Walt Adams, a demolition company official, tours Charity Hospital. The closed hospital is scheduled to be torn down after receiving $340 million in damage from Hurricane Katrina.

by Jim Rogalski

The OB-GYN needed help in a hurry. His patient was in premature labor with twins and his New Orleans hospital did not have a single open bed available, never mind room for three.

The doctor called a friend on the other side of town— Joseph Miller, MD'73, HS'73-'77, an OB-GYN and perinatologist faculty member at Louisiana State University (LSU)—for help.

“His hospital was not equipped to take care of the babies,” Miller says. “I called to see if we could handle taking the twins, but the reality is we could have taken the mom on the delivery unit but we didn't have the facilities for her babies. There was no room at the inn.”

So the woman was rushed north to a hospital in Baton Rouge.

That story is not a portrait of New Orleans in the direct aftermath of Hurricane Katrina, but is rather how New Orleans looks today, a full 18 months after the storm's fury nearly leveled the city and destroyed major portions of the infrastructure.

"People here feel enormous anxiety about the future." -Richard F.Dalton, Jr., MD, HS'75-'79

Progress is glacially slow in every aspect of recovery, and the health care sector is in turmoil with critical shortages of hospital bed space; psychiatrists to treat a heavy demand for mental health services; physicians to treat the uninsured and Medicaid patients; and nurses and hospital support staff. Uninsured patients are flooding emergency rooms with acute as well as non-emergency conditions and creating a financial strain on hospitals.

“People are talking about New Orleans in terms of health care being the crisis after the crisis,” says Ellen Zakris, MD’87, the section chief of radiation oncology at Tulane University. “There are not enough beds; there’s more uncompensated care and a totally insufficient number of psychiatric providers. Since the hurricane there has been much more stress in the city, more suicides, and more Post- Traumatic Stress Disorder (PTSD).”


Scarce Care for the Walking Wounded

When the hundreds of thousand of people fled the city when the storm hit, hundreds of doctors and health care workers joined them and many simply never came back.

The Louisiana Department of Health and Hospitals (LDHH) says that prior to Katrina there were 1,574 primary care physicians licensed in New Orleans. Today just 460 are practicing, and many of them do not treat the uninsured.

Of the 208 licensed psychiatrists prior to the storm, just 42 have returned.

Ellen Zakris, MD'87

“It’s a real mess,” says Miller. “We need health care providers of every description,
and we need affordable housing (for them to live).”

Psychiatrist Richard F. Dalton, Jr., MD, HS’75-’79, is so swamped in private practice that he says he “feels enormously guilty because I have to turn people down all the time. I wake up at 5:30 a.m. and work until 6:30 p.m.”

While more than a third of the city’s population still has not returned, residents slowly are coming back and rebuilding their homes. Unfortunately, the health care workers are not following them, and the trickling influx of people—both returning residents and migrant workers coming to help rebuild—are adding to the already stressed health care system.

Dalton, a professor of child and adolescent psychiatry at Tulane and the clinical director of mental health for the Juvenile Justice Program through LSU, says the city is filled with “walking wounded—they go to work day by day and are trying to get it together. People here feel an enormous anxiety and worry about the future. In children there is increased anger and acting out in school. It’s somewhat of a crisis.”

Children feed off of adults’ emotions, Dalton says, and he is seeing a lot of
children absorbing the worries of their parents. “There are issues of Post Traumatic Stress Disorder, but there is a significant number of children who don’t have PTSD but have sub-threshold symptoms that clearly warrant treatment,” he says. “It’s nebulous anxiety issues that really reflect the parental concerns.”

Riding It Out

Yet, despite the many new challenges they face, Miller, Zakris, Dalton, and
fellow Duke-trained doctor Fortune Dugan, MD, HS’73-’77,—citing either family ties, a deep fondness for the city, or a sense of obligation to their patients who remain—are among the physicians who decided to return to the Big Easy, where their professional lives are anything but easy.

