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Down In New Orleans
PREFACE: Everyone is vulnerable. One day we can be fine, the next day we’re definitely not. On 29 August 2005, Hurricane Katrina slammed ashore in New Orleans, rending levees, flooding much of the city, and leaving death and devastation. Now, two years later, the city still struggles to regain its footing. Progress is slow, and dislocation remains a prominent feature of life. Sleeplessness, depression, and full-blown post-traumatic stress disorder are a part of life for many. Physician Ben Springgate, a New Orleans native, returned to his hometown to help after Hurricane Katrina, and he’s still there, still helping. His patients are exhausted, he tells us, and so is he. Meanwhile, writer Judy Karasik knows what it means to deal with an ongoing vulnerable medical reality. Her fifty-nine-year-old brother, David, has autism and mental retardation, disabilities that have always been a part of her life. Now, with their mother approaching age ninety, Judy is taking on a new role: sibling advocate for David. Instead of having him become increasingly unconnected to anything but his private world, she wants him to have a job, to be with others, to make a contribution. But systems that could work to help employ people like David are piecemeal and improvisatory, leaving Judy, her family—and us—unsure about what tomorrow will bring.
MS. M AND I SIT DOWN ACROSS from each other in the examining room. She leans forward and whispers her reason for the visit. "I can’t sleep anymore, Doctor. I get up early in the morning," she tells me, slowly shaking her head, "and I’m busy all day, so I should be able to sleep." Her dark eyes squint against the light to see me better. "Then, at night, I just lie in the bed with my eyes open. I’m so tired. I haven’t slept well in months. And I’m like...at my wits’ end. I’ve tried everything. Nyquil. Wine after dinner. And I don’t even like to drink. Prayer. Nothing seems to help." It is October 2006, fourteen months after Hurricane Katrina. We are in New Orleans, in the St. Anna’s Mobile Medical Unit, a recreational vehicle housing a program that serves people living in flood-damaged sections of the city. I’m the unit’s medical director. My colleagues and I screen, provide urgent or short treatments, and refer out serious or chronic problems. Two mornings a week the mobile unit parks here, across the street from a FEMA trailer village, opening onto the sidewalk along a historic cemetery. Sunlight reflects off the whitewashed cemetery wall through the window behind Ms. M and from the trailers framed in the glass behind me. We are in St. Roch, an Eighth Ward neighborhood of mostly low-income African Americans. St. Anna’s is one of about five mobile units around the city that are funded by nonprofit agencies seeking to increase access to health care since the failed levee system led local clinics, hospitals, and housing for health professionals to be washed away with everything else. At our unit we see twenty people a day—a patient load limited mainly by a lack of personnel. I read Ms. M’s chart. She’s like most of the people we see here, in that this is her first visit to the unit and the first time she has seen a doctor since the flood of 29 August 2005. She is African American, thirty-five years old, and uninsured. Her three children are staying with family in Houston. The home she is trying to restore is here. She shuttles between the two cities. Ms. M found us after reading one of our "free health screenings" signs we posted at a nearby intersection. I am a New Orleanian. I’ve been a health services research fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at the University of California, Los Angeles, since July 2005. While visiting home one weekend, I was forced to evacuate from Katrina’s path. Four days later I returned to Louisiana to help with postdisaster medical relief. Afterward, I arranged with my program directors to continue working on health care recovery projects here. My work has been emotionally challenging—much harder than my internship at Tulane University and at Charity Hospital, once one of the nation’s largest hospitals dedicated to serving the poor, shuttered since Katrina. Trying to advocate for health care that is less available to the city’s poor people than it is in some developing nations has been heartbreaking; my internship was merely exhausting. "You know, a lot of people are feeling like you do," I say to Ms. M. "Insomnia’s really common nowadays for people who live here or who are just coming back." In fact, depression and post-traumatic stress disorder—symptoms of which are present in about a third of New Orleanians, according to Harvard’s Hurricane Katrina Community Advisory Group—can also lead to insomnia. These symptoms are about twice as common as they were before Katrina, and more common than has been documented after other disasters, reflecting in part the magnitude of the devastation and slow pace of reconstruction. "Well, I don’t know about how common it is, but I’m not sleeping...I’m always on edge. I lose my patience so quickly. I never used to be like this. I have my kids to take care of, and I can’t keep up with everything if I can’t sleep...you know, I’m fixing my house around the corner," she gestures toward St. Roch Avenue, "and traveling back and forth from Houston." Ms. M’s t-shirt and jeans are stained and dusty. Most places in her neighborhood were flooded and still stand uninhabited.
