Charity Begins (and Ends) at Home

May 25, 2007
Surgical Rounds®, February 2006, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

Charity Hospital was a casualty of Hurricane Katrina. Severely flooded, the already suffering structure totally failed and rendered medical care impossible. Evacuation of the patients was painfully slow and difficult, and the intensive care unit pa?tients were transported by boat to Tulane University Hospital and transferred from there by helicopter to other indigent-care facilities. The State of Louisiana, the institution's proprietor, has since condemned the building and announced that it will not reopen. The last operation at the facility was a trauma case performed by two Tulane surgery residents with their attending.

Opened on May 10, 1736, Charity is the oldest continuously operating hospital in the nation. The first Charity Hospital, named L'H?pital des Pauvres de la Charit?, was built with funds provided by local businessman and bene-factor Jean Louis, and supported only by private donations. Its successor, built in 1743, was constructed near the edge of the city across from the St. Peter Cemetery?an interesting juxtaposition. Paradoxically, it was almost totally demolished by a devastating hur?ricane in 1779.

The third Charity Hospital was named "San Carlos" for the Spanish King, Charles III, who chartered the institution (France had ceded Louisiana to Spain in 1762). Since its major benefactor was the Spanish aristocrat Don Andres Almonaster, it was also called the Almonaster Hospital. Care was provided by the Ursuline nuns, the first religious involvement in such an institution in the New World. The hospital was consumed by fire in 1809, beginning a 6-year hiatus with no permanent home.

The fourth Charity Hospital opened in 1815 and was built by the fledgling State of Louisiana. Stimulated by a population explosion after the Louisiana Purchase, the institution was supported by a tax on gambling (as it still was when it closed in 2004). The mortality rate was an extraordinary 30% because of multiple epidemics.

There were two major advances with the inception of the fifth Charity Hospital. First, the facility became the bailiwick of the Daughters of Charity, an arrangement maintained for more than 150 years. Second, the hospital became affiliated with a newly developed medical school, the Medical College of Louisiana, which was the forerunner of Tulane University School of Medicine. During its 107-year history, Charity Hospital played host to three other medical schools: the Medical School of New Orleans, which was a Creole and French speaking institution (1856?1870); the short-lived Charity Hospital Medical College (1874); and the Louisiana State University (LSU) College of Medicine (established in 1931). This facility was the workplace of the great surgeon Rudolph Matas, whose ac?complishments at Charity included the first repair of an aneurysm, the first operation using spinal anesthesia, identification of the surgical therapy for appen-dicitis, and recognition of the role of mosquitoes as the vectors for yellow fever.

The current Charity Hospital was built in 1939. It was 20 stories tall and had 2,680 beds. The west wing was assigned to LSU and the east wing was designated for Tulane. Once constructed, the structure settled 18 inches within 4 years. Despite its size and structural problems, Charity Hospital flourished until re?cently. On the other hand, there was a constant battle to keep it compliant with the Joint Commission on Accredita?tion of Healthcare Organizations (JCAHO) re?gulations. For example, steel fire escapes were installed outside of the hospital within the past few years at an extraordinary expense. Asbestos also remained a major factor that limited the utility of the building.

Several months have elapsed since Hurricane Katrina, and the future of Charity Hospital, if there is one, remains uncertain. There are four possible scenarios. It is possible that the State will construct or purchase a new facility, particularly to aid LSU's medical school, since it has lost both of its major teaching hospitals in New Orleans. The economic conditions imposed over the past few months, however, make this problematic. Alternatively, if no decision is made, the hospital will die of attrition. Another option is that Louisiana will make ar?rangements to outsource indigent care to private facilities. Clearly, the best solution would be to provide universal access to health care. With 40 million Ameri?cans without health insurance, it would be great if the mandate began in Louisiana.

Three of these possibilities presuppose a New Orleans without a Charity Hos?pital. While the city and its residents can live without a total-care facility, there are several needs that must be met under any circumstances. These include a level one trauma center, a transmittable disease facility (tuberculosis and human im?muno??de?ficiency virus, among others), and a psychiatric institution. For many, the biggest question is whether medical student and resident education can survive without Charity Hospital.

I may be in the minority, but I am convinced that Charity Hospital is not critical for surgical education in New Orleans (whereas it might be for training in internal medicine). I think this is likely true in most (if not all) surgical residencies. Indigent facilities are work-inefficient and subject residents to nonproductive scut work. Since they usually do not pay adequate salaries, surgery departments have to allocate precious resources to make up for wage deficiencies. Thus, medical schools essentially pay to subsidize the hospital for care provided by their faculty, an untenable role reversal. Nursing care is often uneven at best, and trainees provide a disproportionate share of the direct patient care. Because of the nature of the patient population, diseases are too often diagnosed and treated at advanced stages. Finally, there are relatively few bread and butter cases.

As far as I am concerned, the future of surgical education is in private hospitals, not indigent facilities. The days of "see one, do one, teach one" are gone forever.

In New Orleans, several of the private hospitals, including Mercy, Methodist, and Baptist, are closed indefinitely or for the next several years. Touro Infirmary and Tulane University Hospital are currently open. In conjunction with hospitals in adjacent parishes, there are adequate facilities to provide the backbone, with excellent general, specialty, and tertiary care. There is also every reason to expect that multi-institutional programs will be designed to maintain training programs at very high levels.

In the introduction to his scholarly pre-Katrina history of Charity Hospital, John Salvaggio, MD, wrote caringly that "because of inadequate financial and community support, Charity Hospital's future is uncertain. It may be made into a public corporation, ?privatized,' sold to the medical schools, rebuilt, or taken over by a for-profit health maintenance organization. Nevertheless, whatever the management fate, Charity will likely survive as it always has, because it is un?equivocally needed."* The next few years will determine if Dr. Salvaggio's assessment is correct or not.

Reference

*Salvaggio J. New Orleans' Charity Hospital. Baton Rouge, La: Louisiana State University Press; 1992.