BEFORE THE UNITED STATES CONGRESS

HOUSE SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

OF THE

HOUSE COMMITTEE ON VETERANS' AFFAIRS

and expose dangerous practices or criminal activities. I know this because the VA has

conducted a campaign of personal destruction against me for the past six years. The

VA has conducted this campaign because I chose to do the right thing when

confronted with the apparent murder of 40 Veterans by a VA nurse at the Harry S.

Truman Memorial Veterans Hospital in Columbia Missouri during the summer of 1992.

I earned the ire of the VA for a number of reasons. First, at the request of the Acting

Chief of Staff, Dr. Adelstein, and the Chief of Staff, Dr. Dick, and with the assistance of

my colleague, Dr. Simpson, I led an internal scientific investigation that confirmed

earlier suspicions that a particular nurse, Mr. Richard Williams, caused these deaths.

Next, I pushed the Hospital Director, Mr. Kurzejeski, to promptly inform the police that

we suspected murder. Mr. Kurzejeski refused to do this. Instead Mr. Kurzejeski

blocked the investigation and threatened to take action against me. With the

help of Dr. Dick, I pressed for higher VA officials to intercede. But, Dr.

Spencer Falcon, the Regional Chief of Staff, and Mr. Albert Zamberlan, the

Regional Director, refused to act. Instead, these officials circulated

documents throughout the system denying the deaths and claiming my

investigation was "flawed." Dr. Adelstein, Dr. Dick, and I then met with Dr.

Alastair Connell, the Assistant Inspector General for Healthcare Inspections

and complained that VA officials had blocked the investigation, but Dr.

Connell did not resolve the problem. In February 1993, I wrote Stephen

Trodden, the Inspector General, a detailed letter specifying my charges of

obstruction, but Mr. Trodden also refused to investigate. After Mr. Williams

left the VA to work at a nursing home, I pressed Mr. Kurzejeski to inform

the Missouri State Board of Nursing of the results of the internal

investigation implicating Mr. Williams in these deaths. Such notification

was in accordance with state law and VA policy. Mr. Kurzejeski refused to do

this. Instead, Mr. Kurzejeski - and later the new Chief of Staff, Dr. Bauer

- threatened to take action against me if I continued to press this matter.

After exhausting all internal avenues of appeal, in January 1995 I publicly

aired my concerns of "murder," "obstruction," and "cover-up." The VA,

however, denied these accusations. I had to "blow-the-whistle" before Mr.

Trodden would begin an investigation. Six months later, Mr. Trodden and his

subordinate, Mr. Kroll (the Assistant Inspector General for Departmental

Reviews and Management Support) released a 66-page report that rejected my

claims of "cover-up" and "obstruction."

On October 25th 1995 the Subcommittee on Hospitals and Healthcare conducted

a Hearing to receive Mr. Trodden's report. I testified at that Hearing. I

testified that the report was "wrong and dangerous." Wrong because it was

"an incomplete, dishonest, biased, flawed, and distorted" presentation of

the events in Columbia. Dangerous because accepting the report promoted "the

cover-up" of these kinds of incidents and endorsed "the VA policy of

intimidation of whistleblowers."

This Subcommittee commissioned the United States General Accounting Office

to review the investigation conducted by the Office of the Inspector General

(OIG). On May 13th 1998 the GAO replied that the OIG report was indeed

"misleading." Amongst other things, the GAO noted that the OIG presented

conclusions not based on evidence, did not conduct an investigation into a

cover-up, and misrepresented the facts.

Finally, on August 7th 1998 United States District Judge Nanette Laughrey

ruled on a wrongful death suit filed by the widow of one of the Veterans who

died on ward 4 East, Mr. Elzie Havrum. By a preponderance of evidence, Judge

Laughrey declared that "Nurse Williams killed Elzie Havrum."

My purpose in bringing up these matters is to remind you that unlike the

Veterans Health Administration under the leadership of Dr. Kizer and unlike

the Office of the Inspector General under the former leadership of Mr.

Stephen Trodden, I speak the truth. Now let me tell you how the VA treats a

truth-teller.

Immediately following the 1995 Hearing, Dr. Kizer invited me to Washington

for a discussion on how to prevent these incidents in the future. At the

conclusion of our discussion, Dr. Kizer surprised me by offering me the

position of "Medical Inspector." Dr. Kizer's offer flattered me. I would

like to have had the opportunity to fix these problems from within. But

after visiting Washington and discussing the position with personnel at VA

Headquarters, I concluded that Dr. Kizer's offer was dishonest. As far as I

could tell, Dr. Kizer did not support the Medical Inspector's Office and

would not hold senior management responsible for their misdeeds, so I

declined the position.

