Social justice and health inequality in New Orleans:

An intersectional approach to health before and after

Hurricane Katrina

Ashley AcevedoSOC 529 Sociology of Race, Class, and GenderDr. JacksonMay 5, 2014INTRODUCTION

It has been widely accepted that social stratification

has drastic consequences for those on the bottom end of the

hierarchy. Whether it is educational achievement, annual

income, or stress levels, those who are victim to the

extreme wealth inequality in our country suffer from health

disparities. This paper seeks to explore the dynamics of

healthcare in relation to race, class, and gender post-

Hurricane Katrina. I will start with a brief history of

institutional racism and the role it has played in the

health of minorities in the United States, using health

statistics to show the disparities. I will discuss the issue

of culturally competent care, healthcare politics, law and

the economy. Finally, I will look at these issues as they

relate to those who were victim of the 2005 storm Hurricane

Katrina. I will examine those most affected by the storm,

compare health statistics and resources before and after the

hurricane, and contextualize these issues within the broader

issue of health inequality in the United States.

Health disparities are not random, but are patterns,

which exemplify the lines of stratification in our society.

Those most marginalized populations, typically categorized

by race/ethnicity, socioeconomic class, gender, and age in

US society and globally depict centuries of historical

injustice, that needs to be addressed if there is any hope

of creating a more just and equal society. An examination of

the health impacts of Hurricane Katrina on the poor in New

Orleans is a vital part of examining issues social justice

in the United states and world wide. An in depth analysis of

the health of low income African Americans before and after

the storm sheds light on the intersection of race and class

when natural disaster strikes. However, this is just one

example of a larger issue of social justice in which the

poor’s health is being attacked.

LITERATURE REVIEW

History of Institutional Racism and health in the U.S.

There has been a long history of health inequality in

the U.S. Issues of medical inequality among minorities stem

from years of institutional racism, dating back to the slave

era where African-Americans were considered to be informed

on health issues, and provided healthcare to white

plantation owners (Fauci 2001). Simultaneously, they were

dependent on their owners for their own healthcare, which

was low quality, if they received any at all (Fauci 2001).

Such acts of racial discrimination in the medical field have

continuously limited the access minorities have to adequate

medical services and care. This is a problem that has been

discussed in detail by numerous researchers (Washington

2006; Smedley, Stith, Nelson, and Institution of Medicine

2003; Northington Gamble 1997; Starr 1982… all in Nelson

2011).

Starr (1982) describes the long history of medical

inequality in the United States, and the influence of social

factors on health among minorities. Wilkinson (2009) adds to

the discussion by focusing on the affects of wealth

inequality. This is key to understanding health inequality

in the U.S., as racial minorities experience more wealth

inequality, and thus more health inequalities than any other

group. Many groups have worked hard to bring attention to

this issue, and act as advocates for those vulnerable

populations most affected by wealth and health inequality.

Nelson (2011) describes the Black Panther Party’s struggle

against medical discrimination. They worked to address

issues of segregation of health that were displayed in

over-crowded and often ill-prepared black hospitals, and

the underutilization of white hospitals. The Black Panther

Party remedied this by opening a network of free health

clinics. They fought to raise awareness of medical

discrimination through campaigns to stop unequal medical

treatment and racist medical experiments, such as those to

gynecological operation methods, to test effectiveness of

different anesthetics and antibiotics (Fauci 2001). This

sort of experimentation on African Americans continued up

until the 20th century, with the well-known Tuskegee

Syphilis experiment. They provided preventative care and

testing for conditions like lead poisoning and hypertension

(Nelson 2011). Then in 1971, they sought to raise awareness

about diseases such as sickle cell anemia, providing

screening for this genetic disease and bringing attention

to the racial prejudice involved in ignoring the disease.

The party understood the social and political issues

surrounding health and science during this time period, but

also understood health to be a fundamental human right

(Nelson 2011). However, despite this, many of the

inequalities they fought so hard against are still prominent

today.

