This story originally ran in the Winter 2007 issue of the Suffolk Alumni Magazine.
Tulane University Associate Professor Dr. Karen Bollinger DeSalvo doesn’t get to spend much time with her patients these days. The problem isn’t the usual story of managed healthcare gone awry. The barrier between DeSalvo and her practice is the aftermath of Hurricane Katrina, which has dominated her career and her life since it struck her hometown of New Orleans on August 29, 2005.
Back then, DeSalvo’s hundred hour weeks were primarily spent performing triage. Now, she estimates, “I’m down to 60,70 hour weeks” and “trying really hard to balance my life a lot more.” Yet the bulk of her time still has not returned to her practice. Instead, DeSalvo finds her days dominated by meetings, fundraising, and a variety of administrative duties that go along with her unofficial, post-Katrina role as “DeSalvo, Defacto Healthcare Reformer, City of New Orleans.” Nothing in DeSalvo’s background formally prepared her for these responsibilities, nor did she seek them out. Yet like the city itself, she has risen to the challenge primarily for one reason: there is no choice.
From Card Table to Clinic
In the days before the storm, more than half a million people fled the city in long and exhausting lines of cars headed for places like Lafayette, LA, or farther away to Houston, Dallas and northern Mississippi. They escaped the floods that submerged 80 percent of the city. They watched the devastation from afar on TV screens, scarcely able to believe the horrors unfolding in front of them.
DeSalvo and her husband, Jay, an emergency medicine doctor, were camping in Alaska when Hurricane Katrina bore down on New Orleans. Taking the first flight she could get out of Anchorage, DeSalvo stopped in Texas, where Tulane had set up its administration, before returning to New Orleans a few weeks later.
DeSalvo had been lucky—her home in a suburb of the city was 12 feet above sea level and lost just 12 shingles to the storm. Because of the minimal damage, she left the repairs to her husband and headed back to the city. There, she joined Tulane physicians-in-training who had set up six makeshift clinics around the city. One was in the courtyard of a community center for teens with babies. With just a card table and a cooler, they gave tetanus shots and patched minor wounds. Other doctors practiced in tents, shelters, police stations, and vans.
At the time, the city was still under mandatory evacuation. DeSalvo and her colleagues worked with no potable water, sewerage, or electricity. Most of downtown was accessible by car but well-guarded by the military.
In the beginning, they treated locals and first responders, serving as many as 400 patients a day. “There was no one in charge,” she recalls, “so that actually made things a lot easier, because if you were willing and able and motivated and just kept doing the right thing, you could get an awful lot done.”
One of the makeshift clinics evolved into the Tulane Community Health Center at Covenant House, the embodiment of DeSalvo’s long-held vision to create a responsive and well-rounded public health system. The clinic provides primary, psychiatric, pediatric, mental health, and reproductive health care, as well as job-training skills classes. Patients have access to a burgeoning library and day care center.
To date, the doctors there have treated more than 11,000 patients, the majority poor, chronically ill, disabled, or homeless. De Salvo hopes to use her success as a model as the city and state work to rebuild the public health network.
“Karen is willing to think about health care in a new way that addresses the individuals’ needs, and she steps outside of the traditional health system to address these needs,” clinic coordinator Leah Berger says.
“The need for accessible care is so apparent, so visible,” Berger adds, “yet there is still hesitancy for someone to step forward and say ‘Let’s do something about it.’ Karen took leadership and is making it work.”
From the beginning, DeSalvo’s life seemed to be pushing her to help people who are poor with little choice or voice in health care. In Austin, TX, where she grew up, DeSalvo and her two sisters waited for hours in big public health clinics. Even simple ailments like the flu required her mother, a single parent working as an office manager for a radiologist, to take time off. The image DeSalvo recalls is the look of stress on her mother’s face.
