Hospital

by Julie Salamon

  “I think Astrow has this idealistic vision that Bashevkin will come here,” said Warshawsky. “He doesn’t understand old rifts and old feuds. Everyone looks after their own, that’s how it works. You scratch my back, I’ll scratch yours.”

  What did he think about his rival, Razaq?

  “As a physician I respect him,” said Warshawsky slowly. “But at the end of the day, we are separated by our cultures. Not our cultures. By our race. Our nationality. You can’t deny it.”

  When he was in medical school, he told me, he shared a cadaver with an Indian Muslim. They got along fine until Al Quds Day, the last Friday of Ramadan—designated by the Ayatollah Khomeini after the 1979 Iranian revolution as a day for Muslims worldwide to unite in their support of Palestinians and denunciation of Israel. (Al Quds is the Arabic name for Jerusalem.)

  “Come Al Quds Day—where they moan how they lost Jerusalem and are going to reconquer it—I would punch the guy in the face and he would punch me back,” recalled Warshawsky with satisfaction. “And then the next day we’d be sitting in class working together again. Muslim-Jewish fights on campus were the big thing. We would call in the big boys from the JDL [the Jewish Defense League], and they would come in with their gangs, and the other side would come out and say, ‘Death to Israel.’ You’d smack a guy, and the next day this is the same guy you’d have a conversation with about the biology of cancer cells.”

  He grinned a little wildly. “It’s crazy,” he said. “It is. It is the same thing here.” He lowered his head and glanced around. The tables were occupied by mixed groups of various ethnicities eating and chatting.

  As noted, Warshawsky had a good sense of drama.

  He modified.

  “It’s simmering,” he said. “It’s undercurrents. I tell you straight out, there’s a lot of complications in physician-patient relationships precisely because of this. Because physicians don’t understand other cultures, and a lot of these cultures do a lot of things that are very distasteful to a lot of physicians. I can only say for myself, as a Jewish physician, I’ve struggled, and there have been times I’ve asked someone else to take care of a patient.

  “Like when an Arab guy came from Ramallah, got off the plane, got an angiogram that showed he needed an operation, and came to this hospital thinking he could just walk in and get it, and I found that very very disturbing.

  “Picture me in Lebanon, say—if I was allowed to go into the country, which I would not be—or Saudi Arabia, breaking my leg and needing medical attention in the hospital. What are my chances of coming out of that hospital alive? I’d say zero. And yet with impunity those same people walk into this hospital dressed up in traditional gear expecting charity in a Jewish hospital.

  “But this is America,” he said. “You’re not allowed to turn someone away from the emergency room.”

  He nodded his head toward a group of Orthodox doctors who sat at a nearby table. “A lot of things upset me here as well,” he said conspiratorially. “But I can’t really talk about it, because you can’t talk badly about your own people, even though they are guilty of many things that are despicable. It doesn’t look good on you to talk badly about your own nation.”

  Only a few months were left until the fellows were to be graduated. Warshawsky was frustrated with Astrow’s delay in making a decision. The young doctor wondered aloud if Astrow was too soft to be chief. “He isn’t narrow-minded like most of them,” Warshawsky said. “He’s incorporated the humanistic side of medicine, which is very unusual. I see that with patients. But administration is a different animal. You can either do it or you can’t. You need single-mindedness, the ability to detach yourself from feelings.”

  Warshawsky continued. “Dr. Astrow is a universalist. He sees things in terms of multicultural, including Christianity, Buddhism . . . we can all just get on. He’s missing the point. Because we can’t. Astrow, I don’t think he understands it that well.”

  He shook his head. “I don’t know if Kopel understands it completely,” he said. “I don’t know if I understand it completely.”

  Lisa Keen, social worker, the former sixties radical who often took me on rounds with her, always seasoned her observations about hospital life with peppery commentary about the doctors and nurses. The Prince, she told me, was a good one, compassionate.

  What about that not-so-compassionate stuff he said?

