 So, now we're going to shift gears to one of our star shortsfellows here at New America, Sherry Fink, who is going to give a presentation on resilient health care, entitled Lessons from the Diarist of Scenarios. Sherry is the winner of the 2010 Pulitzer Prize for Investigative Reporting for her story about deaths at the Memorial Medical Center in New Orleans after Hurricane Katrina, a project she did while she was with ProPublica and it got published in the New York Times Sunday magazine. And Sherry is in her second year as a shortsfellow here at New America. Sherry? Thank you, Andres. Actually, when you read the little quote about Aunt Violette, it put me in mind of my 103-year-old grandmother, who I just visited, and she also survived two husbands and went through a hard time. She actually lived through World War I in Romania and can remember the bombs falling. And she also has some memory problems. And the other day I was chatting with her and I said, gosh, you've really survived a lot, you know, you define resilience. She said, yes, I've been through a lot. World War I, World War II, World War III, and World War IV. So that's a real resilient character. We should know something we don't. Let's hope not. But earlier Andres quoted Winston Churchill saying that success is going from failure to failure without a loss of enthusiasm. And my career has sort of been going from disaster to disaster without a loss of enthusiasm. So I focused on disasters both as someone who trained as a doctor, doing medical aid work for a number of years in conflict and disaster settings, and then as a reporter reporting on a number of those. And so this talk will be from that perspective. And I think also if we're going to be quoting Winston Churchill, the quote that might be most apt for this presentation, it goes, if you're going through hell, keep going. And so when we think about the resilience, the resiliency of our health care system, or in particular I'm going to talk today about hospitals in disasters, one way to define that would be the ability to continue functioning as a hospital in these hellish circumstances in a crisis for an extended period of time, which is something we probably all want, particularly if the crisis involves injuries or pandemics or the type of crisis where we would be really relying even more than usual on this really critical sector of our society. And for me, one of the questions about resilience was put into sharp focus when I thought about a particular comparison of two hospitals during Hurricane Katrina and what happened there. And one of them, Memorial Medical Center, which you see here a picture of, it was a venerable community hospital. It had been around since the 1920s, treated your usual range of surgical and non-surgical acute hospital problems, had a least independent long-term care unit as well, independent of that hospital. Superb reputation in New Orleans. People very proud to work there, worked there for decades for generations of families. It was long a faith-based nonprofit. It was called Baptist Hospital. It had recently become part of a well-known for-profit hospital chain, Tenet. And the other hospital in this little comparison was the old public charity hospital, which provided care to people who didn't have other options, who might not have health insurance, who were the poor, many of them with advanced tuberculosis or HIV or AIDS. The hospital was short on money. It was a beautiful art deco structure on the outside, but inside it was kind of run down and there were plans by the owner, the Louisiana State University and the state, to possibly get rid of it and build a new hospital before the storm. And so, you know, increasingly people who had the money didn't choose to necessarily go there. So where would you want to spend, well, if heaven forbid you were going to be sick in a disaster or had a loved one, how many of you would rather be in the nice community hospital? I mean, if you had to pick between those two. And then how many of you would rather be in the charity hospital? Okay, no hands. So yeah, so that's what we would think typically. And so what actually happened in the disaster in Hurricane Katrina in 2005 was these two hospitals were a few miles from each other. Both structures withstood the hurricane fairly well, but later the floodwater surrounded them. Both of them had critical infrastructure vulnerabilities in that their electrical power system components or backup power systems were below flood level and they lost power and they waited a long time for rescue. And so as one crude measure of resilience, the ability to keep functioning as a hospital in these types of horrific circumstances, let's just look at this little chart here. So number of patients, almost the same between the two hospitals. The number of days it took to get the hospitals rescued. Memorial Medical Center being part of this large hospital chain was able to at last have their, the owner tenant sent some hospitals, sorry, helicopters privately owned, got people out a day earlier than charity, which really waited till the very end for the, you know, all the public assets to come in. They didn't have a company to come and rescue them. Took an extra day to get all their patients out. But look at the number of deaths, 35 or so. Roughly it's a little debatable, 34, 35 at Memorial and around three at charity. So that's a big difference. And at Memorial Medical Center, basically when I interviewed people, I spent a long time looking at this situation. And this is the chapel at that hospital that was turned into a makeshift morgue. You can see just some of those 34, 35 bodies there. People who worked there told me that the medical care really just completely broke down. They said, we were essentially, when we lost power, we were a shelter. We weren't a hospital anymore. They were fanning patients. You can see this picture in the parking garage waiting for a helicopter to come. A doctor said, you know, highly trained doctor said 10 years of medical training and med school did not, you know, give me