Building a Healthier New Orleans

August 2006

One year after Hurricane Katrina, the Tulane Prevention Research Center is working hard to ensure that a rebuilt New Orleans is known for its culture, not its chronic diseases.

New Orleans residents struggle with debris on their streets as the city tries to put itself back together one year after Hurricane Katrina. The Tulane Prevention Research Center wants to help rebuild the city in a better, healthier way.  Enlarge picture.

One hundred people sit in the Musician's Union Hall in New Orleans on a steamy Wednesday summer night, listening to the Louisiana Recovery Authority. The presenters explain how the residents can help rebuild their city, devastated by Hurricane Katrina a year ago. A storm threatens to end the presentation when the power goes out. But in the pitch black room, as thunder shakes the small building, all 100 people stay in their seats.

"Finish what you were saying," someone says.

A little thunder can't shake the resolve of people who lived months without electricity or gas and still drive past miles of rubble on streets yet to be repaired. They are determined to recognize their city again.

Two of the audience members are from Tulane University's Prevention Research Center, funded by the Centers for Disease Control and Prevention as part of a nationwide network to prevent chronic disease. Center staff members have attended more than 60 community meetings since January, and they have something to ask. What if New Orleans wasn't just brought back? What if it was brought back better? Healthier?

New Orleans, world-renowned for its jazz and jambalaya, has never been the healthiest of cities. The CDC has consistently ranked Louisiana among the worst states in the country for obesity, cancer, and infant mortality. Many health problems concentrated in poor, urban neighborhoods and could be traced to unhealthy diets and a lack of physical activity.

Click here * to learn more about the Tulane Prevention Research Center's ideal healthy New Orleans neighborhood. (PDF-743K)

The Prevention Research Center (PRC) had planned before the storm to work with at least one of those neighborhoods, to show that a community-led intervention project could increase physical activity. In the researchers' and community members' vision, the built environment would be changed to make it easier for people to spend time outdoors. Changes could include adding sidewalks for pedestrian safety; adding parks for recreation; increasing lighting and visibility to reduce crime; locating schools, health clinics, and stores with fresh fruits and vegetables within walking distance of residential areas; making public transportation easy to access; and ridding neighborhoods of crime-attracting liquor stores. Each of these "healthy neighborhood" concepts is backed by research.

But after Katrina's flooding, miles needed to be rebuilt. What was once a research project for the PRC became an opportunity and a mission: to improve not just one neighborhood, but all of them.

Tom Farley, M.D. M.P.H., director of the Tulane Prevention Research Center. Photo courtesy Department of Community Health Sciences, Tulane University School of Public Health and Tropical Medicine.

"We had a historic opportunity to rebuild things differently," said PRC director Tom Farley, M.D., M.P.H. "We wanted to say, 'Stop, don't rebuild things how they were.' How many times have any of us said, 'If I had to rebuild it again from scratch, I certainly wouldn't rebuild it this way.' Well, we can rebuild it from scratch."

Just after the storm, he convened in Baton Rouge with health officials and experts who released one of the first plans for a better health infrastructure, "Framework for a Healthier Greater New Orleans."

"I insisted we incorporate in it the idea of building healthy neighborhoods," Dr. Farley said. "We're not just rebuilding hospitals and clinics."

That report went to all levels of government and the media. New Orleans mayor Ray Nagin asked Dr. Farley to sit on his Bring New Orleans Back Commission's Health and Social Services Committee.

In July, the city and a nonprofit group, Greater New Orleans Foundation, agreed on a unified process to plan how to rebuild the city's neighborhoods. Planners, funded by the Rockefeller Foundation, are gathering information from all previous plans and reports and taking input from neighborhood residents across the city. The hope is to have a city plan by the end of the year to present to the Louisiana Recovery Authority for federal rebuilding money.

A year after the hurricane, just under half of metro New Orleans' 450,000 population is back. Rebuilding progress is slow and sometimes hard for residents to see. About 50,000 returnees live in trailers set up by the Federal Emergency Management Agency (FEMA), in trailer parks or, more commonly, on their front lawns. Debris from gutted houses still lines the streets, and it appears faster than the city can clean it up. Abandoned, flooded cars are a common sight. Homes are scarred with spray-painted messages like "all clear" or "one body inside." Crime is up, thought by police to be tied to rising drug traffic. In some areas of the city, there is a sense of normalcy. In other parts of the city, many businesses and restaurants remain boarded up. Few schools and grocery stores are open.

If people weren't healthy before, post-hurricane life hasn't helped, says Carol Fernandez, MS, who serves on the community advisory board for the PRC. She is working with the PRC on a program promoting vegetable consumption and she is very interested in measures to help corner groceries provide more produce.