  Watch him, she said.

  A few weeks later, I caught up with him sitting at a nurses’ station on Kronish 7, looking at the chart of a fifty-nine-year-old woman from Bangladesh.

  “She’s gone,” he was saying brusquely to Keen, who was the social worker on the case. Suppiah showed her Mrs. Devi’s CAT scan on a computer screen. Cancer of the colon had spread to her liver, abscesses measuring seven centimeters.

  “That’s what you are going to tell her?” Keen asked. “She’s gone?”

  Suppiah shook his head, but still, there was no avoiding it. “This is a death sentence,” he said.

  Keen wanted Suppiah to talk to the family about the prognosis. She was concerned that the doctors parading through Mrs. Devi’s room had been so preoccupied with the immediate issues of lab tests and treatment plans, with the patient’s progression through the system, they had forgotten to tell the family the true meaning of all this activity. Through the patient-rep office, she found someone who spoke Bengali, a technician in the blood bank, who agreed to meet Suppiah in front of the patient’s room.

  Keen felt a duty to patients and their families, to provide hope (when there was none), to make them believe that someone cared about what happened to them (which someone did, at least in an abstract way). She knew that the impersonality of the hospital lent a certain futility to her mission, but she persisted, even though she was scheduled to retire in June and could have taken it easy.

  Suppiah arrived shortly before the interpreter and peered into Mrs. Devi’s room. She was curled up in her bed like a child. She was tiny, even tinier than her husband, a slight man with a weathered face, wearing a red-and-white checked scarf around his neck. He was a contractor who worked with his son. The son, in his thirties, had acquired American heft; he had a sweet, chubby face. His English was minimal, though he had lived in the United States for fourteen years. His father followed him ten years later. The mother had stayed in Bangladesh, caring for the rest of the children, arriving in New York two years before she showed up at Maimonides.

  Suppiah agreed to talk to Mrs. Devi’s husband and son. Keen and I joined them outside the patient’s room, where we smiled and nodded awkwardly at one another, waiting for the interpreter to arrive. His name was Asm Rahman, a slender man in a shirt and tie, with brown skin and black hair worn slicked back, who had studied medicine and wanted to become a physician. For five years he’d been working in the Maimonides blood bank. There was no private room for family conferences on that floor. Suppiah— and Rahman—had to deliver Mrs. Devi’s death sentence under a fluorescent light in a busy hallway.

  Suppiah fixed his gaze on the family as he explained in great detail what he saw. Certain phrases popped out. “Large mass sitting on the colon . . . multiple areas of infection . . . probably why she has fevers and belly pain.” He paused every so often, and the son and father turned their attention to Rahman, as he interpreted word for word, as Suppiah instructed him to do.

  “Do they understand what I just told them?” Suppiah asked Rahman.

  “I understand,” the son said sadly, in English.

  Suppiah looked at him gently. “Could you tell me what I said?”

  The son nodded, turned to Rahman, and spoke at length in Bengali.

  Rahman nodded. “He says he knows there is a large mass in the colon and liver and an infection. He wants to know what they can do about it.”

  “First is to get a biopsy,” said Suppiah, “To take a piece of tissue and analyze it, but this is complicated by the infection. I haven’t seen her yet, but from what I see on the CAT scan, she is very, very sick.
I cannot stress that enough. She is very sick.”

  As Rahman interpreted, apparently taking Suppiah at his word, skipping nothing, it was clear that the message had been received. Both son and husband looked stricken. Their eyes reddened. They seemed oblivious to the movement in the hallway: an old man walking by slowly, trailing his IV drip; orderlies wheeling someone on a gurney.

  Suppiah said the disease looks like cancer, very advanced. The son and the father began to weep.

  Suppiah said he understood (from Keen) that the family didn’t want Mrs. Devi to know the details of her illness. Could he ask why? The son replied, “That’s what she wants.”

  Suppiah said, “I’m not going to tell her anything, but I need to examine her. Does she speak any English?”

