By MICHAEL D. KLEMENS
Bernard Turnock: defamer of Illinois chickens but defender of Illinois health
In August Illinois Department of Public Health epidemiologists confirmed that chickens in Illinois were laying eggs contaminated with salmonella. The technicians determined that chickens' ovaries were infected and that the bacteria was being transmitted in intact eggs, not through cracks in the shells. Sampling indicated that as many as five eggs in 1,000 could be contaminated. The department issued a warning advising individuals to keep eggs refrigerated and to cook them well to kill the bacteria. It urged use of pasteurized eggs for hospitals and nurseries and in recipes calling for raw or undercooked eggs. And the department set about changing rules for handling eggs. The warning irritated Larry Werries, the director of the state Department of Agriculture. Werries accused the public health department of overreacting and said he planned to complain to Gov. James R. Thompson.
No complaints ever reached the ears of Dr. Bernard J. Turnock, director of the Department of Public Health. And Turnock expects none over what he quips was the charge that he was "defaming Illinois hens." Turnock maintains that his department is supposed to identify health hazards, attempt corrective actions and alert the public. He recalls the 1985 salmonella crisis that sickened 17,000 state residents: "Nobody was defaming Illinois cows at the time. We were trying to deal with and prevent health problems among people and provide them reasonable information."
Although Werries' complaints bother Turnock not a whit, other aspects of the salmonella situation do. He feels the media paid too little attention to the advisory that was based on sound public health work. "We were told, 'Well no one had died.' 'All right,' we say and we go on, but we continue to push that advisory because we think it's important," he says. "And perhaps no one will die."
That is Bernard J. Turnock the public health professional talking. You will likely never hear Turnock the politician speak, because there is no such animal. Turnock came to the department after Gov. James R. Thompson canned his predecessor for vacationing in Cancun during the 1985 salmonella crisis traced to the Hillfarm Dairy in Melrose Park. Amidst the hubbub over the outbreak that killed six, panicked thousands and spawned political accusations, one Thompson insider says that the governor looked for the best professional he could find. That turned out to be Turnock, who holds both medical and public health degrees. Turnock had been chief of the Family Health and the Emergency Medical Services divisions at the Illinois department from 1978 until 1982 before moving to the Chicago Department of Health, where he was deputy commissioner and, for six months, acting commissioner.
Turnock returned in 1985 to a department whose professional staff had been decimated. He found two other doctors with public health degrees, down from the eight to 10 who had been there when he first joined the department. He has gotten the number back to the 1978 level. "I think that's an example of the lack of depth of professional expertise in the agency and how that had deteriorated over time. I think one could make the same argument for public health nurses, or nutritionists or other kinds of public health professionals. That remains a problem," Turnock says.
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But those who run state agencies operate in both the professional and the political worlds, and Turnock has had his problems in the political sphere. In 1987, as a collection of AIDS legislation was moving through the General Assembly, senators balked at confirming Turnock's reappointment because of his opposition to portions of the package. And one insider says the director was reluctant to make the required, but often fruitless, calls on legislative opponents. When Turnock dispatched a trio of assistants to testify against the contact tracing bill, he riled many lawmakers, recalls Sen. Aldo A. DeAngelis (R-40, Olympia Fields). DeAngelis, sponsor of the voluntary contact tracing bill that passed, sees differences between Turnock's approach to AIDS and that demanded by constituents: "Health professionals want something to be clinically correct. The General Assembly tends to be a bit more reactive. I think that sometimes it's extremely difficult for a professional in a field to adjust to the political world as well. . . because they tend to be purists."
Eventually the two sides reconciled, and Turnock's appointment was confirmed. DeAngelis believes Turnock was in less trouble than most thought: "I don't think there was a capitulation on his part in trade for his confirmation." And DeAngelis has no problem with Turnock's administration of the AIDS laws that were finally passed.
Paul O'Connor, now deputy director for marketing with the Department of Commerce and Community Affairs but then an assistant director at public health, "worked" the AIDS bills in 1987. O'Connor says that during that debate Turnock stood virtually alone and weathered a firestorm from the General Assembly on one side and the gay community on the other. "He's an ideal public servant. He does what is the right thing to do and he offers himself up to take the heat." O'Connor has gotten the credit for winning Turnock's confirmation but says he should not: "The conventional wisdom in the frenzy of the hallways was that they [Turnock, revenue director Roger Sweet and nuclear safety director Terry Lash] were in trouble. When it came right down to it, the will of the governor prevailed. I got a lot of credit for getting him through the process, but I didn't."
What did clear the process was a package of 17 bills, down from the 69 AIDS bills that were introduced. O'Connor says that Turnock worked with Thompson to decide which bills should be signed, which vetoed and which changed with the amendatory veto. "I think it was the best that could have happened," O'Connor says. "What evolved out of the governor's office was, I think, a brilliant patchwork quilt. There was an accommodation and the public health was served."
