By the 1990s, Harlem Hospital, Kings County, and Bronx Municipal were on the verge of losing their state accreditation. And a key reason, many believed, was the growing disconnect between the aims of the affiliated medical schools and the needs of the public hospital patient. The medical schools were moving more and more toward specialized training; the patients, lacking a primary physician, were most in need of a general practitioner. The inevitable result, a city official complained, was a style of medical care that had “little to do with the needs of the communities.”
Bellevue’s weaknesses lay elsewhere. According to the nonpartisan United Hospital Fund, the scourge of AIDS and homelessness—of patients “who are sicker, more difficult to manage, and sometimes more dangerous than in the past”—had taken a heavy toll on the hospital, which saw fourteen executive directors come and go in the years between 1983 and 1997. “We’ve had more Bellevue heads than [Yankees owner] George Steinbrenner had managers,” a local assemblyman fumed. “It is beyond belief—a terrible embarrassment for the city.”
There were many reasons for the exodus. One director was fired for covering up the embezzlement of an aide. Another was let go for refusing to make the budget cuts demanded by City Hall. “I will only run a hospital where I feel I could walk in and be a patient myself,” she declared. Still another, recruited from Houston, took umbrage at the un-Southern hospitality. Having arrived with no place to live, he was housed “in an old, dreary, mice-infested section of the hospital that had been converted into an apartment” and then left to eat Thanksgiving dinner in a nearby coffee shop. “I don’t need to subject myself to that kind of life,” he announced upon heading back to Texas two weeks later.
The privatizers saw evidence of failure at every turn. That upward of $3 billion was spent each year to prop up a dysfunctional system surely spoke to the corrupting influence of labor unions and city bureaucrats. Cutting costs and raising standards were unrealistic goals; the system wasn’t about to reform itself. The logical solution, therefore, lay in shuttering the worst of these hospitals and selling off the others, Bellevue being the possible exception. The poor wouldn’t suffer—indeed, they’d be better off—because private hospitals would be more efficient in spending the government dollars set aside for their care.
Pushback from the unions and public hospital administrators was to be expected. But a blue-ribbon mayoral commission, chaired by the president of the New York Academy of Medicine, also raised objections. Twenty-five percent of the city’s population lived below the federal poverty line, twice the national average; most came from minority neighborhoods where private hospitals were few and far between. New York’s public system treated more homeless people and substance abusers, more AIDS, tuberculosis, and psychiatric patients, than any other provider in the country. Its emergency rooms and outpatient clinics served as primary care facilities for the city’s huge underclass—a role that private facilities seemed unlikely to fill. Much like Mayor John Lindsay three decades before, the panel concluded that “the city should remain in the hospital business, because of…its social responsibilities in this area, including the necessity of assuring that care be provided to all who need it.”
Privately, however, the committee chair was far less certain. The city’s concern for the indigent sick was “a nice thing, a good thing, a proper thing,” said Dr. Jeremiah Barondess. But those in charge lacked the knowhow to run a modern hospital system “in a world this complex politically, socially, [and] medically.” Why, then, had his panel concluded otherwise? Barondess didn’t say, but the pressure was intense. Community activists had demanded that the panel hold open sessions in minority neighborhoods, and Barondess reluctantly complied. Closing down the “publics” thus became a matter of race and class played out in an angrily divided city. Barondess honestly believed that privatization would remove the medical safety net for the most vulnerable New Yorkers, despite assurances to the contrary. But he also feared the ever-widening gap between a private system free to pick and choose its patients, and a public one left to treat the unwanted remainder. The wiser path, he thought, was to seek improvements in the status quo—and hope for the best.
