Chun S. Race and disaster relief. Harvard Public Health Review. 2021; 30.
Natural disasters represent common, yet often ignored, contributors to wealth inequality. With the ongoing global threat of climate change, floods, wildfires, and hurricanes increasingly have become regular phenomena that inevitably overwhelm local emergency response and infrastructure and result in large-scale damage or loss or life.  Institutional racist policies have ensured that socioeconomically disadvantaged groups and racial and ethnic minorities bear a disproportionate burden of the economic and structural destruction and morbidity and mortality resulting from natural disasters. By nature of their scope and devastation, relief efforts often necessitate external or governmental assistance. While often dispatched without hesitation, it is critical to examine how disaster response structures and relief may further exacerbate and contribute to existing racial inequities.
In 2017, storms in the U.S. such as Hurricane Maria, Irma, and Harvey caused $300 billion in damages. And since 2000, nearly 99% of American counties have had to reckon with the consequences and aftermath of some form of natural disaster.  As an emergency medicine resident physician, the field of disaster response and humanitarian crises are of particular interest. But it is necessary to first understand the contextual factors that have consistently disadvantaged minority groups in such settings and, secondly, to adopt a public health lens when overseeing the deployment of resources and funds. We have an ethical responsibility to ensure that relief efforts are based on principles of equity and need.
In August 2005, Hurricane Katrina devastated the Gulf Coast and the city of New Orleans in particular. The costliest tropical storm to strike the continental U.S., the hurricane resulted in $125 billion in damages, 1500 deaths, and the displacement of thousands of people, most of them racial and ethnic minorities.  At the time, 60% of the city’s population was living at or below the Federal Poverty Line. The poor, most of whom were Black, lived in neighborhoods closest to the city’s poorly maintained levees and dams. When these barriers failed during the hurricane, minority communities bore the brunt of the flooding. Mayor Nagin had ordered a mandatory evacuation of New Orleans, yet many who lived in the low-lying areas were unable to do so due to financial constraints or limited access to transportation. 
Following Hurricane Katrina, images of people stranded on their roofs caught national attention and sympathy, but it was the grossly insufficient aid that triggered public uproar. The majority of televised footage featured lower income families, predominantly Black, as they waded through muddy waters awaiting rescue or frantically searching for family members in temporary shelters. Meanwhile, President George W. Bush was on vacation and initially largely shielded from the severity of the situation by aides who did not want to burden him with details. This eventually mounted to justifiable outrage and indignation towards the inept and disjointed efforts endeavoured by the federal government. Over 90 international partners and allies offered $854 million in cash or oil but many of these donations and gestures of goodwill were outright declined or unclaimed. Italian medical supplies were left to spoil, Swedish planes were not offered clearances to land, and Cuban healthcare workers were turned away. By April 2007, only $40 million of the original $854 million pledged had been utilized.  During a national benefit concert held in the wake of this apathetic response, rapper, Kanye West, infamously declared that “George Bush doesn’t care about Black people.” 
These events and the delayed federal action reflect long-standing patterns of racial inequity in disaster response. The Great Mississippi Flood of 1927 primarily impacted sharecroppers who lived close to the river. The 1995 heat wave of Chicago led to the deaths of over 700 people, mostly elderly Black people living in substandard housing. And still today, Black people tend to live in coastal areas vulnerable to hurricanes and tropical storms.  Indeed, a history of racist policies has played a role in the unsafe buildings and neglected safeguards in neighborhoods that caused communities of color to be disproportionately affected in disaster settings.
Interestingly, an eerily similar but dramatically different response took place during Hurricane Betsy in 1965. The levees on the Industrial Canal in New Orleans collapsed and floodwaters surged into the Lower Ninth Ward.  Louisiana senator, Russell Long, appealed to President Lyndon B. Johnson directly, calling on him to visit his devastated state. The President flew into the city five hours after this phone call and pledged to cut bureaucratic “red tape” in order to offer immediate aid.  While some would argue Johnson’s anomalous swiftness was politically motivated—he had lost the state of Louisiana the year prior in the federal election—he also had a strong track record against racial discrimination with the passage of the Civil Rights Act of 1964. This atypical response may also signal a time preceding the implementation of neoliberal economic and social policies that institutionally protected white privilege through the guise of “free market” rhetoric.  Nevertheless, events and shortcomings of disaster relief have continued to erode public trust in government. Natural disasters clearly unveil the means by which structural racism has systematically isolated and excluded minority populations politically, economically, and environmentally. But that is not the only story they tell.
