BETHESDA, MD—In August 2005 the one-two punch of Hurricane Katrina and the failure of the New Orleans’s levees resulted in massive destruction throughout the city’s infrastructure, including its health systems. As those systems have been rebuilt, officials have learned valuable lessons about how to make them less vulnerable to disaster. Physicians who have had a hand in that rebuilding spoke about those lessons to an audience of researchers and physicians at the National Institutes of Health last month.

Opportunity After Disaster

“The storm comes and goes, but the flooding leaves quite a bit of damage behind, and that’s one of the reasons we’ve had so much trouble getting back on our feet,” explained. Karen DeSalvo, M.D., associate professor of medicine at Tulane University and NIH funding recipient. Both Tulane and Louisiana State University’s medical schools were hit hard, with both shut down for many months.

“From our standpoint at Tulane, we had this immediate scramble to figure out what [to do] next,” Dr. DeSalvo said. “All the buildings where we worked and saw patients and taught students were flooded and stayed that way for a number of weeks.”

Tulane’s medical school did not open again until March 2006, and students did not arrive until several months later. In the meantime, the city’s health leaders struggled to find their footing, but also realized they had an opportunity to improve the city’s poor healthcare system.

“Looking forward was something that started very early in October [2005],” Dr. DeSalvo said. “This was something that was initiated by the CDC and the Public Health Service to help us think about whether we wanted to rebuild what we had or maybe think about doing something different.”

“We had a clean slate. On the one hand, we had nowhere to work, but on the other hand we could really take an opportunity from this tragedy and really build a modernized system,” Dr. DeSalvo explained.

Prior to the hurricane and the flooding, Louisiana was a state that historically ranked last in many categories of healthcare quality. It ranked last in Medicare quality of care, and provided that care at the highest cost. Its patients had some of the poorest health outcomes ranked by nearly all accepted measures. The state had a high-risk population, both high in poverty and poor in health literacy. And the state had very low rates of insurance coverage.

Over the last three years the city and the state have been undertaking an overlapping series of framework efforts to define what the best possible healthcare system for New Orleans would look like. Those efforts have centered on reforming healthcare financing, improving quality, redesigning care delivery and redesigning the city’s information technology system.

The Dangers of Centralization

xThat flooding hit certain areas of the city particularly hard, including the Lower 9th Ward, New Orleans East, St. Bernard Parish and the downtown New Orleans area where many of the city’s medical centers were located. “The safety net of our system—the linchpin of that was really the Charity Hospital System, which was in downtown New Orleans—was actually in a flooded area. All of the clinics for the safety net system, predominantly happened downtown in this system,” Dr. DeSalvo said. “Historically we had used the public hospital system, Charity Hospital, for care of uninsured. And so our safety net system had been this financially and geographically centralized system. Katrina really exposed the frailties in the safety net system for us.”

Charity Hospital was one of two teaching hospitals in New Orleans. It was closed following extensive damage caused by the flooding. The Tulane Medical School and Louisiana State University Medical School buildings were adjacent to Charity Hospital, and much of the hospital’s workforce came from there. Following the hurricane both the workforce and the buildings needed replacing.

As the city looks at how it must redesign its care delivery system, the centralized safety net of old is an option that has gone by the wayside. Even before the flooding revealed the dangers of putting so much of a city’s healthcare resources in one place, it was an imperfect system. “The centralized safety net was convenient to the medical schools and to the students but not so much for the population,” Dr. DeSalvo said.

After the flooding, as the city’s physicians, medical students, and volunteer health workers returned, they began to create what were then temporary tent clinics, many of which were set up in buildings abandoned following the flooding. That temporary measure has grown to provide better care for citizens than the previous system did. “There are, across the city, 83 [care access points] serving 140,000 people. As of last month we can boast that we have the highest density of high-quality primary care in the country. We didn’t just put primary care there, we put high-quality primary care there,” Dr. DeSalvo said.

Dealing with Displacement of People and Records

When the city evacuated, patients left in droves, with many returning some time later to find their former healthcare clinic gone, or showing up in distant cities needing care. “The mental health stress of undergoing such a large disaster—1,500 deaths in a city which is actually quite small—is a huge burden. And looking at the landscape and how it’s changed, many are having difficultly when they return and how to cope,” explained Keith Ferdinand, M.D., a clinical professor at the Morehouse School of Medicine, and a cardiologist working in New Orleans before and after the hurricane. “One problem that hospitals and patients are struggling with together is the destruction of medical records by the disaster,” Dr. Ferdinand explained.

“One of the major problems was the absence of uniform electronic health records. People showed up in Atlanta, Dallas, Little Rock with very serious medical conditions, and all they could tell the provider is that they were on a white pill, a blue pill, etc.,” he said.

“We learned very quickly after Katrina, we couldn’t find our patients,” Dr. DeSalvo added. “We didn’t have databases on them.

We didn’t know who was on Coumadin and who wasn’t. And we don’t want to go through that again.”

The only hospital that avoided this problem was the Department of Veterans Affairs medical center, which used electronic medical records and was able to save the information, even though the facility was destroyed. The medical schools are leading the way in establishing electronic health record systems throughout their clinics in the hopes of avoiding such problems in the future.

Areas Still Unrecovered

Physicians also left the city in droves and many have still not returned. While the central areas of the city are receiving easy access to care, those areas that were hit the hardest by the flooding—those farther away from the major medical centers and the universities—are still struggling to find providers. “Medical centers have essentially rebuilt and medical students are motivated because of this tragedy at the medical center at Tulane and LSU. Many of the physicians are now located downtown in the medical center,” Dr. Ferdinand explained. “But if you go into the Lower 9th Ward and areas farther away from the center of the city and the rebuilt areas, you still have a disproportionately [low number of] primary and specialty physicians.”

Another area struggling with lack of care is New Orleans East—an area where much of the city’s African-American middle class lives. Currently the city’s healthcare leaders find themselves in a debate over how to best provide care, and whether a new hospital in that neighborhood would really be the best way to serve the population.

“One of the questions that has arisen is should we go to New Orleans East and build a hospital. There are questions that need to be answered before [we do that],” Dr. Ferdinand said. “Would a hospital ever make enough money to stay afloat? We have a deficit of primary care and prevention.”However, the leading causes of mortality remain chronic diseases, and an increase in hospital beds might not be the best use of resources. And so as the city looks at how to rebuild its health infrastructure, its leaders are being forced to consider all options, not just the conceptually simple and possibly expensive and inadequate one of building new tertiary structures.

“Just building inpatient beds in the Lower 9th and Eastern New Orleans would not be the answer,” Dr. Ferdinand concluded.