Robert L. Citron dies at 87; central figure in O.C. bankruptcy

Robert L. Citron, the Orange County treasurer whose bad bets on exotic Wall Street investments resulted in what at the time was the largest municipal bankruptcy in U.S. history, died Wednesday. He was 87.

Citron died at St. Joseph Hospital in Orange of complications from a heart attack, said his wife, Terry Citron.

Until the 1994 financial collapse, Citron was a low-key bureaucrat who won praise from Orange County supervisors for earning much higher yields from the county's complex array of investments than many other government agencies. His investment pools attracted funds from governments around the country as well as from schools, cities and public agencies.

The county declared bankruptcy Dec. 6, 1994, buffeted by losses that, when the final count was tallied, amounted to $1.64 billion. The county was forced to postpone repayments on bonds it had sold, ruining its credit rating, but eventually repaid its creditors in full. The bankruptcy sent shock waves through Wall Street and the municipal bond markets. It also made national headlines, with some asking how such a prosperous county could become insolvent.

A grand jury investigation would later find that the treasurer who over the years won so much praise for his investment skills relied upon a mail order astrologer and a psychic for interest rate predictions as the county's treasury began to falter.

Citron pleaded guilty to six felony counts, including filing false statements to participants in the Orange County Treasury Investment Pool. His lawyer, David Wiechert, submitted medical testimony indicating that Citron was in the early stages of dementia.

Citron was sentenced to work in the county jail, sorting inmates' requests for personal items by day before returning to his home in Santa Ana. He never spent a night behind bars but worked for months in the jail's commissary. He remained on probation until 2002.

In a 1997 interview with The Times, Citron insisted that he was duped into making rashly imprudent investments by Merrill Lynch. He became a key witness in Orange County's $2-billion lawsuit against the investment giant. The suit said that Citron was a "pigeon" for greedy brokers at the investment house.

Merrill Lynch maintained that the bankruptcy was Citron's fault. It later settled the case with the county, paying $400 million.

A third-generation Californian, Citron was born in Los Angeles on April 14, 1925, according to public records, and grew up in Burbank. Because he had asthma as a child, his family moved out to the town of Hemet in the foothills of the San Jacinto Mountains. His father, Jesse, was a doctor who earned a measure of fame for being liquor-loving W.C. Fields' doctor and weaning him off Scotch.

Citron rose through the ranks of the county's treasury department to become county treasurer-tax collector, a post he held for 24 years. He was one of the few Democrats to hold countywide elected office in a region dominated by Republicans. He lived in Santa Ana, just a few miles from work, and was famous for his long hours. In a 1994 interview, his wife told The Times that the weekends were hardest for her husband because he could not go to work.

"He can barely stand the weekend at home," she said. "He can't wait to get back. I think he'd go crazy without that job."

The bankruptcy tarnished Citron's name as well as the county's. County government slashed hundreds of jobs and cut budgets. Orange County's repayment plan siphoned money from four county departments every year, affecting projects big and small.

Citron's assistant, Matthew Raabe, was convicted of fraud and misappropriation and served 41 days in jail before the verdict was overturned. Taxpayers spent $1 million on his defense. The county's financial director, Ronald S. Rubino, was tried on fraud and misappropriation charges, but a jury deadlocked in favor of acquittal. He pleaded no contest to one record-keeping violation under a deal that allowed his record to be erased after a year. County Supervisors Roger R. Stanton and William G. Steiner were indicted by a grand jury on grounds of failing to safeguard public funds. The indictment was later dismissed by an appeals court ruling that said failing to do their jobs wasn't a crime.

Citron is survived by his wife of 57 years.

scott.reckard@latimes.com

Times staff writers Shelby Grad and Robert J. Lopez contributed to this report.

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Deepening Crisis for the Dreamliner

Noboru Tomura/Asahi Shimbun, via Associated Press

An All Nippon Airways flight in Takamatsu, Japan, after an emergency landing on Wednesday.

