Dying of neglect in Oregon

Chris Bouneff

In October 2009, a man died in the Oregon State Hospital in Salem. His name was Moises Perez. He was 42 years old, and he had been in the hospital for 15 years. According to a report from the State Office of Investigations and Training, his daily routine was eating, sleeping, watching the Price Is Right, and being picked on by other patients.

He was overweight and had a heart condition that threatened his life. His family visited him every week and tried to advocate for him. But in the end he died. Officially, he died of a medical condition. In truth, he died of neglect. The state of Oregon allowed him to rot to death at what can today be loosely termed a hospital. I write this not to point fingers but to make a point. More than 40 years after Ken Kesey published his novel on state mental institutions and more than 30 years after the movie version was filmed on those very grounds, the Oregon State Hospital is still a reflection of the Dark Ages of treatment for those living with mental illness.

My involvement with the state hospital goes back about 10 years. Ten years ago, state leaders recognized the problem. They professed how much they cared. They said changes were forthcoming. We’ve moving as fast as we can, they said.

Some two years ago, the U.S. Department of Justice issued a scathing report of clinical treatment and living conditions at the hospital. The DOJ issued its report under the threat of a federal lawsuit. In response, there were legislative hearings and pages and pages of Excel spreadsheets advertised as “crosswalks” that showed what was going to change. There was a flurry of activity, assurances of movement. Things were happening rapidly. Improvement was coming. We’re serious this time. We’re moving as fast as we can.

Two years later, Moises Perez died of neglect. For those of us who hoped the state was serious, that leaders who had direct oversight of the Oregon State Hospital were really serious this time, the OIT report came as a shock. As I read it, I alternated between rage and tears. No one -- absolutely no one -- should live the life that Moises Perez lived.

This time around, the organization that I represent -- the Oregon chapter of the National Alliance on Mental Illness -- along with Mental Health America of Oregon and Disability Rights Oregon aren’t taking state leaders at their word. This time around, we want the state of Oregon to enter into a formal agreement with the U.S. Department of Justice that spells out exactly how things will change and, more importantly, when things will change. If the state is unwilling, we want DOJ to sue the state. One way or the other, we want actual change.

Because I’m tired of hearing the same words. In response to our call, the governor and leaders who oversee the state hospital have offered the same words of assurance. This is an Oregon problem needing an Oregon solution. We’re very concerned. This was a wake-up call. We’re moving as fast as we can. This from a governor who officially becomes a lame duck as of November and from leadership who may be replaced soon thereafter.

A colleague of mind in the mental health advocacy community has been waging this same battle since 1986. He’s been hearing these same lines for more than 20 years. I just hit 10 years. I respect my colleague more than he will ever know and would be grateful if I could emulate only a fraction of his career. But I don’t want to look back 20 years later and be able to make the same claim.

We don’t need talk. We need somebody to do something. We need real action. We need changes soon. And we need real accountability.

Recently, a spokesperson working for the state said, as part of a longer statement, that “today’s hospital is not the same one it was a few years ago.” I agree with that portion of her statement. The problem is it’s the same hospital that was depicted in Kesey’s novel in 1962.

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