Because of the importance of the intersections of race,

class, and gender in healthcare, it is extremely important

for research to examine the health of women of color. They

are a population who experience many of the inequalities

both of women and minorities, and yet are one of the most

underserved populations in the healthcare system. Minority

women are affected by difficult access to adequate health

care, making them victim not only to poor health in

comparison to men, but also to that of other women. For

example, gender-specific illnesses such as breast cancer are

much more deadly among minorities in the United States,

despite having nearly the same mammography-screening rate as

white women.

Healthcare politics, law and the economy

Many who have studied inequality in the healthcare

system have discussed the need for culturally competent

care, which Randal (2002) says means that one has to

consider a person’s race, class, gender, sexual orientation,

culture and education level when providing care for them, as

each of these things may change the best way to treat them.

The basic premise of cultural competency is that all

healthcare providers should be able to properly serve

patients who are culturally diverse, and maintain an

understanding and respectful demeanor (Randall 2002). The

idea is that in order to address inequalities in health

status, we need to recognize the different histories of

patients (Randall 2002). Randall (2002) gives the example of

the growing need for healthcare services that are bilingual,

and thus are respectful of growing Hispanic and Asian

American populations as well as others. This is a problem

when considering that many places have laws in place that

limit access to public services, including medicine, to

those who can speak English, making it difficult for

immigrants to get necessary healthcare services. Randall

(2002) stresses that this includes not only speaking the

same language as the patient, but also using language that

is appropriate for the patient’s literacy level. This means

explaining medical forms, procedures, etc. as clearly as

possible to ensure that patients understand, realizing that

using complex medical jargon is not appropriate when

speaking to patients, and yet also being respectful. This is

something that the Black Panther Party struggled to achieve

in the 1970’s.

The Panthers saw that many in the medical field behaved

in an arrogant and dismissive way towards the average

person, especially in the case of poor blacks (Nelson 2011).

In response, the Panthers would often accompany patients to

their appointments, thus validating their experiences, and

empowering them to speak up for themselves, or helping them

to do so if necessary. Most importantly, the Panthers helped

people to demand respectful treatment (Nelson 2011). This is

both necessary in terms of adhering to our own laws against

discrimination, but also in adhering to international law,

such as the International Convention on the Elimination of

All Forms of Racial Discrimination (CERD), Article 5 of

which states that everyone has the right to public health

and medical care, regardless of their race, ethnicity, and

culture (United Nations 1965).

Inequality in New Orleans

Historically, New Orleans has had a large black

population, although until the years leading right up until

hurricane Katrina, it had the most segregation of large

American cities (Fussell 2007). This increase in racial

segregation was not standard with the rest of the United

States, but rather reflects years of policy leading to a

concentration of low-income African-Americans in the most

vulnerable part of the city. This results in an area where

there is often high unemployment, poor healthcare, and lack

of many other resources.

Socioeconomic inequality between blacks and whites has

been misleading, and has lulled us into a feeling of

normalcy when looking at inequality in New Orleans. The

difference between black and white incomes in New Orleans is

proportional to the national average, despite the fact that

the comparative scale of this disadvantage for New Orleans

compared to other metropolitan cities is much worse.

According to the 2000 U.S. Census Bureau, the black poverty

rate in New Orleans was 35 percent, which was the highest

large city black poverty rate in the country.

Despite the fact that the poverty rate in New Orleans

has remained stable since the 1970’s, the amount of

concentrated poverty in the area increased by 66 percent

(Berube and Katz 2005). This proved to be a major problem

when Katrina hit, as neighborhoods with the highest levels

of concentrated poverty were those with the most residents

remaining after the evacuation. Therefore, was these

predominately poor black neighborhoods that were most

affected by the storm. Brazile’s (2006) analysis shows that

black neighborhoods experienced about 25 percent more

flooding than white neighborhoods.

