TESTIMONY OF EDWARD H. ADELSTEIN, M.D., D.V.M. BEFORE THE UNITED STATES CONGRESS HOUSE SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS OF THE HOUSE COMMITTEE ON VETERAN'S AFFAIRS March 11, 1999 MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE My name is Eddie Adelstein. I am a pathologist at the Harry S Truman Veterans Hospital in Columbia, Missouri and have worked there since it opened in 1972. I also am a licensed Veterinarian and serve as Deputy Medical Examiner of Boone County. HISTORY OF VA ADMINISTRATION, PRACTICES AND POLICIES Mr. Kurzejeski was the Director when I was chosen as Chief of Laboratory Service in 1979. He had already established a reputation as an erratic non-programmatic autocrat, who rewarded his friends and punished his enemies. Reprisals were common. Although numerous attempts were made to remove him from this position, he was strongly supported within the "good old boy network," so clearly defined within the VA administration. He tried, unsuccessfully, to force me to hire an unqualified individual for a critical position in the laboratory, where I learned that "lying" was an acceptable administrative tool, that both he and his administrative staff were capable of using. Thus began my introduction into the rules of reprisal that permeate this institution. It is clear that for cover-ups to occur, no actual spoken conspiracy is necessary. No matter how heinous the crime, and the resultant cover-up, everyone knows that if you tell the truth, you will be punished, but if you take part in the cover-up you will be rewarded by promotion and considered a loyal team player with a bright future within the VA system. This was evidenced by the fact that many involved administrative people, including Mr. Kurzejeski received promotions or bonuses as a direct result of their actions regarding the 4E deaths. Clearly individuals who demonstrate principles of high integrity and honesty will not be placed in critical administrative positions. Under this selective system, it is not surprising that serious ethical problems continue to plague the VA administration. The principles of the new VA under Dr. Kizer have also contributed to this punitive environment, when his first words to the VA were "If you think your job is secure, think again." Change has not been produced by rational cooperative actions, but by fear and reprisal activities. In spite of these problems, I choose to work at the VA because it was the last altruistic health care delivery system and I felt honored to take care of Veterans who risked their lives to save America. We were relatively unencumbered by profit motive and teaching and research opportunities were plentiful. That paradigm has shifted. BACKGROUND INFORMATION ON INCREASED NUMBER OF SUSPICIOUS DEATHS ON 4 EAST In the summer of 1992, I was the acting Chief of Staff at the hospital when I was informed that nurses were complaining that an increased number of deaths was associated with a single male nurse. The quality assurance program had not gathered any data and I asked Dr. Gorgon Christensen, a well trained hospital epidemiologist and his research colleague, Dr. Andrew Simpson, to review the data and establish statistical correlations. They worked quickly with myself and Dr. Earl Dick, the Chief of Staff and determined that these deaths were associated with a single nurse and all evidence pointed strongly to the murdering of Veterans within our hospital. It was only when Dr. Christensen, facilitated by Dr. Dick, met with a blue ribbon panel of respected VA directors and Chief of Staffs against the orders of Mr. Kurzejeski and was told that "he was a foolish young man to be here" did I begin to understand the lack of ethics that permeates this organization. Although, they clearly understood the implications of the possible murder of up to 40 patients, they also understood the implication of "telling" and as a group made the choice to "cover up". The failure of Dr. Dick, to control Dr. Christensen, labeled him a trouble maker and a non-team player. For this action, he was threatened by the Director. In spite of numerous attempts to contain these events within the institution, eventually through the efforts of Drs. Christensen, Dick, Simpson and myself, extensive investigations have taken place. When we disclosed and reviewed our findings to The OIG of the VA we were told by Dr. Alastair Connell, the Assistant Inspector General for Healthcare Inspections, that we were now all protected under the Whistle blower protection act. I remember that very vividly because I was offended both by the name "whistle blower," and that as the Deputy Medical Examiner, I was only doing my job. It is interesting that in an affidavit Dr. Connell denies that he made that statement. The OIG reluctantly carried out a delayed investigation, produced a flawed, dishonest report, and was rightfully criticized by the GAO report. This report in May of 1998 stated the OIG report was misleading. The GAO noted that the OIG report presented conclusions not based on evidence, never actually investigated the cover-up and misrepresented facts. Although the GAO investigators did not believe that a "cover up" had occurred within the OIG, those