Betty's In Charge

Is Dallas County's most explosive bureaucrat ruining the health department?

Betty Culbreath sits intently on the edge of her chair, her elbows planted on her desk and drawn tightly to her coiled frame. Tension emanates from her, like beams from the virescent lamps used to zap germs in the tuberculosis clinic several floors below her office in the county Health and Human Services building.

One of the most powerful administrators in Dallas County, Culbreath is visibly perturbed at the prospect of being questioned.

Her large almond eyes glare through a pair of red-rimmed glasses. She speaks in a steady, deliberate voice that is uncharacteristic of the veteran bureaucrat, who is better known for her blunt mannerisms and stinging outbursts.

For the first time in her 12-year county career, Culbreath's professional credentials have been questioned. There have been questions by doctors. Questions by employees. Questions by reporters.

Clearly, Culbreath is sick of the questions.
They have dogged her since last October, when the Dallas County Commissioners voted to merge the health and human services departments--two of the most essential county agencies--into one unit, a move prompted by the abrupt resignation of health department director Dr. Randy Farris. In the same stroke of the pen, the commissioners named the 55-year-old Culbreath as the combined departments' executive director.

The promotion made Culbreath the first non-physician ever put in charge of the health department. And, thanks to the whopping $22,000 raise that came with it, the former right-hand aide to Commissioner John Wiley Price is now in the top tier among Dallas County's 5,400 employees in compensation: She earns $90,000 a year.

In the relatively obscure world of Dallas County politics, Culbreath has become Price's most prominent protege. Since he hired Culbreath in 1985 as a low-ranking, $24,696-a-year administrative assistant, Price has taken Culbreath in hand and guided her straight up the county's employment ladder. And it was Price who worked hardest to give Culbreath her biggest promotion to date--the reins to the merged departments.

It's not that Culbreath isn't a capable administrator. In fact, she is widely respected as a bare-knuckled, no-nonsense manager--a reputation she earned first as Price's aide-de-camp, then during her five-year tenure as the director of human services, and finally during a brief stint in 1993 as the interim director of the county's juvenile department.

Since her most recent promotion six months ago, Culbreath--who has never been mistaken for a shy or retiring type--has taken the health department by storm, causing more than a few eyebrows to rise.

After promoting two of Price's political pals to act as her bureaucrats-in-chief--including Zachary Thompson, whom Culbreath took from a $36,060 salary to $68,124 in four short months--Culbreath promptly deleted six managerial positions. She trumpeted her reorganization as a great cost-saving measure for the county, although county records show that, with employee raises taken into account, less than $200,000 will be saved out of a $33 million budget for the combined departments.

But Culbreath's big focus has been on the day-to-day operations of the health department. Already, Culbreath says she has brought order and efficiency to what was once a disorganized department. Walls are being painted and floors mopped. Once-cluttered rooms are now clean, their contents placed on shelves and properly labeled.

But Culbreath's attention to detail goes way beyond whether the public restrooms are clean. "We don't allow anyone to pop popcorn before 11 in the morning. You'd be surprised how many people come here hungry, and to have the smell of food cooking is just obnoxious," Culbreath said proudly during a recent walking tour of the offices, located in a drab county office high-rise along Stemmons Freeway.

Although it's hard to argue against clean, orderly medical offices--and the prospect of fewer bureaucrats pushing papers in them--there's a much bigger issue at hand now that Betty Culbreath is in charge of protecting the health of the 2 million people who live in Dallas County.

AIDS? Tuberculosis? Syphilis? Meningitis? For the first time in the county's history, there's no doctor on call.

Culbreath may have her employees marching in uniform at her command--popcorn safely locked away in drawers--but critics question whether she has any grasp at all of the county's broader health issues.

Last month, in a series of interviews about her new job, Culbreath was asked to explain what the county's health needs are and how she plans to meet them. She paused before answering. "Well," she said. "I can't tell you what the health needs are for the county."