Health and Healthcare of African Americans in the U.S. and New Orleans prior to

Katrina

In 2013, the Center for Disease Control and Prevention

(CDC) released a report analyzing health disparities and

inequalities in the United States. They found that

nationally, four of the leading causes of death for African-

Americans are heart disease, cancer, stroke, and diabetes

(CDC 2013). This might not seem so bad when considering that

according to the CDC and Agency for Toxic Substances and

Disease Registry’s (ATSDR) National Center for Health

Statistics (NCHS) 2004 report, these illnesses comprise four

of the ten leading causes of death in the U.S. for all

Americans. However, the likelihood of minorities being

affected by these illnesses in comparison to whites is much

higher.

The report, also found that, despite national decreases

in infant mortality, African Americans have infant death

rates twice that of whites in the U.S., (CDC 2013;

Fauci2001). African American babies also typically have

lower birthweights, and are more prone to premature death

than white babies (Fauci 2001).They reported that deaths

related to heart disease are 40 percent higher among African

Americans, and those related to cancer are 30 percent

higher. Fauci (2001) found that African Americans are more

likely to be ailed by illnesses such as tuberculosis,

asthma, cervical cancer, acute respiratory disease,

appendicitis, hernia, pneumonia and influenza than white

Americans. Similarly, ‘African-American men have 100% more

deaths due to diabetes, 92.6% more deaths due to cerebral

vascular disorders, 88.4% more deaths from cirrhosis of the

liver and 81.8% more deaths due to pulmonary infectious

diseases than European-American males’ (Fauci 2001: 48).

This has had drastic effects on the overall life

expectancy of African Americans, with white males living 7

years longer on average than African-American males, a fact

that many have tried to excuse by pointing the homicide rate

among African Americans, but which simply is not supported

by health data (Fauci 2001).

An important aspect of figuring out why African

Americans experience more deaths from issues like heart

disease and cancer, is to look at patterns of access to

healthcare across race, class and gender. Addressing issues

of health across the lines of race, class, and gender has

been of even greater importance following the events of

Hurricane Katrina in 2005, which resulted in the deaths of

at least 1,833 people, making it the third deadliest

hurricane in U.S. history (Knabb 2005). At least 1,100

Louisiana citizens died as a result of the storm, and 700 of

the deaths from the hurricane occurred in New Orleans alone

(U.S. Congress 2006; Warner 2005).

Before the hurricane, Louisiana had some of the poorest

health statistics in the United States (Rudowtitz et al.

2006). The rates of infant mortality, heart disease and

diabetes were very high, with huge disparities in

minorities’ health status (Rudowtitz et al. 2006). African

Americans, who made up about 33 percent of all Louisiana

residents, and 66 percent of New Orleans residents were all

more likely than whites to experiences medical issues with

heart disease, diabetes, and asthma (Rudowtitz et al.

2006).Prior to Hurricane Katrina, New Orleans had one of the

nation’s highest rates of people without medical insurance

(Rudowitz, Rowland and Shartzer 2006). Many seeking medical

assistance in the city relied on the Charity Hospital system

for care (Rudowitz et al. 2006; Select Bipartisan Committee

to Investigate the Preparation for and Response to Hurricane

Katrina. 2006.). According to Rudowitz et al. (2006),

Charity Hospital was the main healthcare provider for the

poor and uninsured in New Orleans pre-Katrina. Rudowtitz et

al. (2006) cite that inn the summer before Katrina hit,

approximately 23 percent of residents of New Orleans lived

below the poverty line. This number was higher in place that

got struck hardest by the hurricane. Prior to Katrina, 48

percent of Orleans Parish’s 437,186 person population 32

percent of Jefferson Parish’s population of 448,578 were

what Rudowitz et al. (2006) described as low income, meaning

they lived below 200 percent of the federal poverty level.

There is a strong connection between primary medical

care, income, and overall health. Lack of medical treatment

reduces the amount of preventative care received, as well as

leading to later diagnose illnesses. This makes it more

difficult and expensive to treat and cure. Unfortunately,

for those who are low income, many may not have access to

good primary health doctors, or may use the emergency room

as their form of primary healthcare because of lack of

medical insurance. Rudowitz et al. (2006) explained how high

poverty rates in Louisiana prior to Hurricane Katrina’s

impact on the Gulf Coast, contributed to 21 percent of

residents, about 900,000 people, being without health

insurance, compared to the national average of 18 percent of

all non-elderly residents being uninsured, making it one of

the highest rates of uninsured residents in the country.

