The next week I took the train to Geneva for our meeting. The train was one of those things that the Swiss made sure to save from the nineteenth century, and I loved it. As an American I was supposed to have a love affair with the automobile, but in Switzerland I’d learned it was more like a bad marriage, where you stay together because there is no one else. In Switzerland there was someone else, quiet and clean and safe, who arrived on time and took me exactly where I wanted to go. The train stopped in the center of town, and ten minutes later I was walking up the hill toward the Hôpitaux Universitaires de Genève (HUG). As I got nearer, I saw signs posted with increasing frequency; they showed a car horn with a red slash through it and the reminder QUIET: HOSPITAL ZONE.
I hadn’t seen such signs in a long time, I suddenly realized as I was walking. When I first arrived at Laguna Honda, they’d been all around, and then, somehow, they weren’t. What had happened to them? When did they disappear? Those signs had been a reminder not only not to honk your horn, but that the sick needed quiet, rest, and peace, and I missed them. Although it was just as well they were gone, I thought as I got nearer the HUG, because the one thing that Laguna Honda was not, was quiet, and car horns were the least of it. Televisions and radios; beepers and cell phones; overhead announcements, incoming faxes, IVs, oxygen equipment, EKG monitors—every new machine had its own signal and its own alarm. The only places at Laguna Honda that were quiet were the linen closets. And yet peace, rest, and noninterruption were healing, as everyone knew; they were Dr. Quiet; and the Swiss, apparently, hadn’t forgotten him.
From the outside the HUG seemed like any hospital in the States—big, multistoried, an office building—but inside it was different. It was not crowded. Its floors were polished, and its light natural. Its patients looked different, too. They were dressed in slacks, shirts, and ties, or dresses, stockings, and heels, and they were waiting quietly in the lobby.
Dr. Hoefer met me at the elevator, and we went up together to his office, where he explained how his department worked. Community Medicine in Switzerland was where the Swiss put their public and social programs, he told me: their immigrant outreach programs, their alcohol and drug programs, their epidemiology and public health divisions, and their tropical medicine. He also had an acute medical division and an emergency room, as well. Then he passed me the schedule he’d made up for me; over the next few weeks I would get a chance to spend some time in each of those units. On my last day I would go with a team of his doctors to visit a rehabilitation hospital in France. And now, what about something to eat?
He took me down for lunch in the hospital cafeteria. I was impressed. It was a modern, spacious, and well-lit place, but what amazed me was the food. There were fresh salads and soups, and chefs in white hats slicing rack of lamb and preparing omelettes to order. Most remarkable, at the end of the line were little bottles of Swiss wine and three kinds of beer on tap.
Was this the doctors’ cafeteria? I asked Dr. Hoefer.
No, it was for everyone, he said, doctors, staff, patients, visitors. The food that went up to the patients’ rooms came from the same cafeteria, and, yes, patients were permitted wine and beer. As a matter of fact, doctors prescribed alcohol: red wine at meals, beer for the anorexic, sometimes schnapps at night, for sleep.
He ordered a small steak, a salad, a little bottle of red wine, and so did I. And as we ate, I thought about Dr. Diet.
At Laguna Honda, Dr. Diet had once had his day. There’d been a time when diet—good food and drink—was just about the most important thing the hospital had provided to its patients. I’d even seen menus from the century before, with their pint of wine or four ounces of whiskey every day, their beef stew for breakfast and dinner, their holiday meals of fresh game in plum sauce. Even when Dr. Jeffers had first arrived, he told me, the neighbors would still make a point of coming to the hospital for lunch and for dinner.
No longer. It wasn’t that Dr. Diet wasn’t considered, exactly. There were almost as many dieticians as doctors at Laguna Honda, and each dietician made sure that each of her patients received the appropriate amount of vitamins, minerals, and fluids, and whatever special diet the doctor prescribed. But what with all the dieticians and special diets, there wasn’t much left in the budget for chefs.
On the ecomedicine unit, I decided after I’d finished my steak and wine, once we discontinued all those unnecessary medications, we would use the savings to increase the food budget.