TOKYO — The two largest Japanese airlines said Wednesday that they would ground their fleets of Boeing 787 aircraft after one operated by All Nippon Airways made an emergency landing in western Japan, heightening concerns about the safety of the U.S. manufacturer’s latest plane.

The 137 passengers and crew members aboard Flight NH692 from Ube, in western Japan, to Tokyo used emergency slides to leave the aircraft early Wednesday after battery trouble and an “unusual smell” in the cockpit prompted its pilots to land instead at Takamatsu airport, according to All Nippon, or A.N.A. The jet’s main battery in the front of the plane was later found to have become discolored and to be seeping electrolyte fluid, All Nippon said.

The public broadcaster, NHK, said smoke had entered the cockpit, although All Nippon could not confirm that report. One passenger was taken to a hospital with hip pain but was later discharged, All Nippon said.

The emergency landing followed a string of problems in the past month with the Boeing 787, known as the Dreamliner, including a battery fire, fuel leaks and a cracked cockpit window. All Nippon said the problems Wednesday involved the same lithium-ion batteries that caught fire last week in Boston on a Dreamliner operated by Japan Airlines.

Ryosei Nomura, a spokesman for All Nippon, said Wednesday that the airline was temporarily grounding all 17 of its Dreamliners for inspections, leading to the cancellation of 38 domestic and international flights. Japan Airlines also said in a news release that it would ground the five Dreamliners it was operating; two other aircraft were already undergoing safety checks.

Akihiro Ota, the Japanese transportation minister, said that the emergency landing had raised concerns about the Dreamliner’s safety and that he would dispatch officials to investigate. “I see this as a serious incident which could have led to a serious accident,” Mr. Ota said in Tokyo.

Osamu Shinobe, vice president of All Nippon, said at a news conference at Haneda Airport in Tokyo, “I apologize for the grave concern and trouble we have caused our passengers, their families and others.” He said the airline was still investigating.

All Nippon and Japan Airlines said the planes would be back in the air after safety checks, though it was unclear how soon that would be. There were, for now, no plans to review their use of Boeing’s new jet, the airlines said.

The U.S. authorities have also voiced concern about problems the Dreamliner has faced but endorsed it as a safe airplane. Last week, the Federal Aviation Administration ordered a comprehensive review of the Dreamliner’s manufacturing and design, with a special focus on the plane’s electrical systems. But in a news conference last Thursday, the transportation secretary, Ray LaHood, made no mention of grounding Dreamliners.

Still, the review is unusual, just 15 months after the Dreamliner entered service following a lengthy certification process by the F.A.A. It comes amid a formal investigation by the U.S. National Transportation Safety Board of what caused a battery fire on a Japan Airlines plane that flew to Boston from Tokyo last week.

The safety board said it was “currently in the process of gathering information about the B-787 emergency landing in Japan earlier today.”

Eight airlines now fly the Dreamliner: All Nippon Airways and Japan Airlines in Japan own 24 of the 50 delivered by Boeing since November 2011. The other operators are Air India, Ethiopian Airlines, LAN Airlines of Chile, LOT of Poland, Qatar Airways and United Airlines of the United States.

Boeing has sought to ease concerns about the plane’s design and reliability, and has insisted it was no more trouble-prone than other new commercial airplane programs. Boeing officials said Wednesday they had no comment on the Japanese groundings.

Updesh Kapur, spokesman for Qatar Airways, reiterated Wednesday the airline’s view that the Dreamliner was safe but declined to comment on the decisions by the Japanese carriers. Qatar Airways operates three Dreamliners and has orders and purchase options for 57 more.

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“Banshee” head Greg Yaitanes: secrets galore, but hold the olives

NEW YORK (TheWrap.com) – Like many TV creators, Greg Yaitanes isn’t crazy about the alternate identities people adopt online – and the Emmy-winning former “House” executive producer gets to explore anonymity and becoming someone else in the new Cinemax series “Banshee.”

“I’ve been harassed by ‘House’ Twitter fans for years now. I’m always kind of surprised at people’s level of saying something that they would never say to my face – that they would never say to another human being’s face,” he said.

