My Own Country

by Abraham Verghese

  “How is he?” I asked.

  “He’s fine,” Carol said. “He’s sitting here in the office. Do you think you can see him?”

  I rushed over to find Raleigh now dressed in Robin Hood boots with skin-tight purple slacks, a chiffony shirt with a frilled collar. The heavy application of mascara around his eyes matched his present mood: solemn, somber, tragic—but every bit as unreal as before.

  He said he had fought with his grandmother the previous evening, had been rejected by a former lover and then had the door slammed in his face by his mother’s new boyfriend. Nobody wanted to hear about his HIV status. As an attention-getting device, HIV had no effect.

  And so he had overdosed and had his stomach pumped out in his local hospital, a ritual that both he and the hospital had been through before. I was his last physician of record. The emergency room had arranged to have him in my office in the morning.

  Now the hurt, angry and scared little boy was easy to spot behind the mawkish facade. Carol and I made calls and got Raleigh admitted to a halfway house where he could stay temporarily. I called Fred Goodson and had him come see Raleigh and bring him into their newly formed support group. Though we had given Raleigh information about TAP and the support group, it had probably been too much to expect him to follow up on his own. In putting Raleigh under Fred’s care, I had as secure a feeling as if I had put him in professional therapy. Joyce, my secretary at the VA, explored a job-training possibility for Raleigh.

  What had happened to Raleigh was a forceful reminder to me that there was a lot I could do, a lot I had to do, for our patients even if we had no therapy for HIV. I could no longer sit and be the consultant and pontificate over the progression (or lack thereof) of the disease; I was providing primary care, total care for this group of patients, whether I liked it or not.

  Unexplained fever in a transplant patient, fever in a missionary returned from South America, a bizarre rash in a leukemic—these were the summonses to intellectual adventure, brain teasers. But now, in our AIDS clinic, there were many, many visits—just like Raleigh’s last visit—where nothing at all happened. The virus was there, but it lay dormant. There was no diagnostic puzzle.

  I was, as never before in my career, intensely aware of the patient-physician relationship. It sat there as a tangible entity. I could palpate it on the first visit and feel it grow thereafter. In the one-shot encounter of the in-hospital consultation, everything was stacked in my favor: I walked in with advance billing as “the specialist called in for fever,” I established rapport, got the facts from patient and chart, sniffed out clues, examined body fluids, made recommendations—sometimes with dramatic impact on the patient—and sallied out. Raleigh’s suicide attempt shook me: I was seeing him for a deadly viral infection for which I had no treatment, and yet here he had almost died before the virus could get him. I had failed to appreciate what he was going through and perhaps underestimated the comfort I could have brought him in spheres of his life unrelated to the virus. In the absence of a magic potion to cure AIDS, my job was to minister to the patient’s soul, his psyche, pay attention to his family and his social situation. I would have to make more home visits, make more attempts to understand the person I saw in the clinic, be sure I understood the family dynamics by meeting all its members. Some of this I was already doing as a matter of interest. I would now have to do it out of necessity.

  But I would pay a price for this. My training had not really prepared me to be this kind of doctor. We were trained in hospitals, not in patients’ homes; we were biased toward technological interventions in the form of drugs and needles; words like the “soul,” the “spirit,” were considered dirty words. There was no or little payment for the nontechnological kind of medicine: hand-holding, family visits, home visits had no billing codes; bronchoscopies, colonoscopies and PAP smears did. For me to practice the folksy kind of medicine that was required would not only cost me monetarily, it came at the expense of time with my family and time for myself.

  As if to drive home my isolation and the peculiar medical practice I had created for myself, I saw Doyle, the medical student for whom I served as adviser. He was my last appointment for the day. When we had last sat down, I had suggested he go to a big city to take an elective, to get a feel for what big city medicine was like. He had gone to a big city, but instead of going to the university hospital and medical school, he had chosen to take an elective with a group of three private cardiothoracic surgeons. The men were, according to Doyle, superb technicians, trained by Cooley and other pioneers in the area. They hardly needed a bedside manner: the metaphor of what they did—cracking the chest, stopping the heart, rerouting the plumbing—said everything; it even subserved speech.

