Rebuilding Health care in New Orleans

In the early morning of August 29, 2005, the storm surge from Hurricane Katrina breached New Orleans's levees. Most of the city was submerged, and hundreds of thousands of people fled their homes. One of Katrina's casualties was the New Orleans health care system. Charity Hospital, where more than 60 percent of New Orleans's residents received their care, and where most of Louisiana's doctors receive medical training, was in ruins. Medical clinics were closed or operating with little staff, as physicians, nurses, and other medical professionals left the city. Most never returned.

Among those who still call New Orleans home is Dr. Karen DeSalvo, chief of general internal medicine and geriatrics at Tulane University School of Medicine. DeSalvo runs the Tulane University Health Clinic at Covenant House, a small neighborhood medical practice that she and several colleagues built to take care of the city's most vulnerable patients. DeSalvo believes that neighborhood-focused clinics like these may provide the key to rebuilding New Orleans's fractured health care infrastructure. She spoke with Newsweek's Joan Raymond about the progress that has been made, and what still needs to be done. Excerpts:

NEWSWEEK: It's been two years since the storm hit. Do you still think about how bad it was?
DeSalvo: You can't help but think about it. It was surreal, almost physically painful. We had no clue where people were, and we had no real connection with the outside world. There was no power, or only generator power. There were no operating ambulatory facilities. There was no 911. It was Wild West medicine. Our Tulane residents who did stay set up tent-based care, literally putting tents on street corners and figuring out how they could help people. We saw a lot of cuts, a lot of bruises, and a lot of rashes from all the funky water. We would see a lot of folks with chronic diseases like heart disease or respiratory disease. We just had to stabilize them and get them out. Sometimes you couldn't do anything at all for someone, and for a doctor that is still the hardest thing, no matter what the circumstances.

What made you decide to stay?
This is my home. It was never a question of leaving. It's a question of staying and rebuilding a better system to replace the one that wasn't all that good prior to the storm.

What do you mean?
Even before the storm there was discussion that the old system wasn't working. Louisiana had a lot of health care problems. The state had some of the highest health expenditures in the country, but some of the worst health outcomes. People would rely on emergency rooms for everything. Care was fragmented. Clinics were located downtown, not in neighborhoods. And the hours were set up for the doctors' convenience, not the convenience of the patients.

These kinds of models aren't what patients need, and it isn't the best way to deliver care.
What we were looking to do then and what we are doing now as a result of Katrina is figuring out ways that allow us to decentralize care, bringing care to patients where they live, whether they have insurance or not. No city in the U.S. has ever had the opportunity that we have right now. We lost almost everything, except a will to make things better.

How did the clinic start?
During the second week of September 2005, we set up a card table, and there was a big red cross painted on a cardboard sign. We had some stethoscopes and some first-aid supplies. Our job then was to try and do what we could. We don't have the card table anymore. We have exam rooms and a bilingual receptionist and a waiting area—all of which we painted and constructed with volunteer help right in Covenant House, a former home for unwed mothers. It's not fancy, but it is wonderful and serviceable.

Who are your patients?
These are mostly people from the surrounding neighborhood, which includes the Treme and Bywater areas. These are low-income neighborhoods, with rich artistic and musical traditions. The people here come from all walks of life. We have people who didn't have insurance prior to the storm, the working poor, and some health care workers and technicians, who lost their insurance after the storm. We see teachers, police, people who have decided to stay.

How many patients do you have?
We see about 950 patients a month, and we have about 3,000 patients in total so far who call our clinic their medical home. We have three full-time and one part-time doctor, as well as a case manager and a social worker. The Tulane residents-in-training also come through here, which is very helpful and a great learning experience for them.

Do you provide full-service primary care?
We are still not one-stop-shopping. But considering that we started with practically nothing, today we can do quite a bit for people, including mental health care, which is very important post-Katrina. A lot of people are suffering with PTSD, and others with established mental health conditions have lost their providers. Unfortunately, there are still very few inpatient beds for these people. We can do some diagnostics, and well as EKGs. Some of the more advanced diagnostics, especially with cardiac care, do have to be sent out. But we have established electronic medical records for our patients, which is extremely helpful. We also do a lot of onsite peer education for chronic conditions like diabetes.

What is the biggest problem you foresee in the future?
Sustainability. Doctors aren't good at politics or government. What we are trained to do is to take care of people and let somebody else worry about where the dollars come from. But all of that has changed for us. I never thought I would testify in front of a Congressional committee. But now I know when I train residents that I need to explain how important it is to understand how government operates and how the laws affect a practice. Right now we, the medical community, are paid by how often Grandma goes into the hospital. The reimbursement is really poor for keeping Grandma healthy and out of the hospital. All of that has to change, or New Orleans won't be the only city facing a health care infrastructure that collapsed.

As a primary care doctor you can only do so much. How is the specialty care situation?
It's getting better, but it has a ways to go. We need neurosurgeons. We need ophthalmologists. We need orthopedists. If you have a heart attack or a stroke in New Orleans today, you are probably going to be okay. The system is up and running. But if you have a crush injury, or you need brain surgery from some kind of trauma, the situation is much more challenging.

Are you optimistic?
I'm almost pathologically optimistic. None of us, I don't believe, have worked this hard since we were residents. If we all pull together, we can bring New Orleans back, and we can make it a better place, a healthier place, for everyone. This city is very special, with some very special people. We are going to survive and thrive.