For the family of victims, current and former employees and congressmen alike who have listened to the debate over the cause of the deadly Legionnaires' disease outbreak at the Veterans Affairs Pittsburgh Healthcare System over the past 10 months, the most frustrating part has been the responses, or non-responses, from local and national VA officials.
Sometimes the VA has refused to answer questions; sometimes it has answered but deflected.
And sometimes, as the VA's undersecretary for health, Robert Petzel, did during a congressional hearing Monday before about 100 people at the Allegheny County Courthouse in Pittsburgh, the VA seems to ignore all the news reports, internal documents and federal investigations that have revealed at least some of what went wrong that led to the deaths of as many as six veterans and sickened another 15 in 2011 and 2012.
Dr. Petzel appeared at the hearing to try to convince members of the U.S. House Committee on Veterans' Affairs that the VA was doing all it could to make changes in response to problems at VA medical centers across the country, including the Legionnaires' outbreak in Pittsburgh.
"The lessons learned in Pittsburgh [after the outbreak] are now being used at all our medical centers," he told the two committee members and three Pittsburgh-area congressmen who appeared, emphasizing that there will be new Legionella-related policies nationwide to prevent such a problem from occurring again. "The VA is committed to providing the highest quality of care. Our veterans deserve no less."
Legionnaires' is a water-borne disease caused by the Legionella bacteria that, when inhaled into the lungs, causes a severe form of pneumonia that is often fatal. Research over the years has found that it can be prevented with various water treatment systems, like the copper-silver ionization system the Pittsburgh VA had in place for years until the outbreak.
But trying to make Pittsburgh part of a larger problem has been a continuing drumbeat from the VA since the Pittsburgh VA first revealed last November that it had a Legionnaires' outbreak, and it was not lost on VA critics in interviews after the hearing.
"The purpose of [the VA's explanation] is to take Pittsburgh off the hook and make it everyone's problem," said Janet Stout, a Legionnaires' expert who worked for the VA for three decades until she and her colleague, Victor Yu, were forced out in a dispute with management in 2006 -- a move many believe led to the outbreak.
U.S. Rep. Tim Murphy, R-Upper St. Clair, said he took note of Dr. Petzel's comment and saw it as "part of that disconnect that shows people [at the VA] still aren't taking responsibility for it."
After the hearing, Dr. Petzel also told reporters that the Legionnaires' outbreak in Pittsburgh was also at least partly the result of a broader "epidemic" of Legionnaires' cases that occurred in all of Allegheny County in 2011 and 2012 -- and not just because of mistakes made by Pittsburgh VA employees.
After a reporter passed on Dr. Petzel's claim, Legionnaires' experts and family members of the victims in the audience Monday said it was the first time they had heard of the outbreak being tied to any countywide epidemic -- a claim county health officials have never made.
"You're kidding," said Maureen Ciarolla, daughter of John Ciarolla, 83, of North Versailles, who was the first fatality in the outbreak when he died in July 2011. "Unbelievable."
"That's a new one," said Judy Nicklas, the daughter-in-law of William Nicklas, 87, of Hampton, the last veteran to die during the outbreak. "That's a new diversion tactic that they're hanging their hat on now."
Dr. Stout found the claim that an "epidemic" in Allegheny County was responsible for the VA's outbreak to be "another example of [the VA] not being accountable."
The problem with trying to say that Pittsburgh's outbreak is tied to a national, or even county, problem, is that the VA's own inspector general has conducted two investigations that found that the Pittsburgh outbreak had nothing to do with any of the VA's Legionnaires'-related policies, let alone a countywide epidemic.
The first report in April found that the outbreak was because of decisions people in Pittsburgh made to not follow the policies that were already in place.
The second report in August found that there was no national, systemic problem with dealing with Legionnaires' -- except in Pittsburgh. The only national problem, the report found, was that too many VA medical centers were not following all aspects of the 2008 Legionnaires' guidelines.
When asked by a reporter about the contradiction between the findings of the inspector general reports and the VA's attempts to use Pittsburgh's outbreak to make national changes, Dr. Petzel would only say: "We don't think [Legionnaires'] is a problem that just exists in Pittsburgh."
During the 3-hour, 20-minute hearing, Dr. Petzel engaged in a tough question-and-answer session with committee chairman, U.S. Rep. Jeff Miller, R-Fla., and Mr. Murphy over the VA's use of bonuses to reward senior executives.
Some of those who have received VA bonuses headed medical centers or regional networks where there were preventable deaths of veterans, including regional director Michael Moreland, whose area includes the Pittsburgh VA.
Mr. Murphy asked specifically about a $63,000 bonus Mr. Moreland received three days after the April inspector general report was released blaming the Pittsburgh VA for a series of mistakes that led to the Legionnaires' outbreak.
"If you knew then, what you know now, would you still recommend Mr. Moreland for this award?" Mr. Murphy asked Dr. Petzel.
"I would," Dr. Petzel said defiantly, drawing some chuckles and gasps from some in the audience, which included several dozen veterans and family of veterans.
Dr. Petzel said eventually VA employees will be disciplined for the mistakes that led to the outbreak. But the VA was prevented from acting because there is an unfinished criminal inspector general investigation into allegations that some Pittsburgh VA employees falsified Legionnaires'-related records.
"All we're told is that the investigation is continuing," he said.
Sean D. Hamill: email@example.com or 412-263-2579. First Published September 9, 2013 7:45 PM