overgrowth to take hold, which can mean health effects that will bear out over years and lifetimes. (D)

The documented dangers of excessive mold exposure are many. Guidelines issued by the World Health Organization note that living or working amid mold is associated with respiratory symptoms, allergies, asthma, and immunological reactions. The document cites a wide array of “inflammatory and toxic responses after exposure to microorganisms isolated from damp buildings, including their spores, metabolites, and components,” as well as evidence that mold exposure can increase risks of rare conditions like hypersensitivity pneumonitis, allergic alveolitis, and chronic sinusitis.” (E)

“The area’s historic flooding has many of the region’s hospitals facing a monumental crisis, as more than 1,500 patients had been evacuated by Tuesday afternoon.
Twenty-three licensed hospitals across the Houston region have taken the extraordinary step of evacuating their sickest patients because of rising water or compromised services as Tropical Storm Harvey continues to lash the area…
Even worse, as many as 25 additional hospitals in the Houston area now carry “internal disaster status,” which means they are considered vulnerable to shutting down or shuttling their sickest patients to new locations, said Darrell Pile, chief executive of the Southeast Texas Regional Advisory Council, whose catastrophic medical operations center is coordinating the response to the troubled hospitals.” (F)

(A) Hurricane Harvey’s Public Health Impact Extends Beyond Flooding, “Disasters magnify fragilities that are already present in society.”, by Erin Schumaker, http://www.huffingtonpost.com/entry/harvey-public-health-impact_us_59a42136e4b06d67e33913a6
(B) Public health dangers loom in Harvey-hit areas, by By nomaan merchant and carla k. johnson, http://abcnews.go.com/Technology/wireStory/public-health-dangers-loom-harvey-hit-areas-49476410
(C) The health dangers from Hurricane Harvey’s floods, by Ben Guarino, https://www.washingtonpost.com/news/to-your-health/wp/2017/08/29/the-health-consequences-to-expect-from-hurricane-harveys-floods/?utm_term=.df3c601e3be3
(D) Will Flooding in Texas Lead to More Mosquito-Borne Illness?, by Julie Beck, https://www.theatlantic.com/health/archive/2017/08/will-flooding-in-texas-lead-to-more-mosquito-borne-illness/538242/
(E) The Looming Consequences of Breathing Mold, James Hamblin, https://www.theatlantic.com/health/archive/2017/08/mold-city/538224/
(F) Hospital crisis deepens as water rises; 1,500 patients evacuated so far, by Jenny Deam, http://www.chron.com/business/article/Hospital-crisis-deepens-as-water-rises-1-500-12159473.php

“Water poured into hospitals. Ambulances were caught up in roiling floodwaters. Medical transport helicopters were grounded by high winds. Houston’s world-renowned health care infrastructure found itself battered by Hurricane Harvey, struggling to treat storm victims while becoming a victim itself….
The response to Harvey, now a tropical storm but still wreaking havoc over the state, promises answers to whether health officials learned lessons from the catastrophe of Katrina when it comes to the medically vulnerable — in particular whether they did enough to prepare for the disaster and to move patients out of its path.
“We’ve made significant investments,” Dr. Umair Shah, executive director of Harris County’s public health department, said in a telephone interview on Sunday. “The challenge is until it unfolds there’s so many moving pieces and it’s never the same as the situations you’ve previously encountered.”
Responders point to dozens of improvements, from better engineered structures to well-practiced cooperation, that are helping protect lives. Still, sometimes even the soundest plans have been foiled.” (A)

“Houston’s unprecedented rainfall on Sunday pushed area medical facilities to take precautions — including, in some cases, evacuations — in a bid to protect patients.
Texas Medical Center early Sunday began closing its massive “submarine” doors, designed to seal off lower floors — Texas Children’s Hospital, as well as Memorial Hermann-Texas Medical Center and TIRR Memorial Hermann Hospital, deployed the doors, a spokeswoman told the Houston Chronicle.
The system is part of a safety upgrade installed after Tropical Storm Allison devastated the medical campus in 2001, the Chronicle reported. That storm drowned tens of thousands of laboratory animals and forced patient evacuations. Decades of medical research were lost as well…. (B)

