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Charity Hospital still stands like a colossus amid the medical district in New Orleans, the city's tallest hospital at 289 feet. When the building opened in 1939, it was the country's second-largest hospital with 2,680 beds. Generations of physicians trained in the art deco building and Level I trauma center.

Until Hurricane Katrina struck five years ago, nearly all of New Orleans' uninsured patients were treated there or at Charity clinics in the surrounding blocks.

Immediately after the storm hit on Aug. 29, 2005, the hospital was fine.

"Then the levees broke, and the water started rising," said internist Cathi Fontenot, MD, who was the hospital's medical director when Katrina struck. "It flooded the basements where the backup generators were. Once the basements filled up, the electrical switch gears blew, and that's when we were in trouble."

It took five days to evacuate Charity Hospital, which has been closed ever since -- fenced in by barbed wire.

Charity is unlikely to reopen. The Louisiana State University system, which operated the hospital, said it would cost too much to fix the aging building and pushed for a new $1.2 billion, 424-bed facility to take its place.

The giant, drab, gray Charity Hospital building -- stained by years of unwashed soot -- represents an era in New Orleans' medical past.

The city's history is now divided into the time before Katrina and the years after the storm. Physicians say that, after five years, the remarkable trend is not how much the city's health system has recovered but how it has been reshaped.

About half of New Orleans' residents are uninsured or on Medicaid. Before the hurricane, many received their care in Charity's emergency department. That system of care has been replaced by a fledgling network of more than 90 outpatient community clinics, many nationally certified as medical homes.

"After" effects

When the levee failure left 80% of New Orleans underwater and all but three area hospitals closed, it was difficult for many to imagine an "after" story worth telling.

As of July 2006, New Orleans had less than half the 450,000 residents who lived there before the hurricane. More than 4,000 New Orleans-area physicians were displaced, according to an October 2005 estimate by Thomas C. Ricketts, PhD, MPH, a professor of health policy and administration at the University of North Carolina School of Public Health.

A spring 2006 survey of New Orleans physicians found that 25% still had not returned, according to results published in the July 2007 Disaster Medicine and Public Health Preparedness. New Orleans-based Tulane University School of Medicine laid off a third of its faculty, and the LSU School of Medicine laid off a quarter of the faculty at its New Orleans and Baton Rouge, La., campuses.

"Katrina destroyed everything I had built," said Floyd A. Buras, MD, a pediatrician who returned a month after the storm to find his small group practice in New Orleans' hard-hit Gentilly neighborhood a total flood loss. "Conceptually, you can relate to a building burning down or something. But this was more than that. It's like you woke up one morning and there were no people. The relationship I had built with 15,000 people disintegrated in one day."

The latest U.S. Census Bureau estimate is that more than 350,000 people live in the city -- about 80% of the pre-storm population. In 2008, the most recent data available from the Louisiana State Board of Medical Examiners showed the 3,681 licensed physicians in the Greater New Orleans' two largest parishes -- Jefferson and Orleans -- accounted for 84% of the pre-storm total. Dr. Buras, for one, re-established his practice in Metairie, La., a New Orleans suburb in Jefferson Parish.

After talk of closing LSU's New Orleans campus, the school is operating again in the city. Both the school and Tulane report that their medical school enrollments are higher than pre-Katrina levels. They have begun hiring clinical faculty again, and Tulane and LSU officials hope a proposed medical center complex will give the next generation of physicians a top-notch place to train.

Meanwhile, nearly three-quarters of the area's hospitals are open again. The Government Accountability Office concluded as early as September 2006 that the area had more staffed beds per 1,000 residents than the national average.

The physician decision

The recovery of New Orleans' health care system is by no means complete and was no sure thing. Individual physicians often faced gut-wrenching decisions about whether to return.

Pre-Katrina, Prateek Adhikari, MD, was an emergency physician at the now-shuttered Pendleton Memorial Methodist Hospital. When the storm hit, he and his wife, a nurse anesthetist, were childless. That made it easier to return to New Orleans weeks after fleeing to Tennessee. Today, they have an infant son to consider.

"I'm not sure what we would have done if we'd had a kid then," Dr. Adhikari said between sips of coffee he brewed in the ED break room of Tulane Medical Center, where he is chief of emergency medicine.

For some physicians, the disaster proved too much to bear.

Bong Mui, MD, came to the New Orleans area after leaving Vietnam in the 1970s. He was a family physician in Chalmette, a suburb in St. Bernard Parish that was badly flooded. As chief of staff at the now-demolished Chalmette Medical Center, he worked through the storm while his wife traveled to Houston to stay with family.

Katrina destroyed Dr. Mui's solo practice, the family's home and his wife's day spa business, all in Chalmette.

The devastation was the family's second major trial. Dr. Mui was studying in the United States when South Vietnam fell, leaving him separated from his wife and daughter for six years. During the days following Katrina, they found themselves separated again.

"We lost contact for two days, and she didn't know what happened to me," Dr. Mui said. "She didn't know whether I had drowned or not."

