Bellevue

by David Oshinsky

  While the Duquesne and Morales breakouts had raised fundamental security concerns, they lacked the emotional impact of the Hinnant murder, which left the entire hospital in shock. It was, said one observer, the difference between watching The Great Escape, on the one hand, and Psycho, on the other. If this could happen to a doctor, it could happen to anyone—a defenseless patient, a nurse making rounds, a visitor using the restroom. Hinnant’s boss, Dr. John Pearson, spoke of two lives being taken that afternoon—his final memory of Kathryn bouncing into his office to announce that the results of her amniocentesis had just come back and everything was fine with the baby. “She was so loved,” he whispered, “and so tiny.”

  Steven Smith was found guilty of first-degree murder and sentenced to life in prison. “We thought he was faking,” a juror said of his insanity defense. Asked if he had anything to say, Smith mumbled. “I’m sorry…I didn’t get what I expected I should have got”—meaning a death sentence. Following the trial, the city offered Dr. Hinnant’s family $2 million to settle their much larger claim against Bellevue. The family refused, leading to a court battle that would ultimately absolve the hospital of negligence in the murder. “I don’t think there is a juror who isn’t angry about this occurrence, who isn’t very disappointed with Bellevue Hospital,” said one of the dissenting members. On appeal, a panel of five state Supreme Court justices dismissed the family’s lawsuit in a 3–2 decision. The law did “not require a hospital security system to be flawless,” said the majority. And no one could reasonably expect a place like Bellevue, whose population included a “high percentage” of violent, criminal, antisocial, and homeless patients, to be perfectly safe. Put simply, it had done its best with what it had.

  On one level, it was hard to disagree. Budget cuts over the years had forced the Health and Hospitals Corporation to reduce security across the public hospital system. The gap was such that Columbia Presbyterian, a voluntary hospital with fewer beds than Bellevue, had three times the number of security personnel—250, as opposed to eighty. In addition, Columbia Presbyterian had installed card-reading machines that alerted authorities to anyone wearing a stolen identification badge. Bellevue, by contrast, could barely pay the salaries of its bare-boned security force. The average officer earned $23,600 after three years on the job, half that of a New York City beat patrolman, and carried only handcuffs and a nightstick. (New York City Corrections officers assigned to the male prisoners did have firearms, which were not allowed on the wards.) Derided as “toy cops,” the Bellevue force spent much of the shift at fixed positions, rather than patrolling the halls and stairwells. Indeed, one of the first things that Steven Smith had told the police detectives who interrogated him was: “Bellevue security sucks.”

  There was more to the story, of course, than sorry policing. Steven Smith was on probation for a string of serious crimes, yet the justice system had completely lost track of him. He’d come voluntarily to Bellevue threatening suicide and homicide, yet he couldn’t get himself admitted. And the reason, it appeared, had as much to do with overcrowding as with a botched diagnosis. At the time of Dr. Hinnant’s murder, Bellevue’s adult psychiatric wards were running at “103.9 percent of capacity.” There simply wasn’t room for another homeless addict with violent thoughts swirling in his head.

  Public hospitals reflect the social ills of the inner cities that surround them. In the 1970s, as crime and drug addiction soared, Bellevue opened a Methadone Maintenance Treatment Center on the ground floor. Theft had always been a problem at the hospital, mostly by the staff. Now almost everything began to disappear—typewriters, adding machines, purses, drugs, needles, syringes, even the candlesticks from the Catholic chapel. “Clusters of men gather daily near telephone booths and elevators, lean not-so-casually against pillars and walls, linger near doors and stairwells,” wrote a New York Times reporter under the headline “Intruders Find Bellevue an Easy Target.” Asked why nobody tried to remove them, a security guard replied, “With what? What have we got to protect ourselves?”

  In 1985, the city closed Bellevue’s massive psychiatric building and moved the patients to the top floors of the main hospital, along with the prison wards. Though crumbling and in disrepair, the psychiatric building gained new life as an eight-hundred-bed men’s homeless shelter, the city’s largest, just a block from the Bellevue lobby and connected to the hospital by a guarded underground tunnel. Within weeks, the shelter had reached maximum capacity.

