by Peter Elkind
Reopening after a year, the Green was eventually placed under the control of the newly created Bexar County Hospital District—a special taxing entity set up to fund the public hospital directly. An independent board of appointed managers governed the district, whose bylaws stipulated that it provide for the “indigent and needy sick” of Bexar County. The ultimate power of the purse—the crucial matter of setting the district’s tax rate—remained in the hands of the county commissioners.
It would be the federal and state governments that would change everything—transform this Dickensian hospital for the poor, set amid the downtown squalor, into a sleek temple of modern medicine, planted in the affluent suburbs. In the years after World War II, federal dollars came to shape every aspect of American medicine. Through an array of new grant programs, Washington poured billions into health care: for construction of new hospitals and medical schools, for high-powered research, and—through Medicare and Medicaid—for treating the poor and the elderly. The opening of the federal purse produced a building boom; new hospitals and medical schools began springing up everywhere. The Robert B. Green’s demise was fated with the state’s decision in 1961 to award a medical school to San Antonio.
Hoping to end a persistent physician shortage, city fathers had been lobbying for a University of Texas medical branch for years. An unusual offer had brought success: a commitment to provide the medical school with a three-hundred-bed teaching hospital, free of charge to the state. In accepting the deal, the Texas legislature had added a condition that entwined the fate of the two institutions further: The hospital must be located within one mile of the medical school. This meant that the county would have to provide a hospital wherever the State decided to put the medical school. A furious battle ensued.
On one side stood advocates of downtown: With a much-needed renovation, the Green, already the county’s charity hospital, could serve as the teaching hospital as well. Most teaching hospitals used sick poor people as cannon fodder for the instruction of medical students and inexperienced doctors; the Green obviously had plenty of what is known in academic medicine as “clinical material.” It also made sense to continue treating the city’s indigent at an institution close to where most of them lived. And pairing the medical school with the Green would serve the auxiliary goal of urban renewal: The medical school and the expanded Green would bring hundreds of white-collar jobs to San Antonio’s rotting downtown core. Center-city merchants, the Catholic Church, organized Hispanic groups, and the Green’s longtime patrician patrons backed downtown.
But a group of chamber of commerce leaders and real estate speculators had an altogether different idea. They focused not on the most obvious goals of the medical school and hospital: to train doctors and care for the poor. Alert to new ways of modern medicine, they looked at the institutions and saw Economic Potential. They envisioned the medical school and its teaching hospital, a new teaching hospital, as anchors to a sprawling new suburban medical complex—a rival to the famous Texas Medical Center in Houston. A quartet of real estate speculators already had offered a gift of one hundred seventy acres, adjacent to the Oak Hills Country Club, eleven miles northwest of downtown. That was enough land to provide the medical complex with room to grow for years. The speculators had promoted the concept by luring Methodist Hospital to the area with a donation of twenty-seven acres. Such benevolence was a shrewd investment, an example of what is wryly known among land merchants as “enlightened self-interest.” The speculators had snatched up more than two thousand acres of surrounding land cheap; they were betting on the medical complex to send values in the sparsely populated area soaring.
Offered a gift of one hundred acres for the medical school, the University of Texas board of regents opted for the suburban site. The defeated downtowners were mollified with a promise from county officials that the Green would never be abandoned. Construction of the new Bexar County Hospital and the University of Texas Medical School, situated next door, began in March 1966. By then, the seductive appeal of federal grants—Washington offered two dollars for every dollar put up locally—persuaded the county commissioners to build a far more grandiose hospital than originally planned: 564 beds instead of a mere 300.
The new Bexar County Hospital was dedicated on November 9, 1968. Amid much pomp and ceremony, Texas governor John Connally declared “South Texas Medical Center Week,” and everyone marveled at what the public treasury had built. The $17 million hospital sat on twenty-nine acres, rose twelve stories tall, and contained 485,000 square feet—eleven acres of floor space. San Antonio’s newspapers filled entire sections with gushing praise: THE NEW FACE OF MEDICINE IN SAN ANTONIO; NO EQUAL IN DESIGN, BEAUTY; ANY ORGAN TRANSPLANT COULD BE PERFORMED; and SERVICE AVAILABLE WILL BE WELL WORTH COST TO TAXPAYER. Even the cafeteria won acclaim: NO LONG LINES; SELDOM ANY WAITING.
A single headline captured the county’s overarching ambition for the institution. It read: SUPERB CARE: NEW HOSPITAL EXPECTED TO SERVE INDIGENT AND WELL-HEELED. Since 1917, the Green had accepted only charity cases and charged nothing for medical care. Bexar County Hospital would be different; it would charge people what they could afford to pay. County officials imagined that the new hospital would draw plenty of private patients to subsidize operations. “For the first time in the history of the community,” the hospital’s top administrator proclaimed, “there is going to be a single kind of care—the same kind of care—for those who can pay and for those who can’t.”
It was wishful thinking. Despite Bexar County Hospital’s location among the moneyed, despite its affiliation with the high-powered doctors at the adjacent medical school, the hospital was destined, like the Green, almost exclusively to serve the poor. No matter how much they heard about the cutting-edge care at the new institution, most well-heeled San Antonians were unwilling to rub elbows with the city’s rabble.