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Historically, Bellevue’s Emergency Department is one of the crown jewels of the city system. Heart attacks and car wrecks, AIDS and crack cocaine overdoses, shootings and attempted suicides, poisonings and prison fights, frostbite and rotted feet—are dealt with at all hours, seven days a week. It isn’t unheard of to treat a homeless man with a body temperature of 66 degrees—the equivalent of hibernation—or an immigrant with leprosy. Indeed, part of Bellevue’s mystique lies in its handling of the sort of unusual cases that periodically light up the tabloids—the woman crushed by a construction crane in midtown, saved from certain death; the music student pushed under a moving subway, her severed hand miraculously reattached. “This is war zone medicine,” a Bellevue emergency room doctor observed in 1990. “You’ll never go anywhere in the world and see something we haven’t seen here.”
Hyperbole, though not by much. When word first reached Bellevue on September 11, 2001, that an American Airlines flight from Boston had crashed into the North Tower of the World Trade Center, the staff prepared for the worst. But to those familiar with Bellevue’s history, the news had a familiar ring. In 1945, a fog-blind military craft bound for Newark Airport had flown into the upper floors of the Empire State Building, killing fourteen people and injuring hundreds. Bellevue’s entire ambulance corps had rushed to the scene that summer morning; among those evacuated was an elevator operator named Betty Lou Oliver.
Occurring a week before the atomic bomb was dropped on Hiroshima, and two weeks before the Japanese surrender, her personal story still made the front pages. One of the plane’s flaming engines had broken free and severed the cables of her elevator, parked without passengers on the seventy-fifth floor. The car rocketed downward, crashing through the shaft and landing in the subbasement. Miraculously, Betty Lou Oliver survived. “She was in a state of profound shock,” a doctor recalled. “Her pulse was so weak, it was hard to tell whether she was dead or alive. She had a fractured spine, concussion of the brain, a broken kneecap, several other fractures, and multiple burns and abrasions.” A priest performed last rites.
Oliver endured several months of skin grafts and surgeries. She was fitted with leg braces and taught to walk again—“put back together, almost piece by piece,” in the words of a supervising physician. Oliver expressed her gratitude on the day she was discharged, saying, “This couldn’t have happened at any other place but Bellevue.”
September 11 also revived memories of 1993, when terrorists bombed the World Trade Center garage and Bellevue received the bulk of the wounded. After that, like other urban hospitals, it began to prepare for future attacks. In 1996, a journalist visiting Bellevue came upon a drill for a deadly sarin gas attack, like the one in Tokyo the previous year. “Oxygen tanks were piled by the door. Canisters of atropine, a drug used to control muscle spasms, were stacked in metal carts. Everyone donned blue plastic coats, masks with Plexiglas shields, rubber gloves and boot covers, then turned toward the emergency room door, waiting for the casualties to barrel through.”
On the morning of 9/11, the smoke billowing from the North Tower was clearly visible at Bellevue, less than three miles away. “It’s gonna be a big one,” a nurse remarked. “They’ll be coming in droves.” Eighteen minutes later, the South Tower was hit and, as one doctor on duty put it, “the hospital shifted gears like I’d never seen in my twenty-five years working there.”
The night staff, preparing to leave, remained in place. Routine surgeries were canceled to clear the operating rooms, and patients able to leave the hospital were quickly discharged. A physician’s diary read: “The second tower falls. Alumni begin to arrive….Twenty nursing students in green scrubs flock in. A group of residents in starchy whites ask what they can do.” Outside, a line of volunteers snaked around the building, waiting to give blood.
The most common memory of those on duty at Bellevue that day is the helplessness they felt. “Thousands of medical workers—doctors, nurses, medical students, technicians, orderlies, therapists, clerical workers—were poised [for action],” a staffer wrote, “but there were no patients…no one came.” Records show that 169 World Trade Center victims were treated at Bellevue on 9/11, and twenty-five more in the following days. It’s an extremely small number given the estimates of seven to ten thousand people in each tower that morning, even more so considering that most of those who did reach Bellevue were classified as “walking wounded” with injuries that didn’t require admission, such as corneal abrasions, minor lung issues, and cuts and bruises.
