“I wasn’t going to leave my animals behind!” Vanessa told me later. “You never know how long it’s going to take before they let you come back, and you may not have power or nothing for weeks.” To evacuate all these animals, Jimmy hooked a trailer to the back of their pickup, and they loaded up crates and cages, and headed north. The macaw rode up front in the cab.
With a mandatory evacuation in effect all along the coast, the drive up to central Texas took nearly sixteen hours. Rain battered the truck. There were hours-long lines at gas stations. Emergency shelters were open in Houston, but Vanessa didn’t want to go to a shelter, where she’d be separated from her animals. Then again, there was no money for a hotel, not with what they were putting into gas. Vanessa had been out of work since a car wreck the year before messed up her back, so Jimmy’s salary was all they had.
They crept north through the heavy evacuation traffic until they hit a state park in central Texas. But they were turned away there—too many animals. As they were leaving the park, Vanessa heard a strange noise from the trailer. She went back to check the animals, and a puppy was having a seizure. “That near broke my heart,” Vanessa said.
She and Jimmy drove to an emergency vet, where the puppy was treated for low blood sugar. And the veterinarian, seeing how exhausted Vanessa and Jimmy looked, said they could camp in the parking lot. Vanessa wept with relief. And there they stayed, walking the animals on leashes, until it was safe to go back toward Galveston.
The TV in the vet’s office rolled coverage of Ike. The flooding was awful. Nineteen people were dead. Somebody’s pet tiger escaped after the storm and was roaming the Bolivar Peninsula. The hurricane passed over central Texas on Saturday, but the worst brute force of the winds and rain had gone.
MEDICAL STUDENT KRISTY MITCHELL did not plan to evacuate. She owned her home, because Galveston is the kind of decayed glorious city where a medical student can buy a house with a turret and finance it partly on student loans. She was a St. Vincent’s director, and a fourth-year student with strong ties to the island. When the National Guard knocked on her door the day before the storm, Kristy was baking popovers.
Kristy evacuated, but nearly one-third of Galvestonians did not. A whole contingent of Galvestonians decided to ride out the storm at the Poop Deck, which was right on the seawall. Ike was only a Category 2 storm—it didn’t sound so bad.
Hurricanes are categorized according to wind speed. As a Category 2, Ike had winds of up to 110 miles per hour. What made Ike so devastating was not merely strong winds, but the size of the hurricane. Nearly six hundred miles across, it covered much of the Gulf of Mexico and caused a massive storm surge before it. This storm surge sank Galveston: The seawall protected buildings on the north side of the island, but the storm surge pushed water into the bay, flooding the island from behind. Just as in 1915 and 1961, the north side of the island got the worst of it. The flood knocked out the whole first floor of St. Vincent’s House, where the preschool had been. The clinic areas on the upper story were spared.
“Everybody knew this neighborhood would flood,” Michael Thomas Jackson, the minister of St. Vincent’s House, said to me. “We’re sitting here at three feet below sea level.” As went New Orleans, so went Galveston: The black community, having once been segregated to flood-prone neighborhoods, remained there. They put down roots—or they were unable to escape—until they were forced out after the hurricane.
KRISTY’S ROOMMATE RIMMA snuck back onto the island the week after Ike hit, flashing a UTMB badge to get past three checkpoints where National Guardsmen with huge guns strapped to their chests shifted and stared on the causeway leading to the island. “I just said, ‘We’re with UTMB,’ ” Rimma said. She did not say that she was a first-year medical student.
The people who had been living in Galveston’s public housing did not get back so easily. Many were bussed to shelters across the state. When the buses attempted to return, they were sent back at the checkpoint—the “look-and-leave” policy for Galveston residents that had been enacted a week after the storm was abruptly canceled. When people tried again to return, many learned that they had no homes to return to. The public housing, home to about six thousand Galvestonians, was all condemned. St. Vincent’s was not condemned, nor were many of the flooded buildings on the north side. Debate would rage for years over exactly why the public housing was condemned instead of repaired, with many people seeing it as a deliberate move to force out the poor. And Galveston would drag its feet rebuilding the public housing, delaying even after the federal government ordered the city to rebuild. In the meantime, the people who used to live there—including many people who loved Galveston, and had generations of family in town—scattered across the state and beyond.
