PHOTO © TED SOGUI / CORBIS
Editor's Note: As Hurricane Sandy hits the east coast, we are reminded of the phenomenal role civil society organizations play in disaster. This particular story, about the vivid experiences of the leaders of the Coastal Family Health Center in the wake of Hurricane Katrina, is a powerful epic read and a reminder about what really matters.
In mid-2005, with patients numbering more than 30,000, Coastal Family Health Center (CFHC) had developed into a complex operation. Its nine sites were spread throughout the Mississippi Gulf Coast in a mix of buildings and trailers. Providing medical and dental services, and with a mission to serve all seeking treatment without regard for ability to pay, Coastal Health was funded, as most community health centers are, by a mix of sources, including patient payments, private health insurers, and government grants. Their patients had their own complex issues—CFHC provided specialized services to those living with AIDS and to those without a home. Most of the center’s patients were uninsured.
Under the leadership of CEO Joe Dawsey, Coastal was in pretty good shape. It was operating on a $10 million annual budget, and although it had only $500,000 in reserves, it owned all of its buildings. In 2004, 175 staff members completed 104,000 patient visits, according to records. Dawsey, who previously led a community health center in Alabama, was hired into the position five years earlier after the organization had started running a serious deficit. Most of the management team was at odds with the board and had left within a short period. Since then the organization has stabilized and expanded. One of the members of the board which hired Dawsey said that she had known for years that executive leadership was wanting at the organization. “We had had a number of lawsuits filed by staff,” she said. “He brought fairness and order, and we have not had one since [then] that I can recall.”
On August 27, 2005, Dawsey and other staff, left the administrative offices in Biloxi for the weekend. They were preparing to batten down the hatches for the coming storm,. making sure that they picked everything up off the floor and covered the desks and computers in case the roof leaked=Dawsey also took some extra precautions like making sure he had contact information for key staff. He also backed up the practice management system (which included digitized patient files , such as billing information and payroll) off-site in two different locations. By early Saturday, however, he realized that if the storm were as strong as predicted, a loss in power could delay payroll. So he and other staff returned to the office to write checks. Then he went home to Mobile to wait out the storm.
“The door itself was open,” Dawsey says about his return on the August 30, and he was unprepared for the damage he would find. “A desk was jammed against it so I had to break through. When I did get inside, the mud was probably six or eight inches deep on the floor, and the furniture was just scattered everywhere. Everything had been ruined. All that was left were the top two shelves of the pharmacy in that building. A couple of other staff people were there just standing outside. I don’t know how to describe it except that they were in shock. Not just because of this, but because their own homes had been flooded. One of those people and I drove over to the Biloxi clinic and it was even worse. Water and mud and stuff was up over the top of it, and everything in that building was ruined. Then we went over to the Gulfport clinic, and the roof had been blown off. So we kept going to visit Vancleave, where there was some damage, but not as bad.”
And it was not just the physical infrastructure of CFHC that was gone, the patient files and billing information had been destroyed in both the original and backup locations.
|Background on Community Health Centers|
|Number of Community Health Centers in 2005||952|
|Number of CHC patients in 2005||14,133,103|
|Number of uninsured patients in 2005||5,623,377|
|Two-thirds of CHC patients are racial/ethnic minorities.|
|Nearly 40% of patients are uninsured, only 14.8% have private health insurance, the remainder receive some sort of public insurance (Medicare, Medicaid, SCHIP, etc.)|
|CHC Revenue Sources3|
|Section 330 grants (HHS)||22%|
|State government, local government, foundation grants||12%|
|Other federal grants||4%|
|Percent of Health Centers Providing Select Services Onsite4|
|General Primary Medical Care||100%|
|Preventive Dental Care||73%|
|Mental Health Treatment/Counseling||74%|
|Substance Abuse Treatment/Counseling||50%|
|Smoking Cessation Program||58%|
|HIV Testing And Counseling||91%|
|Glycosylated Hemoglobin Measurement,Diabetes||85%|
|Blood Pressure Monitoring||99%|
|Blood Cholesterol Screening||89%|
|Weight Reduction Program||76%|
Community Health Center Katrina Factoids6
Dawsey considered it his first order of business to try to contact all of the employees, most of whom were without phone service for several days. Dawsey’s own home phone worked for a few days before it went out, and he started to receive calls from staff members who had evacuated. “Just about all of them were doctors,” he says. “They were all over the country.” Whenever he heard from anyone, he asked those who had remained to make a record of of the details so they could piece together a contact list. It took a month to track everyone down.