  Some of New York City’s homeless surge could be blamed on rough economic times. But the key factor, most experts agreed, was the well-intentioned but woefully misguided policy of moving state mental patients back into their neighborhoods for treatment, a process known as “deins­titut­ional­izati­on.” The belief was that successful new antipsychotic medications combined with group therapy in a familiar setting would be more humane and effective than “forced incarceration” in isolated, often brutal mental hospitals. With little planning and erratic funding, the policy flooded New York City with thousands of severely disturbed and ultimately homeless people.

  Fearful that some might die of neglect, Mayor Koch authorized both a “cold weather alert,” which protected the homeless when the temperature dropped below freezing, and the “involuntary hospitalization” of those “in serious danger of bringing harm to themselves within the reasonably foreseeable future.”* Both plans relied on using newly designated homeless shelters and selected public hospitals with facilities already in place—Bellevue being the most prepared and welcoming destination. By the late 1980s, it contained four separate units for the homeless, split between the hospital and the adjoining shelter, to treat psychiatric issues, medical problems, and substance abuse. “With our traditional sensitivity to the poor and the indigent mentally ill,” said Bellevue’s chief of psychiatry, “we [now] accept our responsibility to the care of the homeless.”

  Each patient was given both a medical and psychiatric exam after being bathed and deloused. One day’s “roundup” included a blind, feces-covered woman who spent her days on the Upper West Side screaming epithets at strangers and a knife-wielding man who lived in a plastic bag in Central Park surrounded by rodents he claimed to know by name. A journalist studying New York’s “Mole People”—those living in the railroad and subway tunnels beneath the city—watched an evening roundup in which six homeless men agreed to leave “after some cajoling and promises that they will be taken to Bellevue rather than the Fort Washington Shelter.” It wasn’t hard to see the appeal. Bellevue provided fine basic care; it was safer and cleaner, and in some cases brought about quick (if mostly short-term) results. “These people…you wouldn’t believe what they look like,” an advocate for the homeless explained. “Some have toilet paper wrapped around their heads because they don’t want their ideas flying out or new ones flying in. And after a week in Bellevue, eating and sleeping [well], they go before a judge and they say, ‘I don’t know why I was brought here Your Honor, I just want to get out and get a job.’ ”

  The alternative in this instance, the massive Fort Washington Shelter in upper Manhattan, housed a small unit for the mentally ill. A Times reporter described the sheer menace of Fort Washington after making an unannounced evening visit: “Noises arise in the darkness: the moans of men having sex with men, the cries of the helpless being robbed, the hacking coughs of the sick, the pounding of feet running through a maze of 700 cots packed into one vast room.” While anyone willing to look could see the utter failure of these giant shelters, there were few ways to fix the problem because neighborhood resistance to small-scale group homes was simply too intense.

  “Wintertime was the worst,” wrote a devoted, if disheartened, young physician. “The cold weather drove the homeless into the hospital, and all of Bellevue seemed a fetid, overcrowded, wretched purgatory to which we were committed to the end of our residency…if ever that would arrive.” She wasn’t alone. Dealing with the homeless in such large numbers tested the most idealistic of souls. A th
ird-year NYU medical student noted the emotional contradiction of Bellevue in these years—yearning to serve the underserved, yet facing the reality of what that entailed. “An acrid smell of cheese gone bad accosts me as I near his coat,” he wrote of an all-too-common encounter. “This is awful. I feel I have to walk away, maybe find a toilet somewhere to vomit. Doesn’t he know how bad he smells? How can he live with himself?”

  The patient was homeless and drug-addicted, his arm “scabrous and pocked.” A festering boil on his ankle looked “about to burst.” There had been untold numbers like him in the past, but never in such heavy concentrations. “Please let me go home and get some sleep,” the student silently pleaded. “And please God, please, do not make me touch [him] until he has had a shower.”