"If you don't take care of you and your health, then you're not going to be able to address all the rebuilding issues," Ms. Fernandez says.  "For you to fight the insurance company, work on the house, all the things you need to do personally for rebuilding, if you're sick, if your health declines, you're not going to be able to do that."

But Ms. Fernandez acknowledges the challenges; she, too, faces them. She commutes three hours from Lake Charles, Louisiana, where she moved after the hurricane. She and her husband and her two boys stay in a FEMA trailer when they are in New Orleans. Once you squeeze a man, a woman, two growing sons and three dogs into a 240-square foot trailer, she says, there's really no elbow room to chop vegetables for a healthy dinner. Fast food becomes very tempting.

An August article in the Journal of the American Medical Association reports that anxiety and stress are getting to the residents. The suicide rate in New Orleans has tripled in the past year, and mortality on the whole has gone up 25 percent. Ms. Fernandez estimates she has been to 10 funerals in the past year.

"Maybe their health was already compromised, and it's just exacerbated that," she says.
So she and the PRC are trying to make health an easier choice to make for an already burdened population.

Kate Parker, MPH, program manager for the Tulane Prevention Research Center's core project, stands by a beached boat in an empty lot in the intervention neighborhood. Hear her vision of what this empty lot could become in a healthy neighborhood. Read transcript. Enlarge picture.

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Kate Parker, MPH, program manager for the PRC, struggles to find her way around the Upper 9th Ward. Although she's driven the area dozens of times, mapping out a route to conduct physical activity observations, she finds it hard to orient her colleagues—many street signs have been down since the storm. The facility that makes the street signs was flooded.

When the PRC staff reunited last fall, they decided to move ahead with their research project to show how community-driven physical change could affect one neighborhood, and at the same time to educate the city and planners about healthy neighborhoods.

"Now being the time when everyone is hyped up and super interested in what the new city can look like, there's no better time," Ms. Parker said.

The decision to continue with the project was cemented after the center conducted a survey *(PDF-734K) this spring, funded by the Robert Wood Johnson Foundation, asking 1,073 returning residents what they want to see in their rebuilt neighborhoods. A resounding number cited less crime, good street lighting, clean streets, public transportation, grocery stores, parks, and sidewalks—just the things that the healthy neighborhoods plan would target.

The PRC's chosen intervention area remained the same—a small slice of the St. Roch and St. Claude neighborhoods in the Upper 9th Ward. This historic residential area is bounded by several high-traffic roads. Once, it was home to the legendary streetcar named Desire, which brought customers to shops on St. Claude Avenue, but the streetcar was replaced by a common bus in the 1940s. Jazz musicians such as Jelly Roll Morton lived here. Before the hurricane, the area was 90 percent African-American, and 40 percent of people owned their homes.

Most of the intervention area had just 1 to 3 feet of floodwater, coming to the top of the front steps on most houses but not covering the floors. Several blocks that were more flooded were not attracting residents back as quickly and had to be dropped from the study. People started moving back last fall and the PRC estimates about 30 percent were back by July, based on observations of the number of non-flooded cars in the neighborhood, trailers, for sale signs, and lights on in houses at night.

This fall the PRC is beginning to gather baseline data by conducting 700 interviews in the intervention area and two comparison neighborhoods.  Staff will also observe and count how many men, women, and children are biking, walking, playing or running outside. In January, the PRC will train 20 community health advisors from the intervention neighborhood, and together the group will choose the first environmental change to implement. Money for the intervention will come from the PRC, but also, they hope, from new funding sources and donations from groups that have an interest in improving the city.

Ms. Parker wants to leave those 20 people with greater capacity to influence and rebuild their neighborhood. "It doesn't take physical labor on the neighborhood's part, just a constant barrage of meetings and phone calls to get people to listen to you," Ms. Parker said. "It's not just a let's-give-you-the-money sort of situation. It's more about giving people skills."

Frederick Jarmon moved to the intervention neighborhood in May with his daughter Ani, 1. Listen to Jarmon's concerns about the area and his wishes for Ani to have a safe place to play.  Read transcript.

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Because choosing the physical change in the neighborhood will be a participatory process, the PRC staff doesn't know what the project will be. But this neighborhood has plenty of areas prime for change, they say.

Playgrounds are currently covered in trash or used as trailer parks. If parks were restored, they could be used as places for children and adults to exercise.

"You want to have it where it's okay for the kids to play, but it's not safe for them," said Frederick Jarmon, 22, who moved to the neighborhood in May with his daughter Ani, 1, after staying in hotels for months after the hurricane. "I let her run around, but I'm pretty sure she'd like to swing, things of that nature, get on a sliding board."