“But for the patients and staff inside, it was pretty much business as usual. Most of the TMC hospitals adopted a shelter-in-place strategy, which meant they called in staff prior to the storm and divided them into shifts of working and rest, on the premises, so they wouldn’t have to leave the hospital. Previous experience from storms suggested this was the best strategy; evacuating patients is a tricky process, since sometimes the evacuation procedure can be more medically dangerous if traffic jams out of a vulnerable area mean people will be stuck in ambulances or makeshift mobile care units for hours on end.” (C)

“Water flooded the basement of the Ben Taub General Hospital, disrupting food, pharmacy and central supply services. Ben Taub, one of only two comprehensive, level 1 trauma centers in Houston, says their concern now is finding ways to get critical care patients to safety.
“Our first concern is patients on ventilator support,” hospital spokesman Bryan McLeod said.
For now, 17 to 18 patients require ventilator support to breathe, McLeod told ABC News. After they have been evacuated, McLeod said, the hospital plans to move the rest of the approximate 350 patients.” (D)

“Nurses and doctors at Cook Children’s are preparing for at least 10 babies’ arrival as Hurricane Harvey edges closer to making landfall.
Children’s Medical Center in Dallas is also flying out to bring back several babies to care for away from the storm. Physicians are worried high winds and flooding could create major power outages and a shortage of clean water and food.” (E)

“At Texas Children’s Hospital, staff took turns on 12 hour shifts beginning Friday night to care for the 600 patients across three facilities. Doctors also called in women with high risk pregnancies who were due to give birth imminently as a precaution, and housed them in the Marriott next door to the main campus so they could be at the hospital quickly when their labor began. That meant their babies would also have access to the neonatal ICU if they needed it, rather than risking a dangerous ride through the storm to get to the hospital. “We assessed every patient, every pregnant mom, knowing that if they delivered and were unable to get to us, it would be devastating,” said Cris Daskevich, senior vice president at Texas Children’s.”(C)

“Preparation is key, according to Dr. Andrew Rhim, a physician and assistant professor at the University of Texas MD Anderson Cancer Center, one of the leading oncology institutes in the world. “MD Anderson was hit really hard in 2001 during Hurricane Allison,” he told Fortune in a phone interview. Rhim wasn’t at the center back then–but he says that administrators took that event as a wakeup call and worked to shore up disaster management in the years since. “The response to Harvey has been a product of those preparations.”
MD Anderson is currently experiencing some flooding, forcing appointment cancellations and closures for outpatient procedures. But there hasn’t been an evacuation, and the facility remains staffed for inpatients who cannot be discharged, according to Rhim. That’s thanks to preventive measures like flood gates which minimize damage and so-called “Ride Out” teams that prepare to, well, ride out the storm. These include nursing and technical support staff, custodial and food management, and extra food, water, and changes of clothes (in addition to a barrage of emails and other communications between administrators and staff).” (F)

(A) Houston’s Hospitals Treat Storm Victims and Become Victims Themselves, by SHERI FINK and ALAN BLINDER, https://www.nytimes.com/2017/08/28/us/hurricane-harvey-houston-hospitals-rescue.html?_r=0
(B) Harvey: Houston flooding pushes hospitals to act, Greg Toppo, https://www.usatoday.com/story/news/2017/08/27/houston-flooding-pushes-hospitals-act/606802001/
(C) What Happens When a Hurricane Hits a Hospital, by Alice Park, http://time.com/4919261/hurricane-harvey-houston-texas-medical-center/
(D) Hurricane Harvey: Houston-area hospitals preparing to evacuate patients, by MERIDITH MCGRAW DAN CHILDS, http://abcnews.go.com/US/hurricane-harvey-houston-area-hospitals-preparing-evacuate-patients/story?id=49457425
(E) Hospitals Join State Agencies Helping People In Hurricane Harvey’s Path, by Jeff Paul, http://dfw.cbslocal.com/2017/08/24/hospitals-join-state-agencies-helping-people-in-hurricane-harveys-path/
(F) How Hospitals Prepare for a Hurricane Like Harvey, by Sy Mukherjee, http://fortune.com/2017/08/28/hurricane-harvey-md-anderson-hospitals/

When I was growing up in Queens in the late mid-1950s the two “go-to” hospitals were Long Island Jewish and Booth Memorial.

