Hospital

by Julie Salamon

  The diagnosis made him angry. An iatrogenic illness. If they hadn’t drawn his blood, maybe he wouldn’t have been sick. He would have been fine. He knew that his reaction was irrational, that he was lucky, and that the doctors hadn’t caused the disease but found it. A year on sulfasalazine and the Crohn’s symptoms never reoccurred. Even so, the experience left him with an enduring skepticism about overtesting patients. He remained acutely aware of the ramifications of giving a diagnosis; the worries, frustration, and anger it could trigger; how simply articulating a disease could disrupt a life.

  Ability. Affability. Availability. Patients often don’t distinguish among these, warned an associate dean at his graduation from medical school. Remember that.

  Astrow remembered. He also remembered the angry critiques of the medical system he read as a medical student, as relief from the crush of data he had to memorize. Books like Medical Nemesis by Ivan Illich, the former Roman Catholic priest (whose mother was Jewish) whose fierce antiestablishmentbooks and articles grabbed the imagination of baby boomers in the 1970s and then were largely rejected or forgotten.

  Much later Astrow would often reread an essay called “The Patient as a Person” by Abraham Joshua Heschel, the rabbi who wrote learned, emotional treatises on Jewish law and marched with Martin Luther King Jr. Astrow especially liked one section of the essay, originally delivered as a speech at the American Medical Association in 1963: “The truth of being human is gratitude, the secret of existence is appreciation, its significance is revealed in reciprocity. Mankind will not die for lack of information; it may perish for lack of appreciation.”

  Heschel gave that lecture in an era when paternalism was the accepted relationship between doctor and patient. By the time Astrow became a doctor almost twenty years later, openness prevailed, an attitude Astrow believed in and practiced. But he found that honesty could be more treacherous than deceit. Cancer forced patients and doctors into the realm of philosophy by bringing the uncertainty of existence into sharp focus.

  Another lesson from Astrow’s medical-school years: His father had been taking bromocriptine, a medication used in the treatment of menstrual and fertility problems that had been found useful in controlling Parkinson’s symptoms. Martin Astrow was under the care of the leading expert on Parkinsonism at Columbia Presbyterian, who urged hospitalization when the patient began having strong dystonic reactions to the medication— causing him to flail wildly. The doctor told him to come into the hospital to have the dose readjusted. By the time Martin arrived, he had broken into a cold sweat and was in pain so severe that the admitting doctors decided not to do an EKG. He was given a private room and assigned a fourth-year medical student to look after him.

  Three days later an EKG revealed that the pain attributed to a drug-reaction muscle spasm had been a major heart attack. He survived, but with severe heart-muscle damage.

  As Astrow received this immediate education about the frustration and fallibility of medical science, he also began wondering about the source of character. Why was his father able to cope with his illness with such courage?

  For several years Martin continued to work, until the Parkinson’s made it too difficult for him to walk. But he didn’t despair, or at least he didn’t reveal any despairing feelings he might have had (except for those occasional displays of anger). Astrow’s mother remembered Martin’s answer to the doctor they saw at Mount Sinai, a man close to his own age at the time, about sixtyfive, who looked at her husband pityingly, as he asked his patient how he passed the time.

  Martin seemed surprised by the question, his wife recalled. He had been immersed in reading the works of Einstein, contemplating modern physics. “I have plenty of things to do,” he told the doctor. “I read. I watch television. I exercise.”

  When he was sixty-seven years old, on Valentine’s Day, he put all the family photographs into albums and organized the bookshelves. His wife went shopping for a new television set to replace theirs, which was broken. They were going out for dinner that night to celebrate Valentine’s Day, as they always did. While at the store, Ruth heard her name being paged. It was Martin calling to say he’d fixed the television; she didn’t need to buy a new one. That evening they went to dinner at a seafood restaurant, as planned.

  Maybe the fish they ate was from the ocean, Alan Astrow speculated. A heavy salt load would explain the pulmonary edema that killed his father that night.

