“You’re too cautious. Don’t you like to speculate?”
“Not really, but you can.”
“Hey, I just thought of something. This is a chance to figure out which T cell functions are critical in preventing opportunistic infections. Cancer and transplant patients get Pneumocystis, but their immune systems are too blitzed by chemotherapy for anyone to get useful data. If an immunologist compared lymphocytes from your pre-GRID patients and those with full-blown GRID, maybe she could tease out exactly how T cells prevent opportunistic infections.”
“Sounds like you’re describing your future fellowship research.”
“Maybe so. Thanks for the idea!”
“It’s your idea.”
“I wouldn’t have thought of it if I wasn’t taking care of your patient.”
The irony of this conversation wasn’t lost on Kevin. He’d chosen his specialty over oncology largely because infections often had definitive cures and cancer didn’t. Yet, here he was attempting to treat the “gay cancer” with no effective medications other than short term fixes for the opportunistic infections that complicated the syndrome. He was constantly dealing with death and dying. Now he’d inspired the career of a future oncologist.
VIII
HERB WAS IN GOLDEN Gate Park at dawn on Wednesday, jogging under a cotton ceiling of fog. He loved this type of sky, the range of hues—off-white, pearl, cinder, gunmetal, silver, slate—and the bracing clarity, nothing bleached by direct sunlight or hidden by glare. The fog also made it cool enough to run comfortably in a polypropylene shirt that wicked away the sweat. After two miles, he had passed through the stiffness, burning in his sternum, and cramping in his side. It was effortless now. He was being carried by the rhythm of running, the cadence of his pace and breathing in four-four time. Soon there would be an exhilarating taste in the back of his throat, like glacial water with a pinch of gunpowder. He could sustain this pace for an hour, a slower one for two or three, before lactic acid accumulating in his muscles finally undid him in a surge of nausea and exhaustion.
Herb began running seriously as a fifth grader, motivated by his father’s enthusiasm for the upcoming 1948 Summer Olympics, the first to be held since the 1936 games in Berlin. Like all United Nations staff, his father viewed renewal of the Olympics as a perfect metaphor for the fledgling organization—an amicable competition that all countries could participate in equally and peacefully.
Herb was the fastest boy in his elementary school and fantasized about track-and-field record holders. His favorite athlete was Jesse Owens, the black American who had won four gold medals in 1936. Looking in a full-length mirror, Herb focused on his long, muscular legs instead of his eyelids, which made him the butt of classmates’ jokes. What if he trained to be the fastest boy in his town, Herb wondered, or the whole of Long Island? Who would dare tease him then?
He wheedled his mother into driving around the neighborhood while he studied the odometer and a street map until settling on the best course. He started jogging every other day, adding a kilometer to his distance each week. As soon as he could run ten kilometers without stopping to catch his breath, he ratcheted the effort up, and his times came down. He read about training regimens at the library. He searched local newspapers for reports of high school track meets and went to several, making notes on the runners’ form and clocking their speeds.
Once the Olympics began, Herb rode a bus each afternoon to UN headquarters where he watched newsreels of the day’s highlights with his father. They had good-natured arguments over which countries would win. Herb had more conversation with him in those two weeks than the entire rest of his childhood.
Herb was fascinated by Emil Zatopek, the Czech who broke the world record for ten kilometers, running it in under thirty minutes—a superhuman feat to a boy who couldn’t cover the distance in less than an hour. The agony on Zatopek’s face in finish-line phsotos convinced Herb that anyone capable of enduring great pain could be a winner in life. He vowed to emulate his hero’s example.
The following summer, he trained for a one-mile race in a countywide competition. The day before the event, his father called from the UN. There was an international crisis. He couldn’t leave.
His mother drove him to the Nassau county fairgrounds. Surrounded by dense forest in full leaf, they milled awkwardly among the young athletes and proud parents—all white. Herb’s race was the last. Their wait was interminable. He kept expecting to hear a disparaging comment, but every glance in their direction was politely tolerant. Herb’s mile was over in six minutes. He came in second and was satisfied. This was no village contest, he explained to his mother. It represented half the population of Long Island.