of us from rural Missouri would have felt that the work "Misleading" should have been replaced by "Lying, and cover-up". Apparently, we will never understand the wordsmithing of the Washington beltway. In August of 1998, I testified in a civil suit brought against the United States of America by the Plaintiff, Helen Havrum, who was the wife of one of the 4E patients who died. All other suits had been successfully repulsed by the VA legal team and Justice department. After hearing the evidence the United States District Judge Nanette Laughrey ruled that the preponderance of evidence was so great, that she faulted the VA for failing to protect Mr. Havrum, when they knew or should have known of this danger, and that in her opinion the witnesses for the plaintiff were credible, but the witnesses for the FBI were not credible and self-serving and the she stated clearly, "Mrs. Harvrum, I believe that Nurse Williams killed your husband with an injection of codeine one hour before his death." She awarded the plaintiff $450,000. This decision is presently being appealed. Again in words that we understand in rural Missouri, I would paraphrase her by saying "A massive cover-up occurred within the entire VA health care organization, and that the evidence put forth by the best experts of the FBI were not believable." It was during my testimony that I gave evidence that the VA organization was well aware of the possibility of 40 deaths, that Jessie Brown, himself or his office had determined that this nurse would never again work in a VA hospital suggesting to me that they knew that they had a serial killer, but not only would not take responsibility but would allow this nurse to have the opportunity to hurt or kill other patients. HANDBOOK OF REPRISALS In a letter dated September 8, 1998, Mr. Everett wrote a letter to Mr. West, Secretary of Veterans' Affairs asking for concrete actions and responses to questions regarding VA employees: Gorgon Christensen, M.D.,Earl Dick, M.D., Edward Adelstein, D.V.M.,M.D. and W. Andrew Simpson, PhD. In this letter asking for specific information regarding VA's whistle blower protection and policies regarding the above, he states "On a number of occasions I have stated my belief that the VA suffers from a culture of tolerating favoritism, cronyism, harassment and reprisal..... Reprisal can be as subtle as it is ugly. To the best of my knowledge no written report has addressed this pivotal letter. I would propose to document the following acts of reprisal as they pertain to the above VA employees. They are as follows: Campaigns of disinformation The two most flagrant examples include: 1. The assistant to the Chief of Staff, telling everyone that Dr. Dick was "mean" and "incompetent". Dr. Dick was not given the option of replacing this individual with one who would support him. 2. The administrative staff systematically informed the majority of VA employees that our action to expose the VA for failure to protect patients would result in closing of this hospital and that we, the whistle blowers, would be responsible for losing their jobs. This form of reprisal still continues. Threats to job security There are many examples of this. In general due process as clearly outlined by regulations are not followed. Examples include the following: 1. Mr. Kurzejeski collaborated with the Dean of the School of Medicine to pressure Dr. Dick from his job, because he supported the disclosure of the 4E deaths. This pressure became so intense that the health of Dr. Dick was compromised and he yielded to the daily cruel harassment produced on both sides of the street. He agreed to step down and his medical career was effectively destroyed. He was replaced by Dr. John Bauer, the private pick of the Dean, as 50% of the search committee found this appointment unacceptable. He continued to harass Dr. Dick in an effort to drive him from the VA hospital. 2. Dr. Bauer took multiple actions against Dr. Christensen, both professionally and personally and while not directly involved in the 4E deaths took action to prevent Dr. Christensen to report this nurse to the Missouri Board of Nursing. 3. He, I was informed, attempted to get the Dean to have me fired. 4. Dr. Simpson, after suspiciously losing his grant support from highly regarded research activities, lost his VA position as an associate career scientist and the University took multiple punitive actions against him as he was a tenured employee at the University of Missouri. 5. When I was preparing affidavits to support Dr. Dick, I was interviewed by a VA lawyer, Mr. Burke. He called me at home the next morning at 6:45 a.m. to inform me that he needed me to sign an affidavit of our conversation. When I explained that I had already written an affidavit and would not sign his, he informed me that he would have the Director order me to sign and failure to do so would threaten my job. I challenged this logic and never heard from him again. I did however consider it intimidation. Recruitment of professionals to take action against whistle blowers. In this environment of reprisals, there are always individuals who see this as an opportunity to advance their careers. This is encouraged by the administrative staff and there are many examples where this occurs. 