  Martin Astrow had lived to see his son become a doctor. He had celebrated Valentine’s Day with his wife. He’d arranged the bookshelves and fixed the television. He had left his house in order.

  Would he have lived longer if someone had done an EKG on him that first night at Columbia Presbyterian, a decade earlier? Undoubtedly— maybe—if he had been struck by the disease just a little later, when treatment of heart disease had progressed, much of his heart muscle might have been saved. But back then? Astrow couldn’t say.

  Much of Astrow’s job would be helping people live with uncertainty, even those with an optimistic prognosis. Hopefulness was less likely to be a lie now—far less than when he had begun to practice oncology. But cancer continued to be an elusive disease. Could he ever say with certainty there would be a remission, even when it was likely for certain kinds of cancer after certain kinds of treatment? Some other disease could come into play, as it did with his father. The prospect of death was always present for everyone, but cancer made the inevitable hard to ignore. The only real variable was timing.

  The more experience he acquired, the larger the questions loomed.

  Where did goodness come from?

  Was it possible to be truthful and kind?

  Could you be kind and command respect?

  Those were the things Ruth and Martin Astrow’s son thought about.

  Jill Nathanson grew up without religion. Her mother was a classical musician, a pianist. Her brother Roy Nathanson became a saxophonist of some renown. Jill painted. Art was the family’s theology.

  Autumn 1988: She was in her middle thirties, living in her studio on the Lower East Side, pregentrification, cooking on a hot plate, when she picked up a book called Major Trends in Jewish Mysticism, written by the Kabbalist scholar Gershom Scholem. She didn’t know how the book had wound up on her bookshelf. Someone may have given it to her, or maybe she’d bought it, thinking it was cool—she couldn’t remember. For years she had been trying to understand unknowable things, like the depth of suffering that led her mother to commit suicide. Attempting to make an inchoate universe more comprehensible, Nathanson had scaled down her work, from big splashy paintings to smaller pieces that made her feel better, closer to finding hopefulness in the mystery of strange, shifting colors.

  Things still felt dicey. While her art comforted her, the art world seemed cynical and shallow. Her life devoted to creating art hadn’t created an orderly existence. She sought redemption in color but found she wanted more.

  One day she picked up Scholem on her shelf, hoping to find an answer in the intricacies of Jewish mysticism. But to her devoutly secular eyes, the words on the page seemed just as tangled—and perhaps even more incomprehensible—than earthly existence or the depths of blue.

  No help.

  Not long afterward Marshall Meyer entered the picture—literally, she saw him on television—and changed her life. Meyer was a rabbi, born in Brooklyn, raised in Connecticut, who had spent years in Argentina. He became a vocal adversary of the military government that had imprisoned or killed thousands of people, known as los desaparecidos, “those who have disappeared.” He tried to save lives of the persecuted and visited hundreds of them in jail, including a well-known journalist, Jacobo Timerman, who later dedicated his record of torture and humiliation, Prisoner Without a Name, Cell Without a Number, to Meyer. In 1985 the dynamic rabbi was asked to take over B’nai Jeshuran, a Conservative synagogue on the Upper West Side of Manhattan that had shrunk to eighty families. In short order he revitalized the congregation, eventually drawing thousand
s of people with his message that life could have meaning, urging social responsibility across religions and borders.

  Suddenly Nathanson found coordinates for her sense of urgency: the book on her shelf and the rabbi on her television. It was time for action. She went to B’nai Jeshuran one Saturday morning but stood frozen outside when she realized she had a pocketbook with her and remembered vaguely that you weren’t supposed to carry money on the Sabbath. She returned a week later and still was uncertain about how to enter. This time she saw something on a flyer that might offer a possible antidote to her ignorance. She decided to return yet again on Wednesday night, for a course called Introduction to Judaism.

