"Lead, follow or get out of the way."
Lee Iacocca said it and Dr. Hugh Stallworth quoted it in an article written before he took command of the St. Louis Department of Health in the fall of 2002. For the rudderless department, the new health director seemed to be just what the doctor ordered -- a highly regarded professional who promised to bring a bold new vision to a languishing agency, an African-American who might even help to bridge St. Louis' racial divide.
Stallworth's arrival was preceded by rave reviews that impressed the search committee; he was a strong leader who could at last administer much-needed life support to a staff demoralized by years of mismanagement and financial chaos.
Stallworth practiced medicine for ten years and earned his public-health stripes during successful tenures in county health departments in California. He had valuable experience working with cash-strapped governments, having navigated Orange County's health department through bankruptcy.
Reporting to work in October 2002, the 58-year-old Stallworth inherited more than just a ninth-floor office in an old building where the elevators seldom worked. Before taking the job, Stallworth did some intelligence gathering and was keenly aware of the department's history of upheaval: six directors in ten years.
"What I came away with was the department was neglected. It was absolutely neglected -- fiscally, leadership-wise, politically," Stallworth recalls.
Other problems abounded. His second-in-command, health commissioner Melba Moore, had been beset by a string of scandals. Sexually transmitted diseases, HIV and childhood lead poisoning were off the charts. St. Louis ranked second in the nation for gonorrhea and third for chlamydia. The infant mortality rate was shameful, especially among African-American babies.
"What I found, whether it was talking to people from the medical schools, the undergraduate schools, the nursing schools, [was that] people did not know how bad the health indicators were in St. Louis," Stallworth says.
But where others saw setbacks, Stallworth found opportunities. The temperamental elevator was a chance for exercise, a nine-story climb he made two, three, sometimes four times a day. Immediately after his arrival, he set to work. He took an almost unheard-of step, suggesting partnerships with the St. Louis Board of Education. The two agencies, he envisioned, could work together to tackle the problems of violence, teen pregnancy and sexual diseases.
Stallworth included his department managers in preparing a long-term strategic plan. He stressed customer service. He reached out not only to the medical community but to all of St. Louis through speeches and panel discussions at public forums. After just a few months on the job, Stallworth was stunned when the mayor's office proposed slicing the health department's general fund by 11 percent. He enlisted the help of health department advisory-board members, encouraging them to write letters to key decision makers in the city. Let them know why the cuts would be disastrous, he implored them. Stallworth prevailed, but he would pay a price.
It was never smooth sailing for Hugh Stallworth, despite the ardent backing of the medical community and his board. Just a year after taking the job, it became painfully clear that he had fallen from grace and was no longer in charge of setting the city's public health agenda.
Stallworth's undoing came to a head on November 13, 2003, when Rita Kirkland, Mayor Francis Slay's take-charge executive director of operations, appeared for the first time before the health department's advisory board. At that stormy meeting, Kirkland suggested that the department take a new direction -- a direction with which Stallworth could not agree.
Almost from day one, the tension between Stallworth and the mayor's office had been building and now, with 2005 budget negotiations rolling around, the mayor's office -- and Rita Kirkland in particular -- went on the offensive. It was not a polite policy debate that transpired during that fateful November meeting.
A rail-thin woman who favors dark lipstick and red nail polish, Kirkland knows her way around City Hall, having spent twenty years working for the city in one capacity or another. In the summer of 2001, before Stallworth took over, Kirkland and Melba Moore had worked in tandem to bring a semblance of financial order to the reeling department.
These days, Kirkland is one of the mayor's chief arm-twisters, enforcing the mayor's plans and tolerating little dissent.
"It is no secret that the health department has been somewhat dysfunctional for the last 30 years, and we have been very lucky to have two good administrators in the last two years with Dr. Stallworth and Melba," Kirkland said at the meeting, according to a transcript of the session.
Kirkland wanted the advisory board to take a radical step: Eliminate four department clinics -- tuberculosis, sexually transmitted diseases, HIV and immunization -- and scrap the clinical part of the lab, which includes STD and TB testing. Kirkland proposed that ConnectCare, the region's so-called healthcare safety net for the poor and uninsured, could run the clinics. She went on to assure the advisory board that she and Moore had approached ConnectCare, and the healthcare group was in favor of the idea.
"We're not just talking about dumping services on ConnectCare, we are talking about working with them," Kirkland said.
"How much money will the city save by this?" asked Lee Liberman, the retired chairman of Laclede Gas Company and a health-advisory board member.
Kirkland estimated the savings at $4.6 million.
