Noteworthy News Articles on Mental Health Topics, September 7-10, 2001

Study Finds Light Drinking May Fight Stroke, But May Also Shrink Brain
Lisa Falkenberg, Associated Press- 9/7/2001

DALLAS -- Moderate drinking may reduce the risk of certain types of stroke and scarring in the core of elderly people's brains, a study found. But alcohol may also promote shrinkage of the brain a condition seen in Alzheimer's patients. Elderly light drinkers those who take one to six drinks per week were found to have less scarring than teetotalers or moderately heavy drinkers, defined as those who have more than 15 drinks a week. And moderately heavy drinkers were 41 percent less likely than nondrinkers to have ''silent strokes.'' ''It adds to the evidence that moderate drinking is not in and of itself a harmful activity,'' said study author Kenneth J. Mukamal, an instructor at Harvard Medical School and associate in medicine at Boston's Beth Israel Deaconess Medical Center.
    The bad news is that every drink is associated with greater brain shrinkage, Mukamal said. The findings, based on MRI scans of the brains of 3,376 people over age 65, appear in Friday's issue of Stroke, a journal of the American Heart Association. Experts said it is hard to tell if silent strokes and scarring are worse than shrinkage because the effects of the three conditions are not fully known. ''At this point we just don't know enough to have an idea about how they counterbalance each other,'' said Mark J. Alberts, professor of neurology and director of the Stroke Program at Northwestern University, who was not involved with the study. ''More studies have to be done to show if the benefits of alcohol outweigh the risks.''
    Silent strokes are lower-level strokes that patients do not notice. They happen when a vessel that delivers blood to the brain becomes blocked, causing brain tissue to die. Scarring, called white matter disease, occurs in the brain's wiring and can impair intellectual ability and motor skills such as walking and buttoning a shirt. It increases with age. In the study, light drinkers were 32 percent less likely than nondrinkers to have scarring in their white matter.  Brain shrinkage, called atrophy, also has been linked to dementia. ''It's been clear that alcoholics have shrunken brains,'' Mukamal said. ''It was a bit of a surprise that it wasn't just alcoholics.''
    Alberts and Mukamal said patients should not change their drinking habits based on the study's findings. ''There's so many ways alcohol can affect a person's body that no one should be changing how much alcohol they drink on the basis of one or even two studies,'' Mukamal said. Much of alcohol's protective effect against strokes is thought to stem from its ability to raise levels of so-called good cholesterol. Alcohol also is known to be a mild blood thinner. That can prevent clots from forming in blood vessels. Alberts warned that the conclusions were skewed because researchers excluded some people, such as those who suffered more serious strokes or were too sick to undergo MRIs.

Managed Care Works, Report Says
Patricia Anstett, Detroit Free Press- 9/7/2001

A national report released Thursday shows that despite all the negative reports you've heard about managed-care plans, most members are satisfied and are getting key services. But the fifth annual report also shows wide variances between health plans in Michigan and elsewhere regarding the 12 services and tests measured by the National Committee for Quality Assurance (NCQA), the nation's largest managed-care accreditation agency. For example, 81.6 percent of the M-CARE members had their cholesterol tested within the first year of a hospital discharge for a heart procedure or problem, the report shows. SelectCare HMO and Blue Cross and Blue Shield of Michigan's point-of-service (POS) plan -- a type of managed-care plan that allows members to see more caregivers outside their established network -- tied for lowest reported screening rates: 67 percent got follow-up cholesterol tests.
    In another area of high interest, 84 percent of women insured through HealthPlus of Michigan received a yearly mammogram, compared with 74 percent for SelectCare and 55 percent for OmniCare. Another area showing lower rates of service was follow-up care within the first week of hospitalization for a mental health problem. SelectCare had the best rate, with follow-up for 92 percent of its members; Blue Care Network was the lowest, with 80 percent.
    Dr. Jack Billi, associate professor of internal medicine at the University of Michigan, said the report is an important tool in picking a health plan. But he urged consumers not to read too much into the statistics. "Many things contribute to a score that aren't necessarily the fault of a health plan," including a person's reluctance to see a doctor or follow his or her recommendations, Billi said. Still, many plans are working with doctors to boost rates. M-CARE, for example, sends Billi the names of patients who have not had a mammogram during the past year, so his office can follow up with them.
    The report is available at www.ncqa.org and covers 372 plans with 63 million members. Michigan plans include: Health Alliance Plan of Michigan; M-CARE HMO; SelectCare HMO and SelectCare POS; Care Choices HMO; HealthPlus of Michigan HMO and Health Plus of Michigan POS; Blue Care Network; Blue Cross and Blue Shield of Michigan POS; and OmniCare POS and OmniCare HMO.
    The report indicates whether a plan is accredited by NCQA, a key indicator of a plan's strength, experts agree. Consumers also can see how a plan fared on 12 of 60 measurements tracked by NCQA. Then they can compare rates to local, state and national figures. The report lists only accredited plans or ones seeking NCQA accreditation. All also must agree to have quality-assurance statistics released publicly.
    A third of the nation's health plans aren't in the report because they aren't accredited -- an exhaustive process that takes several years -- or they wouldn't agree to the public release of their statistics. Traditional plans like Blue Cross and Blue Shield of Michigan also are not included in the report because there is no national quality-assessment tool yet for them. Reasons for why plans don't want the information listed include the time and money associated with collecting follow-up data and poor member health in urban areas, which may give an overly negative picture of a plan. OmniCare, for example, released some but not all of its information because it lacked enough data in some areas to give an accurate picture, said Vernal Blakley, vice president of medical management.
    In the future, more diseases and conditions -- including outcomes after a cancer diagnosis -- might be added to improve the report cards, said Dr. Eve Kerr, staff physician at the Ann Arbor Veterans Administration Hospital, and an internal medicine specialist at U-M. Her research interest is improving quality-measurement tools for health plans. She applauded improvements made during the past decade in measuring health care quality because "consumers have a right to know if they are being treated appropriately."
    Dr. Vince Kerr, medical director of Ford Motor Co., which has played a large role in helping the NCQA developing quality measurement tools, said the ratings will save money as well as improve health. He estimated that Ford would gain the equivalent of 200 employees a year by reducing employee sick days because of improved health outcomes.   To motivate people to join the best plans, Ford offers employees and retirees only accredited plans. Ford provides additional incentives, such as reduced out-of-pocket expenses, to motivate people to pick the best plans, which are outlined on the Web site for the Greater Detroit Area Health Council, www.gdahc.org

Justices' Landmark Ruling Orders Murder Defendant Released from Mental Institution
Scott Sunde, Seattle Post-Intelligencer- 9/7/2001

Because a judge found him insane, Thomas Reid escaped a long prison term for shooting his Bremerton roommate to death. Now Reid, 26, is legally escaping the state mental hospital. The Washington Supreme Court set Reid free yesterday, deciding he was cured and no longer a danger to society. In a 6-3 decision, the court rejected arguments from prosecutors that Western State Hospital should still have some hold over him.
    "When an insanity acquittee demonstrates he has regained his sanity, the basis for his confinement in a mental institution vanishes, and he must be released," Justice Richard Sanders wrote in the majority opinion. "The statute requires Mr. Reid's unconditional release from custody, and it is so ordered." Other people have been found not guilty of violent crimes by reason of insanity and later released from state mental hospitals. But those cases typically result from a trial judge ordering a release.
    This may be the first time the state's highest court has mapped out when someone acquitted on an insanity defense should be released from a state mental hospital, said John Cross, Reid's attorney. "That's disturbing," Kitsap County Deputy Prosecutor Randall Sutton said of the ruling. He said there is probably no basis for an appeal to the federal courts, so Reid will be set free. "This was a serious crime. He basically got high, went nuts and killed his roommate," Sutton said. He noted that some states have changed laws so that trial courts can issue a verdict of guilty but insane. A person convicted under such a law could be put in prison after being cured of his mental illness.
    Reid shot Aaron Hughes, 19, to death in August 1994 in the Bremerton apartment the two shared. Prosecutors charged Reid with first-degree murder. But experts later testified that he suffered from mental illness. One of the experts said Reid suffered from paranoia brought on by drugs. Reid had been using LSD a couple of months before the shooting. Prosecutors did not present their own psychological experts.
    Before trial, Kitsap County Superior Court Judge M. Karlynn Haberly ruled in February 1995 that Reid was not guilty by reason of insanity. The judge committed him indefinitely to Western State Hospital. Reid became a model patient in the hospital's ward for the criminally insane, even completing his high school education there. Three years ago, the hospital concluded that he showed no evidence of psychosis, even when he wasn't taking medication, and that staying in the ward could do him no more good.
    But lower courts and Western State decided that Reid should be released only conditionally. Stress or drug use could bring about a return of mental illness, they decided. He was required to live at the hospital, submit to random drug tests and seek permission to drive a car and engage in any activity away from Western State. He later moved off hospital grounds, but remains under the institution's control for virtually every aspect of his life, attorney Cross said.
    In the Supreme Court ruling yesterday, Sanders was joined in the majority opinion by Justices Gerry Alexander, Charles Smith, Charles Johnson, Barbara Madsen and Susan Owens.  Justices Tom Chambers, Bobbe Bridge and Faith Ireland disagreed with the majority. "Society has a legitimate interest in protecting its citizens from those who commit violent acts," Chambers wrote. He noted that Reid's mental illness could return with drug use and that the man has no history of living independently in the community.