The health department is one of those government agencies that catches the public eye only when something has gone horribly awry. The rest of the time, its work goes unnoticed by the average county resident.

But in times of crisis, the swiftness with which the department diagnoses and responds to an epidemic is critical--and can save lives.

In Seattle, for example, public health officials issued an urgent medical alert in 1993 when hundreds of people became violently ill after eating fast food contaminated with a strain of E. coli bacteria. More than 700 people got sick, and four children eventually died during the outbreak. On a smaller scale, Dallas County health officials, led by Dr. Charles Haley, instantly warned residents in 1995 when they detected evidence of an encephalitis outbreak spread by mosquitoes. Twenty people were infected with the disease; three died. Health officials mobilized quickly to spray insecticides and monitor local hospitals for people with encephalitis symptoms.

Most of the county health department's business, however, is routine. Its 178 employees ensure that the water supply is safe to drink and the air safe to breathe. They also carry out tasks such as inspecting houses and restaurants, collecting rats, and monitoring sewer systems.

The department also controls the spread of diseases such as AIDS and tuberculosis through a variety of immunization and early-prevention programs and clinics. If there's an outbreak, staff doctors and nurses act quickly to prevent illnesses and deaths by coordinating treatment among public and private health professionals throughout the county.

"A health department is basically a medical office," says Dr. Charles Haley, who resigned last month as the department's epidemiologist after more than a decade in the job. "The work is done under standing doctor's orders. A physician cannot take a medical order from a non-physician. Nurses can't give shots without an order."

In some ways, the health department also functions as a police force. It has legal authority to enforce quarantines, ranging from the routine confinement of people infected with disease to the removal and destruction of tainted food products.

"If you have a prostitute that is infected with syphilis, you have to go out and find that person and treat them, regardless of whether they want you to find them," says Haley, who has earned a national reputation for his public health expertise.

Since so many of the health department's functions require a doctor's authority, local medical officials were shocked by Culbreath's appointment as director of the health department. But commissioners made the move in such a stealthy manner that doctors never had an opportunity to organize any opposition.

The changes followed Dr. Randy Farris' announcement last September that he was resigning as the health department's medical director to take a job with the U.S. Public Health Service in Dallas. The department had stood alone since it was created, but Farris' departure paved the way for commissioners to fold it into the county's human services department, which Culbreath had headed since 1991.

The merger--and Culbreath's appointment as head of the combined departments--was carried out virtually behind closed doors, discussed in secret by the court and revealed to the public only as a done deal. When announced, it immediately set off alarm bells among area health professionals, who rely on the health department for a wide range of medical services.

The ill feelings worsened in December when word was leaked to the media that Culbreath was quietly reorganizing the department and eliminating several medical positions. Soon afterward, longtime employee Dr. Charles Haley announced he was resigning as the department's epidemiologist.

Until now, Haley has publicly declined to criticize Culbreath, citing new job opportunities as his sole reason for leaving his county post. But last month, in an interview with the Dallas Observer, he confirmed speculation that the new administration contributed to his decision to leave.

"I don't know that these changes are necessarily bad, but they were ones that I was uncomfortable with, and I didn't particularly want to stay," Haley said. "Decisions seem to be done in a more compulsive manner, rather than a deliberate one."

The departures of Farris and Haley--the department's two top docs, both of whom were highly regarded--left the department short of doctors. Only three physicians remain on staff today, besides those assigned to the jail, which has its own medical staff. This skimpy depth chart has made area health professionals wonder whether the department is even capable of making competent medical decisions on a day-to-day basis--let alone during a crisis.

"I was alarmed because of the turnover and the instability. Ultimately, if it [the department] fails, Parkland will be the recipient of that," says Dr. Ron Anderson, CEO of Parkland Memorial Hospital.