While Dawsey was attempting to locate staff, the remaining board began to filter back into the area. At 73, Karlyn Stephens was the founder of the organization. Her family had not evacuated, having been through a number of previous scares. “It was me, my husband, my son, my daughter, my son-in-law, and the dog,” she said. “The storm started getting really bad, and at some point we went to the second floor of the house, but then our neighbor’s roof blew off and that knocked our roof off, so we swam for it” to an oak tree where everyone—including the dog—spent the next 10 hours clinging to the branches.
“It was loud and cold,” she says. “We watched the house crumble, and we couldn’t really talk to one another. We just had no idea what to expect next.” Stephens’s son, who is 45 and retarded, also has diabetes. “But he hung on,” she says, and as soon as people came to their rescue, she headed to a shelter. But the shelter had no medication, so the Stephenses headed to the hospital to get Josh’s blood levels tested. “We couldn’t get the help,” she says. “They were busy doing triage, and dead bodies were lying around. It was an unimaginable scene, but I knew I needed to get Josh the help he needed, and there were no pharmacies left.”
The family decided to head to Alabama, then returned a few days later, and Stephens drove directly to Coastal Family Health. “My cell phone, along with everything else, was gone,” she says. “Joe and the optometrist and a few others were there trying to organize things.” It never occurred to Stephens that the center wouldn’t rebuild, even with its massive challenges, and she was surprised by being asked the question.
The skeleton crew at Coastal Health set to work opening up free care clinics wherever there was a safe site. Dawsey describes the process:“The first one we opened was Leakesville. They had a generator up there, and we opened it with one practitioner and one clerk. The sheriff had to give us the fuel for the generator and for those employees so they could come to work. We just had to move fast and patch everything together. People started calling from New York, like the Children’s Health Fund, [which] was volunteering to help staff a clinic site. We opened three more sites within the next week or so, but there was still no contact from the state or the feds. By the second week, we had five sites going—working with our reserves and contributions and volunteers.”
Iris Toche is a patient who received care at CHFC said, “After the storm, I needed my meds. So I went to where Coastal used to be, and of course that was just completely gone. It was all gutted out; there was nothing there. I called the open number they had posted, and they told us that they had relocated two or three blocks down the road. . . . Somebody had donated a trailer, and they opened up in that little trailer. So I went down there and got what I needed. . . .
“Of course it was the same old story: “How did you do? Are you okay?” “How are ya?” One of the ladies in there, she had lost everything. She said “There ain’t nothin’ left. Girl, there’s nothin’.” But there was somethin’ left; she was there working. I guess, it was just a relief for her to have a place to go.”
Dawsey says, “We were getting all kinds of donations as far as medicines and so forth.” “Payroll was our only expense, because there was no place to buy supplies anyway. Finally, about three weeks later, we heard from the state and FEMA [the Federal Emergency Management Agency]. At one point, we were operating about 25 different locations, and we were not the only ones providing health care in the area. There was the Red Cross and the Salvation Army, and maybe a hospital in Kentucky would send a team down and set up a site, but there was no coordination whatsoever.”
Stephens describes the first call to the Department of Health and Human Services, the organization’s major funder. After hearing about the clinics’ destruction, a contract officer told Dawsey that he supposed that meant CFHC wouldn’t need as much money as previously. “Of course we let them know that was not the case and that we intended to take care of everyone who walked in the door”—or, rather, the tent flap. Coastal went on providing free care from September through the following June out of trailers, tents, and in shared space.
Through all of this, a steady stream of patients found the center wherever it provided services. Donna Young is a self-described member of the “over-the-hill gang” living on fixed income. Young says when Hurricane Katrina hit, the office she used to go to on Division Street was completely demolished. “Everybody had nowhere to turn, and then Coastal came back real fast,” she says. “They were working under extremely limited circumstances, but they managed to keep the doors open and got medicines and provided a lot of other help for people like me who didn’t know where to turn.”