Kid Involvement Helps Addicted Moms
Amanda Shorey, Associated Press- 9/7/2001

WASHINGTON -- Drug- and alcohol-addicted women who involve their children in their treatment programs are less likely to continue abusing substances and committing crimes, according to a report released Thursday. The national study also found that women who entered treatment while they were pregnant had far fewer premature or low-birth-weight babies compared to untreated alcohol or drug abusers, and infant mortality rates were substantially reduced. The Substance Abuse and Mental Health Services Administration surveyed over 5,000 women across the country from 1993 to 2000. Besides trying to prevent substance abuse, many treatment programs focus on improving women's physical and mental health and providing job training.
    "I was doing heroin, smoking cocaine, selling my body - doing things I wasn't supposed to do. I was hopeless and useless and I saw no way out," said Jackie Hinton, who graduated from a program at Seabrook House in Seabrook, N.J., with her two sons in 1996. "Now, I'm not just living, I'm existing," Hinton said. "My children hug me, tell me they love me, and tell me they're proud of me. And I didn't used to be proud of myself."
    The study found that women who stayed in a program for more than three months were more likely to stay off drugs and alcohol, stay employed and keep custody of their children, and less likely to be arrested. Rebecca Taylor, vice president of treatment services at Seabrook House, said that since kids are often in foster care when their mothers seek treatment, the mothers tend to drop out if they can't see their children. She said that besides providing treatment, Seabrook House teaches women parenting skills. "We have children who are the most difficult to parent with parents who have the most difficulty parenting," said Taylor. "Chemical dependency is costly, but it can be treated. It reduces other costs and salvages this country's families."
    Seabrook House also provides prenatal, pediatric, physical and mental health services, as well as vocational training and legal advice. "Keeping children with their parents while their mothers learned parenting skills, as well as how to live drug- and alcohol-free, is itself a laudable goal," said Westley Clark, of the substance abuse agency, at a press conference Thursday.
    Tom Miller, director of health policy studies at the Cato Institute, a public policy research foundation, said, "You need a little caution when rolling something like this out on a grand scale since it is based on a fairly modest study." He said that although the results seem promising, he doesn't think the participants have been out of the study long enough to know whether they have "truly licked the problem."
    On the Net:
Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov
White House Office of National Drug Control Policy: http://www.whitehousedrugpolicy.gov/

Message of Sibling Sharing Now Applies to Caregiving Roles
Marilyn Kennedy Melia, Chicago Tribune- 9/7/2001

The graying population is forcing millions of adults into the unfamiliar role of parenting a parent. For many adults, an even more emotion-laden and problematic situation involves their siblings, as they try to work together to take care of Mom or Dad. "Siblings are the people with whom we have the longest relationship, from the cradle to the grave," said Frida Friedman, a clinical social worker with The Phoenix Institute, Chicago, who has just completed a doctoral study on sibling relations when caring for an aging parent.
    But where there are deep roots, there are also deep conflicts. The term "sibling," after all, is most often paired with "rivalry." A childhood spent with brothers and sisters is fraught with little negotiations and bigger battles. Remember: "Mom, he's on my side of the room!" or "She's taken my sweater again!" Adults, even those who've had minimal contact with their siblings since childhood, can experience a resurgence of old rivalries and resentments when they re-establish ties to care for a parent. "A lot of feelings never get resolved and come to the front with the care issue," said Denise Brown, founder of Caregiving.com, a Park Ridge-based Web site focusing on caregiving issues. Because area senior centers have been hearing about sibling difficulties, many now have social workers to mediate disputes.
    "We have several different programs," said Holly Lichtman, supervisor in the elder-abuse program at the North Shore Senior Center, Northfield. "Some services are funded through the federal government and are offered for free, and some are fee-based and are offered through our geriatric-care management services." Likewise, at the Council for Jewish Elderly in Chicago, the increase in family distress has kept social workers busy providing mediation services at an hourly fee, said Robyn Golden, clinical director at the council. Fortunately, social workers report that a family meeting, where siblings have an open forum to honestly share grievances and opinions under the calming direction of a third-party mediator, usually help siblings come to a resolution.
    Friedman, who studied 40 sets of siblings for her doctoral thesis, said: "I found that people really want to work something out with their siblings. They don't necessarily want a really strong friendship, but they want to be able to get through this [taking care of a parent] with some kind of collaborative relationship." Moreover, some siblings experience a renewed appreciation for each other, and their ties help ease the emotional pain of caring for a sick or dying parent.
    Each family is unique, but the experts can identify the emotional strains afflicting adult siblings like physicians can diagnose particular diseases. One common scenario is that one adult child [usually a daughter] has assumed the brunt of the duties, perhaps even having an elderly parent live with her, and resents the fact that other siblings aren't pitching in to help enough. Another problem afflicts families where one or more siblings live in the same vicinity as a parent, but the others live out of town; these out-of-town siblings don't provide help but do offer plenty of advice and criticism. Finally, simple differences of opinion about the type of care a parent needs can be a big source of conflict.
    Ruth Engel of River Forest, for example, says that she and her brother grew up in Ecuador, and came from an exceptionally tight-knit family. Now her 80-year-old mother lives in Florida, and Ruth and her brother, a resident of Washington, D.C., coordinate her care long distance. Engel's brother is divorcing, but when he was married, his wife didn't agree with the amount of care both he and Engel believed their mother required. "We are a close family, and she came from a rather disengaged family. It ended up putting a wedge between my brother and me in terms of the care of my mother, who is in basically good health," Engel said. Engel said she realized that her brother was "caught between two worlds." She also said, "I am extremely nurturing and feel quite responsible for my mother, who is a Holocaust survivor. I may have exaggerated what needs to be done." Engel, who is a clinical social worker by profession, may be more cognizant of the dynamics within her family than a layman. Golden said she often sees tensions arise "when one sibling doesn't like what the other is planning." Then, siblings clash over details like whether Mom should have a nurse, or whether someone should be checking on her each day, when the larger issue is Mom's safety or actual health needs. Different siblings have different values and opinions on the scope of care that's necessary. A family meeting often is the solution. Siblings can then speak their mind and listen to each other. As long as siblings are able to compromise somewhat, "usually there's a solution in the venting," said Golden.
    Cookie Arnold of Glenview said that her sister lives five minutes away from her parents' home. Her two brothers live in the Chicago vicinity but much farther away from their parents' Morton Grove home. Arnold's parents, now both in their 80s, have started needing more intense household help. An area senior center has started delivering meals, and cleaning help has been hired, but Cookie and her sister have been devoting more time to check on their parents. Both time-pressed, they wanted more help from their brothers, and arranged a family meeting conducted by the CJE. Arnold said she and her siblings "all found the meeting a civil way to discuss our different ideas about how to deal with the problems. We all signed a contract about what we'd be doing."
    The most serious sibling problems, said Donna Wagner, director of gerontology for Maryland's Towson University, occur in cases where a parent needs intense caregiving and it falls on the shoulders of one sibling and his family. The natural response is exhausted resentment. Although it may not work in every family, experts say the only remedy is to state your position clearly. It's also crucial to clear away the emotional debris of childhood.
    "For whatever reason, we remember what happened to us," said Brown. "If we think our parent had a favorite, or if one of our brothers or sisters picked on us," then these past emotions become tangled with the present, she said. For instance, Brown said: "Suppose there are two sisters. One is the major caregiver and the other perceives that [the caregiver] has always been the favorite. The caregiver sister wants help, but her sibling thinks she's just taken over because she wants to and because she's the favorite. In a meeting, the sister might say, `I resent that you spend so much time with Mom.' The caregiver sister could then say how much she needs her sister's help."
    There can be rewards in forging an adult relationship with siblings. Susan Newman of Wilmette said that she and her brother were four years apart, and when she was young she wasn't particularly close to her older brother. "He went to private school when I was 11, and then he went to college," said Newman. When they both began to coordinate long-distance care for their parents in Florida, "I got to appreciate him," said Newman. Now that her parents are gone, her relationship with her brother is particularly comforting. "He has shared much more with me than he ever did before."