Anderson is hesitant to criticize Culbreath, however, whom he grew to respect while she served as a member of Parkland's board from 1989 to 1991. "Her heart for public work was always there for the patient," Anderson says. "When political things happened here, and she was John Wiley Price's appointee and he asked her to vote a certain way, she voted her conscience."

But Anderson's concern for the well-being of Dallas County residents goes far beyond any collegial admiration for someone. Although Anderson would never say so, he, more than anyone else in Dallas, understands how severely limited the county commissioners are in terms of understanding--or even caring about--public health issues. Middle-aged, white, heterosexual Republican men whose lives revolve around the Christian Coalition and the Rotary Club do not typically feel threatened by the galloping spread of sexually transmitted diseases.

Nonetheless, these are the men who approve Anderson's hospital budget and criticize him constantly for taking high-profile stands on controversial medical issues. Anderson--to his credit--spoke openly about the dismantling of the county health department, and what he's trying to do about it.

Anderson and some of his colleagues have been pushing Culbreath to recruit a replacement for Farris--who, according to county documents, Culbreath had considered not replacing in order to save money. Anderson would also like to see Culbreath develop an overall health plan for the county.

"A city this size should have a pretty clear plan for what it wants to accomplish--what its responsibilities ought to be in public health," he says.

Anderson's sentiments echo those of other area health professionals, who say the health needs of the county will remain in jeopardy until Culbreath replenishes the supply of doctors in the department.

"There's 6,000 doctors that deal with county health issues on a daily basis. Where do they go to get answers to the questions they have?" asks Dr. Roland Black, president of the Dallas County Medical Society. "Right now, if a doctor calls me and says we have an outbreak of meningitis, what do I do? We have no place to go."

If Culbreath is to succeed in her new job of managing the county's health needs, she clearly will need to rely on the advice of local doctors, whom she can call upon as needed to make up for her lack of medical expertise.

Culbreath has recently started a dialogue with Black and his colleagues, but her relationship with them so far has been thick with tension.

Perhaps Culbreath would do well to stop reacting so defensively--and explosively--anytime someone so much as hints that things need improving over at her county health department.

When asked recently to respond to concerns about the lack of doctors on her roster, Culbreath went on a verbal tirade about doctors--particularly her predecessors, Farris and Haley--who, she claims, were so administratively incompetent that the health department she inherited was a disorganized, dirty, do-nothing mess.

"I didn't start the controversy. What is it? That I'm black, that I'm not a doctor? I haven't told not one doctor what to do, neither has one doctor been cut," Culbreath told the Observer. "The last doctor wasn't doing too good. Give me a break about your fucking doctors, who don't manage a damn thing. Shit, girl, give me a break about the fucking doctors."

In time, Culbreath may manage to build bridges to the area's doctors. If she doesn't, though, chances are her bosses on the commissioners court either won't notice or won't care.

The five-member court is dominated by men who are not only moral conservatives, but fiscal fundamentalists who never saw a social program they didn't want to gut or a salary they didn't want to freeze (except, of course, their own, which they consistently, and generously, raise). Not surprisingly, they run a sprawling bureaucracy that has also been historically short on high-ranking minorities--something that John Wiley Price has made a career out of exposing in bureaucracies citywide.

In 1995, national health officials sharply criticized the court when several commissioners waged a moralistic battle that forced the department to cease distribution of condoms and needle sterilization kits for AIDS prevention. The commissioners had attacked health department doctors and their colleagues who loudly opposed the cuts, including Ron Anderson and members of the Dallas County Medical Society, and accused them of promoting immoral behavior.

In a last-ditch effort to save the needle program, a coalition of Dallas doctors--including the brother of epidemiologist Charles Haley--unsuccessfully tried to persuade state legislators to change state law in an attempt to recall commissioners Jim Jackson, Mike Cantrell, and Ken Mayfield.

