By Chuck Strouse
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By Terrence McCoy
By Ryan Yousefi
By Ciara LaVelle, Kat Bein, Carolina Del Busto, and Liz Tracy
By Pepe Billete
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By Kyle Swenson
Info:Correction Date: 12/17/1998
The Doctor is Out
Beset by internecine battles, troubled leadership, and funding cuts, the local office of the Florida Department of Health is in need of intensive care.
By Ted B. Kissell
Dr. Kunjana Mavunda sits, arms folded, behind her desk in the small, gray office of her private practice on Ponce de Leon Boulevard. In her lilting accent -- she is Indian by descent, Kenyan by birth -- the bespectacled 41-year-old respiratory physician mentions that she attended medical school in Poland.
Like most Kenyans, Mavunda grew up speaking both English and Kiswahili, in addition to her parents' Indian dialect. Her medical school courses were in Polish, a language she didn't speak before enrolling. She learned it well enough to earn her M.D. in 1980.
Mavunda moved to Dade County in the early Eighties, earning a master's degree in public health from the University of Miami and learning Spanish in the process. After nine years on the UM faculty teaching pediatrics and pediatric pulmonary medicine, she started a private practice in 1996. In October of that year, one of her former professors at UM, Dr. Eleni Sfakianaki, recruited her to join the Miami-Dade County office of the Florida Department of Health (DOH).
Mavunda signed on with the state agency at a crucial point in its history. Previously it had existed as a part of Florida's Department of Health and Rehabilitative Services (HRS). In 1996 the DOH became a stand-alone department and continued a shift in emphasis away from the traditional mandate of primary medical care for the poor. Locally those services were assumed by the Public Health Trust, the Miami-Dade County agency that operates Jackson Memorial Hospital, among other health care facilities and services.
Employing 970 people, the Miami-Dade branch of the DOH still offers clinical services at ten local outlets. Among these services are treatment for tuberculosis (TB) and sexually transmitted diseases (STDs), screening for HIV, family planning, a Healthy Start program for newborns, and immunizations. Recently, though, the DOH has concentrated on monitoring disease trends and preventing outbreaks that could become epidemics.
As director of epidemiology and disease control, Mavunda figured to play a vital role in the DOH's redefined mission. Her enthusiasm, however, quickly turned to disillusionment. The DOH, she found, was an agency beset by political infighting, ineptitude, and poor leadership. "There are a lot of diseases within the county that the department is not addressing," she says now. "People are getting sicker, and the environment is getting worse."
Mavunda did not keep her concerns to herself. In December 1997, she sent a terse memorandum to Dr. Sfakianaki, the department's medical executive director and Mavunda's immediate superior. "I do not have the staff to investigate" reported cases of hepatitis C, Mavunda wrote. "We do not have the time or the resources to adequately follow up chronic hepatitis B cases. This can be an explosive situation." Mavunda added that despite what she described as an efficient departmental staff, her short-handed team could not keep track of food-borne-illness complaints, and that her reporting of cases to Tallahassee was being delayed.
In fact the home office in Tallahassee noted that for 1997 the Miami-Dade DOH office accounted for 61 percent of the missing case-report forms statewide. "The reason for this negative report is that my staff is busy investigating and acting on acute problems," Mavunda noted, "and unfortunately that takes priority over paperwork."
Personnel moves, Mavunda says, also seemed ill-conceived, even capricious. Her suggestions for the epidemiology unit, which include replacing high-salaried administrators with lower-paid but more essential outreach and clerical workers, were ignored, she recounts.
As a single mother with two children and her parents living in her home, Mavunda continued to run her private practice one day per week even after taking the DOH job. Her father, who had helped her manage the practice, died in June 1997; Mavunda says she originally planned to close the practice and devote her energies solely to the health department. Instead, this past March, less than two years after joining the DOH, she resigned in disgust. "I was not able to do the job I was hired to do," she charges.
Dr. Sfakianaki hired another highly regarded physician in 1997, Dr. Toye Brewer, to head the department's section dealing with HIV, TB, and STDs. The 42-year-old Brewer, like Mavunda, was charged with reforming her unit. As part of these efforts, Sfakianaki and Miami-Dade DOH's executive administrator Annie Neasman requested two reviews of the local STD program: one internal, the other conducted by an internationally recognized STD expert. Both found shoddy record-keeping and substandard clinical care.
Equally disturbing, the 1997 reviews attributed many of these problems to the department's half-dozen physicians who specialize in STD diagnosis and treatment. The reviews also noted that nearly all of these doctors, most of whom had worked at the DOH for years, were actively resisting the reforms proposed by Brewer and her superiors.
Neasman concedes that her agency has had its problems, but attributes these to decreasing funds. As for the low-quality service at Miami-Dade's five STD clinics, she says she and her staff are doing everything they can to improve the situation.