  No, said the son.

  Suppiah smiled. “That works out very good,” he said. “I don’t speak Bengali, so I won’t be able to tell her.”

  The son and father looked blank, not comprehending the weak joke.

  Suppiah explained that Mrs. Devi should sign a health proxy form, giving her husband and son the right to make decisions about her treatment. He touched the son’s hand and offered more details about controlling infection, antibiotics, chemotherapy.

  The son asked, “What is the prognosis? What is the best and the worst?”

  Suppiah hesitated. “The problem with this question is her infection,” he said. “If I give her therapy now, she will die from the therapy. If this is cancer, people who have this type of cancer and no infection, the average life survival is a year, a year and a half. Because of her infection, this can be much shorter than that. I’ll know more when I get the results of the biopsy.”

  Suppiah and Rahman went inside to examine Mrs. Devi.

  Keen held the son’s hand and urged him to tell his mother everything.

  He shook his head. “I tell her she has an infection.”

  Keen said, “My guess is, your mother knows.”

  The son shook his head. “She don’t tell me nothing,” he said in English, his face twisted with grief. “If she told me something, I’d bring her right away. Only now she said she had a pain over here.” He pointed toward his lower torso.

  Keen asked him if he would like an imam to pray with. He said he would ask his father, who had followed the doctors into the room.

  When Suppiah emerged, rubbing Purell on his hands, the son pressed him for answers. Suppiah again was gentle. “I know you are looking for an answer,” he said. “I wish I could give it. We will do what we can.”

  Rahman, a Muslim like the Devis, told the husband and son that the hospital would do everything that could be done, and they responded, “What happened is God-given,” and he said the doctors would use the latest technology.Later he told me, “I feel sad because this is a great loss for them, but I don’t know how to console them.”

  The hurt and love in the eyes of the son, the tender helplessness of the young physician and the blood-bank worker required no translation. Transcendence one minute, frustration the next. The convergence at Maimonides distilled the sweet and sour verities of humanity into a heady, combustible brew that could expand consciousness or cause it to implode.

  As a child I was inculcated with unwavering belief in the miraculous nobility of America-the-refuge, country of immigrants. In our small rural town in Ohio, my Hungarian-speaking Czech-Jewish father was welcomed as a hero for his willingness to set up a medical practice in a poor, remote place that was not attractive to most American-born doctors.

  No one seemed to consider him a threat. But nostalgic appreciation of immigrants—an appreciation easy to come by when there weren’t many of them—had diminished to the vanishing point in recent decades by the large influx of newcomers, many of them illegal. Their willingness to take tough jobs for low wages had made them objects not of gratitude but of hostility. Their untaxed wages didn’t contribute to the cost of running schools or hospitals—though they did fatten the bank accounts of those who employed these desperate, hardworking people.

  Immigrants were dispersed throughout the country, but New York remained a major gateway. The public hospitals were the mainstay for people who had no coverage (and no documentation). Many of them ended up at Maimonides.

  Location, location, location.

  Under the Brezenoff-Brier regime, Maimonides moved its primary-care clinics out of the hospital into smaller offices located in the surrounding neighborhoods. This was both a marketing and a social-services decision: Go where the patients are. Urdu was the main language on Newkirk Avenue, Spanish in Sunset Park, Russian at the Fifty-seventh Street site, and Chinese (in several dialects) on Eighth Avenue, a few blocks from the new cancer center. About eighty-five thousand patients a year—more than double the number who were admitted to the hospital—were treated at the clinics. The hospital made an effort to install doctors and staff who spoke the same language and, when possible, were from the same background as the patients.

  Bing Lu, a native of Wushi (now Wuxi), a coastal city near Shanghai, was the medical director of the Maimonides Primary Health Service in Brooklyn’s Chinatown. He estimated that as many as 80 percent of his patients there were Chinese. We met in his small office at the end of a hallway that led to several examination rooms; residents periodically interrupted to ask questions about the treatment for respiratory ailments. The weather had turned cold.

