At County Health Services Helm : Ex-Top Navy Doctor Still Faces Rough Seas

Dr. J. William Cox has an unusual idea of fun.

At age 59, after retiring from a career in military medicine that culminated in three years as the U.S. Navy’s surgeon general, Cox found himself agreeing in January to take over the beleaguered bureaucracy of the San Diego County Department of Health Services.

The department’s hospitals had been under state and county investigation. Some federal funding for patients had been withdrawn. Turmoil in the department had helped topple the county’s chief administrator. Morale among the 2,000 employees was notoriously low.

The department was also confronting new problems--How to care for patients dying of AIDS? How to stop the spread of the disease? The state Legislature was mandating innumerable new health programs. At the same time, it was withdrawing funds.

“It was a challenge,” Cox said simply, when asked why he would invite the aggravation. “ . . . I knew what I was walking into, so it was no surprise.”

This month, after six months on the job, Cox is wading into a sort of baptism by fire.

- On July 28, he is to present to the Board of Supervisors his recommendation that they support a dramatic loosening of the limits on AIDS testing--proposals that have won some medical authorities’ support but also opposition from the county’s own task force on AIDS.

- At the same meeting, he expects to serve up to the board a list of health programs that currently receive more than the minimally required county funding. The board is looking for $20 million to build new jails; some of it may come out of Cox’s hide.

Cox’s list will include the County Mental Health Hospital in Hillcrest, the only public hospital for the severely mentally ill. Though the system is still severely under-funded, the county spends more on mental health than is required to receive state matching funds.

Edgemoor on List, Too

The list will also include Edgemoor Geriatric Hospital, the county’s nursing facility of last resort. There, too, the county is spending more than required. But Cox said the state pays the county less than half the real cost of each patient day.

“If (the supervisors) were to take ‘overmatch’ that the county has invested in Hillcrest, then it’s very simple,” Cox said. “Instead of mentally ill, dangerous patients being hospitalized at Hillcrest, they’ll be in Sheriff (John) Duffy’s new jail.”

Meanwhile, Cox is, as he puts it, “up to my earlobes” in other explosive issues for the department--a sprawling network of hospitals, clinics, contracts and services with an annual budget of $152 million.

- Cox is asking the county’s school districts to pay the full cost of the county public health nurses who serve in the schools. “They’re screaming like banshees,” Cox mused. “And I don’t blame ‘em.”

- In the coming months, the department must help assess the public health impact of the proposed SANDER plant, the giant trash burner that would be among the county’s largest polluters and is already the subject of a grass-roots movement to block its construction.

In an interview recently, Cox expressed an openness to the arguments of the plant’s proponents, who contend that while SANDER will generate a lot of pollution, it will generate less than the landfills currently in use.

“The issue isn’t can you prove that SANDER is 100% absolutely, perfectly, totally safe,” Cox contended. “It’s is it safer than other things? There has to be an alternative to the way we dispose of solid waste. Or we’re going to bury ourselves in solid waste.”

- The federal immigration reform law threatens to create a new class of residents whose health care the county could end up having to provide. Cox has been working with other counties to try to ensure that the new residents are eligible for state programs and support.

- Within the department, Cox and others have been reassessing the entire mental health program, reorganizing the department under a plan drawn up before he was hired and redefining the department’s purpose in a coherent statement of mission and goals.

Cox’s qualifications for the department’s directorship are difficult to question.

A compact, dapper man with a trim mustache and thick wave of silver hair, Cox spent 30 years rising through the ranks of the Navy’s medical establishment. With both an MD. and a Ph.D., his appointments included stints in San Diego, Subic Bay, Philadelphia, London and Washington.

Won New Navy Hospital

In the late 1970s, he was commanding officer of the Navy Hospital in Balboa Park, where he fought and won a bitter fight to build a new hospital in Florida Canyon. Appointed in 1980 by President Carter, he then served three years as the Navy’s surgeon general.

“He’s good. In every way,” said Vice Adm. Willard P. Arentzen, who preceded Cox as surgeon general. “He’s a good cardiologist, a good internal medicine man. He gets along well with his civilian counterparts. He’s just very good at it.”

“I think he stuck to his guns,” said Rear Adm. Frances Shea Buckley, director of the nurse corps while Cox was surgeon general. “That’s always an issue in Washington. . . . He was a man of principle.”

Others describe Cox also as an accomplished politician.