DeSalvo’s career path started to take shape around the age of 12 after observing doctors for a school report. She would eventually fund her dream by waiting tables and taking out loans. As an undergraduate at Suffolk, DeSalvo saw herself traveling to far-away countries to teach and improve health care. She spent a semester overseas and graduated from Suffolk with degrees in biology and political science. DeSalvo says Suffolk instilled a sense of “can-do” in her. “I was resourceful,” she says. “At Suffolk, there was a lot of self-made people.”
For her residency, DeSalvo chose New Orleans, where her family had roots going back for generations. Fittingly, she spent four years in the city’s center of public health, Charity Hospital, affiliated with Tulane University. DeSalvo credits Suffolk biology professor Henry Mulcahy for helping her gain admittance to Tulane Medical School.
At Tulane, DeSalvo learned she didn’t need to travel over oceans to find people who needed better health care—she just had to cross the street. DeSalvo recalls questioning a middle-aged patent about whether her chest pains lasted for minutes or seconds. The patient’s response was jolting: “Which is longer?”
“It completely changed my paradigm of history-taking,” DeSalvo says. “I thought, ‘Boy, she may say anything to appease me or may say something that’s not completely right.” DeSalvo realized the current system wasn’t meeting the needs of the population it was designed for.
This epiphany drove much of DeSalvo’s pre-Katrina research, as she developed strategies to identify and treat high-risk individuals, a challenge in a public health system that produced some of the worst results in the country. She also worked to find ways to increase the face time patients got with doctors and had begun studies on visits to doctors by groups of patients with the same sickness.
For this work, Tulane named DeSalvo as C. Thorpe Ray Chair in Medicine, a prestigious endowed position that gave her greater flexibility and less restrictive funding for her research. She still holds the chair, and is also the chief of general internal medicine and geriatrics at Tulane School of Medicine. When DeSalvo, now 41, landed that spot, she was the first woman and one of the youngest to ever head the unit. In 2002, she received her master’s degree from Harvard School of Public Health, was selected as a Robert Wood Johnson Faculty Scholar, and won a NIH-sponsored faculty development award.
In the wake of Katrina, DeSalvo was able to tap into two very different strands from her past, each indispensable to navigating the minefield of healthcare reform. On a personal level, there was the influence of her mom, “the person who knew everybody you know, the person who knew the postman’s name and what was going on with his kids. I have a little bit of that in me, too, so that helped.” On a wider scale, DeSalvo drew upon her dual training in public health and medicine. “We tend to think of systems more than individuals,” she explains.
Yet as Katrina quickly revealed, New Orleans really had no system in place. “It felt like we had been hiding this in our house and CNN showed up, threw open the door, and revealed all of your flawed family…whatever the stereotypes are of people you want to hide in your house.” Ironically, opening the door had a positive effect, DeSalvo says, because “until it’s so publicly revealed, it’s hard to get it changed.”
Just as the hurricane itself revealed previously hidden issues about race and class, the individual experiences of patients peeled back the veneer or normalcy, exposing a dysfunctional healthcare system.
“There was a guy who came in with short breath,” DeSalvo recalls. “He came down here to do construction work. It’s like, ‘Well, I think you have heart failure and, oh, by the way, you have high blood pressure and I think you have diabetes, and we don’t have any way to do lab tests to know if any of those things are true or causing trouble to your heart. So here’s some medicine and good luck.’ You practice medicine by the seat of your pants, kind of hoping for the best.”
Prescription for Reform
As the hurricane brought into sharp focus, more than a quarter of New Orleans’ population lives below the poverty line and more than one-third of the population is black, constituting what DeSalvo says is an understudied and undeserved minority group. Low-income patients are more likely than others to suffer from more than one chronic condition, such as obesity, heart disease, or diabetes.
Already strained before the hurricane, New Orleans’ public health care system is now on the verge of collapse, according to DeSalvo. Few hospitals have re-opened since the storm, and because of workforce and space shortages, acute care facilities fill to capacity as soon as their doors open.
