Twelve Patients: Life and Death at Bellevue Hospital (26 page)

“Andreas had cirrhosis from drinking. Can I get that from my weight?” She put it straight on the table. She’d refused to call her father anything but Andreas after he hit Irene.

“Yes, it can cause cirrhosis.” I pushed back from the table.

“I don’t even sip a beer on a
quinceañera
and I could have the same thing as my alcoholic father, who broke his neck under the influence of Coke and rum in my own building.” She spoke softly and to herself more than me. A rhetorical commentary on the absurdity of life.

“Marta, you have other problems from obesity that are not trivial. I see that you have seen a specialist in breathing problems. You have severe sleep apnea. It is also associated with hypertension and heart problems.”

“My daughter Irene thought I was dying. I stop breathing for long periods at night and she rushes in to wake me up. I would snort like a horse, she told me after she waited for what seemed like fifteen minutes to her. She called me
la potrilla
, the filly. For many years at work here, I was exhausted all the time. I was going home, cooking, and going to bed earlier, but I never felt rested. One of my neighborhood doctors heard my daughter call me
potrilla
and she asked more questions about snoring and tiredness. That’s how they stumbled on the diagnosis.

“I thought it was stress, family issues, money problems, Andreas’s drunkenness—life, you know! So I have a breathing machine at home. I hook myself up at night with a plastic mask and strap. Between my mother’s equipment and my machine, our apartment resembles a car mechanic’s shop—or a Stephen King movie,” she added, smiling finally.

“Yes, Marta, that plus hypertension, high fat levels in your blood, arthritis in your knees that makes it hard for you to walk, you are on six different medications, and you see four different doctors routinely plus at least half a dozen specialists in the last couple of years, from endocrinology to pulmonary to orthopedics to a liver guy.” I let the facts hang there for a few seconds. Obesity is the new scourge—an epidemic of diseases, all interconnected, beginning in early childhood. How ironic that the disease of affluence begins early and hits the poorest classes the hardest.

“What bothers me the most of all is the page on family history.” I pulled out a sheet with some indecipherable physician scribble on a barely legible Xerox. “It says here that your daughter has diabetes. We haven’t talked about the elephant in the room, have we?” I didn’t speak this with any irony.

“You mean that I have diabetes and that I have been on different medications for diabetes and have started insulin two years ago?” she said to the table.

“No, not about you, Marta.” She looked at me.

“Your daughter, Irene, has diabetes and is on metformin. And your daughter’s son, Jaime, who is seeing Dr. Nguyen here at Bellevue, has a metabolic syndrome. Meaning his system is diabetic in all senses except the high blood sugar.” Talking about her daughter and grandson brought Marta’s gaze right into mine.

“Your family through four generations is a disaster zone of medical diseases and all of their complications.” I added, not for effect, but just to speak out loud what I was thinking: “No more than twenty feet from us, your mother is being kept barely alive, a miracle of modern technology. And from her point of view and yours, from what you just said, it’s not much of a life. You have just shown me your own reports, which say exactly where you are headed. Marta, you are a very smart woman. Let’s figure out a solution.” I didn’t want to rely on Wizard of Oz technology to treat organs in extremis.

There was a parallel track running in my head as I was reading Marta’s medical record. Were the members of this multigenerational family victims of their own irresponsible behavior, an inability to make the “right” health decisions for themselves and their kids? No one forced them into White Castle or Wendy’s. No one else loaded up baskets with high-fat salty snacks in the neighborhood bodegas or carts in C Town supermarkets.

But, I thought, that does not explain the epidemic nature of this disease. What about the trillion-dollar industry that overproduces food in gargantuan quantities and fights for every square inch of the attention of every consumer around the world? It targets young consumers using social media experts who test colors and songs and pay off sports figures and media stars to hawk their wares. There’s no gun to anyone’s head, but there is a brain trust of über-advertisers, marketers, psychologists, sociologists, anthropologists, food scientists, and brain researchers unlocking the secrets to taste and pleasure. They study brain-based neurohormonal control and the environment to create vast demands for their products. What’s the difference between this kind of addiction and the cultivated addictions to nicotine, cocaine, crystal meth, or heroin, for that matter? This is real translational research,
from the National Institutes of Health bench laboratories to the corporate marketing strategists to your neighborhood food store.

