When Ray Nagin, the mayor of New Orleans, ordered the city to evacuate for Hurricane Katrina on 28 August 2005, two days later than he should have, he exempted hospital staff. There were 2500 patients in hospitals and nursing homes, and no plan for getting them out. Memorial Medical Center had 238 patients, some of them moved there from another hospital, which had been considered less safe. Six hundred Memorial employees – doctors, nurses, administrators, technicians, pharmacists, therapists, cooks, janitors, security guards – also decided to stay, many more than necessary, and many of them also brought their families and pets with them. The hospital was large, modern, well regarded: most of the staff had sat out hurricanes there before. They stayed because they felt a duty to their patients and because the roads out of the city were clogged; there was no public transport. There were probably more than two thousand people and more than a hundred cats and dogs at Memorial on 29 August, when it started raining.
The hospital administrators thought they were prepared for a major hurricane, or indeed for almost any disaster. Their Emergency Preparedness Committee had met every year to talk through 47 different scenarios, including volcanic eruptions (there are no volcanoes in Louisiana) and a ‘VIP situation’, such as an injured head of state. After 9/11, it put together a plan more than a hundred pages long for dealing with a bioterrorist attack; its plan for a hurricane was 11 pages, and useless. The committee assumed that the hospital’s emergency generator could run for three days, although it had never been tested for that long and was kept in a basement, several metres below sea level. When the city lost electricity and the emergency generator failed, the people inside Memorial stopped thinking of it as a hospital. Foul water rose eight feet high. Without air-conditioning, the temperature was above 40ºC. The plumbing system stopped working, as did the phones, refrigerators and lifts. The morgue flooded and they ran out of body bags. The stink of human shit, dog shit, the dead, was inescapable.
There were rumours that New Orleans had fallen to armed gangs, also that drug addicts were on their way to raid the hospital’s supplies. Most of New Orleans was black, but most of the doctors and administrators at Memorial were white. ‘I figured, what would they do, these crazy black people who think they’ve been oppressed for all these years by white people,’ one of the doctors told Sheri Fink. ‘I mean if they’re capable of shooting at somebody, why are they not capable of raping them or, you know, dismembering them? What’s to prevent them from doing things like that?’ In his memoir – self-published, self-justifying – the chief of medicine, Richard Deichmann, claimed it was necessary to shut down the hospital fast because ‘patients with all kinds of serious infections … in intimate, unsanitary conditions with everyone else’ could be an ‘explosive incubator for an infectious disease outbreak’.Even so, he was ‘startled’ when a nurse asked him if it would be humane to euthanise the sickest patients. ‘Euthanasia’s illegal,’ he remembers saying.
Evacuation by helicopter and airboat became possible on 31 August, but only for a few people at a time. Outside the hospital, people were still clinging to rooftops and drowning in attics, and rescue crews were overwhelmed. Boats, mainly piloted by civilians, took out most of the healthier patients, staff and their relatives; some of the dogs and cats went with them, the others were put down. Some of the sickest adult patients were given the lowest priority in the evacuation, with only a skeleton staff left behind to care for them.
Anna Pou, an otolaryngologist, was seen carrying a ‘handful of syringes’; a doctor overheard her telling patients: ‘I’m going to give you something to make you feel better.’ The doctor who saw her remembered it because it was odd: ‘Nobody walks around with a handful of syringes and goes and gives the same thing to each patient. It’s not how we do it.’ By the time the Coast Guard finally evacuated the last living person on 2 September, 45 patients had died, far more than at any other hospital in New Orleans. Twenty-three of them were found to have been injected with high doses of morphine and sedatives, probably the reason for their deaths, but the bodies were recovered after more than a week in high temperatures, and it was hard to tell.
Two weeks after the hurricane, the Mail on Sunday published an interview with a female doctor from New Orleans, without giving her name or the name of her hospital:
I didn’t know if I was doing the right thing. But I did not have time. I had to make snap decisions, under the most appalling circumstances, and I did what I thought was right. I injected morphine into those patients who were dying and in agony. If the first dose was not enough, I gave a double dose. And at night I prayed to God to have mercy on my soul. This was not murder, this was compassion. They would have been dead within hours, if not days. We did not put people down. What we did was give comfort to the end.
In a television interview, Pou denied that she’d killed any patients, only that she’d eased their pain. She also said that the patients who died had all been close to death before the storm hit. This wasn’t true. Emmett Everett had been at Memorial awaiting a colostomy: his condition wasn’t life-threatening. On the morning of his death, he had fed himself breakfast and asked nurses to make sure he wasn’t left behind. But he was a quadriplegic who weighed 380 pounds: no one was going to help carry him up the stairs to a helicopter or down to a boat. Most of the other dead patients were elderly residents of the hospital’s long-term acute care unit; some were dependent on ventilators, but when the storm hit none had been considered in immediate danger of dying.
Some of the Memorial staff blamed Tenet Healthcare, the very profitable Texan corporation that owned the hospital, for abandoning them. It’s not an easy company to like. The year before Katrina, Tenet had paid $395 million to settle claims that doctors had performed unnecessary heart operations for profit. In 2006 it paid $900 million to settle a federal case for Medicare fraud and overbilling. During the storm, before they lost power, hospital administrators had sent Tenet executives emails letting them know that the hospital was flooding, and asking for help: ‘WE NEED TO GET PATIENTS OUT OF HERE NOW!’ The response was they should just wait for the National Guard: ‘Good luck.’ A similar hospital, Tulane, also lost power during the storm, but it paid for private helicopters and buses to get everyone out early, and didn’t lose any patients. Tenet put its resources elsewhere: $29,000 in campaign contributions to the senior Louisiana senator and nearly a million dollars to the senator’s aunt to represent Tenet as a lobbyist.