Before Liberman would agree to anything, he said, "I want to know first how our director feels." Then he added, "[The] city's main motivation -- and I am sympathetic to it -- is to get their budget down."
"No," Kirkland shot back. "The city's primary focus is to make sure we are streamlining our operations."
Sister Betty Brucker, the retired president of St. Mary's Hospital and a board member, expressed her reservations about making such a drastic change without involving the Regional Health Commission, which recently began a study on streamlining the city and county health departments. "Why couldn't there be some joint planning?"
"I have no problem with that," Kirkland said, "except that right now, we do have a deficit, we do have to get out of this building....We don't have the luxury of time right now."
Stallworth, meanwhile, disagreed with Kirkland's calculation of how much money would be saved by eliminating the clinics. He said that some of the clinics she wanted to cut were funded by outside grants -- not city money.
Liberman wondered whether the health department was the only place the city could find the cash to stop the hemorrhaging.
"No, this is not the only place and there is only one other place to get this kind of money is [sic] public safety -- shutting down fire houses, cutting back the number of police officers," Kirkland replied.
"My position is very clear," Liberman said. "This man runs the Department of Health. We are the board. If he is for it, I am for it. If he is not for it, I have great concerns. I have been around here for a long time; he is the first director for health....the first we have had on this job who is effective....."
Kirkland tried a different tack. "We have a lot of respect for Dr. Stallworth. But I don't want you to feel like you have to pick between us. We are a team -- or we should be."
Though Kirkland saw ConnectCare as the panacea to the budget woes, others questioned ConnectCare's competence.
Reverend Jerry Paul, president and CEO of the Deaconess Foundation, advised: "The only thing I would encourage you to do is to be straightforward about this. This is a cost-cutting measure.....You really don't have confidence in ConnectCare."
Said Stallworth: "The two things that concern me are [shutting down the] STD and TB [clinics]," he said. "And we have talked about this, so I'm not back-dooring anyone in my concerns about this."
Kirkland snapped back, "So we have talked, so we have talked, so we have talked."
Stallworth opposed the move because ConnectCare did not have the health department's experience in treating STDs. In the first nine months of 2003, the health department handled 839 gonorrhea cases, while ConnectCare had treated only 80.
"We have seen them in the morning until the night -- nothing but STD cases," argued Stallworth. "We have a level of expertise because we are connected with the CDC [Centers for Disease Control and Prevention]."
Later in the meeting, Stallworth cited a state health department report that indicated the city health department's STD clinic had outperformed the rest of the state.
"Where did those numbers come from?" Kirkland demanded. "I want to see the whole report."
Stallworth also vigorously opposed the idea of gutting the TB clinic, noting there was a tuberculosis outbreak spreading through homeless shelters among children, families and elderly people who "go back and forth in between homelessness, having a home, not having a home, back and forth."
As for immunizations, Stallworth explained that the health department had already started a campaign to encourage families to use independent, federally funded health clinics instead of the health department. The number of shots they'd administered had dropped. Only a few weeks earlier, he had submitted a strategic business plan to the mayor that would have kept a small staff on hand to administer immunizations, continue providing hepatitis A and B shots and branch out into a money-making travel clinic.
Immunizations and the travel clinic could be sacrificed. But Stallworth was upset that the mayor didn't talk to him about the strategic business plan that he'd assembled with his staff.
"We have talked about this plan," Kirkland said. "I can't sit here and not let that go."
Stallworth insisted he heard nothing from the mayor.
"Yes, you did," Kirkland interrupted. "Wait, stop."
"No, excuse me just a second," Stallworth said. "Let me finish, let me finish."
"This is very inappropriate, Dr. Stallworth," chided Kirkland. "I don't want to leave today with the sad misnomer [sic] that we have not talked to him. We have. We talked to him for two hours."
Liberman suggested that Kirkland put in writing the proposal she wanted the board to endorse. "It seems we have to decide if our director wants to go that way or how far he wants to go."
Kirkland pushed back: "There is one boss for the city of St. Louis and that is the mayor. And we both work for the mayor."
"I understand that you are doing [the mayor's] work," Liberman replied. "[But] you are chipping away at what [Stallworth's] job is."
Kirkland fumed. She said the department's revenue stream was running on empty and making little or nothing from the clinical work it performed. Advisory board chairman Dr. Rick Kurz, former dean of Saint Louis University's School of Public Health, stressed that they'd only had a year to fix the problems.
"No, you have had more because I started cleaning this department out in '01," Kirkland snapped.
"But we didn't have a director then," Kurz responded.
Liberman added, "You cleaned it up pretty well -- you got a new director."