Passing the guardsmen, Rimma saw wrecked boats cast adrift on the road, broken lumber and shingles, miles of wreckage strewn over the east end of Galveston. The fetid water had receded, leaving a thick layer of sludge laced with pollutants, including arsenic and lead from the flooded refineries in Galveston and Texas City.
UTMB is also north of Broadway, and so the first floor of most buildings was flooded. Critical hospital employees—enough to run a streamlined emergency room and operating room if the need should arise—had stayed through the storm. The hospital power failed because the generators were in the flooded basement, and so the docs and nurses spent the day of the storm in darkness, listening to wind and rain batter the hospital. When a technician managed to rig up enough power to turn on the red-and-blue UTMB light atop the hospital tower, everybody cheered. The light sent a bright signal across the devastated island: the hospital was open.
One UTMB building spared from flooding was the Galveston National Lab. The lab had been built to be hurricane-proof, so there were only two signs of damage there. At the first-floor entrance, a welcome carpet was damp. And hundreds of research animals had to be killed when backup power failed.
In the days after the storm, power was routed to essential buildings where patient care and temperature-sensitive research was going on. Elsewhere, the power (including the air-conditioning) was cut. In the UTMB anatomy lab, the human cadavers that first-year medical students had been dissecting before the hurricane rotted in the heat. Rimma and her classmates would never dissect, missing out on a key ritual of becoming doctors.
Arriving at Kristy’s house, Rimma opened the door to find that she had been lucky: Floodwater had risen just over the floor, soaking rugs, before draining out through the air ducts underneath. But a rancid odor filled the house. Rimma traced it to the kitchen—it was a pound of rotten butter, left on the counter from Kristy’s popovers.
ST. VINCENT’S HOUSE was already up and serving people on the day that Rimma snuck back onto the island. Mr. Jackson had returned to Galveston two days after the storm as a first responder, and he led St. Vincent’s workers in making the House a hub for critical services. The Red Cross would drop off food, ice, and essential supplies, and Mr. Jackson and his team would hand these supplies out on the street.
With the medical students dispersed across the state and the future of UTMB in question, the student-run free clinic would take weeks to resume services. When it did, Kristy and the other student directors fanned out across the island trying to find their patients. They knocked on doors, left flyers, and asked anybody who was around if so-and-so patient had been seen. The houses they went to, mostly north-side houses where the uninsured patients lived, were devastated. Most folks were gone, but some people were living in these damaged, mold-infested places.
“I’m not sure how many people we actually found at home,” Kristy said, “but it was the minority.” At one house, a man had ascites—fluid in his belly, as Mr. Rose had had—so badly that Kristy could diagnose it from the street. She encouraged him to come to St. Vincent’s to see a doctor. “I’m not sure if he ever did,” she said.
On the day the student-run free clinic opened again, a line of patients was waiting out front at St. Vincent’s House. Mos
t of them were longtime patients of Dr. Beach, the faculty sponsor for the clinic. He had cared for some St. Vincent’s patients for decades; they had his cell phone number, and he had been able to let them know about the clinic opening. Dr. Beach was the first volunteer to arrive that day. When his patients saw him, they stood up and cheered.
MY INTERVIEW AT UTMB was rescheduled. It was finally held on the campus of a medical school in Houston, about six weeks after the storm. My friends in Galveston told me that things were still chaotic on the island. There were still wrecked boats blocking some of the minor roads, and many medical students had been sent to other hospitals across the state. The UTMB ER would not be up and running until the following summer.