I pulled my focus back to the here and now. “Marta, first things first.” I held up the manila folder. “The health issues you have now are not going to get better on their own. No amount of wishful thinking will change the outcome. And the Virgin of Guadalupe is silent on this issue. You know that.” The corners of her mouth hinted at a smile. I didn’t play the Virgin card very often, and hope was not a plan.

“I can see from Dr. Reyes’s notes that you have been through virtually every diet and group without success.”

She nodded. Clearly she knew a lot better than I did about diets and dieting. “So what, Dr. Eric. Is there nothing to do? Did I really miss
el barco
? I need to be careful,
la vida no es un sueño
, life is not a dream”—one of her favorite expressions. It was exactly the right question to ask. I looked at Marta and thought about her mother having heart surgery to squeeze out some more earthly existence, if luck cooperated.

“Have you discussed surgery for obesity? Bariatric surgery?” I didn’t hesitate to bring up the subject any longer. After extreme skepticism about a surgical “solution” for serious obesity, I had become a convert of sorts. At least for Marta, as an individual. Surgery would do nothing to combat the epidemic of global obesity. It would take political will on the scale of the surgeon general’s report on cancer and smoking to change the rules of the game even slightly. Smoking was still the biggest single killer in our society, over four hundred thousand deaths a year. Every generation of physicians has a prototypical disease, the one that wreaks havoc with almost all the organs. Learned professors of medicine would say, “You can learn all of medicine by studying disease X.” For my father’s generation it was syphilis. For my generation it was alcoholism. For the current generation it would be obesity, hands down. It affected every organ.

“Dr. Reyes looked into it, and I simply cannot afford it. It is over fifteen thousand dollars. We barely make it from rent check to rent check. And you have to pay cash in advance.” This was the biggest-growth surgical business in this country. Hundreds of thousands of operations
were being done every year. It was surgery in a high-risk population and not something you fooled around with unless you really knew what you were doing. Fatalities from elective surgery were the stuff of the
New York Post
. No one wanted to end up between those covers.

“Look, Marta, we have a program here for weight surgery that I would like you to look at and judge for yourself. The payment is not an issue.”

She looked up in disbelief. But she quickly looked down again. “I know there are many types of surgery, and it can be dangerous. Particularly with the medical issues I have. I have to look after my family, you know.” She was right on the button and better that way. If she proceeded it would be with full knowledge aforethought.

“Okay,” I said. “Think it through. Go to the Wednesday conference open to the public; you can meet Dr. Parikh and decide for yourself. The surgical part is over my head. The reports from Reyes are in black and white. Your mother is three doors down the hall. My job is to get you to the right doctors. The rest is up to you. But you have to do something. This is not a situation where you can do nothing.”

“I will think about it,” she assured me. “I will come up with a plan.”

That was the last time I saw her before Irene’s death. I still could not believe it. Marta’s aged mother had gone home, against all odds. And now the joy of Marta’s life, her real
amor
, was gone. Thinking back on our earlier conversation, I realized how much higher the stakes were than either of us could imagine.

I, and half the hospital it seemed, went to Irene’s funeral. A cortege of vans, school buses, official cars, Dial 7 limousines, and private vehicles snaked its way down Manhattan’s spine past the Essex Street Market and over the Williamsburg Bridge. Magnificent views south onto the gentrifying warehouses and tugboats pushing their huge loads against the rapid East River current sprawled out beneath a gray sky melting into the infinity of Brooklyn. The car was silent except for the regular clicks like a railroad car from the metal braces slicing across the asphalted road. We were all lost in our own thoughts about the
senselessness of so much of what we saw every day. The carnage of wasted lives from violence, bad decisions, carelessness, drugs, alcohol created a mobile shell that we carried with us through the days and years of work. It was a semi-permeable membrane that allowed small doses of the raw pain and suffering to penetrate but effectively kept most of it out. When a senseless death occurred within the protective force field, we were all vulnerable. We were very exposed. The pain of our own immediate losses, a spouse’s life-threatening illness, a drug overdose of a beloved cousin, the jealous rage that took a life ruffled the silence with a barely suppressed scream. Irene’s death had spread a low-lying cloud of agitation and vulnerability through everyone.