The reason is painfully clear. Catastrophes of this scope tend to have three zones, a trauma expert explained. “The center zone is death on impact. The middle zone is gravely injured. The outer zone is minimal injury.” The Twin Towers collapse had no middle zone. People either died in the buildings or walked away covered in soot but physically intact—too stunned, or relieved, or even guilty, to seek medical aid.
With so few victims arriving, some at Bellevue rushed to the scene. “Police cars barreled up and men and women wearing red scrubs clambered out,” recalled a physician at Downtown Hospital, a few blocks from the fallen Twin Towers. “They were surgeons from Bellevue…who, despite our phones being down, had guessed where the patients were being taken.” Minutes later, an intern arrived on a motorcycle, his backpack filled with supplies. Downtown Hospital, a 150-bed operation, treated more than a thousand people that day, most for superficial wounds. One rescue worker had a finger amputated after cutting himself on a piece of metal, and a severely burned woman was ambulanced to Bellevue because, as one doctor noted, “morphine was all we could offer her.”
The Bellevue interns who reached Downtown Hospital were shocked by their assignments. Expecting trauma duty, they were told to search the smoldering wreckage of Ground Zero for body parts to be sent to the Medical Examiner’s Office for identification. “We took heads, arms, legs, and labeled them and put them in the truck,” one wrote of the assignment. “I thought I’d be able to handle it emotionally but…the amount of death that I saw was unbelievable.”
All told, twenty-one operations were performed at Bellevue in the following days. Three of the final Twin Tower victims pulled out from under thirty feet of rubble required extremely delicate surgery, and two survived their wounds. The last person found alive, a Port Authority police sergeant named John McLoughlin, had led the rescue attempt in the North Tower moments before it collapsed. “Initially, I thought I had died,” said McLoughlin, who spent twenty-two hours pinned under a girder. “I lost all sense. I had no sight. I had no smell. I had no hearing. Everything just went silent.” Put into a medically induced coma, McLoughlin underwent thirty procedures over the next three months to remove dead muscle and tissue from his crushed lower body. His kidneys failed, forcing him to undergo renal dialysis, and he was placed on a respirator after developing a severe bacterial infection. But his recovery bore witness to the enormous skill of the medical teams left waiting for other victims to arrive. “So many lives were lost that day,” one of the attending surgeons remembered. “At Bellevue and NYU, we were prepared to save more, if we only had the chance.”
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For weeks after the Twin Towers fell, the city was blanketed with flyers of the missing: “Has anyone seen Richard ______, 36, black hair, brown eyes, a firefighter; please contact his family at _________.” Hundreds of them were taped to a two-hundred-foot-long construction fence at Bellevue, which became a makeshift memorial covered in weatherproof plastic. What struck those who passed it each day were the strikingly personal images of the missing—at weddings and anniversaries, receiving their diplomas, vacationing at the beach, wearing gowns and tuxedos. In one photo, a father is sitting on the grass next to his young daughter, the block letter words reading: “Have You Seen My Daddy?” As the flyers grew in number, so, too, did the length of the fence. New Yorkers named it “The Wall of Prayers.”
It was the same as the ones that sprang up at Grand Central, Penn Station, the Port Authority, St. Vincent’s Hospital, and dozens of other places—only larger. That was due, in some measure, to the fact that Bellevue abutted the Medical Examiner’s Office, where the identification of the victims was taking place. One of the doctors who had rushed to Ground Zero recalled the enormous white coroner’s tent that suddenly appeared below his office window. “I would look down during nights on call and see the constantly illuminated procession of trucks bringing remains for forensic analysis,” he wrote. “I lost track of how many months they were there, but however long it was, the lights shining on the ceaseless work never turned off.”
In fact, Bellevue had long been a gathering place for those seeking information after a catastrophe—partly because it housed the city’s largest morgue, and partly because it treated so many of the wounded. Crowds had flocked there after the Civil War Draft Riots, the bloody Orange Day parades, the General Slocum disaster, the Triangle Shirtwaist fire that killed 146 garment workers in 1911, the Empire State Building plane crash, and the 1993 World Trade Center garage bombing. The Wall of Prayers remained at Bellevue for two months, with grief counselors on duty. In November 2001, a private memorial was held for the hospital staff as the Wall was taken down. Several hundred people attended; Protestant, Jewish, and Muslim religious leaders read prayers. The scribbled notes and photos that covered the Wall are preserved at the Museum of the City of New York.
