“I’ve been interviewed,” Gwen said, unable to contain her excitement. “There aren’t openings for this July, but there will be next year. They all but offered me a position.”
“Great! I’ll still be here. Flagler’s taking me on as a fellow.”
“Fantastic!”
Once they were seated inside, Kevin said, “I was going to call you. Larry Winton’s autopsy report is done.”
“What did it show?” Gwen whispered as the lecturer stepped to the podium.
“It’s complicated. Don’t worry, we didn’t miss anything reversible. I’ll explain later.”
After grand rounds, Kevin hailed Herb and told both of them about the autopsy findings. In addition to the lung destruction caused by Pneumocystis pneumonia, every one of Larry Winton’s lymph nodes from his neck to his pelvis was shrunken and scarred.
“That fits with the low lymphocyte count in his blood,” said Herb. “And having no immune system left would be why he got Pneumocystis. But what wiped out his immune system?”
“There’s no smoking gun,” Kevin lamented. “All the slides were negative, except for some cytomegalovirus inclusions in the liver and gut. The pathologist said that was more likely a result of immune suppression than the cause. He’s seen the same thing in transplant patients.”
“Sorry, Kevin. I’m afraid the Winton case is going to remain a mystery. It happens.”
“I tried to reach his family,” said Gwen. “I called the phone number we had and went to the last address he used. No luck. If I’d been able to contact a relative, I could have found out about his family history. Most immune deficiency syndromes are inherited, aren’t they?”
“Good thought, Gwen,” Herb said.
“I’d like to write up the case for publication,” Kevin volunteered. “I’ll put it together if you’ll edit the draft.”
“Kevin, I would love to help you publish something, but a single case of unexplained immune deficiency won’t appeal to any broadly read journal. If there was an identifiable cause, like a toxin that hasn’t been reported before, you could easily get it accepted. Or if you had a series of patients like this one tied together by a common thread, even if it was only geographic location. You could sell that to reviewers. But one case with a mysterious cause won’t be perceived as advancing knowledge.”
“Yeah,” Kevin reluctantly agreed.
“You’ll be here another two years. I’m sure Pneumocystis will be the first thing we think of if someone with progressive pulmonary disease and no obvious diagnosis is admitted. And if we do find more patients with Pneumocystis, you could investigate family histories and environmental exposures and get one of the immunologists on the Hill to figure out what’s behind it.”
Gwen gave Kevin’s shoulder a fist-bump.
“I’ll help if you lead the charge,” she said.
“That’s right,” said Kevin, his mood upbeat again, “Gwen will be here. She’s going to finish her medicine residency.”
Herb met Gwen’s eyes. Though he was well aware of how attractive she was, he limited his regard to other virtues he esteemed in house staff. She wouldn’t have come to the ICU twice while Winton was dying if she didn’t feel responsible for her patient, didn’t care deeply about what was happening to him.
“Your clinic experience will be a big plus here,” Herb said. “We have attendings greener than you.”
Flushing, Gwen asked, “Kevin told you about me?”
“No, Flagler. I ran into him right after he interviewed you. He was impressed. But don’t expect him to acknowledge it to you.”
“How flattering. I’m glad he thinks my experience will be an asset. I wish I did.”
“Oh my! And self-deprecating, too? We’ll see how long that lasts here.”
“You’re in if you’ve got Flagler’s vote,” Kevin crowed. “This is a great time to be in medicine, Gwen. Huge changes are coming. Molecular techniques like DNA cloning are going to revolutionize diagnostics. Biotech companies will be making totally new kinds of treatment possible.”
“Brave new world,” she mused.
“And we’ll be right at the cutting edge! It’s going to be cool, very cool.”
An Epidemic, 1981
I
AFTER KEVIN’S FELLOWSHIP ENDED, he was hired as an attending physician at City Hospital. His nights and weekends were generally free of responsibilities, and he wasn’t lonely anymore.
One hour past sunrise on the last Sunday of November, he stood exposed to a wet Pacific wind, shivering at the high point of an East Bay trail. Donning the fleece jacket and wool cap he had taken off during the steep hike up didn’t make him warmer. Neither did cuddling with his lover, Marco, who was four inches shorter and had the sinewy physique of a long-distance runner. Kevin jammed his hands under his armpits and jogged in place.