While Lawmakers Grapple with the Insurance Haves, the Have-Nots Press On
Connie Lauerman, Chicago Tribune- 9/7/2001

Uninsured Americans are more than 40 million strong, and they are all around us. They may be the waitresses who pour our coffee in restaurants, the substitute teachers who sometimes take over our children's classrooms. Or the nanny, the cleaning lady, the artist down the street, the freelance writer, the part-time clerk in a drugstore who also works a second job, the neighbor who lost his job when a company folded or moved out of town.
    Congress has been debating a patient's bill of rights for the already insured and has considered revising the rules under which the poorest Americans are served through Medicaid, also numbering about 40 million. Meanwhile, the vast population of the uninsured still lives in fear of the next unexplained ache. They're living on a prayer, hoping that an accident or serious illness won't strike them or their loved ones and turning to charitable clinics when necessary. They're good, industrious, taxpaying people who live under the constant threat of financial ruin.
    Cherie and Walter Knitter of Wheaton have been struggling without health insurance for several years. Walter was a sales manager until the company he worked for closed its local office a year and a half ago. Even with full-time employment, insurance wasn't a benefit. Now he's doing some consulting work while trying to find a full-time job with benefits. The Knitters, both 44, have five children ages 6 through 16, all diagnosed with attention-deficit disorder. With income from sales commissions unsteady in a shaky economy, the premium for family insurance coverage at $700 a month would have been prohibitive.
    When Cherie, trained as a lab technician, took a low-paying job to help out, it turned out to be counterproductive. "Everything kind of fell apart at home because the kids need structure," she said, "and by the time taxes and insurance were deducted, I wasn't clearing that much." She said she spends a lot of time worrying about her family's health. "My 13-year-old loves skateboarding. Even though I insist that he wear a helmet and wrist guards, it's very scary thinking about him getting hurt. You have to make sure they understand that they have to be really careful. We can't just pack them up and take them to the emergency room. It's costly."
    For treatment of their children's ADD, they take them to DuPage Community Clinic, a facility staffed by volunteer doctors and nurses that asks for only a $5 voluntary donation. It's part of a loose safety net of clinics and sympathetic doctors who lower their fees or extend credit to the uninsured. The Knitters would prefer to make it on their own, but for now they're grateful for the clinic's help. They also take their children to a pediatrician who gives them a discount. "It's still $60 a visit per child," Cherie Knitter said. "In the winter season we usually have a running balance of $500 or $600 for them."
    Upon learning of KidCare, a state program to insure children, the Knitters said they may look into that for help.
The elder Knitters try to take care of themselves, eating healthy food and handling minor problems with over-the-counter remedies. "I went to an urgent-care center for a throat problem, but other than that I haven't seen a doctor since my postpartum exam after the birth of my 6-year-old twins," Cherie said. "Luckily, neither of us has been really ill, knock on wood. It's scary; we're getting older. I pray that God watches out for us until things get better."
    In 1999, 42 million, or more than 1 in 6 non-elderly Americans, did not have health insurance, according to the Kaiser Family Foundation's Commission on Medicaid and the Uninsured. Eighty-three percent of the uninsured are in working families, 71 percent employed full time and 12 percent part time. Low-wage workers are less likely than others to be offered insurance as a benefit either through their own or a spouse's job, and the cost of private insurance may be economically out of reach.
    "Seventy percent of the people at our clinic are working," said Joyce Poll of the Community Health Clinic in Chicago. "But either they can't afford the premiums, their employer doesn't offer health insurance, or they give it to the employee only. Some won't take that because they feel guilty being the only one in the family with health insurance."
    What's more, the insurance void grows even larger when other screening limitations are taken into account. A Kaiser report released this summer on the accessibility of health insurance for consumers "in less than perfect health" showed that even if coverage is available, benefits may be limited, and premiums may come with a surcharge. The study followed seven hypothetical consumers through the applications process with 19 insurance companies and HMOs in eight markets around the country, including Arlington Heights. All of the applications of a 36-year-old man who is HIV positive were rejected, as were 55 percent of the claims of a 62-year-old overweight smoker with high blood pressure.
    But even people with mild and common health conditions such as hay fever and asthma faced rejection. Karen Bonnes, 39, of Burbank, a clinical social worker, is typical. Bonnes contracts her services to nursing homes and makes visits to the homebound. Yet she cannot get affordable health insurance because she has epilepsy, a disorder that developed as a result of a head injury almost 20 years ago. "Even though the seizures are under control with medication, it's considered a `pre-existing condition,'" she said. "I've tried to get insurance, but the premiums would be $380 a month. I don't even make $380 a month." Bonnes is treated by a family practitioner associated with Access to Care, a health-care program based in Westchester that serves low-income, uninsured people in suburban Cook County, charging nominal fees. Still, "every day of my life I'm afraid of something happening," Bonnes said. "I had an emergency appendectomy three years ago at Oak Forest Hospital, and I'm still paying on the bill. I pay $10 a month. I never get ahead financially."
    Lorraine Leon, 66, of Chicago, retired a year ago but was forced back to work to pay the costly insurance premiums for her 60-year-old husband, Salvador. The couple work in a small suburban tool factory. They had been paying $400 a month for his share of an insurance premium under the Illinois Comprehensive Health Insurance Plan, a program meant for low-income people who cannot afford standard health insurance, and $100 for her Medicare supplement. Salvador's premium recently increased by about $25. Even so, they have to pay the first $1,000 of the cost of the medication Salvador needs to treat his high blood pressure. "I can't quit work," said Lorraine Leon, "and I'm frightened about what would happen if my husband got laid off. "All we made last year was $42,000 for both of us. That is hardly anything nowadays. We have to pay our house taxes. Thank God we just finished off paying the mortgage or we'd be choking. My 17-year-old grandchild lives with us. She works in a drugstore part time to pay for her clothes. "I have been in good health. So far I only had a hernia. I don't know what I am going to do if I have to buy medicine."
    Uninsured medical expenses often lead to financial collapse. An article published in the May issue of the New York University Law Review that analyzed bankruptcy filings in 1999 as part of an ongoing Consumer Bankruptcy Project estimated that more than half a million middle-class families turned to bankruptcy courts for help after illness or injury that year. As a cause for bankruptcy, it was second only to "poor debt management."
    "The biggest effect of not having medical insurance is delay of proper care," said Dr. William Preston, an internist in Western Springs who volunteers his services to Access to Care, which pays him a reduced rate. "Sometimes people end up being sicker, and they get admitted to the hospital in crisis. For example, gallbladder attacks. People will put up with the pain, struggle through it rather than have gallbladder removal. And when they're finally forced to have it done, it's because the gallbladder is ruptured, and that becomes a more serious problem." Preston said he chose to participate in Access to Care because of the realization "that people often end up uninsurable or underinsured for reasons beyond their control. It isn't always voluntary, and for those who are the `haves,' that's sometimes hard to remember. I see no reason to penalize them."
    Lucy Hall of Hanover Park, a 44-year-old single adoptive mother, was in a bad way one day a while back when she was taking her two daughters, now 9 and 10, to see a physician under their insurance associated with the adoption. Hall felt terrible but did not seek help because she was without medical insurance since she lost a managerial job when the company folded. She turned to full-time substitute teaching so that she could keep the same hours as her daughters. (She plans to earn a master's degree and get a full-time teaching job.) She found herself silently repeating a mantra: "I can't get sick. I can't get sick." But her children's doctor noticed her distress and referred her to a free clinic. As it turned out, her blood pressure was elevated and she also needed an echocardiogram. Though she acknowledged, "I'm out on a limb," she has turned to the community for help reluctantly. "I don't have the money to pay," she said. "It's a pride thing."
    The situation seems bleak, but Dr. Richard Corlin, president of the American Medical Association, believes things could change if ideology would give way to pragmatism. "We need to be prepared to accept incremental improvements," he said, noting that proposed solutions in the past would not have solved the entire problem and were rejected accordingly. For starters, the association proposes a change in the federal tax code to redirect current tax subsidies from employer-sponsored health plans to income-related, refundable tax credits to individuals, a change that would benefit lower-wage earners. The doctors' group also proposes that the consumer rather than the employer be allowed to choose a health plan that would be portable if an individual changed jobs.
    The United States is the only developed country without universal health care, noted Dr. Quentin Young, a Chicago internist and an officer of Physicians for a National Health Program, a 9,000-member organization founded in 1988 that advocates national single-payer health insurance. "Every one of the 18 industrial, democratic societies from France and Scandinavia to Canada and Japan have come to believe and act on the premise that it is important to the whole society that its entire population have health care, that leaving it to individuals is self-defeating," Young said. "The relationship between illness and ability to pay is inverse," he added. "The sick get poorer and the poor get sicker."
    Depending on family income levels, children, at least, may not have to do without health-care coverage. The State of Illinois offers an insurance program known informally as KidCare, for children up to age 18 and pregnant women, and helps in paying premiums of employer-sponsored or private insurance plans. KidCare has several insurance plans whose costs depend on family income. Under its "assist plan," for example, all of the children's health-care costs would be paid for a family of four with a monthly income of about $1,956 or less. Under the "premium plan," a family of four with a monthly income of $2,207 to $2,721 would pay a $3 to $5 co-payment for medical visits and prescriptions in addition to a $30 monthly premium.

