In Katrina's wake: healthcare crises in New Orleans: Dr. Joseph L. "Joel" Andrews spent two weeks in the New Orleans area in December 2005 as a physician volunteer for the American Red Cross Hurricane Katrina Disaster Relief Programs. Three months after the hurricane had hit, he witnessed firsthand the storm's devastating effects on residents in the city's various communities.

MY FIRST NEW ORLEANS HOUSE CALL is one I will certainly never forget. I was working in the Red Cross office in Metairie when I received an urgent request to help evaluate a very agitated man in Mid City. I left the office immediately and drove south on Interstate 10 to North Carrollton Street.

I met Arlo, a retired psychologist and Red Cross volunteer mental health worker from California, in the parking lot of an abandoned Burger King. Arlo had visited a client, Floyd S., the previous day at the request of a Red Cross emergency crew. Floyd had told the crew that he would die if he didn't receive his medications soon. Arlo had found him in an extremely frantic state, with probable diagnoses of schizophrenia, manic-depressive disorder, and hypertension, along with other medical conditions.

I followed Arlo down a side street. The wooden houses on this block had received major hits, both from Hurricane Katrina's high winds and from the storm's floodwaters. Most sported bright blue FEMA tarps, designed to stop water from leaking through roofs whose shingles had been torn off by Katrina's strong winds. Tall debris piles littered sidewalks on both sides of the street, blocking some access points. Cars were coated with dried flood muck.

Arlo and I entered the shotgun-style house where Floyd was staying. Although the building was elevated about four feet off the ground, the flood surge had done its dirty business. The house smelled dank from muck and mold. Filthy clothes and furniture were strewn haphazardly in the front room. Horizontal brown lines on the walls about four feet above the floor were evidence of the levels that earlier flooding had reached. Clearly, no one had done any cleanup here in the three months since Katrina struck.

We found Floyd lying on a bed in the back room of the house. We asked him to come out to the front room, which he did reluctantly. I asked him to sit and settled down across from him on a filthy rocking chair. Then I tried to take a medical history. Floyd told me that he was fifty-three, but his unkempt gray dreadlocks, lined face, jumbled speech, and unruly white beard gave him the appearance of a man twenty years older.

I ascertained that Floyd hadn't taken his psychiatric or blood pressure medicines in more than three weeks, since he was unable to get his prescriptions filled. The more we talked the more manic and incoherent Floyd became. Then he stood up and ran out the door.

Arlo and I went outside and saw Floyd talking to three men on the front porch of a house a few doors down. We approached the men, who told us that Floyd became increasingly agitated when he couldn't take his meds. Neither his wife nor his sister could tolerate him this way, they said, so he often came to them. The men sometimes brought food to him, and Earl, a tall man in yellow Lakers sweatpants, said that he had occasionally paid for Floyd's medications in the past. Agreeing that he needed immediate hospitalization to get him back on his medications, Arlo and I took Floyd back to his own home.

Standing in the street, I used my cellphone to call East Jefferson Hospital (in suburban Metairie) to talk to the emergency room doctor who had written Floyd's prescriptions three weeks earlier. He wasn't there, so I called the hospital's record room in an effort to learn more about Floyd's diagnoses and treatments. The clerk there told me she couldn't release any information unless I faxed her a release signed by the client. I told her I didn't have access to a fax machine and there was no way I could get this man to sign a release in his current condition. The clerk hung up.

I then called the New Orleans police, since they were the only organization who could provide transportation to the hospital. Five minutes later a squad car pulled up, then another, and then another, until finally a squadron of six police cars blocked the street. A posse of twelve New Orleans police officers emerged from their cars and walked toward us. They chatted amiably to each other, like attendees at a law enforcement convention. When they asked if Floyd was armed, we said we didn't think so. A stocky officer frisked him, then snapped handcuffs around his wrists. Understandably, Floyd's demeanor worsened as he sat forlornly on the front steps.

I asked a police officer, "Why all the cops and the cuffs?"

"For a show of force," she replied. "The cuffs are because recently an officer got shot in a similar situation." Six squad cars then departed. One hauled away a handcuffed and now severely distraught Floyd.

Two days later I returned to Floyd's neighborhood with Tim, another mental health worker. A diverse collection of Floyd's neighbors, both blacks and whites, clustered on the street in front of his house. One man in preppy attire, definitely out of place in this neighborhood, identified himself as a mystery writer. He said he'd come to reclaim a book that he had previously lent to Floyd. The writer sported a pair of hiking boots hanging by their laces around his neck. He'd brought them for Floyd, he said, who was currently shoeless.

Floyd's neighbors told us that the police had taken him to Ochsner Foundation Hospital in Jefferson. They brought him back at three o'clock in the morning with more paper prescriptions but without any actual drugs.

We found Floyd on the steps of a ramshackle religious shelter several blocks away. As I climbed the steps, Floyd smiled, greeted me by name, and started singing "Somewhere Over the Rainbow." Why that? I thought. Then I remembered. The first time I met Floyd I had introduced myself as "Dr. Andrews. You know, like Julie Andrews." Now I patted him on the shoulder and told him that it was really Judy Garland who sang The Wizard of Oz song; that Julie Andrews had starred in The Sound of Music. Floyd just kept singing "Over the Rainbow" anyway. He looked pleased with himself. I too was pleased that he was in a better mood and "with it" enough to smile and reach out to make some social connection.