Even before the dedication, it had become apparent that Bexar County could not afford to operate two separate hospitals. When construction on the new hospital ran $2 million over projections, administrators had cannibalized the budgets for x-ray and lab equipment to finish the building. When voters refused to raise their taxes to run the new hospital, the state legislature had to bail out the county by authorizing the tax increase anyway. A looming financial crisis prompted the resignation of the hospital administrator before the new building was a year old.
Seeking to trim expenses, county officials had begun cutting back at the Green. With the opening of the new facility, the fifty-one-year-old hospital dropped from 290 beds to 125. Most inpatient medical services moved north; along with a few emergency patients, only the maternity and newborn nursery wards remained. In December 1976, county officials announced the closing of those wards as well; they had decided to convert the old hospital exclusively for outpatient-clinic use.
Community groups organized rapidly. The past decade had seen a transformation in San Antonio’s Hispanic population. Mexican-Americans now represented a majority, and after domination by Anglos since the Texas Revolution, they had learned to exercise political power. Their leaders screamed betrayal, recalling the old promises to preserve the Green. As the proposal to transform the downtown hospital wound its way through the state’s regulatory labyrinth, they pushed local and federal officials to act.
In December 1978, the U.S. Justice Department and the San Antonio city government filed a federal lawsuit to block the move. Arguing that the transfer of maternity services would deprive impoverished Hispanics and blacks of proper maternity care, they branded the hospital district’s plan an act of racial discrimination. The suit noted that the Green handled more than six thousand births a year, that 80 percent of the mothers were Hispanic, 7 percent were black, and that almost all of them lived much closer to the Green than to the Bexar County Hospital. The suit pronounced the new hospital in the suburbs “not only physically but also psychologically too distant from a large segment of the patient population.”
The dramatic trial in feder
al court was a testament to the inadequacies of Bexar County’s medical care for the poor. Among the parade of witnesses was a young Mexican-American councilman named Henry Cisneros, destined to become the city’s mayor and a national symbol of Hispanic achievement. Cisneros testified that relocation of the maternity ward and nursery would make it difficult for Hispanic and black mothers to reach the hospital before giving birth. Most of his constituents were poor and many lacked cars, Cisneros said. Forcing them to travel to the “ridiculously located” Bexar County Hospital would jeopardize many lives.
Hospital district witnesses testified that it was the Green that endangered lives. They claimed that the old hospital was too inefficient and ill-equipped to remain in use and too decrepit to renovate properly. Echoing the words of those who had staffed the Green fifty years earlier, one doctor said conditions there resembled “a battlefield situation.” After a sixteen-day trial, a federal judge agreed. “…Not only was no discrimination intended by the Hospital District, but none was effected,” ruled the magistrate. “On the contrary, when the relocation is completed, a first-class general hospital will be provided at the Oak Hills site, without discrimination, to every qualified obstetrical patient, so that optimum health care will be made available to each indigent mother and her newborn child.”
Work began promptly to transfer the maternity wards and nursery, the last vestiges of the Green’s days as a full-service hospital. With the addition of new outpatient clinics, the Robert B. Green Memorial Hospital was re-christened the Brady-Green Community Health Center.
By then, the businessmen’s dream for the South Texas Medical Center had become reality. With the UT medical school and Bexar County Hospital serving as magnets, the complex attracted new hospitals, office towers for private doctors, a cancer center, an institute for religion and health, and dozens of other facilities. Gifts and purchases of land enabled the special foundation set up by the chamber of commerce to expand the medical center to 683 acres—more than any comparable project in the nation and three times the size of its famous rival in Houston. Even in 1978, with construction crews toiling away on new projects, so much vacant land remained that the foundation leased out more than a hundred acres for cattle grazing.
The area around the medical center was booming too. The prairie bought by the speculators had given way to apartments, banks, restaurants, hotels, strip shopping centers, and fancy housing developments. The speculators had acquired the land during the 1950s for between $500 and $2,000 an acre; the 1961 decision to build the county hospital and medical school nearby had tripled its value overnight. As values multiplied further, the original speculators sold off some of their holdings and developed other tracts themselves. By 1978, land around the South Texas Medical Center was going for $60,000 an acre.
The new medical center shifted the care of San Antonio’s poor to a vastly different kind of institution. The Green was an old-fashioned charity hospital, dirty and crowded, resigned to its miserable image, focused exclusively on patient care. Bexar County Hospital was a creature of the world of modern medicine. Its existence meant better medical care for the city’s indigent: supervision by medical school doctors expert in cutting-edge technology; hands-on treatment by young residents with greater skill; and, despite the unending money woes, access to better hospital facilities and equipment. But modern medicine also was more specialized and impersonal, and the new hospital reflected those changes too. Much of the medical faculty cared more about research than about treating patients. Unlike the Green, Bexar County Hospital was striving with ambition. It cared acutely about its image and lived in fear of litigation—concerns tended obsessively by administrators in a newly burgeoning bureaucracy.
