So Why Did I Become a Doctor?
THREE DAYS AFTER sixty-second birthday, I fly to Stavanger, Norway, to attend an international psychiatric conference, after which I travel with my hosts, Dr. Gerd-Ragna Bloch Thorsen—organizer of the conference and director of the local psychiatric hospital—and her husband Olav, a general practitioner, into regions of Norway that can be reached only by foot.
For several days, along with two other couples, friends of Gerd-Ragna and Olav, we make our way into the Ryfylke mountains, north of the Lysefjord, into a part of the world that is, I write in my journal, “outrageously beautiful—the most extraordinary landscape I have ever seen: every few meters, a new vista, new and remarkable beauty. Fog and sun—mystery and radiance—!” Although it is now the second week of June, the weather is cool, and we hike through mist and drizzle much of the time, up and down hills of rain-slick, moss-covered rock, through muddy streambeds, across open fields, along forest trails bordered by shrubs and trees of astonishing diversity, and through narrow gorges and valleys that open suddenly onto sunlit, golden meadows, or give rise to steep, cave-pocked mountains. By the time we stop for lunch on the first day, take off our backpacks, and eat—we sit on boulders that form a half-moon around a waterfall—I am, through four layers of clothing, drenched through with sweat.
We take shelter for the night in an unelectrified cabin, fish in a nearby lake, watch wandering sheep graze in the distance, talk, read, and play cards by candlelight. Although we bring artifacts of civilization with us—cameras, watches, books, matches, canned food—the workaday world seems far away, and it feels wonderful to be bone-weary from the day’s journey, to have sweat dry and cool on my body, to sit by candlelight, eating and sipping wine, laughing and exchanging stories.
I had visited with Gerd-Ragna and Olav two summers before, in June of 1998, when I was a guest speaker during Stavanger’s annual psychiatric conference (called, refreshingly, banners heralding the event strung across the city’s central square, “Schizophrenia Days”), at a time, eight months before surgery, when I had had no intimation that my heart’s arteries were closing down. Gerd-Ragna now teases me about my “condition”—she claims we have gone at an uncharacteristically sluggish pace all day in deference to it—and when my companions inquire, I find myself telling them the story of what happened, then listening to them talk about illnesses and accidents they’ve survived.
We also trade stories about places we’ve traveled to in other years, and when I talk about my time in Alaska, what I recall first of all is the openness of the landscape—the absence of people and habitations in a place where slightly more than six hundred thousand people, most of whom dwell in and around the city of Anchorage, live in a territory more than double the size of Texas.
I describe flying in a single-engine plane north of the Arctic Circle, of circling in dense cloud for nearly an hour, then emerging to see a gorgeous expanse of land and water appear below: wide horizons and endless vistas—ocean, forests, inlets, streams, and fields that seem, in their sudden stillness and beauty, preternaturally pure and serene.
How, I recall wondering at the time, could a world that appears so lovely and peaceful contain any menace, any danger? And how, having had my life returned to me, could I ever be unhappy again—how ever again take even the meanest detail of life for granted? In that moment—I touch my chest with the palm of my hand, feel my heartbeat, feel heat rise through my clothing—the landscape below seemed to correspond to a landscape within: to a sense that within me vast expanses of wondrous territory were being born.
In the semidarkness of a cabin far from home, remembering and talking about this moment, ordinary things—eating, talking, laughing; a spoon, the reflection of candlelight on a window, the palm of my hand—seem extraordinary. I see myself in Alaska—in Kotzebue, at midnight—leaving my hotel and walking along the beach. The sky is a pale, clear blue, nearly white at the distant horizon, and I cannot tell where water ends and sky begins. The sun is out as if at midday, and on the Arctic Ocean young people are swimming and water-skiing. Saved from darkness for a while, a month past the summer solstice, the world lies all before me, suffused in mystery and wonder, alive with possibility.
I sit and look out to sea, and think about how, only five months before, I was deep in anesthetic sleep, my heart—this three-quarter pound oblong of flesh—disconnected, drained, and worked on by human beings who mended it and then returned it to me. It is the fact that people actually held my heart in their hands—that it was physically touched, and that, in a prolonged moment, tenderness and technology joined to save my life—that now astonishes, and humbles.
Imagining my heart, like the tiniest of infants, being cupped in skilled hands, and wondering about the unknown ways this literal laying on of hands has wrought changes in me, I find myself feeling grateful for having survived—of course—but more grateful for having been ill: for having had heart disease, for having had my chest opened, for having been operated on. This, I think, is my true and great good fortune, for had my arteries not been severely occluded, and had my heart not been repaired, I might never have known how dear I was to my children and friends, and how lucky I was, in a life as precious as it is fragile, to know them.
