“At the very least, the [Philadelphia Health] department’s overall mission – to protect public health in Philadelphia – ought to have prompted more responsiveness and sharing of information about the reckless doctor in West Philadelphia”
Editor’s note. Abortionist Kermit Gosnell stands charged of eight counts of murder. In this section, “How Did This Go On So Long?,” of its 261-page the Grand Jury denounces the “bureaucratic deficiencies and neglect that, for decades, allowed someone like Gosnell to wantonly break laws, harm and endanger women, and kill viable babies in the secure knowledge that no official overseer would intervene to stop him.”
Philadelphia’s Health Commissioner told the Grand Jury that he is taking steps to improve the department’s procedures.
Dr. [Donald] Schwarz, Philadelphia’s health commissioner since January 2008, testified twice before the Grand Jury. He expressed appropriate regret for his department’s inaction. And he personally took responsibility. We found refreshing his acknowledgement of fault, his candor, and his evident efforts, at least since being called before the Grand Jury, to find out how and why his agency failed to protect the West Philadelphia community from a notoriously dangerous doctor.
But while he accepted responsibility personally, Dr. Schwarz seemed to excuse department employees who ignored the serious – and obvious – threat to public health posed by Gosnell’s clinic, and he provided feeble excuses for their inaction. We saw no evidence that the city health department had initiated an internal assessment to determine how Gosnell fell through the cracks – either in November 2009, when the Medical Examiner performed an autopsy on Mrs. Mongar’s remains, or in February 2010, after publicity surrounding the raid made the horror at 3801 Lancaster Avenue known to all.
When Dr. Schwarz testified the first time before the Grand Jury, he should have known that many department employees were well aware of Gosnell’s operation. He should have known this because professionals within the department who had information about the dangerous conditions in Gosnell’s clinic should have told him. The health commissioner assured the Grand Jury that the department is now taking steps to address problems that prevented the department from responding as it should have. He identified structural problems – and a corresponding mentality among health department employees – that contributed to the city health department’s ineffectual handling of complaints about Gosnell. The department has several very different responsibilities. The tasks it oversees range from conducting autopsies to testing for sexually transmitted diseases to dog-catching. Each function is handled by a different division with different staff.
The department’s involvement with Gosnell’s clinic touched several divisions and sections. One unit, the Division of Disease Control’s STD Control Program, tested lab samples from Gosnell’s clinic, collected data for sexually transmitted diseases, and followed up to make sure infected patients were treated. Kareema Cross testified that employees from the city health department came to the clinic to pick up specimens and blood to check for STDs. The Grand Jury received no evidence that any of these employees informed others at the health department about what they saw during their visits to the clinic.
Another part of the Division of Disease Control has responsibility for the children’s vaccine program, [Lori] Matijkiw’s unit, which provides vaccines to clinics and conducts inspections. Investigating infectious waste complaints is the responsibility of the Environmental Engineering Section. The Medical Examiner, whose office is also part of the city health department, performed the autopsy on Karnamaya Mongar and examined fetal remains seized from the clinic’s freezer.
Thus, when Matijkiw, who worked in the vaccine program, discovered infectious waste in a freezer, that information was never conveyed to the environmental engineering people who could have done something about it. Dr. Schwarz recognized that, at the least, the department should have electronic records that can be shared among divisions. Employees in any unit would then be able to search for all of the department’s records on a particular provider and see the reports of other divisions.
The city health commissioner also identified a more troubling problem. Although he phrased it more diplomatically, what he was describing was an “it’s-not-in-my-job description” mindset displayed by many department employees. When asked why Matijkiw’s superiors had not reported Gosnell to the Pennsylvania Department of State for action against his license, Dr. Schwarz tried to explain:
I would say that I think what happens is people have a narrowly defined job and I don’t think there has been an expectation that people would report to the state as professionals. So I think that is wrong and we are going to figure out a way to change that.
The same narrow view of their job responsibilities was displayed when Matijkiw’s superiors failed to share her report with other divisions within the city health department that could have acted.
Some of Dr. Schwarz’s explanations for health department employees’ lapses were not entirely convincing. For example, he testified that the Director of Disease Control, Dr. Caroline Johnson, told him that one reason “Jim” did not report Gosnell to the Department of State in December 2009, was that “the program people apparently knew something was happening at the site and they didn’t call the state.” It is highly unlikely, however, that anyone at the city health department knew that something was “happening” to Gosnell in December 2009. Mrs. Mongar’s death had triggered no investigation by the state Department of Health. And there is no evidence that the Department of State was doing anything either.
Dr. Schwarz also told the Grand Jury that the city health department is limited in what it can do in response to complaints about medical providers. He gave examples of the kinds of complaints the department can do something about:
I could send somebody out if they have rats. I could send omebody out if someone got diarrheal disease. I could send somebody out if there was an animal, but I can’t send someone out if a person’s injured.
We understand that the city health department did not have the authority to investigate all of the things that were wrong in Gosnell’s clinic. If a patient called up to complain that they were treated badly at Women’s Medical Society, or that Gosnell was violating the Abortion Control Act in some way, the health department would not have jurisdiction. But it could certainly submit complaints to the Pennsylvania Department of State and demand that they be investigated. Furthermore, some issues were directly within the department’s purview – such as the infectious waste problems and the circumstances of Mrs. Mongar’s death.
The latter gave the Medical Examiner’s office authority to inspect the facility and to ask questions in order to investigate the manner of death. At the very least, the department’s overall mission – to protect public health in Philadelphia – ought to have prompted more responsiveness and sharing of information about the reckless doctor in West Philadelphia. Regarding the responsibilities of his department, the city health commissioner displayed a very different attitude from that of the state officials who testified. He did not, for the most part, try to evade accountability – or work – by claiming that his agency lacked authority to do certain things. In fact, he suggested ways to fill gaps in responsibility that Gosnell fell through. He expressed an interest in increasing accountability, responsiveness, and communication among the various local and state agencies.
ven though the city lacks the authority to regulate doctors or abortion clinics, Dr.Schwarz recognized that the Department of Public Health should have a system in place, which it now does not have, to handle calls made by Philadelphia residents to complain about Philadelphia medical providers. When asked if the health department had ever received calls about Gosnell, the commissioner frankly acknowledged: “if someone called, I’m embarrassed to say, I don’t know what would happen.” Dr. Schwarz testified that he sees a role for the city health department in cataloging complaints and helping patients of Philadelphia doctors refer complaints to the proper authorities. Complaints about individual doctors would be forwarded to the Department of State, which licenses doctors and is responsible for investigating complaints and imposing sanctions. Complaints about health care facilities, such as Gosnell’s clinic, would be forwarded to the state Department of Health, which has the authority and duty to license, inspec
t, and sanction them. The health commissioner told the Grand Jury that his department is already considering ways to help callers register their complaints with the proper authority. The process, he said, should include a response to the individual who filed the complaint, letting them know that it was received and what is being done about it.
Dr. Schwarz suggested the health department might fill another gap by conducting routine sanitation and safety inspections of doctors’ offices and clinics. Neither the state nor the city currently inspects them. The city health department does inspect some institutions, such as day care centers, prisons, and schools. It inspects the food services at hospitals, though not the hospitals themselves. Dr. Schwarz acknowledged that the city health department probably could step into that role, although not without hiring more inspectors.
The Grand Jurors hope the health commissioner follows through on his suggestions. We also wish state officials showed as much eagerness to address the bureaucratic deficiencies and neglect that, for decades, allowed someone like Gosnell to wantonly break laws, harm and endanger women, and kill viable babies in the secure knowledge that no official overseer would intervene to stop him.
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