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Critical Condition 

El Paso Countys public health seized with high infant death rates, suicides, bioterrorist fears and a leadership vacuum

Editor's note: This is the second in a two-part series exploring the recent upheaval in the El Paso County Department of Health and Environment. Last week's coverage focused on the events leading up to the firing of department director Dr. Tisha Dowe. This week, the Independent explores the myriad challenges it will take to rebuild the department in an era of terrorist threats and other public-health emergencies -- and a recently launched effort to consolidate services.

After a shake-up at its highest levels, this is what is left of El Paso County's Health Department: approximately 250 dedicated and apprehensive employees and an acting director who is relatively new to town;

An inexperienced five-member Board of Health, charged with overseeing the department, that includes no physicians for the first time in anyone's memory;

And County Commissioner Tom Huffman, a retired dentist who, serving as the liaison between the county government and the Health Department, recently and loudly complained that at 2.6 cents per person per day, El Paso County taxpayers are being fleeced to pay for "socialized medicine."

What is gone is the department's recently fired director, Dr. Tisha Dowe, and a number of longtime managers and staff who departed under her watch in a mass exodus that some say was caused by Dowe's "dictatorial" leadership style. With them went much of the institutional memory of the organization.

Meanwhile, the county's infant-mortality rate is higher than those of Cuba, Croatia and Malaysia. The suicide rate has skyrocketed. A recent statewide study found huge health disparities among ethnic groups and people of color.

In addition, the federal government has identified El Paso County -- home to five military installations, including the nation's nerve center for space warfare -- as among the highest risk centers in the nation for the threat of bioterrorism. However, the newly named president of the Board of Health has indicated the board plans to move slowly in hiring a new director.

To say that one of the fastest-growing counties in America is at a critical juncture for public health is an understatement.

Huffman's remarks, and the commissioners' failure to appoint a medical doctor to the board, have resulted in widespread belief throughout the medical community that most of the county's elected leaders neither understand nor support the importance of public health and are in fact undermining it.

"The Health Department is much more important to people than the people realize," said Dr. John Muth, who ran the department for 20 years until his retirement in 1999.

"It's that invisible shield that you don't know about until you need it. People think of the Health Department as the social services of health, but in fact, the Health Department is like the sheriff's or the fire department of health."

With the recent upset, some are wondering whether now is the perfect time to restructure the way El Paso County provides state and federally mandated public health care.

No doctor in the house

In its 120-year history, the Health Department has evolved from a city-controlled agency to one jointly overseen and funded by the City and El Paso County. In 1976, the City turned over all functions of the department to the county.

By state law, the Health Department is a separate, autonomous entity. The Board of County Commissioners appoints five volunteer members of the Board of Health that oversees its operation, and the county also contributes approximately $4.5 million each year to the department's $16 million budget, plus another $386,000 for the department's retirement fund.

Traditionally, the health board has included at least one physician. The director of the department -- who is hired by the board -- has also been a medical doctor. The notion is that the manager of public health should be a physician who can present a broad perspective, and that a "backup" doctor should serve on the board for checks and balances.

Last month, however, the commissioners rejected the application from the board's sole physician, Dr. Jack Dillon, an emergency-room doctor, to serve a second term. Instead, when Dillon's term expired, the commissioners appointed Robert Sanford -- an out-of-work businessman with experience in defense contracting who admitted he knows little about public-health issues -- to replace Dillon.

Shortly thereafter, when the Board of Health fired Dowe, it left the Health Department temporarily in the hands of Acting Director Rosemary Bakes-Martin, who is also not a physician.

Among other large health departments in Colorado, only Boulder County currently has a director who is not a medical doctor, and only Jefferson County lacks a doctor on the Board of Health.

Huffman argues that a physician is not necessarily needed to oversee the department. What is really needed, he maintains, is a number cruncher whose management skills are more finely tuned to employee empowerment and human relations.

Dr. James Simerville, a board member of the El Paso County Medical Society, said it may be OK to have a non-physician serving as director if there's at least one physician on the board. Several physicians, he and others point out, also work within the department.

But to have no medical doctor serving in a top-level decision-making capacity, he said, is a concern. Physicians, he pointed out, have professional training in public-health issues. "They need to impart that expertise to the board."

Muth, the retired health department chief, agrees. "The folks that we count on in this world to have the broadest view and the most training are physicians," he said. Other medical professionals, he noted, are highly trained, but generally in much more narrow specialties. "You just never know when important things are going to come up that require someone of broad knowledge to think things through.