Not that Yaitanes has a problem with social media – he was an early investor in Twitter, and used a litany of apps and new technology to make his pulpy drama, executive produced by Alan Ball, as scrappy as a tech startup.

With “Banshee,” Yaitanes gets to explore “the best of the wish fulfillment that people have of reinventing themselves or being able to disappear. In a way, all the characters are reinventing themselves.”

Those characters include a thief who steals the identity of the sheriff in Banshee, Pa., his cat burglar ex-girlfriend, who has eked out a new life as a homemaker, and the villain, a man who becomes a criminal mastermind after he is ousted from his Amish community. Then there’s the identity thief – Job – who keeps changing which gender he appears to be.

We talked with Yaitanes about how he made his show look expensive, how to describe Job, and the importance of counting olives.

The Wrap: The show looks expensive – starting with a sequence in New York in which a bus falls over and skids through an intersection. Can you talk about how you kept costs down?

Yaitanes: It’s a way of thinking from working with startups. They’re often one, two, three man operations when they first operate. Twitter was an example of that. You have to look at what is the simplest, most effective way to do this, to deliver to the consumer. We had a very specific box that “Banshee” could be made in, in terms of our budget.

The first thing that came to mind was what I call the “one olive.” The one olive is a story that originates with American Airlines back in the ’80s, when American Airlines took one olive out of their inflight meal – and saved $ 40,000. It’s all about challenging and making everybody their own producer and their own CEO and asking, ‘What is that one thing I can take out that either saves money or makes us that more efficient over the course of 100 days?’

Maybe $ 1,000 isn’t particularly exciting, but when you do it across a season, that’s an official day of shooting. That’s seven more minutes of content that we can get done that day.

We just looked for all these small ways that I feel put nearly an episode’s worth of saving back into the show, so we could make our show more robust and make the action scenes that much bigger and get the actor that we really want.

These are things that the audience gets to enjoy.

What are some of the cost-saving measures?

We also tried to find our olives by using the apps and technology that’s right in front of us, like Skype and Facetime and iChat so we don’t have to fly everybody around? I think probably 75 percent of the crew including directors were hired through some form of video conferencing. You saw the pilot, with the bus crash. We scouted all of that via Google Streetview. We could find blocks and circle around and look up and down and did all the legwork until we absolutely had to go to New York. So we saved on those flights, those hotels, those per diems.

You’ve invested in so many social media sites. Is there something that want to say on the show about the changing nature of identity when we can all take on different personalities online? Your main character, Lucas Hood (Antony Starr) actually takes on another person’s life.

Lucas does the most obvious adoption. A lot of people’s secrets and new identities and new lives are happening before the series starts, which is why we’ve shot an entire online series with our cast.

One of those characters, Job, is constantly in flux – even in terms of whether he appears male or female. Is he transgendered?

He’s straddling this line of androgyny. We specifically don’t want to answer questions about Job’s sexuality… he is a chameleon. He has something that he can tap into depending on his situation. By the time you get to the finale you won’t believe where Job goes.

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GLAAD Award Nominees: Modern Family, Glee, The New Normal Make the Grade

By Stephen M. Silverman

01/16/2013 at 06:00 AM EST

Adam Lambert (left) and Frank Ocean

David Livingston/Getty; McCarten/PictureGroup

Last July when emerging R&B star Frank Ocean published an emotional letter detailing an early love affair with a man, his "coming out" story made headlines in the hip-hop world and beyond.

Now, the Grammy-nominated songwriter is being honored by GLAAD, the nation's lesbian, gay, bisexual and transgender media advocacy and anti-defamation organization.

Ocean is among the 120 nominees for the 24th Annual GLAAD Media Awards, the organization announced early Wednesday morning. He is being recognized for his critically-lauded Channel Orange album.

Other musician nominees include Adam Lambert (for his album Tresspassing).