1. Dr. Christensen was not allowed by Dr. Bauer to bring in an administrative assistant that he could work with, but instead was ordered to hire an individual loyal to Dr. Bauer, who would serve to report back any events which could be used against Dr. Christensen. This resulted in an investigation from the outside which did not follow due process and had clearly an agenda to destroy the career of Dr. Christensen. 2. Individuals from the research service reported to the director the theft of a narcotic attributed to me. These charges were unfounded. This was done, I believe, to curry favor with University and VA administrative officials. Evaluations This is the most traditional method to punish whistle blowers and in general was applied to all of us. These steps were seen as prerequisites to dismissal. In some instances they were enormously cruel and ignored due process. They are too numerous to document. SPECIFIC ACTS OF REPRISAL TAKEN AGAINST ME FOR MY TESTIMONY REGARDING THE SUSPICIOUS DEATHS ON 4E On October 6, 1997 I gave truthful deposition in the Helen Havrum, v. United States. My deposition was 143 pages in length. Until I testified in the trial of Elzie Havrum, both as a pathologist and as a Deputy Medical examiner, I could view the reprisal phenomena with some degree of detachment. Certainly, my evaluations had gone down, I had been removed from those committees where honesty and integrity would be considered a liability. My research grant was turned down, and simple protocols were being challenged by the research animal committee, but in truth those might have been innocent events, but unusual. I received a letter from our current Director, Mr. Gary Campbell on June 17, 1998 stating "I am specifically concerned about your interaction with a representative of the news media without first coordinating the interview with the facility Public Affairs Officer. I am also concerned that you apparently did not confine your remarks to subjects and activities under your immediate control or supervision." It goes on to say,"I recognize that you have a somewhat different status in relation to the 1992 events...that is a unique situation and does not allow you license to comment on other subjects of which you are not responsible." I responded that "isn't is paradoxical that we take care of those people who risked their lives to save America for the very principles of freedom of speech." I viewed that letter as a warning. In general, since I became a whistle blower regarding the 4E deaths I am not privileged to speak to the press from my office in the VA or from the facilities of the University of Missouri. However, I was encouraged that someone is reviewing the draconian rules and regulations put forth by the new VA as the VHA directive 98-052 now clearly states that physicians can, when requested, express opinions and complete forms for VA patients with respect to patients' health, employability, degree of disability and requirement for licensing. A small victory for freedom of speech. In August of 1998, I gave extensive testimony in civil suite against the government which led to the ruling that the VA hospital had failed to protect its patients and that Mr. Havrum had been murdered. The lawyers for the VA and the Justice Department were very angry and refused to speak to me after the verdict. Further they asked for a rapid transcription of my testimony. Shortly after the Judge ruled against the VA and the FBI, Mr. Wu and an associate from the Subcommittee on Oversight and Investigations met with the local director, Mr. Gary Campbell to counsel him regarding this recent decision and to suggest that he form a task group to prevent this from occurring again. In spite of this meeting, no task force has yet been formed. I learned that at this meeting Mr. Campbell suggested that I had a "drug problem." I had no written documents of this charge, but believed that this was related to asking for and getting permission to borrow from the dog laboratory some Sleep-a-way, a class II controlled substance used to euthanize animals in 1996. I perceived that as a kind of poorly defined threat. On August 31, 1998, I was at home on a documented leave, when I received a phone call requesting me to appear at an Investigatory Board session on September 2, 1998, at 11:00 a.m. I was not told by phone the nature of the investigation, I was not told whether I was a witness or the subject of the investigation. I was not told whether I had the right to counsel. I was not told whether I had the right to present evidence. I did not receive a written notice that any Investigatory Board had been convened. When I came to work on the next day, I was shown documents indicating that I was being investigated for the "alleged theft of a controlled substance". I initially chose not to take these allegations seriously as they stemmed from an innocent humanitarian act carried out in 1996 which had been well reviewed and I had not received any admonishments or reprimands. This was based on me asking for and getting permission to use 10 ccs of a drug to euthanize an aged dog, suffering with seizures and cancer without charge