Sixteen percent of Louisiana residents, and 29 percent of

those residing in Orleans Parish were on Medicaid in 2003-

2004, with more children being ensured than adults, due to

eligibility requirement (Rudowitz et al. 2006). Over half a

million of those, age 65 and older depended on Medicare for

coverage. Katrina affected approximately 66 percent of those

on Medicare.

Hurricane Katrina

Preparation for the storm/evacuation

In 2005, Hurricane Katrina struck the Southeastern

United States with a horrifying blow. It formed on August 23

near the Bahamas (Waple 2005). It first made landfall in

Florida as a Category 1 on August 26th(Waple 2005). The

hurricane strengthened over the Gulf of Mexico to a Category

5, before weakening to a Category 3 storm as it made

landfall again, this time over Louisiana (Arendt and Hess

2006; Waple 2005). On Saturday, August 27, President Bush

declared an emergency for the state of Louisiana, two days

before the hurricane made landfall (Bush 2005; U.S. Congress

2006). The hurricane resulted in the evacuation of about 1.5

million people;(Peek and Erikson 2007 in Zamore). New

Orleans’s population before Katrina was 460,00. Of these,

about 350,00 were evacuated before the storm hit(Peek and

Erikson 2007 in Zamore).

However, the story of inequality lies not only in those

who were evacuated, but rather in those who were left

behind. Between 100,000 and 150,000 were left to ride out

the storm, many because of lack or resources,

transportation, or a place to evacuate too (Peek and Erikson

2007 in Zamore). Not only was the city highly segregated,

but the most affordable homes, and thus those predominately

owned by low income African Americans, were those below at

sea level, an thus experienced the most flooding (Gault,

Harmann, Jones-DeWeever, Werschkul, and Williams 2005;

Elliott and Pais 2006). African Americans are about three

times more likely than whites to be impoverished (Gaultet

al. 2005). Despite the fact that there is such a high

concentration of poverty in New Orleans, there was no plan

in place to help residents evacuate if they didn’t have the

means to do so themselves. The evacuation order recommended

that those without a vehicle carpool with friends, family,

or neighbors. This plan proved problematic for those who had

no such person who had the means of evacuating themselves,

let alone helping them to evacuate (Litman 2006).

There were clear patterns in who was evacuated and who

was left behind. Most who stayed to ride out the storm were

low income African Americans, hospital patients, or the

elderly, many who lived in nursing home facilities (GAO

2006). Because of this, many of the victims of the storm

were elderly African Americans (Peek and Erikson 2007;

Sharkey 2007). 112,000 people in New Orleans, mostly low-

income minorities, did not own a vehicle and relied on

public transportation (Russell 2005; Bullard, Johnson, and

Torres 2009). Because of their economic vulnerability, many

who did not evacuate could not afford to (Haney, Elliott,

and Fussell 2007). The cost of travel, housing, and loss of

income from not working was too much for many to be able to

afford. What’s more, even if someone did own a car and would

have been able to make the trip, many didn’t know anyone

outside of the area, and thus had no place to go (Rudowitz

et al. 2006).

Health during African Americans during the storm

Patterns in Victimology by Race, Class, Gender, and Age

The storm killed more than 1,500 and displaced another

780,000 people (Sharkey 2010). Despite severe damage all

along the southeastern coast, the greatest number of deaths

from the storm occurred in New Orleans, Louisiana, due to

the levee systems that failed when the storm hit, resulting

in 80% of the city being flooded. Age appears to have been

an important factor in those who died from the 2005

hurricane, with over 60 percent of all victims being 61

years of age or older, and 67 percent of victims in New

Orleans alone being over 65 (Warner 2005; Sharkey 2007).