Afterwards, they went to an exhibition hall. Each boy who had won or placed in a dash, jump, or throw was escorted to the stage by his father and received a medal. The mile awards were given at the end of the ceremony. Herb’s mother leapt up when his name was called. He glared at her, shaking his head no, and walked to the stage alone.
Herb was in the ICU by nine, seated at a small conference table, ready for the interns to present their new admissions. He raised his baton, a ballpoint pen wrapped in black electrical tape to conceal the pharmaceutical company logo. The first act opened—a tale of an elderly emphysematous man brought to the ER in respiratory distress. Herb listened carefully, taking notes as the drama unfolded. He enjoyed the house staff, their alternating banter and solemnity. It still surprised him when they appreciated the constructive feedback he could provide.
Next, he had consultation rounds with his new fellow, Harry Simpson, and Gwen. Harry had earned a PhD in physiology during medical school and planned a laboratory-based career in academic medicine. Herb had heard from pulmonologists at the other university-affiliated hospitals that Harry was bright, knowledgeable, and reasonably competent as a clinician. Once Harry started his rotation at City Hospital, Herb learned something else about his new fellow. Harry was terrified by GRID.
Ward residents and attending physicians complained that Harry tried to talk them out of requesting consults on GRID patients. Those Harry couldn’t brush off, he assigned Gwen to evaluate. He called in sick both times GRID cases were scheduled for bronchoscopy.
“Bronchoscopy entails minimal exposure to blood,” Herb pointed out to him. “Plus, you’re wearing a protective gown, a mask, gloves, and goggles.”
Herb showed his fellow epidemiologic papers as evidence there was no risk from such contact. Though Harry claimed to concur, his behavior didn’t change. More disappointed than outraged, Herb was counting the days until Harry’s month at City Hospital would be over.
Herb, Harry, and Gwen began at the bedside of a young man just admitted with severe abdominal pain. Exploratory surgery was being considered. Because he had two prior episodes of Pneumocystis pneumonia, the surgical team wanted advice from a pulmonary consultant before operating. Harry’s pallid complexion whitened a shade as they entered the room.
While Herb was listening to the patient’s lungs, a group of scrub-clad residents and students came in, led by their attending surgeon, Jared Hart. The descendant of three generations of Montana ranchers, Hart was a remarkable character even by City Hospital standards. Five feet, two inches tall, with a huge handlebar mustache, he had a basso voice, swore liberally, kept the pocket of his long, white coat full of Havana cigars, and occasionally addressed female students and interns by their chest circumference and breast cup size rather than their name. Herb stepped aside, yielding access to the surgeon.
Hart pressed the back of his ungloved hand against the delirious young man’s wet forehead.
Holding up one finger and flicking off a drop of sweat, he announced, “Fever!”
He dug his heel of his palm into the patient’s abdomen. The man flinched. Hart abruptly pulled his hand back. The patient howled in agony from the ripping sensation this maneuver induced.
Holding up two fingers, Hart said, “Right lower quadrant rebound tenderness!”
<
br /> He snatched the chart from an intern and thumbed through the pages with a flourish to the laboratory results section.
“Leukocytosis!” he shouted and held up three fingers. “His white count is 18,000. That’s three out of three criteria for appendicitis. We’ll operate today.”
All of Hart’s coterie, as well as Harry and Gwen, stood wide-eyed and silent. Herb had seen this performance before and wasn’t impressed.
“Any objections, Dr. Wu?”
“He won’t survive without surgery, Jared. Please proceed. Just keep the ventilator pressures on the low side so the blebs I saw on his chest film don’t rupture.”
“But, Dr. Hart,” objected a resident. “Is it safe for us to operate? We heard a lecture by Dr. Bartholomew, and he said these patients’ immune deficiency might be transmitted by contact with their blood.”
Hart eyed him coldly and said, “We’re surgeons, Dr. Bryan. We take those risks. We might experience fear, but we aren’t influenced by it. A resident I trained with contracted hepatitis B from an accidental scalpel wound. He died of cirrhosis. In Vietnam, two of my colleagues were blown to smithereens in an operating theater ten yards away from mine.”
