And I was back and looking to settle in Tennessee. A long voyage was over. I had finished all the training I wanted to go through. I was ready to apply my knowledge. When I was an orderly in the Battley Nursing Home in New Jersey (during the period when I was between medical schools), being paid by the hour for changing diapers and giving baths, it seemed as if my medical career had ended. That I would never be a doctor. And then, as I crossed each hurdle—getting back into medical school, becoming a doctor, then an internist, then an infectious diseases specialist—I had naively expected that each milestone would transform me, bring me happiness and peace of mind.
But happiness had come in another form: my infant son, Steven, and the way he added a new dimension to my relationship with Rajani. And instead of escalating goals, I wanted nothing more than to settle in one place and be a good physician. Stateless and roaming for so long, I wanted to put down roots. My son was American by virtue of his birth and his father would become a naturalized citizen that year. I wanted my son to have a permanent home, something I never had.
Johnson City was going to be my town. I felt at peace in this corner of east Tennessee. Finally, this was my own country.
4
AT MOUNTAIN HOME, veterans admitted to the hospital section came from as far as a hundred and fifty miles away; they came from small towns in east Tennessee, Kentucky, southwest Virginia, and even North Carolina.
Some patients, however, came from a hundred yards away: they were the veterans who lived on the grounds in the giant domiciliary buildings. These older veterans had nowhere else to live. Their life was the domiciliary.
Many dom residents had been at Mountain Home for years. Others migrated from one VA domiciliary to another. They arrived in the fall from St. Cloud, Minnesota, or Bedford, Massachusetts, or Butler, Pennsylvania, or Knoxville, Iowa. As winter set in, they moved west to Dublin, Georgia, then to Bonham, Texas, then to Prescott, Arizona, ending up in Palo Alto, California. Or else they moved south to Bay Pines, Florida—a popular winter stop. The end of winter saw them heading north, back to Des Moines, Iowa, or Portland, Oregon, or Montrose, New York.
Rajani and I came to know certain faces well; we spotted them as they wandered around the campus, moving from a park bench under the sycamore tree, to a park bench by the duck pond, to a park bench by the Memorial Theater, cigarettes in hand, each following his own routine. Some of the veterans befriended Steven. Others made moves on Mrs. Stokes, our widowed, elderly baby-sitter, as she pushed Steven in his stroller around the campus. The men could be worldly and charming.
I asked Eloise Stokes if she ever considered their propositions, if she ever entertained the thought of marrying again. Her deceased husband had been a veteran.
“Oh, I do think about it,” said Eloise. “I do get lonely. But then I think, I don’t really want some smelly old man crowding up my trailer for the rest of my days.”
One day they would be there, a craggy, familiar face, sunning by our old oak tree, and the next day they would be gone. We would wonder if sickness had befallen them or had they moved. Then, the next spring, they would reappear to occupy their familiar places, to wave at us as we drove by or walked the baby.
Pneumonia or severe bronchitis in these domiciliary veterans could be a dangerous disease: If they were heavy smokers—and so many were—they often had marginal lung reserves. If they deteriorated, they wound up on a ventilator. And unlike a young person who could be quickly weaned off a ventilator, a veteran who required it became quickly dependent on it. As if the muscles of respiration that had worked overtime for so long had gone into retirement.
I WAS PRIMARILY A Mountain Home VA employee. In the unique VA jargon, I was “7/8 VA,” my salary being seven-eighths of an FTEE, or full-time employee equivalent. The VA was also where we did most of our teaching of medical students and residents and where we carried out research. I had a lab and a technician and I continued research on the hamster model of pneumonia.
In my one-eighth “free time” I consulted at the adjacent Miracle Center—the new crop of students and house staff continued to refer to the Johnson City Medical Center in this way.
The Miracle Center had a much younger patient population and many more women than Mountain Home. The pace of medicine in this community hospital was very different: You could get almost any study from a CAT scan to an angiogram done the same day you requested it. The typewritten results were back on the chart by evening with another copy in your mailbox. At the VA it would take days or weeks to achieve the same thing; the radiology department at the VA was notoriously poor: “the armpit of Mountain Home,” as the interns called it.
