RAND Health News
RAND Health Researcher Ken Wells Travels to New Orleans to Help Plan for City's Future Health Care
Personal Notes and Pictures: A Consultation Trip to New Orleans
Kenneth B. Wells, M.D., M.P.H.
Summer, 2006
I have just returned from New Orleans, where I was a consultant to the planning for the city's future healthcare. I was also supporting one of our UCLA Clinical Scholars, Ben Springgate, who has been implementing a study of access to care in New Orleans.
It was an overwhelming experience. I had heard that post-Katrina New Orleans was like a third world country. Even so, I was not prepared for what I saw, heard, and experienced. The physical damage to housing and infrastructure is so extensive as to almost defy imagination. I drove mile after mile past abandoned houses, malls, and ripped-out gas stations. Major buildings—even entire hospital complexes—have been damaged and abandoned. Signs everywhere advertise for workers to help gut buildings, remove refrigerators, and destroy mold.
The houses have painted dates, where workers have checked for remaining bodies. Outside damaged hospitals, tattered American flags wave.
In many areas, only one or two houses on the block are occupied, or someone is living in a trailer in front of their house. In one case, across the street from one badly damaged structure, I saw someone running a business from another badly damaged structure.
In these areas, you know that there is social isolation, a sense of abandonment, and basically no civic services. Other areas were relatively normal. Nonetheless, everyone you meet needs to talk about their experience—but then, after a while, you can tell it is too hard to go on.
Many people not only lost everything themselves, but suffer from the knowledge that everyone in their family lost everything they had—multiple generations of housing, belongings, and jobs.
Many are living in trailer parks, which have been set up everywhere. Some communities oppose the new trailer parks, increasing both neighborhood tensions and housing problems.
The problem is not going away, and may get worse with the next storms. People say that New Orleans may be evacuated five times in the next six months. And, of course, New Orleans is not the only troubled city. Baton Rouge, for example, has doubled in population and is facing all the problems of becoming a major urban city overnight, and now competes with New Orleans for funding. Funding continues to be a problem. Many say that much of the allocated funding has not arrived at the ground level, either for healthcare, mental health c are, or for housing or subsistence needs.
Both physical and mental healthcare is scarce. Many (40%) are uninsured. Many top physicians in all specialties are leaving, trickling away each week. Free primary care clinics are the main healthcare facilities available to the largely low-income, uninsured population of children and adults. Well-run storefront clinics are managed entirely by volunteer doctors, who themselves are typically uninsured or unpaid for their work. Regardless of insurance status, many people prefer a neighborhood storefront clinic for its ease of access. Transportation services are minimal, especially in the 9th Ward and St. Bernard's, further complicating access.
There is not one ob-gyn for the city's uninsured. According to several medical directors, very few pelvic exams are being performed in the free clinics. Most healthcare facilities do not have labs, or labs are only now coming on board. Pap smear results take two months. There is minimum TB testing, and sputum results take three days instead of immediate feedback. For months, in the absence of lab results, care has been based on guesswork. Follow-up is hard because people can't be tracked.
Medications are still hard to get, although availability is improving. Even antidepressants are expensive and must be largely or entirely paid for out of pocket. In some cases, the free clinics help patients apply for charitable donations of medications through pharmaceutical or other agency programs providing free or reduced-fee generics.
The mental health system was weak before and is much worse now. The problem is an enormous need coupled with very few available providers. Depression is being encountered on a scale never seen before. There does not seem to be group grief counseling available, or group therapy of any kind, for the poor. Most of the available psychiatric care is through the free clinics, with long waits, provided by a few faculty and house staff from the local universities or volunteer providers from afar who spend a few weeks in the clinic. At the same time, therapists and educators (who could become lay therapists) are unemployed or underemployed, because they lost their jobs, were laid off, their companies closed, or people do not have enough money to afford them.
A positive development is that some schools are implementing CBITS (Cognitive-Behavioral Intervention for Trauma in Schools), an intervention developed by our UCLA/RAND Center for Research on Quality in Managed Care and the Los Angeles Unified School District to help children deal with post-traumatic stress. 200 school personnel have now been trained in CBITS. However, healthcare providers have no knowledge of this resource.
Many New Orleans schools are closed. Signs have been posted to help people find schools.
Children are receiving care in the free clinics. However, providers report feeling unprepared to deal with any serious childhood problems, psychiatric or physical.
Some clinics screen for depression, but providers have no time, training or support for recommending an appropriate course of action. Severe mental illness presents special problems. The emergency rooms and jails have become the care system for persons with severe illness, and some providers have been trying to train police to address new levels of responsibility for triage. But most of the mental health need is for mild/moderate depression, anxiety, and insomnia. There are no psychiatric beds for the entire city currently.
Yet interest in and support for mental health care is everywhere. All providers—public and private—talk about this gap as a very high priority. Incidentally, many providers are feeling the same mental distress as their patients, but there is no help for them either. I have heard about provider need repeatedly since the beginning of this disaster, from people like Greer Sullivan at the University of Arkansas and Grayson Norquist at the University of Mississippi at Jackson.
Even though key leaders are talking about the importance of mental health care, they are not discussing specific psychosocial or psychotherapeutic strategies, because such strategies do not fit the primary care infrastructure—the only infrastructure available to the uninsured. Grass-roots efforts to explore filling this gap are just beginning. Faith-based programs, for example, are trying to provide practical help, such as helping people gut their homes before they lose their property to the city, providing food, and bringing in an important symbol of New Orleans' identity—musicians. They are also trying to develop outreach and screening programs in collaboration with primary care. There is little precedent for such approaches and people are doing their best to put together programs by talking to others who have such programs, such as the QueensCare faith-based health partnership supported by our Clinical Scholars Program.
But that's just the beginning. Because immediate day-to-day needs are so pressing, no one has any time for program evaluation. Nonetheless, everyone I talked with would like such evaluations, and view them as important to their future. Providers are interested in evidence-based models to improve care, but basically need them delivered, tailored, and supported with regular, on-site help in training and implementation.
Providers say that screening for mental disorders is something they could do, but when you ask what they will do if the patient needs help, you are likely to get a look that is a mixture of realization and hopelessness. Primary care providers say that they could do 1-2 rounds of antidepressants, if they only had a "friendly" psychiatrist to call and discuss it with; but still they might not yet be able to send samples to a lab to check for liver problems, etc. But even solving these problems would not solve the most obvious problem with supporting mental health recovery: finding approaches to deliver psychotherapy for the most common mental disorders that are even more prevalent after the storms, as well as support for dealing with substance abuse.
Yet people are resilient. I saw both pride and commitment, and discouragement and anger (lots of it) and hopelessness, all mixed together, like the houses that are painted purple and orange and make you smile until you see that the roof is gone and the windows collapsed, and smell the mold as you drive by. Then you notice a "no bulldozing" poster, affirming people's desire to maintain their property and have their lives back, or a brightly painted sign saying "I'm alive, and I'm home," to welcome visitors, or "I love you and will be back!" as a message to friends.
Well, that's a bit of a story from my "eyes" which I hope gives some sense of the picture for New Orleans populations, and their courageous providers and community leaders.
Contact Info
Kenneth B. Wells, MD, MPH
The RAND Corporation
Director, UCLA/RAND Center for Research on Quality in Managed Care
kwells@ucla.edu or Kenneth_Wells@rand.org
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