Who really killed Dr. Erlinda Ursua?

Who or what is to blame for the death of Dr. Erlinda Ursua, bludgeoned to death by a 37-year-old patient, Rene Pavonan, during an exam November 19 at John George Psychiatric Pavilion? Hospital administration, the California budget system or Arnold Schwarzenegger? Maybe all of the above.

As related in my recent posting, there had been plenty of signs that all was not well at the hospital, including several CalOSHA citations. In addition, the union representing workers at John George cited other problems.

Linda Joseph, staff director for Service Employees International Union Local 616, said the union had been urging management to improve safety measures.

The assaults and state citations "are a direct result of misplaced priorities," she said. "They have financial difficulties. Instead of looking at misplaced programs to save money, they just cut staff, and with limited staff they aren't able to cover."

Seems like the union was on to something. Now more details are emerging.

• More than 100 violent incidents by patients were reported during 2002 at John George, the San Francisco Chronicle reported Friday after reviewing state Department of Health Services logs. Those incidents included assaults on patients or workers.
  
  
• The hospital is overseen by the Alameda County Medical Center, which runs Highland Hospital and other health care services for poor and uninsured residents. The center faces an $80 million deficit and already has closed clinics and cut back services. County supervisors agreed this week to ask voters to raise the county sales tax in an attempt to stop further cuts.
  
  

Logic suggests that these financial problems led the hospital to bypass offers of assistance from the Alameda County Sheriff's Department .

Medical center officials were so concerned about the potential for violence at the hospital that they twice asked the Alameda County Sheriff's Department for proposals to increase security, according to Sheriff's Capt. Gary Schellenberg.

But officials never went ahead with those proposals. Efton Hall, interim chief executive officer of the medical center, said that the decision to reject the sheriff's security proposals wasn't based on cost, but that the medical center wanted to consider other options, including bids by outside security agencies.

Maybe. But the cost of stationing Sheriffs and deputies at the facility ranged from $1.3 million to $2.1 million for the cash-strapped institution.

On the other hand, the Sheriff's department didn't think that they couldn't have stopped the killing anyway, unless they were present in the room with the doctor. What was needed was an attendant in the room with the doctor and patient, which was one of the measures CalOSHA had recommended that the facility take.

CalOSHA had fined the facility for not having an injury prevention program (a requirement for all employers under California law) and not reporting violence-related injuries sustained by workers at the facility. The agency recommended that the hospital place surveillance cameras in the exam rooms and other areas of the hospital, never leave a staff member alone with a patient, and hire police officers to handle security.

As much as I'd like to join the union in trashing the management of the facility (and it’s likely that they may be somewhat at fault – I don’t know all of the details), I think the root cause of the problems at the hospital may go much deeper -- in California and around the natin.

As Paul Krugman described a while back,

California's slide into irresponsibility, in which politicians refuse to acknowledge any connection between the government services the public demands and the taxes that pay for those services, is being replicated all across America.

Krugman pointed out that it was initiatives that got California into this mess: Proposition 13, which cut property taxes, and later, Proposition 98, which mandated that the state replace educational funding cut due to Prop 13.

When voters, whipped into an anti-tax frenzy by right-wing radio talk/T.V. show wingnuts, as well as politicians seeking to ride the their wave, refuse to see the need to raise taxes to pay for needed government services, you end up with more needy people getting fewer services in understaffed facilities. While the underfunding has ramifications throughout society -- especially for the patients and their families -- it is the workers at the facilities who are literally putting their bodies, and in some cases, their lives on the front lines of these ideological battles.

Security guards and County Sheriffs are fine, but what's really needed is more staff -- adequately paid staff to provide proper therapeutic help, and adequately paid staff to provide support.

OSHA recommended that staff never be left alone with patients. But when the facility is underfunded and understaffed, that's simply not possible. For years, mental health staff have been injured and killed when overseeing numbers of patients without any backup. And how many employees are needed to attend to potentially violent patients? Think about it. Obviously, one is not enough.

Two? OK, so one get's attacked. If there aren't adequate alarms or video camera's (along with attendants to respond), that leaves one person to summon help and the other to deal with other patients until help arrives. Guess how many trained attendants the American Psychiatric Association recommends are needed to safely take down one violent patient. Five.

And how much help is available to come to the assistance of workers who are in trouble? What happens to their patients in an understaffed institution?

There are now two full time deputies on overtime pay posted at the psychiatric hospital. The hospital has added security guards, begun screening visitors and patients with hand-held metal-detection wands, flagging patients' medical records if they pose potential threats because of violent behavior, and attendants have been accompanying physicians into exam rooms.

That’s fine for now. But none of those measures are cost-free, and some area quite expensive for a cash strapped county medical center.

The proposed sales tax increase, if it passes, would provide a temporary solution.

The medical center provides care to the county’s indigent and uninsured and includes Oakland’s Highland Hospital—which serves the majority of Berkeley trauma and emergency patients and is the lone specialized medical care option for Berkeley’s estimated 9,000-11,000 uninsured residents.

The medical center has seen its $353 million budget busted by funding cuts, expense increases and swelling ranks of the uninsured they are mandated to serve.

Last year, 63,500 of the center’s 125,000 patients were uninsured. Coupled with increased expenses for employee benefits and drugs and reductions in government aid—including a $7 million cut from a federal program aiding public hospitals—the center has struggled to balance its books, said spokesperson Rachel Kagen.

But thanks to the Governator many more severe cuts to local health services are on their way.

Which brings us to Krugman’s second point

the state faces a huge deficit, and spending must be cut. But shouldn't the state also seek more revenue? During California's last crisis, Governor Wilson increased the sales tax and temporarily raised income taxes on top brackets. This time Governor Davis proposed doing more or less the same thing — but Senate Republicans refused to go along. Their counterproposal relied entirely on spending cuts — but, tellingly, offered no specifics about what, exactly, should be cut.

Arnold, Republicans in general, and the right wing talk jocks have made certain that in the public mind, budget cuts are gut, tax increases are kaput. And those opposing this line are running scared.

But the choice really isn’t simply between tax increases and tax cuts, between "big" government, and people getting to spend their "own" money.

The question is who will pay for the things that society demands to make life in this country civilized and livable? If those who already have more than enough money are to pay, then their taxes need to be raised. The other option is budget cuts and increases regressive sales taxes and “user fees,” in which case the poor and struggling middle class end up forking out the dollars, while those who don’t have the means to help themselves -- unemployed, the disabled, the mentally ill -- end up "paying" in form of fewer services.

In the meantime, workers are paying the price with their health and their lives. Callifornia, and a handful of other states that run their own OSHA programs, like Minnesota, Oregon and Washington occasionally cite employers for exposing workers to the threat of workplace violence. Federal OSHA, although it issued guidelines for health care, social services and retail workers, has not handed down a workplace violence citation since 1995, fearing that a General Duty Clause citation will be struck down by the Review Commission or the courts. Maybe it's time for OSHA to start working seriously on a workplace violence standard.

Who really killed Dr. Erlinda Ursua? She was just the latest victim of right-wing demogogy and anti-big government tax-cut zealots -- the same people who sponsored the California recall in the first place. So, Arnold, maybe this one isn't on you. But the next one is.