The real surprise in the abrupt resignation Tuesday of Los Angeles County health director Thomas Garthwaite was that he stuck around as long as he did. Hes only the latest in a string of men hailed as saviors of the mammoth and perpetually crippled health system who escaped a few years later just shy of being run out of town on a rail. Robert Gates was hounded out by county supervisors for not rescuing them from the fiscal crisis of the mid-1990s, and was replaced by Mark Finucane, who was fired over a series of run-ins with individual board members when he tried to simultaneously follow their instructions to cut costs and, along the way, to keep his hands off the public hospitals and clinics that each supervisor was protecting in his or her own district.
Garthwaites tenure, which began in 2002, was marked by the long-delayed reckoning over the Martin Luther King Jr./Charles Drew Medical Center in Willowbrook, where patients most in need of a public hospital were treated but, far too often, also mistreated to death, in some cases. King/Drew has long been in crisis, but only on Garthwaites watch, as patient deaths became too horrendous to ignore and as the Los Angeles Times finally focused its attention there, did the hospital attract sustained criticism.
In the weekly board meetings in which Garthwaite was called on to give a public accounting of King/Drews failings, and the health systems generally, he appeared more and more world-weary and beaten down. Most of the barbs thrown his way are just part of the job, and are taken in stride each week by other county department leaders who have struck the delicate balance between doing their jobs and currying the political favor needed to keep from getting fired. But Garthwaite carried the burden of several million county residents who rely on public hospitals as their only form of medical care and have been watching one hospital after another close, or threaten closure. In the last several months, whether because of the relentless pressure or because of his own failure to keep his eye on the ball, Garthwaite began screwing up in earnest. For example, he recommended the closure of the obstetrics unit at King/Drew to save money and give the medical center some space to breathe, he neglected to mention that making that move would mean the loss of millions of federal dollars.
Herb Wesson, who oversaw King/Drew as a special assistant and earlier as chief of staff for Supervisor Yvonne Burke, said that Garthwaite lacked the leadership skills to navigate his way through the turmoil.
I think that without a doubt he was a good physician, said Wesson, who began his tenure as a Los Angeles city councilman on the day Garthwaite resigned. Tom wanted to do the right thing. But he had been banged up for a while, and didnt know how to put together the alliances, how to outreach and work with others.
Plenty of blame can be set at Garthwaites feet, but not without the follow-up admission that he probably did as well as anyone could in the job. It was his task to run the nations largest local health system while reporting to a five-member board that often takes the latest Los Angeles Times story as its agenda.
For example, when the Times began reporting last year on patient deaths and questionable practices at King/Drew, the subject of each story whether it be nurse competence, the cleanliness of mattresses, the honesty of physicians in their time-keeping rose to the top of the list for the weekly Garthwaite grilling. When the papers five-part Pulitzer Prizewinning series almost exactly a year ago crystallized the problems of the hospital anew, the supervisors lashed out at Garthwaite as if the problems were being reported for the first time.
The supervisors never seemed to be able to decide whether they were supervising the county health system too carefully, or not carefully enough.
Burke, in an interview last year with the Weekly, said she and her colleagues could hardly be held accountable for medical or administrative matters that were beyond their understanding.
But that never stopped the board from lambasting Garthwaite for the most technical of failings, if they happened to have been reported in the Times that week.
Ive watched the board publicly humiliate health directors for years with their Tuesday-morning quarterbacking, said Lark Galloway-Gilliam, executive director of Community Health Councils. I think that things have gotten worse with the boards involvement in the process, with the level of detail they get into. Its just a Tuesday-morning circus act.
But while the board is focusing on contracts and newspaper headlines, Galloway-Gilliam said, it is missing the big picture, like making sure the quality-assurance systems are in place, or forming strategic plans for the health systems future. She wants the board to turn oversight of the health system over to an independent panel, to free the supervisors from medical administrative decisions and to free the health system from the supervisors.
Garthwaite, too, wanted a chance in governance. That matter has itself gotten a hearing from the board, which has dragged its feet on the question and tabled it for now.
In a sense, the supervisors did remarkably well with Garthwaite, who lasted just under four years in the job. Joel Bellman, spokesman for Supervisor Zev Yaroslavsky, pointed out that Garthwaite is leaving King/Drew in the hands of well-regarded hospital administrator Antoinette Smith Epps, and has filled long-vacant but crucial positions elsewhere in the organization.
Even three years ago the board had not seriously engaged in addressing the King/Drew problem, Bellman said. We have disciplined dozens of people, moved aggressively over the last few years to run the system in a more systematic way. He helped us draft and pass Measure B, which directs new tax money to trauma care.
In hindsight, it may look like these were obvious or simple fixes, but they were a mountain to climb at the time, Bellman said.
In one further tragic twist, even Garthwaites successes are the health systems failure, since it was his charge to preside over shrinking funds and diminished services.
Its been that way for more than 20 years. Bob Gates was charged with matching the still-renowned health system of the 1980s with new policy and fiscal realities of the 1990s, and he responded by shrinking the department but not enough. Mark Finucanes job was to shrink it further, and he got the Clinton administration to bail the department out with billions in exchange for converting a hospital-based system to an out-patient system.
Then came Garthwaite, to wean the county from public-health dollars in the political atmosphere of the Bush administration.
If the Board of Supervisors retains direct governance over the health system, it must find yet another director with the medical and administrative know-how and the political savvy to keep the board at bay, at least temporarily, while trying to fix intractable problems.
Garthwaite, meanwhile, may recover his own health by leaving the county. He said he will take a job with Pennsylvania-based Catholic Health East.
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