When I return and talk with Jerry about what I’ve been thinking and feeling, he responds by telling me about his travels, and about how they proved crucial in his career.
“Going to Nigeria, and living there for two years,” Jerry says, “was the defining event of my life. I was one year past medical school, early on in my internship, and I was sort of groping around, actually thinking for a while of going into psychiatry.
“This was 1964, and I knew I didn’t want to go to Vietnam. So I enlisted in the Public Health Service as a Peace Corps doctor. It was an option that closed down a few years later, but at that time it enabled you to do your national service without being in the military. And I was very lucky, you see, because what happened was that I experienced a series of revelations about what another culture and society are, and that led to a new understanding of disease.”
Jerry and I are sitting in my living room on the West Side of Manhattan, an hour or so after he has given a lecture at Roosevelt-St. Luke’s Hospital on the importance of adherence in the treatment of AIDS. The concept of “pharmacological forgiveness” (normally, if a patient takes 80 percent of a prescribed medication, there are few problems) does not apply to AIDS, Jerry explains. When it comes to AIDS, if you have 80 percent adherence you only get, at best, 50 percent suppression of viral replication. (This happens because in the presence of partially suppressive therapy, viral replication will select for viral variants with resistant mutations.) To have a good outcome, one needs at least 95 percent adherence—perfect or near-perfect adherence for the duration of the patient’s life, and in this AIDS is unique, Jerry says, since no other infectious disease requires lifelong therapy.
He talks about the importance to adherence—and, thus, to survival—of the doctor-patient alliance. He cites studies, including several of his own, that document the most significant variable in the initiation of therapy, and the single, most important element in the doctor-patient alliance: trust in the doctor. He reviews ways of overcoming patient resistance and mistrust, and goes over protocols and design interventions that encourage adherence. The key is simplification—reducing pills and doses as much as possible. “It is naive and unrealistic,” he says, “to expect that most patients can adhere to complex antiretroviral regimens, perhaps for life, without thoughtful, practical, and continuing support.”
Most clinicians, alas, receive little training in assessment and support of adherence, but studies make clear that they, and their patients, benefit when they do, and when responsibility is shared. “The wonderful biomedical advances that have become available for the treatment of AIDS must be accompanied by parallel behavioral practices,” Jerry tells his audience. “This is why the patient-provider relationship is very precious, and why we should be proud of it, and honor it, and not neglect it.”
“Most of the time when we live in another place, we’re tourists,” Jerry says. “We’re there for a little while, and then we move on, and we don’t get to really understand much of the culture. By the end of my first year in Nigeria, though, I began to appreciate enough about both the culture and the society for things that had not made sense to me to begin to make sense.”
My sublet is on the first floor, street-side, of a building on West 54th Street. Jerry sits in an easy chair in front of the window, and while he talks I watch men and women, policemen and policewomen, moving about in front of the station house across the street—the 18th precinct—coming and going to and from the precinct and the nineteenth-century courthouse—in former times, Men’s Night Court—next to it.
“What am I doing here? I asked myself,” Jerry says, “and the answer was, I’m here as an agent for change. But then I thought: Who am I to be here to change this culture? There’s a certain arrogance in thinking that way—part of an old colonial mindset.
“Well, I said to myself, I brought Western medicine, and we could argue that perhaps medicine, of all things, is an intervention that, though it changes the culture, still provides a definable good.” Jerry stops. “But okay—let me give you an example of what happened there—of how and why things changed for me.
“I wondered why it was that the Nigerian children had a higher infant mortality rate than we do, and part of the reason, I saw, was that they were exposed to multiple diseases at the same time during their first year of life, whereas our kids are protected by being separated from one another. We raise them in our own little nuclear environments, and only at a later point do they go on to nursery school and kindergarten. Then they start getting diseases, but one at a time—and they’re already much stronger and able to handle them.
“But in Nigeria, the children would be together from six months of age on—as soon as weaning ended, the older siblings would take care of the younger kids and you would see these bands of kids who’d range in age from one year to about six or seven, and they’d all be together. And Nigerian kids have little in the way of toys or dolls or playthings. They have a stick or a hoop and they play with each other, not with objects.
“So a lot of kids would be sick with a lot of different things at the same time. In order to change the impact of multiple infectious diseases that result in higher mortality, then—and forget about vaccinations for a second—you have to change the tribal practices and separate the kids, but if you separate the kids, you change the way they learn to relate to one another, which is part of the genius of the culture.
“And I said ‘Oh my God, look at that—we don’t know how to organize our lives like this. It’s different, and it has an effect on childhood diseases, and if you want to improve childhood mortality, in a sense you have to change childhood development, and do I really want to do this?’