And O'Connor suggests that Turnock's understanding of politics may be better than most give him credit for. He suggests that Turnock quietly takes the heat: "In the political tactics of survival and moving forward an agenda, I think he's pretty good." O'Connor also tags Turnock's refusal to be moved by politics as a strength: "The positions he takes so strongly are not because he's got an intransigent ego, it's because it's the right thing to do based upon medical science and practicality. He just will not move from those. His confirmation before the Senate and his paycheck were not sufficient reason. That's not because he's a butthead. It's because he thinks it's the right thing to do. I know some of these are alien concepts."
Jeffrey C. Miller, Thompson's chief of staff, acknowledges that Turnock does not get on as well with lawmakers as some directors, but says he is getting better. And Miller says that sometimes it should not be expected: "On issues like how to deal with AIDS, Barney's role is to represent as forcefully and effectively as he can the consensus judgment of the public health establishment, where he shares it. If in fact he does that there are members of the General Assembly he is not going to get along with. It's as simple as that."
Senate confirmation was not the only trouble that Turnock got himself into during 1987. When it came time to take the budget cuts forced by the failure of Thompson's tax increase, Turnock opted to whack programs that served a relatively small number of chronically ill individuals and to keep money for prevention programs. The $.5 million that the state had spent to buy clotting factor for 150 hemophiliacs was eliminated. Money for kidney dialysis was cut from $1.5 million to $.9 million. And state funding for organ transplants was reduced from $1.9 million to $.9 million. Turnock was accused of pulling the plug on the ill and of returning to medieval medical practices. Before lawmakers restored the money, Turnock and Thompson were berated for bureaucratic barbarism.
Turnock says the decision to cut the programs was not easy but was right. "I think we're forced to make choices, and I think we have to be true to the principles of good government and good public health and make judgments about what the most efficient use of those resources would be." And in choosing to emasculate programs that served a few in favor of prevention programs, the department tangled with the penultimate health question: "Perhaps more than anything else this is the classic and the cosmic prevention-versus-treatment argument."
The depth of the reaction did not surprise Turnock, who argues that such debate must be forced. "Everybody has to deal with this issue of resources and what's the responsible role of government. Either we can accede to the loud, vocal interest groups and not serve the public, or we can try to move to where there's more of an equilibrium between prevention and treatment." And it is not a battle that is being waged only in Illinois. Oregon has eliminated payments for transplantation services and now uses it for prenatal care. Turnock says he would, if allowed, do the same thing again, knowing that there would be howls of protest: "It's something we've got to do or we're letting other and not necessarily the right voices dictate the direction and the priorities we're taking. And I think that's happened too long in this agency and a lot of other state agencies."
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After getting himself in plenty of trouble in 1987, Turnock jumped back into the frying pan again in 1988. Even before he defamed Illinois hens, the director was tangling with the Illinois State Medical Society over new AIDS legislation. The society had gotten an amendment added to a bill in conference committee on June 29 to allow doctors to test patients for AIDS without the informed written consent required under the 1987 AIDS bills. Turnock lobbied hard and publicly for a veto of the measure. He wrote columns in newspapers across the state seeking pressure for a veto.
Turnock fears that individuals will be less likely to come forward for voluntary testing if they think they may be tested without their knowledge. He fears that doctors will focus attention on those who test positively for the virus and not spend enough time counseling those uninfected but at risk because of their lifestyles. And he fears that testing will increasingly fall to public sector testing sites. Turnock calls doctors the "pillars of private enterprise" and says they believe that government should not interfere in the doctor/patient relationship. "I think sometimes they don't fully appreciate the implications of what they do and what they may do very well in their private practice, and I assume that they have the same feelings about public health people, that we don't fully appreciate and understand the burdens that government can bring to the doctor/patient relationship."
When decision time arrived, Thompson sided with the doctors and signed the bill into law (P.A. 85-1399). Turnock says he believes that Thompson found his concerns abstract and believed they would not necessarily come true. One administration insider sees no great import in the governor's siding with the doctors over his public health chief. "He [Turnock] is still here. That's all you need to know. I don't think Thompson objects to people disagreeing with him, particularly if he can see and understand their purpose."
For his part Turnock says that Thompson is a good boss. He has found the governor, whose father is a doctor, more sympathetic to health and public health issues than someone from a different background. "He certainly gives issues a fair shake, even very difficult issues. I'm amazed at his quick grasp of many of the nuances of many of the issues that we deal with and at the range and the scope of the questions that he asks about these things."
Turnock acknowledges that he has gotten on less well with the lawmakers on some issues, most notably AIDS. He believes the department works well with members of the General Assembly on constituent concerns and with the legislators who specialize in some of the public health issues. He acknowledges differences over AIDS: "I'm not sure that is representative of their general feeling on public health or health in general. I think it's more reflective of how difficult and volatile AIDS issues are in general and of the pressure on them to help solve this legislatively."
Turnock arrived on the scene with public health, here and across the country, in disarray. Nationally the focus on health programs had shifted from the prevention cherished by public health professionals, to high technology treatment alternatives. The successful campaigns against polio, measles and smallpox are just a memory. "I think probably public health has been quiet or silent too long here in Illinois about some of the basic prevention strategies," Turnock says. "As we conquer all of the infectious diseases and the sanitary type problems and many of the specific health care conditions, we come back to a series of health problems that we will never be able to deal with adequately until we stress primary prevention. It becomes clearer and clearer that public health and prevention are the right responses to these problems."