When I returned to Columbia, I confronted an increasing office crisis. Under

my administration, the Research Service at the Harry S. Truman Memorial

Veterans' Hospital had always been a calm and productive unit. This changed

when I blew the whistle in 1995. For the first time I faced controversy and

angry criticism, prompted - I believe - by my VA superior Dr. Bauer in

retaliation for my whistle blowing. I know that Dr. Bauer interfered with my

administration of the facility. For example he blocked the selection of an

administrative officer for the facility, leaving that position open for ten

months. I also know that he met with other Research Service personnel and

encouraged them to agitate. I complained about this at the 1995 Hearing and

the Chair, Congressman Tim Hutchinson, promised to protect me. Facing more

problems, I appealed to the Chairman for help. My appeal backfired. Instead,

Dr. Bauer leveled a variety of charges against me, such as poor

administration of research funds, mismanagement of the equipment inventory,

and unprofessional and disruptive behavior. On August 19th 1996 he asked the

Hospital Director, Mr. Campbell, to relieve me of my duties. Instead Mr.

Campbell, asked Dr. Feussner, the Chief Research and Development Officer for

the VA, to appoint a national panel to review my performance.

Dr. Bauer then confronted me with his charges. Even though I knew the

charges were bogus, I believed it would be pointless to try to fight the VA,

so I asked if we could negotiate my resignation. Dr. Bauer refused. Over the

next two months my attorney repeated this offer to Mr. Campbell and to Dr.

Kizer, but they also refused. For this reason, I am convinced the VA

intended not to just eliminate an inconvenient employee, but to destroy my

professional reputation. It seems to me the VA intended to destroy the

credibility of my accusations by destroying my professional credibility.

On November 6th & 7th, 1996 a national VA Panel reviewed my performance.

They did not follow due process. I was not allowed advice of counsel. There

was no record of the proceedings. I was not allowed to hear and rebut the

testimony against me. I was able, however, through a "Freedom of Information

Act" request, to obtain a copy of some of the documents leading up to this

review. Before the review, I prepared and submitted a detailed rebuttal to

these documents. In the exit interview, the Panel appeared mollified by my

rebuttal and agreed that the evidence did not support the charges. I thought

that ended the matter, but eight months later on June 23rd 1997, Mr.

Campbell presented me an unsigned, undated copy of the Panel report, which

ruled against me and recommended my removal. The next day, Dr. Bauer

provided me my 1996 annual performance appraisal, eight months overdue, in

which he rated me "unsatisfactory," setting the stage for my forced removal.

With the help of legal counsel and, I suspect, members of Congress, Mr.

Campbell stopped Dr. Bauer's action. Subsequently, Dr. Bauer left the VA and

returned to the University of Missouri where he now supervises me as the

Interim Chairman of the Department of Internal Medicine.

With the departure of Dr. Bauer, I have calmed Research Service and

reestablished our tradition of quiet efficient service. Throughout the

ordeal I have kept our expenditures under budget while maintaining full

administrative services. In 1997 & 1998 we were one of the few Research

Services in the VA system to demonstrate an increase in research funding. In

1998, we set aside $70,000 from operating funds for the recruitment of a new

physician investigator to the hospital.

The hospital, however, does not credit me with these successes. Instead I

continue to work in a hostile environment. The hospital forced me to give up

my position as Chief of Infectious Diseases. Hospital senior management and

Dr. Bryant, the Dean of the Medical School, avoid contact with me and ignore

my communications. For example they asked me to compile a strategic plan,

which I did with considerable effort, then they completely ignored the plan.

Senior management and Dr. Bryant have also excluded me from committee

appointments, such as the VISN Research Task Force and the VA

Hospital-University "Partnership Affiliation Council," which would normally

be a matter of course for my position. I am also excluded from all planning

and management functions, such as the Hospital's recent actions to obtain

funding to expand research space. This management exclusion curtails my

influence and signals to all coworkers and colleagues senior management's

displeasure. In case any one has missed the message, both senior management

and Dr. Bryant, have publicly complained on numerous occasions that the bad

publicity - caused by my actions - could close the Hospital, hurt the

University, and cause people to lose their jobs.

This past August, in the weeks surrounding the Havrum trial, the reprisals

escalated to a new level of activity. On July 10th - while on vacation in

Canada - I found a message pinned to my tent to call the office. Believing

that a member of my family had died, I returned the call and learned that

without explanation or warning Mr. Campbell had vetoed my appointment to the

VA Disciplinary Appeals Board. This meant that Mr. Campbell had also

cancelled the training I was scheduled to receive the following week in

Denver.

After my return to Columbia, I learned that Dr. Adelstein would be facing a

Board of Investigation over an incident that had taken place in December

1995. I was peripherally involved because I had filed a report on the incident with Dr.

Bauer a year earlier in August 1997. Apparently Dr. Adelstein asked a Research

Service employee for some "Sleepaway" to put to sleep his neighbor's dog. The

animal was suffering from cancer and Dr. Adelstein did not have the drug on hand.