to a faculty member after working hours. Since I am a licensed Veterinarian and maintain my own supply at home, it was a simple act of kindness to save me 40 minutes of driving time to perform a kindly act after working hours. In no case had I misrepresented these events. Dr. Hoyt, the Chief of Radiology, had been interviewed before I was to meet with the committee, and without informing me specifically of their questions, informed me that "This was the greatest threat to my professional career that I would have to deal with." He further informed me that he was approached by one of the board members who told him that he needed to be aware that political agendas at multiple levels were being played out around this investigation. I have secured a notarized statement attesting to this information. Based on that information I secured an attorney to represent and advise me in dealing with this board of investigation. He advised to quickly obtain affidavits from the animal Lab manager, who willingly gave me the drug, and the faculty member whose dog I euthanized. He also gave me good advice in saying "Don't be angry with this investigative team, they are just doing their job. While they have no qualms in destroying your career, it's just business." This board was unusual in that it was generated, not at the local level, as is the rule, but directly by our VISN director Mrs. Crosetti and Mr. Campbell. During my testimony, it became clear that this board was not looking fairly for the facts pertaining to their charges, and I provided them with the critical affidavits indicating that I had never stolen anything, that control of these drugs were different from the general class I narcotics used on humans. Further the Investigatory Board was unable to state the legal basis for the allegation of "theft" of define any standard by which I could be judged. They did suggest that my lawyer might look at "21 U.S.C. - 843(c) which prohibits "place(ment) in any newspaper, magazine, handbill, or other publications any written advertisement, and is obviously not the legal basis for the allegation of theft of a substance that is not a Schedule I substance. The Board determined to take no disciplinary action against me except for a verbal counselling, which I have contested. In an example of convoluted vengeful thinking, they did take action against Dr. Christensen for not taking specific steps against me, even through he had carried out a complete investigation and did not have the authority to deal with this issue. The timing of this investigation, plus the admitting of the political motive by one of the investigators, coupled with the fact that this had already been investigated and there was no evidence ever presented to suggest "theft" leads me to believe that this is witness reprisal. Even when these charges were determined to be false, they must be addressed and documented each time I reapply for my medical license. Further, this reckless and callous attempt at witness reprisal for my testimony in the Harvrum trial could perhaps act as a deterrent against me for further testimony involving other patient complaints against the VA regarding wrongful deaths. Since I testified both as a VA pathologist and the Deputy Medical Examiner of Boone County, I see this as a significant violation of an appointed official with well defined legal responsibilities. I have sent by mail this complaint to the Federal Judge, Nanette Laughrey, the U.S. Office of Special Counsel and to Mr. Everett, Chairman of the House Subcommittee on Oversight and Investigations. SOLUTIONS There is no pleasure in the documentation of wrong doing. Certainly the VA at the highest level must realize that they are sitting on a ticking time bomb, where if not defused by honest actions, it will be revealed that the largest health care system to be fatally flawed and undeserving of the trust of patients. If, as in this case, where there is extensive documentation as to patient deaths, local cover up and obstruction of justice, cover-up and documented lying by high officials and if no action is taken, we must assume that the laws of the land are selectively enforced and our legal structure is without meaning. If these people are allowed to go unpunished, rich in retirement benefits and bonus awards and the truth tellers (Whistle blowers) punished, this will stand as a critical example which will discourage truth and reward deception. This behavior needs to be rapidly reversed. It is no wonder that the people of the United States of America so distrust our government. I ask you in the name of justice to pursue all aspects of these events. I believe that a grand jury should be convened, individuals deposed, the truth revealed and punishments levied. There will never be a stronger case with this degree of documentation that will send a signal to the VA, the FBI, and the OIG that it is not business as usual. This is an opportunity to redefine government and justice. I can only hope that you and the committee have the strength and will to pursue these actions. Respectfully submitted, Edward H. Adelstein, D.V.M., M.D. Pathologist, Harry S Truman Veterans Hospital Columbia, Missouri Back to News of the Hearing on |