Among the other familiar nominee names in the mix of 25 English-language and 33-Spanish language categories are: TV's Modern Family, Smash, Glee, The New Normal, Anderson Cooper 360, The Amazing Race and The Daily Show. For motion pictures, The Best Exotic Marigold Hotel, The Perks of Being a Wallflower and ParaNorman – plus the documentaries How to Survive a Plague and Vito – are nominated.

Also being recognized: PEOPLE (for outstanding magazine coverage overall) and PEOPLE En Español – for two magazine articles: "Amor genuine," by Cristina Saralegui, and "La lucha de Bamby," by Isis Sauceda.

For a complete list of nominees, click here.

"Images and stories from the LGBT community continue to push support for equality to historic levels," GLAAD president Herndon Graddick said in a statement with the announcement of the nominees. "Now more than ever, viewers not only accept gay and transgender characters and plot lines, they expect them – just as they both accept and expect LGBT people to be a valuable part of their everyday lives."

The GLAAD Media Awards ceremonies will be held in New York on March 16, at the New York Marriott Marquis; in Los Angeles on April 20, at the JW Marriott; and in San Francisco on May 11, at the Hilton Union Square.

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ER visits tied to energy drinks double since 2007

SAN FRANCISCO (AP) — A new government survey suggests the number of people seeking emergency treatment after consuming energy drinks has doubled nationwide during the past four years, the same period in which the supercharged drink industry has surged in popularity in convenience stores, bars and on college campuses.

From 2007 to 2011, the government estimates the number of emergency room visits involving the neon-labeled beverages shot up from about 10,000 to more than 20,000. Most of those cases involved teens or young adults, according to a survey of the nation's hospitals released late last week by the Substance Abuse and Mental Health Services Administration.

The report doesn't specify which symptoms brought people to the emergency room but calls energy drink consumption a "rising public health problem" that can cause insomnia, nervousness, headache, fast heartbeat and seizures that are severe enough to require emergency care.

Several emergency physicians said they had seen a clear uptick in the number of patients suffering from irregular heartbeats, anxiety and heart attacks who said they had recently downed an energy drink.

More than half of the patients considered in the survey who wound up in the emergency room told doctors they had downed only energy drinks. In 2011, about 42 percent of the cases involved energy drinks in combination with alcohol or drugs, such as the stimulants Adderall or Ritalin.

"A lot of people don't realize the strength of these things. I had someone come in recently who had drunk three energy drinks in an hour, which is the equivalent of 15 cups of coffee," said Howard Mell, an emergency physician in the suburbs of Cleveland, who serves as a spokesman for the American College of Emergency Physicians. "Essentially he gave himself a stress test and thankfully he passed. But if he had a weak heart or suffered from coronary disease and didn't know it, this could have precipitated very bad things."

The findings came as concerns over energy drinks have intensified following reports last fall of 18 deaths possibly tied to the drinks — including a 14-year-old Maryland girl who died after drinking two large cans of Monster Energy drinks. Monster does not believe its products were responsible for the death.

Two senators are calling for the Food and Drug Administration to investigate safety concerns about energy drinks and their ingredients.

The energy drink industry says its drinks are safe and there is no proof linking its products to the adverse reactions.

Late last year, the FDA asked the U.S. Health and Human Services to update the figures its substance abuse research arm compiles about emergency room visits tied to energy drinks.

The Substance Abuse and Mental Health Services Administration's survey was based on responses it receives from about 230 hospitals each year, a representative sample of about 5 percent of emergency departments nationwide. The agency then uses those responses to estimate the number of energy drink-related emergency department visits nationwide.

The more than 20,000 cases estimated for 2011 represent a small portion of the annual 136 million emergency room visits tracked by Centers for Disease Control and Prevention.

The FDA said it was considering the findings and pressing for more details as it undertakes a broad review of the safety of energy drinks and related ingredients this spring.

"We will examine this additional information ... as a part of our ongoing investigation into potential safety issues surrounding the use of energy-drink products," FDA spokeswoman Shelly Burgess said in a statement.

Beverage manufacturers fired back at the survey, saying the statistics were misleading and taken out of context.

