How We Do Harm (7 page)

Miss Asher’s encouragement stoked my imagination.
My family and their friends saw some potential in me and mobilized to help.

Uncle Fred, my mother’s brother, was always there with a wad of crisp cash: “Here, buy a book.”

My father worked as a janitor at the VA hospital in Dearborn and had a sideline business of running numbers, an illegal lottery, there.
Miss Farris, a white nurse at the VA, talked to me whenever she stopped by to pay off her numbers debts.
For my seventh birthday, Miss Farris gave me my first doctor kit.
It had a microscope and a stethoscope.

My father’s bookies, too, were eager to chip in.

They kept peeling off bills even after I went off to college: “Here is ten dollars.… Here is twenty dollars.”
One of the bookies gave me $100 for my eighth-grade graduation, a substantial sum in 1973.
They knew I would not blow the money on reefer.
I was a good bet.

*

HELEN
and I talk about civil rights and social justice, too.
I tell Helen about my hope that a genuine popular movement will form to make medicine accessible, driven by science, and trustworthy.
I tell her that I realize that nothing short of another civil rights movement will do.
“Everything else has been tried,” I say.

“We need another Martin,” she says.

It’s a wish.
When I hear it from people I respect, I counter that the civil rights movement was first and foremost about equality, but it was quickly focused on the most obvious rights: the right to sit wherever the hell you want on the bus and the right to vote.

“These rights are important, but the right to equality in health care is no less important, and it has been left behind,” I reply.
“This is tricky in part because it’s not as clear—and not as much about race—as the bus regulations in Montgomery.
You can hope and pray for someone like Martin.
Meanwhile, we must do what we can.”
Then I add, “As you have, Helen.”

We both know death is near, and I don’t want to miss my chance to tell Helen how great a privilege it was to watch her rise above her deadly experience with Cadillac care, to cast away anger about her losses, to triumph over cynicism and mistrust and blossom into a genuine advocate.

Chapter 4

Skepticism

WHEN THE DISEASE GATHERS
a momentum we can’t break, Helen accepts that she is dying.
One of my great privileges as a physician and as a human being comes when from her hospice bed Helen asks me to speak at her funeral.

I have it flowing good when that day comes.
I want to make my speech good for her.
I talk about all she overcame in her life, how she struggled, how she displayed good humor, how she helped other patients.
How she learned about the problem of women ignoring breast masses, sometimes for years, and that she helped us found a choir of breast-cancer survivors to communicate health messages to the black community.
How she counseled other breast cancer patients, most of whom were not as sick as she was, but who felt sorrier for themselves than she did.
How she took seriously her responsibility to teach and motivate the medical students, residents, and fellows and even the old men of the department to give the best care we can in a compassionate way.

I don’t mention how ashamed I am that medicine had used Helen.
That she received a bone marrow transplant without being told all that was known about it, and, more important, all that was unknown.
She got the transplant because she was insured and doctors could convert her suffering into cash.
Maybe her original doctor simply failed to ask the fundamental question.
Maybe he failed to be scientific.
Maybe the money helped cloud his judgment.

A funeral is not the place to discuss intellectual dishonesty, malfeasance, and conflicts of interest in medicine.

*

MY
parents met in Detroit and settled on Philadelphia Street, in the area called Black Bottom, the black part of downtown.

I was born on July 4, 1959.
In February 1960, using the GI Bill, my parents bought a “two-family flat” at 4224 Burlingame, in a West Side neighborhood then mostly inhabited by the Jews and Catholics, most of whom worked for the Ford Motor Company.

My mother quit her job as a hospital cashier to take care of my two sisters and me.
We were living on my father’s earnings as a janitor at the Veterans Administration hospital in Dearborn, his sideline of running numbers, and his moonlighting as a furniture upholsterer.
Also, we rented out the apartment upstairs to help make mortgage payments.
This was my father’s idea of security.

I remember a color television being delivered on a cold day in February 1963.
This is one of my earliest memories.
My mother was pregnant with my little sister at the time.
It’s a happy memory, an image of optimism, freshness, beginnings.
Twelve two-family flats were on our block.
We were the second black family to move in.