“I mean, sure—kids shouldn’t die. But on the other hand, there are certain things about this culture that are vibrant and beautiful and have to do with interpersonal and interfamilial kinds of things that we don’t have, and that I think we suffer from not having. Now, on any scale of things it’s better to prevent childhood mortality—of course—but on the other hand you have to appreciate that some of the technique for doing this is going to change the society at a fundamental child-rearing level. So this is what began to dawn on me near the end of my first year there.
“I’ll give you another example,” Jerry says, and he proceeds to tell me the story of the first medical article he wrote, about a disease called schistosomiasis.
“Many of the Peace Corps volunteers were high school biology teachers, and we organized a program and taught them to recognize schisto in the urine.* The host for schistosomiasis—it’s also called bilharziasis—is a snail called bulinus that comes from East Africa and is endemic to the Nile.
“But they didn’t consider it a disease. The Yoruba word for it is itosi aja, which means ‘dog’s gonorrhea,’ and they saw it as a kind of coming-of-age—the equivalent of menarche in girls. And this raises a very interesting question: If a pathologic entity occurs in a hundred percent of people, is it a disease?
“Now the natural history of schisto is that it goes away in time because your body creates an immune response to it. You’d see the rates rising in schoolboys up to the age of about twelve to fourteen, and then they’d go down. And the rates in girls were close to zero, and I said, How could this be? What’s going on?
“So I sat on the banks of the rivers there and watched how the rivers were used, and this is what I learned. In the morning, before the sun would be fully out, the river was used by the mothers and their infants. The mothers would wash the clothes, and the babies would splash around in the water.
“At noon, when the sun was at its highest, the kids on their lunch break from school would play in the river. It would be the boys mostly, and not the girls, because they were a little modest and didn’t have bathing suits and wouldn’t go naked into the river. But the boys went in their underpants. And in the evening, the older men would come back from the fields and use the river, and wash themselves and then go home.
“Now the biology of schistosomiasis is that it has a complicated life cycle whereby the snails are the intermediate host. You pee or drop a load and it gets into the snail and then it grows in the snail and emerges into infection of the person—it’s spread by contact with skin in infected water, and God, or nature, seems to have provided for the snail to come out according to the availability of sunlight, so the middle of the day was when the cycle for transmission was best set up: the sun was out, the snails were out, the boys were out peeing and swimming in the water, and bingo!
“So that explained why the rates were higher in boys of that age and it was kind of a revelation—like ‘Boing! Now look at that—it has to do with how the stream is used, and is a combination of biology and behavior,’ and this made me appreciate that disease is not just about biology, but a combination of many forces that combine to result in disease etiology.”
Jerry talks about having become enamoured of the richness of the spiritual world that was part of life in Nigeria, and about the complexity of their religious beliefs and practices.
“Yoruba have about four hundred deities,” he says, “and they exist for every kind of life experience, and are involved in different forms of worship—different costumes, different music, different sculptures, different in everything that relates to each particular deity.
“So there was this enormous array and richness of religious practice that, although it contained within it a vague concept of a supreme deity called Oduduwa, was essentially animistic. And this meant that everything you touched was alive, and had a spiritual life, and was connected.
“So they had that, but they didn’t have penicillin. And we have penicillin but we’ve lost that to some degree, and what I thought was that in an ideal world you’d want both. There are always tradeoffs. In order to have penicillin, I reasoned, we in some ways gave up some of our spiritual heritage. Now I’m a penicillin doctor and I’m surely not abandoning that. But what happened during my time there was that being in another culture took from me the belief in perfectability and progress I’d been schooled in as a twentieth-century American because it made it clear that progress always comes with a price.
“Then, my two years up, I returned to the States, and looking back, what politicized me when I got back here, I think, was living in the midst of the material wealth of our society after having lived in an environment poor in material resources but rich in other ways, and observing—feeling!—the maldistribution of wealth in our own country more so than at any other time of my life.
“Now my parents were socialists, and I used to go to these socialist summer camps, but nothing prepared me for the way things struck me on my return, and how, within our own society—and forget the disparities between rich and poor nations— but how there was such an enormous maldistribution right here at home, in access to health care especially, and what I decided was that if I were to be poor, it would be better to be a poor Nigerian than a poor American. Because in their culture if you were poor, although you’d rather be rich, you weren’t devalued for being poor. Whereas in our society, if you’re poor you’re a nonperson.
“I had been a very honored man in Nigeria, and when I came back I lived on the Lower East Side, in an apartment as big as this rug”—he points to a ten-by-twelve-foot Persian rug on the floor—“for thirty-five dollars a month, and I went back to the grind of being a resident—to being on every other night—where I was low man on the totem pole.
“But I was determined to finish my training, and my intention was to prepare myself to go back to the developing world. I wanted to train in infectious diseases and public health, but at the time there was no opportunity to do this in New York, where there was only one school of public health, at Columbia, but it was separate from the medical school, and I had begun to have this vision of merging the two.