But mainly the deaths at Memorial were folded into a larger story of federal ineptitude. Before the storm, the National Guard should have commandeered buses and directed traffic out of the city; ambulances and Medevac helicopters should have descended on Louisiana to take sick people to hospitals in other states. The Army Corps of Engineers had known for years that the levees were sinking and done nothing; rescue operations were shambolic and inadequate. Hugo Chávez rubbed it in by offering to send Louisiana a planeload of Venezuelan aid workers. Fidel Castro offered to send doctors. On 1 September, Condoleezza Rice was spotted in Manhattan shoe-shopping at Ferragamo: a symbol of a government that didn’t care. Inspired by Anna Pou, the television show Boston Legal put a fictional doctor on trial for killing patients during Katrina. Her guilt is never in question, but her lawyer persuades a jury that it doesn’t matter. As she had been abandoned by the American government during the hurricane, the American government had no right to punish her. ‘This was not the United States of America. During that horrendous week, the United States of America was nowhere to be found.’
Pou and two nurses were arrested for murder, and a New Orleans grand jury had to decide whether prosecutors had enough evidence to proceed to trial. Pou’s lawyer could have requested a change of venue, but he knew better: a poll showed that 76 per cent of Orleans Parish thought Pou and the nurses should be let off. The sample didn’t claim that the women were innocent, only that they didn’t want to see them punished. Rallies were held in Pou’s support, and benefit parties; on talk radio and in the newspapers, Pou and the nurses were heroes who had done their jobs when so many people hadn’t. The two nurses were given immunity from prosecution in exchange for their testimony, but whatever they said, the grand jury declined to indict Pou for murder. (The proceedings of the grand jury are sealed.) Pou returned to practising medicine and now often lectures on ‘ethical directives’ in emergencies. ‘The duty to care sounds easy, great. It’s not always so; it’s more romantic on paper,’ she told hospital executives not long ago in Sacramento. She also helped to write and pass laws in Louisiana to shield medical professionals who remain ‘in harm’s way’ from litigation; she was of course sued by her patients’ families. As far as Deichmann is concerned, the Memorial staff ‘worked day and night in deplorable conditions to save so many lives’, and he dedicates his book to them. He can’t believe that any of his colleagues would have killed patients, but he also didn’t realise that so many people had died. At the end of the book, he suggests – foolishly or disingenuously – that corpses may have been brought to the hospital from somewhere else.
Sheri Fink wasn’t at Memorial during the hurricane, but she has interviewed hundreds of people who were, first for the website ProPublica and for the New York Times, now for her unsettling and excellent book. She says that the unnamed doctor who told the Mail on Sunday that she had killed her patients was indeed Anna Pou. Another doctor, now deceased, also confessed to her that he had killed patients at Memorial: some of his colleagues knew, but kept quiet.
Fink was a doctor before she became a reporter, and she has practised medicine in war zones. Her previous book, War Hospital, is about doctors under siege during the Srebrenica massacre. She sympathises with the Memorial doctors, but notes that the hospital never came close to running out of personnel, drugs, food and bottled water. The rumours that armed gangs were on the way were only rumours, almost certainly (she implies, but doesn’t quite say) grounded in racism. A cancer institute, connected to Memorial, never lost power, and stayed cool: some doctors took naps there in recliners designed for chemotherapy patients, made coffee, watched TV. Patients could have been moved there, but apparently no one thought of it. She suggests that one of main reasons Memorial lost more patients than other hospitals was a failure of triage: the sickest patients should have been evacuated first. Pou later told a radio programme that during a disaster a doctor has to do ‘the greatest good for the greatest number of people’, what she called ‘reverse triage’. It’s not that prioritising healthy patients doesn’t sometimes make sense: in the middle of a battle so that soldiers can rejoin the fight, or if resources are so limited that treating the sickest will leave many more people to die. But there were enough staff and supplies to care for all the patients at Memorial. The evacuation was proceeding. And if it hadn’t been? Fink’s line is that hospitals at least need to have triage protocols (few do) so that frightened and exhausted people aren’t left to debate medical ethics on the spot.
As for how the Memorial doctors ought to have behaved during the storm, Fink points to the staff of New Orleans’s Charity Hospital: public, older and poorer than Memorial, often the only resort for sick people without health insurance. When the storm hit, it had twice as many patients as Memorial, including a crowded intensive care unit. Like Memorial, it lost power, plumbing, lifts, phones, computers; flood damage was so severe that it would have to close and has not reopened. But Charity staff had drilled for a hurricane and levee failure. They had spent a federal grant (intended, after 9/11, to help hospitals prepare for terrorist attacks) on portable generators, oxygen-powered ventilators, a ham radio and special disaster training for hospital security staff. When they were able to start evacuating small groups of people, they sent out their most vulnerable patients first. Doctors and nurses maintained regular shifts; rumours that the city had fallen to violence were quashed with the rule ‘You can only say it if you’ve seen it.’ They lost nine patients. Staffers continued to provide physical and occupational therapy sessions, as usual.
But most American hospitals are still fundamentally unprepared for natural disasters. Fink was in New York during Superstorm Sandy in 2012, when hospitals and nursing homes were exempt from evacuation orders as they had been in New Orleans. ‘After everything we should have learned from Katrina, we saw hospitals lose power, hospitals being evacuated in the middle of a hurricane, ICU babies taken out by hand down darkened staircases, hospitals that knew that they had vulnerabilities not evacuating in advance.’ At Bellevue, the oldest public hospital in the US, volunteers had to form a human chain up 13 flights of stairs to deliver fuel to a faulty generator. Only one building in lower Manhattan didn’t go dark: Goldman Sachs.