AAMC Reporter: March 2009

The Price of Ike: UTMB in Galveston Continues to Struggle

Just a few days after Hurricane Ike raked the historic island city of Galveston, Texas, last fall, Garland D. Anderson, M.D., dean of the medical school of the University of Texas Medical Branch (UTMB), walked the campus to assess the damage.

"It was as if nothing catastrophic had happened," he recalled. "There were no windows blown out, no visible roof damage."

Then he went inside the buildings.

"This was the kind of storm," he said, "where you don't see the effects right away."

Inside, the storm's impact was acute. A wall of water, pushed by winds topping 100 miles per hour, had poured through the ground floor of almost every building. Mold now polluted every surface. Drywall sagged and crumbled. Mechanical and electrical systems sat in silent, soggy ruin.

All told, Ike has caused UTMB an estimated $710 million in costs related to building damage, cleanup, infrastructure and equipment losses, business interruption, patient evacuation, and student relocation. UTMB was forced to close temporarily and relocate many of its students. John Sealy Hospital, the UTMB health system's main revenue source, was forced to drastically reduce capacity, choking off incoming dollars just when they were needed most.

And could be a long time before UTMB is back on its feet. Just as the initial serenity of the campus belied a ravaged interior, a series of painful cutbacks and debates over recovery efforts—and perhaps the very future of the institution—are roiling beneath a surface of optimism. Positive strides have been made, and there is real hope among UTMB officials for a new and better institution down the road. But in the meantime, major storm clouds loom the horizon."

So far, the largest challenge has been economical," said Karen H. Sexton, R.N., Ph.D., executive vice president and CEO for hospitals and clinics at UTMB. "We sustained a tremendous loss of physical facilities, as well as business interruption and the dispersion of labor. But there is nothing more urgent on a daily basis than to get the hospital up and running and patients back again. Logistically, it's been a very difficult process since Sept. 13."

The infrastructure loss came primarily from flooding, when more than 1 million square feet of business space received between six inches and six feet of water.

"Nothing—phones, utilities, IT, elevators—escaped damage," Sexton said. "So much was under water. It brings you full circle to how dependent you are on those systems."

Perhaps most difficult for the close-knit city of Galveston have been the job losses. Some 2,400 employees, or about half the UTMB staff, were laid off—far fewer than the 3,800 job cuts initially authorized by the University of Texas (UT) Board of Regents, but enough to cause further hardship in a community already dealing with its own cleanup and recovery efforts. The UTMB system, which includes the medical school, John Sealy Hospital, a separate hospital to treat Texas prisoners, and a large clinical network, is Galveston County's largest employer.

"The [layoffs] were made based on positions we wouldn't be needing for the next 12 to 24 months," explained Sexton. "Although we hope to bring many of them back, they were encouraged to take positions elsewhere."

She said that many staff found employment on the Texas "mainland," largely in Houston and its surrounding suburbs.

"We did not want to retain people based on seniority, but by skills needed, so we pushed the decision down to our programs and units, allowing managers to make these decisions, given that they were the closest to the work and the individuals. In some cases, whole programs were closed down."

Three months after Ike, only about 2,400 full-time employees remain at UTMB's hospital and clinic network, and only half are currently deployed—the rest remain on administrative leave, but are on salary, according to Sexton. "We felt this was the right thing to do for people who have suffered so much loss in their work and personal lives."

One month after the storm, the hospital was able to open a 16-bed maternity unit, infant nursery, and neonatal care units. By the end of January, the hospital's medical, surgical, transplant, and geriatric units were operational, as were the surgical and burn intensive care units. Seventy-five of UTMB's 79 primary and specialty clinics have reopened (24 on the island and 55 on the mainland), but those on the island itself are running with reduced services and medical staff.

"We have most of our primary care and specialty care back, but in a newly configured way—downsized," Sexton said. "We are serving a diminished population on the island."

UTMB's medical school, founded in 1891, is the oldest in Texas and has educated one in four Texas doctors.

As Ike loomed, "Our first priority was the safety of our students and residents," said Anderson. Like the hospital's inpatients, students and residents were relocated to other medical campuses on the mainland. Within a week of the storm, the nearly 600 third- and fourth-year students were continuing their clinical rotations at mainland hospitals in Clear Lake and Houston. They are expected to begin returning to UTMB in early 2009 as more clinical facilities open. No patients, staff, or students were injured during the storm.