This is put into perspective when considering that only 12

percent of New Orleans’s population is over 65 years old

(Sharkey 2007). This is reminiscent of the high death toll

among the elderly in the 1995 heat wave (Kleinberg 2002). In

the case of Hurricane Katrina, many of the victims seemed to

be unable or unwilling to travel, and many already had

medical problems that increased their risk of death from

drowning during the hurricane, or heat exhaustion in the

days that followed. Those areas experiencing the worst

damage form the storm were between 75 and 100 percent

African American neighborhood (Logan 2006).

Health and Healthcare after the storm

Health after the storm

Due to the severe damage and flooding caused by the

storm, many of the victims spent days trapped in their homes

and other places, waiting for help to arrive. Most were

without food, potable water, medicines or other medical care

(Rudowitz et al 2006).Charity Hospital’s available space for

mental health patients dropped by nearly 35 percent after

the storm, causing a major problem for many for whom Charity

had been their primary source of both inpatient and

outpatient mental health care (Rudowitz et al. 2006). It

also proved problematic as time passed after the hurricane,

and rates of PTSD among survivors of the storm increased

(Chen, Keith, Airriess 2007).

Many studies have shown that men and women are not

equally affected by natural disaster. Intersectionality

between race, class, and gender results in high risk for low

income women of color during and after natural disasters

(Blaikie et al 1994). This is even truer for the women of

New Orleans, who experienced a higher rate of poverty than

any other place in the U.S., even before Katrina struck

(Litt 2008). Their situation was made even more difficult by

the fact that women are still considered primary caretakers

of their families, and women were responsible for evacuating

their children and elderly parents (Peek and Fothergill

2008).

Research shows that the combined stresses of loss of

resources, lack of social support, and frustrations caused

by disaster response had significant impacts on health of

hurricane survivors (Adams 2013; Boyd-Franklin 2010). Adams

(2013) cites that there were increases in the rates of

hypertension and pulmonary disease following the storm. Both

of these conditions are linked to stress and were already

more prevalent in the African American community prior to

Katrina, putting an already at risk population in even more

grave danger of health complications (CDC 2013). Increases

in drug abuse, insomnia, and depression were also evident

after the storm (Adams 2013).

Feelings of racism and classism were rampant after

Katrina, with 60 percent of blacks reporting that they felt

slow responses by government were race based, and 63%

indicating that they thought it was because of class (Boyd-

Franklin 2010).

In 2007, a study was published investigating perceived

levels of racial discrimination the affects on the health of

Black survivors of Katrina, living in New Orleans (Chen,

Keith, Airriess, Li , and Leong 2007)Chen et al. (2007) used

mixed methods of data collection including interviews, focus

groups, and analysis of public documents. Not only did they

find that minorities are at higher risk for poor health, but

that there was a direct relationship between health

discrimination, and economic conditions (Chen et al. 2007).

Their results showed that about half of respondents reported

being treated badly during Katrina due to racial

discrimination and about the same number showed financial

strain after Katrina (Chen et al. 2007). These two factors

together resulted in an increased likelihood for PTSD

related symptoms in survivors following the hurricane. Chen

et Al. (2007) attributed this to survivor’s frustrations

about their ability to return home after the storm, the lack

of financial assistance, and in consistent information how

to access more aid. They also found that symptoms of PTSD

among survivors were less prevalent in this reporting strong

social support. Chen et al. (2007) cited several sources

discussing the relationship between economic factors and

health of Black female survivors. They noted increased risk

levels among those already living in poverty, especially for

Black female single heads of households in New Orleans (Chen

et al. 2007).

Healthcare after the storm

Hurricane Katrina destroyed much of the infrastructure

in New Orleans, and with it the healthcare system, affecting

access to healthcare for those who needed it most (Rudowitz

et al. 2006; Committee to Investigate. 2006.). Because of

the damage the storm caused to the infrastructure,

approximately 220,000 jobs were lost, leaving many without

health insurance or employment (Rudowitz et al. 2006). This

damage was compounded by the fact that the city’s

infrastructure was so devastated by the storm that many of

the hospitals most used for medical care, including those in

the Charity Hospital system, were closed for well over a

year following the hurricane (Rudowitz et al. 2006). This

disproportionately affected low income African-Americans,

who comprised seventy-five percent of patient before the

storm (Rudowitz et al. 2006). Twenty percent of these people

made less than $20,000 a year, making it that much harder

for all those left without medical care or coverage

(Rudowitz et al. 2006; Committee to Investigate. 2006).