A lot.
For the sake of Dr. Merryman, as well as Dr. Diet.
I spent two weeks at the HUG. I learned that public medicine in Switzerland dealt with the same problems we did in America and in many of the same ways, though with certain differences.
During my day on the medicine unit, one of the doctors called in sick, and I got the chance to see patients with the medical students. At the end of that afternoon, the chief of medicine, Dr. Mendes, showed me around. First we went to the acute medical unit, where patients were hospitalized when they needed an expeditious, thorough evaluation. Instead of having to spend weeks as an outpatient, getting tests and seeing different specialists, a patient could get all the tests, a diagnosis, and a plan in a few days, usually. It was much more efficient and sometimes safer, he pointed out.
We used to be able to do that, too, I told him, before the cost-effective, health-care efficiency movement took over. Now it was impossible to put someone in the hospital just for a workup, and sometimes it took us months to figure out what was going on. How was it that they could still do it in Switzerland?
No HMOs, he said. At least not yet. In Switzerland, medical care was still private; doctors had their own private offices; and patients had their own private doctors. The cost was manageable because of certain government policies. First, every Swiss citizen had to buy basic health insurance, which insurance companies were required to sell on a nonprofit basis. Under a certain level of income, the government subsidized those premiums. The insurance companies could still make a profit, though, because they were allowed to sell supplemental health insurance on a for-profit basis.
In addition, since there were always patients who fell through this net, the government subsidized public hospitals like the HUG, which incidentally provided places for medical research, and for medical and nursing training as well. The overall cost was also manageable because malpractice wasn’t an issue in Switzerland. Doctors were never sued. He didn’t know why. Maybe Switzerland didn’t have enough lawyers.
Health care was still not cheap, of course—it made up 12.5 percent of the GDP—but that was still less than in the States, and almost everyone was happy with it. Doctors were not as well paid, it was true, but since medical education was free, they didn’t have such huge loans to pay back and didn’t have to make as much money.
“What about the emergency room?” I asked. “Your division runs that, too. Can I see it?”
“Of course.”
He took me down a hall, to a large room whose door was open, though its lights were off. It had seven beds in it, each with plumped pillows and a down coverlet. But it was empty.
“Here’s the emergency room,” he said.
There must be a language problem, I thought. “The ‘emergency’ room?” I confirmed. “For emergencies? But it’s empty. Where is everyone?”
Dr. Mendes shrugged. “It’s usually empty. Trauma cases go to the surgical unit, obstetrics to obstetrics, and there aren’t many medical emergencies because when patients get sick, they go to their own doctors.”
We stood at the door for a minute while I looked at that nonemergency room. What kind of medical system had no emergencies? Even more remarkable, what kind of medical system fluffs up the pillows, starches the sheets, and lays down coverlets on top of its beds?
I spent two days with the alcohol and drug rehabilitation unit, a day with the unit in charge of epidemiology and immigration, and one afternoon with Dr. Em, the tropical medicine specialist.
Dr. Em was short and rou
nd and energetic, with round glasses, and I sat with her all afternoon while patients from Africa and the Middle East came through her office. They spoke many languages and had diseases quite unfamiliar to me, but who I remember best is Miss Q. from Cameroon.
Miss Q. was tall, slim, and a very dark brown, and she wore her hair in woven rolls about her face. Her features were thin and delicate, and despite the pockmarks on her cheeks, she was pretty. Also, after her year in Switzerland, quite Swiss, wearing a dark gray skirt, close-fitting knit top, and stylish black-framed glasses. In French with an African cadence, she explained to Dr. Em that now that she’d finished her secretarial course, she was going back to her native Cameroon, and she wanted to find out if there was any new treatment for her disease.
What were her symptoms? Dr. Em asked.
Well, every few months she would get a fever, her muscles would ache, and her skin would start itching. A day or two later her vision would get blurry, and sometimes she would see a little worm shape crossing her line of sight. Then she would feel better until her next bout.
