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Medical Alert, Part I 

An all-system breakdown threatens the survival of El Paso County's public health

Editor's note: This is the first of a two-part series about El Paso County's Health Department. This week, the Independent explores the events leading up to the recent firing of department director Dr. Tisha Dowe and the county government's increasing involvement in a department that is supposed to be maintained as a separate entity. Next week, we will explore the history of the department, its current leadership and where we go from here.

Dr. Tisha Dowe claims she never saw the bullet coming.

On Feb. 22, Dowe was fired from her job of three years overseeing a department that is charged with maintaining the public's health and safety for the half-million people living in El Paso County. Dowe, 52, said she was shocked.

Her bosses on the Board of Health declined to specify the reasons for their decision to oust Dowe after a closed-door meeting that lasted only a few minutes. Dowe had, at the board's request, been on paid administrative leave from her $147,000-a-year job since mid-February.

Tom Huffman, the chairman of the Board of County Commissioners that appoints volunteer members to the Board of Health, claims he doesn't know precisely why Dowe was fired, pointing out that the Health Department is supposed to operate independently of the county government.

But e-mail correspondences and other documents obtained under Colorado's Open Records Act paint a clearer picture of events that ultimately led to Dowe's demise. (Selected e-mails may be viewed online at www.csindy.com.) Specifically:

Over the past several months, county staff and commissioners became intimately involved in the inside operations of the Health Department, despite the county attorney's assertion that the department is supposed to function as an entirely separate entity.

The involvement ran so deep that, on taxpayers' time, a county staffer recruited and tutored a selected citizen to serve on the Board of Health. The employee, Jeff Green, helped successful health board applicant Karen Rooks Nauer fine-tune her letter of interest, asked the county's attorney to OK her appointment despite concerns that she had a conflict of interest, and asked the commissioners to meet with him to discuss her qualifications.

Dowe claims that county staff subsequently told her to sign a contract with the company that employs Nauer without first sending it out for bid, a procedure Dowe believes was, at best, an ethical breach, at worst, a violation of law.

Commission Chairman Huffman, who is the county's liaison to the Board of Health, attended board meetings only infrequently, and bypassed the board to deal directly with Dowe, bombarding her with requests and demands. In addition, Huffman's involvement in day-to-day operations has become so intense that he has attacked ideas for specific health department program support.

Huffman's and the county staff's involvement led to bitter feuds that escalated until Dowe was fired.

Everywhere you turn

By state law, the Health Department is designed to be an autonomous entity set up to ensure the public's health and safety. So what has the Health Department ever done for you?

"Turn on your tap water and you're drinking, thanks to the Health Department, some of the best water west of the Mississippi," said Krzys Myszkowski, who served as acting director until Dowe's 1999 appointment.

"Go to a restaurant and eat in a clean facility. Go to any child-care center -- a huge amount of people use child care in El Paso County -- and when you walk in, see how it's clean and well administered. That's thanks to the Health Department.

"The air we breathe on a daily basis, where no clouds of pollution hang over the city -- that's thanks to monitoring by the Health Department.

"The Health Department monitors for outbreaks of disease and is the reason why there is not a high incidence of [sexually transmitted diseases] and gonorrhea [in our community]. Every time you want to travel overseas, the Health Department is where you turn for immunizations. When you want to put in a septic tank, or drill a well, the Health Department does the inspections.

"The list goes on and on," Myszkowski said. "Our life is made better daily because of the Health Department."

As well as offering state-mandated services, the El Paso County Health Department, like most others across the country, has broadened its scope by offering tobacco and violence prevention programs, alcohol and drug treatment, prenatal care, and child and adolescent health services, including low-cost immunizations.

Since the Sept. 11 terrorist attacks, local health departments have also taken on the major responsibility of preparing for potential bioterrorism attacks. Home to the Air Force Academy and four military bases, including the nation's nerve center for space warfare, the county has worked in conjunction with the Health Department, the military and law enforcement to install a program to respond to potential attacks.

The buzz word

El Paso County's Health Department receives the bulk of its funding from state and federal sources, private grants and service fees. However, nearly one-third of its funds comes from the county government, and the five-member Board of County Commissioners appoints the five members of the Board of Health, which oversees the department.

The setup is designed, in part, to restrict partisan politics from dictating the details of public health.

Still, in recent years, the department's growing budget and broad services have become a political target of some county commissioners, all conservative Republicans. In particular, the commissioners' newly named chairman, Tom Huffman, who serves as the county's liaison to the Health Department, has accused the department of engaging in "socialized medicine" at taxpayers' expense.

"Is it the government's role to ensure that the health care of everyone living within our borders is taken care of? No," Huffman said.