Refusing to go along with the budget cuts and washing his hands of St. Louis-style "closed" politics, the embattled Stallworth joined the swelling ranks of former health department directors two months later.
Stallworth refuses to go into the "graphic, gross details," of his departure but says, "I can tell you -- it is ugly in St. Louis. I feared for my reputation. It is just very, very ugly. I never know what's going to come out. I never know what's going to be said."
When Dr. Stallworth arrived at the department, political appointee Melba Moore was already entrenched as health commissioner, a post whose relevance has since faded, having been created during an era when the city had its own hospitals. When the hospitals were closed years ago, the two agencies were combined, but the health director and health commissioner appointments remained. Although the health commissioner technically reports to the health director, the department has, in reality, been a two-headed bureaucracy. The duties and responsibilities of the commissioner and director aren't well-defined. But in this instance, Moore and Stallworth each had a separate pipeline to the mayor. When the power struggle ensued, the outcome would be determined not by qualifications but by political connections.
Moore was appointed by Mayor Slay in 2001, the year an audit of the health department discovered $559,000 worth of checks had gone undeposited. Instead of making a trek to the bank, an employee simply stuffed the checks in a drawer and forgot about them.
Shortly into her tenure, Moore earned a reputation for putting politics above public health and pushing the blame for department failures onto subordinates.
In April 2002 the department failed to pay its pharmaceutical bills. Vendors wouldn't deliver supplies, including antibiotics needed to treat sexually transmitted diseases, and the department was forced to borrow drugs to meet the demand.
Moore blamed an employee, who was subsequently forced to resign.
Three months later, in July 2002, Moore was back in the news when it was revealed city health inspectors tried to shut down two restaurants, The Edge and Bar Italia. Health inspectors discovered a dead rodent behind the ice machine at The Edge, a favorite eatery for local politicians. The St. Louis Post-Dispatch reported that improper meat-storage temperatures and a mousetrap in the dining room led to low scores. Bar Italia, meanwhile, had failed to obtain a mandatory health permit.
Jeff Rainford, the mayor's chief of staff, called Melba Moore to intercede on behalf of The Edge. Ward 28 Alderman Lyda Krewson asked Moore for help with Bar Italia.
Moore intervened and the restaurants stayed open. When the news broke, she told the Post-Dispatch that the health inspectors were rude and unprofessional. A Post-Dispatch editorial followed: "Hello, Melba? Health Department inspectors exist to protect the public's health, not the sensitivities of restaurants that fail inspections."
In late August, the accounting firm of Rubin, Brown, Gornstein & Co. released another audit that concluded that the health department's late paperwork cost it $207,000 in HIV and AIDS money. The fiscal mismanagement occurred on her watch, but in an effort to dilute the bad news, Moore announced that the health department had persuaded Dawn Anderson, an RBG accountant, to assume the position of fiscal manager for the department.
Asked about his relationship with Moore, Stallworth says, "It didn't start out real bad -- but it got real bad."
Some advisory board members believe that Moore became the mayor's office eyes and ears in the health department and that Stallworth, clearly a man who didn't relish political intrigue and back-stabbing, let it happen. By washing his hands of the political role, Stallworth allowed his authority to be undermined and solidified an alliance between Kirkland and Moore, who then pushed their own vision of public health.
When asked if he riled the mayor's office and earned the reputation of a loose cannon because of his public campaign to protect his department from the budget cuts and clinic closures, Stallworth agrees it had caused friction. But he adds, "That wasn't the first turning point. There was another turning point, but I'd really rather not talk about that now. It got worse as there was a change in the mayor's staff, when one individual retired and another took her place."
Stallworth wasn't the only target. Brenda Quarles, respected for her work combating lead poisoning in the area, also had a short stint in the department. After Quarles criticized uncoordinated efforts within city agencies to fight lead poisoning, Moore fired her for allegedly missing a grant deadline.
Dawn Anderson, the former auditor who'd been lauded as the person who was going to right the ship in the fiscal department, also left the department in January 2004.
Stallworth says Anderson received "absolute pressure to get certain things done in a certain way -- not just from Melba but the mayor's office also. And all of it was not an above-the-board kind of thing." He declined to elaborate, saying only, "It was a bad, bad scene, and it was something that I couldn't protect her from because my bosses were in cahoots with my second in command [Moore] to get this thing done."
The final straw for Stallworth was the push from the mayor's office, spearheaded by Rita Kirkland, to purge the department of the clinics.
"What they were talking about was not really a partnership but shifting the responsibility of a particular function over to someone, some group that I did not believe held the expertise to do it," Stallworth says.