The consultations at the Miracle Center were also different from Mountain Home. Sally Jameson, a sixteen-year-old, newly diagnosed with leukemia and receiving chemotherapy, typified the Miracle Center experience. Every time she received chemotherapy, her white cell count would drop and make her very prone to infection.
One morning when I went to see her she was complaining of facial pain. I was fearful that this was mucormycosis—a life-threatening fungal infection of the sinuses that develops in just this setting. I saw nothing in her nose. But on her hard palate I could see a telltale black eschar; I scraped it, put it on a slide, added a drop of saline and placed a cover slip over it and took it to the lab. Under the microscope I could see the broad filaments of Mucor. In the absence of white cells, this fungus could march right through tissue and bone, straight up the orbit and into the skull. The disease was not amenable to any form of medical therapy. Only immediate and bold surgery to cut out every trace of the fungus, well past its advancing border, could help. The surgeons responded promptly and saved her life. Eventually her leukemia went into remission.
Heroic surgery was also called for with Jeff Viner, a former biker who had been a paraplegic for many years as a result of a motorcycle accident. He was admitted for unremitting fever from a monstrous bedsore over his tailbone. Since he felt no pain, he had neglected this sore for years, continued to sit directly on it, insisting on riding in his wheelchair and being in the upright position as much as he could. To be horizontal was a reminder of his paralysis. To be upright and on wheels, even if it was a wheelchair and not his Harley Sportster, was crucial to his psyche.
He had several episodes of septic shock as the bacteria from the pus pocket spilled into his bloodstream. It was only when the smell that emanated from this sore had driven all his friends and his girlfriend away that Jeff accepted the need to deal with it. By then the bedsore stretched across both buttocks; it had rotted through into his pelvis, it threatened the blood vessels within. There seemed to be no surgical way to approach this bedsore short of a hemicorporectomy—amputation of the lower half of his body below the belly button.
I had seen patients in Boston who had a hemicorporectomy. It was disorienting to enter their room: you felt as if someone was playing a trick with mirrors. Their body ended just below the ribs. If they wanted to go anywhere, the stump of their trunk was fitted into a prosthesis that resembled a candle-holder and then they were lifted into a wheelchair.
My respect for the surgeons at the Miracle Center went up several notches when they were able to pull off the operation. A team of orthopedists, neurosurgeons, urologists, plastic surgeons and general surgeons carried out the surgery. The orthopedists sawed through the upper lumbar vertebra, and the neurosurgeons tied off the spinal cord and dealt with the plexus of nerves that emerged from it. The urologists diverted the ureters from the bladder to an artificial bladder they created out of small bowel. This bladder opened high up under the right rib cage. The general surgeons diverted Jeff’s feces into a colostomy that opened high under his left rib cage. At this point, the final cut was made and Jeff’s pelvis, his genitals, his buttocks, his legs and feet were slid off the table into the receptacle below. The plastic surgeon brought the long skin flap around like a tailcoat and fashioned a stump for what remained of Jeff’s body. The surgical result was excellent.
Psychologically, even though what had been cut off was paralyzed and nonfunctional, even though this operation had saved his life, it was a devastating blow to Jeff. Despite intensive preoperative counseling and therapy, it was weeks before Jeff began to talk and engage with the outside world.
One of the more challenging cases I saw was a cognitive puzzle—the internist’s equivalent of a hemicorporectomy. Mrs. Virginia Longtree, a pleasant, retired school nurse, was referred to me for “FUOs”—fevers of unknown origin—along with mysterious phlebitis that had baffled her physicians.
She had me stumped. She was admitted repeatedly to the hospital, each time with high fever and a nasty cellulitis and phlebitis. Each time I saw her and failed to tie it all together, it increased my frustration. I began to consider exotic things like Familial Mediterranean Fever, a condition common in Sephardic Jews, even though Mrs. Longtree was Southern Baptist with Scotch-Irish roots.