During my two weeks making home visits in New Orleans I saw firsthand Katrina's effect on people. I also saw the storm's effect on infrastructure, especially in the most heavily damaged Lower Ninth Ward, where powerful waves from the breached levees had pulverized wooden houses and left only splintered timbers.

I visited sections of New Orleans with moderate house damage, such as Mid City and Lakeview and the suburbs of Metairie, Kenner, and Westwego. Many of these neighborhoods still had no electric or water services. When I visited these houses with Molly, a Red Cross caseworker, I discovered that most of the owners didn't have flood insurance. Their savings have been depleted by months of living as evacuees. After returning to New Orleans these homeowners dipped further into savings to rehabilitate their gutted homes, often at the mercy of scarce and expensive contractors.

The evening after Floyd sang to me on the porch, I attended a panel discussion by the Health/Social Services Committee, part of Mayor Ray Nagin's Bring Back New Orleans Commission. The news wasn't good: thirteen of seventeen public health clinics were destroyed by Katrina, only two of New Orleans' eleven hospitals were then open, and most doctors offices were still dosed. Most patient records were destroyed or lost. Most evacuees had moved elsewhere without their medications, prescriptions, or records. And about 50 percent of evacuees had no health insurance. The New Orleans healthcare system, always shaky, now lay shattered in Katrina's wake. There were no medicines for Floyd and thousands of other residents of New Orleans because these residents had close to nothing--no money, no insurance, no telephone, no transportation.

At the Health Committee's meeting, former U.S. Surgeon General David Satcher lauded the residents of New Orleans for their "resiliency and commitment." He noted, however, that the trauma and violence many children endured during Katrina made it likely that they, as well as many adults, would experience Post-Traumatic Stress Disorder, increasing their tendency toward violent behavior as they grew older.

Next, the chairs of six subcommittees (Primary Care, Specialty Care, Hospitals, Public Health, Environmental Health, and Social Services) presented their proposals for improving health in New Orleans. They noted sadly that Louisiana had placed forty-ninth out of fifty states in measures of the quality of healthcare before Katrina. Their wish lists that night included measures that didn't exist before the storm, such as improved cooperation and coordination between hospitals, universal access to all health facilities, and better evacuation plans to prevent a similar catastrophe.

I noted two important shortcomings with the hundred or so proposals on these planners' wish lists: no mention was made about how all these desirable proposals would be paid for, and no one gave a timetable for when they would actually take place.

Several days later I made my way down unlit corridors leading to a warren of small rooms in a building on Burgundy Street, not far from the French Quarter. I was making a house call on Clara D., an eighty-seven-year-old lady living alone with her black dog, Girlie. A former shrimp factory worker, Clara had been evacuated to nearby Kenner after Katrina; she had returned to her cluttered two rooms only a short time before we met.

In addition to multiple health problems, Clara was most worried about her lack of finances. She received $579 a month from Social Security and $75 in food stamps, which she said would soon decrease. Her rent was $400 a month. Little was left to pay for medical care and drugs. And, like most elderly shut-ins in the Big Easy, Clara had no phone, no transportation, no doctor or clinic, and no accessible pharmacy.

I spent more than thirty minutes on my cell phone trying to obtain healthcare services for Clara, to no avail. Each published resource number I called accessed only a recorded message, which merely listed many more numbers to call. No actual services were provided. I felt like shouting, "We need services, not numbers! And we need them now!"

Despite the optimistic dreams of its healthcare planners, New Orleans still has a long way to go to create an effective medical care infrastructure to provide equitable delivery of high-quality healthcare for all. Only one half of pre-Katrina hospital beds are usable. Six of nine hospitals remain shuttered. Of the ninety healthcare clinics that existed pre-Katrina (where most of the poor got their care) less than twenty are functioning now. Nursing home beds are scarce.

Much has been said and written to explain the catastrophe that was New Orleans before, during, and after Katrina: inadequacy of the levees, lack of evacuation planning and execution, slowness of government agencies such as FEMA to respond to the emergency, and so on.

What can we learn from looking at the problems that have plagued New Orleans?

As previously stated, Louisiana was ranked forty-ninth out of fifty states in healthcare outcomes before Katrina. Post-Katrina plans abound to improve its healthcare system, but the essential ingredients--adequate funding, careful planning, and coordination--are still questionable. Clinics, private practices, hospitals, pharmacies, and patient transportation all still need strengthening over a year later.

The fact that many poor New Orleanians, mostly blacks, remained for days or weeks in a severely flooded city because there were no means to evacuate them came as a surprise to many Americans. The fact that many elderly, frail people were left behind to die unnecessarily was a cause for shame throughout the United States. Can widespread poverty be addressed successfully in a city that has lost half its population and many more jobs? It will require the political will, careful and coordinated planning, much work, and much money to remedy.

Perhaps city officials and healthcare planners should figure out how to more effectively harness the underappreciated strengths demonstrated by the neighbors of New Orleans' poor, elderly, and ill. The compassion and care, demonstrated so admirably by Floyd's neighbors every day, might well help to address the significant challenges the city now faces in bolstering healthcare.

Finally, will important lessons be learned in time? If another powerful hurricane occurs, will the New Orleans healthcare system be strong enough to withstand the new strains placed on an already overburdened system? This issue must be faced here and now, not somewhere over the rainbow.

Dr. Joseph L. "Joel" Andrews of Concord, Massachusetts, is a practicing internist and a Lecturer in Medicine at Tufts University School of Medicine in Boston. He is also a freelance writer and author.