Howell and Elliott from Rice University examined the effects of natural disaster on wealth among different demographic groups. In their study, they followed twenty U.S. counties from 1999 through 2013 and over 3500 families. It revealed that “as local hazard damages increase, so does wealth inequality, especially along lines of race, education, and homeownership”.  White people who lived in counties with approximately $100 000 in damages during the study period gained $26 000 in wealth. However, those who lived in areas that had $10 billion in damage gained over $125 000 over the same time period—the harder hit the community, the more wealth white people amassed. In contrast, for communities of color (Black, Latino, and Asians) that were severely impacted by $10 billion dollars’ worth of damage, they lost $27 000, $29 000, and $10 000 respectively. These results were uncovered even after adjusting for age, education, homeownership, family status, residential mobility, neighborhood status, and county population.  The overwhelming conclusions were that whites accumulated more wealth compared to people of color, and that wealth inequality worsened in counties that were hit harder or more frequently by disasters.
Furthermore, when relief aid organizations such as the Federal Emergency Management Agency (FEMA) became increasingly involved, this inequality appeared to increase. In counties that received $900 million in aid from FEMA, white people gained $55 000 more than similar whites who lived in counties that received only $1 000 in aid.  Conversely, Black people who lived in these highly funded counties accumulated $82 000 less on average compared to similar Blacks who lived in the counties that only received $1 000 from FEMA. In other words, the more aid FEMA provided to counties deeply affected by disaster and meant to lift affected communities, the more the wealth gap would widen between whites and blacks.  Certainly, the results highlighted the strong association between wealth inequality and the cost from natural disasters, but it also cast an uncomfortable spotlight on the longstanding and problematic features in the programs and distribution of aid from FEMA.
This has been witnessed through several major disaster events in the past few years. Following Hurricane Katrina, a significant proportion of African Americans were displaced to neighboring states. And the federal funds submitted to rebuild and restore districts in New Orleans were noticeably uneven. Ten years after Katrina, 90% of the city’s residents had returned to their former neighborhoods, but only 37% of residents from the predominantly black Lower Ninth Ward had moved back.  In 2012, after Hurricane Sandy overwhelmed densely populated sections of the northeastern coast, many regions housing lower income families and people of color did not receive equal attention in aid. This was a consequence of several policies in New Jersey that heavily favored homeowners, who were often white, at the expense of renters, many of whom were Black and Latino families. There was a strong emphasis on the burden of mortgages for homeowners when, in reality, many renters shared similar claims, costs, and were likely to be more financially vulnerable with less assets. Access to government assistance or recovery capital that were dispatched to damaged areas were significantly more challenging for minority groups.  In addition to disaster aid information offered exclusively in English, three non-profit agencies reported that nearly 80% of recovery relief applications were rejected when they should have been approved. And, of course, information regarding the appeals process was available only in English 
In November 2020, a report from the National Advisory Council was submitted to the FEMA Administrator outlining how government aid often worsened inequality by shortchanging low-income communities.  The council was comprised of 35 members appointed by the FEMA Administrator and included health practitioners, emergency managers, and budget experts. It was established by Congress following Hurricane Katrina and releases annual reports detailing outstanding problems as well as possible solutions.
The most recent version of the annual report focused on equity which has been in the forefront of national discourse of late. FEMA was faulted for providing aid to wealthy homeowners while low income families sank further into poverty. Those who were underserved continued to stay underserved throughout the dissemination of aid.  While the nature of disasters can be quite variable, it reported that often minority populations bear the impact of mortality and economic devastation. Overcrowded housing, unreliable electrical power grid systems, and exposure to gun violence may predispose these communities, but the factor of systemic racism must also be acknowledged. Black communities have consistently been placed in highly susceptible or exposed areas in times of crisis, and the federal aid meant to mitigate the effects of disasters have done little to soften the blow for these hard-hit communities.