He looked west across the bay beyond Mount Tamalpais to the Farallon Islands then east to where the Contra Costa hills, tinged with green after a week of early November rain, rolled toward the Sacramento River delta and faded into haze.
“On clearer days, you can see snow on Sierra peaks from here,” said Marco.
With his black hair in curly ringlets, sparse silky beard, strong chin, and deep set eyes, Marco could be the object of a Latin Adonis or Che Guevara fantasy. Both appealed to Kevin’s prurient interest. He slipped a hand into the gap between Marco’s jeans and the hollow of his back and lightly brushed his olive skin.
“That too cold?” he asked solicitously.
“I’ll warm you up,” said Marco and leaned his head against Kevin’s shoulder.
“This view is incredible!” Kevin exclaimed. “What a great idea to come here.”
“Hah! You weren’t so happy when I woke you up at four thirty. See, you should listen to me more often.”
“You’re right about that,” Kevin concurred with a carefree laugh.
Squinting at the horizon, he asked, “How far do you think Mount Tam is from here?”
“Twenty miles, más o menos”
“Twenty miles como la cuerva vuela?”
“Sí,” said Marco, amused by Kevin’s literal translation of “as the crow flies.”
“If we had a telescope, the kind amateur astronomers use, do you think we could see people standing on Tam peak?”
“I haven’t a clue, mi amor. But you know what? You have a lot of curiosity for someone who claims not to be a real scientist.”
Kevin gave him an enigmatic glance, seductive enough to entice Marco into kissing him. As Marco’s tongue darted inside Kevin’s mouth, a shrill, insistent beeping sounded. Startled, Marco drew back. He saw Kevin’s neck pulsing and his pupils dilate.
“Adrenergic response to your pager, or was I arousing you?”
“Both, unfortunately.”
Marco parked in front of the massive, Art Deco building on the Berkeley campus where he was completing a post-doctoral fellowship in cell biology. They had stopped at a pay phone on the way there. Kevin had called the hospital and was told about a patient brought by ambulance to the emergency room, somebody of consequence from the mayor’s office. The medical resident on call said the patient had fever and altered mental status. She also suspected he had Gay-Related Immune Deficiency.
Marco offered his car keys. Kevin gave him a contrite smile.
“Querido, it’s OK. I can run my gels now instead of tomorrow. I’ll have the data one day sooner for those obsessive-compulsive Science editors holding my paper hostage.”
After two years of coddling and massaging embryonic mouse cells, Marco needed results from just one more experiment to parry a final reviewer’s objection to publishing his paper in a prestigious journal.
“Really? You’re not disappointed?”
“Kevin, I think you’re confusing me with someone else’s long-suffering, submissive wife. I’m happy to go to work. I’ll page you when the blots are developed. You can pick me up at the BART station, and we’ll go out to celebrate.”
“No, no. I’ll drive back as soon as I’m done. Then you won’t have to wait. I don’t mind hanging out here until you’re finished.”
“So now you’re going to do penance?”
Kevin looked away, and Marco sighed. They had been through this script before. Feeling guilty, Kevin would shut down. Marco, annoyed that he wasn’t responding, would criticize him for not breaking free of his psychic chains. Catholic bondage Marco called it. If particularly irritated, Marco would raise Kevin’s refusal to tell his family about his live-in lover as a prime example, and Kevin would retreat further.
Marco had looked up the common noun “catholic” in an English dictionary and informed him the meaning was “of liberal scope, inclusive of all humanity.” Kevin believed class difference was the underlying issue. He had mentioned that possibility once, and Marco gave him the silent treatment for a week.
It’s all right for Marco to rail about the prejudice, homophobia, and narrow mindedness of South Boston, Kevin had brooded, but not for me to point out how the privilege of growing up in a luxurious Mexican villa and attending an elite Jesuit boarding school in Europe has given him the freedom to become whomever he wants to be.
Time to lighten up, thought Kevin.
He smirked and said, “What kind of penance did you have in mind?”