Youth Boot Camp Investigated in Death Is Starting Another Session
Jacques Billeaud, Associated Press, 9/8/2001

PHOENIX -- A group that ran a ''tough love'' boot camp where a 14-year-old died this summer has a new class registered for a program designed to teach discipline and respect to troubled youngsters. About 20 children were expected to arrive Saturday for the start of the 13-week Right-of-Passage program, which is separate from the group's tougher desert boot camps.
    Police and some parents have questioned whether the America's Buffalo Soldiers Re-Enactors Association should take in more children since it remains under investigation in the July 1 death of boot camp participant Anthony Haynes. ''It makes me sick to my stomach,'' said Chris Hanner, whose son was sent home with other campers after Anthony's death. No criminal charges have been filed in Anthony's death, and the autopsy report by the county Medical Examiner's Office declared the death accidental. It said he died of complications from near-drowning and dehydration after being made to stay in direct sunlight for up to five hours in 111-degree heat.
    Maricopa County Sheriff's investigators, however, have alleged in a search warrant affidavit that camp operators abused the campers, deprived them of adequate food and water and denied medical care. A year ago, participants in another boot camp operated by the group reported that they were kicked and subjected to other cruelty by drill instructors. Authorities said no juveniles were injured, and no arrests were made. Lawsuits have been filed by Anthony's parents and by Cathy Mesa, who says her son was beaten, forced to eat mud and deprived of sleep during the camp.  Maricopa County Sheriff Joe Arpaio said Friday that he had hoped the group would hold off further camps until the investigation was complete. Anthony's mother, Melanie Hudson, was urging parents to reconsider sending their children, said her attorney, Michael Wade.
    Camp director Charles Long's office directed phone calls to his attorney, David Burnell Smith, who called Anthony's death a ''tragic accident.'' Smith said the death hasn't changed camp procedures but it has made the staff more sensitive to dehydration and other physical problems. ''What it has brought about is more emphasis on watching the kids, making sure if they get any indications that they need water, that they get water,'' Smith said. ''If they need any kind of medication, they will receive those.''
    Theresa Triplett, whose son has attended two summer camps and four weekend programs held by Long's group, believes the camp is safe. Her son is part of the new class. ''I understand that the parents have fears and concerns,'' said Triplett, president of the Buffalo Soldiers Parents Association. ''But the program has helped a lot of children.''
    Smith said the group's focus after Anthony's death was to continue with children who wanted to finish the program.  ''It's one of those unfortunate accidents that everybody wishes they could change,'' Smith said. ''We don't think anybody was criminally responsible for this young man's death.''
    On the Net: America's Buffalo Soldiers Re-enactors Association: http://www.thebuffalosoldiers.com

Despair Plagued Mother Held in Children's Deaths
Jim Yardley, New York Times- 9/8/2001

HOUSTON--She picked at her head until she scratched bald spots on her scalp. Her blackest depressions left her mute and catatonic, unable to recognize any semblance of hope, She tried to commit suicide in June 1999 and berated herself for failing. She thought, as a nurse, she should at least know how to kill herself. And barely a month after that first suicide attempt, Andrea Yates tried to slash her own throat before her husband grabbed the knife. Later, she admitted: "I had a fear I would hurt somebody. I thought it better to end my own life and prevent it. There was a voice, then an image of the knife. I had a vision in my mind, get a knife, get a knife."
    These details of a woman tormented by periods of psychosis and depression emerge in more than 1,000 pages of medical records recently filed in court by lawyers for Mrs. Yates, the mother who has admitted drowning her five young children one by one in a bathtub in their home in the Clear Lake section of Houston. Mrs. Yates, 37, has inspired both outrage and pity in a case that has resonated so deeply across the country that the National Organization for Women has condemned the decision by the local district attorney to pursue the death penalty.
    The medical records--written observations from doctors, psychiatrists, nurses and social workers during and after her hospitalizations since 1999-- portray a shy woman bereft of self-esteem, overwhelmed by raising her five children with little help, yet unable to admit her frustrations or ask for help. Her two suicide attempts in 1999 followed the birth of her fourth child, Luke, when postpartum psychosis was diagnosed, and she fell into another bout of depression and psychosis this year after her fifth child, Mary, was born. The records also seem to provide a grim foreshadowing. Barely two months before the death of her children, Mrs. Yates was found staring at a bathtub filled with water. Her husband believed she intended to kill herself and sought medical help.
    Her husband, Russell Yates, a NASA engineer who eulogized his five children at their funeral and who has expressed support for his wife, is depicted in the records as sympathetic and loving during her hospitalizations. Yet he is also described by one doctor as controlling. In one group therapy session, Mrs. Yates said her husband allowed her two hours a week of personal time. A psychiatrist fretted that the couple's determination to have a big family was putting a severe strain on Mrs. Yates, who home schooled the children. "Apparently the patient and husband plan to have as many babies as nature will allow!" the psychiatrist, Dr. Eileen K. Starbranch, wrote in 1999. "This will surely guarantee future psychosis and depression."
    The release of the medical records, which were filed in court last week, comes as prosecutors and defense lawyers are preparing for a hearing next week to determine whether Mrs. Yates is competent to stand trial. State District Court Judge Belinda Hill has prohibited lawyers and others, including Mr. Yates, from discussing the case, but Mrs. Yates's family has said to the local news media that they think she may be found competent because she has improved since taking medication in jail. Mrs. Yates's lawyers have already entered pleas of not guilty by reason of insanity to the murder charges.
    According to the medical records, Mrs. Yates had never been treated for mental illness before her first suicide attempt in June 1999, roughly six months after the birth of her fourth child. Doctors diagnosed post-partum psychosis and depression after she attempted to overdose on her father's prescription medicine. Her father, according to some of the records, had a history of depression, while two of her brothers and a sister also had suffered different degrees of mental illness. Mr. Yates said his wife also faced additional stress from helping to take care of her father, who had Alzheimer's disease. "She states that she just wanted to sleep forever," one record said of Mrs. Yates's first suicide attempt.
    Mrs. Yates spent the next week at a local hospital, where she was prescribed Zoloft for depression. At the time, the Yates family was living in a converted Greyhound bus, and Mr. Yates told a hospital social worker that he was training his sons, including the 3-year-old, to use power drills, because they enjoyed woodworking. The social worker filed a complaint with Children's Protective Services, but the state agency ultimately declined to pursue it.
    One record said Mrs. Yates was discharged after seven days because of insurance restrictions. Records described her as "quite depressed" upon her discharge but no longer suicidal. But on July 21st, less than a month later, Mr. Yates found his wife holding a knife to her neck. He admitted her to another hospital, and doctors learned that she had stopped taking her medications. Mrs. Yates described hearing voices and having a vision about getting the knife. She said that she had first had such a vision after the birth of her first child. Asked what may be missing in her life, Mrs. Yates told the social worker that "she spends all her time in child care, has been living in a motor home part time and with her elderly, medically frail parents part time. "Patient agrees she needs more help with child and home responsibility, needs some activities only for her." She remained hospitalized for 19 days and began attending group therapy sessions. She was also prescribed the anti-psychotic drug, Haldol, and began to improve.
    Near the end of the hospital stay, Mr. Yates became "very eager" for his wife to be discharged and "is putting some pressure on her" to leave the hospital, a psychologist wrote, noting that Mrs. Yates would continue outpatient therapy. "He reports that the patient is 90-95% back to normal; she reports it's more like 70-75%," the psychologist wrote. She noted that Mr. Yates planned to work half-days at home and that the family had moved into a new house. "Nevertheless, stress levels will remain high," the psychologist continued. "This couple plans to have the patient home school their children. They also hope to have additional kids. Suggested they consider patient's best interest in making these decisions."
    The birth of her fifth child prompted another bout of depression and psychosis in Mrs. Yates earlier this year, according to records. Her father had also died a few weeks earlier. Between March and May, she spent four stints at a psychiatric hospital. In April, her physician, Dr. Mohammed Saeed, sought a court order to have her committed, nothing that she was catatonic and had scratched bald spots onto her head. He dropped the proceeding after Mrs. Yates voluntarily agreed to sign herself into the hospital. On her first day at the hospital, May 14th, records indicated that Mrs. Yates was still depressed and had suicidal impulses. She asked to go home and start outpatient treatment, records how. Dr. Saeed agreed and discharged her for the last time.

Drug Addicts Patrol Alleys to Aid Junkies in Vancouver
DeNeen L. Brown, Washington Post - 9/8/2001

VANCOUVER, B. C. -- The Vancouver Area Network of Drug Users is a group of intravenous drug users and former users. In return for light office work and alley patrols, they receive small, daily stipends. Drug use or former drug use are the only requirements for work here.  "Only users can speak for users," Earl Crow says. He has long, blond hair. He was once a musician. Now he's an addict and president of VANDU. He says he kicked heroin but still smokes crack cocaine. Each day he and other users from VANDU go out on the streets in patrols to hand out clean "rigs" -- needles and other paraphernalia. "The full works for a clean hit," Crow says. They check users strung out in public to make sure they aren't overdosing and are feeling "healthy" -- as healthy as addicts can be. "The quality of heroin is good in Vancouver. To try to withdraw is hell," Crow says, as he and fellow VANDU member Mel Hennan walk an Eastside street around noon. "I can't describe the pain in your body. ... When you are wired, it's very hard to come down."
    Crow stops at the entrance to an alley. A brown, thick liquid runs along the brick pavement and into a drain. A tall woman in a white miniskirt and torn stockings scratches at her leg, then pokes in a needle. A man in a red sweat suit sits in the middle of the alley. Crow nudges him. The man gets up and puts his head down on a Dumpster as if it were a pillow. "If they are just sleeping and breathing, we don't disturb them. If they are not breathing, we know training for CPR," Crow says.
    Hennan is looking for signs of an overdose. "People who OD on down (heroin) look like they are going to sleep while walking," Hennan says. "I OD'd about four times on heroin. One time, I paralyzed my leg. Four months later, I got my feelings back." The stench is like that of an overturned portable toilet. Orange needle caps litter the alley. The junkies don't move, or run, or hide. Instead they sit, working with their intricate vials and packages and needles, searching for veins. "Can't you spare some money?" shouts one man. "You don't understand, lady. I'm in a lot of pain. I need morphine in my body." Up close, he has pink sores on his mouth. He is staggering. He has lost his shirt and is about to lose his pants. There are scars on his bronze skin. "This is like never-never land," Hennan says.
    A couple wearing shorts and carrying maps and a camera walk through the crowd of addicts. Crow stares at them. "Now that is stupid. They are crying out, `Tourists!' People up there have razor blades that will sever anything. They would cut (the camera) off his neck. And he'll say, `Why did they steal from me?' They are so obvious when you go around with $2,000 worth of camera equipment in a drug area. That's why."