The funding picture was continuously shifting, but Dawsey kept pushing on every front. In November, Dawsey says, he got a call from a state Medicaid contract officer, who let Dawsey know that a long-disputed bill to the tune of more than $900,000 was cleared for payment. “I was smiling through the mud! Then she said, ‘The check should be cut Friday.’ Well, then Friday, she called and said the person who was to cut the check was on leave. I was thinking, ‘A state agency [has] only one person who can write a check?’ But anyways, that kind of thing went on for five weeks. I kept calling her, and it was always something else. And then in the end, they denied owing us that amount. They actually said, ‘Well, if you can prove that we owe it to you, . . . ’ They had found out that we had lost all of our records. So we had no way of proving anything.”
In the wake of the storm, this was not the only officially delivered slap in the face to CFHC, but it was an unkind cut. Over this period, most of the center’s financing came from new sources. In January 2006, CFHC got a new federal allotment, but insurance payments did not kick back in until 2007, almost two years after the storm. The organization received money from foundations and individuals, but the largest operating donation it received was from the Middle Eastern country of Qatar, a small but wealthy Muslim country, which gave a total of $3.4 million.
During the first year of rebuilding, Stephens says that the board, normally comprising 15 people, operated with a core of three or four decision makers. “I am usually a stickler for process,” she says, “but Joe needed backup on the enormous numbers of decisions CFH was faced with. Thank goodness he’s not someone who acts like a maverick; he’s a consulter. So those of us who were there, we did it.”
Attracting the necessary mix of resources to keep afloat in a confusing environment required that the organization be as high profile as possible not just in the region but across the country. Dawsey describes the center’s best decision in the days following Katrina as that of involving volunteers. “You know, Hands On group, Project Hope, AmeriCares. There’s several different groups, and I started working with these people who would come in and leave, and they would take the message back out. They would start meeting with other people. That was what I did: just contact the volunteers that would come down here, and they would take the message back out, call me back with different funders they’d found.”
As Dawsey describes the organization now, you hear exhaustion in his voice. He is, he admits, tired. Although CFHC has rebuilt the organization’s information systems by installing a state-of-the-art health information technology system and is on good financial footing, the organization currently has six building projects underway. These projects,says Dawsey, are broadly overseen by him with the help of someone who would normally work as a facilities manager. He expects this reconstruction phase to take another 18 months.
Meanwhile Dawsey has all of the problems that other health centers are experiencing only intensified. Staff has built up to 122 from the original 175, but recruitment is a major problem. Staffing may be more difficult in the storm-damaged Gulf region than elsewhere, but it is a system-wide concern. “The center director in Mobile called me this morning to say they are having a terrible time, because the hospitals are hiring all of the doctors, and he cannot pay competitive salaries. That is something all community health centers are going to have to face together.”
Meanwhile the organization is having cash flow issues related to multi-layered approval processes for federal payments that flow through state agencies. Considering Dawsey’s past experience with the $900,000 bill that remains unpaid by the state, this truly requires a suspension of hard-won caution. “I don’t even want to think about the possibilities,” he says.
And then there is what Dawsey refers to as the region’s “mental health problem,” which is not, he assures, confined to the patients. “I’ve had more complaints in the past three months than I have had in the past 10 years,” he attests. “There is a lot that leads to this. People’s expectations were raised when we were doing free care. They still expect to be seen on an entirely free basis, without paperwork and on an immediate basis, which is not always possible. But, generally, I think that tempers are short on both sides —staff and patients.”
Stephens describes the whole Gulf Coast region as “clinically depressed.” She includes herself in that diagnosis, saying that it is much more difficult for her to keep things ordered in her mind now. “We are an area full of open wounds and still reeling from the injustice of the whole thing,” she explains. But Stephens is as passionate as ever about Coastal Family Health Center’s mission. “When I started organizing for the center in 1972,” she recalls, “the area was first in the nation in infant mortality and last in life expectancy. The adult illiteracy rate was 48 percent, and there was little access to health care for low-income people “Health care should be a right in this country,” she says.