Two years later, those commissioners haven't forgotten the gesture.
"Is this the same [Dallas County] Medical Society that in the last session of the legislature was going to go down and get a bill to have the commissioners recalled? Yes it is," says Jim Jackson, the ringleader of the court's conservative majority. "These guys are not my friends, and they're not going to like what I do."

Jackson, one of only two commissioners who returned the Observer's phone calls, says the merger of health and human services was designed to streamline bureaucracy and save money. Although Jackson dismisses fears that the court is cutting back on health services, he's unwilling to elaborate on why Culbreath was appointed and why she subsequently reorganized the departments.

"We should have a department that puts out a good value for the dollar spent," Jackson says. "I don't know what it is that she may or may not be planning for the next six months, but I will tell you that I have a lot of faith in her."

It's easy to see why. The commissioners court would blindly back Culbreath in this position for many reasons. Consider this: She's cheaper than a doctor. She has disdain for doctors. She's a taskmaster with no qualms about cutting people at the knees--especially if it plays to the commissioners' tight fiscal desires. And she's close to John Wiley Price, who was the only commissioner who fought like a tiger against his brethren in an attempt to save the needle program.

So what if the department becomes controversial again--or proves to be a shadow of its former self? The court appointed the perfect candidate to defend its politically scarred health department. After all, who's going to argue about needle distribution with a former social worker who has a drug-addicted son and is famous in the African-American community for helping people in need, oftentimes with money from her own pocket?

But Culbreath's clout extends even farther than that. Outside the county bureaucratic machine, Price has helped Culbreath build a formidable political career. She has held a host of positions on various city and county boards, all of which culminated in February with the appointment of Culbreath as chairwoman of the Dallas/Fort Worth International Airport Board--a powerful seat that is guaranteed to boost Culbreath's profile locally and nationally.

County Judge Lee Jackson admits Price "pushed hardest" for Culbreath's appointment to lead the merged departments, but says her performance as the human services director made her the obvious candidate for the job.

"It was a pretty short transition from the discussion about an interim directorship to whether there was some possible synthesis between the two departments," Jackson says. "Almost instantly, it [the merger] became a permanent possibility. As soon as we began that discussion, Betty Culbreath was one of the first, if not the first, names to be suggested."

The discussion lasted most of September, but the court's public agendas contained no mention that a merger was being planned. All discussion took place behind closed doors, under the premise that the court was simply discussing a personnel matter.

On October 1, the court formally announced Farris' resignation and appointed Dr. Eunice Stanfield, a staff physician, as the health department's acting medical director. No mention of a merger was made in the minutes of the court's agenda, but clearly the court was already moving in that direction. Culbreath had been lobbying in favor of the idea for weeks.

Culbreath had informed the court by memo that a merger could save the county about $71,044 annually, mostly savings from Farris' $126,792 annual salary. Money from Farris' salary--which was meager compared to those of private physicians--would instead be used to give raises to Culbreath and her soon-to-be announced assistants.

"The proposed merger of Dallas County Human Services with the Dallas County Health Department is a good idea and will work," Culbreath wrote the commissioners in a memo dated September 24. "The full impact of the merger should be realized during the next 90 days."

On October 8, the commissioners voted unanimously to merge the departments--and make Culbreath the director of the new Dallas County Health and Human Services Department.

No one is saying that Culbreath doesn't have the skills to manage the new mega-department's 217 full-time employees and its $33 million budget. She is good at getting ducks in a row. But Culbreath's new job description is to protect the health of the county's 2 million residents. And no matter what she says about the so-and-so doctors, that's a whole new ball park for her.

Betty Culbreath says she hasn't forgotten that it took her 12 years to land in her expansive office overlooking Stemmons. When she moved into it, she brought with her an old chair that now stands sentry in the corner.

"Every day I look at that chair because, you see, I know where I come from," Culbreath says. "I know where I can go back to, and I ain't scared to do that."