  Lu, who was forty-seven years old, wearing a dark suit, a white shirt, and a tie, looked like a prosperous Chinese businessman, a common sight in these heady days of commercial globalism. He apologized for his garrulous-ness. When I heard his story, I was glad he didn’t skimp.

  He told me that he had studied traditional Chinese medicine, including acupuncture and herbal remedies, as an apprentice to a famous physician. He learned the four main diagnostic methods: wang (inspection), wen (listening and smelling), wen (asking), qie (touching). “Touching the pulse is very important,” he said, “and so is looking at the tongue. Today, for most patients I still look at their tongues.”

  He continued, “Once you gather this information, the processing is based on a very elaborate or complex hierarchy of theorems we call bian zheng lun zhi, almost like a therapy based on dialectical analysis of syndrome, juggling within the mind of the physician.”

  Yet his teacher encouraged him to study Western medicine, telling him he could always return to Chinese-style practice later. Bing Lu entered medical school in the spring of 1978, at the end of the Cultural Revolution. For almost ten years much had been stalled in China, including university studies. Bing Lu became merged with a driven generation, the so-called class of ’77, the first group to take entrance exams in a decade, a class whose slogan was “We have to catch the time back.”

  He had big ambitions—the biggest, and most secret, to win the Nobel Prize. He had it all planned out. First step was coming to the United States to study. In China he was doing research in medical biology on the hepatitis B virus, probably the direst illness for Chinese, with a chronic infection rate of between 5 and 15 percent. He arrived in New York in the spring of 1986, to begin his career as a Nobel-aspiring researcher—studying the hepatitis virus—at Albert Einstein College of Medicine.

  When he told me about his youthful dream, Lu laughed with embarrassment. Eight years into his quest, his wife was on his back to be more practical. They already had one child. Being a clinician was secure; research was quixotic and paid poorly. So he took the qualifying exams to become an FMG, “foreign medical graduate”—now known as the more politically correct IMG, “international medical graduate.”

  Even after being away from the trenches in the lab for so many years, he was surprised at how much he remembered from medical school. “I’m accustomed to working very hard, not a problem,” he said. “Some residents would turf patients, and I would say, ‘Fine, turf to me, I’ll learn something.’” (Definition of “turf,” from House of God, Samuel Shem’s frisky bestselling novel about life as a medical intern: “to get rid
of, get off your service and onto another, or out of the House altogether. Key concept. It’s the main form of treatment in medicine.”)

  Bing Lu trained at the Miriam Hospital, affiliated with Brown University’s medical school in Providence, Rhode Island, another Jewish hospital. I asked him about his religion, a question that didn’t seem impertinent at Maimonides.

  “Nothing official,” he said. “I kind of believe in a somewhat abstract higher being,” he said. “I don’t think it’s Jesus, not Buddhist per se, not exactly God. In Chinese we call it tien, which is actually ‘sky’ in Chinese. If you are puzzled, don’t know why life is unfair, you look to the sky and go, ‘Oh, sky, why does this happen to me? Why is this injustice?’”

  At Miriam he often questioned his decision to leave research. One day a doctor who had become his mentor asked him, “Don’t you see life as a series of compromises?”

  Lu paused in his story. The room was quiet except for the buzz outside of patients and staff moving around. The practice was constantly growing; in a couple of months, it would move to the old Kopel-Bashevkin faculty practice offices a few blocks away, near the new cancer center.

  “I like to talk, my wife says,” said Lu, who wore his discontent cheerfully. “If you like, we can visit her. Her office is nearby.”

  We went outside and walked past a bubble-tea place. We stopped for a minute to say hello to Cheng Neng Fang, a doctor of traditional Chinese medicine, a skinny man with a wispy beard, whose shop was packed with all kinds of teapots and drawers filled with herbs and roots. Lu said something to him in Chinese. He nodded and handed me his business card.