She tells what is for her an iconic CFHC birthing story that began when a woman showed up at the door of the United Church of Christ mission she and her husband ran with her pregnant 13 year old daughter who was actively in labor. “I actually thought the girl was retarded,” she said, “she was in renal failure and when I asked her questions she just vaguely looked at me without answering. The mother had taken her to three doctor’s offices and a hospital and they had been turned away at each place and the mother was in a panic. The only thing I could think of to do was to have the mother take her to the hospital and refuse to leave. She was scared that they would arrest her but I figured both the hospital and the cops would be too afraid of the liability issues if they did not pay attention. The girl did finally have her baby in the hospital and she and her baby came out healthy but I decided then that something had to be done and eventually part of that organizing produced Coastal Health.”
In “Legacy of Disaster: Health Centers and Katrina One Year Later,” the National Association of Community Health Centers reports that the states of Louisiana and Mississippi were ranked 49th and 50th, respectively, for health-care infrastructure. That shaky foundation was eroded yet further when some 6,000 physicians in the counties and parishes affected by Katrina were displaced, according to the report. Some 25 percent of these missing physicians had specialized in primary care. Before Hurricane Katrina, Mississippi was rated highest in the proportion of low-income people in the population and first in the nation in the percentage of adults with high blood pressure. It ranked second in the percentage of adults with diabetes. Now, of course, there are the heightened needs caused by stress, unemployment, and unstable living conditions—not to mention the respiratory problems that were caused by mold and demolition. What also hits health centers such as CFH, according to Dawsey in an interview in Mississippi’s Clarion-Ledger (Rupp, August 28, 2007), is that the demographics are changing. “Pre-Katrina, the pediatric side helped balance out the uncompensated care, because most children have some kind of insurance. But now we don’t get a lot of that business. The children have left.”
A dedicated core of people never considered giving up at Coastal Family Health Center. Individuals —board members, doctors and other health professionals relocated in troubling numbers but Coastal Family Health had not finished its work and so it remains. Its work, in the context of the nation’s health-care crisis, Coastal Health is critical in two ways, says Stephens. “First, we have to be here for people today and tomorrow, but also our ability to maintain and act quickly and effectively in the midst of all of this is testimony to the strength of community health centers as a cost-effective and flexible health network that can do what it takes to meet the community where it’s at. The country needs to look at this as a model for the delivery of primary health care overall. We stand as a lesson and model in the middle of the national health-care crisis.”
Commentary: A Concentric Circle of Devastation and Displacement
Any organization exists within concentric circles of stakeholders/environmental forces that act upon it, and upon which the organization acts. For any nonprofit organization, a shaky ring—whether it is a global crisis, a national economic downturn, governmental retrenchment, unstable local politics or climate, or even wayward board members or staff—can lead to service and security disruption. When a crisis impacts a series of these concentric rings, the impact on the core organization may well become amplified. This is part of the story of CFHC.
The first crisis Joe Dawsey faced was the innermost organizational facilities crisis—Hurricane Katrina happened most immediately to the infrastructure of the organization. The devastation continued in waves coming out from that center. Crisis came from the missing and displaced staff, and then from the missing and increasingly re-located board. The local community, devastated as well by the storm, could offer few resources, at the same time, supplying more pressing issues of concern. The local government and the Feds, disbelieving, then stymied, could also offer no relief. Not only was help from that circle not forthcoming, further pain was inflicted when previous contracts were violated. A crisis of any of these rings would have brought hardship upon the organization. Cascading crises in each one meant that response and recovery would have to start again at the core.
The good news for Coastal was that the CEO and the board remained committed to the organization’s mission against a backdrop of widespread and often personal disruption and suffering. That “core” inner circle was able to keep the organization functioning with makeshift facilities and tremendous resolve to service both old and new demands for assistance. With a solid core, the organization is trying to rebuild relationships to the outer rings. As it does so, Coastal would be well served by strategizing how dependent it has to be on the circles furthest from its core.
Rikki Abzug is Associate Professor of Management at the Anisfield School of Business of Ramapo College of New Jersey.