To orient us to Galveston at my off-island interview, the doctors showed a video that UTMB medical students had made. The video toured the hospital, the research buildings, and a bit of the island—all shot before the storm. Near the end of the video, a medical student popped out from behind a huge oak tree and said, “Galveston is verdant!” At that, the tall doctor in a suit and cowboy boots sitting next to me winced. Hundreds of oak trees on Galveston had been killed by the salty floodwaters.
I did not know at that time how much the hurricane and its aftermath would change my medical education. I did not know that the disaster, like Hurricane Katrina, would disproportionately affect the lives of poor people. Even if I had known that, I might have wondered what that could possibly have to do with me. The message the doctors gave us was that the hospital would surely be up and running in full service by the time my class started clinical rotations in our third year of medical school. If the hospital was running, it seemed, everything would be fine.
And anyway, Galveston was resilient. The town survived the Great Storm of 1900, and people there endured the years of recovery and rebuilding. The hospital had a century of history of taking care of those most in need. Surely, in this time of great need, UTMB and the city would rise to the occasion together.
My letter of acceptance to the MD/PhD program at Galveston arrived in the mail. When I opened it, I remembered watching the video footage of Hurricane Ike in the days after the storm. Reporters filmed the flooded north-side neighborhoods from a helicopter. In the middle of all that water, gas lines inside one of the houses had caught fire. The helicopter kept circling and circling around that lone house as it burned.
* Yup, 1865. Texas resisted emancipation from 1863 to 1865, and did not act on the new law until forced to do so.
† Karen Sexton, Lynn Alperin, and John Stobo, “Lessons from Hurricane Rita: The University of Texas Medical Branch Hospital’s Evacuation,” Academic Medicine 82, no. 8 (August 2007): 792–796.
CHAPTER 5
THE FIRST THING SUSAN MCCAMMON AND HER HUSBAND replaced after the hurricane was their piano. Susan had been a musician long before she was a head-and-neck cancer surgeon, and by that point in her life she would tell you that the two practices—piano and surgery—were bound in her cerebellum, her muscles, her median nerve. You practice a particular movement over and over and then the thousandth time you do it, something changes—the notes become music, the surgery becomes a thing of beauty.
At UTMB, Susan had been a busy surgeon before the hurricane. She often ran two operating rooms at once. She trained junior surgeons, and she worked on a committee that tracked the funding for indigent patients. The goals of this committee seemed fairly clear: to provide as much care as possible to uninsured and indigent patients, using a limited pool of money. She also took classes at the Institute for the Medical Humanities, and derived satisfaction from being part of a hospital where her patients—because head-and-neck cancer patients are often working class or poor—got the same excellent care as insured patients. Busy as she was, Susan thrived. She felt herself at home in the total identity that medicine offered. Becoming a doctor was, for her, becoming a complete human being.
The early days after the storm were busy. Susan’s first concern was to find her patients who were undergoing radiation. Head-and-neck cancer care is almost always multilevel: it can require chemotherapy, surgery, and radiation. Susan knew that any interruption in a radiation regimen—even just for a few days—could reduce her patients’ chance of survival. A break in radiation therapy allows the stronger, radiation-resistant cancer cells to proliferate. So, along with her nurse, Susan immediately set about trying to catch up with these patients.
This was not easy. The island was still under evacuation orders, and Susan was in an extended-stay hotel in Dallas. Galveston-based patients were scattered all over the state and beyond. Landlines were not working and cell phone service was spotty; many of Susan’s poorest patients—the ones who had lived on the streets or in the Salvation Army shelter on Galveston—didn’t have cell phones. But she did what she could, and the MD Anderson Cancer Center in Houston agreed for a few weeks to accept UTMB cancer patients who were undergoing active radiation treatment at the time of the storm. So some found care there, some were treated elsewhere, and some patients could not be found.
Her next step was to find placements for her resident surgeons, so they could continue their training. Susan bought a fax machine and set up a temporary office in the hotel. She began calling residency programs around the state and beyond, asking them to take on the trainee surgeons from UTMB—at least for a month or two. This was all concrete work, and for a time, it kept Susan’s mind off of the disaster.