In the early 1970’s the hospital system in the NYC metropolitan area was anchored and dominated by internationally renowned academic medical centers (then defined as a medical school and its primary teaching hospital on the same campus) – e.g., Columbia Presbyterian, Mount Sinai, NYU and Cornell. Academic affiliations were in place with area hospitals for teaching medical students and training residents.

Probably triggered by the North Shore/ LIJ merger in 1997 (North Shore was already a regional system with 10 hospitals) we have seen a rapidly accelerating merger trajectory from regional hospital systems focusing on becoming integrated health care delivery systems, to mega systems focusing on geographic reach, to super-size systems which have started or taken over medical schools, functioning almost like insurance companies and investment banks.

Some examples of the scale of super size systems:
North Shore, recently rebranded itself as Northwell Health, has annual revenue of $7.0 billion.  The LIJ name is history. http://medicine.hofstra.edu/about/history/history_nslij.html
The Mount Sinai Health System * has 3,535 beds on 7 hospital campuses.http://www.mountsinaihealth.org/about-the-health-system/facts-and-figures
New York Presbyterian includes two medical schools. Booth Memorial is now NYP Queens. http://www.nyp.org/about-us
RWJBarnabas Health, created by the merger of two mega systems, serves a geographic area that covers 5 million people, or more than half of New Jersey’s population. http://www.mycentraljersey.com/story/money/business/consumer/2016/03/31/robert-wood-johnson-barnabas-health/82489800/
Followed by the merger of Hackensack and Meridian https://www.meridianhealth.com/media/press-releases/2016/hackensack-university-health-network-and-meridian-health-announce-board-members.aspx
Geisinger, the powerhouse in central, south-central and northeast Pennsylvania now includes AtlantiCare in New Jersey http://www.geisinger.org/pages/about-geisinger/index.html  A number of New Jersey hospitals have academic and programmatic affiliations with NYC and Philadelphia medical schools.

All of the super-size systems are not-for-profits.

The NFP corporate veil has been weakened by the Atlantic Health System, owners of the Morristown Medical Center, agreeing to pay the town $15.5 million over the next 10 years in a property tax settlement based on its for-profit subsidiary profits. http://www.nj.com/morris/index.ssf/2015/11/atlantic_health_to_pay_morristown_155m_to_settle_t.html This is a template for all NFP hospitals in New Jersey and nationwide.

In New Jersey for-profit systems have been created or bought previously NFP hospitals. While “prohibited” in New York, recently there was talk of allowing for-profits demonstration projects particularly focused on rebuilding the hospital system with “other people’s money.”

In April, 2016 “The Federal Reserve and the Federal Deposit Insurance Corporation said that five of the nation’s eight largest banks — including JPMorgan Chase and Bank of America — did not have “credible” plans for how they would wind themselves down in a crisis without sowing panic.” http://www.nytimes.com/2016/04/14/business/dealbook/living-wills-of-5-banks-fail-to-pass-muster.html

Are NFP super size hospital systems structured to handle a “bubble”? Are we ready for some to become “for-profits” to have access to capital?

The FTC opposed the 1997 North Shore/ LIJ merger, which was “approved” through litigation. Now in New Jersey and New York Certificates of Need for super-size mergers are awarded in a few months time.

Maybe it’s time for STRESS TESTS!

UPDATE
Northwell* Health said in a statement that it will wind down its four-year-old CareConnect Insurance Co. business over the next year, after it suffered financial losses linked to a program designed to steady the exchanges where consumers can buy coverage.
https://www.bloomberg.com/news/articles/2017-08-24/new-york-hospital-system-shuts-obamacare-unit-after-losses

* North Shore is now Northwell