My Own Country

by Abraham Verghese

  At one level I felt sorry for Duke; most of us at one time or other had trained in large referral centers like Duke. We had referred in our notes to rural physicians who sent patients to us as “LMDs”: local medical doctors. Now I was an LMD and from my vantage point I could see how a large institution like that could appear impersonal and uncaring.

  “I don’t need the money, Abraham. I feel also from the spiritual standpoint I have to find a way to forgive the culprits. Besides, I don’t wish to spend the rest of my life in court seeking a judgment I might well not live to receive.”

  I suggested to Mr. Johnson that we had a duty to let Duke know what had happened. It was possible that they had other patients who had been transfused that they needed to track down. I looked at Bess; we were both thinking about the family from Kentucky that she had befriended and that she had briefly corresponded with.

  I said, “Perhaps they will feel obliged to try to give you priority into an AZT trial. Even though Mrs. Johnson is asymptomatic, she too might be a candidate for experimental therapy.”

  After a long pause during which he put his hands behind his head and stared out of the window, he said, “Abraham, you write to them. I don’t want to deal directly with them. And if they want to treat me, let me know.”

  With that, one of the most remarkable couples I had ever met left for home after a two-week hospital stay that was unremarkable but for a weight gain of seven pounds and a vision of Christ.

  I WROTE TO Duke University outlining the relevant facts:

  “. . . Sometime during his hospital stay, immediately postsurgery, he received several blood transfusions and within four to five weeks developed a syndrome consistent with acute HIV infection and subsequently has developed lymphadenopathy that is consistent with the AIDS-related complex. In addition it appears his wife has become an asymptomatic carrier. There is no reason to believe that Mr. Johnson acquired this infection in any other way than by the blood transfusion during the course of his hospitalization at Duke University Medical Center.

  “He has asked me to write this letter to you because he and I both feel it is important that you are aware of this tragic occurrence. If it is possible to trace the blood transfusions that were suspect and perhaps see if other individuals have been infected and perhaps are unaware of it, this also may be very important. Despite this tragedy, Mr. Johnson bears no rancor against Duke or the physicians taking care of him. He has been able to forgive and to accept his illness. His purpose in having me write is, first, because he and I both feel that if there are any new modalities of therapy that might be tested at a large university center like Duke, perhaps Mr. Johnson should be one of the first to be allowed to receive such therapy. . . .”

  The response was prompt and concerned. I had letters from the cardiac surgeons and the cardiologist. It appeared that Will Johnson had a bleeding disorder; this was why he had required so much blood. I had a phone call from the Chief of Infectious Diseases at Duke University, David Durack, who was a respected expert on AIDS. He expressed his dismay at what had occurred and asked that the Johnsons be scheduled to come to the Duke HIV clinic as soon as possible. He personally would see them.

  If by some chance Will had returned to Duke when he had the “viral” illness a few weeks after his surgery, and if he had been referred to Durack, in all likelihood his illness would have been diagnosed for what it was.

  I conveyed the news to the Johnsons back in their home in Kentucky. From that point on, they were once again under the care of Duke, though I had frequent bulletins about them.

  IN JULY OF 1987, the AZT study was finally published in the New England Journal of Medicine. The study findings were dramatic: 145 subjects received AZT and 137 received placebo. When the study was terminated, 19 persons had died in the placebo group and only 1 in the study group. Opportunistic infections developed in twice as many patients receiving placebo as those receiving AZT. A rise in CD4 cells was seen in the AZT group.

  Here at last was the breakthrough we had waited for! There were limitations to AZT availability: It was restricted to persons who fulfilled the definition of AIDS; about half the patients who were eligible did not tolerate the drug in the doses suggested; it would cost a patient $8,000 to $10,000 a year; it was still cumbersome to procure. It was no cure, but it was the only show in town.