It was a bizarre set of symptoms, I thought, though I did remember something like it from medical school.
What did Miss Q. have? Dr. Em asked me.
I didn’t know, but Miss Q. did because everyone in her village had the same thing. She had loiasis.
Then Dr. Em reminded me that loiasis was caused by the loa loa, a parasite spread by the tabanid fly of the African rain forest. It had a complicated life cycle, which depended almost entirely on human beings. People acquired the infection when they were bitten by a fly carrying the microscopic loa loa larvae in its proboscis. As the fly fed on the blood, those larvae entered the skin and migrated into the subcutaneous tissue, where they matured into the adult loa loa worm. Still under the skin they met each other and mated and reproduced the next stage of their life cycle, the microfilariae, which then entered the bloodstream by the thousands. When another tabanid fly bit, it picked up these microfilariae, which matured in the fly’s gut into the infective larvae, and that was how the disease was spread.
The human body was allergic to the adult worm, Dr. Em went on, and so whenever the adult worm moved around, the body would react with the fever, joint pain, and itching that Miss Q. described. Sometimes the adult worms even migrated across the eye, causing the worm shapes that Miss Q. sometimes perceived. Loiasis caused much suffering and millions of dollars of lost productivity in Cameroon and other African countries, although it wasn’t fatal. But the only sure way to get rid of loiasis would be to eradicate the tabanid fly, and that would mean eradicating the rain forest.
And—here Dr. Em turned to Miss Q.—there was a treatment for loiasis called diethylcarbamazine. But it wasn’t perfect. It caused strokes and kidney damage in patients who were severely infected with loa loa, and treatment, therefore, had to be monitored closely. Also, it didn’t reliably kill every adult worm, so the disease could recur even after treatment. And, of course, anyone living in Cameroon would likely get reinfected. Since Miss Q. was returning to Cameroon, where her treatment could not be supervised and where she would probably get bitten again, Dr. Em would not recommend a course of treatment.
As Miss Q. listened to Dr. Em, I watched her. She was quiet and composed. When she heard that there was a treatment for her painful, debilitating disease, but not for her, not if she wanted to go home, she didn’t cry or get angry. She simply squared her thin and elegant shoulders, just a bit. Which meant that she would go back to her village, her family, and her country, and do the best she could with her fate.
I admired that. I didn’t know whether I could do the same. I thought not. There was a whole tradition behind Miss Q.’s composure; it went way back; it was deep, mature, grown-up. Not American, with our youthfulness, our rebelliousness against fate, and our refusal of fate, too. Which rebelliousness was what led to the unraveling of the life cycle of loa loa, of course, to diethylcarbamazine, and would lead to other even more effective antifilarial medications.
I never forgot Miss Q. Partly because loiasis was an interesting, an unusual disease, one I had never seen before. There was something fascinating as well as horrible about living creatures for whom we are their homes and cities—where they are born, mature, grow old, and die, and where they travel, sightseeing in our blood, lungs, and even eyes. But mostly I remembered Miss Q. because it was the first time in many months that I’d been inside the special space that doctor and patient create together. Miss Q., with her quiet manner and her fortitude, had reminded me just how much there was to learn from patients, and not only about illness and disease.
My last experience at the HUG was the next day. The rehabilitation unit was visiting a French alcohol and drug rehabilitation hospital in the Alps, and I went with them. Sitting in the backseat between two other physicians, I didn’t see much during the drive, but when we arrived, I knew where I was. The Hospital of Saint Bruno, with its arched stone entrance and wings of high, arcaded windows, was a long-lost relative of Laguna Honda.
Dr. Lapin, its resident physician, met us at the entrance. He really was a resident, too—he lived in the Hospital of Saint Bruno just as the interns and nurses used to do at Laguna Honda, and just as the podiatry students still did, despite Dee and Tee. We would go on the tour first, he told us, and then we would have our lunch and our meeting.