With a sneer, Hart delivered the coup de grâce.
“It’s an occupational hazard, Dr. Bryan. If it makes you uncomfortable, find another job.”
Hart marched out of the room. His team docilely followed.
Herb had never heard this soliloquy and rather liked it, though he suspected its veracity. Given his height, had Hart really been inducted into the military? Herb turned to share the question but checked himself on seeing Harry’s crimson cheeks and ears. Better to save it for later, he decided, when he and Gwen would be alone.
In the afternoon, Harry went to a seminar, and Gwen helped Herb with bronchoscopies. Their first patient was a scrawny, wrinkled man who had smoked a pack of cigarettes a day for fifty years. A week ago, his doctor ordered a routine chest x-ray that revealed a spot the size of quarter in his right lung.
The man’s pupils dilated when Gwen rolled a gurney into his room. The fear he exuded didn’t abate until she gave him an intravenous sedative in the bronchoscopy suite. Now he was in a dopey, half-sleep state.
While Herb advanced the bronchoscope, Gwen looked through a second eyepiece. She could see images from the tip of the fiberoptic cable as it snaked past the vocal cords and headed south along the trachea, past glistening pink mucosa stained with nicotine. Herb made a sharp turn into the right mainstem bronchus and came to a sudden halt in front of a fungating mass that blocked any further passage. Gwen cringed. It was the coin lesion on the x-ray, magnified to the size of a boulder.
She held the bronchoscope as he manipulated a sheathed wire running alongside the cable and connected at the tip to a tiny forceps. Before the procedure, Herb had showed her how squeezing the trigger at his end of the wire closed the sharp metal teeth at the other end. Through the lens, she watched the instrument bite off a piece of tumor.
“Ugh,” she cried and immediately regretted her outburst.
She whispered an apology.
“Don’t worry,” said Herb. “He’s too deep to remember any of this.”
“Poor guy.”
“It is what it is.”
To Gwen, his comment didn’t sound callous. She heard simultaneous sympathy, philosophical detachment, and sadness. An ideal attitude, she thought. After working with Herb for three weeks, she was in awe of how centered he was, always balanced between objectivity and empathy. Gwen wished she could do that. She had contemplated asking him to teach her how, though it was inconceivable making such a request wouldn’t embarrass both of them. He was handsome, too. She momentarily wondered why she hadn’t married someone like him instead of Daniel. Instantly, she knew the answer. It would be intimidating to live with anyone so perfect.
The forceps bit off two more pieces of the tumor, and Herb retracted it into the sheath. Gwen set the bronchoscope down, donned latex gloves, and opened a vial of formalin. Herb withdrew the wire. When the forceps appeared, Gwen grabbed the stainless steel pincers and placed it in the formalin. Herb released the trigger. They watched, neither commenting, as shreds of malignant tissue floated to the bottom of the vial.
Gwen rolled the patient back to the wards. She finished gathering information on two new consults, then met up with Herb in his office where she presented the new cases. Herb took note of how efficient, thorough, and concise she was. It made listening to her presentations a pleasure, and it spoke volumes to him about her character. He had observed that those who went into medicine solely for prestige or money tended to invest little energy in being accurate or to the point.
He also enjoyed her sense of humor. Gwen was the kind of resident he wanted his division to recruit into its fellowship program. However, she clearly wasn’t excited enough by procedures to become a pulmonologist. Perhaps an infectious diseases fellowship, he mused. Not that it mattered because Kevin would have to expand his GRID clinic soon, within a year at most, and his affection for Gwen was transparent. He was certain Kevin would find a position for her.
The two new consults were a routine exacerbation of emphysema and a rare autoimmune lung disease. After discussing the cases, Gwen had a question about the man they had biopsied earlier.
“What do you think his prognosis is?”
“Based on the big mediastinal lymph nodes we saw on his chest film, it has to be bleak.”
“It could still be small cell, couldn’t it? Then chemo would be an option, even with metastases, right?”
