The patients were earthy and appreciative and spoke a brand of English that made diagnosis a special challenge. Who knew that “fireballs in the ovurus” meant uterine fibroids, or that “smiling mighty Jesus” meant spinal meningitis? Or that “roaches in the liver” meant cirrhosis? Soon, “high blood” (hypertension), “low blood” (anemia) and “bad blood” (syphilis) became part of my own vocabulary as I obtained a patient’s medical history.
It was at one of these small hospitals that I met Essie, an affectionate woman with pretty doll’s eyes, a generous bosom and dimples deep enough to get lost in. Essie worked as a lab technician. Like so many of the other hospital staff, she was from the area and, except for a brief sojourn in Kingsport, Tennessee, had lived her entire life there. The tiny communities nestled in the hollows and connected to each other by narrow mountain roads provided a security that made city life difficult to contemplate. Her parents and her brother and cousins all lived within a mile of each other.
“I know one day I might have to leave. Say if the jobs around here dry up. But I can’t imagine living anywhere else.”
This attitude made jobs precious. One was apt to encounter people whose first job was also their only job and they had worked at it for twenty years or more.
Of course, not everyone felt the same way. Many of the young felt confined by the little towns and had moved at least to the Tri-Cities area (Johnson City, Kingsport, Bristol) or even farther afield to Knoxville, Atlanta, Charlotte or Memphis.
Essie’s brother, Gordon, was a case in point. It seemed he couldn’t wait to leave their small town. She said he had moved to Kingsport as soon as he finished high school. Shortly thereafter he moved to Atlanta. Then, after a year in Atlanta, Gordon had vanished from the face of the earth.
The small hospital where I moonlighted the most had an on-call room leading off the ER corridor. There I could read, sleep, or watch TV till a patient signed in. Or I could come out to the nurses’ station and shoot the breeze with the ER clerk, with the nurses, with Essie, and with “J.D.”—the part-time security guard and self-styled entrepreneur.
J.D., Essie and the rest of the gang took it on themselves to not only feed me but also expand my Appalachian folk lexicon and coach me on the right way to “talk country.” I was a quick study.
It became a challenge for them to find food that I would not eat. I enjoyed corn pone. I tolerated hominy grits. But I loved homemade biscuits, a great improvement on “whopping” biscuits—the frozen kind you whopped on the refrigerator door to open. I graduated to poke salad and tasted “dry-land-fish” (fried mushrooms) and ramps—an oniony tuber that you excreted in your sweat glands for weeks after. I tried and liked squirrel stew. Baked possum in a collar of sweet potatoes looked better than it tasted, while coon tasted better than it looked. Hog brain with scrambled eggs both looked and tasted wonderful.
In return for the incredible hospitality and the culinary treats, I would sometimes relent and crack the ER staff up with my mimicry of the regional accents of India. The nuances that differentiated a Punjabi accent from a Madrasi accent from a Gujarati accent were appreciated by the ER folk: The staff physicians in the tiny community hospitals that served the scattered mining towns of southwest Virginia, east Tennessee and Kentucky were predominantly from India or the Philippines with a smattering of Pakistanis, Koreans and Palestinians.
The few white M.D.s and D.O.s around, it seemed to me, were near retirement or else were serving out a National Health Service commitment. It was evidently difficult to entice young American medical school graduates into these isolated and often depressed rural areas where reimbursement depended heavily on the health of the coal mines and on being willing to have a large proportion of Medicaid patients in the practice.
Meanwhile, year by year, more foreign physicians, recruited by the same word-of-mouth that brings fresh blood to the newspaper kiosks, motels, gas stations, taxi fleets, restaurants and wholesale groceries of America, were completing their training in American urban war zones and moving into these rural havens.