"You've got to have the broad training that physicians have, especially now. We are now, and will be continuing to deal with threats of bioterrorism. We have saber rattlers at the highest level of government and the cloud will continue for some time -- whether it's a cloud of bacteria or a nuclear cloud -- I would think the entire community would feel safer with a physician on the board."

The board feels handicapped

When it became obvious that the county commissioners did not plan to reappoint Dillon to the board, at least two sitting board members pleaded with the commissioners to reconsider.

"Could you accept that we, the Board of Health, believe we need a medical doctor on board?" wrote Royann Killoren, then the board's vice president in a Feb. 19 e-mail to Huffman.

"Consider, if you will, the current situation. We are all volunteers and wish to do a good job. We believe we are handicapped by the lack of a physician. How about asking the Medical Society to send forth three more candidates? Maybe there will be someone more to your liking."

Like Killoren, board member Terry Thatcher underscored the fact that, of the four remaining board members, three have been appointed within the past 14 months. In a Feb. 15 e-mail sent to all five county commissioners, Thatcher asked that Dillon be reappointed to provide more continuity to an inexperienced board. Not having a physician, she wrote, would be a "serious error."

"Even though I had been monitoring the BOH for more than four years prior to my appointment and reading much of the material sent to the board members, I have still had much to learn," Thatcher pointed out. "I feel that appointing a new member who has apparently said that he knows very little about the [Health Department] would be a real travesty."

Amid criticism that the commissioners had recently appointed another health board member -- Karen Rooks Nauer -- with a conflict of interest because the company she works for brokers the county's health insurance, Huffman fired back.

In a memo distributed to critics, Huffman stated he believes that anyone who stands to experience a positive or negative benefit from anything related to the Health Department has a conflict of interest and therefore should not be named to the Board of Health. This includes, Huffman said, essentially all local health-care professionals, including doctors.

Jim Alice Scott, a county government watchdog, terms Huffman's comments "ridiculous."

"Most boards, committees, commissions and advisory bodies ... have people on them who, by Commissioner Huffman's tortured reasoning, would have a conflict-of-interest," she noted. "In fact, the City/County Regional Building Committee, which has seven members, requires that six of [them] be persons with direct involvement with the building industry; the Criminal Justice Advisory Board is made up primarily of individuals employed in the criminal-justice system."

Huffman's position also runs counter to the county's own requirement that "[Board of Health] applicants should possess knowledge of, and be concerned with the wide range of health issues within the community."

Tortured and simplistic

However, those guidelines were ignored last month when commissioners appointed Sanford in a 4-1 vote. The only dissenting voice came from Commissioner Jeri Howells, who has loudly and consistently argued in favor of the need for a medical doctor on the health board.

During Sanford's interview, when asked by County Commissioner Ed Jones what he knew about the Health Department, Sanford responded, "I've read a bit but to tell you the truth, not a lot."

(In stories about Sanford's appointment, The Gazette has referred to him as a "retired businessman," even though during his interview with commissioners Sanford indicated he is currently looking for a new job. He expressed confidence that whatever new position he accepts will not interfere in his ability to serve on the health board.)

Despite the lack of qualifications, Jones subsequently made the motion to appoint Sanford, though the commissioner did not explain his rationale for why he believed Sanford was the best candidate of five applicants. The incumbent board member, Dillon, had the endorsement of the 800-member El Paso County Medical Society. The other three, while not physicians, have extensive experience in health-related fields.

The decision outraged the Medical Society, as well as members of the community who voiced their alarm, accusing the county commissioners of "arrogant behavior" and their logic for not wanting to reappoint Dillon "tortured" and "simplistic."

"Attacks through the use of biological and chemical weapons aimed at our civilian communities require new, stronger and more effective relationships between public health and clinical medicine," the Medical Society said in a written statement. "Yet our county commissioners have chosen this time of challenge to weaken our system."

In a Feb. 15 communiqu to county commissioners, citizen Ruth Fetler wrote that she could not understand why the commissioners would prefer, over a physician, an out-of-work man "whose only qualification is that he knows something about finances."

"The health of the community should come first," Fetler wrote. "Frankly, it looks as though the [Board of County Commissioners] is trying to find a job for a friend."

Killoren, who has since been elected president of the Board of Health, said the board now plans to ask the Medical Society to appoint a member to serve in a non-voting advisory role, an idea that Muth predicts will likely be rejected.

"It's the Medical Society's position, and has been for a long time, that there ought to be a physician on the board, and it would be counter-productive to have a non-voting [representative]," Muth said.

Simerville confirmed that the society is cool to the idea. "It doesn't make sense," he said, to have someone serve without voting power. "I think that's totally not what the Medical Society would want."