Marco’s stern disapproval dissolved.
“Touché,” he chuckled. “Penance later. Now that I’m here, I’m going to run the gels. But first…”
Marco sat on a bench and opened his arms. Kevin sat on his lap, and Marco massaged Kevin’s neck.
“That’s an impressive talent you have,” Marco murmured, “Making things funny when they get too heavy. I’ve never been with someone who could do that.”
Paralyzed by the compliment, Kevin didn’t reply.
“Don’t give up on teaching me, querido.”
“You sure?”
Marco dangled his car keys and said, “Go my son. Your sins have been forgiven.”
Kevin kissed him on the cheek and took the keys.
“Qué injusticia,” Marco grumbled as he watched Kevin drive away. To keep from dwelling on the benighted souls who had raised and still haunted his lover, Marco recalled the night they met.
A crowd of fifteen thousand had filled Castro Street for the 1980 annual Halloween bacchanalia. Half were in costume while the rest gawked at them. Alcohol was the drug of choice here, and lines of riot police filled the neighborhood to prevent a repeat of the previous year’s melee when gangs of fag-bashers from nearby blue collar suburbs had attacked gay men. Marco had come with Robert, a fellow grad student. Both were dressed as lab rats in white coats. Lengths of rope served for tails and pieces of broom straw taped to their cheeks for whiskers. As they crossed Castro Street, a skinny teenager sliced off Robert’s tail with a switchblade. He ran away whooping, swinging the trophy over his head. Robert cursed the boy who returned to confront him and jabbed the knife at his testicles. He missed low by an inch, slicing through the femoral artery. Robert collapsed in a pool of blood which expanded at an alarming rate.
A hefty, six foot pirate appeared, bedecked in a white flounce shirt and a blue bandana that couldn’t contain his thick red hair. A policeman recognized the pirate, called him “Doc,” and cordoned off space for him to work. Kevin pulled down Robert’s pants, carefully inserted his bare thumb and forefinger into Robert’s wound, and pinched the artery. The bleeding stopped.
Marco was amazed by Kevin’s equanimity as he was helping EMTs lift Robert into an ambulance while keeping a firm hold on the artery and reassuring Marco that his friend would be fine. Kevin talked the driver into letting Marco ride with them. In the ambulance, Marco got Kevin’s phone number. The following evening, Marco brought over an expensive Medoc which they had just begun to explore when other appetites took precedence.
Driving west on the Bay Bridge, Kevin tried to soothe himself. He envisioned the panorama they had seen at the top of the trail. That failed to calm him. The brief telephone call had put him in red alert mode. Kevin had become the local expert on immune deficiencies at City Hospital. Everyone would expect him to provide definitive guidance on what tests to perform and what medications to administer to this patient.
Kevin tried harder to imagine the scene before his pager beeped. He wondered how he and Marco might have looked to a passing stranger. Did their physical differences make them an odd couple? Would a passer-by be repelled by seeing them kiss? Furious for having that last thought, Kevin pounded the dashboard. How could he allow a scintilla of the old self-hatred back into his consciousness? Why couldn’t he shed it? He was living in San Francisco now. Being gay was totally acceptable here. What was his problem?
II
DANA PEARLSTEIN, A PETITE junior resident, pushed a somnolent man on a gurney toward the only unoccupied bed in City Hospital’s intensive care unit. Dana had two months of experience leading a medicine team and was twenty-six hours into her on-call shift. Her impeccable make-up remained intact, but her confidence, appropriately tenuous at this point in her training, was waning, especially with her last admission. She’d heard rumors the patient had a lot of clout in local politics, and he was gravely ill.
Once Dana saw Kevin enter the ICU, her hunched-up shoulders relaxed. Kevin looked at the toothpaste-advertisement smile she gave him, the thin man asleep on the gurney, the familiar intravenous solutions, portable cardiac monitor, and oxygen tank, then back to Dana’s smile. He calmed down.