Specifically, Huffman, a retired dentist, believes it unfair that the county has become the vessel for public health services that are not provided by the private sector. Critics say his positions are radical and unfairly target the indigent and the working poor, who are often the primary beneficiaries of health department programs.

"He's badly misinformed," said John Potterat, the longtime director of the department's STD/HIV programs until what he claims was a forced retirement last year (see "Feeling Queasy," p. 17).

Potterat pointed out that while Huffman has been critical of government-funded services, like programs that provide methadone to heroin addicts and immunizations to poor children, he has not offered up any criticism over Medicare, which is also a government program, but whose recipients are of a higher class stratum.

"'Socialized medicine' is a buzzword," Potterat said. "It's like asking, 'When was the last time you beat your wife?'"

Responsibility without authority

County officials insist the main reason for their recent deepening involvement in Health Department affairs wasn't motivated by politics, but by concerns that the department was being poorly run. They claim decisions made by Dowe -- against their advice -- could lead to increased costs that the county may ultimately be asked to cover.

"She didn't know what the hell she was doing," County Administrator Terry Harris now claims of several of Dowe's decisions leading up to her firing.

Harris pointed out that, though it is not supposed to micromanage the Health Department, the county provides an estimated $4.5 million of the department's $16 million annual base budget.

"We have a responsibility, when we give $4 million to $6 million to any outside agency, that there be absolute strings, requirements and conditions on that money," Harris said. "That's the way it should be and always will be."

His position runs contrary to a legal opinion issued last December by the county's own attorney, Mike Lucas, in which Lucas wrote: "the BoCC [Board of County Commissioners] has no legally mandated authority over the Board of Health, and therefore the Health Department's, day to day operations."

The recent shake-up included a push to overhaul the directors who oversee the Health Department at least as early as last May, documents show.

Then, County Administrator Harris, himself a former Republican county commissioner, sent an e-mail to his elected bosses. In that correspondence, Harris suggested they "may want to do some hard recruiting" to fill upcoming Health Board positions being vacated by Dr. Brian Olivier and Harvey Vieth, a dentist and former local Republican Party chairman.

"Let me know if I can help," Harris advised.

An issue of control

While conflict between county officials and the Health Department had been brewing for a while, what brought it to a head were seemingly mundane issues: changes in the county's payroll system and employee health-insurance plan.

Until last year, the county had administered the Health Department's payroll and insurance. But when the county decided to switch to new programs, Dowe and the Board of Health weren't sure the new systems would work for them.

The Health Department's accounting needs were different from the county's due to the complex variety and accounting requirements of the department's funding sources. Adapting the county's new systems to accommodate their needs could cost up to $1 million, Dowe argued. So the Health Department began exploring the idea of running its own payroll and insurance.

Over the next several months, a flurry of meetings, e-mails and occasional confrontations among the key players followed, as Health Department and county staff wrangled over the proposed changes.

Dowe expressed concern that county staff were meddling and trying to protect their bureaucratic turf by stonewalling the Health Department's attempts to manage their own insurance and payroll programs. She was particularly upset with County Benefits Manager Jeff Green, a former employee of the health insurance company PacifiCare, who had joined the county last June and became the point man in dealing with the issue. "This appears to be an issue of control," Dowe wrote in an October e-mail to Olivier, then the president of the Board of Health.

County staff, meanwhile, countered that they were merely trying to make sure the Health Department knew what it was doing. Green said that, contrary to Dowe's claims, "It will be substantially less for the taxpayers to stay with the county systems." He accused Dowe of having "invented" the estimate that it would cost $1 million to join the county's new payroll system. In internal communiqus, Harris, at one point referred to the estimate as "bullshit."

Tried to warn her

In recent interviews, Green and his boss, County Human Resources Director Mark Bell, said they had numerous meetings and communications with Dowe to discuss the implications of the Health Department's switch. They tried to warn her, they said, that what she was doing could end up costing more money and could leave the department's employees with an inferior health plan.

While Dowe characterized Green's involvement as interference, Green said the county had a responsibility to make sure that Health Department employees would experience no interruptions in their paychecks and insurance coverage, which was still the county's obligation until the switch had been completed.

Ultimately, it was the department's legal prerogative to decide what to do, Green and Bell acknowledged. But Dowe still needed to communicate her intentions to county staff to ensure a smooth transition, they argued. That's where the biggest problems arose, they said. According to Green and Bell, Dowe would repeatedly say she was planning to do one thing, and then do another without informing them. Trying to communicate with her, Bell said, was like "going down various rabbit holes" and "banging heads against the wall."