The Hospital of Saint Bruno, he explained, had been built in the nineteenth century as a tuberculosis sanatorium, when the only treatment for tuberculosis was regime—a diet of eggs, milk, and meat; and the quiet, sunlight, and fresh air of the Alps. Although that treatment had worked surprisingly well, after antibiotics against tuberculosis were discovered, the hospital had been emptied and almost torn down. But then it was realized that its out-of-the-way location, fresh air, and good diet might make the hospital suitable as a rehabilitation facility for alcoholics and drug abusers, and it was reopened.
Dr. Lapin turned and walked through the arched stone entrance, and we followed him through a hall and out into a wide corridor. On our left were floor-to-ceiling windows; they faced south, he said, for the sunlight and vitamin D that did help cure tuberculosis. On our right were the rooms of the patients. The DOJ would have been pleased. Each one was private, with the narrow bed, small desk, and wooden closet that the French favor. But they were empty, the patients being at group therapy sessions that lasted all day.
We followed Dr. Lapin into the great room, which reminded me of Laguna Honda’s hall for its smokers and poker players. Two patients were sitting in wooden chairs under the windows, and Dr. Lapin introduced them. Again I thought of Laguna Honda, because Madame Rouen was just as yellow, swollen, and spotted as Mrs. McCoy had been on the day she arrived; and Monsieur Noir, young, sallow, and shriveled, would have fit right in among our poker players, assuming he knew how to play poker. Then we went outside and saw the tennis courts for exericise, the green lawns for rest, and the wooded hills behind the hospital for meditative walking.
Finally Dr. Lapin led us to lunch in the doctors’ dining room.
The dining room was entirely of polished wood—floors, walls, ceiling—and very quiet, without windows. Its long table was set for eight, with gold place plates, silver settings, three wineglasses, and one tiny glass for liqueur. And for the rest of the afternoon we ate and drank as course after course arrived, and wine after wine was poured.
Dr. Lapin and the HUG doctors discussed the treatment of alcohol and drug abuse, though I can’t tell you what they said. I wasn’t paying attention. Mostly I tasted and sipped, and looked around at the heavy, quiet walls. Especially after that third glass of wine, they seemed to exude stability and security, with their memory of many such meals, and their expectation of many more.
I thought about how, after tuberculosis was cured, the Hospital of Saint Bruno had not been torn down. Someone had recognized that there was still a need for such a place in modern France, this century for alcoholics and drug abusers. I thought about how, even after a cure for a
lcoholism and drug abuse was discovered, there would still be some such disease without a cure, some illness whose victims could profit from the prescriptions of those old-fashioned physicians—Dr. Diet, Dr. Quiet, and Dr. Merryman.
Sipping my cognac, it pleased me to think that the Hospital of Saint Bruno would have still another incarnation, another go at curing some illness in the old way. And I wondered for the first time in almost a year: What was happening at Laguna Honda? Was it going to be rebuilt as the Department of Justice had demanded? Or was it going to be closed and torn down?
So that night I called Dr. Fintner for news. I was scheduled to reappear on the first of July, and remembering the place as I left it, with Dr. Major packing up and the hospital’s future uncertain, I telephoned with some anxiety.
Dr. Fintner answered, and she sounded just the same. Diffident and hard to bring out at first. Everything was fine, she said, and she was looking forward to my coming back.
But what was going on? I asked. Did Dr. Major leave? Who replaced her? What about Dr. Stein and the rebuild? What about the DOJ?
Oh yes, Dr. Major was gone. Dr. Romero was medical director now, and two part-time doctors had taken her place on the admitting ward. It had been kind of hectic. As for the future, well, Dr. Stein had just come out with his recommendation, which was to build a new and even bigger hospital, and the board of supervisors was looking into it. It would cost hundreds of millions of dollars, though, and most people thought it would be better to just close the hospital down and use the money to take care of patients at home.
“But they don’t have homes, Julie.”
“I know. That’s the problem.”
“And even if we gave them homes, they don’t have families to help out. And it would be expensive to provide everything they’d need at home—it would be like setting up a thousand minihospitals, with round-the-clock nursing care and daily doctor visits. Isolating, too.”
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 16