  Two months after Dr. Hinnant’s murder, a survey taken by Bellevue’s Department of Social Work classified 43 percent of the hospital’s adult inpatient population as homeless, the figure rising to 70 percent in the psychiatric division. And a second survey of 298 patients brought involuntarily to Bellevue showed most to be single men with a history of schizophrenia who had been living on the streets for at least a year. A fair number were drug addicts, HIV-positive, and suffering from tuberculosis; fewer than 5 percent had families willing to accept them back into their homes. As a result, the average length of stay for a psychiatric patient at Bellevue rose from about ten days in the early 1970s to thirty-seven days by 1992. “[We’ve] changed from a receiving hospital to an intermediate and long-term patient care service,” its psychiatric director admitted, adding: “We cannot [just] turn our patients out into the streets.”

  In truth, Bellevue had become hostage to circumstances it couldn’t hope to control. The AIDS crisis, the crack cocaine epidemic, the deins­titut­ional­izati­on of state mental patients, the adjoining men’s shelter, the “cold weather alerts,” the “involuntary” commitments—each took a heavy toll. “I hate to put it this way, but we’re sort of the waste basket for the rest of society,” said the head of Bellevue’s psychiatric emergency service. “We take the people the other social agencies can’t deal with, those who fall through the cracks.”

  But Bellevue, with the best of intentions, may have aggravated matters by the very nature of its social vision. On a given day, one could see a long line of semiconscious men on gurneys—what the staff called “the choo-choo train of drunks”—who had staggered in for a hot meal, an aspirin, and some free clothing from a veritable warehouse of goods donated by volunteers who distributed them to thousands of homeless patients each year. “We treat all the problems of society,” a Bellevue social worker explained. “How can you send a person out in the cold without a coat?”

  It was an admirable sentiment, but hardly problem-free. Was it wise to blur the line between homeless patients in need of medical and psychiatric attention, and those who looked upon Bellevue as a place to get warm, to be fed and to be used as a physical extension of the shelter next door? A homeless man in a wheelchair had been stabbed to death in the tunnel between the shelter and the hospital, and several Bellevue patients had been sexually assaulted, the last attack occurring a few months before Dr. Hinnant’s murder. “Our security stinks,” said Irwin Freedberg, the chair of dermatology, parroting Steven Smith’s much quoted description to the police. He added: “The front lobby is a mess. I have never seen this hospital dirtier.”

  Could Dr. Hinnant’s death have been prevented by better police training, a reasonable security budget, a stricter policy toward the homeless, or perhaps all three? Opinions varied. Some at Bellevue saw the murder as a rare tragedy that could have occurred in any public facility serving a diverse clientele. Of course, security must be improved, they agreed, but not at the expense of turning Bellevue into a less welcoming place. But others were left wondering whether the hospital they loved had begun to take on the look of a soup kitchen or a bus terminal. A young physician, noting that Bellevue had experienced three major security alerts on the day of Dr. Hinnant’s murder—the other two being a hanging in a psychiatric ward and a drowning in the dermatology ward—vented his frustration to the press. “The risk of working in a place of such minimal security and an ever present criminal element is now constantly at the edge of our consciousness,” he fumed. “We share a sense of violation and outrage, and many of us will never be the same.”

  Gerald Weissmann, the distinguished researcher and clinician who began his career at Bellevue in the 1950s, feared that a corner had been turned. Life was “less hazardous for young doctors in my day,” he wrote. No one then could have imagined a scene in which “an unshaven derelict…in a scruffy scrub suit [and] a stethoscope around his neck…roamed around the hospital.” For Weissmann, the presence of such deranged predators rested squarely with muddle-headed state officials who had closed the asylums with little forethought, allowing “the mad and violent to prowl the streets.” But he wondered whether a conservative future historian “might find that we are unknowing accomplices in Kathryn Hinnant’s death”—that she “died for our liberal creed.”

  * * *

  * Legal battles soon followed. A woman living on a midtown subway grate sued the city after being brought to Bellevue against her will for medical and psychiatric treatment, which she refused. “I’m not insane,” said Joyce Brown, who went by the name Billie Boggs, “just homeless.” Though virtually every psychiatrist who examined her disagreed, finding Brown to be a severe danger to herself, and incapable of functioning without powerful antipsychotic drugs, a judge released her. The Boggs case complicated an already difficult situation, since by New York state law, a patient cannot be held involuntarily for more than sixty days without a court order. At Bellevue, a courtroom set aside for that very purpose—Room 19E2—became a very busy place, with a steady stream of patients, including some with drug-resistant tuberculosis and other dangerous conditions, contesting mandatory confinement and treatment.