"This report does not share information about the overall health of those who may have consumed energy drinks, or what symptoms brought them to the ER in the first place," the American Beverage Association said in a statement. "There is no basis by which to understand the overall caffeine intake of any of these individuals — from all sources."

Energy drinks remain a small part of the carbonated soft drinks market, representing only 3.3 percent of sales volume, according to the industry tracker Beverage Digest. Even as soda consumption has flagged in recent years, energy drinks sales are growing rapidly.

In 2011, sales volume for energy drinks rose by almost 17 percent, with the top three companies — Monster, Red Bull and Rockstar — each logging double-digit gains, Beverage Digest found. The drinks are often marketed at sporting events that are popular among younger people such as surfing and skateboarding.

From 2007 to 2011, the most recent year for which data was available, people from 18 to 25 were the most common age group seeking emergency treatment for energy drink-related reactions, the report found.

"We were really concerned to find that in four years the number of emergency department visits almost doubled, and these drinks are largely marketed to younger people," said Al Woodward, a senior statistical analyst with the Substance Abuse and Mental Health Services Administration who worked on the report.

Emergency physician Steve Sun said he had seen an increase in such cases at the Catholic hospital where he works on the edge of San Francisco's Golden Gate Park.

"I saw one young man who had mixed energy drinks with alcohol and we had to admit him to the hospital because he was so dehydrated he had renal failure," Sun said. "Because he was young he did well in the hospital, but if another patient had had underlying coronary artery disease, it could have led to a heart attack."

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Follow Garance Burke on Twitter at http://twitter.com/garanceburke

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With laughter and tears, fans bid farewell to Huell Howser

Everyone thought they knew what Huell Howser would have said if he'd been standing outside Griffith Observatory just before sunset Tuesday afternoon.

If he'd climbed the observatory steps in a short-sleeved button down, khakis and work boots and taken in the hundreds who had come to celebrate him, a crowd stretching in glorious honeyed light beyond the Astronomers Monument and into the overflowing parking lot.

If he'd known that his fans had started arriving about 9 a.m. for a public memorial due to start at 3:30 p.m., that among them were teenagers and nonagenarians, some of whom had driven for hours — from the far-flung California cities and small towns he'd visited, from the mountains and deserts he loved.

If he had seen Lynne Green, 90, of Woodland Hills holding court in high style in the first row of folding white seats, wearing a jaunty red hat decorated with a red feather and telling everyone she met about how, after she'd signed up at 80 for Buddy Powell's commercial acting class for seniors, Howser came to do a show on the class and "made me one of his featured speakers."

It was so easy to picture Howser there, plunging happily into that crowd, microphone in hand, stopping to squeeze the shoulders of people bundled in winter coats, scarves wrapped around their heads, and warming them up in his Tennessee drawl with a loud "Howdy!" or a "How y'all doin'?"

L.A. City Councilman Tom LaBonge arranged the memorial for Howser, who died last week at 67, and who became a California household name in three decades of exploring the state's people and places in his homespun television shows.

Similarly exuberant and smitten with the state, LaBonge and Howser were longtime friends. But even those in the gathering who knew Howser only from watching TV spoke of him as if he were family. Some teared up as they affectionately swapped stories about him with the strangers they found themselves standing next to in the crowd. They talked about how his shows had sent them out, in search of the obscure monuments and the hole-in-the-wall diners and the odd festivals he'd told them about.

"He always found something cute to say, no matter what. I had a big crush on him," confessed Joy Fisher, 78, of Mid-Wilshire.

Teresa Cerna, 65, of West Hollywood said she had a crush on him too, for "his personality — so warm — and his accent." She said that she'd raced to make it to the observatory from Newport Beach, where she works in a private home as a cook, and that she'd once waited outside Pink's for 2 1/2 hours to get Howser's autograph.

Gloria and Beverly Pink, dressed in pink, took a break from their family's famed 73-year-old hot dog stand to attend, carrying with them the sign for their $5.80 "Huell Dawg" — two hot dogs in one bun, with mustard, chili, cheese and onions. The bright yellow sign, which they pulled off the wall for the occasion, fittingly is in the shape of California.

