Bellevue

by David Oshinsky

  It was a heady moment for Bellevue. “She is our flagship,” said Mayor Bill de Blasio. “She serves in the toughest times and makes [us] proud.” In its year-end “Reasons to Love New York” issue, New York magazine listed Bellevue twice in its top ten. Number 7 read: “Because Dr. Laura Evans Saved Craig Spencer’s Life.” And Number 8 added: “Because Dr. Laura Evans Saved Craig Spencer’s Life with the Help of 119 Others”—which included snapshots of the nurses, doctors, technicians, pharmacists, waste managers, and security officers who had served on Spencer’s detail.

  In praising Bellevue, New York had inadvertently exposed the downside of the Ebola experience. Caring for Craig Spencer had taxed the institution beyond its limits. So many experienced nurses were involved that patients in the adult and pediatric ICUs had to be moved to other hospitals. Exhaustion set in, especially among those having to wear and discard the heavy protective gear. Some staffers spoke of being shunned by frightened coworkers; others, fearful of harming their families, asked to sleep in the hospital. There were rumors of “sick-outs” and high absentee rates, and the constant bedlam of roving TV crews thrusting microphones at anyone in medical scrubs.

  Saving Craig Spencer’s life was an extreme challenge. The cost ran into the millions; treating Spencer’s medical waste alone was estimated at $100,000 a day. “We like to think of ourselves as a ‘bring it on’ hospital,” Bellevue’s chief of medical service recalled. “We’re essential. We can handle just about anything.” For all the fear and trouble it brought, Ebola proved him right.

  Epilogue

  Within a day or two of Craig Spencer’s medical discharge, Bellevue became Bellevue again. Staffers went back to their normal posts; the ICUs returned to full capacity. The media packed up and moved on. The Great Ebola Scare of 2014—the one that barely reached American shores—is now a fading memory. Though the seventh-floor isolation ward remains “active,” and the occasional “suspicious” traveler from West Africa is brought in for quarantine and testing, the urgency is gone.

  It was no accident that Bellevue, a former pesthouse, took in Craig Spencer. In treating the “Ebola Doctor,” Laura Evans and her team trod the path first taken by young Alexander Anderson during the yellow fever epidemics of the 1790s and followed thereafter by generations of nurses and physicians battling cholera, typhus, puerperal fever, influenza, tuberculosis, and AIDS. It’s among the services long demanded of Bellevue by the nation’s largest, densest, most diverse city—and one certain to continue. History assures us that Ebola will be fully tamed, but that the next “fatal strain” is also bubbling up somewhere—in a bat cave, a pig farm, an open-air poultry market. That’s the nature of the war between humans and microbes. There is never a truce.

  To enter Bellevue’s main lobby today is to see the intersection of the present and the past. In 2005, a five-story atrium designed by Pei Cobb Freed opened to rave reviews. One side contains a sleek, glass-enclosed galleria housing the hospital’s many inpatient clinics. The other side contains the brick-and-granite facade of the old administration building designed by McKim, Mead & White, with its ornate carvings and quaintly dated inscriptions. (One reads “Employes,” a common usage a century ago.) The floor is polished marble, gaslight sconces are on display, and down a long corridor sits a horse-driven ambulance from 1898. There’s a beefed-up security presence, and no visible signs of the damage left by Superstorm Sandy.

  Yet it is in the patient areas where the past and present truly intersect. Bellevue plays many roles, as Craig Spencer’s case made abundantly clear. But its primary one—to serve the poorer classes of a constantly evolving city—remains unchanged. Today, as before, its patients are overwhelmingly immigrants and their young children—no longer from Europe, but from Mexico, Central America, the Caribbean, West Africa, South Asia, and China. (Whites now rank last in the category of “patient race.”) Few at Bellevue carry private or group health insurance. Indeed, the hospital receives more money from the Department of Corrections for treating prisoners than it does from Blue Cross/Blue Shield. Most patients rely on some form of Medicaid; the rest are called “self-pay,” a euphemism for “no-pay,” meaning the uninsured.

  As a vital safety net hospital, Bellevue relies heavily on programs like the state’s Indigent Care Pool and the federal government’s Disproportionate Share Hospital plan to pick up what the city cannot afford. This largesse has been rapidly declining, however, and there are fears that Obamacare’s restrictions on undocumented immigrants, who are ineligible for public coverage, will make things even worse. The principle of free medical care for the indigent in New York remains firm; but the implementation, excepting the Great Depression of the 1930s, has rarely been harder.