It was clear to Stallworth after the contentious November 2003 meeting "that I was not going to be able to do the kind of quality job that I am capable of and know that is needed, know that was needed in that situation. And I have high standards for myself and my staff. I attempted to change the system; that didn't work. The system didn't want to be changed."
On January 29, 2004 -- the day before he met with Mayor Slay to discuss his status as department leader -- Stallworth gave his two-weeks' notice.
(Phone calls to Mayor Slay, Rita Kirkland and Melba Moore for this story were not returned.)
In early February, the advisory board grappled with how to proceed in the wake of Stallworth's resignation. Some members say resigning en masse was discussed. Others deny that. Speaking on background, one board member likened the choice to that facing U.S. companies operating in South Africa during apartheid: Does one stay and try to change the system from the inside, or by remaining, do they become part of the problem?
The members of the advisory board chose to stay and soon decided to ask the mayor to let the full twelve-member board serve as the department's interim director.
On February 13, two weeks after Stallworth bid a reluctant farewell, Dr. Rick Kurz told the advisory board that Jeff Rainford had informed him that Melba Moore would become interim director and would report to the board.
Kurz admitted that the board serves in an advisory capacity and has no legal ability to make decisions. Nonetheless, the board pressed ahead, offering its recommendations on the budget and the department's vision. The members made a commitment to open up their meetings and encouraged the public and the media to attend while they debated the health department's future and struggled with the immediate issue of cutting $1.6 million from the budget.
The advisory board considered Kirkland's proposal to rid the health department of the STD, tuberculosis, HIV and immunization clinics. The members also discussed adding disease investigators and a public relations professional. The medical community balked at the STD clinic closings, worried that cash-strapped teens who didn't want to tell their parents about their predicament wouldn't find free and confidential services at other clinics.
It took five months for the board to come to essentially the same conclusions Stallworth had reached back in November. The STD and tuberculosis clinics needed to stay. The HIV clinic couldn't be closed, because the grants that funded it couldn't be passed around based on budgetary whim. Immunization shots went to the independent, federally qualified People's Clinic. The entire lab stayed open for business. The only services that went to ConnectCare were the hepatitis A and B vaccinations. The total savings of the tentative budget is just over $1.2 million.
The City of St. Louis Board of Estimate and Apportionment recently approved the plan. It must still go through the board of aldermen before it receives a final blessing.
The question of whether the STD clinic will survive the 2006 budget process is uncertain. Some board members favor shipping the work out to independent clinics. Others aren't convinced. For now, no one seems to favor losing TB clinics.
The advisory board also has other big problems to solve. With only seven months remaining on the lease of its Grand Avenue headquarters, the health department has yet to find a new home. It is also a department devoid of a qualified, experienced leader. The board says it can't get involved in the department's day-to-day operations and must rely on Moore to provide accurate information.
When asked about the quality of department management since Stallworth left, Sister Betty Brucker says, "I think Melba Moore is bending over backwards to do what is right and to get the place straightened out, and I think that for the most part, from my perception, she certainly has the support of the staff."
Says Rick Kurz: "I was sorry to see he resigned, but frankly, that's water under the bridge at this point in time. It's not something anybody's going to fix, so we're going to move along in a positive way to [take care of the] health of the city of St. Louis."
Adds Kurz: "Don't get a scapegoat so everybody feels better, that's not the answer here. And if you go that route, and the media on occasion goes that route, it's not going to help us."
At an April 16, 2004, board meeting, Rita Kirkland pushed the board to use its closed executive session to a greater degree, a move she said was justified after a meeting at the Office of the City Counselor.
Lee Liberman challenged this view. "I think we need our own lawyer, somebody that represents us. Rita is wonderful, but she represents the mayor."
The board is now deliberating about when to begin the search for yet another health-department director.
When Liberman raised the question of when the search should get under way, some advisory members said the board wouldn't be ready until other key issues are resolved, such as the fate of the STD clinic and the location of the department's new home.
Said Sister Brucker: "I don't think any intelligent human being is going to walk into something like this -- not knowing what's going on."
Liberman replied, "An intelligent human being came in and left."
In March Hugh Stallworth found a new job as health director in Monterey County, California. He says he's pleased with the new post, happy to work in a place where his credentials and experience are appreciated, in an environment where he thinks he can accomplish something.
"But clearly," Stallworth says of St. Louis, "I left a lot undone which I continue to agonize over. I learned a long time ago that you don't want to wrestle with a pig, and the reason is you both get dirty. But the difference is that the pig likes it. There are a number of things that happened while I was in St. Louis, and most of them will probably remain between my wife and I."