The conflict turned personal. In a confidential e-mail to Harris on Dec. 17, Dowe accused Green of having "ruined relationships that were fine until he came around. ... I hate to see him have an opportunity to devastate the County/Health Department relationship." Ten days later, Green and Dowe had a confrontation at a county office building. According to a written account by Green, Dowe broke down in tears and, during a two-hour episode, called him a "liar." Green referred to her conduct as "unprofessional," and, in a subsequent e-mail response, county Finance Director Julie Johnson, who had also gotten involved, opined that Dowe was "acting like a big baby."

Guts in knots

At the time that Green and other county officials kept pushing Dowe on the payroll and benefits issues, the Sept. 11 attacks and the ensuing anthrax crisis gave the Health Department another headache to deal with.

On Oct. 15, Dowe sent an e-mail to Harris and other county managers asking for a reprieve. County staff had just told her that if the Health Department wouldn't use the new payroll system, the department would also lose the county's information-technology support.

"We are responding with the sheriff and police and to all suspicious circumstances," Dowe wrote. "I have activated our Emergency Response Team and we are going to have to shut down some Health Department normal activities to meet the demand on us.

"Terry, please help me calm this situation down," Dowe beseeched the county administrator. "My staff and I have our hands full responding to the current health emergencies and concerns about the county stopping all infrastructure support unless we agree immediately to go on [the payroll system] is tying our guts in knots."

Dowe signed off the letter, "Please, help me."

Meanwhile, Huffman was on his own crusade. In a series of e-mail demands, the commissioner began going directly to Dowe -- not the Board of Health -- and asking for budget figures and a slew of other information.

Dowe and board President Olivier became increasingly alarmed at the county's level of involvement in the operations of the Health Department.

Huffman indicated he was "upset" that Dowe hadn't discussed the health-insurance switch with him, Dowe wrote in an e-mail to Olivier in September. She also said Harris had told her that if the department were to seek its own insurance, Huffman "would never vote for any funding for the Health Department."

Records show that despite Huffman's growing interest in the day-to-day operations and his complaints about not receiving information, he only attended four out of twelve Board of Health meetings last year. Meanwhile, in a message to Olivier, Dowe complained that Huffman was "developing an expectation that I take direction from him. I never felt that expectation from [County Commissioners] Jeri Howell or Ed Jones," both previous liaisons to the department.

"It was constant," Dowe said in a recent interview. "I couldn't get work done. It just became constant questions and requests for numbers and it never was good enough."

Eventually, Dowe said she asked that those communications be made more appropriately through her bosses -- the Board of Health -- but she continued to be the focal point of the county's anger.

Getting personal

Huffman's involvement began to extend to potential programs being considered by the department. In one case, Huffman warned the Health Department against supporting the Task Force on Children's Firearm Safety, designed to educate youth on gun safety and organized in part by former Health Department Director Dr. John Muth.

"I will tell you up front that any attempt locally to follow the folks trying to classify firearms as a health problem will not have an easy row to hoe in El Paso County," Huffman wrote in an e-mail to Dowe on Sept. 10 last year. "I would specifically prefer that the Health Department remain uninvolved with this organization."

Huffman was also questioning the department's expenditures and the scope of its programs. He made several requests for budget figures, as well as outlines of which Health Department programs were "mandated" by state law, and which ones were not.

Huffman and Dowe argued at length, in meetings and via e-mail, over whether the Health Department spent more money per county resident than comparable health departments around the state.

Huffman defended his involvement. "There is nothing illegal about communicating with the Health Department," he said in a recent interview.

Dowe, he said, was not forthright. "We would shake our heads at some of her statements and say, 'That's just not true.'" Huffman declined to specify which inaccuracies he was referring to, other than saying, "[Dowe] sees things the way she wants to see them."

"Desire" vs. "interest"

Meanwhile, by last November Green's involvement in Health Department operations stretched to his recruiting and coaching a longtime professional and personal acquaintance, Karen Nauer, to serve on the Board of Health. Nauer is an area vice president of Marsh USA, a brokerage firm that's paid by the county to arrange health-insurance coverage for county employees. She is also a former nurse who previously worked for the Penrose-St. Francis Health Systems and coordinated the Women's Center at Memorial Hospital.

In an e-mail sent to Green, Nauer included her draft application to the Board of Health, as well as her rsum. "Let me know your thoughts," Nauer wrote. " If it looks okay, would you forward this to [the commissioners] via e-mail? Thanks."

To which Green replied, "Your resume is great," and advised her to underscore her background in the medical field and to state in her letter of interest that she has a great "desire" serving as a health board member versus "interest."

"I think that you have a really good shot in getting this position. Each county commissioner will read the letter and resume," Green promised.