  That night she walked in, only to find that the class was, as she said, “extremely boring.” So much for karma. She sneaked out and was standing in the hall, about to leave, when someone beckoned her into another room. She obeyed. As she sat down, an imposing figure strode in. He was the rabbi she had seen on television, even more impressive in life, who actually fit the description “a bear of a man.” He began his lecture on Rabbi Abraham Joshua Heschel. Nathanson was again mesmerized by Meyer. This was no theoretical lecture. Meyer had been Heschel’s secretary and translator, his successor in a quest to translate learning and theory into justice and decency.

  Despite the power of his rhetoric, she couldn’t stop herself from glancing around, from evaluating the aesthetics of her surroundings. “I was a decorative painter at the time—for money—and the room was very dingy. It had these crummy walls,” she said. “I found myself in an ugly room with the world’s worst sponge-painting job.” She also noticed her fellow classmates— a few elderly couples and eight youngish men who were so incredibly square-lookingthat she couldn’t believe she was sitting in this dreary room with such conventional characters. But when they began to talk, she was bowled over. “The class was fabulous, just amazing,” she said. Though her intent hadn’t been to meet a guy—at least not her acknowledged intent—suddenly she saw a roomful of very interesting, possibly single men.

  One of those men was Alan Astrow, wearing corduroys and Hush Puppies. He introduced himself after class, and when they discovered they both lived downtown, they rode together on the subway. His shoes kept coming untied. He said maybe they could have coffee sometime, but then he never called.

  Nathanson stayed in the class. She and Astrow didn’t speak further after that initial subway ride, though she always noticed when he walked into the room, head bowed, dragging his coat on the floor. As the weeks passed, she found herself paying special attention when he talked in class. At first she thought his thinking was simplistic, because his manner of speaking was so straightforward, almost childish sometimes in its directness. Then she listened. “Weird,” she said. “Smart. Weirdly brilliant, the things he would say. He would just be able to pull things from past reading but say them in such a simple way they would sound strange.”

  She believed that this dorky man with the carefully combed brown hair, sweet smile, and sleepy blue eyes was truly an original thinker. Wednesday after Wednesday she listened as unique observations poured from his mouth, foot-noted with references to obscure texts, reaching conclusions that transcended the usual divisions between conservative and liberal, platitudinous and radical.

  Six months after he said they might have coffee sometime, he called and asked her to go to the theater. “I’m going to say it was Twelfth Night, but if I’m wrong and he finds out, I’ll be chopped liver,” she said. “He remembers everything. Every play we’ve ever seen. With me, I don’t like it, gone.”

  She laughed. “Even if I do like it.”

  They joked that they had nothing in common. She was slight and fast, unafraid to climb forty feet in the air to work on scaffolding, splattered with paint, arguing with construction workers. He was cautious, wore white doctor’s coats, and pondered metaphysical matters. She was happy with take-out Chinese food; he liked fancy French restaurants. She knew nothing about religion; he seemed to know everything.

  But she felt comfortable with him. They were the same age. They had lunch together and liked each other. “He was so careless, so absentminded about himself, so unprecious,” she said. “I was comfortable with him because I’m not that orderly.”

  He also seemed innocent, strangely pure—until she found out he was dating someone else, a woman even more countercultural than Nathanson considered herself to be. She was conventional enough to decide, at thirty-five, that she wanted marriage and children, so she did the conventional thing for a woman who chose to succumb to the biological imperative. “I gave him an ultimatum,” she said. “I told him we couldn’t continue to go out if he was dating her.”

  They married. They had children, a boy and a girl. They moved to the Upper West Side, to an apartment big enough to encompass this new life—a life that outwardly may have had the predictable trappings of the New York Jewish intelligentsia but which for them was a surprise, daring and experimental.

  Without Marshall Meyer she doubted they would have found each other. “Reading this text together brought out something original in both of us,” she said, and then corrected herself. “‘Original’ is the wrong word. Something deep and unconventional. We spoke our souls in some ways in this setting that we would not have if we had met without the class.” Meyer touched what they had in common: a fundamental inability to pass through life lightly, a willingness to stand apart, a desire to search for the sacred in beautiful and terrible things.