Dr. Adelstein is also a veterinarian and he sometimes provides small

services like this when circumstances demand it. Sleepaway is a long acting

barbiturate, which is used exclusively for killing animals, which is why we

had some in the research animal facility. The employee gave the drug to Dr.

Adelstein and Dr. Adelstein failed to replace the amount of drug he had

used. The next hospital drug audit detected the discrepancy, prompting an

investigation. The drug auditor apparently resolved the issue, because

nothing more happened. My assistant informed me of the event because it

occurred in Research Service. I didn't see any reason to take any further

action since Research Service was not responsible for the inventory of this

drug, Research Service was not involved in the drug audit process, and the

drug auditors seemed satisfied the problem had been resolved. Nevertheless,

the following August, in connection with another incident, a research

employee complained. So I compiled a complete report on both incidents and

filed it with Dr. Bauer. I heard nothing more about the matter until the

following July, just before the Havrum trial.

The Havrum trial was held between July 27th and August 8th (As an aside,

during the trial, a nurse provided sworn testimony that the hospital used

Boards of Investigation to attack employees rather than for legitimate fact

finding.)

By direction of senior management, without my knowledge and before the Board

of Investigation had been convened, on August 20th the hospital reported to

the Drug Enforcement Agency the incident involving Sleepaway and Dr.

Adelstein. In filing the report, the hospital claimed this incident had just

come to their attention. Naming me by name, the hospital said I had failed

to report this incident to them. This was a lie. The hospital's drug auditor

had picked up this incident in January 1996. If it required reporting, the

auditors should have reported it then. I personally had reported the

incident to Dr. Bauer, the Chief of Staff, in September 1997. If the report

required filing, it should have been reported then. The hospital knew about

this incident for at least 11 months before filing this report.

On July 22nd Mr. Campbell asked Mrs. Patricia Crossetti, the VISN Director,

to appoint a Board of Investigation for the Sleepaway incident. The Board

members received their appointment letters on August 27th and on September

1st 1998, Mr. Campbell signed a letter from Mrs. Crossetti expanding the

scope of the Board of Investigation to include my performance. On September

1st the VISN conducted a Board of Investigation. The Board asked me to

testify, but they did not warn me that I had been made a target of this

investigation. I did not have advice of counsel, I was not allowed to submit

evidence in my favor, and I was not prepared for the Board's accusatory

questioning.

In the end, the Board concluded that I should have informed my superiors of

this incident and recommended that I receive written and oral counseling,

which I later received. The Board did not criticize anyone else in this

matter besides Dr. Adelstein and me.

After this incident the VA took a different approach to attacking me,

reorganization. Our VISN has only three Associate Chiefs of Staff for

Research and Development positions: St. Louis, Kansas City, and Columbia. On

November 5th, our office received a proposal from Mrs. Crosetti's office

that research in the VISN be reorganized into East and West "orbits." This

reorganization would eliminate Columbia. The proposal, however, encountered

heavy criticism. My understanding is that we will be reorganized into East

and West orbits, but Research Service and the ACOS/R&D position in Columbia

will be left alone.

It is impossible to fight a six-year campaign with the Federal government

and maintain high level professional productivity as a scientist, physician,

educator, and administrator, but I have enjoyed success. I continue to

publish research articles and I have obtained a Merit Review research grant.

I regularly receive top scores for my teaching. My physician colleagues

selected me to be added to the list of "Best Doctors" and my University

colleagues elected me to the faculty senate.

This ordeal has taken a heavy personal toll. The monetary cost has been

ruinous. I have spent $43,000 in legal expenses plus another $8,000 in

miscellaneous expenses (mailing, photocopying, telephone calls, FAX

transmission, etc.). The thing that hurts the most is the impact this has

had on my family. My daughters have grown-up while their father has battled

the VA over murders and cover-up. The battle has embarrassed them and

intruded on their childhood. The battle has taken me from my wife and

daughters. It has also hurt my friends and coworkers. Some have become

targets simply because they were associated with me; others like Dr. Andrew

Simpson, seem to have become targets because they also helped me in fighting

this issue. For example, during this period of time Dr. Simpson unexpectedly

lost his VA research funding and had to transfer from the VA to the

University of Missouri. At the University he encountered more problems, such

as proposals to move him to a new location 200 miles away or cut back his

12-month appointment to a nine-month appointment. These proposals originated

in the office of the Dean of the School of Medicine. Perhaps they thought

that if they could force Andy to leave Columbia I would also leave.

I will not leave. I will finish this. I insist that the VA cease behaving

like a public monarchy populated by little emperors and queens. I insist the

VA start conducting its business like a public service, according to public

law, staffed by public servants who "put loyalty to the highest moral

principles and to country above loyalty to person, party, or government