The New York Times
Tuesday 24 July 2007
New Orleans - At the tip of Bayou St. John in the Mid-City neighborhood here, the brown and white bulk of Lindy Boggs Medical Center looms behind a chain-link fence. Nineteen people died at the medical center after Hurricane Katrina, and now the hospital itself is dead, sold to developers who plan to replace it with a shopping mall.
On the surrounding streets - Bienville and Canal and Jefferson Davis - lies the wreckage of a once-bustling medical corridor. Doctors' offices sit empty behind five-foot-high water marks, and nearby clinics wait to be demolished. In back of one medical building, a gaping refrigerator still holds jars of mayonnaise and Mt. Olive Dill Relish.
Harder to see, but just as tangible, people here say, are the other ripple effects of the flood and the closed hospital: workers displaced, houses for sale and, of course, patients forced to seek health care many miles away. If they have returned to New Orleans at all, that is, given the grave wounds to the health care system.
"I've been telling people, don't bring your parents back if they are sick," said Dr. David A. Myers, an internist who lived and worked in Mid-City before the flood and has moved his home and practice to the suburbs.
Of all the factors blocking the economic revival of New Orleans, the shattered health care system may be the most important - and perhaps the most intractable.
Except for tourism and retailing, health care was the city's biggest private employer, and it paid much higher wages than hotels or stores. But there are now 16,800 fewer medical jobs than before the storm, down 27 percent, in part because nurses and other workers are in short supply.
Only one of the city's seven general hospitals is operating at its pre-hurricane level; two more are partially open, and four remain closed. The number of hospital beds in New Orleans has dropped by two-thirds. In the suburbs, half a dozen hospitals in adjacent Jefferson Parish are open - but are packed.
Fixing the city's health care system "is critical both for the short and the long term," said Andy Kopplin, executive director of the Louisiana Recovery Authority. "Short-term, having confidence that the health care residents need will be available and accessible is vital for folks who are returning," Mr. Kopplin said. "Long-term, it's important for employers - and health care is a huge business in New Orleans."
Studies suggest that hundreds of doctors never returned. And some of those who did, especially specialists and young physicians, are leaving, said Dr. Ricardo Febry, president of the Orleans Parish Medical Society, which has lost more than 200 of its 650 members. The exodus has "been a steady trickle," Dr. Febry said.
The city's mortality rate appears to have risen sharply in 2006, although state and local officials disagree about the level and persistence of the increase.
With the stress of life in the flood-ravaged city, the limited health care and insurance, the lingering mold and the discomfort of living in trailers, doctors report that the patients they see are often far sicker than those they treated before the storm. And even residents with health insurance can have a difficult time finding someone to treat them.
Government officials and civic leaders are floating plans for the future of the city's medical system, for a state-of-the-art hospital, for a cutting-edge system to cover the uninsured, even for a "bio-innovation center" that would be an engine for economic growth. The question is what will happen in the meantime, which is likely to be many years long.
"We have to find a way to survive to that point, to provide care, or our city will collapse," said John J. Finn, president of the Metropolitan Hospital Council of New Orleans.
Waiting for Care
The problems with health care hit hardest on the poor and the newly uninsured, but they also affect doctors and patients, politicians and entrepreneurs, the displaced and the returned - and everyone at any level who has the misfortune to turn up in a jam-packed emergency room.
Consider the case of Bernadine R. Fields, 50, who learned firsthand how far people have to go for major medical care. A supervisor of city 911 dispatchers, Ms. Fields was among the many laid off after the storm.
The money she had saved for her retirement went for repairs to her house in New Orleans East. By last July, she could no longer afford the $367 a month it cost to continue her health insurance, or all the medicines she needed to treat her high blood pressure, or the $250 it would cost to see a doctor.
So she kept ending up in one of the few open emergency rooms, waiting for hours. After one of these episodes in April, she was told she needed transfusions to treat anemia - but there was not a bed available in New Orleans for an uninsured patient.
Ms. Fields finally got the treatment she needed - but only after an ambulance took her to the state-run hospital in Baton Rouge, 80 miles from her home and family. She stayed there four days.
"I devoted 15 years of my life to serving the public," she said, "and when I need to be served, there is no one to count on."
Ms. Fields's neighborhood in the eastern section of the city, like other stretches of town, cannot recover unless medical care becomes available there, officials say, and neither can large sections of the economy. Doctors and hospitals, though, are reluctant to return unless the population does.
"I'm just hoping and praying nobody dies," said Frederick C. Young Jr., president of the Methodist Health System Foundation, which is working with the city to try to reopen a hospital there.
The sharp contraction in the health care industry has economic effects, too, for coffee shops and florists and medical-supply companies. Marshall F. Gerson, whose family has owned the Ellgee Uniform Shop downtown for almost 70 years, said sales of scrubs and other medical uniforms had fallen to about half their pre-storm level.
"At this time of day when times were good, it was bustle-bustle here," said Mr. Gerson, 63, standing in his shop late one recent afternoon. Now, "the foot traffic is almost nil."
By working harder and selling more industrial and restaurant uniforms, Mr. Gerson has kept his business going but, he said, "I'm not a happy person when I get home."