Howser was so humble, the ladies Pink said, that he wouldn't cut in line when he visited, even though everyone knew who he was and vied to offer him the chance.

Tuesday's gathering featured a lineup of speeches, from the director of the observatory, the executive director of the Los Angeles Conservancy, pop culture historian Charles Phoenix and others. As the sun began sinking just before 5 p.m., an LAPD helicopter circled in a salute.

Then Howser's voice suddenly boomed from the speakers, singing "California, Here I Come." LaBonge asked everyone to sing along, and they did. As the song played again and again, people joined him, singing and dancing on the observatory steps.

It was heartfelt. It was hokey. It felt just right.

Everyone thought they knew what Howser would have said if he'd seen it.

"Oh my gosh!" they could practically hear him. "That's amaaaaaazing!"

And on this day, it would have been an understatement.

nita.lelyveld@latimes.com

Follow City Beat @latimescitybeat on Twitter and at Los Angeles Times City Beat on Facebook.

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Pakistan Supreme Court Orders Arrest of Prime Minister

W. Khan/European Pressphoto Agency

Supporters of Muhammad Tahir ul Qadri, who addressed protesters outside parliament on Tuesday, repeated calls for the ouster of the government.

ISLAMABAD, Pakistan – Pakistan’s supreme court ordered the arrest of Prime Minister Raja Pervez Ashraf in a corruption case on Tuesday afternoon, dramatically raising the stakes in a tense standoff between the government and its opponents.

The court order came as an enigmatic preacher turned politician, Muhammad Tahir ul Qadri, addressed thousands of supporters outside parliament and repeated calls for the government’s ouster. In earlier speeches, he said that a caretaker administration led by technocrats should take its place.

The confluence of the two events stoked growing speculation that Pakistan’s powerful military was quietly supporting moves that would delay general elections that are due to take place this spring, most likely through the imposition of a military-backed caretaker administration.

“Victory, victory, victory. By the grace of God,” Mr. Qadri at the conclusion of a speech to his supporters who were camped outside the parliament.

It was not certain that the two events were linked. Some analysts said that in calling for the prime minister’s arrest, the court, which is led by the independent-minded chief justice Iftikhar Muhammad Chaudhry, was simply taking advantage of anti-government sentiment generated by Mr. Qadri in order to pursue its longstanding grudge against President Asif Ali Zardari.  

Whatever the motivations, the court’s actions added to the chaos in Pakistan, with the stock market dropping 3 percent after word of the court’s order came down.

In its order issued Tuesday, the Supreme Court ordered the National Accountability Bureau, a government body that investigates graft, to arrest Mr. Ashraf and 15 other senior current or former officials, including a former finance minister and a former finance secretary.

The case relates to longstanding allegations that Mr. Ashraf took millions of dollars in kickbacks as part of a deal to build two electricity power plants while serving as minister for water and power between March 2008 and February 2011.

The order comes more than a year after two opposition figures filed a complaint in the supreme court against Mr. Ashraf. Three months later, in March 2012, the court ruled that that power plants were illegal, ordered their closure, and instituted proceedings against Mr. Ashraf.

The case has particular political resonance because Pakistan’s energy crisis, which has seen severe electricity rationing across the country, is the source of some of the main complaints against the government.

Fawad Chaudhry, a senior adviser to Mr. Ashraf , said that any attempt by the court to arrest the prime minister be "illegal and unconstitutional."

"Under the law, the court cannot arrest him," he said, adding that his office was awaiting official notification of the reported court order. "If it has done so, it is illegal and unconstitutional." 

President Zardari has called a meeting of senior advisers at his Karachi residence to discuss the crisis late Tuesday, he added. 

Mr. Zardari’s supporters have painted the prosecution as part of a politically-tinged drive by Justice Chaudhry to unseat Mr. Zardari. Mr. Ashraf came to power last summer after the supreme court forced his predecessor, Yousaf Raza Gilani, to resign from office over another corruption-related case.

