Doctors Within Borders

NEW ORLEANS, Sept. 1 -- Among the many things destroyed by Hurricane Katrina a year ago was the illusion of adequacy in the system of health-care delivery here.

No one suggested the city had an ideal health-care system, but it worked, after a fashion. Nevertheless, everyone knew it was clearly outmoded and unfair in favor of the well to do at the expense of poor residents, who made up the vast majority of the population.

Paradoxically, Katrina's crippling blow to this city has given health care planners the unprecedented opportunity to essentially start all over again, a medical redevelopment project never seen before in a major American urban community.

Optimists believe that by scrapping the old and starting from scratch New Orleans health-care can become a model to emulate. Others view that as a Pollyanna-like dream. Skeptics see New Orleans as irretrievably crippled, a city without a future, its life blood draining away without a way to stop it.

Greg Henderson, M.D., director of anatomical pathology at the Ochsner Clinic in New Orleans, believes that the city can revive, and health care can help pioneer a better community. "The most pernicious thing in New Orleans was the development of a class system of medical care," said Dr. Henderson said.

The Charity health care system expanded by Louisiana Gov. Huey P. "Kingfish" Long in the 1930s provided free care to the poor, a progressive system in its day, but it was heavily weighted toward acute services and end-of-life care, at the expense of primary care and prevention.

As a result, said Michael Ellis, M.D., a clinical professor or otorhinolaryngology at Louisiana State University, Louisiana ranks at or near the bottom for all measures of health status.

Many Louisiana citizens suffer from the effects of poverty, including poor nutrition, high rates of diabetes and obesity, unhygienic living conditions, substance abuse, crime ridden neighborhoods, and other factors that have negative effects on health. To compound the problem, nearly one-fourth of all Louisianans are uninsured and have poor access to early care, pointed out Dr. Ellis.

So he and other sees in Katrina's aftermath the once-in-a-lifetime chance to remake the health care system into one that is proactive and can serve the basic medical needs of all of the state's citizens.

They have proposed creation of a three- to five year-long pilot program called Health Access Louisiana. The system, being developed in cooperation with the Heritage Foundation, a conservative Washington think tank, combines elements of the fledgling universal health insurance system in Massachusetts. It includes proposals for ensuring equal access for all to high quality care, periodic right to change coverage options, portability, employer mandates for insurance, and subsidies for patients in the so-called high-risk insurance pool.

Other groups are proposing the establishment of neighborhood health centers for providing primary care and disease prevention services, with funding from a mix of public and private sources.

"The concept of community health centers," Dr. Henderson said, "is that rather than having a massive gray stone building where people go as a hospital of last resort, we decentralize the health system to reach the underserved community, so there's a true system of health care and prevention rather than treating disease after the fact, when it may be too late."

Of course Katrina did more than lay bare the inequities of the health-care system. The storm revealed that emergency responders at all levels were poorly equipped to cope with a large-scale disaster.

"If 9/11 was a failure of imagination, then Katrina was a failure of initiative," wrote members of a congressional committee investigating the preparation response to Katrina. "It was a failure of leadership."

The investigators wrote, "In this instance, blinding lack of situational awareness and disjointed decision-making needlessly compounded and prolonged Katrina's horror."

The investigators found that the medical system was unprepared for wide-scale emergency services and evacuations of patients with special needs, such as those on dialysis or life support. They also found that communications and coordination efforts were inadequate for the task at hand.

"Most hospital and Veterans Affairs Medical Center emergency plans did not offer concrete guidance about if or when evacuations should take place," they wrote. "New Orleans hospitals, Veterans Affairs Medical Center, and medical first responders were not adequately prepared for a full evacuation of medical facilities. The government did not effectively coordinate private air transport capabilities for the evacuation of medical patients."

"Everyone has the same story for their own entity, whether it's Memorial Hospital, Charity Hospital, or some neighborhood stranded," said Dr. Henderson. "It's the same story again and again: what happens when multiple levels of failure happen all at once."

He experienced those failures first hand, as the only physician caring for 30,000 people stranded at the city's convention center in the aftermath of the storm.

"One of the real lessons learned in the whole Katrina experience that is relevant to physicians is what an incredible absence there was of direct medical care for the couple hundred thousand people who were stranded here," Dr. Henderson said.

Dr. Henderson advocates creation of a volunteer medical force, modeled after the National Guard. Physicians, nurses, and other health care personnel who volunteered for the service would be given time off for training sessions and emergency preparedness drills. Local units would be able to be deployed rapidly to wherever they're needed in a given state or region, where they know the available hospital resources and the lay of the land.

There are currently several models for such a service, including the Texas Medical Rangers, based in Houston, and medical response teams based in Oregon and North Carolina.

In the aftermath of terrorist bombings in Nairobi and Dar es Salaam, Tanzania, Massachusetts General Hospital worked with the State Department and Department of Health and Human Services to create the International Medical and Surgical Response team.

The group consists of a 20-member advance team and 30-member follow-up team. The members can perform triage, provide definitive care, and evacuate patients as necessary. Like soldiers going into combat, each team member carries a full complement of specialty equipment, and the team also hauls along a Deployable Rapid Assembly Shelter, or DRASH tent, the modern equivalent of a MASH unit. The DRASH Tent is equipped with surgical equipment, drugs, ventilators, and other supplies necessary to create an emergency medical facility on the fly.

The units could help to ensure that care was directed where it was most needed, Dr. Henderson noted.

"In New Orleans, we had the problem where there simply weren't any doctors," he said. "But then as the drama unfolded over the next two weeks, we had the bizarre problem of having too many doctors, and we had people showing up who we weren't even sure were doctors. There were also doctors who would have volunteered but were worried that they weren't licensed to practice in Louisiana."

The medical guard system he proposes would address questions of licensing, insurance, and liability, freeing team members to concentrate on performing their duties, Dr. Henderson said.

Related Katrina Coverage:

• New Orleans Now -- Few Doctors in the HouseA Multimedia Special Report
  This special report from Zach Wise, a MedPageToday contributing photographer, presents the sights and sounds of New Orleans medicine a year after Hurricane Katrina.