“I made inquiries, and I found out that there was a new program in Boston where you could train in infectious diseases while also getting a master’s in public pealth at Harvard. So I went to Boston.”
Jerry sighs. “I never really made it back to the developing world—though I still have hopes of doing so—because this was a period when we were at the beginning of community medicine, and after I arrived in Boston, I started getting involved with neighborhood health centers and clinics. I worked in Roxbury, with poor blacks and their families, and also with the Black Panthers. Did you know that?”
I say that he told me this before, but that he hadn’t given me a lot of details. He closes his eyes as if to see again the world he knew three decades ago, and when he does, I see the young man I knew nearly fifty years ago.
How can it be, I wonder, that this guy I used to go to parties and basketball games with (Jerry was official timekeeper for our high school games), whom I hung out with on Flatbush Avenue, rode the trolley car and subway with, went to classes with, and played ball with all through high school and college—with whom I’ve spent hundreds of hours talking about sports and politics, about girlfriends and wives, about our friends, our children, our work, our hopes and dreams and hard times—has become this remarkable doctor: a man who fairly breathes optimism into the air around him, and a man who, during the epidemic outbreak of AIDS in the mid-eighties, was attending the funerals of dozens of patients every month in a time when not one of the hundreds of patients he treated recovered.
In 1982, early in the AIDS epidemic, Jerry alerted the Centers for Disease Control to the fact that AIDS could be transmitted hetero-sexually—that the sexual partners of heterosexuals with AIDS were in danger of contracting it.*
“We had a few male patients who had female partners,” he recalls. “The female partners were not drug users, so if they were at risk it was through sexual transmission, and I had one of the partners in clinic, and I started to examine her. I put my hands on her neck, and I felt these huge lymph nodes and I thought to myself, ‘Oh shit, she’s got it—it’s the end of the world.’ That was the way it came to me. I mean, there are a limited number of gay men in the world, I reasoned, but many many more heterosexuals.
“Did you ever see Wild Strawberries?’ Jerry asks. “Well, there’s a scene in the movie where the old doctor’s walking in a town, and there’s a clock that doesn’t have any hands on it—typical Bergman—and there’s a hearse that drives off and a coffin falls from it. It was very disturbing—and I had a dream that was similar. I was walking on Jerome Avenue in the Bronx, near Montefiore, and this train is going by overhead, and the green grocer stalls are all out, and there are lots of cars and trucks—but there are no people. They’ve all died from AIDS.”
Jerry was also the doctor whose research team, at Montefiore, made the discovery that HIV was not transmitted by casual and close interpersonal contact, and that therefore health-care workers tending AIDS patients were at little or no risk, not even from the accidental needle pricks that had been causing terror on the wards.* “The transmission of HIV,” he concluded in the second of two articles he published in the New England Journal of Medicine in 1986 and 1987, “occurs only through blood, sexual activity, and perinatal events.” Moreover, “the available data indicate that HIV transmission is not highly efficient in a single or few exposures,” so that “the widespread dissemination of HIV is more likely the result of multiple, repeated exposures over time by routes of transmission that are strongly related to personal and cultural patterns of behavior—particularly, sexual activity and drugs.”
What pleased Jerry most about these discoveries was their potential to reduce the epidemic of fear that had followed upon the epidemic itself. In this instance, as in others, his boundless optimism was matched by his clear-eyed realism. The fear of catching AIDS from someone at home, at school, in an office, swimming pool, or any other public place turned out to be unfounded; those who had contracted AIDS, therefore, did not have to be ostracized or quarantined.
“Although we are confronted by a public health problem of potentially catastrophic dimensions,” he wrote at the time, “it is essential to appreciate that unwarranted fears of HIV transmission have compounded the suffering of young men, women, and children infected with HIV and have blunted an appropriate societal response aimed at reduction of transmission.”*
Just as, for Jerry, the patient is always more than his or her illness, so each medical student he works with is always more than the sum of his or her clinical experience and expertise.*
After a patient with AIDS died one day, I was with Jerry when he took the young resident who had been the patient’s doctor aside, and reviewed the case with her. “You worked very hard for her,” he said, simply and quietly. “Thank you.”
Later that day, he invited a young Chinese medical student, Karen Xiaoda, to talk with him privately. She was a brilliant student, he told me, and he had noticed that she was somewhat distracted and tired. When they met in a room used for AIDS patients to visit with their guests, and Jerry asked her how she was doing—he was concerned, he said, because she seemed unusually exhausted—she told him that yes, she was somewhat overwhelmed: her father had died during the past year, and now her mother, who was fifty years old, had breast cancer, and was in the Intensive Care Unit at a New York City hospital. As she talked with Jerry, she began crying, and Jerry put his hand on her arm (even before his discovery about the finite ways in which AIDS could be transmitted, Jerry had always been hands-on with patients and colleagues), and said, “You should be with your mother.”
