Karen B. DeSalvo, MD, MPH, MSc
Tulane University
University Presidential Advisor for Public Medical Services
Executive Director, Tulane Community Health Center at Covenant House

• What happened in New Orleans after Katrina regarding the care of vulnerable populations?
• What are lessons learned from that experience and recommendations?

• As seen on TV
• 49th or 50th on UnitedHealthFoundation rankings for the past 6 years
• 20% of the population uninsured
• 250,000 vulnerable

• Centralized Charity Hospital System
  • State run
  • Hospital based clinics
  • Staffed by Tulane and LSU faculty and residents
• Antiquated systems without patient linkage to primary care physicians and without EHR

• Traditional
  • Poor
  • Women-headed households
  • Elderly
  • Homeless
  • Severely mentally ill
  • Immigrants

Morrow, Disasters, 1999

• Burden of chronic illness
  • Poor control
  • Multiple medications
• Lower literacy
• Social support weaker
• Less financial reserves
• Lack of medical home

Centers for Disease Control and Prevention. Health alert network
http://www.phppo.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00233;
DeSalvo, JGIM, 2005; www.statehealthfacts.org; Greenough, NEJM, 2005

(image: satellite photos of New Orleans before and after Katrina)

(image: photo of flooding caused by Hurricane Katrina)

• Doctors without hospitals or clinics
• Patients without doctors
• Public resources focused on shelters and the displaced
• In the city
  • First responders
  • Citizens who stayed behind
    • Vulnerable populations
  • Day-trippers

Niyogi, et al, AJMS, 2006 in press

• In a disaster, everyone is vulnerable
  • 200,000 homes destroyed
  • Loss of social networks
  • Unemployment and loss of insurance
• All providers become the safety net

(image: photo of post-Katrina flooding damage)

(image: photo of post-Katrina flooding damage)

(image: photo of post-Katrina flooding damage)

• On the fly
• Uncoordinated silos
• Unavailable medical information
• Broad scope of needs
  • Urgent
  • Chronic disease
  • Mental health
  • Educational

• Flexibility
• Makeshift system
• Borrowed resources
  • Private
  • Local governmental
  • Federal
• Ask forgiveness not permission

(image: photo of Clinic hand made sign located outside of Tulane University Square)

(image: photo of New Orleans area hospital)

(image: photo of military planning session. DeSalvo, et al, Health Affairs, 2006)

(image: photo of U.S. Navy Hospital Ship, USNS Comfort)

(image: 4 photos of Temporary Ambulatory Settings)

• Safety
• Site
• Staff
• Supplies
• Storage
• Scope of services
• Standard of care

(image: photo of make-shift medical clinic in New Orleans. DeSalvo, Annals, 2005)

(image: photo of medical staff consulting patient)

(image: photo of doctor consulting elderly patient)

• Mitigate disease, suffering, and death
• Sustain infrastructure, the economy, and societal functioning

Homeland Security Council: National Strategy for Pandemic Influenza.
http://www.whitehouse.gov/homeland/nspi.pdf

• Exposed
  • Weakness in our public health infrastructure
  • Problems with a centralized health care system
  • Complications of fragmented health system
  • Lack of systems to coordinate and communicate with clinicians
  • Need for regional coordination for persons with chronic disease

Greenough, NEJM, 2005; DeSalvo, ASIM, 2006; Redliner, Pediatrics, 2006

• All Hazards Planning
  • Communication, redundancy, systems
  • Worst case scenario
• Public private partnerships
• Legal documents in place to allow partnerships
• Partnerships between medical and social services sectors
• Regional care networks

(image: map of New Orleans area titled "Health Services in Greater New Orleans, New Orleans Health Department, Current as of 10-27-05")

(image: photo of mobile healthcare vehicle)

(image: photo of health care providers in New Orleans)