The chair--its vinyl upholstery split by time and wear--was assigned to Culbreath in 1985 when she began her ascent as a career county employee. While Culbreath says she has discovered that public service is her mission in life, you could also say that public service sure beats Culbreath's former life in the private sector.

From October 1983 until June 1985, Culbreath was in charge of store security at Eckerd Drugs, where she was assigned the task of controlling loss prevention. The job paid $21,000 a year.

In the summer of 1985, when Culbreath was laid off from her job at Eckerd, she went to work as Price's administrative assistant in his county Road & Bridge District No. 3, where she earned $24,696 a year. Price referred her for the job. Over the next six years, Price consistently gave Culbreath great job reviews and steady raises. By 1991, when Culbreath was named director of human services, she was earning $55,000 a year.

As Price's longtime assistant, Culbreath quickly became known as a woman who gets things done--especially by her personal efforts to guide needy constituents through the confusing world of government agencies. Among dozens of Culbreath's legendary good deeds, she personally helped an ex-inmate get on the road to self-sufficiency upon his release from prison--to the point where she dug into her own pocket to buy him an identification card so he could begin job hunting. Another time, Culbreath bought a pink bicycle for a man who was laid off on Christmas Eve and couldn't afford to buy a gift for his daughter.

While Culbreath was taking on the burdens of so many others, she had her own serious problems as well. Her son, Dirk Culbreath, was a crack cocaine addict who ran afoul of the law several times because of his drug problem. (In 1985, he pleaded no contest to misdemeanor theft; in 1992, he pleaded no contest to misdemeanor handgun possession; and in 1995, he pleaded guilty to felony cocaine possession and was placed on five years of probation.)

Culbreath says she worked tirelessly for seven years to help her son.
"It's not a sore spot because he's a substance abuser," Culbreath says. "It's a sore spot because from day one that I found out my son was on drugs in 1992, I went everywhere that you could go to get some help for my son."

Considering her experiences with her son, Culbreath is--not surprisingly--a believer in a tough-love management style that treats employees like family.

"You got to discipline your disobedients, but you also got to praise 'em when they're doing good," she says, adding that she leads by example. "I wouldn't ask any employee in this building to do anything I wouldn't do. And I do it all. I move furniture. I move boxes. I mop. I clean bathrooms. I pat patients on the back. I do all of that."

But life under Culbreath is no honeymoon. Two weeks into her new position, Culbreath issued a memo-ultimatum to the troops that made it clear who was in charge--and who wasn't. "DO NOT GIVE ANY INFORMATION TO ANY MEDIA PERSONS REGARDING HEALTH AND HUMAN SERVICES," Culbreath wrote in the one-page memo to staff. Only doctors were allowed to speak to the press, she stated.

Culbreath tightened the leash on her employees again on November 8, 1996, when she ordered that all outgoing correspondence must first be reviewed by Zachary Thompson, the former human services operations manager, who Culbreath promoted to be her deputy director and spin doctor.

"Recently, correspondence went out with grammatical and spelling errors. This type [sic] activity is unacceptable as it reflects on the Department," Culbreath wrote, overlooking her own grammatical error. "Mr. Thompson will ensure that correspondence is correct and return it to the individual submitting the information following his perusal."

In those early weeks, if anything was clear, it was that Culbreath was calling the shots and nobody should bother to ask why. In signing off on one memo, Culbreath wrote: "Your cooperation is mandatory."

When Culbreath subsequently instituted her big departmental reorganization--eliminating six positions, while promoting two Price-Culbreath acquaintances--the rank-and-file in the health department began buzzing. There had been no warning, no meetings. Just a memo from the boss.

Culbreath didn't bother to gather input from anybody in the department, either, including the medical staff.

"I don't know of anyone who was involved in those discussions other than the commissioners and Ms. Culbreath. We were told what happened, and that was that. There was no input from us," says Dr. Haley.

Former TB program manager Charla Edwards, whose position was eliminated by Culbreath, echoed Haley's comment.