  Along with this breakthrough there appeared a number of other new innovations: It was possible now to prevent Pneumocystis carinii pneumonia either by administering an aerosol of pentamidine every two weeks or by giving the patient oral Bactrim every day. The studies to prove this were not yet out, but it had become common practice in AIDS clinics all over the country. And a drug called ganciclovir was now available to treat the dreaded onset of blindness in AIDS caused by CMV retinitis. Our ability to treat Candida infections was improving with the use of ketoconazole; a drug called fluconazole, which was effective against Cryptococcus (the kind of meningitis that Scotty Daws had), promised to be available shortly.

  I felt suddenly empowered. Not only did I have a drug for my full-blown AIDS patients, I had a feeling that soon AZT would be indicated for asymptomatic individuals and might prolong life. There appeared to be other antiviral agents on the horizon.

  My read of the tea leaves was that we had turned a corner in AIDS: we might now convert it from a fatal disease to a chronic disease, a chronic disease to which the patient would eventually succumb but in the interim might live a useful and productive life.

  18

  IN THE FALL, the mountains of Tennessee glowed like molten lava in every direction. Pine needles crackled underfoot and stuck to the carpet in our house, bringing their scent within. Every day a cluster of leaves collected in the niche between the windshield and the bonnet of my car. The leaves were so brittle that they snapped and popped in my fingers when I tried to lift them out intact.

  At Mountain Home, the lawns were covered with a fiery carpet of leaves. They were plastered against the wire fence, caught like fish in a net, until the VA groundskeepers came and picked the fence clean.

  The giant oak tree near the old skating pond stood unshakable. Every year it grew more familiar. When I went jogging, I began at this oak tree, stretching my calf muscles while leaning against it. Where once low branches had extended out, there were now big hollows. If no one was around, I wrapped my arms around its trunk and hugged it like an old friend, breathed in its fragrance, felt the reassuring scrape of bark against my skin. With the flesh of my arms joined to the tree, my feet between its knobby roots, I felt connected to Mountain Home, to my adopted country, to the earth. I wanted to stop time.

  But despite its placid veneer, the VA was abuzz with change. Rumor had it that we were slated not only for the construction of “bed towers” but also for the construction of a new nursing home and domiciliary. Change had also come about in the form of new faculty recruits. Two of my former fellow residents had returned to Mountain Home as junior faculty after completing fellowships in hematology and oncology. We who had stalked these hallways at all hours, dressed in scrub suits, now watched others ruling the hospital during the night’s quiet hours. In the corridors we exchanged secret smiles, thought about how once we had plotted revolution, had considered blowing up the radiology department to inject some life into that sluggish section.

  Every subspecialty division was adding new members. Steve and I were recruiting for an additional infectious diseases faculty member. We found Felix Sarubbi, an academician who had been on the faculty at the University of North Carolina at Chapel Hill before joining the Asheville VA. He was well published—a true scholar—and was well known in academic infectious diseases circles.

  Fil plunged right into the business of infectious disease consultation at the VA and Miracle Center. For a while, my workload was divided in half: Fil rounded at the Miracle Center and saw consults there for a week while I covered the VA. The next week we reversed roles. Fil scheduled a half-day clinic of his own at the University Practice Group an
d began not only to see new HIV-infected persons, but also to get to know some of my old patients in follow-up.

  I could not imagine such luxury. There was one week when I played tennis every day, clocking out of the VA at 4 P.M. like everyone else.

  But the workload was decreased for only a short while. Soon we were seeing twice the number of consults from the Miracle Center; there was a perception that since there were two of us we could handle more. There were more calls from Northside Hospital. And HIV patients were now coming from far and wide; we each saw at least one or two new patients a week. Now that we were using AZT, with its propensity to cause anemia, we had to follow blood counts closely. As a result, we saw our patients at more frequent intervals than before AZT.

  ON A THURSDAY MORNING, October 1987, my beeper went off at 6 A.M. The answering service informed me that Dr. J, a dentist, wanted me to call him at home. I had never heard of Dr. J. He was from a nearby town.