It has become apparent that several programs in place by FEMA systematically benefit affluent populations. The process of contracting agencies is complex enough, but the reimbursement that FEMA offers to cover the costs of infrastructural repairs and cleanup only assists neighborhoods that can afford to pay the required match. Federal law mandates that FEMA can reimburse up to 75% of recovery costs incurred from disaster if states are able to fork over 25%.  Another noteworthy FEMA program is one that provides emergency cash to households, the Individual Assistance Program. These funds are not readily accessible as individuals must navigate a complicated application process which includes registering with FEMA and demonstrating specific eligibility. Typically, it is those with time and income that are successful in their claims. Similarly, FEMA’s National Flood Insurance Program serves only individuals who can actually afford to buy flood insurance, thereby benefitting wealthy segments of the population.  Moreover, the access to disaster aid offered is largely based on the value of one’s home and property ownership which disenfranchises homeless populations. 
An unfortunate and misguided narrative that is often perpetuated following these events is that the inequality faced by minority populations has always been there; the disaster did not create it.  However, as Howell and Elliott’s work has illustrated, despite holding disaster costs constant and comparing people with similar income, education, and neighborhood characteristics, the actions of FEMA and the federal assistance administered exacerbates wealth inequalities.  This ought to prompt policymakers and government agencies to reconsider how relief is provided in these settings.
Curtis Brown, co-founder of the Institute for Diversity and Inclusion in Emergency Management, argues for embedding equity in emergency management to reduce fatalities and costs, and other advocates have created guidance to promote more equitable recovery.  The NAACP has issued a toolkit that provides practical steps for community leaders and recommendations of explicitly incorporating value statements. And Dr. Alessandra Jerolleman from Jacksonville State University has suggested four guiding principles for just recovery—it begins with equality, harnesses community capacity, requires ability to exercise agency, and demands equal access. She emphasizes that a colorblind recovery that does not consider historical context is not just but acknowledges it remains challenging to articulate and define “just recovery” .
In the National Advisory Council’s report to the FEMA Administrator, they explicitly opined that FEMA presently does not meet the equity requirements of the Stafford Act, which was issued to assign orderly federal assistance to state governments during natural disasters.  However, legal measures recently implemented that work to rectify the history of inequity are highlighted. For example, in a damaged building that requires refurbishment of the front entrance, typical disaster assistance may simply lead to the repair of the front stairs while an equity-based perspective might also consider installing a ramp to accommodate all individuals with disability. Prior to the Disaster Recovery Reform Act in 2018, FEMA legally was only permitted to provide the same amount of funding to everyone.  Legislative changes has allowed the organization to give more support to individuals with more need.
To push forward on the agenda of equity, the document encourages the FEMA Administrator to create an equity framework, perhaps through the assistance of an advisory committee, to evaluate whether grants increase or decrease equity over time.  This process ought to be data driven with information provided along categories of race, income, etc. The impact or outcome of FEMA funding programs need to be measured and monitored through specific metrics and goals with a focus to target underserved populations. The characterization of a complex community in need cannot be simply reduced to the single variable of gross capital loss. One suggestion includes incorporating the County Health Ranking into the aforementioned equity standard to provide context of the social determinants. Additional recommendations include ensuring the FEMA workforce reflects the population it serves through recruitment from Historically Black Colleges and Universities and implementing an educational series on cultural competence for all employees.  All of these measures can work to improve the effect, efficiency, and equity of FEMA interventions.
In the field of emergency medicine, particularly during a natural disaster, it can be tempting to immediately “dive in” and attend to the massive need for relief, treatment, and support given the urgency of the situation. But all efforts and agencies are not above fair critique and examination of its intended and unintended outcomes, especially for racial and ethnic minorities. It has become evident that governments often fail to properly invest in sustainable and equitable emergency preparedness solutions that require thoughtful and measured consideration. People of color continue to be susceptible to large-scale environmental disaster, and climate change will only ensure that these minority groups continue to be disproportionately affected. Structural racism is embedded within the interventions of relief organizations, such as FEMA, and unfortunately serve as vehicles that widen the wealth gap in this country and in the especially vulnerable settings of disaster. Restructuring relief efforts and programs with an equity framework is necessary to ensure aid is appropriately targeted and benefits those most severely affected.
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Shannon is a resident physician in emergency medicine based in Toronto, Canada working towards a Master of Public Health with a focus on global health. He is interested in elements of disaster response such as infectious disease outbreaks and equitable distribution of relief aid. Ongoing projects include humanitarian impact evaluation and innovative financing for global surgery.