Whether there was any link between the court order and Mr. Qadri’s march on Islamabad – billed by the preacher as a “million man march” but in reality far smaller – the timing was certainly striking.

In his speech Mr. Qadri – who returned barely one month ago to Pakistan from Canada, where he also holds citizenship – demanded the immediate resignation of the government, and painted the country’s elected politicians as “criminals” who deserved to be prosecuted for corruption.

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Verizon may be prepping a new mid-range Samsung smartphone with a 720p display

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Bachelor Sean Lowe: My Girl Must Love Dogs

For any of the 25 women looking to win over this season's Bachelor, Sean Lowe, here's a tip straight from the source: "The girl I'm dating must be into my dogs," he tells PEOPLE.

The proud pet parent to two pooches, a boxer named Lola and a chocolate Labrador named Ellie, Lowe says, "For so long it's just been me and my two dogs, and I'm certainly not going to replace them with any woman."

Having had both animals for the past six years, the hunk has developed a special bond with the duo – though he admits his quest for love has forced him to make some changes.

"For many years, my dogs would sleep in the bed with me," he says. "I'm a big guy and I've got two good-sized dogs, so it's a full bed. Then I just realized one day, 'Alright, if I get married and a woman's going to join me in the bed, there's not going to be enough room.' I had to break the dogs of the habit of sleeping in the bed."

Luckily for Lowe, the pair have taken to their new accommodations easily.

"They're very intelligent dogs; they pick up on things really quickly," he says. "They learn pretty fast."

To hear more from Sean Lowe – including how his dogs help him navigate the dating world – check out the video above.

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Hospitals crack down on workers refusing flu shots

CHICAGO (AP) — Patients can refuse a flu shot. Should doctors and nurses have that right, too? That is the thorny question surfacing as U.S. hospitals increasingly crack down on employees who won't get flu shots, with some workers losing their jobs over their refusal.

"Where does it say that I am no longer a patient if I'm a nurse," wondered Carrie Calhoun, a longtime critical care nurse in suburban Chicago who was fired last month after she refused a flu shot.

Hospitals' get-tougher measures coincide with an earlier-than-usual flu season hitting harder than in recent mild seasons. Flu is widespread in most states, and at least 20 children have died.

Most doctors and nurses do get flu shots. But in the past two months, at least 15 nurses and other hospital staffers in four states have been fired for refusing, and several others have resigned, according to affected workers, hospital authorities and published reports.

In Rhode Island, one of three states with tough penalties behind a mandatory vaccine policy for health care workers, more than 1,000 workers recently signed a petition opposing the policy, according to a labor union that has filed suit to end the regulation.

Why would people whose job is to protect sick patients refuse a flu shot? The reasons vary: allergies to flu vaccine, which are rare; religious objections; and skepticism about whether vaccinating health workers will prevent flu in patients.

Dr. Carolyn Bridges, associate director for adult immunization at the federal Centers for Disease Control and Prevention, says the strongest evidence is from studies in nursing homes, linking flu vaccination among health care workers with fewer patient deaths from all causes.

"We would all like to see stronger data," she said. But other evidence shows flu vaccination "significantly decreases" flu cases, she said. "It should work the same in a health care worker versus somebody out in the community."

Cancer nurse Joyce Gingerich is among the skeptics and says her decision to avoid the shot is mostly "a personal thing." She's among seven employees at IU Health Goshen Hospital in northern Indiana who were recently fired for refusing flu shots. Gingerich said she gets other vaccinations but thinks it should be a choice. She opposes "the injustice of being forced to put something in my body."

Medical ethicist Art Caplan says health care workers' ethical obligation to protect patients trumps their individual rights.

"If you don't want to do it, you shouldn't work in that environment," said Caplan, medical ethics chief at New York University's Langone Medical Center. "Patients should demand that their health care provider gets flu shots — and they should ask them."

For some people, flu causes only mild symptoms. But it can also lead to pneumonia, and there are thousands of hospitalizations and deaths each year. The number of deaths has varied in recent decades from about 3,000 to 49,000.