  Some problems seem to defy solution. Scattered throughout Bellevue today are forty to fifty patients receiving Alternate Level of Care (ALOC). Many hospitals have them—though in smaller numbers and in much better shape. The acronym refers to someone in an acute care hospital who no longer needs acute care. But the person cannot be discharged unless he has somewhere safe to go. Some stay for two months at Bellevue, some for two years and longer. A fair number have died there. It’s a staggering drain on Bellevue’s limited resources, and it speaks volumes about the kind of patients it routinely admits.

  There’s a young man with AIDS, “very combative—sent to Bronx Lebanon and sent back same day.” A “homeless female” from the Caribbean with “cognitive impairment. Sister stopped returning our calls.” A seventy-seven-year-old man from Sri Lanka, “demented. No family here. Needs a walker.” An “undoc. homeless man—dementia…cannot function in a shelter.” “A middle-aged male with cog. issues—malnutrition, lice, HIV, dementia—all referrals denied.”

  A voluntary hospital can more easily discharge its ALOC patients because many have family attachments and private insurance. Bellevue has no such luxury. “Think of fifty valuable beds in an eight-hundred-bed hospital that never turn over,” an official said. “Fifty beds! It’s a sad commentary, but you just can’t release vulnerable patients without considering the consequences.” A physician familiar with these patients describes them as “our triple threat—undocumented, uninsured, undomiciled.” In truth, he adds, “they’re not so different from Bellevue’s medical population. They just stay a lot longer.”

  More than a third of Bellevue’s current inpatients fill its once notorious psychiatric wards. It is no surprise, therefore, that familiar diagnoses like “schizophrenia” and other “psychoses” are among the leading causes for admission. But today there are popular diagnoses that were barely acknowledged at Bellevue a century ago, such as “cocaine dependence,” “opioid abuse,” and “cellulitis and other bacterial skin infections”—the scourge of the homeless. There are few better barometers for studying a city’s social needs.

  Several years ago, four NYU doctors with deep ties to Bellevue wrote a stirring defense of the role of the public hospital in American medical education. Where else, they wrote, could an aspiring nurse or physician, “not yet accepting of the status quo,” confront the “harsher inequities” of modern life, from AIDS and substance abuse to homelessness and prison health care? Public hospitals “embody a sense of mission. The core ethos of working in a place that exists to minister to the sick regardless of the walk of life or ability to pay is enormously influential in shaping the worldview of [those] in training.”

  It wasn’t for everyone, they admitted. Ethos and adventure went only so far. Bellevue was frustrating and chaotic—under-budgeted, understaffed, and crammed with patients “whose unmet psychological needs foster frequent repeat hospitalizations.” Still, those who trained there got to experience “the very values that led them to the choice of medicine as a career.” In treating the weak, they strengthened themselves.

  That training mission remains firmly in place. What has changed at Bellevue over the years is the research component, which, while ongoing, no longer dazzles. The laboratories that nurtured the likes of William Welch and Hermann B
iggs, Walter Reed and Albert Sabin, Dickinson Richards and André Cournand, are mostly gone. The patient-oriented research that once occurred in great public hospitals like Bellevue has been usurped, to a great degree, by Contract Research Organizations (CROs) that rely on subjects from the larger community for clinical trials. Hospital patients no longer dominate this process. And the research itself, based on genetically engineered animals, cells in culture, crystals, mass data collection, and a veritable army of laboratory personnel, is no longer a priority of the city’s financially strapped public hospital system. It is no surprise that the locus of activity has shifted a few blocks north to the impressive facilities in and around the NYU Langone Medical Center, where competitive federal grant money pours in and top research scientists are aggressively recruited.

  NYU receives close to $170 million a year from the city to provide medical services to Bellevue. It’s a relationship that goes back more than a century, and in comparison to New York’s other affiliation contracts, it has worked extremely well. Bellevue’s emergency services are second to none. Its clinics provide first-rate primary care, and its doctors are master diagnosticians, having seen just about everything. Imagining Bellevue without NYU, or vice versa, seems an affront to history. One remains a premier teaching hospital; the other provides structure, continuity, and academic prestige.