Andrew Jackson, 62, agrees. "The kids, they need pools, something to keep them busy," he said, watching his neighbor's children play in front of his house. "They used to use the park in the summer, now they're up and down the streets." He has lived in the neighborhood 41 years and luckily, the damage to his house was minimal—a roof leak and a torn gate.

"When I came back, I was the only one back, me and my godfather," he said. "We cleaned up the streets." Mr. Jackson had no utilities until December and had been taking cold baths and cooking on a Coleman stove, driving to a suburb for ice. His godfather has since died. "He got worse after the hurricane came in," Mr. Jackson said. "I think that had a lot of effect on it."

A neighbor recently mowed the empty lot on their street and tied a cord across it so that people wouldn't dump garbage there. The city comes once a week to pick up garbage, but piles are still everywhere, as well as broken-down cars and even abandoned boats, beached when the floodwater receded. Flocks of pigeons gather to feed at the mounds of junk.

Another potential project would improve pedestrian safety so that people feel safe walking outside. Several intersections in the intervention area are hotspots for traffic accidents involving pedestrians, according to Jennifer Ruley, a PRC advisory board member and engineer.

"We can focus on making those safer, through sidewalk improvements, intersection improvements, crosswalks, bus shelters, better lighting," said Ruley, who is stationed at city hall and helps push through projects that improve safety for bicyclists and pedestrians. She thinks the city has a great setup for bicycling and walking—it's small, has flat terrain, there are not too many large freeways interrupting access and there are many roads that connect to each other. "The challenge is making it more bicycle- and pedestrian-friendly," she said. By making St. Claude Avenue, a commercial corridor, more attractive and safer, "you could improve not only the streetscape but also the economic environment."

So could bringing back a streetcar line on St. Claude Ave., something that business owners in the neighborhood would like to see. The PRC believes public transportation also enhances public health in a number of ways. It gets people out of cars, which increases their physical activity, and reduces air pollution from cars, helping to limit asthma.

When more people are on the street, it also helps reduce crime, which Dr. Farley says is not something that people normally think of as an environmental function. But police records show that more crime happens around liquor stores and in unlit areas. Actions such as putting windows and porches on buildings to keep people's eyes on the street, putting transit stops in well-lit areas, and removing liquor stores can make a difference to safety and health, both in reducing someone's chance of being a victim and in encouraging people to spend more time outside. "It's not like we're going to make crime disappear from New Orleans," he said. "But even if we could reduce it by 10 percent that would be a huge advantage."

This landmark on St. Roch Avenue in the intervention neighborhood, boarded since Hurricane Katrina, could become vibrant once more with cafés and a farmer's market, providing nearby healthy food for neighborhood residents, according to Tulane University's Prevention Research Center. Enlarge picture.

The PRC would also like to see healthier food in the neighborhood, which has few grocery stores nearby. People without cars depend heavily on corner groceries, said Greta Gladney, president of the St. Claude Merchant's Association and a longtime community activist who serves on the PRC advisory board. One measure could be to help corner grocers afford to buy coolers for fresh produce, she said. She wants to see stores like she's seen up north, with displays of fruit, iced melon, and pineapple, and flowers along the streets. She also has plans for the St. Roch Market, a landmark in the neighborhood that most recently was a fish market with celebrated seafood po-boy sandwiches. Since the storm it has been boarded. Ms. Gladney imagines a renovated structure that would include cafes with bright umbrellas and a weekly farmer's market. The building's attic could store historical artifacts from the city's Mardi Gras Indians, African-American revelers who dance down the neighborhood's streets.

"Food, eating here, so much of it is culture, folks having grown up eating certain foods, a certain way," she said. "I see the market as an opportunity for people to try out foods, recipes, and meals they haven't tried before."

So far, only about three or four of the 44 members of the St. Claude Merchant's Association are back in business. "I think there's hope among people who have come back, and determination," Ms. Gladney said. "But it's going to take awhile."

If the hurricane and flood divided New Orleanians' lives irrevocably into before and after, at least there's a sense that after is somewhere that is okay to be—stronger, more empathetic, and very proud.

Amid the piles of debris across town, small signs poke out in front of houses. "We're coming back!" they say, or "Rebuild."

"I have never seen civic engagement at levels that I've seen in New Orleans, even close, anywhere else, ever," Dr. Farley says. "It used to be, if a neighborhood organization had a meeting and five people showed up, they were happy. Now we have meetings where 200 people show up. It's unbelievable. I hope we figure out how to sustain that enough to channel it into rebuilding a healthy city."

Jennifer Ruley thinks that's possible. In addition to working on the PRC project goals and making the city more pedestrian-friendly, she, like others at the PRC, is also involved in rebuilding her own neighborhood.

"What I've heard from people is we don't want to return to August 28th New Orleans," Ms. Ruley says. "Ultimately, we want to see our communities rebuilt in a smarter, more healthy way."

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