MS. M IS THIRSTY. I go to get her a cup of water. In the mirror above the sink, my blue eyes carry dark bags and have more lines than I should have at age thirty-four; my short blond sideburns show growing hints of gray. I’ve been tired, too—wiped out by a different kind of stress and fatigue than those plaguing Ms. M. My exhaustion comes from feelings of powerlessness and futility. I have few options to help people like Ms. M. The solutions I do have to offer—referrals to overwhelmed safety-net services—are often too little, too late, for the large number of people with unmet needs. At least half of the patients this mobile unit sees could benefit from stress management, therapy, or psychotropic medication. Few of them, Ms. M probably among them, will receive it. Why? Because getting people like Ms. M to come in at all is a challenge. No one here wants to be labeled mentally needy or, in their view, "crazy." People see others experiencing the same thing they are and say to themselves, "It’s no worse for me than for anyone else," without recognizing that everyone else could use a little help, too. There are also other, more pressing things competing for their time: Residents like Ms. M are trying to rebuild their homes and, like her, are often traveling back and forth between temporary housing and New Orleans. They are still dealing with insurance companies and trying to raise their kids. A recent Henry J. Kaiser Family Foundation study found that 54 percent of black New Orleanians and nearly half of all city residents still experience major disruption of their lives in terms of housing or their social networks. As well, in the absence of familiar sources of health care, many residents are reluctant to visit new, unknown physicians. Far fewer health care providers remain in the city than before Katrina. Estimates suggest that only 15–30 percent of physicians who practiced here before remain today; among those are few psychiatrists, primary care doctors, or specialists. Patients who do seek care can often wait in line all day. The nearby neighborhood clinics to which we refer patients are so overworked and understaffed that they are forced to turn people away by 10 a.m., only two hours after opening. We know full well that the people we send to these clinics will need transportation, time (which many of them don’t have), patience, and more than a little savvy to get the care they need. These problems also apply to care at our partner clinics and at the extended network of hospitals and clinics in Houma or Baton Rouge, sixty to seventy-five miles away, where, for a few hours a week, some of the scarce specialty and diagnostic services for the uninsured can now be found. We know that to draw more needy residents into this threadbare local health care system at all, much more information—a few intersection signs aside—needs to be spread within communities about where residents can go to receive what health care is available. The truth is, in the context of this city’s overwhelming problems, I often wonder what good I am doing for people like Ms. M who are experiencing such ongoing trauma. I love the practice of medicine and value the social side of medicine that helps New Orleanians tackle the larger problems in their daily lives. I volunteer to provide health care at St. Anna’s because it also offers free legal support for those struggling to keep their homes and teaches English to newly arrived immigrant workers who are helping our neighbors rebuild. Through the Common Ground Health Clinic, on whose board I serve, volunteers distribute protective gear and hygiene kits to Latino day laborers involved in demolishing and reconstructing housing, engage neighbors in caring for a community garden as a way to improve patients’ interest in and options for obtaining nutritious food, and host crawfish boils to bring residents together to relax and build community ties. In light of how much else there is to do here, I sometimes daydream about quitting medicine to become a carpenter—so that at day’s end I’d have something solid I could put my hands on, so that I would know I’m helping people in a concrete way by putting a roof over their heads in the midst of all the destruction and loss.