  19

  SANDY

  Shortly after Dr. Hinnant’s death, a group of security experts held a workshop, “The Bellevue Murder: Could It Happen in Your Hospital?” Nothing remotely resembling a consensus emerged. Those from the private hospitals couldn’t imagine a scenario in which a doctor would be killed under their watch. “It’s hard for me to believe that someone could be living in a cubicle or storage room and not be noticed,” said the director of security at New York’s elite Memorial Sloan-Kettering Center. “We don’t have an area of the hospital that’s not monitored….An ill-kempt person will stand out here.”

  Those representing the “publics” offered no such guarantees. Their hospitals faced “large numbers of homeless, an AIDS epidemic, increasing violence, the crack explosion, overcrowding, and tight budgetary restrictions.” While not denying Bellevue’s egregious security lapses, they noted that “unkempt” people were the rule at public institutions, and that Bellevue counted more than its share. Could the murder of Dr. Hinnant have occurred in any big metropolitan hospital? Of course—though the fact that it happened where it did was no great surprise.

  Indeed, several weeks after Dr. Hinnant’s murder, yet another squatter was arrested at Bellevue for criminal trespass. He’d been living in the hospital basement for at least two months, posing as a TV repairman and harassing patients. He was finally spotted carrying four trays of half-eaten food back to his subterranean quarters, where security guards found a stack of stolen visitor’s passes. “We work hard and head off a lot of incidents,” an official insisted. “But we have doctors who don’t wear their IDs. We have people who tape locks open on the stairways so they don’t have to wait for the elevators. We have employees who don’t bother to report suspicious persons on the floors. Then they complain that security stinks.”

  The Hinnant murder began a decade of intense scrutiny for New York’s beleaguered public hospital system. The early 1990s would see both an uptick in hospital crime and a cluster of wrongful death suits that reignited the debate over privatization. At Manhattan’s Harlem Hospital, the
body of a missing psychiatric patient turned up in an airshaft a few yards from his room. At Bronx Municipal Hospital, two patients died after one’s cardiac monitor was disabled and the other received too much anesthesia. The most publicized case involved Yankel Rosenbaum, an Orthodox Jew attacked by a mob during the Crown Heights Riot of 1991. Rushed to Brooklyn’s Kings County Hospital, Rosenbaum died in the emergency room. A review of his treatment showed that a poorly supervised intern had missed the stab wound responsible for Rosenbaum’s death.

  Medically speaking, Bellevue remained head and shoulders above these other institutions. Even those demanding privatization agreed that tampering with “the flagship of public hospital care in the United States may not be politically feasible.” What set Bellevue apart, even in the worst of times, was its powerful connection to New York City’s top medical schools. One had only to look at the near disintegration of Harlem Hospital under its affiliation contract with Columbia (P&S) to see the difference. Columbia had served Bellevue with distinction for generations before pulling up stakes in the 1960s. Now, however, its neglect of the Harlem partnership was so complete that its own dean conceded the point without a hint of embarrassment. “[We’re] a big institution,” he mused. “Certainly there are times when we’d have liked the university to pay attention to the Harlem affiliation.”

  Things were no better at Kings County, whose partnership with Downstate Medical School was described as “terrible” when it came to providing quality patient care. “I can’t tell you now with a straight face that we get $475 million worth of service from the affiliates,” the head of the Health and Hospitals Corporation admitted. The sad truth was that medical schools like Columbia and Downstate were taking large sums from the city without giving back much in return. The tradition of service—the sense of mission—that prevailed among physicians at Bellevue had been forged over centuries. NYU had been training its students and house staff there since before the Civil War, and a fair number of them, known as “Bellevue lifers,” stayed on for their entire careers. While incidents like the Hinnant murder no doubt strained the NYU-Bellevue partnership, the institutions were too interdependent to think of parting ways.