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But these pledges did little to mollify Brewer. In June of this year, she, like Mavunda, bolted from the troubled department, taking a faculty job at the University of Miami.
The DOH's shift away from primary care reflects a nationwide trend a decade in the making. In the late Eighties and early Nineties, private health maintenance organizations (HMOs) began to accept Medicaid patients en masse, leaving to public health departments a diminished client population, mostly uninsured and nonpaying. For this reason Miami-Dade's branch of the DOH has been downsizing for several years and turning over its primary-care clinics to the county's Public Health Trust.
As the number of insured patients has dwindled, so has funding from the state legislature. In response, Neasman says, she has concentrated her resources ($44 million for 1998-99) on the "core functions" of public health, the services that private doctors are unlikely to assume, including STD treatment among the poor and indigent.
And so Eleni Sfakianaki created a new position -- director of STD, HIV, and TB services -- to ensure that the department was delivering the best possible care. (HIV and AIDS are generally considered distinct from other sexually transmitted diseases, by the DOH and the medical community in general.) Her choice for the job was Toye Brewer, an expert in infectious diseases. Today Sfakianaki describes Mavunda and Brewer as "my star recruitments."
Part of the process of improving STD care involved the two evaluations requested by Sfakianaki and Neasman, one of which was conducted by a team of reviewers from Tallahassee. When the six reviewers (doctors, nurses, and administrators) came down in June of last year to scrutinize every aspect of the Miami-Dade STD treatment program, Toye Brewer had just begun her job.
The review group released its fifteen-page report one month later. In her assessment of Miami's five STD clinic operations, nurse and senior DOH staffer Karla Schmitt noted that "clinicians" (meaning the doctor or nurse who conducts examinations) were routinely providing substandard care.
"For whatever reason, they weren't following the state guidelines in treating people," Schmitt says today. Among the deficiencies she noted: Clinicians were still treating gonorrhea alone, without simultaneously treating chlamydia, when "federal and state guidelines recommend presumptive treatment for both infections in the presence of gonorrhea"; treatment of a woman for any STD was sometimes delayed until her next menstrual period, a delay which, if an infection were present, could lead to complications, even sterility; and many clinicians were reluctant to dispense (or were unaware of) proper medications. Even routine procedures such as Pap smears, which test for abnormal or cancerous cells on the cervix, were being inadequately performed.
Not only were clinic staffers providing poor service, but they weren't keeping track of the services they did provide. The existing system of records, an abbreviated computer printout, "does not allow the provider to fully document findings," Schmitt wrote.
Given the suspect record-keeping, Schmitt now questions the low number of STD cases reported by the Miami-Dade DOH. "Miami-Dade County has 40 percent of the state's population, and it doesn't deliver 40 percent of the STD cases," she says. "There's no reason it shouldn't. It has a young, poor, sexually active population. It ought to have more cases than it does." Last year Miami-Dade (population just over two million) reported an average of 25 STD clinic visits per day, the same as Orange County (population 800,000), and fewer than Duval (26 visits per day, population 742,000).
Schmitt's section of the report specifically criticized the performance of six STD clinicians, five of whom were doctors. That number itself seemed wrong to Schmitt. No other urban county in Florida employed more than two clinicians at its largest STD clinic, and most employed no full-time physicians, relying instead on nurse practitioners. The "nurse-practitioner model," Schmitt says today, is the nationwide standard for STD care, both for financial reasons (Miami-Dade's DOH doctors earn between $65,000 and $75,000 annually; nurse practitioners earn between $50,000 and $55,000), and because many in public health believe that nurses, trained to be more empathic and less judgmental than doctors, are better suited for STD treatment.
Schmitt also pointed out that the doctors appeared to be underworked. In April 1997, for instance, the five clinicians at the main DOH clinic on NW Fourteenth Street (four of whom were doctors) averaged 8.6 physical exams per day, "one-third the state standard," Schmitt wrote.
In sum, the picture Schmitt painted was of high-priced doctors standing idle, performing incompetently, and filing inadequate records; "out-of-date, both in guidance and documentation," Schmitt observes today.
A former department employee who asked not to be identified concurs, especially with regard to the doctors' competence. "They do not want to treat herpes and genital warts because they [the doctors] are from the Eighties and they haven't read anything since then," the source asserts. "They know gonorrhea and syphilis and they don't want to be bothered with anything new."
The report, Schmitt notes today, took into account the funding reductions that have beset Miami-Dade's DOH office. "They do not get all the money they would need to serve the population, but that doesn't mean they're managing the money they have well," she says. "The foundation of a good STD program is efficient clinics with quality care, active outreach, and good relationships with private doctors. None of that is happening yet in Miami-Dade."