  Everything about being a doctor changed for Astrow during a hematology elective when he was a resident at Boston City Hospital. It was late fall of 1982, or maybe early winter 1983. He drew blood from a patient with a rare diagnosis, and after that nothing was the same.

  Later the memory was embarrassing, in the light of the disaster that followed, but Astrow’s first response to the diagnosis was excitement: toxoplasmosis of the brain, a disease a doctor-in-training might read about but would never expect to witness. Pregnant women would come to know about toxoplasmosis, the disease spread by cat feces that could result in severe damage to babies in the womb. Caused by a single-cell parasite called Toxoplasma gondii, its presence goes unnoticed by most people infected with it. “Severe cases are more likely in individuals who have weak immune systems,” explains the Web site of the Centers for Disease Control and Prevention (CDC), the U.S. government agency assigned to promote and protect public health. Back then, however, there was no CDC Web site. There was no Internet. The CDC had only recently classified a mysterious outbreak of symptoms and infections related to a collapse in immune systems as AIDS, acquired immune deficiency syndrome. That summer, July 1982, the CDC reported 413 cases of the new disease in the United States with 155 deaths; a year earlier the CDC had reported seeing 108 cases.

  Astrow was only dimly aware of these cases when the man with the toxoplasmosis of the brain died, followed by a Haitian patient with tuberculosis, and then a pronounced number of young men showed up who were deathly ill with aggressive lymphoma or Kaposi’s sarcoma (KS)—another disease so rare a resident might expect to see one or two over an entire three years of training. By the time Astrow began his fellowship at New York University, in 1983, KS had become an epidemic; all three hospitals serviced by NYU residents and fellows were overrun with young men suffering from fevers of unknown origin or from atypical or fungal infections.

  When he entered medical school, AIDS didn’t exist, at least not as a known disease. When he entered the field of hematologic oncology a decade later, it became his life’s work. In 1986 he joined the staff at St. Vincent’s in Greenwich Village, the heart of the gay community in New York. The hospital turned two entire floors over to HIV units, trying to cope with the onslaught of KS and AIDS-related lymphomas. The hospital’s residency program suffered. No one wanted to come to New York to train because of AIDS.

  Astrow was surrounded by death—grisly deaths submerged in pain, stigma, disfigurement—early death, imposed on his peers, men in their twenties and
thirties. The dead included his best friend, a surgeon at St. Vincent’s. They included a sweet young hairdresser, a patient, who gave Astrow a blue sweater someone had given him from Bloomingdale’s. Twenty years later, after more than 550,000 people had died of the disease in the United States, after protease inhibitors had tamed the plague and transformed it into a chronic illness, Astrow still wore that sweater. He thought of that young man every time he put it on, like a ritual blessing for the dead. A kind of kaddish.

  By comparison with those grim days, Astrow’s dilemmas at Maimonides were minor, which didn’t stop him from worrying about them. He realized he had to repair his unwitting breach of etiquette, caused by inviting a non-Orthodox speaker to his spirituality conference at the cancer center. He sent Dean Twerski a polite e-mail to say he understood there was a problem.

  Twerski could be fearsome, with his haunted eyes and deep, resonant voice that harmonized with his intellect. Biberfeld had convinced him to join the board because he was Hasidic and lived in the neighborhood. Twerski had seen great improvement in the medical care at Maimonides over the past decade, but the community was always ready to pounce. “What happens in the hospital in fifteen minutes will be known in every synagogue,” he once told me. “That’s a very hard way to run a hospital, where everyone knows everything. There’s been a slipup, I’ll get calls, eleven, twelve o’clock at night: Someone is in the emergency room, and things aren’t moving. I will go over, and things will start moving.”

  But he called Astrow in response to his e-mail and was sympathetic to the doctor, if not to his predicament. Twerski didn’t buy Astrow’s proposition— that the yeshiva-educated minions in Borough Park would be eager to hear alternate views from another branch of Judaism. He told Astrow it was a bit of an insult, to bring an outsider to a community where there were so many scholars. What Astrow saw as a chance for discussion, Twerski saw as a slap in the face.