Katrina and Rita, the unprecedented September hurricanes and massive Gulf of Mexico surge, overpowered the levees of New Orleans and flooded state coastlines. They also exposed the poverty of US public health infrastructure, weakened by years of budgetary neglect.

Tens of thousands of New Orleanians were trapped in the city. They were mostly poor African Americans who had no cars and no access to the limited numbers of buses that were available. Fifteen thousand eventually made it to safety in the Astrodome stadium. Thousands more sought refuge in an unattended convention centre, virtually unknown to authorities. Here they attempted to survive in extreme heat, without adequate sanitation, water or food for several days. The ill, elders, and children suffered most; several died; a third had been injured by the storm; 40% had chronic diseases; a third were without necessary medications. Over half had no health insurance and many were not eligible for Medicaid, the public health insurance for the poor, because they did not fit the narrow categories of that programme—for example, they were not parents of young children.¹ Worse, dozens of elders were left unattended in nursing homes and medical facilities. As a result, they died; this lead to criminal indictments against culpable health personnel.

The hundreds of thousands of Americans, both citizens and “illegal” residents trapped in coastal towns and cities were vulnerable to this catastrophic disaster because of three failures of public policy: poverty, growing again in recent years, and the dearth of public measures to reduce it; the inadequacy of emergency planning and resources despite years of warning; thirdly, the deterioration of environmental regulation to protect coastal wetlands, land use, and storm mitigation. …