But then, on her fourth admission, I confronted her: her blood cultures had made the diagnosis! I had found fecal, vaginal and tap-water bacteria—an almost impossible combination—in her bloodstream. There was no way this could happen unless she was doing something weird to herself. She broke down and admitted that she had been deliberately injecting her bath water into her limbs to produce factitious fever. An hour later, she became hostile, recanted her confession, cussed us all out and left the hospital abruptly. We never heard from her again. In retrospect she was typical of patients with factitious fever: they often have a medical background, the psychopathology that drives them is complex and bizarre, they bolt when confronted, and the prognosis for recovery is poor.
The third arena in which I saw patients was the University Physicians Group office, which I went to once a week. All the physicians employed by East Tennessee State University (ETSU) had at least a half-day a week clinic there. My half-day was on Wednesday afternoons and I rarely had more than one or two patients. The very nature of ID practice—at least in the pre-AIDS era—was that it was hospital-based.
The consultations in the clinic tended to be fairly routine, though colorful. I remember Tracy Oliver, a sweet, nineteen-year-old college cheerleader who, after Homecoming night, had forsworn sexual intercourse for the rest of her life: she had picked up gonorrhea, Herpes simplex and venereal warts all from a single sexual encounter. I tried to console her by pointing out that she was not pregnant and had not contracted either syphilis or HIV. At this she burst into tears; the thought of AIDS had not crossed her mind till I mentioned it.
I also remember the garrulous Reverend K from a very distant county who, when we finally got off the topic of the origin of my name and St. Thomas’s incredible mission in south India, complained of “fire at the end of my pecker and honey-colored milk a-dripping out.” I told him that I needed to step outside and get a special agar plate to culture for gonorrhea, at which point he said, “While you’re at it, Doc, you might get one for my throat too.”
“All right,” I said. When I was at the door, he made to stop me once again, but I had caught on now.
“I know,” I said. “One for your backside, right?”
“There you go!” said the Reverend K.
I also tested him for “bad blood” which by now, 1985, meant both syphilis and HIV. He was negative.
I WAS THE DE FACTO AIDS expert in Johnson City even though there was no AIDS to see. My role was limited to talking about AIDS.
The story of the young man who had come home from New York and died in Johnson City was not known outside the hospital. Even in the hospital, it was suppressed like a shameful memory.
But television, Time, Newsweek and the supermarket tabloids were giving prominent coverage to AIDS. Perhaps this was why the Johnson City Press decided to do a special on AIDS and asked if I would help. I agreed on the condition that I get to look at the final product and approve what they quoted me as saying. A pleasant young lady interviewed me. She borrowed slides and printed material for the article.
When the time came to go to press, I made several calls to see the proofs but kept being put off. Ultimately I was told that there was no time for me to see and approve my section.
I insisted. I pointed out that I had lent them a drawing I had made of the “AIDS iceberg,” a drawing that depicted a giant iceberg marked off in sections. The tip of the iceberg, the part that floated above the water, represented AIDS patients. The submerged part represented people who had HIV infection but no symptoms or signs as yet. The iceberg illustrated dramatically that for every known AIDS case there were anywhere from twenty to one hundred other infected persons who had not surfaced; it showed that it was insane to react negatively to, say, a schoolchild with AIDS: If a schoolchild had AIDS, the odds were high that other children and teachers and parents in the school also had the virus.
I told the Press I would withdraw permission for them to use the drawing if they did not let me see the galleys. They relented.
When they had wanted my help they had been solicitous and had come to my office at my convenience. Now, on the eve of publication, I found myself walking around their building, trying to track down the galleys. But I was glad I did: they had quoted me as saying there were possibly a half to one million AIDS cases in the United States. I had said there were possibly that many HIV infected individuals in the country; they had confused the tip of the iceberg—AIDS—with the whole iceberg!