The foreign doctors—with some glaring exceptions—were well received. They developed reputations as sound physicians. Though they were friendly, the majority chose not to integrate with the community except at a superficial level. They retained many of their foreign customs, the women wore saris, they were very protective of their children, and most of their socialization was with each other. In the corner of the kitchen or in a separate puja room would be a collection of Hindu icons: invariably Lakshmi (the goddess of wealth) and Ganesha. Also Muruga, Venkateswara, Sai Baba, Durga, according to taste. Once a day the incense and the oil lamp would be lit, the silver bell rung and burning camphor waved around the idols. And at least once a year the family would travel to the Hindu temple in Nashville to do a more elaborate puja or mahabhishekam.
The effect of having so many foreign doctors in one area was at times comical. I had once tried to reach Dr. Patel, a cardiologist, to see a tough old lady in the ER whose heart failure was not yielding to my diuretics and cardiotonics. I called his house and his wife told me he was at “Urology Patel’s” house, and when I called there I learned he and “Pulmonary Patel” had gone to “Gastroenterology Patel’s” house. Gastroenterology Patel’s teenage daughter, a first-generation Indian-American, told me in a perfect Appalachian accent that she “reckoned they’re over at the Mehtas’ playing rummy,” which they were.
Rajani and I, perhaps because we were of a younger generation, traveled easily between these two worlds: the parochial world of Indians in America, and the secular world of east Tennessee. For the Indian parties, Rajani wore a sari and we completely immersed ourselves in a familiar and affectionate culture in which we had our definite place as the juniormost couple; but at night we could don jeans and boots and go line dancing at the Sea Horse on West Walnut or listen to blues at the Down Home.
I REMEMBER AS AN INTERN in 1981 reading a New England Journal of Medicine article with the curious title “Pneumocystis carinii Pneumonia and Mucosal Candidiasis in Previously Healthy Homosexual Men—Evidence of a New Acquired Cellular Immunodeficiency.” It described the seminal AIDS cases in Los Angeles. Companion articles described cases in New York and San Francisco. Three things about these reports stayed in my mind: gay men, immune deficiency, and death.
I knew precious little about gay culture.
In college I had picked up and parroted the snide asides and took part in the buffoonery and condescension that constituted the heterosexual response to homosexuality.
For me, reading about ritualized meeting places like bath houses and gay bars and understanding the extent of gay culture was astonishing and eye opening. It was as if a whole megalopolis had existed around me, intertwined with my city, and yet invisible to me. I was intensely curious.
I knew no openly gay men. I only knew the stereotype. I sensed the stereotype might be as untrue as the stereotype of the southerner, the redneck. If the southerner was a born racist and terribly intolerant, I—a brown-skinned foreigner—had never experienced this. In fact, the first time I experienced racism, felt it as a palpable presence in my daily life, was in Boston, not Tennessee.
The month the first papers on AIDS came out, the disease became a topic for late-night, idle discussion in the Mountain Home VA and Miracle Center cafeterias. AIDS seemed so far away, so bizarre: New York and San Francisco were its epicenters. We were seeing in our lifetime, so we told ourselves, yet another new disease. And surely, just like Legionnaire’s, Lyme disease, toxic shock—all new diseases—we felt this new disease, this mysterious immune deficiency, would soon be understood and conquered.
To say this was a time of unreal and unparalleled confidence, bordering on conceit, in the Western medical world is to understate things. Only cancer was truly feared, and even that was often curable. When the outcome of treatment was not good, it was because the host was aged, the protoplasm frail, or the patient had presented too late—never because medical science wa
s impotent.
There seemed to be little that medicine could not do. As a lowly resident, I was inserting Swan-Ganz catheters into the vena cava and the right side of the heart. Meanwhile, the cardiologists were advancing fancier catheters through leg arteries and up the aorta, then using tiny balloons to open clogged coronary arteries or using lasers in Roto-Rooter fashion to ream out the grunge.
Surgeons, like Tom Starzl in Pittsburgh, had made kidney, liver, heart and heart-lung transplantation routine, and they were embarking on twelve-to fourteen-hour ‘cluster operations” where liver, pancreas, duodenum and jejunum were removed en bloc from a donor and transplanted into a patient whose belly, previously riddled with cancer, had now been eviscerated, scooped clean in preparation for this organ bouquet.
