In Post-Katrina New Orleans, Efforts Under Way to Build Better Health CareIn Post-Katrina New Orleans, Efforts Under Way to Build Better Health Care

Oddity is not a medical condition that can be treated or cured. But Fred Cerise, MD, says the sheer peculiarity of reassembling health care systems, jobs, and homes a year after Hurricane Katrina pummeled New Orleans and the surrounding Gulf Coast hangs over health professionals in the city like a chronic illness.

“Our biggest challenges have to do with just the oddity of this entire situation, of putting society back together en masse,” said Cerise, secretary of the Louisiana Department of Health and Hospitals, during an August briefing on the state of New Orleans' health that was sponsored by the Henry J. Kaiser Family Foundation.

“It's not as if we are going to evolve back into normalcy here, and so we have issues dealing with work force and infrastructure that are just incredibly complicated,” he said. “When we look at work force issues, things like housing become such an important piece. That's just hard to overcome.”

The health care work force, and therefore health care for the people of New Orleans, has changed radically in the past year. Cerise cited “a significant loss of physicians,” estimating, based on recent telephone surveys, that perhaps as few as 35% of primary care physicians who were practicing in New Orleans before Katrina are still there.

One of the city's dominant health insurers, Blue Cross and Blue Shield of Louisiana, has reported receiving claims from only about half the physicians who were submitting claims before the hurricane struck, Cerise said. “Probably somewhere between 35% and 50% is a fair number for physicians remaining in the area,” he noted.

Compounding the overall physician shortage is a lack of certain health specialists. Psychiatrists and dentists are in particularly short supply, Cerise said. “We had a shortage of nurses, nurse assistants, and nurse aides in the area before Katrina,” he added. A video that the Kaiser Foundation presented during the briefing referred to shortages of orthopedists, oncologists, and ophthalmologists.

Karen DeSalvo, MD, MPH, chief of general internal medicine at Tulane University Health Sciences Center, said most health professionals in New Orleans have gotten past the point of practicing medicine from ice chests on card tables. But she said staff shortages limit clinics' hours of operation and therefore patients' ability to obtain care.

“It is very difficult to find staff to help with the front desk, to find nurses, to find medical office assistants, to find social workers,” DeSalvo said. “[Physicians] do everything in the clinic because we haven't been able to find anyone else to work.”

Most patients who have nontraumatic acute health problems—DeSalvo mentioned skin conditions as an example—can access health services. But she said preventive care, health screenings, and diagnostic tests are difficult or impossible for most patients to obtain.

Maintaining continuity of care has been an ordeal for many patients with chronic health conditions. In the video and in a new report that the Kaiser Foundation prepared for the briefing (http://www.kff.org/uninsured/080806pkg.cfm), dozens of hurricane survivors described the obstacles they have faced in finding health care since Katrina struck. Among them was an HIV-positive woman in her late 50s who evacuated alone from New Orleans with only a 3-day supply of medication—the amount the group home where she lived would give her.

The woman went without medication for an unspecified period of time because the local hospital in the small Louisiana town to which she fled did not have antiretroviral drugs on hand. She now lives in a nursing home in New Orleans, but she said her HIV specialist will leave the city soon. She has asked all the health professionals she sees to write letters explaining her treatment regimens so she will be prepared if another hurricane strikes.

The Kaiser report indicated that some patients with HIV infection whose medication was disrupted after the storm had lower CD4 cell counts by the time they reconnected with their physicians or found new ones and resumed medications. Some survivors with hypertension and diabetes tried to manage their conditions on their own when they were cut off from their physicians and were not able to refill prescriptions.

Also in the Kaiser video, Peter DeBlieux, MD, director of emergency medical services at Charity Hospital, said that in one recent month the reconfigured hospital—a makeshift emergency department and walk-in clinic located in an abandoned department store—treated 4200 patients for emergency conditions. He estimated that it will take 5 to 8 years to rebuild New Orleans' health care system.

But the major question, said panelists at the briefing, is how to create a post-Katrina health system that serves New Orleans' low-income population better than before the storm. Charity Hospital, the centerpiece of care for poor, uninsured patients in New Orleans, was destroyed. The building has been deemed unsalvageable. In April, Charity's Trauma Care Center reopened at Ochsner's Elmwood Hospital in nearby Jefferson Parish. Charity's sister hospital, University Hospital, hopes to reopen this fall. The number of safety-net clinics for the poor and uninsured has dropped dramatically since the hurricane, from 90 to 19 in Orleans Parish, according to statistics in the Kaiser report.

DeSalvo said the current focus is on building a decentralized system that does not have safety-net services heavily concentrated in downtown New Orleans, as was the case in the past. “We really want to flip that so that it is much more patient-centered and much less doctor-centered,” she said, adding that patients should be able to walk or bike to their physician's office instead of having to take two or three buses.

In addition to redesigning the logistics of health services for the poor and uninsured, establishing electronic medical records has become a priority. Some 30 000 patient records were destroyed when 42 inches of floodwater rushed through the Daughters of Charity Health Center.

Destruction of hospital medical records was one problem, but another was that many individuals simply did not have written information about their personal health needs. “People were evacuated without any medical records, not knowing their medications or what their allergies were,” said Dominic Mack, MD, project director of the Regional Coordinating Center for Hurricane Response at the National Center for Primary Care of Morehouse School of Medicine, Atlanta, Ga.

If there has been a breakthrough since the hurricane, De Salvo said, it has been in the creation of partnerships between the city's academic institutions and a mix of public and private agencies. “We have all come out of our walls to create a new fabric in the city that I think will mean much better patient care,” she said.

One example she gave was that of the Partnership for Access to Healthcare, a network including the Louisiana State University Health Care Services Division, Charity and University Hospitals, the New Orleans Health Department, and several federally qualified health centers. Before Katrina, the network was trying to improve safety-net health services. Post-Katrina, the network welcomed other organizations interested in strengthening the safety net. Among those that stepped up was Common Ground, a faith-based organization that opened a free clinic offering immunizations and care for some acute health conditions.

From outside the Gulf region, help also came from Operation Assist, a collaboration of the Mailman School of Public Health at Columbia University in New York, NY, and the nonprofit Children's Health Fund. Before Katrina, Operation Assist had about 17 programs nationally that use mobile medical units to reach individuals in remote areas. Several of the mobile units were deployed to the Gulf Coast following Katrina.

Now, said Irwin Redlener, MD, director of the National Center for Disaster Preparedness at the Mailman School of Public Health, Operation Assist is forming permanent programs and partnerships with Louisiana State University, Tulane, and some institutions in Mississippi.

In “mega-disasters” such as Katrina, Redlener said, private organizations and community-based programs play an important role in providing assistance, and their role should be scaled up. “They have to have fully engaged governmental partnerships where there really are resources to fix things for the long term,” he said. “This is one of the most important lessons we can take out of this.”