An Era's End
The future of Mr. Gerson's shop - and in many ways the future of health care in New Orleans - is bound up in the thorny question of what if anything will replace the hospital known as Big Charity.
Since it opened in 1939, Charity Hospital's imposing building downtown has provided basically all the medical care - emergency, acute and basic - for the city's poor, and served as a training ground for generations of doctors.
Despite some community protests, Louisiana State University, which ran the hospital, closed it permanently after the storm, saying it was too damaged by basement flooding. The state plans to replace it with a $1.2 billion complex that officials believe will attract insured patients as well as the poor, will also care for veterans and will serve as an economic catalyst for the city. But the hospital's future is now the subject of a debate about the best use of federal health care dollars, even after the state agreed to pay $300 million to get the project off the ground.
The federal government would prefer that the state build a small hospital and use its federal dollars to buy private insurance for the poor. Dr. Frederick P. Cerise, the secretary of Louisiana's Department of Health and Hospitals, said that plan would help less than half of the uninsured.
On a positive note, the city's trauma center, which treats gunshot wounds and other serious emergencies, reopened in February at University Hospital downtown, which like Charity is part of the Medical Center of Louisiana at New Orleans. But the number of beds at University remains limited, and the building is so outdated that it will eventually have to be replaced, said Dr. Cathi Fontenot, the medical director.
In the meantime, the sick have to go somewhere. Often, that somewhere is Ochsner Medical Center, a huge private hospital complex in the western suburb of Metairie that looks like a mall, with a computerized grand piano that entertains patrons in a sunny atrium.
Before Hurricane Katrina, patients waited just 20 minutes to be seen, said Dr. Joseph Guarisco, chairman of emergency services at Ochsner, and surveys found that 99 percent were satisfied with their care.
After the storm, the number of people coming to the emergency room jumped, on some days reaching nearly twice the pre-hurricane volume. The number of psychiatric patients soared.
The uninsured, who had made up a small percentage of emergency patients at Ochsner, began accounting for more than a quarter of emergency room patients. Waiting times routinely topped an hour. The patient satisfaction rate fell to 34 percent.
This year, Dr. Guarisco reorganized the emergency room and cut the waiting time back to about 20 minutes.
But the other problems remain. "The hospital, post-Katrina, struggled financially," Dr. Guarisco said, "and it still struggles to this day."
Bad Time for a Fracture
No one thinks that emergency rooms are a good way to provide basic everyday health care, but government efforts to attract doctors and to open more neighborhood clinics have gotten off to a slow start.
Volunteers and nonprofit groups are trying to fill the breach, treating thousands of patients a month in more than a dozen low-cost clinics in the city. In many ways, the clinics have been a success for their patients, as they are elsewhere in the country, but they represent just a drop in the city's ocean of medical need, health officials say.
Some were open before the storm but have expanded; others are new, like the Common Ground Health Clinic, which provides free medical care four days a week in an old corner store in the Algiers neighborhood, across the Mississippi from the French Quarter. People wait outside in the heat for the clinic to open, and it is always jammed.
One recent Tuesday, the patients included a city employee with a neck problem, a college student with uncontrolled menstrual bleeding, a bartender with high blood pressure and glaucoma, and Nellie M. Lindsey, 54, a scrap hauler who was suffering from what she called "cancer stones."
Before the storm, Ms. Lindsey said, she would have sought treatment at Charity, but she is so happy with the Common Ground clinic - despite the long waits - that she took her adult sons and daughter there for checkups.
Most of the people who come to the clinic hold at least one job, and many are working two, said Anne Mulle, a family nurse practitioner who came from California after the storm to help and ended up staying.
In addition to longstanding problems like hypertension, diabetes and heart disease, most patients have anxiety, depression and stress, which are even harder to treat, the clinic staff says.
"We can take the health piece off your worry list," said Dr. Ravi Vadlamudi, a Tulane University doctor who serves as the clinic's volunteer medical director. "But we can't get you a better job market or housing market; we can't do anything about the schools; we can't do much with police problems. I can't do anything about most of what bothers you."
For patients who need more complicated care, including mammograms, stress tests and vision treatments, the clinic can make referrals to St. Thomas Community Health Center, which Dr. Donald T. Erwin founded in 1987. The fact that clinics are now collaborating - and recently qualified for federal financing - is a new and welcome development in what can seem like a bleak medical landscape, Dr. Erwin said.
Another change he has seen, he said, is that even people with insurance are having a hard time finding doctors, getting tests and continuing prescriptions, so are turning up at his clinic, where they now make up about a quarter of the patients.
"Before the storm?" Dr. Erwin continued, and held a thumb and forefinger together to make a zero.
Counseling and mental health treatment are notoriously hard to find in New Orleans these days, and doctors say this is an especially bad time to break a leg, given the shortage of orthopedists.
Even patients with the means to pay and doctors who have returned can face long waits for treatment. Dr. Myers, the internist who used to practice in Mid-City, said recently that a new patient would probably have to wait two months for an appointment, though he would find a way to get existing patients in sooner. He estimates that 80 percent of those patients have returned.
Dr. Myers said he had been trying for months to lure another doctor to the area to join his practice.
"This is a great opportunity for people who have courage," he said.
So far, he has found no takers.