In addition to Sanford, the four other members of the Board of Health now include:

Killoren, a consultant to several local nonprofits and governmental organizations, who has served on the health board for 14 months;

Anne Russell, the board's vice president, who holds a master's degree in public health and is serving her second term, having first been appointed in 1994;

Terry Thatcher, a clinical social worker who, serving her first term, was appointed seven months ago; and,

Karen Rooks Nauer, an executive with the insurance brokerage Marsh USA, whose appointment to a first term three months ago caused the conflict-of-interest furor.

"We are in no hurry"

Meanwhile, the Health Department's day-to-day business is being handled by Bakes-Martin, previously second in command at the Health Department, who stepped in as acting director when Dowe was dismissed on Feb. 22. Bakes-Martin worked as a supervisory health scientist with the Centers for Disease Control in Atlanta before moving to Colorado Springs in August 2000. In addition to serving as acting director, Bakes-Martin continues to work for the CDC.

Last week, Killoren said that in the fallout following Dowe's firing, "We're making certain that the staff is all stabilized and feeling comfortable."

"We're very, very happy with our acting director," she said. "At our last [meeting], we discussed the process of finding a new director, and my sense is that we are in no hurry to do that because everything is going so well and introducing a new element is not a practical thing to do."

The board, Killoren said, plans to talk more about how to recruit a permanent director at its next meeting this week.

"We are not attempting to do anything at a fast pace; we're going to work cautiously," she said.

Many health-care experts, however, underscore the urgency of the situation. Dr. Muth, for example, said it behooves the Board of Health to immediately launch a search for a new director.

"It isn't as if the Health Department is totally at sea -- that would be the wrong picture to paint," Muth said. "But it is certain, especially in these times when we have to worry about bioterrorism, that they need a physician at the helm with the experience to stabilize it."

Dr. Ted Eastburn, a cardiologist and Colorado Springs city councilman also cited the need for an experienced Health Department director as the U.S. government prepares to issue grants to local health departments to help prepare against terrorism.

"There's a golden opportunity about to emerge, and the Health Department without a director runs the risk," he said. "The federal government is going to be sending out what amounts to blank checks for Homeland Security, and we need to be in the position to take full advantage of that."

Eastburn pointed out that, regardless of the leadership situation, thanks to a devoted staff of health-care workers, he predicts the day-to-day business at the Health Department will get done.

Over the long term, though, leadership becomes a requirement in order to strategize five to 10 years down the road -- which, in fast-growing El Paso County, means a lot.

"That's what you lose by not having a director," Eastburn said.

21/2 cents a day

Also contributing to the uncertainty about the department's direction has been a tendency on the part of Huffman and numerous county staff in recent months to micromanage the day-to-day operations of the Health Department -- which by law is supposed to operate as an autonomous entity.

The county's involvement led to a feud with Dowe and ultimately culminated in Dowe's dismissal.

Huffman has accused the Health Department of spending too much money. However, a comparison with health departments in other large Colorado counties -- using budget figures provided by the departments and excluding Denver -- suggests that what El Paso County taxpayers are asked to contribute is not unrealistic or overbroad.

Overall, El Paso County's health department does spend more money per resident than any other comparable health department. At $16.3 million, its total budget is outmatched only by that of the Tri-County Health Department serving Adams, Arapahoe and Douglas counties, which stands at $17.5 million. The tri-county area, however, has almost twice as many people as El Paso County.

Though the average budget is relatively high, the portion paid for by county taxpayers -- $4.5 million -- is consistent with other similarly-sized departments in Colorado. With the retirement-fund contribution included, it equates to $9.45 per county resident per year, or approximately 2.6 cents per day. Outmatching El Paso County, which includes the City of Colorado Springs, are Jefferson County, at $9.89 per resident per year; Pueblo city and county, at $10 per resident; and Boulder County, at $13.90 per resident.

The El Paso County Health Department raises the remaining $11.3 million in its budget -- more than any other comparable health department -- from state and federal sources, service fees and private grants.

Huffman has also made clear his position that offering nonmandated services through the Health Department, the beneficiaries of which are often the working poor and indigent, is "socialized medicine."

Many health-care professionals, including Eastburn, dispute that stance. By law, Eastburn argues, the government must ensure the public's health and safety.

"State statutes make it clear that government agencies can charge a fee for cost recovery, but also makes it very clear that no one will be denied personal health services for failure to pay," he noted. "It's pretty enlightened, in my opinion, and so everyone should be working to the same end."

Worse than Cuba

Instead, public health in El Paso County has fallen victim to politics and power struggles. The turmoil comes at a time when the Health Department is grappling with serious public-health crises.