Children Died as D.C. Did Little
Sari Horwitz, Scott Higham & Sarah Cohen, Washington Post- 9/9/2001

The decision sealed the fate of 2-month-old Wesley Lucas. D.C. social workers were assigned to protect Wesley from his neglectful, cocaine-addicted mother. So they allowed the baby to stay with his mother's boyfriend. The 69-year-old man was dying from lung cancer, but the workers promised to provide a caretaker to help. They decided not to send anyone over the long Presidents' Day weekend in 1998. That Saturday, Wesley began to cry, a plaintive wail that echoed for hours down the narrow four-story stairwell of a pale yellow Northeast Washington apartment building. Finally, there was nothing but silence. When a maintenance worker opened Apartment 5's brown steel door on Tuesday, the man was found face-up in his bed, dead from his disease. On his chest lay Wesley. The baby boy had died of severe dehydration. His death was officially ruled an accident, and his tiny body was cremated.
    Social workers, who have an obligation under D.C. law and a federal court order to protect children like Wesley, later said they believed there was little risk in leaving the baby alone with Lucas over the three-day weekend. "Who would have thought that the harm would come in the form of no food, water or other sustenance?" government officials wrote.
    Wesley Lucas is among the 229 boys and girls who perished from 1993 through 2000 after their families had come to the attention of the District's child protection system, a network of social workers, police officers, judges and other city employees. The children include Rhonda Morris, Cecelia Rushing, Robert Williams, King Richardson, Diante Aikens and Brianna Blackmond, whose death last year outraged the city. In a yearlong investigation, The Washington Post obtained records documenting the deaths of 180 of the 229 children. The circumstances of the deaths – and the District's culpability in many of them – have been hidden from the public for years. Some children died in accidents or shootings on the streets. Others succumbed to disease. But one in five – 40 boys and girls, most of them infants and toddlers – lost their lives after government workers failed to take key preventive action or placed children in unsafe homes or institutions, The Post found. Although 15 of the 40 deaths were ruled to be due to natural causes, government officials reviewing those cases found numerous critical errors. Seventeen of the deaths were homicides, most of them in homes.
    Thousands of once-secret documents provide an unprecedented look inside the city's child protection agency – the only one in the nation to operate under federal court control as part of a large-scale reform effort that began in 1991. The records illustrate how the decade-long effort failed some of the District's youngest wards. Interviews and additional investigation uncovered the reasons the children lost their lives, the government agencies involved, and the identities of the workers who committed critical mistakes and errors of judgment.
    NickiColma Spriggs, 15, her spine curved sideways at a painful right angle, sat in a wheelchair waiting for an operation that never came and died in a nursing home hallway. Eddie Ward, 13, was put on a bus, alone, and ended up dead in a dilapidated house, his body pockmarked with insect bites. Sylvester Brown, 8, was left with a mentally ill mother who stabbed him so many times that the medical examiner couldn't count the wounds.
    The Post could not determine the government's role in 49 of the 229 children's deaths, because key documents or files were never created or could not be located, or were part of pending homicide cases. What can be determined is that top government officials knew that D.C. children were dying for avoidable reasons and did little about it. Police officers did not fully investigate abuse reports, leaving children with violent or drug-addicted parents or relatives. Social workers did not adequately monitor neglected children. Frail newborns were permitted to go home to drug-addicted and mentally ill parents without follow-up services. Judges sent children to unlicensed foster homes, or to institutions far from the District where their care went unsupervised.
    For years, these persistent breakdowns have been cloaked in secrecy. Confidentiality laws drafted to protect children and their families have had the effect of shielding government officials from scrutiny and allowing them to escape accountability. The secrecy has prevented some of the worst details about the child deaths from becoming public. Those details have surfaced only at closed-door internal government meetings, where witnesses are summoned to discuss how and why children die. The D.C. Child Fatality Review Committee – whose three dozen members include child protection agency supervisors, police officers, doctors, government lawyers and others – was created a decade ago to review children's deaths and recommend ways to prevent future deaths.
    After protracted negotiations with city lawyers, The Post obtained the previously undisclosed records of the child death reviews: death certificates, police reports, autopsies, caseworker notes, hospital records and internal death summaries. The documents provide a rare look at a process that takes place in nearly every state but remains largely out of public view. The records cover cases from 1993, when the fatality committee began to review child deaths, through 2000, the most recent period for which complete documents were available. An analysis of those records, along with hundreds of interviews with government officials and family members, found that:
* Four severely disabled children died after they were placed in unsafe or inappropriate facilities.
* Nine children died after social workers and police officers conducted flawed investigations into abuse or neglect complaints or failed to remove the children from unsafe homes.
* Eleven medically fragile infants died after they were sent home to drug-addicted or mentally ill parents whose troubles were known to social workers or hospitals.
    In eight years of confidential reports, fatality committee members issued more than 300 warnings about these and other problems in reviews of the 180 deaths, the analysis showed. They proposed specific solutions to the mayor, the D.C. Council, the police chief, the director of the Child and Family Services Agency and the chief judge of D.C. Superior Court. But over the years, even as some officials left and new ones took over, the great majority of the proposed solutions went unheeded. "No one paid any attention to us," said Elizabeth Siegel, a lawyer and fatality committee member.
    Mayor Anthony A. Williams (D), who was elected in 1998, is working to revamp the entire system. Last year, the mayor mounted a lobbying campaign to recover control of Child and Family Services from the federal court. That happened in June. Williams named a high-profile former Clinton administration official to head the agency and increased its budget and staff. "If we're going to hold people accountable, we ought to at least hold them accountable for how we're treating kids," said Williams, himself a foster child.

Federal Takeover
When a child dies in the District, two reviews take place. First, the Child and Family Services Agency conducts an internal review focusing on its handling of the case. Second, the Child Fatality Review Committee examines the roles of all city institutions. In the 180 child death files The Post obtained, the agency issued 358 warnings, criticisms and recommendations; the committee issued 312 of its own.
    The Post constructed a computer database that documented patterns in these 670 findings. The analysis found mistakes at each stage of the child protection process. Doctors, educators, counselors and others who are required to report abuse and neglect frequently failed to call the emergency hot line set up by the District to summon police or social workers. David Wynn, a 2-month-old premature baby who had suffered from dehydration and pneumonia, died in a home where the mattresses were black with filth and hamburger meat rotted in the kitchen. A pediatrician had noted concerns in the boy's chart that he was being neglected, but he never called the hot line.
    When people did call, social workers and police repeatedly did not conduct thorough investigations. Devonta Young, 23 months old, died after being beaten by his mother. Nine months earlier, a doctor had reported to the agency that Devonta had second-degree burns on his feet. A social worker closed the complaint as unsupported without interviewing relatives or neighbors, who were aware of the abuse.
    Once the District opened a case to monitor a child, there were significant gaps. Social workers repeatedly failed to make required home visits every two weeks. Robert Charles Williams Jr., 11, died after his father punched him twice in the chest, angry that his developmentally delayed son could not read a clock. Social workers monitoring Robert in his grandmother's home were unaware that his father was staying in the house. A background check would have shown that the boy's father had 10 criminal convictions.
    When police or social workers removed children from their homes, safe places were hard to find, and services often were not provided. Social workers placed Eddie Ward, 13, in a group home that had a contract with the city. He ran away, was picked up by police and was returned to the home. Workers there said they had no vacancies and told Eddie to take a bus back to the agency. They never ensured that he arrived safely. Three days later, Eddie was found dead inside a closet in a dilapidated Southeast house.
    Washington was supposed to be a national model for child protection agencies. Ten years ago, U.S. District Judge Thomas F. Hogan delivered a landmark decision in LaShawn A. v. Barry, a case brought in the name of a D.C. foster girl, that held the city liable for failing to protect its children's constitutional rights. "The District's dereliction of its responsibilities to the children in its custody is a travesty," the judge said when he ruled. Hogan set new standards for safeguarding the "LaShawn children." He also ordered the city to examine every child death under its supervision. That mission fell to the fatality committee. "Many deaths related to child abuse and neglect are preventable," the committee members wrote in their first public report in April 1994. But their detailed discoveries about government mistakes in those deaths would be kept confidential for years.
    In February 1995, a horrific murder became front-page news. Rhonda Morris, 3, was beaten, strangled and burned with cigarettes by a cousin, Aaron L. Morris, 19, who was later convicted of involuntary manslaughter. Morris had earlier admitted to biting Rhonda's older sister and breaking her arm, fatality committee records show. But the D.C. corporation counsel's office, the city's lawyers, declined to pursue an abuse complaint against Morris. After Rhonda died, Judith Meltzer, the court-appointed monitor hired by Judge Hogan, concluded that the corporation counsel and six other D.C. government agencies made mistakes contributing to Rhonda's "avoidable death." Seeing little improvement, the American Civil Liberties Union lawyers who brought the LaShawn suit demanded a federal takeover. On May 22, 1995, Hogan complied, issuing another landmark decision applauded by child advocates. It was the first time in the nation that a federal judge had taken complete control of a local child protection agency.