Starzl was an icon for that period in medicine, the pre-AIDS days, the frontier days of every-other-night call. My fellow interns and I thought of ourselves as the vaqueros of the fluorescent corridors, riding the high of sleep deprivation, dressed day or night in surgical scrubs, banks of beepers on our belts, our tongues quick with the buzz words that reduced patients to syndromes—“rule out MI,” “impending DTs,” “multiorgan failure.” We strutted around with floppy tourniquets threaded through the buttonholes of our coats, our pockets cluttered with penlights, ECG calipers, stethoscopes, plastic shuffle cards with algorithms and recipes on them. The hemostats lost in the depths of our coat pockets were our multipurpose wrenches and found uses from roach clips to earwax dislodgers. Carried casually in sterile packaging in our top pockets were seven-gauge, seven-inch needles with twelve-inch trails of tubing. We were always ready—should we be first at a Code Blue—to slide needle under collarbone, into the great subclavian vein, and then to feed the serpent tubing down the vena cava in a cathartic ritual that established our mastery over the human body.
There seemed no reason to believe when AIDS arrived on the scene that we would not transfix it with our divining needles, lyse it with our potions, swallow it and digest it in the great vats of eighties technology.
I HAD MADE UP MY mind that I wanted a career in academic medicine. If there was glory in medicine, then I was not satisfied with the glory of saving a patient and having the family and a few others know about it. The rewards of private practice—money, autonomy, the big house, the big car, the big boat, the small plane, the bubble reputation in a provincial hospital—were not enough for me. I loved bedside medicine, the art of mining the patient’s body for clues to disease. I loved introducing medical students to the thrill of the examination of the human body, guiding their hands to feel a liver, to percuss the stony dull note of fluid that had accumulated in the lung, to be with them when their eyes shone the first time they heard “tubular” breathing or “whispering pectoriloquy” and thereby diagnosed pneumonia. The acclaim of the lecture hall, the lead article in the New England Journal of Medicine, the invitations to be a keynote speaker at gatherings of my peers—these were the coins I wished to hoard.
My mentor in Tennessee was Steven Berk, an infectious diseases specialist fresh out of training at Boston City Hospital. Boston City Hospital was for many years the premier infectious diseases (ID) training program in the country. Steve, a quiet, unassuming and shy man, had already published several important papers prior to coming to Tennessee. His ability to see research opportunities in the wards, nursing home and domiciliaries of the VA excited me. Steve was quietly cataloguing the causes of pneumonia in the elderly, a domain in which he would become the world’s expert. And I was along for the ride. I came to value a good sputum specimen that was not contaminated with saliva as much as I valued gold.
I became Steve’s shadow. I worked long hours in the library looking up references, painfully composing the first draft of a manuscript that he would then take and revise and hand back to me for further work.
I took Steve’s rationale for why he had gone into ID as a specialty and made it my own. Infectious diseases, he said, was the one discipline where cure was common. In the battle of man against microbe, man was winning. Astute diagnosis was rewarded by a return to perfect health. Death from infection used to be common on bone-marrow-transplant wards and on leukemia wards. Now, he pointed out, with newer, more powerful antibiotics, better diagnostic tools, and a new understanding of immunology, ID physicians were getting the upper hand.
But I also had a selfish reason for picking infectious diseases. Most medical residents flocked to cardiology or gastroenterology or pulmonary medicine—specialties rich in invasive procedures (and therefore very lucrative). Fellowships in these areas were very competitive. Unlike the internship year (where foreign graduates were in much demand and were critical to the survival of many inner-city hospitals), both foreign and American medical graduates were competing for the limited number of fellowship slots across the country.
Comparatively few people went into ID. My chances of going to a top-notch university to train were best if I opted to specialize in ID.
Steve was delighted when I told him my decision. We mapped out a strategy: I would apply for a fellowship in infectious diseases at Boston City Hospital as well as at Yale, Tufts, Stanford and San Francisco General Hospital. We hoped that Steve’s strong letter of recommendation, as well as the three scientific papers I had now published, would erase my foreignness.