The academic hiatus for the 40 or so first- and second-year students was surprisingly short as well; they were back in class within four weeks of the storm, although many lecture halls are still unusable and class meeting space is at a premium. The campus's oldest building, known as "Old Red," is still drying out, its foundations compromised by loosened stone. "It's hard to tell yet how much damage the historic building sustained," Anderson said. It has long been home to the school's gross anatomy lab; current first-year students are now learning with models rather than cadavers.

Rather than worry too much about their own problems, UTMB students have lent a hand to the school and the Galveston community. Just 10 days after returning to campus, students insisted on hosting the school's annual Halloween party for local kids—although it had to be held outdoors. About 500 trick-or-treaters showed up in costume.

Anderson noted that by shortening the academic vacation schedule, UTMB students will be able to finish the year on time. Meanwhile, the school continues to recruit students for the fall 2009 entering class.

"We will enroll just as many students as we did in 2008," said Anderson. "We intend to educate as many doctors as ever."

Even before Hurricane Ike struck, there were concerns about the future of UTMB, particularly regarding its financial sustainability. Large deficits have eroded the medical center's century-long mandate to care for the state's poor and underserved just as surely as Ike's floodwaters. By 1998, indigent care costs reached $260 million annually, and 37 percent of UTMB patients lacked health insurance. At the time of the storm, the health system was $35 million in the red, despite a round of cost-cutting that eliminated 381 jobs.

In addition, UTMB's facilities and infrastructure were aging and in need of repair even before Ike. And then came the storm. After Sept. 13, local observers began to speculate about how much investment the UT system was willing to make to restore the campus to its previous level of service.

In the year prior to the storm, the UT system had only been able to purchase $100 million in flood insurance, with a $50 million deductible. "We were very fortunate to obtain even this amount of insurance coverage, and, given the losses in Hurricane Ike, the availability of similar insurance in the future is uncertain," UT System Chancellor Kenneth I. Shine, MD, told the Texas House Select Committee on Hurricane Ike Destruction in December.

Although the UT Board of Regents has publicly declared support for UTMB, State Senator Steve Ogden has expressed skepticism about the board's true position.

"UT is using the hurricane as an excuse to do what they've wanted to do for a long time, which is to reduce their presence in Galveston and go somewhere else," he told a reporter in January.

But in his December testimony, Shine offered encouragement to the doubters.

"Let me emphasize that the University of Texas System and its regents are firmly and absolutely committed to a vibrant and productive University of Texas Medical Branch campus on Galveston Island. We have 100 buildings, $160 million in annual research money, a new national lab, and important educational programs in medicine, nursing, allied health professions, and graduate studies. We are also committed to the presence of a hospital and emergency room on the island, the final size and shape of which is currently being examined. We hope to restore a Level I trauma center at the hospital when facilities such as a blood bank are restored and adequate funding is available."

Higher Ground

There is plenty of debate over whether Galveston needs such a large hospital, especially considering the island's vulnerable geography.

"There is no reason to believe something like this [storm] couldn't happen again," Sexton said. "But our campus has tremendous assets. It is not easy to just pick it up and move it. Instead, we need to diminish our risks and protect our assets."

As far as protection from future storms goes, the obvious task is to move everything higher, positioning vital functions on upper floors. It could also be an opportunity to streamline campus facilities.

"There are also new opportunities for green building, and we have several of these efforts going on as we rebuild the infrastructure," Sexton said, noting that the least-efficient buildings are likely to close permanently. "We are taking our current campus master plan and overlaying it with the new situation we're in."

One model for future campus construction lies on the campus itself. UTMB's just-completed Galveston National Laboratory held up to the deluge. Built to withstand a Category 5 hurricane and a 35-foot storm surge, the building, which had still not officially opened, sustained virtually no damage—just a few damp rugs at the entrance. It served as shelter to medical staff riding out the storm, and generators powered freezers that preserved research specimens from all over the campus that otherwise would have been lost.

The new laboratory finally held the lab's dedication ceremony on November 11, 2008, an event that cast the building as an icon of the "new" UTMB, and a symbol of rebirth for the campus community and the island's residents at large.

—By Martha J. Frase, special to the Reporter