  Doyle, the medical student, said, “I never saw a single patient awake. And the only operation I saw was Cabbage!” (Coronary Artery Bypass Graft).

  “Cabbage after Cabbage after Cabbage. We would be cruising down the highway, me sitting in Dr. S_____ ’s Ferrari, on our way from Holy Oaks to High Plains Medical and Dr. S_____ would call ahead on his car phone, and by the time we got to the OR and were scrubbed and ready, the patient was asleep, his chest painted and ready to go. Dr. S_____ would start to crack the chest while I and the physician assistant—who has been with him for sixteen years, and could probably do the whole thing himself—would scramble to harvest the veins from each leg. And it was all we could do to get the veins out before he was ready to use them—he was so quick. His partner Dr. B_____ who had finished at another table would join us, and pretty soon Dr. S_____ would leave to go on to the next table while Dr. B_____ bypassed the last artery and me and the PA closed up. Dr. B_____ started a third case, while the third partner Dr. V_____ joined Dr. S_____. And at some point I would be in Dr. B_____’s Mercedes, and he would be calling ahead to Dillard Hospital and the next set of patients was being put to sleep and pretty soon Doctors S_____ and V_____ would show up there.”

  I asked Doyle about postop care. I pictured rounds at the bedside in the ICU under the banks of monitors and with printouts from the arterial and venous catheters. I pictured exciting discussion of hemodynamics.

  “They had these preprinted postop order sheets which covered every exigency. Broad parameters were defined: if the patient’s heart rate or temperature or blood pressure was to fall out of that range, then the nurse was to call. If the cardiac output measured by Swan-Ganz catheters fell below this many liters, they were to use dopamine. They were to keep the patient tanked up but the lungs dry by keeping the pulmonary capillary wedge pressure at so many millimeters; any higher than that and they give Lasix, less than that, give saline. For a major problem, the nurse called the physician’s assistant who had seen it all. Just for the sake of form, he might call in the cardiologist—never the surgeon. You know there’s this phalanx of cardiologists who feed the patients into the surgeons’ mill and then take care of the patients for years to come.”

  I asked again: “So what about postop care, Doyle?” I was thinking of Will Johnson and his Cabbage operation.

  “It was kind of like a howdy-doody rounds. We’d circle round the intensive care units, our team of about fifteen people, and the patients would still be out of it from the surgery and would be on a ventilator and with chest tubes coming out of their front and sides. And then we’d prod them—literally prod them to see if they stirred—glance at the numbers on the monitor, the doctor would sign the physician assistant’s note, and then the whole team would troop on.”

  “So how did you like it, Doyle?”

  “Are you kidding? I loved it!”

  God help us!

  For Raleigh, for the Johnsons, for all my patients in the HIV clinic, I would have to do a lot more than prod them with a ruler.

  17

  SEVEN YEARS INTO THE EPIDEMIC, four years after the virus that causes AIDS was discovered, two years after I saw my first HIV-infected patient in Johnson City, and I still had no treatment to offer. Hand-holding, counseling, moral support
, platitudes, bromides, prognostications, homilies. But I had nothing in the way of a remedy.

  When an opportunistic infection developed, I reacted: I scrambled to nail down the cause of the fever, the basis for the opacity on the chest x-ray, the reason for the seizures or the cluster of sores that had sprung up around the chest like an encircling belt.

  At a Parks and Recreation tennis tournament that week, I had come up against a powerful kid, hitting with two fists on both sides and wielding a fat graphite racket that strongly resembled a sledgehammer. He had me on a long string, had me scrambling from side to side on the baseline. It was all I could do to get my racket on the ball, keep the ball in play, get it over the net, make him hit it one more time. But eventually I would send up a floater or a short ball on which he closed in, set himself, and then punished me by pounding it into a corner, sending the chain-link fence into song and ending the point. Without a new offensive weapon of my own, the next point and the next point and the next would go the same way. This was how I felt off the tennis court, in the AIDS arena—I was badly in need of a new weapon.