the skills or it was, you know, I couldn't use those skills. All I was reduced to was fanning people and giving them sips of water. It wasn't acting as a doctor. And in the end, the doctors were so desperate, some of them described to me that they intentionally hastened the deaths of some of those patients. Around 21 or so were found later to have evidence of morphine and sedatives in their bodies. And a number of the doctors who I interviewed told me that they had intentionally hastened the deaths of their patients because of the horror of the scenario and their sense that this is what was best. And one doctor who has said that she didn't intentionally do that but she was arrested and accused of some of these deaths of patients. And in fact, it was taken to a grand jury which chose not to indict her. So this became a huge issue in New Orleans. Lawsuits have gone on for years. They're still going on over who bears responsibility for the deaths and the suffering at the hospital. Huge loss of trust in the community. You can see it really split the community. The healthcare workers stood up behind their colleagues and others in the community felt that that health workers should be punished for this. You know, where does the finger of blame lie? And so that's what happened at Memorial. At Charity, the staff tell a different story. In some ways very similar. They worked hard just like at Memorial, desperately trying to help people in these horrific circumstances, no power, extreme heat in the hospitals. But interestingly, even though they were perhaps under even more extreme conditions of existential threat, there were really literally some shootings outside the hospital. They waited longer to be rescued. The doctors there described continuing to provide medical care to their patients. And so, and this is just a picture of one of them handbagging a patient who needed artificial ventilation when the ventilators stopped functioning. They did that at Memorial for part of a day. Apparently at Charity Hospital, they did it for several days without giving up, just continuing to try to keep those patients alive. You know, very difficult. It actually hurts to keep squeezing an ambu bag for long periods of time. And they made shifts and they kept those patients alive until rescue. So what could account for these differences and results? And so I'm going to just tip it, just talk very briefly today about this. But my real feeling is in the thesis is that although we're spending more and more on our healthcare system, it's in the news. We all know that. We are actually doing it in ways that make hospitals less resilient. Medicine is evolving under economic, commercial, and technological pressures. And in many cases, the forces that are shaping the evolution aren't aligned to make resilience to crisis situations a priority. And the stakes I'd argue can be measured both in lives, but of course, these are rare events. So, you know, the numbers of lives may not be huge, but there's also this loss of trust in this key sector of our infrastructure. And so let's go back to the Katrina example. And I'm just curious, a few people want to just suggest, what do you think accounts for the difference in the death tolls at the two hospitals? Can you think of some possibilities? Throw some out there. Yes, please. Okay, so patient conditions, that's an excellent point. So it could very well be that the charity hospital just had a different patient population and these patients weren't as sick. You know, that is one possibility. And we can't really, it's hard to know the answer to that. Apparently they did have very sick patients too, but there could be differences in that surely. Yes, teamwork, more resilient people. So we've got sort of organizational issues and personal issues that could have been different. Yes, yes. So the charity hospital might have had experience doing more with less. And that is certainly true. And the way that some of them described it to me was these were Vietnam-era ER docs who worked there. There was this bravado machismo. We're at the toughest place. We can handle it. The people who worked there were attracted to a certain level of drama and chaos. And one of them described to me, quote, we always functioned at a certain level of chaos. Yes, who else? Yes. Yes, exactly. Computers going down. So one of the key issues across many disasters has to do with the reliance on electricity and the systems that we have. Interestingly, out of Katrina, the Surgeon General of the United States at that time made a big deal about this is a reason we need electronic medical records because people in New Orleans were scattered all around. The paper was maybe lost. But in the acute disaster, sometimes electronic records can be a big problem. And it's paper that you need. And in fact, in Haiti, one of the places where I worked, I was, there's a picture somewhere here. So we're looking at technological, organizational, and individual factors that influence this. And I'll show you the picture later. But in Haiti, there was this beautiful system. American disaster responders went out there. It's a federal system. We have national disaster medical system. And they came with their tents, a surgical field hospital. I was able to embed with them. And what they brought was a very sophisticated electronic medical record, except that the fuel kept running out for the generators. And literally, it inhibited their ability to provide effective care because anytime they wanted to see, well, what did the last shift of doctors and nurses do for the patients? They had to try to get one of the computers to look it up. There weren't paper records. And it became an issue. So I think that this is something, another vulnerability that we have. Yes, yes. And so this is one of the key forces and the key issues here with health care system and resiliency is this issue of redundancy versus efficiency. And another example we can look at is last year's Joplin tornadoes. And we had one hospital that was completely destroyed by a tornado and had to, in the midst