As Dana was handing admission orders to an ICU clerk, Kevin grabbed her stethoscope and took over wheeling the patient to his room. He signaled Dana that he would return in a moment. Kevin noticed a scaly rash on the man’s forehead, a severe type of dandruff common in Gay-Related Immune Deficiency, and the hollow shape of his temples, a sign of muscle wasting. The man didn’t react to Kevin’s calling out his name.
“Mr. Miller,” Kevin said shaking him gently, “Are you OK?”
“I don’t know,” the patient mumbled.
Further questioning revealed he was disoriented to place and time. Kevin listened to his heart and lungs, felt his abdomen, flexed his neck, and used a tongue blade and penlight to look inside his mouth. In addition to the patient’s confusion, there was another abnormality. A white layer, like thinly spread cottage cheese, covered the roof of his mouth.
Kevin sat down at the ICU conference table with Dana and her medical student, and she launched into her case presentation—an account of Mr. Miller’s symptoms and history, her physical exam findings, the laboratory and x-ray results, and finally her formulation of a differential diagnosis and plan of action.
“Mr. Miller is a forty-two year old white male with no prior hospitalizations or chronic diseases. He works as an assistant to the mayor of San Francisco and lives alone in the Marina.”
Dana arched her eyes in feigned surprise. City Hospital patients rarely came from this upscale neighborhood.
According to a friend who discovered Mr. Miller yesterday on the kitchen floor of his apartment, he had been well until a week ago when he began complaining of fatigue and headache. Then he stopped coming to the office or answering his phone. Per the friend, Miller was gay. He didn’t use drugs or frequent bathhouses.
Dana’s physical exam findings were identical to Kevin’s. The blood test results were unremarkable except for anemia and an extremely low lymphocyte count. Dana’s intern had done a spinal tap which showed no white blood cells to suggest meningitis or red blood cells to suggest a brain hemorrhage.
Kevin was pleased by Dana’s presentation—fluent, precise, thorough yet succinct enough to communicate in less than five minutes all the elements he required in deciding what to do next. She had clearly mastered one important skill for leading an inpatient medicine team. She could sift through massive amounts of information, discard the dross, and communicate the essential data in the minimum time necessary without sounding manic.
“I think the white stuff in his mouth is thrush,” Dana concluded
. “That and his low lymphocyte count fit with GRID.”
“What’s thrush? What’s GRID?” asked the student, a frumpy young woman who wore thick-lens glasses.
“Thrush is like athlete’s foot but in the mouth,” said Dana. “It’s a superficial fungal infection caused by Candida. And GRID is Gay-Related Immune Deficiency.”
Turning to Kevin, she added, “Here’s the expert.”
“That’s OK,” he said deferentially. “Let’s hear you explain it.”
Dana eagerly accepted the challenge. She talked about the clusters of gay men in New York, Los Angeles, and San Francisco recently diagnosed with a rare form of skin cancer, Kaposi’s sarcoma, or Pneumocystis pneumonia. All had been previously healthy. Since Pneumocystis only caused disease in people with profoundly impaired immune systems, the syndrome had been named Gay-Related Immune Deficiency. A preliminary investigation by the Centers for Disease Control identified two common denominators among GRID patients—past gonorrhea and syphilis infections and a lifetime history of hundreds of sexual partners.
Dana looked to Kevin. He nodded with approval.
“Kevin has seen, what, ten Pneumocystis cases here?”
He nodded, less enthusiastically.
“And in his clinic he’s seeing lots of gay men who have enlarged lymph nodes and thrush. A couple of them have gone on to develop Kaposi’s or Pneumocystis.”
“Have you biopsied their lymph nodes?” asked the student.
Noting the name on her ID badge, he answered, “Good question, Gail. We did, at first. But the results have been negative—no underlying infection or malignancy.”
Dana chimed in, “Kevin just gave grand rounds. Didn’t you say the number of new patients coming to City Hospital with the pre-GRID lymph node syndrome has doubled in the last four months?”
He nodded somberly.
Gail frowned as she considered the implications of that fact.
Returning to the case at hand, Kevin said, “The low lymphocyte count is a good pick-up, Dana. And that’s definitely thrush in his mouth. So he’s got pre-GRID, if not GRID itself. But why’s he confused and barely arousable? What’s wrong with his brain?”
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