New Orleans, Katrina, and the Death and Life of Cities

What is the city but the people?
William Shakespeare, Coriolanus, Act 3, scene 1

This issue of JAMA marks the second anniversary of the devastation of New Orleans in the wake of Hurricane Katrina—not only the largest national disaster but also arguably the largest humanitarian and political disaster to befall a major US city. On Sunday, August 29, 2005, the eye of the hurricane passed to the east of New Orleans. While on the following day most of the residents (those who remained in the city and those who evacuated) were breathing a sigh of relief that damage appeared minimal, the city was rapidly filling with water through multiple levee breaches. By Tuesday, 80% of the city was under water.

There are many extraordinary stories about survival in the hours and days after the flood. The Commentary by Krane and colleagues¹ in this Medical Education theme issue of JAMA tells one that is less familiar. Medical education in New Orleans has been the responsibility of 2 medical schools: Tulane University School of Medicine (since 1834) and Louisiana State University School of Medicine at New Orleans (since 1931). The original Charity Hospital dates back to 1736. The hospitals and their medical personnel heroically provided medical services until and beyond what most persons would have considered a breaking point, working in facilities that were flooded.^{2 - 3} The Commentary provides an overview of how these institutions were affected and the notable way that their missions continued despite disruption of nearly every possible aspect of the education enterprise: destruction of facilities; loss of communication and electronic information; loss and dispersion of students, trainees, and faculty; and loss of the patient base. The schools nevertheless maintained continuity after the storm, and both the undergraduate and graduate training programs are making a remarkable recovery in a short time. Considering these exceptional efforts leads to reflection on the environment in which they have occurred.

The physical destruction wrought by the waters of Lake Pontchartrain and the Gulf of Mexico is familiar from televised images. However powerful, isolated images cannot convey the impact of driving for miles and seeing an unbroken surrealist landscape of household items in trees, cars resting upright against homes, compressed and contorted houses pushed off their concrete foundations. While these most extreme scenes are mostly gone now, debris remains, as do long stretches where the city has been scoured of homes.

More profound and haunting than the physical loss is evidence of the city's continued social destruction. Even in the neighborhoods where flooding was not apocalyptic, street after street and block after block remain empty of residents. Houses stand without visible damage, but stained by a horizontal ocher-colored stripe showing the level at which the foul waters sat for days, an irrefutable sign of their prolonged encounter with the flood. Houses still bear an additional stigma: a large “X” spray-painted across the front after the home had been checked for habitants, with a figure indicating the number of identified dead. The ongoing absence of people in these neighborhoods in which the edifices appear intact evokes something between a ghost town and the Twilight Zone.

In some areas this is changing. In the absence of a master plan for the city's reconstruction, former evacuees and residents who never left are reoccupying and rebuilding their homes in scattered locations.⁴ The population is now estimated to be back to 60% of pre-Katrina levels.⁵ The French Quarter, which sustained relatively little damage, is touristed. But major economic barriers have prevented many residents from returning.⁶ For example, the Louisiana Road Home program, designed to provide compensation to homeowners affected by Katrina, stopped accepting applications on July 31, 2007,⁷ due to a $5 billion shortfall. The recovery has also likely been affected by the limited number of physicians who have returned and by the closed hospitals.⁸

The potential impact of the social disruption may not be apparent to those who knew New Orleans only through the French Quarter, Bourbon Street, or Mardi Gras. The true culture of the city is much more complex, a reflection of its long international history and blend of ethnic and social traditions. All should not be romanticized; poverty, crime, poor education, and corruption were present before Katrina and need sustained attention. But the results of that unique amalgam, including literature, theater, music, and food, are woven into the fabric of the US national identity. New Orleans history and culture are inherent and vital pieces of the country as a whole, but that culture has been shattered and remains dispersed.

Major cities are usually thought of as immortal. Businesses come and go, and neighborhoods go through series of decline and gentrification. These are evolutions, not aging and senescence. The death of a city is different.

In the life cycles of cities, occasionally a birth can be pinpointed. Washington, DC, and Brasilia came into existence at the moment planners decided to establish each site as a capital. The 1897 Gold Rush defined Skagway, Alaska, as a town. Rarer, though, is the identifiable death of a city. Ancient examples such as Pompeii were due to natural disasters. More modern ones such as Chernobyl involved small towns, not major cities. Abandoned towns in the US West reflected economic decline or events such as being bypassed by railroads.

More common may be near-death experiences with subsequent recovery, such as the Great Chicago Fire or the San Francisco earthquake. The Lisbon earthquake of 1755 resulted in an estimated 90 000 deaths (a third of the population) and destruction of 85% of the city.⁹ These were all centers of commerce and culture, and all were rebuilt. The natural question regarding New Orleans is what is its prognosis.

For a physician, thinking in these terms may trigger an unbidden series of medical metaphors. A city is a living dynamic organism, mirroring the complexity of human physiology with its interdependence of social entities. Watching New Orleans struggle in the unanticipated days after the flood recalled experiences of seeing a patient in the ICU immediately after a severe unexpected stroke. The appearance is so dire that there is a tendency to assume the worst. But this response can be a result of the poor calibration of someone without much ICU experience, unable to recognize the substantial if not complete recovery that can still occur.

On the other hand, watching the events in the Superdome, the convention center, the Lower 9th Ward play out in real time felt like observing a stuttering stroke in slow motion: perhaps the patient will not recover, living out a (possibly shortened) life, a shadow of his or her former self. For a person whose first visit to New Orleans was after Katrina, this would be like having a friend meet someone you have known or admired, but only after a stroke had diminished his or her cognitive and physical capacities.

Where these medical metaphors break down is that aging and its consequences are inevitable and at best can only be postponed; in contrast, the aftermath of Katrina was largely preventable. The risk to New Orleans due to the inadequate and poorly constructed levee system and destruction of the Mississippi delta wetlands was foretold in scientific publications¹⁰ and in the popular media, whose hypothetical descriptions and graphics seem prescient of those that appeared after Katrina.^{11 - 13} There are many courageous scenes of groups such as the US Coast Guard and of individual citizens, all working to save stranded residents after the flood. Yet the entire world watched the human disaster at the Superdome and Convention Center unfurl with the reasonable expectation of imminent rescue that seemed like it would never materialize; this delay was avoidable.

In medicine, prognosis for an individual patient is estimated by comparison with studies of groups of similar patients—looking to history to predict the future. Despite New Orleans' nickname “The City That Care Forgot,” throughout its history the city has faced and recovered from catastrophic events: major fires in the 18th century, yellow fever outbreaks in the 19th century, and frequent but more limited floods. But neither New Orleans nor US history provides a sufficient parallel for comparison with Katrina. A physician's response to a request for prognosis would be “I don't know. I’ve never seen a patient like this before.”

Two years have passed since Katrina, and recovery has occurred, especially in the wealthier and the best-known parts of the city. However, the French Quarter, despite its central place in the history of New Orleans, is only one limited piece of the city. For much of the world, it functions as the public face of New Orleans, but a façade is not the real city. The city is the people.

The collective personality was behind the veneer. Like a patient after a stroke, the question is whether the personality has been lost, with the familiar face only an empty shell, or whether it will reemerge. Society can choose to provide an infrastructure to enable this return, but it is then a matter of time. It will be a tragedy if this culture, which is so ingrained in the nation, becomes lost forever.