We turned off in the heart of the Orthodox Jewish barrio. Storefront synagogues and matzoh bakeries, shuls, and hundreds of new red-brick apartments with metal grilles covering the windows and tiny porches were salted through the neighborhoods for the rapidly expanding community and their large families. A clot of young women gathered on the front steps surrounded by dozens of kids jumping rope and playing tag. We wound our way deep into East New York. We passed chicken wings, Pedro’s Pollo and Pollo Campero, “the best” pizza shops, mofongo Dominican takeout, Jose’s Churritos, Hamburger Heaven, Hamburger Paradise, Hamburger Joe’s, and every national chain plus an infinite assortment of tiny bodegas selling lottery tickets and baloney. Thousands of small shops eking out a precarious existence in no-man’s-land.

A huge granite Catholic church loomed into view when we turned down Myrtle Avenue. Hundreds of our colleagues and friends and relatives from the Sahagún neighborhood network were lined up around a corner slowly feeding into the building. The women wore black dresses and large floppy hats that they held on to as a gust of wind kicked up. The men were in suits of different colors with shiny black shoes. Pockets of people stood in the street, between triple-parked cars, chatting and hugging. Traffic was backed up; a couple of cop cars were pulled onto the sidewalk, and cars were diverted through the red lights. No one honked.

The ceremony helped to heal the wounds. The priest had known the family through four generations. Given the mixed nature of the
masses entering the church—Muslims in hijabs, Jews wearing yarmulkes, Methodists, Lutherans, Evangelicals and Pentecostals and even a few Catholics—Father Martí, a Cuban refugee from the 1980 Mariel boatlift, quickly took stock of the flotsam of humanity that rode the tide to the base of his pulpit.

“We are devastated by the loss of Irene Sahagún. Each and every one of us will carry this loss for our lives. It touches us and reminds us of how fragile life can be, how the flicker can go out with a tiny gust of a breeze. How do we find any meaning in this death, the loss of this young woman?” There was no answer. And he left Jesus aside for the moment. He left the question hanging in the air unanswered and allowed all of us to try to answer it from whatever view we had that might make sense of the senseless tragedy.

It took a long time for everyone to walk past the family, say two words, give a hug, and return into the sunlight. I took a gypsy cab lined with dangling crucifixes and saints back to the hospital, alone. In my hand I had the clear plastic bookmark-size reminder of Irene with her picture, the dates of her life, and her mother’s expression at the bottom, “
La vida no es un sueño.
” Life is not a dream.

What would become of them? What were their options? How could I, or any doctor, treat a medical disease that was essentially a public health catastrophe? We did not have sleuths like John Snow—the man who removed a pump handle on Broad Street in nineteenth-century London to end an epidemic of cholera. How do we put a stop to the obesity epidemic that is killing patients globally in massive numbers? Just talk to your neighborhood pediatrician. My peds colleagues were becoming internists as obesity and its medical “side effects” became ubiquitous. Obesity and its Siamese twin Type II diabetes were obvious correlates of calorie-dense foods, from Agent Orange–colored chips to the vast dead sea of colas. “Pouring rights” put sodas within the reach of every school kid and hospital patient, all in exchange for the pathetic amount of bribe money that went to school districts and municipal budgets starved for tax dollars. These predatory practices of focused advertising consciously, purposefully, put populations at risk.

For twenty years, as a young physician fresh from a big-city hospital
training ground, until middle-aged maturity and experience had saturated me with clinical and hospital-based medicine, I sat in office/exam rooms with patients and their better halves and listened and discussed weight reduction and diet changes plus exercise ad infinitum as the solution to the most common medical ailments that brought patients through clinic doors: hypertension, hypercholesterolemia, reflux esophagitis, heart disease, and strokes.