Those who work with him characterize him as a cool professional. "I think Barney is the consummate public health professional," says Dean Schott, who served as spokesman for the department before moving on to the Department of Public Aid. Schott recalls early in his tenure agency staff coming to Turnock with the day's crises: food tampering with Jell-O, salmonella in a fast food restaurant and a heat emergency. Turnock's advice: "Relax, relax." Schott says, "That's the kind of air that he exudes. Relax. Take care of your job. Be professional."
Sometimes that has meant changes in the way public health is approached. James W. Masterson, deputy commissioner of the Chicago Department of Health, worked for Turnock when he was in Chicago and with him since. Masterson says that his former boss stressed outcomes, implementing a system that monitored hospitals according to birthweights and race-specific adjusted mortality rates. Hospitals whose outcomes were good could get waivers if, for example, their cribs were an inch too close together. Those whose outcomes were poor got attention even if their cribs were far enough apart. Masterson says that the department got national attention for that innovation and that hospital regulation has since begun to move that way. "The system that we put in was visionary and that was Turnock's nucleus of an idea, making sure that outcomes are good."
Former assistant O'Connor says the thing least known about Turnock is his sense of humor: "It's almost constant, and when you get tuned in to him it's like a comedy hour all the time." Turnock displays it in turning aside a question about how a Democrat got to run a major agency for a Republican governor: "I'm also a Catholic and I figure that doesn't make any difference either."
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Turnock identifies five top public health issues in Illinois, but declines to rank them: infant mortality, cancer, heart disease, injuries and AIDS. He sees progress on all: Infant mortaility down 40 percent in 15 years; fewer deaths from heart disease; reductions in number of some cancers; declines in injury death rates; indications that the rate of transmission of AIDS has declined. He also sees more to be done in all areas.
He sees losses, too, primarily in access to health care. Services are unequal and maldistributed, and the number of people without health insurance is increasing. Traditional institutions like hospitals are threatened. "We have all kinds of employers these days who don't provide insurance to their employees, let alone their dependents. There are just so many gaps, and the gaps are increasing because we're becoming more and more of a service-related economy with low paying jobs and lack of benefits and limited ability of Medicaid and other public assistance programs to pick up the slack. So both the private as well as the public sector are going to have to begin to take more responsibility."
Turnock likes public health and the people he works with. He is less fond of "government," where he finds requirements for financial transactions, personnel actions and budget development more cumbersome than they need to be. And he finds it difficult to expand programs that need more money but lack the appeal of AIDS prevention or infant mortality reduction. "We don't have people coming down encircling the Capitol who are there because they didn't get measles. So we're left with logic and reason. To try to use those tools in the process often doesn't convince the Bureau of the Budget or the appropriations committees."
When Turnock, age 41, is not defaming chickens and otherwise running the health department he chases little kids. He and his wife Colleen have four sons aged 10, 4, 2 and 1. They expect a fifth child in March. "Most of my spare time is very productively channeled with them," he says. With only the one son he had found life manageable. "With a lot of little kids it's very tough and demanding. It's much more rewarding to spend time with them than go off to work." In his younger days he also ran, played golf and basketball, and "like everybody else down here" played softball. Jeffrey Todd, executive director of the Illinois Public Health Association, describes Turnock as an "unpretentious person. He drinks beer and doesn't play golf very well."
There will be little respite at the office for Turnock, however, with the plans he has set out for his department. The highest visibility effort will be against AIDS, and there he sees a chance for more federal funds and hope for more state money. He cites polls done by the department (See "The Pulse" on page 30.) as reason to hope that the education campaigns have reduced transmission rates: "There has been a lot of progress made in the last few years that will eventually result in thousands of cases of AIDS being prevented in this state."
More needs to be done. The prevention, education and testing activities as well as public school curriculum must be institutionalized. Voluntary testing must be encouraged, and any obstacles presented by P.A. 85-1399's elimination of mandatory written consent must be overcome. Turnock sees little hope of repeal of the controversial law because the damage is difficult to document. He is readying an effort to repeal the requirement for premarital testing for AIDS, which turned up 15 positive tests among the 125,000 administered in its first nine months. It also saw a 20 to 30 percent decline in marriage licenses issued, Turnock says. The tests are expensive, ineffective because most of those at risk avoid the tests and a problem because of false positives. "We're bringing all of that together for a report that will provide a foundation for folks to relook. Then we will push to get it repealed, but it will be a bloody battle."
And he is using the T-word, just before the election. Turnock would like to raise taxes on tobacco: "There's a state tax on cigarettes, but there's not a state tax on snuff or chewing tobacco. And we could actually benefit from an increased tax on cigarettes." Higher taxes would raise money and discourage use. "It's sound public policy," he argues.
Turnock says that he's doing what he wants to do. The growing awareness of public health's role in controlling the spread of AIDS will bring more attention to him and his department. Public health professionals praise Turnock for boosting and revitalizing the Department of Public Health. His peers praise him for his willingness to take unpopular and unpolitical stands. If only they could convince him to quit picking on Illinois hens.□
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