  He apologized profusely for disturbing me so early and he sounded distraught. His voice was high-pitched and faint, and I could hear the country in his accent lurking under a thin layer of gentrification.

  He told me he had performed a difficult extraction the previous afternoon. That night, he had discovered that the patient was HIV positive. The patient, Ethan Nidiffer, was under my care.

  The tooth had been a deeply embedded molar. He had to cut the gum to expose the tooth. Then he had chipped at bone. The tooth had not wanted to come out. He finally had to split it into four pieces and lever it out. “There was blood everywhere, blood on my hands . . .”

  “Were you wearing gloves?”

  “Gloves, yes. But nothing else. I mean I never thought—”

  “Were you wearing goggles, a mask?”

  “I had my glasses on. No mask. . . . There was blood everywhere. Blood on my glasses. It must have fallen on my skin . . .” Here his voice broke. “Dr. Verghese, I’m so scared. I feel like my life is over. Do you think I will get AIDS?”

  “No, no, no. You should be fine—”

  “—Are you sure? I haven’t slept all night.” He was crying now. “My wife and I . . . we have small children. . . . I’m thinking of giving up dentistry altogether. . . . I’d just as soon raise cattle or move away. . . . If the Lord spares me, I swear I’ll be a farmer or something else, but not dentistry. . . .”

  His diction had slipped way back toward east Tennessee. I spent a long time reassuring him: he hadn’t cut himself, he had no open wounds, he was wearing glasses—he had little to fear. I was a little embarrassed and taken aback by his emotional outburst. I gently asked him if he did not use gloves and goggles on all patients? Was he not aware of the need for barrier precautions?

  “Well, who would have thought in Tennessee. I mean I know when you spoke to us . . .”

  I had given a talk at the Sheraton, three weeks before, to the county dental society. Dr. J had evidently been there. The topic was AIDS and the talk was extremely well attended. The question-and-answer session went on for half an hour. I had spelled it out then, emphasized the “AIDS iceberg”: there were many more HIV-infected persons than most of them realized; they needed to treat everyone they saw as if he were infected. From some of their questions I could tell that they were not using barrier precautions on every patient. (Will Johnson told me he had stopped going to his regular dentist, an old family friend, because despite telling the dentist he had hepatitis B, he could not seem to get him to use gloves.)

  The dentists in town either did not believe there was as much HIV as I was telling them, or were relying on their ability to sniff “them” out from among their other patients; prune “them” from their patient rosters.

  I asked Dr. J how he found out the patient had HIV. Obviously the patient had not volunteered this information before the procedure.

  “Dr. Verghese, you promise you won’t be mad if I tell you? The person who told me was only trying to help. I don’t want him to get into trouble. . . .”

  I insisted he tell me. My tone was commanding. If he wanted me to commiserate with him, have me reassure him and cite statistics for him, he better tell me.

  “It was the pharmacist from Z_______ Drugs. Ethan Nidiffer went there to fill a prescription for penicillin. The pharmacist called me at home and asked me if I knew I had just operated on an AIDS person. I know you’re going to be upset with the pharmacist, but if he hadn’t told me, I wouldn’t have known. Ethan Nidiffer is one of your patients, isn’t he?”

  “If he was, I could not possibly tell you. I would be violating his confidentiality. I would be doing what the pharmacist did. I do think it was highly inappropriate, highly inappropriate and unprofessional of the pharmacist to call you and tell you.”

  “But shouldn’t the patient have told me? What about my risk?”

  “The patient certainly should have—I’m not for a moment supporting what the patient did. Had I known, I would have insisted he tell you. And if this is a patient of mine, you can be sure I will speak to him. And I feel for you, I hate that this had to happen to you. I’m glad that from your description of events it doesn’t sound to me like you are at risk. But it’s important that you use precautions as if every single person you bring an instrument to is potentially infected with the virus.”

  “If I ever operate again.”