Fortune Dugan, MD, HS'73-'77

“Two of the four hospitals we worked out of are gone,” Miller says. “They flooded and closed. Two of my associates left town permanently. One went to Virginia to be with family to ride out the storm, and he was able to secure a permanent job. The other evacuated with his family and went back to where he was practicing before coming here.”

Five of 11 New Orleans hospitals remain closed. Four are acute care hospitals and one is a VA hospital. Patients there were evacuated to other hospitals around the state and region.

Zakris says up to 25 percent of emergency room care at Tulane Hospital currently is uncompensated because of the abundance of uninsured patients—many of them poor residents who cannot afford to leave. That’s up from just 3 percent uncompensated care prior to Katrina.

“This has caused significant deficits in the hospitals,” Dugan says.
Health care definitely is available in New Orleans, Miller points out, but it’s limited.
“A lot of doctors read the tea leaves,” he says, “and saw that their hospital is closed, their practice and patient base is gone, and they need a job. So they took positions elsewhere.”

Dalton says he knows many friends and colleagues who are ready to throw in the towel and leave. The ones who never came back from the start “are physicians in their 30s and 40s with young children who need schools,” he says. “It’s difficult to live here. Two-thirds of the city is still dark at night. It’s eerie.”

Joseph Miller, MD'73,HS'73-'77

Fighting For Nurses

The nursing shortage is especially acute, Miller says, and is limiting hospitals’
ability to open more beds.

“If a train load of registered nurses arrived today they would all have jobs within a week—all of them,” Miller says. “But there is no place for them to live.”

According to the Louisiana Health Works Commission, the New Orleans
region currently has a deficit of 969 nurses and certified nurses’ aids. The Louisiana Board of Nurses reports a 27 percent decrease in the number of nurses who renewed their licenses a year after Katrina.

“There’s a huge fight over nurses,” says Dugan, a cardiologist at East Jefferson Hospital. “We just lost a bunch of nurse anesthetists to Tulane Hospital. Apparently
they outbid us.”

Dugan adds that “it’s difficult having to deal every day with patients who have lost so much. There was a time when every patient in my office every day was crying.”
It’s slowly getting better, though, he says, as hospitals rebuild and more beds are added, “but I still have a lot of patients living in FEMA trailers, and there are areas of the city that will probably never be rebuilt.”

Charity Hospital will be torn down.

LSU was without its Charity Hospital System—a system of two hospitals and several clinics that offer free care for the poor—for a year-and-a-half, says Dugan. “They’ve just now opened some beds at University Hospital.” The other hospital in the system, Charity Hospital, may never reopen, he says.

Because both Tulane and LSU are teaching hospitals, much of the charity care in New Orleans pre-Katrina was provided by residents-in-training. But both institutions were severely damaged by Katrina and forced to lay off nearly 30 percent of their respective staffs.

“Tulane has reopened and we are full service,” Zakris says, “although much smaller. A lot of the house staff has been dispersed all over the state and to other states.”

The Lucky Ones

Zakris, Miller, and Dalton consider themselves extremely lucky to have survived the copious downsizings at their respective institutions. Dugan says he is fortunate that his hospital never lost power or water during or after Katrina.

And all of their homes were spared major damage, making the decision to return much easier. Their respective decisions, though, were not a certainty for several months after the storm.

“Immediately after the hurricane my boss told me he wasn’t sure we still had jobs,” Zakris says, “and that we should try to find some type of temporary work.” She applied for a state license in Florida, where she and her two children fled after the storm. Luckily, she says, she was retained by Tulane and kept receiving a paycheck.

Miller says he was not let go by LSU because “we were already in the community
and seeing patients and generating some billings. Compared to many, I am incredibly fortunate.”

The most common reason physicians have left on their own, Dugan says, is that “if you lose your practice, and you lose your office, and you lose your hospital, there’s not much left to stay for. There were literally people who lost all of these things.”

The federal Health Resources and Services Administration has designated Orleans Parish as a physician shortage area, which gives New Orleans doctors a 10 percent increase in their Medicare reimbursements for certain services.