Though Dr. Mui loved Chalmette and caring for his patients there, Katrina gave his family an unwelcome flashback to its earlier ordeal.

"That experience really made me determined to not want to go through another disaster," Dr. Mui said. He has settled in Houston, where he is back in family practice, seeing 35 to 50 patients a day.

Other doctors stayed in the area but moved their practices out of New Orleans.

Some crossed one of the longest bridges in the world, measuring nearly 24 miles and stretching across Lake Pontchartrain, and relocated to the Northshore area. It's home to towns such as Slidell and Covington and has a wooded, suburban feel a world away from the densely packed streets of the city's French Quarter.

The Northshore served as a lifeline for Michael K. Hill, MD, after Katrina. The storm shut the multispecialty group practice he headed in the New Orleans East area, which took on eight feet of floodwater.

"Our service area was gone, our offices were gone and our physicians were scattered to the wind," said Dr. Hill, an infectious diseases specialist.

Just four of the practice's 27 physicians stuck together to see patients on the Northshore, where the group had a satellite office. The now-six-doctor practice opened a facility last December in a commercial subdivision in Covington. The paint on the wall still smells fresh.

"I didn't know whether I was going to stay here," Dr. Hill said. "I didn't know what the future of this area was."

He commuted an hour from his home in Metairie for the first few months of 2006 before deciding to sell the house and move to the Northshore for good. He sees some protection from the next storm in the choice, as do many New Orleanians who have moved above Lake Pontchartrain. "You don't have levees, and you're above sea level here," Dr. Hill said. "That's the main difference."

There are true die-hards who would never dream of leaving New Orleans. One is Brobson Lutz, MD, an internist and infectious diseases specialist who served as director of the New Orleans Dept. of Health from 1983 to 1995.

"My partner and I are just as busy now as we were before the storm," said Dr. Lutz, who lives in the French Quarter, which did not flood.

He isn't scared of another hurricane.

"I'm going to stay here 'til they haul me out," he said. "If we do get totally flooded, I'm just going to buy a houseboat and anchor it to my office."

As individual doctors struggled with how and whether to rebuild their practices, New Orleans wrestled with how to overcome Charity's closing. Among the city's uninsured and Medicaid patients, a culture of using the emergency department to access basic care was well-established, physicians say. The state ranked fourth nationwide in the rate of emergency department use, with 548 visits per 1,000 residents. Charity's 150 ambulatory clinics handled 350,000 outpatient visits a year.

The way medical care is delivered to the city's indigent patients -- most of whom are working poor and black -- has changed dramatically since Katrina.

"It's not even recognizable," said Karen B. DeSalvo, MD, MPH, chair of internal medicine and vice dean of community affairs and health policy at Tulane. "Prior to Katrina, it was highly centralized financially and geographically. It was a model of care that was heavily dependent on trainees for services, and as a result was not at all flexible in the face of disaster. We had all of our eggs in one basket."

Reshaping care

After the storm, Dr. DeSalvo helped establish street clinics to provide primary care. She is now CEO of Tulane Community Health Centers, six clinics that deliver care to uninsured patients in their neighborhoods.

All the clinics are recognized by the National Committee for Quality Assurance as patient-centered medical homes, providing comprehensive primary care with the help of health information technology, social workers and physician extenders. Among the services is a mobile medical unit, a recreational vehicle bathed in Tulane green that travels to still-underserved neighborhoods such as Gentilly and New Orleans East.

More than 90 neighborhood clinics run by 25 organizations have delivered care to about a fifth of the area's patients -- the vast majority uninsured -- handling nearly 100,000 visits a year, according to the Louisiana Public Health Institute. Patients pay on an income-based sliding scale.

A January Commonwealth Fund survey of clinic patients found that they were less likely than participants in a national survey of adult patients to have medical bill problems. They also were much more confident in their ability to get safe, high-quality care when needed.

Most of the clinics, new or expanded since Katrina, have sprung up with help from the three-year, $100 million federal Primary Care and Access Stabilization Grant, which is set to expire Sept. 30.

The Louisiana Public Health Institute and others are hoping for a Medicaid waiver to extend the grant, but no such waiver had been announced as of this article's deadline.

Daughters of Charity Services of New Orleans, owned by the Catholic nonprofit Ascension Health system, has received nearly $8 million in federal grant money.

The organization runs seven mobile and brick-and-mortar clinics -- all NCQA-certified medical homes -- including a new, 30,000-square-foot facility in the Carrollton neighborhood that will offer primary care, dental care and badly needed mental health services.

Without adequate funding, uninsured patients will lose access to quality primary care services, said Robert M. Post, MD, medical director of the Daughters of Charity Health Centers. That's because there will be a gap between when the federal grant expires and when health system reform's expanded Medicaid eligibility takes effect in 2014.

"If there's no sustainability, or we don't come up with some interim plan, it will all be for naught," said Dr. Post, a family physician who moved to New Orleans from Chicago in 1993.