  I concentrated now on calming Dr. J down. We went over carefully the transmission of the virus. I pointed out to him that there were reports of at least five hundred health care workers with needlesticks from AIDS patients and only one or two had contracted the virus in this way. Dr. J’s exposure, at worst, constituted a “splash” and was of extremely low risk. We went over universal precautions, and it was clear Dr. J had only been giving universal precautions lip service. “I just couldn’t imagine in this town . . .” he kept repeating.

  We were on the phone for another twenty minutes. I was angry with the pharmacist, annoyed with the mewling tone of the dentist, and irritated with Ethan Nidiffer.

  I arranged for Dr. J to get the HIV test done and to repeat it again in six weeks and six months. When I hung up, he seemed calmer than when we had first talked.

  Ethan Nidiffer, the dentist’s patient, was, in his own words, an “over-the-hill Tennessee queen.” He was in his late sixties, and if you saw him on the street you would have thought of him as someone’s uncle or grandfather. He had silvery hair combed straight back, walked with a stoop, and had severe emphysema, which made him pause in midsentence to get a breath. Polyester pants with front slit pockets and western shirts with a polyester blazer were his regular dress. He looked very much like a veteran, which he was, though since he had private insurance he never went to the VA for care. The skin on the back of his hands and on his face was shiny and very thin; it was also as fragile as tissue paper from years of taking cortisone for his emphysema. An inhaler rattled in his pocket alongside his car keys. He had stopped smoking and quit the heavy drinking in the past few years, but despite that was in a delicate state. To have found out he was HIV positive was a cruel blow so late in his life. When I first saw him, I was much more concerned about his emphysema than about his HIV infection.

  Ethan was bitter about the HIV. He had not been very promiscuous, at least by his own account. He had held a steady job in town for thirty-odd years and had taken an early retirement because of his lung problems. He was in the closet and, though unmarried, had never given anyone cause to do more than speculate that he was gay.

  His sexual activity of choice had consisted of performing oral sex on others. Now he rarely left his house. He claimed that for years there were at least four married men who stopped by his house every week for him to perform this service. I had once asked him, “What do you get out of it? Do you come yourself?” He shook his head and smiled: “No, but you wouldn’t understand, Doc.” He said he could count on the fingers of one hand the number of times he had engaged in rectal intercourse. But his luck had been bad because one of those “fingers” gave him HIV infection.


  I had sent him to Duke to see if he would be eligible for the AZT trials on early HIV infection. Duke entered him into a randomized, placebo-controlled trial. I was to do some of his follow-up blood work in my office and send it on to them. When I saw him a month after the enrollment, it was clear to me that he was getting placebo. AZT induces a very characteristic change in the size of the red blood cell that is apparent in one of the indices measured on a routine blood count.

  A part of me was sorely tempted to tell him he was on placebo and for him not to bother going to Duke. The five-hour drives across the mountain were torture for him; in summer, it was hell to breathe in Durham whether you had lung disease or not, so oppressive and humid was the air. Ethan struggled for days after each visit. Yet he went religiously every couple of weeks until he himself was sure he was getting placebo, at which point he dropped out.

  Ethan had managed to keep the fact of his HIV infection hidden. I doubt that my office staff for one moment thought of him as an HIV-infected patient, but for the fact that he was seeing me. There was a bluff, good-ole-boy, old-fashioned heartiness in his manner, in the way he greeted the nurses, flirted with them. There was no trace of effeminacy, only a hint of punctiliousness in his mien that was quite allowable in a confirmed bachelor. When we were in the exam room alone, he was looser, his conversation more risqué, and his manner intimate and confiding. Above all, Ethan Nidiffer abhorred the loud “flaming queens.” That adjective popped up often in his conversation. He himself was an “old queen,” or a “Tennessee queen,” but never a flaming queen. He was the only patient I had met who was critical of ACT UP and felt the cause was already lost since the public had come to associate homosexuality with the loud angry images of ACT UP protesters or members of Queer Nation.