of this disaster where there were a lot of injuries out in the community, stop functioning. Well, there was another hospital very close by that took up the slack. And as we know, in many, many parts of the country, hospitals, because it's inefficient to have too many hospitals in one area, they're starting to close down and become more efficient. But the vulnerability, that's not necessarily a bad thing in normal times, but that makes us perhaps less resilient to disasters. So just briefly, three factors here, three categories of factors to look at when it comes to resilience. And in fact, we've hit some of the main differences between Memorial and Charity Hospital. In fact, kind of similar infrastructure problems in both loss of power as I mentioned, but it was more of, and also just difficult structural issues. This was the route to get to the helipad when the elevators weren't working. You had to go through a little hole into the parking garage, be driven upstairs and walked up these flights of stairs. That was at Memorial at Charity Hospital. They had to go use the helipad at a nearby hospital and get them from one hospital to the other. So these were all challenges, but it really was maybe organizational issues and personal issues that made the difference. And here is an example at Charity Hospital. They did things on an organizational level to try to keep morale up. And you can see Katrina can't tear us apart. Nine West has a big heart. Morale building, they had every four-hour meetings in the lobby. Everyone from doctors, kitchen staff, nurses, janitorial staff would come. They organized a talent show by flashlight. And the other thing is they really kept their routine going. One of the doctors said to me, there was a lot of routine in a completely bizarre situation and all of that routine was very, very helpful to them. They tried to keep shifts and regular sleep schedule. They prioritized getting the sickest patients out first. And on a personal level, there was a lot of fear, particularly at Memorial Medical Center. This is a picture of some of the people who would go by in front of the hospital, sometimes asking for help. One of the doctors who intentionally hastened the deaths of patients told me that he did that in part because he was afraid of what, quote, the animals would do coming from outside to the patients. Would they rape them? Would they kill them? And so he felt the best thing to do for these really sick patients who perhaps were dying anyways or would be soon was to hasten their deaths in that context. And so finally, just to go over the, and this is one of the charity doctors. So enemies of resilience, structural, I think Barry Lynn really hit it on the head when he talked about this just-in-time delivery system and lack of stockpiles. All of these things make it very hard for hospitals to function in disasters. Another issue, or another big issue that's an enemy of resilience in the healthcare system has to do with electrical supplies of our nation's hospitals and the fact that the current standards are really not set up to have backup power systems that would be resilient in terms of a very long-term power outage. They are designed for short-term power outages and one person I interviewed in one of the tornado struck hospitals last year said we'd never run our power systems for more than four hours. And then in terms of the individual levels, the fear, in Japan I interviewed a doctor who was at one of the hospitals that was just outside of the danger zone in terms of the nuclear radiological risk. And in fact, his hospital and his patients were dying because they couldn't get supplies because there was such a fear amongst the truck drivers of driving the supplies to his hospital. So fear really can play a role in frustrating resilience. On the positive side, friends of resilience have to do with also just the redundancy as we spoke about situational awareness, practice. Some of the resilience we saw had to do with with organizations that had actually practiced and drilled. And I've heard that in the, for example, in the tornado-affected hospitals, Coleman Hospital, for example, in Tuscaloosa. We had a network and contact with nearly every hospital in the state offering assistance and that had been set up in advance. And so finally, what can we do? And I think that there is a role for regulation here and there's been a move to sort of beef up disaster preparedness standards for our hospitals over the years by the Joint Commission, which accredits many of our nation's hospitals. And it's met with some opposition and it really, by the hospitals themselves. And it's because it's really putting the onus on these hospitals to say, you know, get generator systems that would have a lot more capacity. And do we really, as a society, expect them to invest in this or do we want to perhaps invest some national resources in helping hospitals to get there? That's a question of, again, of risk and resources and balance. And then also I think that education is another example where we can foster personal preparedness through education and better management capabilities, leadership and disasters. And finally, there's the whole legal question and do we want to be arresting doctors? Do we want to be indemnifying healthcare workers which is going to have a better result in resilience? That's currently an area of big debate. And finally, some of the hospitals after Katrina were sued and there's what's been described as a sort of new theory of liability for hospitals failure to prepare for disasters. And some hospitals have started to settle these cases or in some cases have lost and are having to pay out money. And so perhaps through the legal system would be another way of creating incentives to be more prepared. So although the healthcare system, I believe, is evolving away from resilience in numerous ways, there are plenty of opportunities to create incentives to make it go the other direction. The question is whether we will have the will to do it before the next disaster rather than after. Thank you.