Tulane's Dr. DeSalvo, who chairs the 14-organization safety-net provider coalition 504HealthNet, said the effort to change how primary care is delivered to indigent patients cannot fade away. For all its devastation, Katrina presented a rare opportunity to dramatically improve care in New Orleans.

"I thought, 'We have a chance to rebuild better,' " she said. "I know it can be done, and we can do it sort of one clinic at a time. ... Everyone deserves this kind of care."

In the Sept. 6 issue, read about how dealing with Hurricane Katrina has led to changes in medical disaster planning.

The print version of this content appeared in the Aug. 23 issue of American Medical News.

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 ADDITIONAL INFORMATION: 

Click to see data in PDF.

New Orleans medicine, before Katrina and since

The city has recovered about 80% of its pre-Katrina population, the U.S. Census Bureau estimates. The two parishes that account for most of the metro area's population -- Jefferson Parish and Orleans Parish -- have 84% of the licensed physicians who were practicing there before Katrina. In addition, nearly three-quarters of the hospitals in those parishes have reopened.

Source: "Physician Workforce 2005 to 2008," Louisiana State Board of Medical Examiners, Sept. 18, 2008; "The New Orleans Index," The Brookings Institution Metropolitan Policy Program & Greater New Orleans Community Data Center, August 2009 (www.gnocdc.org/neworleansindex)

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Once accused of murder, Dr. Pou finds deeper connection with patients

Ten months after Hurricane Katrina and a ghastly aftermath she experienced firsthand, Anna M. Pou, MD, was arrested at her home.

Dr. Pou

The accusation: She and two nurses conspired to kill four patients at New Orleans' Memorial Medical Center with lethal doses of morphine and midazolam. Dr. Pou had stayed through the storm to help care for 2,000 people in stifling 100-degree heat, with no power and limited food and water.

The doctor maintained her innocence, saying the medications were meant to alleviate patients' pain and anxiety. A year after the arrest, an Orleans Parish grand jury declined to charge her. Charges against the nurses also were dropped. However, civil lawsuits filed against Dr. Pou by relatives of patients who died at Memorial are pending.

Today, Dr. Pou directs the residency program in otorhinolaryngology at Louisiana State University School of Medicine. In 2008, she successfully lobbied state legislators to enact more protections for physician responders.

The ordeal has strengthened her faith and given her greater empathy when treating patients with cancer.

"I now understand what it's like to, in an instant, have your life be changed completely. Being arrested was like being diagnosed with cancer -- you live with the uncertainty of whether it will ever come back," she said. "Patients will tell me that 'God's forgotten me. He has really abandoned me.' There were times when I felt that way, but I have come to know that's not the case. God never abandons us. Now I'm better able to comfort those patients."

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Tending to the city's musicians

Internist Cathi Fontenot, MD, examines singer-songwriter Jesse Moore at the New Orleans Musicians' Clinic. [Photo by Sean Gardner / www.nolaimages.com]

When singer-songwriter Jesse Moore first visited the New Orleans Musicians' Clinic for care, he didn't provide the intake staff with an insurance card. Like most musicians, he is uninsured. Instead, he gave them a copy of his latest CD and listed names of club owners and musicians to vouch for him as someone who makes a living playing music in the Big Easy.

That was enough to qualify Moore for care at the clinic, where patients are charged a $10 co-pay and then billed on an income-based sliding scale. In March, the clinic arranged for Moore to receive hand surgery for "trigger fingers," or stenosing tenosynovitis. While playing guitar, his fingers sometimes locked when he bent them and then painfully popped back. "It feels like you stuck your finger in a light socket," Moore said.

Now Moore, who lists Dr. John and Jimi Hendrix among his influences, is back recording and playing around town. He has switched to piano. "It's a lot easier on your hands," he said.

The clinic, founded in 1998, has provided care for more than 2,000 New Orleans-area musicians, 90% of whom are uninsured. The musician-centered clinic makes it easier for these "right-brained" patients to navigate the health system, said volunteer medical director Cathi Fontenot, MD.

A social worker helps patients find out about available resources, such as a free, 30-day substance-abuse rehabilitation program funded by the Recording Academy's MusiCares Foundation Inc. A nurse practitioner talks with patients about good lifestyle habits and sticking to care plans, calling those "who need a little extra TLC" at home to check in, Dr. Fontenot said. The clinic is a one-stop entryway to low-cost care, including dentistry, prescriptions, optometry and mental health.

"All they have to do is remember to call one phone number and say, 'I'm a musician, and I need to make an appointment,' " said Dr. Fontenot, associate professor of clinical medicine at Louisiana State University School of Medicine's Dept. of Internal Medicine.

But the clinic's service -- caring for the cultural lifeblood of the city -- could be endangered by looming cuts in government funding. A $1.85 million federal grant that accounts for nearly half the clinic's funding is set to expire Sept. 30.

"Without this clinic, the musicians in this town are up a certain kind of creek without a paddle," Moore said. "This place is a saving grace for us. We cannot let this place disappear."

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