Then she returned to the island, and to the clinic. Her house was wrecked. She still had her job. She had her car. She had her husband and her dog, which snored and drooled amid disaster, as he had always done before. The three of them moved into a second-story apartment near UTMB and hunkered down.
UTMB was also a mess, but miraculously, it stayed open. With John Sealy Hospital flooded, the administration began making arrangements for UTMB patients to be seen at mainland hospitals. Susan and her colleagues were able to use clinic rooms and even operating rooms on the mainland, so many UTMB patients were able to continue getting the care they needed.
Susan felt lucky, even a little guilty, to have her job. In the weeks after the storm, nearly three thousand UTMB employees were abruptly fired under the reduction in force (RIF). In general, a state employee cannot be fired without reason and a type of due process. But in a crisis situation, the state is able to enact the RIF and fire people without other cause. Nobody on the ground could figure out the logic of the RIF—everyone from entry-level medical assistants to surgeons with thirty years of experience got RIFfed. As the waves of firings rolled out across the community, employees like Susan who still had jobs began to consider themselves very lucky. In fact, there was little for many of the doctors to do. With the main hospital shut down and many patients cut, suddenly professionals used to working eighty-hour weeks had a glut of time. How lucky, to be paid to do nothing while three thousand employees had been fired and the rest of the Gulf Coast struggled.
This luck, eventually, would have a silencing effect: those who now considered themselves lucky to have jobs at all mostly kept quiet about the changes at UTMB.
What Susan did not know, at that time, was how deeply those changes were affecting her patients. In the wake of the hurricane, UTMB administration had decided that the university could no longer provide unfunded care. And so Susan’s indigent cancer patients had received a letter, signed by then-chancellor Ben Raimer, that began:
Dear [Name]:
We regret to inform you that UTMB physician Susan McCammon will be discontinuing her professional relationship with you due to the devastation caused by Hurricane Ike to UTMB’s medical facilities and equipment. For this reason, we will no longer be able to offer you medical care at the University of Texas Medical Branch.
SUSAN LEARNED ABOUT the form letters when her patients began showing up at the clinic to ask her about it. They could not believe that Susan, who had cared for some of them for years, would abandon them. And the first time Susan took a letter from the damp and shaking hand of he
r patient, she could not believe it either. Susan McCammon will be discontinuing her professional relationship with you . . . The university couldn’t do this, could they? Not to cancer patients. Not to people who surely would die without care.
In medical school, we learn that nonabandonment is essential to the practice of medicine. Once a doctor has established care with a patient, she cannot abruptly discontinue care without going through a process: explaining things to the patient, transferring their care to another doctor, continuing to provide care until the transfer is established. When patients get dire diagnoses, we learn to tell them that we will be beside them through the whole process. No matter how bad the disease, and no matter how brutal the treatment, we will not abandon them. This may be cold comfort to someone with an awful diagnosis, but the promise of nonabandonment is sometimes the only comfort we can give.
The notion that the university could compel a doctor to abandon her patients was shocking, and at first, Susan didn’t believe it. She began making calls and asking questions, moving higher and higher up the chain of command. At every level, the answer seemed to be yes, they can do this. The state had cut funding for indigent care to UTMB, and in fact, the university had been gradually reducing funding for indigent care even in the years before Ike. Merle Lenihan, an ob-gyn doctor who formerly led the women’s clinic at St. Vincent’s House, worked with a community group called the Galveston County Free Care Monitoring Project to compile data showing that UTMB had been turning away more and more unfunded patients since 2005. Sixty-two percent of unfunded patients referred to UTMB had been accepted for care in 2007, the year before the storm. By 2012, four years after Ike, only 9 percent were accepted. The total revenue dedicated to unfunded patients had steadily dropped, from 18 percent in 2005, down to 12.5 percent in 2007, and in 2009—a year after the storm—only 2.6 percent of UTMB revenue went to care for the uninsured.
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