MANY OF MY LOCAL COLLEAGUES ARE ALSO TRYING to provide high-quality care for their patients, but they end up feeling like they can’t make a real difference because of circumstances beyond their control. New Orleans’ health and social service systems were struggling well before Katrina. Post-Katrina, these systems have been almost entirely destroyed. Ms. M’s insomnia is induced by mental stress, yet, since the disaster, an already limited availability of mental health services dropped precipitously. The number of medical school psychiatry and clinical psychology faculty plummeted after Katrina. Almost all of the local hospital psychiatric beds were closed. Our options for mental health referrals are extremely limited. Although New Orleans was designated as a health professional shortage area for psychiatry, primary care, and dentistry in April 2006 by the U.S. Department of Health and Human Services, efforts to recruit and retain by area health organizations have failed. Health care professionals who returned have struggled to rebuild their own houses. They’ve had to deal with dispersion of longtime patients, flooded business offices, losses of livelihood, and the effects of these traumas on their families. Like others in the community, they have made an effort to come to work every day, to pick themselves up and dust themselves off—to try, anyway. It’s easier for me, because my fellowship and partners like Tulane and RAND support my community-based research, which allows me to volunteer part time at places like St. Anna’s. Meanwhile, as many physicians have struggled to rebuild their practices, they have assumed care for uninsured patients who were once served by Charity Hospital. While these professionals strive to make ends meet and keep their practices viable, in the mobile unit we inevitably have seen more and more uninsured patients who are forced to use fewer services because of cost and who are relying on the emergency room (ER) as their main source of care. The ER can’t legally turn people away, but once discharged from the hospital or the ER, uninsured patients have fewer options than ever for follow-up. Even accessing care for routine conditions like diabetes or depression can be a major challenge. Obtaining preventive services, such as cancer screenings, or getting assessments for treatable conditions is simply not possible for many people in need of them. Huge gaps in services persist, in part because of ongoing attrition among physicians, nurses, and other professionals who at some point throw in the towel and decide to start over somewhere else. With the slow state of community recovery, it’s no surprise that New Orleans isn’t the Mecca of the national health care job market. (Hundreds of nurses could have jobs here today if they wanted them—and if they could find affordable housing.) I stay because I love my hometown and I believe that we will come back from all of this. When, at day’s end, I drive along Tchoupitoulas Street’s riverfront wharves for that perfect nectar cream snoball at Hansen’s Snobliz, jog at sunset under the branching oaks of Audubon Park, or revel in the sound of the Hot 8 Brass Band at Le Bon Temps on Magazine Street, I am reminded of how blessed I am to be part of this city. The schools and parks where I played while growing up in New Orleans East—a flooded Ninth Ward neighborhood built on drained wetlands—are still vacant. But the high-and-dry neighborhoods from Bywater to the Black Pearl that line the Mississippi River’s historic natural levee are full of life. Most of us who’ve been able to return are not giving up on the idea that we can rebuild a safer, better city for everyone. The Kaiser Family Foundation study showed that although half of New Orleanians don’t believe that the city’s rebuilding was a priority for the president or pre-2007 Congress, more than two-thirds of them are optimistic about the future. I sit down next to Ms. M on the examining table as we continue to talk. Ms. M returned to her New Orleans home for the first time in March 2006 to see what was left. She was devastated by what she saw, but she drew hope from the several areas of the city that had begun to recover—the business district, the Marigny, Algiers, and parts of Uptown close to the Mississippi River. She returned again in August to begin working on her home, almost a year to the day since the breaches along the nearby Industrial Canal. Ms. M now travels back to New Orleans every two or three weeks, staying a few days each time. She would like to move back, maybe to a temporary apartment, but she hasn’t been able to find anything she can afford. Since the flood inundated most of the affordable housing stock, rents in much of New Orleans have risen beyond her means. She doesn’t want her children to live among strangers in one of the featureless, fenced-in FEMA villages. We discuss how her insomnia might be due to depression and might be remedied by regular counseling over a six-month period or by daily medication. I ask her whether she is interested in being referred to one of our partner agencies. She thanks me for the referral and says that she will look into it, but she’s not sure how to make it work given her irregular travel between here and Texas. "Maybe when I come back for good," she says. "Maybe sometime after the New Year," she offers with a thin smile. "I hope so," I reply, as she makes her way toward the door and then down onto the broad St. Roch sidewalk. We do not see each other again.
Benjamin Springgate (benspringgate{at}gmail.com) is an internist, pediatrician, and fellow in the University of California, Los Angeles (UCLA), Robert Wood Johnson Clinical Scholars Program.
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A Struggling Medical Workforce