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Bellevue’s role in 9/11 is ongoing. Its pathologists played a major part in identifying the victims, a painstaking process with 1,200 people still unaccounted for, though their death certificates were issued years ago. Its Chest Service partnered with other hospitals to treat the first responders who trekked through clouds saturated with asbestos, glass fibers, fuel ash, lead from pulverized computers, mercury from fluorescent bulbs, and toxins of all kinds. Today, Bellevue houses an Environmental Health Center staffed by NYU Medical School that screens neighborhood residents claiming a 9/11-related lung injury. While looking for the most telling symptoms—shortness of breath, a persistent cough, evidence of “WTC-derived particles”—the center, like Bellevue itself, turns no one away. Many patients come from low-income families without health insurance. Papers aren’t required, and there are few out-of-pocket costs for treatment.
On the tenth anniversary of 9/11, a state-of-the-art “Simulation Center” opened at Bellevue to train first responders and hospital personnel in handling mass emergencies. At 25,000 square feet, the nation’s largest, it contains mock operating rooms, a five-bed intensive care unit, and freakishly lifelike mannequins that can speak, bleed, sweat, moan, vomit, and even deliver a baby in response to computer-generated commands. Fittingly, the center occupies the same space as the old tuberculosis wards run by medical giants like Edith Lincoln, André Cournand, and Dickinson Richards—testament to the ever-changing priorities of urban hospital care.
Shortly after 9/11, a doctor who had been on duty at Bellevue that day jotted down the problems he’d seen. Poor communication topped the list. Like much of lower Manhattan, Bellevue’s phone lines were overwhelmed and cell service was spotty. There weren’t enough two-way radios, which are essential in such emergencies, leaving administrators to rely on medical student “runners” to relay critical information.
Next on his list was the possibility of a blackout. If the hospital’s main power source went down, the survival of the most vulnerable patients would depend on a backup system of unkn
own reliability. Bellevue had dodged the problem this time, he wrote, but the legacy of 9/11 was that unthinkable catastrophes were now a fact of modern life. What would happen if the power cut out for several hours—or more? Was there a plan in place to deal with it? “Often, the capacity of emergency generators is unable to meet [these] demands,” the doctor concluded. “Clearly someone should be assigned to control and conserve these resources.”
Prophetic words, indeed.
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In the realm of “emergency preparedness” at American hospitals, there really are two eras: Before Katrina and After Katrina. Until that point, attention had focused on treating mass casualties arising from a terrorist attack, a gas explosion, a highway pileup—what one expert called “disasters outside their walls.” While there were a handful of previous wake-up calls—the massive Northridge, California, earthquake that buckled several local hospitals in 1994; the immense damage done to Houston’s downtown medical complexes following Tropical Storm Allison in 2001—the danger to patients “inside their walls” seemed rather remote.
Katrina challenged that thinking. When the levees protecting New Orleans gave way in the summer of 2006, flooding the downtown hospitals, patients became casualties. It wasn’t a big story at first, given the immense scope of the hurricane. But reports began to trickle out regarding the horrors that occurred in places like Memorial (formerly Baptist) Hospital, where more than thirty people died, most with suspiciously high levels of morphine in their system. Dr. Sheri Fink put it all together in Five Days at Memorial, a searing account of what happened when the backup generators failed, the water taps went dry, the food spoiled, the air-conditioning stopped, and critically ill patients lay in semidarkness and stifling heat. Isolated and exhausted, the medical staff took to making life-and-death decisions in an increasingly leaderless vacuum—the line between medicine and mercy killing so blurred that a doctor and two nurses were accused of euthanizing patients and brought up on charges of second-degree murder, which eventually were dropped.
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