Karen protested, citing her studies, her work in the hospital. Jerry listened, then asked a simple question: “Where would you like to be now?”
“With my mother in the ICU,” Karen said.
“Then go there,” Jerry said, and told her she could make up the work some other time, that she should think only about being with her mother and shouldn’t worry about anything else.*
On the drive back to Guilford that evening, Jerry told me that Karen’s situation reminded him of what happened when he was in his fourth year of medical school and his father was on a respirator, alone and dying.
“I received the news of his death a half-hour before my final med school exam,” Jerry said, “and I bombed it. But I didn’t tell anybody about my father.” He laughs. “What—me have feelings? Me talk about my emotions with somebody? Me not show up on time—me not be responsible?
“The dean asked me to come in and talk with him. It was my only poor showing in four years, he said. What happened? So I told him about my father, and he said I should have told him about it—should have let him know I was under so much pressure.”
When Jerry walks into a hospital room to visit a patient, or when a patient enters his examining room at the clinic, I am struck each time by the slight, subtle shift in his demeanor—by how, starting with the patient’s hair, forehead, and eyes, his gaze moves slowly and carefully over the patient, as if, invisibly, to touch the patient with his eyes and, I assume, to take in all kinds of things—changes, symptoms, curious or troubling details, warning signs—even while he is engaging the patient, warmly and attentively, in conversation.
I sometimes think of him, and I tell this to the other guys, as being a kind of Brooklyn-born Jewish American Albert Schweitzer. He is a scrupulous and innovative researcher, a fine writer, a patient administrator (the part of his work he likes least), a gifted clinician and diagnostician, and a charismatic teacher who never pulls rank, and whose authority derives from his gentle, unaffected presence, and from his expertise.
He has dedicated his adult life to those in need of his medical knowledge and skills—men and women who often have been stigmatized and abandoned by others—and he does so without sentimentality. (“You are going to see the bottom of the bottom of the human barrel,” he said to me on our way to his clinic the first time I spent an afternoon with him there.) But unlike Schweitzer (or, in our time, a man like Paul Farmer), he has done so without going into exile from the world in which he had grown up, come of age, and had been living.
Jerry is also my friend of many years, and in knowing him, and writing about him, as of my other friends, I remind myself not to try to separate who he is as a doctor from who he is as Jerry, for if I do, I sense, I will err in the same way a doctor errs when he or she separates the disease a patient has from the person in whom the disease has made its home.
Jerry lived in Boston from 1968 to 1981, where, at Harvard, he completed his training in internal medicine, after which he did a year of infectious disease training while also taking courses at the Harvard School of Public Health. He worked in Roxbury as a primary-care doctor, developed several community programs and neighborhood health centers, and was involved with the Medical Committee for Human Rights there, which was, Jerry says, “a kind of radical progressive health organization.”* He did this while retaining his affiliation with Beth Israel (Harvard Medical School), where he continued to teach in infectious diseases.
“The Black Panther Party wanted to develop a health center and asked me and another doctor—an African American opthalmologist—if we would help them,” Jerry says. “We did, and I never felt any sense of discomfort in working with them. They were wonderful young people, and we developed a program with them, rented a trailer, and the Panthers put the trailer next to a housing project on land that had been cleared for 1–95. It was their political statement: that this was how land should be used—for health care, and not for highways to take people to the suburbs.
“So we set up this clinic on abandoned land, and we’d sit there in the evening and a bunch of the young Panthers would come and take a cable out and plug it into one of the lampposts, and that was how we got our electricity. Every evening we’d see twenty or so patients from the neighboring projects, and we developed a program for blood pressure screening, tuberculosis screening, and sickle cell screening.
“I taught the Panthers how to take blood pressure and do the skin testing for TB, and they would go out into the community and knock on doors and do the work. It was wonderful, and I loved it. They lived in a house donated to them by a Jewish doctor who had practiced in Roxbury and retired to Florida, and we’d go into the house, and it was sandbagged, and the windows were blocked off, and there were weapons around, and it was pretty scary.” Jerry shakes his head in disbelief. “But I did it! Sometimes when one of the Panthers was arrested, they’d call me and I’d go to the police station to make sure the person wasn’t beaten up. I’d be introduced as ‘Dr. Friedland from Harvard Medical School,’ and the cops would look at me like—‘What are you—nuts??