Green then apparently sought to influence the decision of the Board of County Commissioners. "I am hoping to have a brief discussion with you as a group regarding the Board of Health vacancy interview meeting for tomorrow," Green wrote in an e-mail to the commissioners on Dec. 3. The commissioners interviewed candidates and appointed Nauer the following day.

While it is the role of County Commissioners, and not staff, to select Health Board members, Green said he considered his role appropriate because he was asked by Huffman to approach Nauer. Huffman confirmed that recruiting Nauer was his idea in the first place.

"I was just a conduit," Green said.

Harris said county staff would not become involved in recruiting candidates for county boards unless asked by commissioners -- which, he said, happens fairly frequently.

"I would never want to do it if they didn't ask us to, because I consider that strictly board business, not staff business," Harris said.

In December, when Dr. Jack Dillon's term on the Board of Health was up for renewal, Green was again busy recruiting -- passing along to Harris information about one prospective candidate, Jim Flood. "I think that a call from you will help to encourage him to apply," Green advised Harris.

Huffman defended Green's involvement as an "intermediary" who has worked with Nauer in the past. "There was nothing inappropriate at all," he said.

However, when told of the involvement, Jim Alice Scott, a county government watchdog who worked for the City of Colorado Springs for many years before her retirement, termed the process "inappropriate." In general, Scott has criticized the county's process of nominating and selecting citizen volunteers as "careless," and "sloppy."

Conflict of interest?

Hearing about the Nauer appointment, several citizens began to ask whether Nauer had a conflict of interest because of her business relationship with the county through Marsh USA.

In a Dec. 12 e-mail, Green addressed the concern by asking the county's attorney Lucas "if you could forward an email to the Commissioner's [sic] stating that the appointment of Karen Nauer would not be a conflict of interest." Lucas did as Green suggested, advising the commissioners that "in my opinion, any perception of conflict does not rise to the level of legal impropriety."

While Nauer works for a company that holds a contract with the county, Lucas said that, because the Board of Health is independent of the county government, there was no conflict. "The [Board of County Commissioners] has no legally mandated authority over the Board of Health, and therefore the Health Department's, day to day operations," Lucas noted.

By that time, however, Nauer had already been appointed to the Board. And Lucas' opinion didn't address the fact that the insurance coverage arranged through Marsh also covered the Health Department. Moreover, after Nauer was appointed to the Board, she proceeded to seek financial compensation for Marsh from the Health Department, again soliciting Green's help.

When the Board of Health made the final determination last Dec. 27 to seek its own employee health-insurance plan, Marsh USA announced it would charge $12,000 in commission to broker a separate plan for the Health Department.

When Dowe balked at the cost, Nauer expressed her "dismay and surprise" in a Jan. 3 e-mail, written in her capacity as a Marsh USA employee and not as a member of the Board of Health, which was addressed to the county commissioners, Dowe and County Administrator Terry Harris.

Before Nauer sent the e-mail, she once again ran it by Green, who told her to "go ahead" and send it. "Mark [Bell] and I strongly support your position," Green replied to Nauer.

Dowe now terms the demand to pay Marsh, at best, an ethical dilemma, at worst, illegal. After all, the proposal had not gone out for competitive bids from other companies that might also be interested in doing the work, Dowe noted, a violation of county procedures.

"When it gets right down to the whole thing, there was no way that I would go along with things that aren't legal or ethical," Dowe said.

The county eventually agreed to pay the $12,000 to Marsh, informing Dowe of its decision in a letter dated Jan. 4. Before the letter was sent to Dowe, Green ran it by Nauer, who replied, "Good letter."

Nauer did not respond to repeated phone messages seeking comment, and the perception of her conflict of interest continues to be a sticking point.

Nauer's predecessor on the board, Brian Olivier, has indicated her dual role of serving on the board and doing business with the Health Department at the same time presents an ethical problem.

"Direct personal or business financial gain to a newly appointed BOH member of the Department of Health, in my opinion, constitutes conflict of interest," Olivier wrote in an e-mail, sent to Dowe and several county commissioners and staff.

Green, meanwhile, maintains that Nauer did not receive any direct commission from the county contract.

But Jim Alice Scott pointed out that Nauer is under contract with the county. "She's also a consultant to the Sheriff's department and is on the board of the Health Department. Can she really, truly represent the interests of the Health Department, as well as other interests which may conflict?"

Morale threatened

In the aftermath of Dowe's termination, she and others express fear that the shake-up will further undermine the department and threaten the morale of a dedicated workforce.

"The big issue here doesn't need to be me; I will be OK," Dowe said. "The big issue has to do with public health in this community and how the system should not be at the whim of whichever way the political wind is blowing.

"I'm just the symptom of a very sick system."

  • An all-system breakdown threatens the survival of El Paso County's public health

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