'Thank God It Wasn't My Case'
Hogan began by trying to rebuild the agency's management structure. He turned Child and Family Services into a stand-alone department answerable to him. He appointed a receiver, Jerome G. Miller, to run the new agency. Miller lasted less than two years. The second receiver, Ernestine F. Jones, resigned last year. Her tumultuous tenure culminated in her arrest in August 2000 by deputy U.S. marshals for disobeying a local judge's order to explain why a neglected toddler was not receiving services from her agency.
    The upheavals at the top of the agency were matched by low morale and turmoil at the bottom. Social workers were besieged, supervising far more children than they could reasonably handle. Judge Hogan tried to reduce caseloads, setting a maximum of 17 children for each worker. But Hogan's order was never followed, and as recently as last year, some social workers were in charge of as many as 60 children. Hogan said judicial ethics did not permit him to discuss the violations of his court orders or any other aspect of his takeover of the child protection system.
    With so many children, social workers often cannot make the required biweekly visits, meet deadlines for status reports to judges or carefully investigate complaints. Several said they come to work every morning fearing news that one of their children had died the night before. "I remember wiping my brow and saying, 'Thank God it wasn't my case,' " said Darryl Webster, a former D.C. social worker. "Everyone says that." The fatality committee cited large caseloads as a problem in 15 child deaths.
    One of those who died was King Richardson, who was born prematurely to a crack-addicted mother and released to a filthy house with no electricity. Three weeks after King was sent home, a social worker decided to stop monitoring him. The next week, the baby died of meningitis. The social worker was in charge of at least 37 children – more than double Judge Hogan's limit.
    The workload is exacerbated by an exodus of veteran social workers, who are extremely difficult to replace. When the jobs are filled, they usually go to recruits fresh out of college. In 1999, 90 social workers left – nearly one-third of the staff. "Children couldn't receive proper services," said Joan Mallory, a social worker who left after nine years. "Social workers were overwhelmed." That year, a group of social workers sent a warning memo to Mayor Williams and several D.C. Council members. "The agency is in more disarray, services are more disjointed and chaotic" than a decade before, the workers wrote. "Employee morale is at an all-time low. . . . Staffing levels have been reduced to a point of crisis." In 2000, 128 more social workers resigned. The shortage affects the agency's ability to investigate neglect complaints. The U.S. General Accounting Office concluded last year that Child and Family Services failed to investigate more than 1,200 reports of neglected children within a mandated two-day deadline.
    While social workers struggled with neglect complaints – dirty homes, no food, children left alone – police had the same difficulties with child abuse complaints, which cover physical violence. In 1993, neighbors of 29-month-old Cecelia Rushing called the police to report screams coming from her aunt's Northeast apartment. But officers "failed to adequately pursue the matter," court records state. Two months later, Cecelia was beaten to death by her aunt. Little had changed five years later. In 1998, police were called to investigate a complaint that 35-month-old Diante Aikens was being abused. An emergency room doctor said he found markings on Diante's arms indicating he had been hit with a cord or "a linear object." Officers did little besides warn Diante's mother to stop hitting him with a belt, a police report shows. They closed the case, saying there wasn't enough evidence to charge Diante's mother with abuse. Nine months later, Diante was beaten to death.

A Highly Publicized Tragedy
If the social workers and police are the front-line troops of the system, the 59 judges of D.C. Superior Court are the officers, presiding over more than 5,100 neglect and abuse cases. The local judges were not answerable to Hogan, a federal judge whose authority was limited to the management of Child and Family Services. The Post interviewed more than a dozen judges. They were unwilling to speak on the record, but they expressed strong misgivings about what they called a "dysfunctional" agency. In separate interviews with GAO investigators last year, Superior Court Judges Zinora Mitchell-Rankin and Kaye K. Christian called the agency's performance "as poor now as it was a decade ago," blaming "lack of staff knowledge," limited resources and high turnover of social workers.
    Several of the local judges were so frustrated with the agency that they wanted to go to the man in charge: Hogan. But one judge told The Post that Hogan refused to meet with them. Social workers have their own complaints about the judges, saying court hearings take up hours that could be spent in the field. With their cases spread among so many judges, social workers bounce from courtroom to courtroom. "Being stuck in court all day is a waste of time," said Charly Mathew, a former D.C. social worker who resigned last year. "We would just sit outside in the hall for hours."
    In December 1999, the system's many flaws combined to produce a highly publicized tragedy in the case of Brianna Blackmond, a 23-month-old foster child. A social worker who thought Brianna should not go home missed a court deadline to tell the judge. The court-appointed attorney assigned to protect Brianna did not visit her for a year and failed to ensure that her mother's home was safe. The judge, who knew the mother had psychological problems, did not hold a hearing and sent Brianna home based on the word of her mother's attorney. The city lawyers supervising the case did not appeal the judge's decision, even though the District's child protection agency opposed the move. Two weeks later, on Jan. 6, 2000, Brianna died from severe blows to the head. The mother's roommate is charged with murder, and Brianna's mother is charged as an accessory. Both have pleaded not guilty. Brianna's death should not have come as a surprise to the fatality committee. The mistakes in her case were similar to the mistakes the committee had documented in scores of earlier deaths.

'Very Frustrating'
The fatality committee began reviewing the deaths of children in 1993 and issued its first round of confidential warnings to city officials the next year. By 1996, committee members said that city officials were not paying attention to their warnings and that the committee had "fallen short" of its goal of preventing the deaths. "We have been unable to move the issues confronting families, children and systems to the forefront," they wrote.
    The committee is made up of representatives from government agencies and a few volunteers from the community who are appointed by the mayor and serve three-year terms. For most of its existence, the committee operated with no staff and no budget. Earlier this year, it received its first appropriation: $296,000. Its members have long complained that their work and warnings were not taken seriously by city officials. "It's very frustrating," said committee member Siegel. "You see these deaths come in and see that if we implemented the recommendations, maybe this death could have been prevented. It's like hitting your head against the wall."
    But critics of the panel say the committee has created some problems for itself. The committee began by announcing a clear mission: "ensuring that all public and private systems responsible for protecting the District of Columbia's children are accountable." But some former government officials say the committee does not follow up on its recommendations and places little pressure on government agencies in its annual reports to the public. The reports include descriptions of anonymous child deaths two years after the fact, with the government's role largely omitted. And some of the most egregious cases of government failures uncovered by The Post were never described in the public reports.
    Those omissions, along with the committee's unwillingness to publicly blame agencies, result in bland reports that attract little attention, said Barry Holman, a former Child and Family Services supervisor who attended fatality committee meetings. "They weren't helpful at all," Holman said. "They didn't really tell us much about what had gone on in the kids' lives, what our agency had done or what the other agencies had done." Committee members said they do not want to be openly critical because that might discourage city officials from participating in the voluntary child death review process. The members also point out that they do note government mistakes by issuing recommendations at the end of their public reports. But the recommendations are general and laden with jargon. For example, the committee stated in its 1998 report that police "should reexamine their policies and practice related to unsupporting abuse cases."
    Critics say that such prescriptions accomplish little because they are not tied to specific deaths. "They're meant to mislead, because they're meant to protect the agency and those associated with it, who might be tarred by this information," said Miller, the former chief of Child and Family Services. "At all costs, they want to avoid conflict, and the reports are generated with that in mind."
    The committee's most recent report, issued in May, contains more specific findings about government mistakes and culpability. This version was prepared at the insistence of D.C. Council member Kathy Patterson (D-Ward 3), who has been pushing for more public disclosure of child death information. The report also was prepared as The Post was gaining access to the committee's confidential files. Sharan James, a government employee who coordinates the fatality committee, said things are beginning to improve under Mayor Williams. "We are seeing a significant difference," James said Friday. "People are taking the committee seriously and moving in the right direction."