For the poor of San Antonio, who now arrived for medical treatment by shuttle bus or borrowed car, the sophisticated new hospital was a sterile, perplexing place. Still they came, day and night, bearing their children in their arms, waiting for hours in the emergency room, where patients were admitted for treatment. In a simple act of faith, they trusted the nurses and doctors and administrators who ran the hospital; they trusted them to safeguard their lives and to make them well. They trusted them because they had no choice. They had nowhere else to go.
Four
Genene Jones said her first emotion on starting work in Bexar County Hospital’s pediatric intensive care unit was “stark, raving fear.” She had not treated children since nursing school. But her doubts disappeared quickly. “The first baby I ever took care of was a preemie with a dying gut,” she recalled. “I picked that kid up, and I knew I was going to stay there.”
Cherlyn Pendergraft, the registered nurse who gave Genene her orientation, wasn’t so sure. The infant, a six-day-old boy with an often fatal intestinal disease called necrotizing enterocolitis, went to surgery, returned to the ICU, and died. Genene had cared for the child only briefly—she’d had no time to develop an emotional attachment—but “she just went berserk,” Pendergraft said; Genene broke into deep, racking sobs, moved a stool into the dead baby’s cubicle, and sat staring at the body.
The pediatric ICU at Bexar County Hospital was down a long fifth-floor corridor—past the little boys and girls playing in the hall, past the rooms of children who had busted a leg or lost an appendix, past the kids who would soon leave the pediatric ward, happy and healed. At the end of the corridor, one walked through swinging double doors and stepped into a different world. Here the children were mostly silent and still, strapped to their beds, hooked up to beeping monitors and a web of wires and tubes. The pediatric ICU was where Bexar County sent its critically ill children who could not afford a private hospital: the infant girl whose raging father had cracked open her skull, the two-year-old who had nearly drowned, the seven-year-old who was struggling to survive a congenital heart defect.
The pediatric ICU occupied a rectangular space the size of a two-car garage. During most of the time Genene Jones was there, it contained eight beds, one or two in each of six separate cubicles. The rooms had large glass windows that allowed the nurses to keep an eye on the patients and on the machines that monitored their heartbeats and breathing. In the back of the ICU was a small room where the nurses could sit and relax. It was filled with supplies and equipment for conducting simple lab tests. Near the entrance to the ICU hung a small locked cabinet where narcotics were stored; most other medications were freely available in an unlocked drug closet.
While patients in the ICU might range up to sixteen years old, many of them were infants. But the pediatric ICU did not treat newborns. Newborn children who were gravely ill went to the neonatal ICU, a floor below, where they received more specialized care and were isolated from the infection that children who had been outside the hospital might bring in. The pediatric ICU was for kids who had been out in the world. Children were brought there to recover from surgery or to be treated for a disease or an injury.
Genene Jones had been entrusted with the lives of such children after a less rigorous screening than a bank would give to an applicant for the job of teller. Facing a desperate shortage of nurses, the county hospital was in the habit of asking relatively few questions; like most busy big-city hospitals, it regarded the possession of a valid nursing license as sufficient ground for trust. On her job application, Genene had vaguely attributed her departure from Methodist Hospital to “conflict.” The county hospital’s personnel department routinely sent Genene’s former employers a written form seeking information about her job performance and her suitability for reemployment. When Methodist returned the form with such questions unanswered, the matter went no further. Nothing in Genene’s personnel file at Bexar County Hospital indicated that she had been fired from her first nursing job for abusing a patient.
Bexar County’s role as a teaching hospital meant that it answered to two masters. The county hospital district maintained and equipped the building; hired and fired administrators and support personnel, including nurses; and paid the salaries of the young doctors-in-training—call
ed residents—who staffed the hospital around the clock. But it was the UT medical school that selected the residents and supervised medical care. While the relationship was administratively unwieldy, both institutions benefited. UT provided the hospital with doctors; the hospital gave UT a place to train its medical students and residents. Because doctors learn by doing, and paying patients don’t like to be practiced on, it is charity hospitals like Bexar County where most American physicians learn to practice medicine.
The pediatric ICU medical staff consisted of rotating teams of pediatric residents—most of whom had graduated from medical school no more than three years earlier—supervised by attending physicians from the UT faculty. A strict hierarchy ruled the doctors. The attendings supervised the senior residents, who had completed at least one year of residency; the senior residents guided the interns, in their first year out of medical school; interns taught the medical students. Residents learned complex medical procedures at bedside, then passed the knowledge on. An axiom summed up the process of medical education: See one. Do one. Teach one.
Residency has often been described as the hazing ritual of American medicine—a brutal rite of passage involving long hours of work under tremendous pressure, with little sleep and low pay. Internship year was the worst. In 1978, interns at Bexar County Hospital worked as much as ninety hours a week for $12,000 a year. As the survivors moved up—suicides and breakdowns were not unheard of—a new class of interns arrived fresh from medical school each July to start the process all over again. It is not myth, but statistical reality, that there are eleven better months to be a patient in a teaching hospital.