New Orleans Health Care Heads in New Direction

NEW ORLEANS -- Towering over much of the Central Business District, Charity Hospital at once represents the past, present, and future of healthcare in New Orleans.

Built in 1939, Charity was the second largest hospital in the U.S. at one time, with more than 2,600 beds. The hospital succeeded a half-dozen predecessors of the same name, the first of which was built in 1736, using a bequest from a French shipbuilder who saw the need for a health care facility for the growing city's poor and indigent population.

Scaled down over the years to about 700 beds, Charity remained the principal source of health care for New Orleans' indigent and uninsured residents. And 70 percent of Louisiana's physicians received part or all of their training at Charity, often called "Big Charity" to distinguish it from the smaller University Hospital, which also is part of the network of state hospitals.

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All of that changed on Aug. 29, 2005, when the storm surge from Hurricane Katrina breached the concrete walls atop the levee system that provided a barrier between New Orleans and the waters of Lake Pontchartrain and Lake Borgne. Flood waters that exceeded 10 feet in many areas of New Orleans also inundated the Central Business District and essentially destroyed the infrastructure of most buildings, including Charity Hospital.

More than four years after Katrina, Big Charity still towers over much of the area, but only a darkened shell of a building remains. Charity may never reopen, at least not as a hospital.

"What we do know is that Big Charity is not going to be rebuilt as a hospital," said Dr. Larry Hollier, chancellor of Louisiana State University Health Sciences Center in New Orleans. "It's not cost effective. It's not appropriately sized for modern health care today. The city and the state have decided that they do not plan to tear down Big Charity. There will be a lot of discussions about what options there might be."

Discussions thus far have included reopening the building as a new city hall, as a research facility, or as a residential facility, he added.

Devastation Reigns

The fetid flood waters stood for weeks in some places, until the concrete barriers could be repaired and water pumped from the city. When the water finally receded, the late-summer New Orleans heat had fueled an overwhelming growth of mold, bacteria, and filth.

All but three of two dozen hospitals in Orleans Parish remained closed for months. Tulane University Hospital, for example, did not reopen until February 2006.

Some hospitals remain closed to this day, such as Lindy Boggs Medical Center and a portion of Memorial Medical Center.

The latter facility provided the setting for some of the darkest moments of Katrina's destruction, as a physician and two nurses were charged with second-degree murder in the deaths of four patients. The charges were eventually dropped, but the nightmarish memories and lawsuits remain.

Making a bad situation worse, physicians and other health care providers left New Orleans in droves, seeking assurances of stable income and better working conditions elsewhere. Moreover, their patients left, too.

At one point, New Orleans' population was estimated to have dropped to about half its pre-Katrina level. About 75 percent to 80 percent of the homes in the city had been destroyed or rendered uninhabitable. Thousands of residents had nowhere to live when the water finally did recede.

Post-Katrina New Orleans epitomized the adage that bad situations bring out the worst and the best in people. The worst received the most attention: looting, muggings, AWOL police officers, and public officials and private citizens alike behaving badly. The good received considerably less attention, especially outside of New Orleans and surrounding areas.

Despite the death (more than 1,800 people died) and destruction (an estimated $110 billion), Katrina brought out the very best in many people.

Doctors Reach Out

Upon returning to the city, resident physicians from Tulane University immediately recognized a huge health care void and set out to fill it as best they could, said Dr. Karen DeSalvo, vice dean and professor of medicine at Tulane.

Tulane residents fanned out over the city and set up makeshift clinics wherever they could find the space and resources: from street corners and tents to buildings that escaped the flood waters. Using whatever medical supplies they could obtain, they started dispensing free health care services.

Faculty, staff, and students at LSU Health Science Center worked side-by-side with clean-up crews to remove tons of trash, damaged equipment, and even human waste from Charity Hospital and other facilities.

The not-for-profit Ochsner Foundation hospitals accepted record numbers of indigent and uninsured patients.

Even as water filled the basements and ground floors of most buildings, patients remained in hospitals and required care. Dr. Lee Hamm, chair of internal medicine at Tulane, commandeered a resident's canoe to make rounds until the streets were passable.

"I didn't know how things were going [at the hospitals]," said Hamm. "We had heard rumors of things not going well, not at those hospitals, but elsewhere. One of the orthopedic residents had brought a canoe to the parking lot -- why I don't know. But it turned out to be useful."

The unorthodox manner for making rounds reassured Hamm and others that patients were being evacuated from the hospitals as well as could be expected.

The decision to celebrate Mardi Gras in 2006 left New Orleans residents bitterly divided, some seeing the celebration as totally inappropriate as thousands of citizens tried to cope with the disaster and others as an opportunity to interject some relief from the dreariness and to show the world that New Orleans would come back.

When city officials decided to let the good times roll, three downtown hospitals were open: Touro Infirmary, Children's Hospital, and Tulane (with a fourth of its bed capacity).

Both Tulane and LSU set up temporary facilities to handle medical emergencies from revelers who partied too hard. The three hospitals increased their staffing to the extent possible. The end result was a Mardi Gras that met or exceeded expectations.

New Models of Care and Training

Rising to meet the challenges posed by Katrina was the beginning of a transformation of health care services in New Orleans. Tulane has played a prominent role in creating a network of community clinics that allow residents to obtain care that is convenient, familiar, and affordable. Rotations at the clinics have been incorporated into the training of interns and residents.

One of the first community clinics established after Katrina recently got a big boost from a New Orleans institution. Owners of Ruth's Chris Steak House, a national chain that started in New Orleans, donated the original restaurant building to serve as the clinic's new, enlarged facility.

The community clinics have begun to shift New Orleans' health care model away from hospital-based care, particularly for indigent and uninsured patients.

"We're testing the waters of innovative ideas for drawing people away from hospitals and into the community," said DeSalvo. "We've also done some interesting things with payment models. The payment model is along the lines of the retainer model, rather than fee for service, and I can tell you that it works."

"The other experiment we've been undertaking is in workforce training and thinking about how we can create a robust environment where students of all disciplines can train together," she added. "We don't just do medical student training here. We also do training for nursing, social work, pharmacy, and we have public health students."

The Department of Veterans Affairs has announced plans to build a new hospital in New Orleans.

LSU is moving forward with plans for a new hospital to replace Charity. As currently conceived, the hospital would be part of a multipurpose medical complex located outside downtown New Orleans.

The Ochsner Health System has acquired several New Orleans-area hospitals, including Memorial Medical Center, adding some security and stability to the city's health care services.

New Perspectives, Too

The adversity of Hurricane Katrina also has changed the people who provide health care services in New Orleans. Medical students and resident physicians, in particular, have a different view about their roles as health care providers of the future. Medical school applications have increased dramatically at Tulane, as has interest in coming to New Orleans for residency training.

In contrast to the University of Texas Medical Branch at Galveston, which faced adversity following Hurricane Ike in 2008, the pace of recovery in New Orleans has been more gradual, in terms of facilities. But, in terms of people, Katrina's effect occurred almost immediately and seems destined to be a lasting one.

"The men and women who came back after the storm were some of the most courageous people I have ever had the fortune to work with," said Dr. Benjamin Sachs, who came to New Orleans two years after Katrina to be dean of medicine at Tulane.

"I realized on my first interview that there was an atmosphere, a drive, a spirit, a whole new screen to paint a totally different picture of the kind of care we want to provide," Sachs said of the health care providers who lived through the destruction and recovery.

"The students grew as human beings," he added. "I think they will make better doctors because they learned resilience. They learned that when life throws you a curve ball that you really didn't expect, that you can overcome it and come back. They also were being taught by people of courage, and that gets into your marrow."