Silence in the Stairwell
Wesley Lucas needed help from the time he was born in December 1997. Interviews with neighbors and records from Child and Family Services and the fatality committee document his final days: His mother, her mind clouded by cocaine, had been accused of neglecting three of her seven children. The District didn't want to take a chance with Wesley. At 69, Charles Lucas was dying of lung cancer. He was the boyfriend of Wesley's mother, who had taken his last name. He was protective of the infant and didn't want him to be taken away like some of the others. Lucas struck a deal with the District. He would keep the baby temporarily. To help watch Wesley, the child protection agency relied partly on the Edgewood-Brookland Family Support Collaborative, a neighborhood group that is paid by the city to provide social services to families. The agency also paid a caretaker to help Lucas and Wesley until a relative could be found to take the baby. Wesley's mother was in and out of the apartment, spending most of her days and nights on the streets. Social workers sent the caretaker three days a week, leaving the weekends uncovered. Lucas did his best, but he was dying. "He was a small, fragile man who looked ailing," recalled Ethel Parker, a social worker from the Israel Baptist Church across the street. Mary Dews, a neighbor who lived across the hall from Lucas, said he was a "very wonderful man, very loving and caring." But he was also "very, very sick. It seemed like he was going to the hospital just about every other day."
    In February 1998, social workers considered extending the caretaker's hours to include the long Presidents' Day weekend, but ultimately did not. Several social workers and their supervisors involved in the case did not return repeated calls from The Post. Louvenia Williams, the collaborative's executive director, checked on the baby on the Wednesday before the weekend. She would later describe him as "happy, healthy and fat." "We knew Mr. Lucas was going to die," Williams recently told The Post. "You can never predict when someone will pass. We assumed he had a little more time to go because he was doing so well." On Saturday, Wesley began to cry. By Monday, there was silence in the stairwell outside the apartment on Saratoga Avenue NE. On Tuesday morning, Wesley's mother came to see Lucas and her baby. She banged on the metal apartment door. There was no answer. She summoned a social worker and a maintenance man. They walked past the green chain-link fence, through the unlocked front door and up the 35 steps to the apartment. At 7:45 a.m., they opened the door. Inside were the two bodies, the elderly man and the baby. Police said Lucas died first. With no one to care for him, Wesley became severely dehydrated, and his heart eventually stopped. He had been dead for three days. He was 10 weeks old.

NYPD Grappling with Cops and Alcohol Abuse in Wake of Tragic Accident
Donna De La Cruz, Associated Press, 9/9/2001

NEW YORK -- When Theodore Roosevelt was the city's police commissioner in the 1890s, drinking was such a big problem he patrolled the bars looking for inebriated cops, whom he fired on the spot. Roosevelt's tough stance didn't stop alcohol abuse by police officers. Joseph McNamara, an ex-NYPD deputy inspector and former police chief in Kansas City and San Jose, Calif., said that when he was rookie cop in the 1950s, ''the drinking was so bad.''  ''We had some guys who were absolute alcoholics, very dangerous to themselves and to us and the community. But no one could report them because the discipline called for them to be fired,'' said McNamara, now a research fellow at Stanford University's Hoover Institution.
    Now, after an Aug. 4 accident in which a police officer killed four members of a Brooklyn family, Police Commissioner Benard Kerik and Mayor Rudolph Giuliani are drafting tougher disciplinary measures against cops who abuse alcohol including the immediate dismissal of any officer arrested on a DWI charge. The new policy, which has yet to be completed, is expected to stiffen penalties for cops involved in other alcohol-related incidents as well.
    But some say such punitive measures didn't work when Roosevelt was commissioner and they won't work now. The police union has already come out in opposition to tougher discipline, saying it will simply push the problem further underground. ''One of the things that does not help the agency, the person or their families is to punish somebody for the pain that they've suffered,'' said Ronald McVey, an associate professor of counseling at John Jay College of Criminal Justice in New York City. ''They should allow the person to get the appropriate help they need at that time. It is difficult to become unaddicted.''
    Kerik and Giuliani see otherwise. ''Getting arrested for drunk driving, as far as I'm concerned, means dismissal from the police department at a minimum,'' Giuliani said. Since the accident, three other city officers have been arrested for driving while intoxicated and another cop was arrested for allegedly pointing a loaded gun at a detective while drunk. In all, 16 officers have been arrested on drunken-driving charges so far this year.
    Only Joseph Gray knows what prompted him to drink for up to 12 hours with his colleagues in a NYPD parking lot and later at a strip club in Brooklyn on Aug. 4. Just hours before his next work shift was to begin, police say, Gray climbed into his van and drove off striking and killing a 24-year-old pregnant woman, her 4-year-old son and her 16-year-old sister. Gray also was charged in the death of the mother's unborn child. Gray has said he's not ''a mindless drunk.'' But rather than face questions at a departmental hearing, Gray resigned three weeks later. The 15-year veteran, who lost his pension, faces a criminal trial.  If Gray has an alcohol problem, he apparently never sought help from a program set up 35 years ago available within the NYPD, called the Counseling Service Unit. Police officials say the unit has helped thousands of cops over the years, although they refused to provide any specific numbers. Gray also could have gone to a program started by a former cop, which operates independent of the NYPD but has its blessing.
    William Genet started POPPA Police Organization Providing Peer Assistance in 1996 to help officers with personal problems. He said cops see themselves as ''fixers'' and are reluctant to seek help for personal problems. That reluctance is evident in the small number of cops who have sought help from POPPA. The first year of POPPA's existence, not a single officer sought help for alcohol abuse. In 1997, the number grew to two, then three in 1998. Six cops asked for help in 1999, and 20 in 2000. So far this year, just 12 cops have turned to POPPA. ''They don't want to come forward themselves because they feel it's going to jeopardize their careers in some way,'' said John Violanti, a criminal justice professor at the Rochester Institute of Technology, and the author of several books and articles on the stress of law enforcement. ''They believe they will be thought of as inferior.''
    Violanti, who served 23 years as a New York state trooper, said it's hard to change the way cops view alcohol.  ''It's kind of a macho culture, where alcohol use is kind of accepted and almost praised to some degree,'' he said. ''If you're able to drink someone under the table, that's considered quite a feat.'' While there's no official statistics on how many cops nationwide abuse alcohol, Violanti said an estimated two out of 10 officers nationwide have some type of drinking problem, compared with one out of 10 people in the general population.
    Experts agree that in order to help cops with alcohol problems, they need to reach rookies and supervisors, not just the alcohol abusers. Academy cadets do take courses on how to handle the stress of police work, but the classroom lessons are much different from the real-life ones. ''With rookies in the academy, they need to know what to expect on the job and how to deal with it,'' Violanti said. ''Don't let them get sucked into the acceptance of alcohol.'' Supervisors also need to be taught the signs of alcohol dependency and how to deal with it, Genet said. ''I think supervisors now get caught up in saying to themselves that if they do something that penalizes the officer, they are responsible for putting an end to his career,'' Genet said. And while all the experts agree that drinking among cops now is not as bad as in the old days, Genet said he's seeing a disturbing trend. ''In recent years, there's been a resurgence of drinking,'' he said. ''It's the new generation of police rediscovering the wheel.''

Criminal Punishment Widely Disparate in Maternal Filicide Cases
Mike Tolson, Houston Chronicle- 9/9/2001