Dr. F. Douglas Scutchfield, director of the San Diego State University graduate school of public health, who hired Cox as associate director when he retired from the Navy, called Cox a “quick study” whose forte is seeing problems and finding solutions.

“He’s a very strong-willed individual,” Scutchfield said. “Bill will listen to all sides of an argument, he will make a decision and he will stand by that decision. And heaven nor earth is going to move him from that if he thinks it’s a good decision.”

Scutchfield characterized Cox as “a master politician” who gets his “ducks” neatly in a row before making a move. “Don’t get in a fight with him,” Scutchfield said. “He can be rough in the clinches.”

Cox can be surprisingly blunt in his assessment of colleagues. Asked in a recent interview about one government official, Cox peppered his description with terms like “absolute disaster . . . extremely opinionated, vindictive . . . shot from the hip.”

“He didn’t need any advice,” Cox said with a snarl. “He was a genius. He knew everything.”

So far, Cox, who earns more than $90,000 annually in his current job, has been warmly received at the county.

Praised by Supervisors

In interviews, he was praised by county supervisors, administrators and members of his staff. They credited him with bringing leadership and direction to the department and at least beginning to restore morale in the department’s beleaguered ranks.

“When we ask a question, we get an answer,” said Supervisor Susan Golding. “When we give a direction, he follows it. Even though that may seem like an ordinary thing to expect, it has been difficult to get before.”

She and others said Cox seemed refreshingly willing to consider difficult decisions, such as whether to end a program or close a facility. Golding said those decisions include whether the county might have to close the County Mental Health Hospital.

Dr. Donald Ramras, deputy director in charge of public health, said Cox had conveyed a sense within the department that “you can’t just whittle away and whittle away and whittle away.”

Cox also received praise from Wyleen Luoma, general manager of the County Employees’ Assn. She observed that although the climate in the department is “difficult and sensitive,” she was heartened by Cox’s approach to employer-employee relations.

However, she expressed concern about the department’s middle managers and their ability to translate Cox’s policies to workers. She accused the middle managers and supervisors of needing “intensive training in communications and employee relations.”

Criticism also came from Dr. Brad Truax, chairman of the county’s task force on AIDS. Truax said he applauded Cox for taking the initiative in his upcoming AIDS prevention recommendations, but said he and the task force differed with several of Cox’s positions.

Truax said the group disagreed with Cox’s support for state legislation to end the requirement for written consent to AIDS virus testing and to allow sharing of positive test results with county health officers and blood banks.

Truax also faulted the health department for what he said has been inadequate attention to AIDS education in the minority and teen-age communities, and for failing to draw up a strategic plan on how to handle the spread of AIDS in the county in coming years.

No. 1 Health Issue?

“If it’s the No. 1 health issue, we aren’t putting our No. 1 resources into it,” said Truax. “And certainly not at the county level.”

To which Cox responded: “I still have to operate a balanced department. Syphilis is going up, penicillin-resistant gonorrhea is going up, alcohol and drug abuse are still a major problem, tuberculosis is still a significant public health risk, sewage, automobile accidents. I can’t take my total resources and put it on what is his No. 1 priority.”

Cox has spent much of his first six months as director of the department doing what he calls “management by walking around”--meeting with the county’s physicians, psychiatric social workers, program managers and, soon, the public health nurses.

He has developed an elaborate schedule of meetings with his deputies and executive staff. The heads of each of the six operating divisions meet individually with Cox for private briefings dubbed “coffee and bullets” for the customary caffeine and bulleted memos.

“Behind these four walls, those deputy directors and my other assistants can say anything they want to say,” Cox said. “They can complain about anything they want to complain about . . . They can literally wrestle me to the floor on any issue they disagree on.

“But once the decision is made, there are only two alternatives,” Cox added. “Walk out smartly and execute, or hang up your suit and go home.”

Cox said he intends to take the same posture in his dealings with the county supervisors.

“You go forward with what you’re doing--(assessing) what it’s costing in county general funds and what will happen if you reallocate those resources to another purpose,” he said. “And if that decision is made (to cut) any of the health programs, it will clearly be because there is a public mandate . . . that jail cells are more important.

“I should clearly be an advocate for help in mental and physical health, and do battle (against) the Sheriff’s Department or the courts or anyone else that would take the resources that I consider already inadequate,” Cox added. “ . . . But the public has to let its representatives know what it is they want. And if they want jails instead of mental health services, so be it.

“But then, get off my back.”