New Orleans: Choosing Responsibility and Optimism

Medicine
David Mushatt '78
Chief of Infectious Diseases
Tulane University Medical Center

“For the first two years, I really didn’t like New Orleans; it felt like a banana republic,” said David Mushatt, about coming to the city in 1989 as a fellow in infectious diseases at Tulane. Founder of the Knights of the Ku Klux Klan David Duke was campaigning, after all; he ultimately won a seat in the Louisiana state legislature. The city grew on David, however—its European, old-world feeling, its Cajuns and Creoles and old jazz. He married, had a family, and “if you stay here long enough,” he alleges, “it grows on you like Spanish moss and you can’t leave.”

David’s commitment to the city now involves more risk and opportunity, more courage, than ever. The post-Katrina health care environment in New Orleans is chaotic and fluid; the future is unfocused. A researcher and clinician, David is the chief investigator for clinical trials testing different strategies for managing long-term treatment of HIV/AIDS. His patients are coming back to the city in disproportionate numbers. Most are poor; some had never left their own neighborhoods before Katrina; they are uncomfortable where they sought refuge and are steadily coming back.

David’s career, with its focus on hands-on clinical care, teaching and research at an academic center, grew out of an exploratory childhood in a scientific family; David’s father tried to interest him in microbiology. “But I like infectious disease because, basically, you are a medical detective,” says David. “There are no invasive procedures. It’s all cognitive. You can’t rely on one test to determine a diagnosis; rather, you have to take a thorough history, perform a thorough clinical exam, find some clues, look at laboratory results and come to a conclusion.”

He also found it exciting to work with people and their diseases in other cultures, and spent time during medical school both in Haiti and in Africa. “You learn how to relate to diverse people and their cultures, and at the same time hone your clinical skills in places without the typical resources to support diagnosis.”

David was looking at infectious diseases fellowship programs when “the second wave of HIV was just beginning to hit. I saw plenty of HIV at the Brigham [Brigham and Women’s Hospital in Boston], but Tulane had just been awarded a National Institutes of Health grant to be one of 15 units in the United States conducting clinical trials on AIDS treatment. I could get involved in that research, and in tropical medicine, and follow up my fellowship with a Master of Public Health, so I came to Tulane. I’m still involved in tropical medicine, malaria research, for instance, but my focus has been AIDS research since that time.”

David is involved with several studies that are looking at the efficacy of treatment over time—whether, for instance, cycling Interleukin-2, which can increase T cells, into the antiretroviral regimens will have significant clinical benefit for patients. All research investigators struggle with the ethical issues involved in clinical studies. Studies like David’s are dependent on large numbers of participants to generate scientifically solid findings. Many of David’s patients are African American. It’s important but difficult to get minority patients into clinical research, according to David. “African Americans are understandably wary of research; everyone is aware of the manipulation of black men in the Tuskegee syphilis study.”

Louisiana has excellent AIDS drug-assistance programs; drugs are available to those who need them. “Adherence is the number-one problem for people who fail HIV treatments,” David says. “People who are dealing with the multiple problems of poverty need multidisciplinary support to adhere to the treatment regimens.”

The best multidisciplinary team for New Orleanians with HIV was and isthe clinic at New Orleans’ Charity Hospital. “It works off a Ryan White Grant, and provides many crucial ancillary services,” David says. “At my private clinic at Tulane Hospital, I refer my patients to the NO/AIDS Task Force where the staff help the patients with housing, legal help, nutrition, counseling, substance abuse issues, etc.”

Charity Hospital, “basically provided all the medical care—emergency, acute and basic—for the city’s poor, and served as a training ground for generations of doctors,” as Leslie Eaton writing for the New York Times put it in a recent article connecting New Orleans’ slow recovery and the wreckage of the health care systems there. Tulane doctors trained at Charity, along with residents from other programs, but Louisiana State University, which ran the hospital, closed it permanently because of extensive flood damage. “Only one of the city’s seven general hospitals is operating at its pre-hurricane level; two more are partially open, and four remain closed,” according to Eaton. “The number of hospital beds in New Orleans has dropped by two-thirds,” she writes. Charity Hospital has reopened its University Hospital campus (pre-Katrina there were two campuses: the old building, which housed as many as 2,000 patients in the 1970s, and the newer University Hospital), but there are fewer beds overall and a dire shortage of psychiatric beds—some patients must be transported five to six hours to northern Louisiana for mental health treatment.

Tulane University School of Medicine and its Hospital & Clinic suffered along with all the city’s medical institutions. Immediately after the storm in August 2005, the medical school relocated its operations to Houston (thanks to the largesse of Baylor and other Texas academic centers), and the main hospital was closed for over five months. According to David, the vast majority of medical staff came back—99 percent—when the hospital re-opened. “However, in February 2006, the university president laid off one-third of all the medical school faculty: M.D.’s, Ph.D.’s, fully tenured professors—150 people,” he says. “Does the university have the legal right to terminate contracts in the face of fiscal disaster? That’s a question some are asking. Staff morale is suffering; animosity is high. Since June 2006 the hospital has slowly hired back for some mission-critical positions, but the president reviews every position.”

As to patients, fewer are insured. Ten percent of patients were uninsured at the Tulane hospital; now 20–30 percent are uninsured. New Orleans’ suburban hospitals are experiencing the same situation. Patients are sicker, and the few clinics that have opened up in the Mid-City are overwhelmed.

Fixing the city’s health care system is crucial to New Orleans’ recovery from every point of view. According to the New York Times, “except for tourism and retailing, health care was the city’s biggest private employer, and it paid much higher wages than hotels or stores. There are 16,800 fewer medical jobs than before the storm, down 27 percent, in part because nurses and other workers are in short supply.” New Orleans is stuck in a Catch-22: attracting population is difficult if health care isn’t solid, and doctors and hospitals are reluctant to commit if patients aren’t there.

Federal and state officials and civic leaders are proposing aggressive, far-sighted and optimistic plans, but reaching agreement, committing resources and implementing the ideas are distant prospects.

The destiny of the big, old Charity Hospital is a big question. David notes, “Charity and the hospitals like it across the country provide powerful learning opportunities for young doctors. They are able to see more of the natural history of numerous diseases played out, they see examples of rare medical occurrences, and they learn some of the noble aspects of caring for people: excellent training, in other words.” David is quick to acknowledge, however, that “rebuilding the Charity of the past would overtly affirm a two-tier hospital system.”

While the public institutions entertain public debate about future configurations, Tulane has engaged Bain & Company to do a full-scale strategic plan. “They’re camped out on campus,” David says, “and I’m impressed with their thoroughness. They’re getting into the trenches, doing their homework, helping the hospital and medical school define direction and service, so that decisions from this point forward fit into an overarching strategic vision.

“I feel that it’s my responsibility to salvage what can be salvaged, to rebuild, to make things better. It’s an incredible opportunity, and those who get involved can only make things better; we can really make a mark, at this point. There’s something good about being on the edge—if I believe in it and work at it.”

CDE

 

Back to Magazine