  Recently, Mayor Bill de Blasio vowed to funnel an extra $2 billion in subsidies into Health + Hospitals, which runs the city’s bleeding public system. Much of the money is earmarked for neighborhood clinics—the aim being primary care over hospitalization whenever possible. But de Blasio made it clear that the public hospital system would be protected—that its centuries of service, led by Bellevue, are part of what makes New York special. “It is not for sale,” he said, “and the city will not abandon it.”

  Lewis Thomas, the physician/essayist and National Book Award winner, liked to tell the story about a New York City street scene at the turn of the twentieth century. A woman lay on the sidewalk, the crowd around her frozen in panic. Then, from the very back, a booming voice was heard: “I am a Bellevue man. Let me through!” The sea of bodies parted. A doctor emerged, medical bag in hand, to revive the woman and bring her to her feet. The crowd burst into hearty applause.

  For Dr. Thomas, Bellevue embodied the better angels of medicine, despite its many warts. His story was about respect and knowledge and helping people who are down. For millions of New Yorkers, it still rings true.

  Acknowledgments

  This project was born, I recall, during a conversation with my good friend Dick Foley, then dean of the NYU Faculty of Arts and Sciences. I was coming to New York following a dozen glorious years at the University of Texas, and the history of iconic Bellevue, the primary teaching hospital for NYU, seemed a natural extension of my growing interest in medicine and public health.

  The generosity of colleagues can hardly be overstated. Sandra Opdycke, author of No One Was Turned Away, a superb narrative comparing the paths of public Bellevue and private New York Hospital during the twentieth century, shared her voluminous research with me—an absolute life preserver given the impact of Superstorm Sandy upon Bellevue’s spotty archive. Dr. Stanley Burns, director of the enormously rich Burns Archive, sparked my interest in medical photography, while Lynn Berger volunteered information regarding Bellevue’s first photographer, O. G. Mason. Dr. Ira Rutkow, author and friend, was an insightful guide to the trajectory of American medicine. Dr. Daniel Roses, a chronicler of Bellevue’s rich history, provided key insights about the hospital’s past.

  No one has done more to preserve that past for other researchers than Lorinda Klein, who critiqued this manuscript with a very sharp eye. Though Lorinda and I sometimes disagreed on the interpretations in this book, her comments proved a most valuable tool.

  Special thanks, as well, to Dr. Doug Bails, chief of medical service at Bellevue, for his guidance in explaining both the workings of the hospital and its vital importance to the city it serves. Doug perfectly represents the spirit of medical excellence and public commitment that have marked Bellevue for close to three centuries.

  Historians depend heavily on the skill and ingenuity of librarians and archivists; I was extremely fortunate to encounter some of the best, including Sushan Chin at NYU’s Lapidus Health Sciences Library; Arlene Shaner at the New York Academy of Medicine; Mariam Touba at the New-York Historical Society; Stephen Novak at the Columbia Health Sciences Library; and Margorie Kehoe and Nancy McCall at the Johns Hopkins Chesney Medical Archives.

  Numerous current and former colleagues at Bellevue and NYU Langone shared essential information: documents, photographs, and personal correspondence. I am deeply indebted to Robert Holzman, Elihu Sussman, Nathan Thompson, Fred Valentine, and Arthur Zitrin, among others. Many sat down with me for personal interviews and reminiscences, often more than once: Martin Blaser, Douglas Bails, Mitchell Charap, Barry Coller, Patrick Cox, Bruce Cronstein, Laura Evans, David Goldfarb, Roberta Goldring, Loren Greene, Martin Kahn, James Lebret, Jerome Lowenstein, Charles Marmar, Ruth and Victor Nussenzweig, Danielle Ofri, Dennis Popeo, David Stern, Elihu Sussman, Nathan Thompson, Fred Valentine, Jan Vilcek, Gerald Weissmann, and Arthur Zitrin.

  In addition, I would like to thank Dr. Robert Grossman, dean and CEO of NYU Langone Medical Center; Dr. Steven Abramson, chief of medicine; and Katherine Wesnousky, chief of staff of the Department of Medicine, for providing a supportive environment for the writing of this book; Katie Grogan for her research assistance; Troi Santos, for his expert photographic help; Marc Triola, for explaining the mystery of numbers to a novice; Amy Lehman, for sharp analysis; and, especially, Stacy Bodziak, for simply being indispensable in all matters relating to the Division of Medical Humanities.