A survey by CDC researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees and 29 hospitals fired unvaccinated employees.

At Calhoun's hospital, Alexian Brothers Medical Center in Elk Grove Village, Ill., unvaccinated workers granted exemptions must wear masks and tell patients, "I'm wearing the mask for your safety," Calhoun says. She says that's discriminatory and may make patients want to avoid "the dirty nurse" with the mask.

The hospital justified its vaccination policy in an email, citing the CDC's warning that this year's flu outbreak was "expected to be among the worst in a decade" and noted that Illinois has already been hit especially hard. The mandatory vaccine policy "is consistent with our health system's mission to provide the safest environment possible."

The government recommends flu shots for nearly everyone, starting at age 6 months. Vaccination rates among the general public are generally lower than among health care workers.

According to the most recent federal data, about 63 percent of U.S. health care workers had flu shots as of November. That's up from previous years, but the government wants 90 percent coverage of health care workers by 2020.

The highest rate, about 88 percent, was among pharmacists, followed by doctors at 84 percent, and nurses, 82 percent. Fewer than half of nursing assistants and aides are vaccinated, Bridges said.

Some hospitals have achieved 90 percent but many fall short. A government health advisory panel has urged those below 90 percent to consider a mandatory program.

Also, the accreditation body over hospitals requires them to offer flu vaccines to workers, and those failing to do that and improve vaccination rates could lose accreditation.

Starting this year, the government's Centers for Medicare & Medicaid Services is requiring hospitals to report employees' flu vaccination rates as a means to boost the rates, the CDC's Bridges said. Eventually the data will be posted on the agency's "Hospital Compare" website.

Several leading doctor groups support mandatory flu shots for workers. And the American Medical Association in November endorsed mandatory shots for those with direct patient contact in nursing homes; elderly patients are particularly vulnerable to flu-related complications. The American Nurses Association supports mandates if they're adopted at the state level and affect all hospitals, but also says exceptions should be allowed for medical or religious reasons.

Mandates for vaccinating health care workers against other diseases, including measles, mumps and hepatitis, are widely accepted. But some workers have less faith that flu shots work — partly because there are several types of flu virus that often differ each season and manufacturers must reformulate vaccines to try and match the circulating strains.

While not 100 percent effective, this year's vaccine is a good match, the CDC's Bridges said.

Several states have laws or regulations requiring flu vaccination for health care workers but only three — Arkansas, Maine and Rhode Island — spell out penalties for those who refuse, according to Alexandra Stewart, a George Washington University expert in immunization policy and co-author of a study appearing this month in the journal Vaccine.

Rhode Island's regulation, enacted in December, may be the toughest and is being challenged in court by a health workers union. The rule allows exemptions for religious or medical reasons, but requires unvaccinated workers in contact with patients to wear face masks during flu season. Employees who refuse the masks can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.

Some Rhode Island hospitals post signs announcing that workers wearing masks have not received flu shots. Opponents say the masks violate their health privacy.

"We really strongly support the goal of increasing vaccination rates among health care workers and among the population as a whole," but it should be voluntary, said SEIU Healthcare Employees Union spokesman Chas Walker.

Supporters of health care worker mandates note that to protect public health, courts have endorsed forced vaccination laws affecting the general population during disease outbreaks, and have upheld vaccination requirements for schoolchildren.

Cases involving flu vaccine mandates for health workers have had less success. A 2009 New York state regulation mandating health care worker vaccinations for swine flu and seasonal flu was challenged in court but was later rescinded because of a vaccine shortage. And labor unions have challenged individual hospital mandates enacted without collective bargaining; an appeals court upheld that argument in 2007 in a widely cited case involving Virginia Mason Hospital in Seattle.

Calhoun, the Illinois nurse, says she is unsure of her options.

"Most of the hospitals in my area are all implementing these policies," she said. "This conflict could end the career I have dedicated myself to."

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Online:

R.I. union lawsuit against mandatory vaccines: http://www.seiu1199ne.org/files/2013/01/FluLawsuitRI.pdf

CDC: http://www.cdc.gov

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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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