“Gail was in terror too, and sure, I knew I was being used, yet I never felt in danger from the Panthers or the police. The police were smart, you see, and they’d drive past the clinic at night, but leave it alone. Still, it was strange, going back and forth—all you had to do was cross Columbus Avenue and you were in a different world. I mean, here you had what was probably the premier biomedical research institution in the world sitting right next to truly abject poverty.”
It is late afternoon in the second week of August 2000—nearly two months after my return from Norway—and Jerry and I are in his administrative office at Yale. The office is long and narrow, filled to overflowing with books, articles, journals, and photos. His desk is piled high with folders, as are several tables. There are framed photos of Gail and their children and, on the walls, posters from international AIDS conferences. I remark on a new, large framed picture facing his desk: a poster of the U.S. postage stamp honoring Jackie Robinson—Jackie sliding into home plate—and Jerry says, “He remains one of my only heroes.” There is a framed New Yorker cover that depicts a paradisal New York—turbaned taxi drivers waving happily to each other, “WELCOME BACK DODGERS” on a banner strung across the middle of the street—and near to Jerry’s desk, a framed hand-lettered passage from Albert Camus’ The Plague:
… so that he should not be one of those who hold their peace but should bear witness in favor of those plague-stricken people; so that some memorial of the injustice and outrage done there might endure; and to state quite simply what we learn in time of pestilence: that there are more things to admire in men than to despise.
Nonetheless, he knew that the tale he had to tell could not be one of a final victory. It could be only the record of what had had to be done, and what assuredly would have to be done again in the never ending fight against terror and its relentless onslaughts, despite their personal afflictions, by all who, while unable to be saints but refusing to bow down to pestilences, strive their utmost to be healers.
Jerry, who has returned a few weeks before from an international AIDS conference in Durban, South Africa, talks with me about how inspiring the conference was, especially the moment when Nelson Mandela appeared, and thousands of people burst into cheers, South Africans dancing and singing, “Nelson Mandela! Ga go no yo a swana na ye…” (“There is no one like him…He brought us our freedom.”)
Jerry has written an account of the conference for AIDS Clinical Care, and has titled his essay “Breaking the Silence.”* He shows me the manuscript, which he has prefaced with an African proverb: “The best time to plant a tree is twenty years ago. The second best time is now.”
The great significance of the conference, and the international attention it received, we agree, is that the world can never again claim to be unaware of the horrific extent of the AIDS epidemic in the developing world. “We know how to prevent HIV transmission, yet the pandemic continues to grow unchecked in most of the world,” Jerry writes. “Surely, lack of information can no longer be blamed for the worldwide shroud of silence regarding the pandemic’s magnitude.”
Attending the conference, he tells me, has also confirmed his decision to return to South Africa during his sabbatical a year hence.
In 1975, Jerry took a leave of absence from Harvard. “I liked being both in the Harvard medical school environment and in the black community,” Jerry says, “and I felt fortunate, and was able to lead this life for a while, but it took its toll, and I burned out. So in 1975, I took a leave of absence, and Gail and I wound up going to Israel.”
Jerry found out about a man from the Harvard School of Public Health, Asher Siegel, who was helping to develop a new medical school in Beer Sheave that would attempt to integrate public health, clinical medicine, and basic science. Jerry and Gail left for Israel with a single suitcase—they had never been there before—and they lived in Beer Sheva, where Jerry was visiting professor at Ben Gurion University of the Negev, and where he taught infectious disease, which was not a recognized specialty in Israel at the time. It was a wonderful place, Jerry says (one of the wonderful things about Jerry is how frequently he uses the word wonderful)—innovative, chaotic, and with a pioneering spirit. He developed a curriculum for the treatment of tuberculosis that integrated clinical care and public health, and he found the experience enormously gratifying.
After his return to the States, he continued teaching and doing clinical work at Harvard and in Roxbury, becoming, among other things, coordinator of clinical training for infectious disease at Beth Israel, Children’s Hospital, the Sidney Farber Cancer Institute, and Harvard Medical School. The Black Panther Party gradually disintegrated, and in 1981, when a new chief of medicine came to Harvard and brought his own infectious disease people with him, Jerry decided to leave.
“Life is not a controlled experiment,” Jerry says. “There’s no way of proving whether you went in the right or wrong direction. It was a very hard move—traumatic for us personally. We’d been in Boston for thirteen years, and had close friends there, and we were integrated into both the medical and political community. We also had three children by then—our first two, as you know, Elisabeth and David, were adopted from Colombia, and then we had Sarah—and they were one, two, and three years old. But we decided to start all over again in New York.
“It seemed like an appropriate job for me, at Montefiore, and at Einstein—being involved with infectious disease and the training of doctors—and the first month I attended there, there were three patients who had this rare new thing called Pneumocystis carinii pneumonia that I had never seen before. Now, I’d been in Africa and the Middle East—there were lots of infectious diseases in Israel—and at Bellevue, and here and there and everywhere. And somehow I knew from the very beginning that this was something new and different and bad, and that it was going to be very big.”