When, after my round of interviews, William McCabe, the Chief of Infectious Diseases at Boston City Hospital and a legend in the field, called me and offered me a position, preempting the other places, I jumped at it.
MY FIRST DAYS IN Boston were anxious and disorienting. When I was on call, I had to cover three hospitals: the Veterans Hospital in Jamaica Plain, Boston City Hospital and University Hospital, both in the South End. Each hospital had its own protocol for parking, for where the patients’ charts were kept, for where you could safely leave your things without being ripped off, for the format of the consultation.
The first weekend I was on call, I was summoned to Boston City Hospital to see a gay male with fever and pneumonia.
This would be my first patient with possible AIDS, my first encounter to my knowledge with a gay patient. It was July of 1983. I had read the burgeoning literature on AIDS and told myself I should not agonize over my own safety. The virus seemed to spread in the manner of hepatitis B: by body fluids and blood. None of the doctors in San Francisco and New York who had taken care of scores of patients with AIDS had as yet contracted it. On the other hand, the incubation period and the asymptomatic phase of the disease could be very long. Still, simply examining the patient did not call for gloves or any other precaution.
I was excited and a little nervous.
Osler, the dean of American medicine who had died in the early part of this century, said that to study medicine without textbooks was to go to sea without charts. But to study medicine without patients was to not go to sea at all.
I was ready to test the waters.
I found parking near the Thorndike Building. A female physician was behind me as I walked down one of the dark, dingy tunnels that ran under Boston City Hospital and connected the different buildings. We both flattened ourselves against the wall as the clatter of an eccentric wheel and a rattly frame grew louder behind us. An electric cart brushed closer to me than I would have liked. It pulled two wagons of laundry. Only the back of the driver’s Afro was visible. I could smell the ammoniacal odor of soiled linen mingling with the tunnel’s faint reek of wet insulation from the pipes overhead.
We rounded a corner and came to a dead end at an incinerator. The doctor behind me laughed. She introduced herself as a new nephrology fellow. She confessed that she had been following me, hoping that I knew where I was going. As we backtracked to safety, we talked about the energy we were expending trying to look unfazed in this new and intimidating environment.
The medical wards were in the oldest section of Boston City Hospital The stairs were uneven and wire mesh extended up six floors to enclose the stairwell and keep anyone from jumping over
the banister. The bottom of the stairwell was dirty, dusty, and littered with cigarette butts that had been pushed through the chicken wire from the floors above.
I found Tony Cappellucci’s room. An “isolation” sticker on his door warned of the need for “blood and body fluid precautions.”
The rooms in the older part of Boston City Hospital were not known for being bright and airy; this room was no exception. The drawn curtains left the room pitch dark. There were two beds in the room. I could make out that one bed was empty and a figure was curled up in the second.
When I approached, a pair of close-set eyes looked at me with suspicion from behind a purda of sorts: he had coiled the bed sheet around his head and across his face.
I introduced myself and Tony gradually emerged from the bedclothes, shielding his eyes as I drew back the curtain. Tony was in his twenties. He had close-cropped blond hair except at the back where he had grown it out. He was about five foot six and had the compact appearance of a gymnast. His face was pockmarked with acne and his teeth were in poor repair; I remember his nails were grubby and the room had a stifling, old-socks odor to it.
His tone was defensive and combative. He said he had been visiting Boston from New York when he fell ill. He was irritated with the treatment he was getting and commented on how much better things were at Bellevue.
“I told them I was gay,” he said. “I was up front about it. And so I’m being treated like a leper. As if I have AIDS. I don’t have AIDS, do I?”
I promised him I would try to answer that after I had a chance to go over him thoroughly. Certainly there was nothing to warrant that diagnosis thus far.
The physicians and nurses had treated him well; his present mood was a result of a trip back from radiology, which in Boston City Hospital required a journey through the tunnels. The male attendants from the transport service who took him to radiology and back had worn gloves and masks and grumbled their displeasure at being pressed into this service. As far as they were concerned he had AIDS.