Also, the city qualifies for the National Health Service Corps Loan Repayment and Scholars Program and the State Loan Repayment Program for new physicians.

All that is helping, but the programs are far from solving the need for charity
care in a city with one of the highest populations of uninsured residents in the country—before and after Katrina.

“A lot of doctors read the tea leaves and saw that their hospital is closed, their practice and patient base is gone, and they need a job. So they took positions elsewhere.”

And it’s doing little to relieve the burden on what few psychiatrists and therapists remain.

Zakris said she made an appointment for a patient to see a psychiatrist, “and had to wait two months to get in. There are only 80 of the 450 pre-Katrina beds open for psychiatric patients.”

Robert Johannessen, the media director for the Louisiana Department of Health and Hospitals (LDHH) says, “Clearly, what comes up the most is the need for mental health care. The mental health care system was inadequate prior to Katrina and is all but non-existent post-Katrina.”

To lure health care workers to New Orleans, the state is creating incentives to attract them. “We just got a grant to provide some money to use as an incentive
to lure health care professionals back,” Johannessen says.

A Hard Place To Live

Despite incentives, “I think it will be hard to recruit to New Orleans for some time,” Dugan believes. He says he can understand why physicians are hesitant to come to New Orleans because of the rising crime rate and the risk of future hurricanes and busted levees.

“One of my partners left. He was a young guy and he lost his apartment and evacuated to his home town in Alabama. They offered him a job, and he stayed. I completely understand.”

Zakris agrees that “it’s hard to live here. There are still areas that don’t have electricity, still neighborhoods that are uninhabited, lots of traffic lights that don’t work, a lot of schools that haven’t re-opened, and housing is just not available.”

Miller says, “Imagine you’re a resident who is finishing a training program, and you’re being offered opportunities in nice parts of America with good schools and nice homes. Or you can come to New Orleans…”

Even basic necessities like supermarkets are missing to the degree that they existed prior to Katrina, Dalton says. “Infrastructure is a huge issue,” he says.

Hope

One of the biggest steps forward for health care in New Orleans is a plan to revamp the entire state health care system. Johannessen says the LDHH has worked with U.S. Department of Health and Human Services Secretary Michael Leavitt on the redesign effort.

Leavitt announced the potential plan in early-February, which calls for redirecting
$770 million from the state’s Charity Hospital System to provide private insurance coverage for about 319,000 uninsured. About $280 million would stay in the Charity Hospital System, but Leavitt warned that there is no guarantee that federal funding for charity care will continue in the future.

Johannessen is quick to point out that “this is a model, not a plan,” and his group has concerns, including how the rest of the state’s estimated 700,000 uninsured residents will get health care, given that the Charity Hospital System will be receiving far less federal money.

“At this point the state and federal government are in negotiations to try to resolve some questions we have,” he says. “We’re confident that at the end of the day we can either find common ground or agree to disagree.” If the latter happens, Johannessen says the state is ready to pursue several back-up plans including exploring the expansion of Medicaid eligibility.

In the wake of the federal government’s handling of post-Katrina efforts so far, Miller says he holds little faith that the federal government will come in with a plan to save the day.

“The feeling here is that (federal government officials) are incompetent, inept bozos,” he says.

There are times that he thinks about leaving, he says, but family connections make that possibility difficult. “I don’t feel bad about staying or about what I’m
doing—I feel it’s very important. But I sure do wish New Orleans was a nicer place to live.”
Says Zakris: “I’m going to stay. I made the decision to come back because I love this city. I love the culture here, the food, music, and ambience. I have a lot of friends here.”

She also remains inspired by the humanity of others.

“Tons of volunteers are still coming to the city from church groups and schools from all over the country,” she says, “and that is really wonderful to see.”

And Dugan is staying because he “still has hope that the city will come back better than it was before. We’re hopefully over the worst and are starting to see some light at the end of the tunnel,” he says.

Miller says he has learned a lot about himself post-Katrina.

“When I go some place and service is slow I don’t get upset,” he says. “I’m just glad that someone is here to do the job.”