By moving to Burlingame, a street near the commercial hub of Dexter Avenue, my family joined the deadly cycle called Black Fright/White Flight.
Yet, race is paradoxically absent from my childhood memories.
It’s possible that it was forced out by a more fundamental concept: safety.

The whites were not stupid and not necessarily bigoted.
They were interested in their own preservation, and they fled the neighborhood because danger was real.
By the time I was five, in 1964, I knew that people stole.
I knew that people shot other people.
I knew what reefer was.
I knew that there was such a thing as heroin.
I knew that drug violence raged outside and that I was not going to get sucked into it.
It was not unusual to hear that a corpse had been found in an alley in our neighborhood.
Murder was what happened when people didn’t pay their drug debts.

My family didn’t leave the house much because we worried about burglaries, and whenever we did leave, we left the light on so the house seemed occupied.
Cars were stolen, car batteries were stolen, even schoolkids’ book bags were stolen, just for the sake of stealing.
Living in fear of violence was the only life I knew.

I would be nearly twenty, halfway through the University of Chicago, before I realized that I was no longer looking over my shoulder or preparing to drop to the ground to evade stray bullets.
(It should be noted that Hyde Park isn’t the safest place in America.
It’s surrounded by projects and guarded by what was then the third-largest police force in Illinois.)
In mid-September 1965, my mother brought me to a Catholic school called St.
Cecilia, seven blocks down the street.
The school had been in session for two weeks.
Still, Sister Lorenzo, the principal, decided to let me in.

The sisters of the Immaculate Heart of Mary, who ran the school, scared me at first.
They walked like pelicans and wore dresses that hid their shoes.
In the middle of my second year, in the spirit of the Second Ecumenical Council (Vatican II), the nuns were allowed to shorten their dresses by two inches, and we learned that they wore funny black, lace-up shoes.

It didn’t take me long to realize that they were exceptionally kind women whose purpose in life was to give kids like me the means to achieve.
My wife disagrees when I say this, but in many respects I think of nuns as the first women’s libbers.
They ran schools and hospitals when women didn’t run any other major organizations.
My respect for the nuns as authority figures influences me to this day as I see women in positions of authority that they did not have just a generation ago.

Miss Asher and I remained in contact even after she prevailed on my parents to enroll me in St.
Cecilia.
At least twice a year through sixth grade, my mother would drive me to the public school, where Miss Asher and I would spend time talking about things I could do, things I would do.
I suspect that these meetings were arranged behind the scenes, with Miss Asher extending invitations or my mother making appointments.
This was a shot of encouragement, and it was effective.

I loved Catholicism: the structure, the pageantry.
And, to the delight of the nuns, I worked my tail off.

My parents, who had not been religious, followed me into the Church.
My mother and Sister Clair Elizabeth Lemer, one of the teachers, became lifelong friends.
Sister Clair taught my mother to sew and got her a discount on a Viking sewing machine, which now belongs to my younger sister.

I didn’t like Catholic services at first, but learned to love them after I was asked to serve as an altar boy.
I worked with Father Ray Ellis, a Lebanese-American priest who would die of a heart attack in his early fifties, when I was in eighth grade.
He had the most amazing funeral I have ever seen.
Every priest in the diocese and several cardinals were in attendance.

Religion fed my ambition, temporarily causing my dreams to veer away from science.
I was obsessed with becoming a bishop.
The life of a parish priest wasn’t good enough.
Later, I saw myself as a Jesuit superior general, or at the very least a Jesuit provincial.
For me, religion wasn’t about God.
It was about playing a leadership role.

After graduating from St.
Cecilia, I was admitted to the University of Detroit Jesuit High School, an institution that has consistently been rated among the top prep schools in Michigan.

The U of D High tuition during the 1973/74 school year was $848, which placed it outside my parents’ reach.
However, Sister Clair came to the rescue.
She contacted her brother, the Jesuit provincial responsible for all the Jesuits in Michigan, Ohio, and Indiana.
The provincial, in turn, contacted a wealthy alumnus, John Kohl, a U of D High graduate from the class of 1937, who owned a building firm in Traverse City, Michigan.
Mr.
Kohl agreed to pay my tuition for four years.

