New Orleans Rises Anew: Community Health After Katrina
Ten years ago, I published a Perspective in Annals (1) describing our efforts in New Orleans in the aftermath of Hurricane Katrina. The mood during that complicated crisis was both urgent and hopeful as we faced the staggering challenge ahead of our city: to completely rebuild andif we had the couragereinvent our city's health care system while simultaneously providing services to people most in need. It was a difficult momentone where all of the things we take for granted as physicians, including our patients and basic health infrastructure, had been stripped away. A decade later, that memory of intense disruption, need, and opportunity is difficult to forget. I remember vividly standing on the streets, in the heat, alongside scores of volunteers, U.S. Public Health Service Commissioned Corps Officers, and federal supporters caring for some of our most vulnerable neighbors. We were addressing an urgent need; yet as we did that work, we knew we had a new patient to treatthe city itself. Since then, our new patient, the city, has not only survived, but thrived. The success came from being resourceful and working from the grassroots up and the grasstops downa real roll up our sleeves effort that meant hosting clinics at folding tables, holding planning meetings in parking lots, and having policy meetings in gutted buildings. It meant we all had to leave behind our conventions of hierarchy. No titles, just professionals and volunteers working side by side. We built the system and the policy framework in a rapid cycle, iterative fashionalways putting community at the center. We knew at that moment, we had a choice: We could go back to the way things were (a fundamentally flawed system full of hard working people) or we could go in a new direction. At the time of the storm, nearly 3 in 10 residents lived below the poverty line and our state was dead last in overall health. We chose to redesign the system into one that would achieve better outcomesa system that the people of our community deserved. Because while Katrina was a tragedy, one where too many of our friends and neighbors lost their lives, their loved ones, and/or their property, it was also an opportunity. Looking back, I am not as impressed by our ability to work hard as I am by our determination to work smart. We chose to try something different, with 4 ambitious goals: to build a new health care system grounded in prevention and primary care; to ensure our entire public health system was enabled with a health information technology infrastructure, ready to take on day to day obstacles but prepared to face another natural disaster; to create a safe environment that fostered improvements in quality of care, both locally and at the state level; and to change the way residents paid for and financed their care by moving from fee for service toward the kind of team based care that grows in the wild when you just allow talented medical professionals to do their jobs. Our progress is as remarkable as it is improbable. Over the past 10 years, New Orleans has systematically and thoughtfully reengineered its health system to meet the bold vision laid out in the wake of the storm. And while the work is far from complete, we have an encouraging story to tell about how vision, tenacity, and civic engagement can empower a community to make better, healthier choices for itself. We built new community health centers where the sites, decor, and even sometimes the staff were chosen by the community members themselves. Today, these health centers provide high quality primary care and mental health services to some of our most vulnerable residents. We established a forum to work toward better quality and outcomes, and we worked to ensure that the health care system was supported by a robust health information technology infrastructure. Despite our success, there is still much work to be done. Although we have expanded access to both care and coverage, too many people in the New Orleans region face financial obstacles to getting the care they need. A patchwork of federal grants and support from the nonprofit and private sectors has helped cover those gaps, but there are real long term concerns about those who are most in need and their ability to pay for the care they deserve. Along the way, we also learned a larger lesson: Although health care is necessary, it is not sufficient to create a healthy community. In New Orleans, we stopped treating patients and started treating community members. And that community based approach has to continue if we are going to see progress. To achieve that, we need more than a strong health care infrastructure. A strong public health infrastructure, accountable to everyone who lives, learns, works, and plays in the communityan infrastructure connects the sectors of our societyis needed. Further, we must think about patients as whole people rather than a collection of symptoms or diagnoses to be addressed. In doing so, we can address the social determinants of health, knowing that excellent medical care will only take you so far if you lack basic necessities, such as a home, access to healthy and affordable food, and a place where your children can be safely cared for while you work. It is this lesson that I hold in my heart every day, and it deeply informs the work I do at the U.S. Department of Health and Human Services, encouraging every community to innovate and find better ways to build healthy neighborhoods from the ground up. It has been a decade filled with optimism, combined with an acknowledgment of the challenges facing communities throughout New Orleans, and I cannot wait to see what the next 10 years brings. With the right building blocks in place, I can begin to imagine how a healthy, vibrant community can expand and grow. I can also imagine the next chapter: one where New Orleans serves as a model rather than a cautionary tale.
Annals of Internal Medicine