Sometimes they use knives, sometimes pillows. Guns are rare, but strangulation is not. Drowning, as all of Houston now knows, is occasionally the method of choice. One woman found a cliff. Interesting stuff, and ultimately trivial. Among women who kill their children for no apparent reason, what really distinguishes one case from another is not the way they did it but the way they are treated by the criminal justice system. One woman ends up in a psychiatric facility, having been found not legally responsible for her actions. Another with a similar background who has done essentially the same thing gets 20 years in prison on a reduced charge. A third goes to prison for life.
    Now comes Andrea Pia Yates, the Clear Lake mother who could pay the ultimate price for the killing of her five children in June. Her first step toward justice, or at least adjudication, will come this week with a mental competency trial to establish whether she's healthy enough to stand trial. The crime of maternal filicide is a challenge as much to justice as to biology. People kill for a variety of reasons, most of them understandable. But loving mothers don't take the lives of their own children. And penal codes are not written with such homicides in mind. Perhaps the only simple conclusion that one can draw from their legal experiences is that courts often don't know what to do with them.
    "The criminal justice system is an extraordinarily dull sword for attacking a problem of this sort of complexity," said Michelle Oberman, a law professor at DePaul University and co-author of a recent book on the phenomenon, Mothers Who Kill Their Children. It can be a taxing dilemma for prosecutors, who must juggle the awful nature of the crime with the mother's state of mind. They do so with the knowledge that no possible outcome is fully satisfying.
    "These are very troubling cases," said Mary Ellen Martirano, a former assistant district attorney in Westchester County, N.Y., who still is haunted by a grisly maternal filicide case she handled a decade ago. "I'm very conflicted about it. I can see both sides." In that instance, 36-year-old Salvadoran immigrant Maria Amaya slit the throats of her four children, thinking she was sending them to a better place. She then drank lye in a suicide attempt. Court psychiatrists found her legally insane, and the prosecution ended. Martirano understood that the outcome, according to the law, was just. Amaya did not have the intent behind her acts to be culpable. But it didn't feel quite like justice.  "My belief is that we ought to change the laws," she said. "It's not adequate to send her to the loony bin for a while and then let her out."
    That concern may have motivated prosecutors in Findlay, Ohio, in 1998. Kimberlee Snyder claimed postpartum depression led her to kill her 5-month-old daughter. Prosecutor Bob Fry agreed to let her plead guilty to involuntary manslaughter and receive a 15-year sentence rather than proceed in the murder trial. She could have been sent to prison for life, or freed completely if the jury believed the psychiatrists who testified on her behalf.
    The stakes are even higher in the case of Yates. District Attorney Chuck Rosenthal's decision to ask for the death penalty may make sense in Harris County, the capital of capital punishment in the United States, but it is almost unheard of elsewhere for this type of crime. In only one instance in recent U.S. history has a woman with a reasonable claim of mental problems been sent to death row for killing her children. She was executed in Arkansas last year. Another homicidal mom, Marilyn Lemak, has been charged with capital murder in a suburb of Chicago. The prosecutor is pursuing the death penalty, though Lemak was offered a life sentence in exchange for a guilty plea. She turned it down, and the case is still pending.
    Last month in Stuart, Fla., a 21-year-old woman threw her infant son down a flight of stairs because she said an inner voice told her to test her faith in God, who would resurrect the child. Jennifer Cisowski was indicted for first-degree murder, potentially a capital crime, but prosecutors have not decided what sort of sentence to seek. In many jurisdictions, the answer to that depends on the perception of the mother's state of mind. Prosecutors in Golden, Colo., recently had to consider the motives of Elizabeth Feltman, who like Yates had been diagnosed with postpartum depression before killing her two young children. "We have a four-part balancing test in deciding on the death penalty, and it's fair to say that serious mental health issues would weigh heavily in that balancing," said Kathy Sasak, a deputy district attorney involved in the case. Sasak said the death penalty, though possible in Feltman's case, was never seriously considered. It is worth noting that Colorado has six people on death row and has executed only one prisoner in 30 years.
    "There are different philosophical attitudes that (prosecutors) bring to these cases," she said. "Like anyone else, we look at whether the facts of a case would support a charge that could result in the death penalty. But that's not where our analysis ends. That's where it begins." Given Feltman's established mental history and the fact that she had been hospitalized days before the killings, Sasak's office was inclined to be understanding. "We have to prove not only the act but the culpable mental state," Sasak said. "It was clear to us that even without the defense raising mental issues, we were going to have to look hard at her mental condition and history because the mental component is part of our standard of proof." When psychiatrists agreed that she had not possessed the mental state to form criminal intent, Feltman's prosecutors did not fight it. She is currently in a state mental hospital.
    Prosecutors in St. Paul, Minn., had a similarly distraught mother in Khoua Her, a Hmong immigrant who in 1998 strangled her six children and then hanged herself in a failed suicide attempt. She, too, may have lacked a true criminal motive. But what she did not have was a diagnosed history of depression. Chris Wilton, who prosecuted Her, said she had a long history of domestic abuse. It had become apparent to Her, Wilton said, that her estranged husband was going to take the children from her. She thought the children would be better off dead, and that she would be reunited with them in the afterlife. "She didn't have that motive, and she wasn't stable," Wilton acknowledged. "But she took the lives of six very innocent children who deserved a much better fate. It's a real balancing act between motive -- why she did what she did -- and the damage she inflicted." The number he came up with was 50 years, which with good-time provisions will make her eligible for release when she is 57. Though Her's lawyers would have argued she suffered from a long period of untreated depression had the case gone to trial, her lack of an established psychiatric profile limited Wilton's sympathy. "I know that she did this for religious reasons," Wilton said. "But to me, that doesn't have anything to do with mental state. If you have a mental state where you can't control yourself without some medication, we treat that differently from someone who decides to do something for religious reasons."
    Harris County prosecutors are under a gag order imposed by the judge in Yates' case and cannot discuss the reasons for their decision to pursue a death sentence. Following precedent was not one of them, however. Several notable Harris County cases in the last two decades that involved mothers who killed their children were dealt with much less harshly. One of these women, Juana Leija, received probation in a plea agreement despite having thrown her children into Buffalo Bayou. "Justice does not mean only a just prosecution but a just outcome of the case," said Dick DeGuerin, Leija's attorney. "You have to temper it with compassion and mercy. I think (the prosecutor) was able to see that this was a case that required compassion and not prosecution."
    Like many defense lawyers, DeGuerin argues that Texas laws should make some provision beyond an insanity plea to lessen the culpability of mentally ill offenders. "People who are crazy need to be dealt with not as career criminals but as someone who is sick," he said. "We need some middle ground between not guilty by reason of insanity and guilty according to the indictment."  Some states have that middle ground. Their laws offer so-called diminished capacity defenses that allow mentally impaired defendants to get a lesser charge or lighter punishment even if they don't meet the strict test of insanity.
    The fact that Texas laws do not is probably the way that the majority of Texans want it, said defense lawyer Allen Tanner. "In California, where I went to law school, people used (diminished capacity) all the time," Tanner said. "Texans are less forgiving of people with mental problems committing crimes. In California, people would ask why he would commit the crime. In Texas, they don't want to know why. They just want the person punished." 
    Oberman, whose book looks in detail at all the types of women who kill their children, understands that reaction, which she feels is typical of many Americans. Other countries give mothers a special status under the law if they kill their young children. There's an assumption that such women are not right in the head and suffer from peculiar motivations. "I'm a pragmatist," Oberman said. "At this point in time, I don't think it's likely that society would accept a system that says we're not going to try these women. It's important that we have a prosecution, that we go through the ritual that memorializes the loss of innocent life and asks questions about guilt and responsibility and prevention."
    Of all those rituals, none may prove more watched than that of Andrea Yates. And it may be the publicity that is her undoing. A less publicized case could slip below the radar. But when you've made the cover of Newsweek, that's no longer an option. University of Houston law professor David Dow said the district attorney's decision to go for death cannot be removed from that context. "Andrea Yates by any rational measure is not a death-penalty case," Dow said. "I don't think there can be any other explanation other than the high degree of publicity it has gotten."  Publicity brings scrutiny. And the last thing District Attorney Rosenthal wanted, Dow said, was to be accused of bias toward white, middle-class defendants. "For a DA not to have sought the death penalty in this case would have taken a great deal of political courage," Dow said.

Study: Up to 400,000 Kids a Year Involved in U.S. Sex Trade
Houston Chronicle, 9/10/2001

WASHINGTON --As many as 400,000 U.S. children are victims of the sex trade each year, from juvenile pornography and street prostitution to selling sex at school, a detailed study released today said. "Child sexual exploitation is the most hidden form of child abuse in the U.S. and North America today. It is the nation's least recognized epidemic," said Richard Estes, a professor at the University of Pennsylvania School of Social Work and the main author of the report on the sexual exploitation of children.
    Based on field research and surveys from 288 federal and local agencies, the study estimated between 300,000 and 400,000 children in the United States were victims of sexual exploitation each year. The report also looked at the child sex trade in Mexico and Canada, but those results have not yet been released. "That figure just blew our minds," Estes said of the numbers involved. "We never at the beginning of the study thought we would encounter so many children in this predicament."
    Estes and his team visited 17 U.S. cities over two years, meeting with federal and local law enforcement agencies, human services departments and hundreds of children living at home and on the streets. Contrary to popular belief, as many boys as girls were affected, but Estes said boys got less attention from law enforcement and social services because of the view that they could look after themselves. "Every place we went, we found for every girl there was a boy involved too. People feel a need to protect girls, and for boys it's thought of as sowing their oats," Estes said, adding that some boys graduated from their years of sexual servitude to become pimps.
    The largest groups of children affected were runaway, "throwaway" and homeless youths, many of whom used "survival sex" to acquire food, shelter, clothing and other things needed to eke out a living on America's streets, Estes said. "Like other groups of sexually exploited persons, street children are exposed to violence, drug abuse, rape and sometimes even murder at the hands of the pimps, `customers' and traffickers that make up their world," Estes said. He said some children sold themselves for sex to high school students while living at home and used the money to buy more expensive clothes and other consumer goods. Many of these children lived in secure middle-class homes, and few parents were aware of what was going on. This group also included American youths who crossed into Canada or Mexico in search of cheaper drugs, alcohol and sex, Estes said. The sexual exploitation of children affected all racial, ethnic and socioeconomic groups, although children from poorer families appeared to be at a higher risk.
    Estes said a disproportionate number of street youths had histories of recurrent physical or sexual abuse at home and took to the streets in a bid to stop it. "It is ironic that running away from home increases their risk of physical violence and sexual abuse," he said. Sexual predators also came from all parts of society and included relatives and other adults trusted by the children. Despite popular notions to the contrary, Estes said strangers committed fewer than 4 percent of the sexual assaults against children. The study found that 47 percent of sexual assaults on children were committed by relatives and 49 percent by acquaintances, such as a teacher, a coach or a neighbor. The researchers also reported that about 20 percent of the sexually exploited children they interviewed were involved in prostitution rings that worked across state lines.
    The study said gaps existed in policies and services intended to combat sexual exploitation of children and help the victims. The researchers' recommendations for dealing with the problem included increasing penalties, enforcing existing laws more vigorously and expanding the federal government's role in fighting abuse.
    On the Net:
National Center For Missing and Exploited Children: http://www.missingkids.com
UPenn: http://www.ssw.upenn.edu