In addition to preparing for potential bioterrorism, the Health Department is trying to combat a disturbingly high infant mortality rate in the county, as well as an explosion in the number of local suicides.

According to the Health Department, the county's infant mortality rate -- defined as children dying before the age of 1 -- is approximately nine out of 1,000, or 36 percent higher than Colorado's statewide average.

That places El Paso County in a category worse than infant mortality rates in Croatia, Cuba and Malaysia, on par with Poland's, and barely better than that of Chile, according to statistics from UNICEF.

Kandi Buckland, the Health Department's chief of maternal, child and adolescent health, says the Health Department is in the midst of an effort to pinpoint the reasons for the county's high rate of infant deaths.

Even though access to prenatal care is believed to play a role in lowering infant mortality, the Health Department recently decided to phase out its prenatal care program beginning March 1, partly due to budget constraints. Buckland said El Paso County's health department was the last in the state to offer direct prenatal care.

Subsequently, the department has turned all new clients over to the Community Health Center, a local nonprofit agency that agreed to accept patients who would otherwise have come to the Health Department. However, the department will still have case managers who work with patients and providers to make sure access to care is available, Buckland said.

Meanwhile, Health Department staff have expressed alarm at a rapidly growing number of suicides in the county. Last year, the county coroner reported 95 suicides, the highest in seven years. The number is up from 75 in 2000 and 60 in 1999. It exceeds the total number of both homicides, of which there were 24 last year, and motor-vehicle deaths, of which there were 55.

Kim Nolen, the Health Department's injury and violence prevention specialist, called the increase "disturbing." Health Department staff are now working with local nonprofit organizations to study the possible causes of suicides and implement a prevention program.

"We really believe that most of the suicides are preventable, and they need to be recognized as a preventable public-health problem," Nolen said.

Simerville said other major public-health challenges include tuberculosis, which is being brought into the area by immigrants from other countries, and sexually transmitted diseases, including HIV and AIDS.

While private health-care providers can treat sick individuals, they have neither the means nor the financial incentive nor the responsibility to track and combat such diseases on a community-wide basis, he pointed out. That, he said, is the role of public health. And that, he said, is not "socialized medicine," as Huffman has termed many of the Health Department's programs.

"Dr. Huffman doesn't seem to realize the importance of such things," Simerville said. "I wish our county commissioners weren't so seemingly closed-minded."

A new idea

Eastburn agrees with Simerville that public-health services are necessary. "If the county is not interested in funding it, that's their call," Eastburn said. "But the services need to be delivered."

In recent weeks, Eastburn has been floating a plan to consolidate many of the services currently being provided by the Health Department, the city-owned Memorial Hospital and the nonprofit local health-care provider, Community Health Centers.

In the scenario, city-owned Memorial Hospital, currently in an expansion mode, would serve as the umbrella for clinical services, such as prenatal care, immunizations and drug and alcohol treatment programs.

He is not sure how the new structure -- which would incorporate services currently provided by two government agencies and a privately owned nonprofit company -- would be governed. But Eastburn said in recent weeks he has had informal conversations with the CEO of Community Health Centers, the CEO of Memorial, Memorial board chairman Dave Palenchar, Mayor Mary Lou Makepeace, Huffman and, until her termination, Dr. Dowe at the Health Department.

"Unless people are just shining me on, I haven't heard any objections from anybody," Eastburn said. "Everyone I've spoken to seems to be almost enthusiastic about it."

Simerville said some sort of city-county cooperation might be a good idea. "I'm glad Ted Eastburn is getting into it," he said.

Though state statutes don't speak specifically to the model Eastburn envisions, they give municipalities wide latitude in how to provide the public-health services required by law. Those services include nursing, immunizations, reporting and prevention of communicable diseases, operation of public-health laboratories, gathering and maintenance of birth and death records, and inspection of restaurants and septic systems.

Under state law, cities and counties can establish health departments to provide these services, and they can also dissolve them. In places where no health department exists, basic services must still be provided and are often handled directly by the local government or contracted out.

Cities and counties can also band together to form district health departments. And the law allows "regional" health departments that have their own taxing authority, though no such departments have been formed.

Eastburn pointed out that El Paso County, one of the fastest-growing counties in the country, needs to be poised to meet its public-health challenges. In addition, the 1992 Taxpayer Bill of Rights and its resulting budget cuts has forced government agencies to evolve from belt tightening to figuring out ways to creatively fund programs to eventual consolidation of services, he said.

"I'm concerned that as the community grows, the need for services grows," he said. "I don't consider us in a crisis right now, but if we don't have a place to evolve, we will be in a crisis."

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