"There was no communication to the program managers. We had no indication that our jobs were being eliminated. We were called in and told," Edwards said in January, before she left the department to take a job at Parkland. "Everybody is in shock. It's all politics."

Culbreath's surprise reorganization--and the subsequent in-house buzz--prompted Culbreath to shoot off another tough-love memo. "The gossip must stop," the missive stated. "The merger is complete and any attempt to damage the Dallas County Health and Human Services Department or its reputation will result in violation of Dallas County policy and procedures. Discipline measures will be taken."

Reorganizations take place every day in the public sector. Sometimes employees like them; often they don't. But they generally don't become big news outside of that department--unless, of course, the boss is inexplicably threatening to cut fingers off the unhappy. Therefore, it should not have come as a surprise to anyone--least of all Culbreath--when the malcontents began quietly talking to the press, in direct violation of the boss' orders.

On Christmas Eve, The Dallas Morning News printed a lengthy article about the "quiet reorganization" of the health department. Instead of merely explaining what she was doing, Culbreath recoiled, accusing nearly everyone under her of being misfits and incompetents, and calling in her favorite political pit bull to defend her honor. "The work product out there was horrible," John Wiley Price told the Morning News. "We don't need a lot of people sitting around drinking coffee and taking smoke breaks...that was happening all the time."

Culbreath piled on, claiming that "people were not doing any work."
Today, when Culbreath is asked a simple question--Is there some reason why she didn't discuss the reorganization with Haley or any other staff members?--her response is vintage Betty Culbreath.

"But who in the hell?" she says exasperatedly. "Listen here, honey. Listen baby, sugar, honey. When you go on a job, do you tell your boss what you supposed to do or do your boss tell you what you're supposed to do?"

Parkland's Ron Anderson says the merger of health and human services ultimately could be beneficial, because the new structure would allow the politically astute Culbreath to act as a buffer between the department and the increasingly conservative commissioners court.

But Anderson adds that the structure will only work if Culbreath hires a strong medical director and empowers that person to make independent medical decisions.

"It's like running a hospital," he says. "Very few hospitals have a physician CEO. Those that do not, though, need to have a very, very strong medical director. And they need to work as a partner, not as a subordinate-superior type relationship. They need to work together as colleagues."

Culbreath's decision publicly to accuse her predecessors of incompetence only makes matters worse. Besides, Anderson says, it makes no sense from a management perspective.

"I said [to Culbreath], 'If you're looking to rationalize this [the reorganization], do it some other way. Don't make people look like they've been bad people after all these years they've given to Dallas County,'" Anderson says. "When I do a job elimination, I do it because I have done a job study. When you're talking about somebody's work productivity, you have to know what the work product is supposed to be."

Last month, Anderson says, he was pleased when Culbreath asked him to tour some of the department's community-based clinics and invited him to serve on a selection committee for a new medical director. The gesture was a "positive sign" that Culbreath is breaking the silence between her administration and the medical community. Even so, Anderson says, Culbreath needs to focus on developing a long-term health plan for the county.

"That's why I've been very candid with Betty and want to help her," Anderson says. "We would be glad to sit down with her and craft a strategic plan for public health."

So far, though, Culbreath appears to be following her own counsel.
Ken Williams, the environmental health manager for Grand Prairie, says he has had no contact with anyone in the department since the merger. "They should be including us in the decision making, because we are ultimately their customer, and they don't know what their customers' wants and needs are at this point," Williams says. "The people who used to know that are no longer there."

Tom Hatfield, director of health in Richardson, says he too is disturbed by the silence.

"There hasn't been any communication," says Hatfield, who adds that Culbreath hasn't bothered to inform him who he should call in the event of an outbreak.

If a case of hepatitis were detected in the city, for example, Hatfield says he normally would have called Dr. Farris or Dr. Haley. "Now, I suppose I would contact someone on the communicable disease staff, but I don't know who that person is," Hatfield says.