When I left the Press it was dark. I was parked a few blocks away. This was a rougher part of Johnson City. There were a cluster of bars here favored by our veterans. There were also a few flophouses where veterans stayed from time to time if they were suspended from the domiciliary for breaking curfew.
A lady in her fifties, with a surprisingly short skirt and a good-sized behind, strode past me, walking purposefully nowhere. She gave me a bold inquiring look. I realized she was a prostitute, albeit a very faded one. The occasional sexually transmitted diseases I saw in our veterans were linked to hookers who operated around this part of town.
The people inside the bars, unlike the ETSU hangouts, were drinking quietly and with great seriousness. Muted music came from the jukeboxes. A domiciliary resident whom I recognized sat alone, sipping on a beer.
I thought to myself: If the young man from New York with AIDS who came home and died was the tip of the iceberg, surely somewhere in this town there must be others walking around infected with the virus. Or did that young man really represent an aberration, a chip off the New York iceberg that had drifted south?
As I drove away, I decided I would be wary of the Press. They were interested in the prurient side of AIDS; the scientific facts merely gave them an opening into it.
Why did this surprise me and disappoint me? I suppose I had expected the town paper to reflect the nicer qualities of its citizens.
BOTH THE MOUNTAIN HOME VA and the Miracle Center were trying to enforce a new code of safety for the handling of blood and secretions. The dictum nationwide was that health care workers should treat every patient as potentially infected with HIV; that was the only way to be safe. But since no one had any real conviction that there was AIDS around, these recommendations were perceived as outlandish. I often saw nurses and lab technicians drawing blood without gloves and I would gently remind them. Some were sheepish—they had a hard time remembering. Others argued that they were actually in more danger drawing blood or starting an intravenous line with gloves; gloves, they claimed, reduced their sense of feel and made them prone to error.
Later that year I gave “Grand Rounds” on AIDS. Grand Rounds was a weekly formal lecture that combined all staff and students from Mountain Home and the Miracle Center. Public speaking always gives me butterflies, and my way of overcoming this is to prepare meticulously and rehearse with my slides in the empty auditorium.
The day of the Grand Rounds, the auditorium was full. I got off to a good start with a graphic collection of slides from my training days at Boston City Hospital—slides that showed how this latter-day plagu
e was devastating inner cities, burdening the public hospitals, changing the face of internal medicine, changing the shape of the African continent.
But during the nuts-and-bolts section of the talk that dealt with diagnosis and treatment of the common opportunistic infections seen in AIDS, I sensed the audience drift away. I was reminded of talks I sat through in Boston when a visiting WHO expert from Africa or India talked about kala-azar or leprosy: it was difficult to relate to a disease you never saw.
I wound down the talk as quickly as I could. I had the eerie feeling that I had just made the prospect of AIDS in our little town more remote.
Afterward, a Mountain Home physician who had been at the VA decades before the medical school arrived came up and patted me on the shoulder. “Interesting, very interesting, Abe.” He fixed a look of amusement and indulgence on me. “Just hope that your speech-making doesn’t rustle any up.”
OLIVIA SELLS, the director of the local Red Cross and a longtime Johnson City volunteer and activist, called on me one morning. Her blood bank was feeling the pinch of AIDS phobia; fewer people were donating blood. Of more concern, people were using a blood donation as an indirect way to get the AIDS test. So far, no one had turned up positive.
Olivia decided there was a need to disseminate information about AIDS outside the medical community of Johnson City. She had a videotape on AIDS, “Beyond Fear,” produced by the Red Cross, which she had already shown to some civic groups. She was, she said, excited that we now had an “AIDS expert” in town, and would I go along with her to show this videotape and to answer questions?
Olivia was a tiny, energetic woman in her late fifties who drove a giant paneled station wagon, favored thin, brown cigarettes that she tossed after two drags, knew everybody in town, and believed “there is nothing you can’t get done if you know who to bug.” Half-moon glasses dangled from a chain around her neck and a giant daybook in a leather case was perpetually in her lap.