Jerry talks about how, sad to say, he was the right person in the right place at the right time: everything in his life, personally and professionally, had prepared him for the work that would consume him from this point on—he was an infectious disease doctor, he had trained in public health, he had been overseas, he had worked with poor people, he had thought for many years about ways in which biology was bound up with behavior and social forces.
“I like to use the analogy of the seed and the wind,” he says, “with the seed being HIV, and the wind being what’s changed in terms of social, economic, and personal conditions that have resulted in the conversion of what was probably a local pathogen into a worldwide pandemic. Because if you look at all the routes of transmission of HIV that we understand—blood-borne, sexual, and birth—the thing that has changed and has resulted in the enormous spread of HIV are largely events of the last twenty-five to forty years of human history.
“The most obvious one is the acceleration of international travel and the ability of people, and hence pathogens—like seeds—to travel from one place to another. Did you know, for example, that HIV was introduced in Japan through American-made Factor VIII, which is used for hemophiliacs? Even precious body fluids like blood and blood products travel all over the world now, whereas in the old days it was very local. If you had an uncle in the hospital who needed a transfusion, you called the family, and everybody came in and donated blood.
“And then there was what I can only call a diabolical alignment of forces that occurred just before HIV entered into the population of people who were injecting drugs.”
Jerry describes how a series of public health measures designed to reduce heroin use by making needles and syringes less readily available—paraphernalia laws that resulted in imprisonment if one was caught with needles and syringes—led to the sharing of needles, and to the development of “shooting galleries,” where you paid a dollar or two for a needle and syringe, injected the drug, and returned the paraphernalia, which was used by the next person, and then the next person.
But such sequential anonymous needle sharing was only one of the elements that led to the explosive spread of HIV, and Jerry lists others, among them the bathhouses used by gay men, the rise in anonymous sex that accompanied sexual liberation, and the detribalization and urbanization in developing nations following World War II that broke down traditional structures, and that resulted in social disruption—large populations of men, separate from women, migrating, becoming concentrated in urban areas, and contracting and transmitting disease.
Jerry says again what he has said before: “You can look at every route of transmission and you will see that what explains the transmission of each route has something to do with how we live as human beings more than it does with the biology of the organism.”
It is this understanding of disease that informs the way Jerry has approached his work as an AIDS doctor for the past two decades.* Like my other friends, however, he did not start out intending to become a doctor. At Columbia, he had been an undergraduate history and sociology major, and when he graduated in 1959, he entered Columbia’s graduate program in sociology.
“Somehow or other, I thought of sociology as being social activism— as something that would change society, which is what I wanted to do,” he says. “I spent some time at the Institute for Social Research, with Paul Lazarsfeld and others, and I quickly learned what sociology was, at least the way it was practiced there, and it was mostly statistical—market research and opinion polls and stuff like that, and I knew pretty soon that this wasn’t what I wanted.
“In truth, I was quite a confused and unhappy young man then. But I kept asking myself, ‘What can I do personally?’ So I spoke with some people and came to believe that I could be the kind of sociologist I’d wanted to be, on a one-to-one basis, if I were to become a doctor. And I guess that in some sense this is what my career in medicine has been—that medicine has allowed me to be the person I am. So I chose to go to medical school both as a personal decision, but also as a choice that meant being involved in social activism. I’m not the kind of person who would lead a political movement, especially one that was without a personal basis, so that from the first there was never any question but that I would care for people, and in so doing exercise my politics through medicine.”
Jerry talks with passion about the global politics of AIDS. He is outraged by the greed of drug companies, and by the restrictive policies of our own government and other Western nations regarding the dissemination of drugs, and he has his own ideas about what might be done, on an international level, to address the enormous needs of those suffering from AIDS in the developing world. He has begun writing and speaking about this, believing that while he is doing the work on an individual and personal basis, he should also be trying to figure out ways of affecting the larger forces that affect health care.
“So I guess I’m trying to figure out ways of influencing the larger systems—where power resides. I mean, think of it this way: what does a Jewish doctor who is white and whose parents lived through the Holocaust feel is our ethical responsibility to forty million people dying in Africa? And how do we begin to address that, politically, in the midst of our affluence? Now, I’ll let the politicians figure out the strategies, but I can give them some medical advice, and this is what I’ve begun to try to do.”
After Jerry dropped out of the graduate sociology program at Columbia, he enrolled in Columbia’s School of General Studies, and, while living at home in Brooklyn with his parents, took the pre-med courses he had never taken as an undergraduate. He was accepted into the New York University School of Medicine (Bellevue) and began his studies in the fall of 1960, at the same time that Phil and Rich, who had begun medical school there the year before, were starting on their second year.