With 155,000 students, the Dallas Independent School District is probably the county health department's biggest client. Dr. Richard Adams, the district's health officer, says he will have to bypass the county in the event of a medical emergency until a new medical director is hired.

"Dr. Haley has worked with us very closely for 12 or 13 years. Not to have that kind of expertise at-telephone is going to cause a problem for us," Adams says. "We'll just have to go elsewhere for the expertise."

Going elsewhere means calling on doctors at the Texas Department of Health, the national Centers for Disease Control, or the infectious control experts at the University of Texas Southwestern Medical School. But these doctors' resources are limited, and they don't have the same ability to act swiftly in times of emergency.

"The health department is the only one that has the authority to actually make an official public health decision," Adams says. "There are a lot of ways that the public health department needs to interact, and having an epidemiologist or a physician there with expertise in communicable diseases is just critical to the public health." Besides Stanfield, only two non-jail doctors remain on the health department's staff--Buu Nguyen and Barbara Gallagher. Both are highly trained in the area of communicable disease, but their workdays are consumed by patients who visit the department's TB and STD clinics.

The displacement of doctors from the department hasn't gone unnoticed among members of the Dallas County Medical Society, who have held a series of meetings to discuss these recent changes.

During an interview in late February, Dr. Roland Black complained that Culbreath had ignored the society's requests to provide information about the changes and did not respond to a written invitation to address its board at a March 4 meeting.

"I don't know why there's no receptivity from the other side of the river on this," Black said on February 26. "As of last night at nine o'clock, we've had no response from her or her office. It's not that we insist on being in the loop, but we'd like to be tangential to the loop. We'd like some information."

Culbreath could not have cared less.
"What are their goddamn concerns? If they got some concerns, why in the hell ain't they over here trying to help?" Culbreath told the Observer. "What the fuck have they done lately for the public health department?"

Culbreath finally did address the society during the March 4 meeting, expressing her renewed commitment to hiring a medical director and an epidemiologist. Although civil service documents show that Culbreath had set aside $66,000 to pay the new medical director, she told the board that the salaries for both positions have now been made negotiable in the hopes of attracting qualified candidates.

"The fact of us starting a constructive dialogue was accomplished last night," Black said after the meeting, adding that he will designate a liaison to work with Culbreath in the future. "The bridge has been built. I'm smiling today."

Seated in her sixth-floor office, coiled and stiff with tension, Culbreath doesn't sound very enthusiastic about the prospect of working side-by-side with members of the local medical community. In fact, the supposed arrogance and incompetence of the department's departed doctors continue to occupy her mind.

"We had people who thought that they owned certain parts of this agency. And it's real different in this health thing," Culbreath says. "Health-care professionals are kind of cliquish. They really believe that nobody has any sense but them."

To illustrate her point, Culbreath picks up a sharpened pencil and makes a mark on a piece of paper before her.

"Suppose you're a phlebotomist, and your job, all day long, is to be over in the HIV testing clinic, and all you do is draw blood. Somebody's got to furnish you with the needle. Somebody's got to furnish you with the tubes you shoot your blood in," she says, penciling two identical marks next to the first.

"Somebody's got to pick the tube up and take it to the lab," Culbreath continues. "Somebody's got to mop when your blood drippings fall on the floor. Somebody has to do your report on that blood drawn."

As Culbreath speaks, she gazes closely at the paper and begins making another row of marks directly underneath the first row. Soon there are three rows, each containing three marks, that are vertically arranged and evenly spaced. The drawing looks like an army formation.

"All you did was drew the blood. So then, what makes you the phlebotomist Jesus?" she asks, drawing a tight circle around the formation and marking an X at the top. "If you--the phlebotomist Jesus--can do all of this and get that patient his result back, then you would be Jesus. But you, the phlebotomist, can't do nothing but stick a needle in the arm and draw some blood.

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