A dramatic increase in mental health issues, including post-traumatic stress disorders and substance abuse, has added to the strain. Adequate aftercare facilities, such as nursing homes, are in short supply so hospital stays are long. A crippled primary care network has driven many to already full emergency rooms.
DeSalvo puts the blame squarely on leadership—or the lack of it.
“There’s a lot of ineptitude and you can quote me on that one,” she says, citing the fact that, as of early December, only 28 out of 77,000 families who applied for federal assistance to rebuild their homes had received money. “I think they’re afraid to give it out because everyone’s looking at them but they’re not willing to stick their neck out. They’re not willing to be leaders.” Yet DeSalvo has concluded that “We can’t fix the leadership problem unless we call for a Marshall plan.”
DeSalvo hopes policymakers use this disruption as an opportunity to make much-needed change. High on her wish list of healthcare priorities are investment in health information technology to help replace the city’s lost medical records, and debt forgiveness for physicians and practices, to ease the shortage of doctors.
Along with frustration, there are signs of progress. DeSalvo has helped raise $6.2 million to support the clinic she runs, just $700,000 of which came from public funds. She’s raised $7 million overall, with the extra funds going toward research. Business, health care, education, and government leaders are finally working collaboratively on the enormous task of revamping the health care system, a welcome development that rarely happened before the storm. “We’ve been through something so intense that differences don’t matter anymore. It’s a uniform struggle,” DeSalvo says.
The Louisiana Health Care Redesign Collaborative represents providers, insurers, patients, and other interests. LHCRC’s goal, like DeSalvo’s, is a patient-centered and quality-driven system accessible to everyone. The collaborative aims to support grassroots efforts that fit that vision while meeting short-term needs to sustain the system in the interim.
DeSalvo has been invaluable to the rebuilding process, says Bruce Passman, president and CEO of the Louisiana Business Group on Health, a collaborative member. “She has unique empathy and intuition that enables her to read between the lines and understand what people feel as well as what they say or do…her ability to gain other people’s perspectives on the issues, as well as the respect she’s earned from the employer leadership of this organization and the other stakeholders has been remarkable.”
Tulane President Scott Cowen authorized a leave for DeSalvo to work at the clinic and on policy development full time, and says she is one of the heroes of the storm. “Her work in helping establish a clinic to treat first responders and ordinary citizens in the immediate aftermath of Katrina was a critical first step in the city’s recovery.”
Even the New Orleans newspaper CityBusiness has recognized DeSalvo among its “Women of the Year.”
DeSalvo acknowledges that her unexpected career turn has had its advantages. “It’s been a professionally great time for me,” she says. “I mean, I joke about it, but I’ve done a whole administrative fellowship at the university level…I was doing things that would probably take me a decade to learn.”
With Katrina, DeSalvo’s career track has forever changed. And yet, there are still the patients—her patients. Even if she can ultimately spend just fiver percent of her time maintaining her practice, DeSalvo feels it will make her a better doctor and a better administrator.
“When I’m actually there on the front lines, that’s when I get a chance to understand what the issues are,” she says. “Then I can step back and advocate for bigger changes to solve the bigger problems.”
If the system DeSalvo and her colleagues develop is successful, it may serve as a blueprint for a nation starved for a working healthcare model. The irony is, should that happened and DeSalvo decamp, her patients and even her city may be a victim of her own success.
“In terms of thinking of leaving, I think it would be a lie to say we don’t all think about that every day,” DeSalvo admits. “It wouldn’t be normal if we didn’t think that because we live in a war zone.”
And yet, she says, “We’re living history. How many people get to put society back together? Hopefully, no one, [but] I understand all the parts of it and how they work and how they don’t work. It’s such a fascinating learning experience. It’s one of the reasons it’s so hard to pull away.”
Besides, she adds, “It’s in my blood to be here. For generations, my people have lived here, and it’s broken. I think it deserves the attention and it deserves people who are willing to make the sacrifices to make it better.”