Research done following the disaster showed that the 44

percent of parents and 10 percent of children with FEMA

housing had no health insurance (Rudowitz at al 2006).

Hurricane Katrina left a visible mark in the city of

New Orleans, not just in the devastation it caused to

infrastructure, but also on the demographic make up of the

area following the storm.Four-hundred and sixty thousand

were made homeless by the storm as of 2005 (Shockley 2010).

Shockley (2010) found that in 2007, the population of New

Orleans was 40% lower than it had been before the storm,

with a 73% decrease in the African American population.

Reasons for this include not being able to afford re-

locating back to New Orleans both from lack of immidate

financial strains, and knowledge of the lack of post-katrina

opportunities in the area (Shockley 2010). Some evacuees

even reported not wanting to return to a place were they

were “unwanted” (Shockley 2010: 109). Frey, Singer, and Park

(2007) did an analysis of the racial and economic

composition of New Orleans a year after Katrina and found

that the black population had a decreasedmore than 20

percent higher than the by white population. In 2006, the

population remaining was more educated and higher income,

and had fewer households with children than shown in the

2000 Census. These findings were consistent, within the

entire metropolitan area, making it increasingly likely that

these people relocated outside of the area. Those moving

elsewhere within New Orleans were more likely to be white,

while those moving to other metropolitan areas like Houston

were young, low-income African Americans. (Frey, Singer and

Park 2007).

LIMITATIONS and SUGGESTIONS FOR FUTURE RESEARCH

Because of the vast exodus of people from the Gulf

Coast area, and particularly from New Orleans due to

hurricane Katrina, it is difficult to get a full and

accurate view of the health impact on those who were most

affected. There is a lack of data concerning health of the

poor in New Orleans before and after the storm. In an

attempt to alleviate this issue, health data from Houston,

an area in which a large number of evacuees were relocated,

was analyzed. While this certainly helps to put the scale of

this issue in better perspective, it by no means gives us a

full picture of the impact Katrina had on the health of

impoverished African Americans in New Orleans. Further

research should attempt to look more closely at health in

areas the experienced a large influx of evacuees after

Katrina.

Future research should look further at the role of

economic inequality in determining the affects of natural

disaster on the poor, and specifically poor minorities. An

in depth analysis of natural disaster victims and survivors

domestically and globally would provide important incite

into the prevalence of issues natural disasters, race,

gender, and class. An analysis of death rates, health

impacts, and disaster recovery using this demographic

information is key in understanding how societies decide who

is worth saving and who is deserving of aid following a

disaster. Looking at these findings within the context of

the push for the security of human rights for all could have

significant impact on further discourse and documentation

regarding issues of social justice.

CONCLUSION

Hurricane Katrina exposed many inequalities resulting

from this stratification, which have plagued our society but

had previously remained hidden. The issue of race and racism

is most certainly an important one when looking at issues of

social justice surrounding this catastrophic event. However,

given the growing economic inequality in this country, and

the clear connection between income, evacuation, and health

impacts for low-income individuals, race alone does not give

a conclusive explanation for what happened. What the

literature shows is that it is the intersection of race,

class, gender, and age in New Orleans, which resulted in

such vast devastation following Hurricane Katrina. It also

provides an eye-opening look at the health impacts of such

inequalities for those in New Orleans prior to the storm,

and the awful ways in which Hurricane Katrina amplified

these inequalities. After this in depth analysis of the

health of low income African Americans before and after the

storm,it is clear that the events surrounding Hurricane

Katrina are not just a unique occurrence, rather they are

part of a deeper problem of social injustice in healthcare,

poverty, and disaster response in the U.S. and world wide.

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