Jerry shakes his head, as if bewildered to be looking back so many years. “Oh I was a very confused young man!” he says again, laughing. “So why did I become a doctor?” he asks. “It’s a good question, and I really don’t know the answer. But okay, we had this doctor in our family, Sidney Feldman, and he was our family doctor. He was a wonderful man, and he was a role model in our family of a gentle, caring person. He loved music—classical music…
“Yes.” Jerry pauses. “Yes,” he says again, to himself, and then: “I remember that he once told me that on his way to the hospital every day he used to drive down a certain street in Brooklyn because there was a beautiful maple tree on that street that was spectacular, and that it gave him great pleasure to drive down that street and look at it. So this man was not just a doctor, but he had a sense of beauty, and I was very taken by that. He was a special person in our family.
“Our family started out on the Lower East Side.* My father was very smart, and went to Cooper Union for a year, but he dropped out, and the story we heard was that he dropped out because he had to support the family. But in retrospect, I wonder. Because I know my father was severely depressed, and was hospitalized at Hillside Hospital—but not in Queens where it was when your brother Robert was first hospitalized.
“The original Hillside is in Hastings, at the top of a place called Hillside Park, and my father was hospitalized there for a year, a ten-minute walk from where Gail and I wound up living, in fact, when I was at Montefiore. It was a family secret we don’t know much about. Then, after he came out of the hospital, he became a window cleaner, and he worked as a window cleaner for the rest of his life. So he was limited not by his intellect, you see, but by his depression. And he used to say, ‘Every window is a pane to me,’ and he was a very gentle, loving man. But my mother was afraid of him, and she used to say, ‘Don’t say anything that will upset your father,’ because I think she lived in fear of upsetting him in a way that might bring back the depression.
“My mother worked as a bookkeeper until she married my father. They were both socialists, and I went to a school run by a labor Zionist organization where I learned Yiddish. We were involved with the Henry Street Settlement House on the Lower East Side—I took piano lessons there—and we went to summer camps, Kindervelt and Kindering, and I worked in both places as a waiter. All the waiters and busboys were children of parents who belonged to this socialist organization, and there were Puerto Rican kids and Polish kids and black kids in the summer camps. We were all in it together, and I loved it, I really loved it, and I guess I was introduced early on to socialist ideals—to tolerance, and to racial tolerance especially.
“My father had a friend named Smitty, a black man who was the janitor for an Ebinger’s bakery on my father’s route, and when my father was on vacation, Smitty would wash the windows for him, and my father would reciprocate and do favors for Smitty. Smitty was the only person I ever remember, outside of family, who came to our home for dinner, and he came with his wife. This was in the 1940s. He was a lovely man, and he was my father’s best friend, and he lived in a black neighborhood in St. Albans.”
Jerry and I reminisce about our childhoods (“Sometimes,” he says at one point, “I think a lot of what I do and the way I react in certain situations comes down to the fact that I’m still just trying to please my unpleasable mother and get my depressed father’s attention”; I smile, tell him about Robert reminding me, recently, of the time our mother said, “Am I the only man around here?”)—about teachers and friends from Erasmus, about the Dodgers, about the street games we played as kids: punchball, stickball, boxball, box baseball, kickball, Chinese handball, Ringalevio, Johnny-on-the-pony, hit-the-penny, heels.
He talks, with enthusiasm, about some of the new programs he has recently initiated at Yale, through which he is trying to find effective ways to teach clinicians not just to provide care, but to prevent disease and the spread of disease. We don’t know how to do this in the clinical setting, he explains, and he has set up several pilot programs that work with primary-care physicians, teaching them how to integrate HIV prevention into clinical practice. It is hard to believe, he says, that this has not been done in an organized way before.
I attend one of these training sessions with Jerry—fifteen doctors sitting around and talking about how, step by step, to talk with patients so as to encourage adherence. Afterward, driving back to Jerry’s home, we talk more about his new programs, and about health-care policy in general—about his belief in the absolute need to invest more resources in prevention and public health measures than in biotechnology, in basic medicine rather than in heroic medicine, and in care rather than cure—and though I agree with him, I say something about being grateful, too, for the existence of biotechnology and heroic medicine, which, after all, saved my life. Though I know, I add at once, that most people do not get the kind of care I did.
“Right,” Jerry says. “You got the best, and the system didn’t screw up for you. And you had access to very good care, and not everybody does. You can’t expect everyone to have equal care all the time, of course, but people should have access.”
I don’t say anything for a while.
“Sure,” he says. He takes his eyes off the road for a second, smiles, then reaches across and puts his hand on my shoulder. “Sure, Neugie. Everyone’s entitled to the kind of care you received.”