  My friend and agent, Chris Calhoun, brought me to the ideal publishing house. At Doubleday, I had the extreme good fortune to interact with Bill Thomas, Dan Meyer, and Kris Puopolo, editor par excellence. Her enthusiasm for the book was infectious. Her patience in guiding it to completion bordered on saintly. Every author should be so fortunate. I owe Kris a debt of gratitude that grows with each reminder of her professional skill and personal kindness.

  Much has changed in my life since this project began, including a new job; the loss of my beloved brother, Steve; and the birth of my amazing granddaughter, June. What has remained constant is my endless good luck in having Jane Oshinsky at my side. Her quiet strengths put my petty anxieties into perspective. Authors tend to be congenital loners; Jane is my cure.

  A Note on Sources

  Much of this book is based on archival material—most coming from places beyond Bellevue Hospital, whose older records, already scattered and poorly maintained, were further damaged by Superstorm Sandy. Fortunately, records relating to admissions and patient care, as well as casebooks, correspondence, and personal papers, are available at numerous other archives, including the Sid and Ruth Lapidus Health Sciences Library at New York University, the New-York Historical Society, the New York Academy of Medicine, the Library of Congress, the National Library of Medicine, the New York City Municipal Archives, the Harry Ransom Center, the Brooklyn College Library, the Health Services Library at Columbia University, the Chesney Archives at Johns Hopkins Medical School, and the archives of the psychiatry department at Weill Cornell Medical Center. In addition, the annual reports of the various city agencies overseeing Bellevue throughout its history are publicly available and remarkably thorough.

  Oral history plays a large role in the book. Dozens of current NYU/Bellevue staffers kindly sat down for interviews, as did former medical students, residents, and faculty. Each interviewee is listed in the acknowledgments. I also used archives of the Columbia Center for Oral History, the American Academy of Pediatrics, and the recently established Oral History Project at NYU Medical School.

  There is a vast literature on the history of medicine, public health, and hospitals in the United States. A good place to start is Charles Rosenberg, The Care of Stranger
s, written thirty years ago but still the gold standard in the field. Other essential works include Jerome Groopman, How Doctors Think; Kenneth Ludmerer, Learning to Heal; Regina Morantz-Sanchez, Sympathy and Science; Sherwin Nuland, Doctors: The Biography of Medicine; Paul Starr, The Social Transformation of American Medicine; and Rosemary Stevens, In Sickness and in Wealth. The literature for New York City is also quite vast. Sweeping histories of public health, the emergence of voluntary hospitals, and the confluence of immigration and disease are found in John Duffy’s massive two-volume History of Public Health in New York City; David Rosner, A Once Charitable Enterprise; and Alan Kraut, Silent Travelers. For an indispensable general history of New York City until 1898, nothing compares to Gotham, by Edwin Burrows and Mike Wallace.

  Certain books were especially helpful to me in providing vital insight and information about specific medical events, trends, and controversies. These include Deborah Blum, The Poisoner’s Handbook, on the birth of forensic medicine; Sheri Fink, Five Days at Memorial, on the medical consequences of Hurricane Katrina; Victoria Harden, AIDS at 30, on the changing face of America’s most feared infectious disease; Steven Johnson, The Ghost Map, on the birth of modern epidemiology; Gina Kolata, Flu, on the mysteries of the 1918–19 pandemic; Howard Markel, An Anatomy of Addiction, on the impact of cocaine on two towering medical figures, one a Bellevue surgeon; Candice Millard, Destiny of the Republic, on the link between a presidential assassination and the rise of antiseptic medicine; Jane Mottus, New York Nightingales, on the revolutionary Bellevue School of Nursing; Ira Rutkow, Bleeding Blue and Gray, on medical progress—and lack of it—during the Civil War; and Ted Steinberg, Gotham Unbound, on the interplay of ecology and public health in New York City.

  The bookshelves groan with memoirs of patients and physicians about their experiences at Bellevue. The most recent include Eric Manheimer, Twelve Patients, a poignant and perceptive account of some of the cases he treated as Bellevue’s former medical director; and Julie Holland, Weekends at Bellevue, a riveting look at the psychiatric emergency room by a physician interweaving her personal experiences with those of patients. There hasn’t been a history of Bellevue per se in sixty years, but Sandra Opdycke’s more recent No One Was Turned Away, a look at New York City medical care seen through the lens of New York Hospital and Bellevue, is a remarkably fluid and perceptive piece of writing.