My immersion into skepticism was about to begin.

Chapter 5

A Wallet Biopsy

MARTIN SCHMIDT
isn’t especially concerned about the light-headed, dizzy feeling that sneaks up on him at the office.
When you are fifty-eight and working a pressure-cooker job at an express package-delivery company, you learn to expect an off-peak day here and there.

Martin is a broad-shouldered six-footer with a full head of hair and a big, bushy mustache.
He played quarterback on his high school football team back in Spartanburg, South Carolina.
He married his high school girlfriend, got an associate’s degree in business, and moved to Atlanta.
Like most people, he grew accustomed to being in robust health, being in control of his life.

Now, weakness starts to descend slowly, like fog.
Then, like fog, it lifts.
Over the next three days, it returns regularly in waves, at home, at the office.
It has logic of its own, lingering longer and longer.
Martin starts to fear passing out.
Eventually, he does, fading away while starting to dial the number of a difficult client.
A coworker finds Martin slumped over his desk, his sleek, black phone emitting frequent, sharp bursts of a siren.

Martin doesn’t remember being loaded in an ambulance.
He comes to just as the crew wheels him into the emergency room of Piedmont Hospital.
Piedmont is one of the more established old hospitals in Atlanta, a place where wealthy and insured people go.
By the time the ambulance arrives, Martin is awake and communicating with the EMTs.

The patient’s blood pressure is low: 90/50.
Listening through a stethoscope, the doctors note that his heart is galloping, 120 beats per minute.
Even as Martin’s heart pumps harder to keep him alive, the blood is not reaching distant destinations.
Extremity pulses are weak.
The doctors note a lack of color in Martin’s skin.

However, the electrocardiogram, the test that checks the electrical activity of the heart, is normal, except for the heart rate.
The lungs are clear, respiratory rate normal, the abdomen soft.
When you get a patient like this, you want to rule out the most obvious explanation: heart attack.
In this case, there is no evidence of damage to the heart, no sign that a heart attack is in progress.

Martin’s blood studies tell more of the story.
The hematocrit is low—26 percent.
This is a measure of red blood cells in the blood.
In an adult male, you expect to see a hematocrit of 42 percent or above.
Hemoglobin—a measure of iron-carrying protein in the cells—is similarly low, 8.1 grams per deciliter.
Generally, in a healthy adult male, you expect to see 14 g/dl, give or take.

Another blood measurement, the mean corpuscular volume—abbreviated as MCV—points to shrinkage in the average size of his blood cells.
You hope to see an MCV of 87 microns.
In Martin’s case, the blood cells have shriveled to 72.
This reading suggests microcytosis, iron deficiency.

Martin has a microcytic anemia, an inadequate amount of blood.
Somewhere in his body, he is bleeding.
The doctors perform a series of transfusions of packed red blood cells.
The objective is to buy time to find the bleed and stop it.

Once myocardial infarction is ruled out, the most common place to lose blood is the gastrointestinal tract.
A rectal exam is performed, and a stool sample has the characteristic look of black tar with the classic smell of blood.
A smear is placed on a guaiac card (A guaicac is a test of stool looking for blood that might indicate colonic polyps or colon cancer.), and developer solution is added.
The paper turns dark blue, indicating the presence of a massive amount of blood.

Martin’s gurney is wheeled out to radiology, and he is placed into the oversize, white spinning circle of a computed-tomography scanner.
The CT maps out his abdomen in a multitude of image slices.
Fortunately, there are no lesions in the liver, but there appears to be a mass in the transverse colon.

By now, thanks to transfusion, Martin’s skin has regained more or less its usual color.
Tests confirm that the immediate crisis has been managed and there is time to take a detailed look.
He is given powerful laxatives in preparation for a colonoscopy.
Martin is under sedation, but is vaguely conscious as the doctor slides a scope into his rectum, through the sigmoid colon, past the splenic flexure, to wind through the colon and reach the lesion in the beginning of the transverse colon.