“True, which is why we had to get tissue. But a small, asymptomatic tumor like this; odds are less than one in five a small cell lung cancer would present that way.”
“Based on the literature or your own experience?”
“Both.”
He opened a drawer of photocopied articles and handed her one.
“Here’s a large series. I’ve seen the same thing here. We get a case or two a month. Nearly all the small, asymptomatic tumors are squamous cell carcinomas. And as you well know, once they’ve metastasized, school’s out.”
Gwen considered the implications of regularly giving this news to people for whom chemotherapy couldn’t help, having to tell each one he had at most a year or two to live.
“Herb, does telling these patients their diagnosis depress you?”
She’s definitely not going into pulmonology, he thought. She might not join Kevin either.
“It makes me sad for them, but not depressed.”
Been there done that, he thought.
“The sadness doesn’t stay with you, doesn’t bleed into the rest of your life?”
“Not anymore.”
“That’s a neat trick,” sighed Gwen. “I need to learn how to do it.”
“You’re a quick study. Stick around. It won’t take you long.”
IX
MARCO WAS ALREADY SETTING up gels in the laboratory before Kevin left for work. He took a break at noon, set down a stack of data printouts in his nook of a carrel, and had lunch—a thermos of strong coffee and a peanut butter and jelly sandwich. While eating, he gazed at the shelf of bound notebooks he had filled during his three years here. His heels bounced on the floor. He was so close to confirming a radical, new hypothesis, it was hard to stay calm.
Since moving to Berkeley, Marco had only chipped away at creating new knowledge. Once his current experiments were finished and the revised manuscript accepted for publication, his apprenticeship with Professor Goldstein would officially end. He would be promoted to full membership in the team attempting to create clones of genetically identical mice from stem cells. Everyone in the lab believed comparing clones of mice that had a single altered gene to clones of unaltered mice was going to become the gold standard for proving what any particular gene did, at least in mice. And because mouse and human genes were so similar, their experiments would create new paradigms for understanding human diseases.
His eyes strayed
to a photo of Kevin with a turquoise lake and snowcapped mountains in the background. Kevin had a rare, contented smile. Marco’s neck muscles relaxed. He had taken the picture last summer in the high Sierras. They had backpacked for a week through alpine meadows dotted with marigold, paintbrush, and penstemon. Each morning they scrambled up boulder fields to find the loneliest outposts of life where only one or two flowers could survive. Marco took photos and kept a meticulous log. At their camp, Kevin gathered wood, made fires, and cooked. The modest effort required to survive in such an austere, exquisite place made him glow with satisfaction.
Marco’s attention wandered to the data printouts. He reached for a pencil but moved past it, picked up the telephone, and dialed Kevin’s pager.
After his morning clinic, Kevin boarded a shuttle to the Hill, the university complex of hospitals, health science schools, and research institutes towering over Golden Gate Park. As he entered a classroom, his pager vibrated and displayed the phone number of Marco’s lab. The instructor was explaining the difference between a t-test and a Chi-square test. Kevin wanted to hear this and made a mental note to call Marco later.
He had begun auditing this introductory biostatistics course once he accepted the handwriting on the wall. To have job security, he had to obtain grants. As a physician who didn’t perform expensive procedures like bronchoscopy, he had no other income-generating options. A grasp of the methods used in biostatistical analysis was one of the skills he needed to submit competitive proposals.
Yet Kevin was still ambivalent about research. Not only had he failed in Flagler’s lab, he had also been burned when he tried to publish a report of the first three Pneumocystis patients they had seen at City Hospital. Herb and he had hypothesized a combination of drug use and multiple bouts of syphilis and gonorrhea infection, features common to all their cases, might have irreversibly damaged the immune system. While typing his final draft, a phone call came from Atlanta. The CDC had investigated five Pneumocystis cases in Los Angeles, all in gay men with a history of many sexually transmitted infections. Their results would be published before Kevin could get his manuscript submitted. The CDC asked him to collaborate. They offered to include the details of his cases in their national dataset, for their statisticians to analyze. Eventually, his name would be on some papers, but not as first author.
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