The Ursulines Convent in New Orleans, one of the first providers of free healthcare in the city when it was built in the 1750s, survived Hurricane Katrina with only cosmetic damage. But Louisiana's other historic healthcare institution the charity hospital system has not been so lucky.
Not only were its two flagship hospitals destroyed by flooding in New Orleans, the subsequent financial and operational strains have overburdened an already struggling system.
Healthcare experts warn that without a large injection of federal money the system upon which many of Louisiana's poorest citizens rely may be severely weakened.
The state's charity hospitals are as close as America gets to a European-style public health system. Set up in the 1920s by Huey P. Long, the maverick Democrat governor of Louisiana and one of the early proponents of big government, the nine hospitals provide free care to the poorest and most vulnerable citizens.
Patients, most of whom have no health insurance, are asked to pay what they can. Often this is nothing.
Even before Katrina hit, the system was desperately short of funds, says Don Smithburg, who heads the charity hospital system. "The waiting lines are huge and the facilities too old," he says.
With about one in five people in Louisiana not covered by health insurance, the demands on the hospitals were huge.
Aside from emergencies, patients sometimes had to wait 12 months to see a doctor and 18 to see a specialist. While the average hospital in the U.S. is nine years old, the average age of the charity hospitals is 25 years, according to the Louisiana State University charity hospital system. Its facilities in New Orleans, most of which will never reopen, were 75-80 years old.
Weeks after Katrina struck the waiting rooms at the system's General Hospital in Baton Rouge are close to capacity. The wait for non-critical care is longer than ever.
"This place has always been busy, but never like this," says one of the porters. The hospitals in Lafeyette, Alexandria and Lake Charles have been under similar strain.
"It is not just treating people who have fallen ill since the evacuation; we have also had to rediagnose people whose medical records have been lost," says Smithburg. "We are seeing a lot of people from New Orleans who had chronic conditions and are in need of chemotherapy, radiation therapy or dialysis. And, of course, we lost a lot of equipment in New Orleans."
Many doctors are working 18-hour days, while other hospitals have been poaching staff. "It is rather like kicking us when we are down and we are asking them to stop," says Smithburg. Hospital managers want to set up a statewide system to identify who is responsible for poaching the medical staff.
Without federal help, Smithburg says, up to 4,000 jobs may have to go even though, post-Katrina, the need for free healthcare may be even greater.
"New Orleans may well emerge from this even more dependent on tourism as a source of employment, and jobs in this industry typically do not offer health insurance," he says.
Diane Rowland, an executive director at the Kaiser Family Foundation, a health think-tank, says the fate of the system now lies in the hands of the federal government.
"With about a third of the state's economy still reeling from the effects of Katrina, Louisiana itself is unlikely to be able to come up with the money to prop up the charity hospital system." She predicts there will be intense competition for federal money between the charity system and the state's private hospitals.
Because the private hospitals have more spare capacity, she says, they may argue for a larger share of any federal resources. "There is a risk that the charity hospitals will be permanently weakened by this crisis," says Rowland. "If they are, one has to worry about the poor and indigent in Louisiana [who] may not be easily absorbed within the private healthcare system ... and will ultimately go uncared for."