  My townsfolk who had the virus in their bodies were, with the exception of Fred, a reticent, almost fatalistic, lot in comparison to their counterparts in New York City or San Francisco. Everywhere but in our town, people infected with the virus were chasing down alternative therapies. ACT UP was rattling the gates of the complacent National Institutes of Health, activists were chaining themselves to the portals of the Food and Drug Administration, a thousand shrill voices were refusing to let them carry on with business as usual.

  I had assumed that the customs and conventions of monolithic institutions like the NIH, FDA and CDC were carved in stone, handed down from God, not amenable to change. But gay men in the form of ACT UP had done what cancer patients, diabetics, lung disease patients, heart disease patients had never done: they questioned authority and brought about change.

  But in our town we simply watched the television spectacle of mass arrests, heard the fiery speeches, saw the five-second newsflash of a bridge being blocked by activists.

  My patients, by contrast, were in hiding. They were not inclined to a public demonstration of any sort, scared lest the tragedy of their HIV infection be compounded by their neighbors’ knowledge of it. My patients relied on me to tell them if a cure was coming, relied on me to tell them that they should be frustrated and angry with the fickleness of Reagan’s commitment to AIDS, relied on me to draw the parallel between Nero and Reagan, between the burning of Rome and the continued lack of a firm governmental response to AIDS.

  I was their surrogate activist, their link to the larger consciousness of AIDS. They visited regularly, they were punctual like churchgoers, they accepted my prescriptions for “Stress-Tabs-with-Zinc,” they swallowed the antidepressants or the appetite stimulants I prescribed, and they went on. Their battle lay largely on the home front: keeping up the appearance of health and hiding the secret of AIDS.

  Meanwhile, the five medical journals I subscribed to and the ten other “junk journals” that arrived unsolicited were clogged with papers about AIDS: new manifestations of AIDS, bizarre new twists to existing syndromes like AIDS dementia, colorful and unexpected side effects of the therapy we used for opportunistic infections.

  And each journal had the story of the rising numbers, the changing epidemiology: more babies with AIDS, more women with AIDS, many more blood transfusion cases now revealed, more minorities, more intravenous drug users, and more countries with AIDS. I thought of these reports as dispatches from the front reaching me in my war room where I sipped bourbon to calm my nerves. The army was advancing, and every second stolen from the war made me feel guilty.

  So far, no one had described the rural experience with AIDS I was seeing: a quietly burgeoning clinic, an intimate primary-care kind of clinic, a clinic with strong resemblances to a secret society with me at its head and the various novitiates and initiates dispersed among the townsfolk, disguised as bakers, shoe repairmen, housewives, priests, waiters, blacksmiths and publicans. We exchanged our looks, our secret signals, in restaurants, in bowling alleys, at chamber music recitals.

  What my journals did not report was what therapies were currently being tested, and whether any had shown promising results. The journals were, like the NIH and FDA, bound by tradition: they reported only completed research, not work in progress.

  And when a study was finally complete enough to meet the rigorous peer review of a journal, it was as a rule preceded by announcements on CBS and CNN and in the Johnson City Press. I would spend an embarrassing day fending off Fred and others who called, saying “I don’t know,” until the journal finally arrived in the mail. When the Johnson City Press called to get my reaction to this or that news report on new therapy, I managed never to be in.

  WHILE WILL JOHNSON was still in the hospital, I made a quick trip to Los Angeles for a national infectious diseases meeting. I met Stuart Levitz, my friend and former tennis buddy from Boston. One afternoon, we managed to sneak out of the meeting early to play tennis.

  Stuart had stayed on at Boston University and University Hospital as a faculty member in infectious diseases. I was surprised to find that I was following a greater number of patients with HIV—close on fifty—than were most of my counterparts in Boston. Yes, the big city hospitals were following hundreds of patients. But since infectious diseases faculty like Stuart had with them a flock of interns, students, residents and fellows, they never personally assumed care for anyone, except perhaps one or two patients in their private clinics.

  Meanwhile, at Boston City Hospital across the street, the hematology-oncology division seemed to have taken over much of the AIDS outpatient care with only a few infectious diseases people working with them. But the infectious diseases division was looking to get back in the game: what had previously been a tiresome and taxing burden was now clearly an exciting research opportunity.

  In the academic centers of America, the big boys of infectious diseases were divvying up the grant money that was now finally pouring into AIDS from the NIH and elsewhere—money that had come late and was still not enough, but at least it was coming. The money was resulting in career changes, creating institutes of retrovirology overnight, providing salary support for a host of ancillary personnel, creating a major expansion in academic infectious diseases. The solitary physicians who had been providing yeoman service for AIDS with little help, and at the expense of all their other projects, were now finding themselves flush with resources: nurses, social workers, office space, salaries to recruit more physicians.

  That evening in L.A., I took part in a panel discussion on pneumonia. At the dinner that followed the meeting, I was seated next to a well-known infectious diseases persona, a chief of infectious diseases at a big city hospital. Every time I saw him he was impeccably dressed: the latest Italian suits, silk ties and thousand-dollar shoes. It was said that no pharmaceutical company would dare launch a new antibiotic compound in North America without getting his endorsement. During my residency and fellowship, I became well versed in his papers and textbook chapters; upon meeting him, I found much to admire in his intellect, his speaking ability, his interpersonal skills and his industry. I was (and still am) slightly in awe of him. Now he was telling several of us of a major grant for AIDS care that his division had received. I was curious to know exactly how he managed to run such a huge AIDS clinic in a big city? What were the logistics? I knew that he was rarely in his office because he was so often on the road, almost an itinerant lecturer. Money for labs, technicians, centrifuges and incubators did not translate into patient care. Who sees the patients? I asked. He lowered his voice and looking around conspiratorially said: “What you have to do is hire ‘drones’ to do the day-to-day clinical work. You can’t possibly be running down from your office to see every clinic patient who shows up on a nonclinic day with high fever or seizures. Your faculty will just burn out. You won’t be able to keep them. It’s impossible!”


  He must have seen the shock on my face because he clammed up and changed the subject. I spared him embarrassment by not pressing him on who these “drones” were. I could well imagine: Indians, Pakistanis, Koreans, Filipinos, Middle Easterners—all doctors with visa problems and the need to remain in a “training” situation till they could make the switch from a J1 visa to an immigrant visa.

  In Johnson City, I was providing all the care for my fifty patients. I was my own drone. And I was getting very tired. And sometimes very angry.

  I CAUGHT the red-eye from Los Angeles and arrived in Johnson City on a Wednesday morning. That afternoon in clinic I saw a new patient, Petie Granger.

  Petie Granger had been living in Baltimore for two years, working as a buyer for a clothing company. Six weeks before I saw him, he called his parents to say he had pneumonia that was not getting better. His father and mother raced up to Baltimore, found him very ill in his apartment, and rushed him to a local hospital. He was diagnosed as having Pneumocystis carinii pneumonia. His parents held vigil at his bedside, dealt with the certainty now that their son was gay and had AIDS. They nursed him in the hospital round the clock. Petie wanted to move back to Tennessee.

  His father and brothers rented a U-Haul and emptied everything from his carefully furnished apartment close to the Chesapeake Bay. As soon as Petie was discharged, his mother took him directly from his hospital bed to a makeshift bed she fashioned in the back of her Ford LTD Wagon, drove him back to the family house in Tennessee, and moved him back into his old room.

  In a week, when Petie could walk again, Mrs. Granger went with Petie to her personal doctor. He had taken care of Mrs. Granger for many years in their town; he was a man in whom she had great faith. As will happen in a small town, she was on a first-name basis with the office staff and considered them her friends. She was sure her doctor would take care of Petie or at least serve as the ringmaster and orchestrate his care.