Sex, Drugs, and Public Health

That deep into Louisiana, the air you breathe is liquid insects. The humid chittering slimes your skin. And after a while, you forget your vibrating eardrums, to relinquish yourself to the incessant vibrato that cocoons you everywhere.

You walk slowly across a lawn beneath the dripping oaks. The hanging moss whispers over your hair. Grass sprawls everywhere. You see only two man-made things: a rusting horse drawn harrow that’s been a lawn decoration for decades, and plantation-era whitewashed buildings to the left, the right, and straight ahead, all staring at each other with the blank look of sphinxes.

You came to see Ghosts, but they hide.

Across the road somewhere is a levee. Which is some kind of dike or water filled gully in reality, but in the languid music of the South, is a mythical icon. Maybe you’ll go see it some afternoon.

You stare at the whitewashed sphinxes: if the Ghosts won’t come out, you’re going in.

“Are you Dr. Mosher? They tol’ us you’d be comin’. Welcome to Carville. Ah’m going’ to ophthalmology clinic. Come along.”

And you follow her white coat as she leads you down corridors of squeaky wood past dozens of silent doors. You are girded, expecting to be startled by Apparitions around each corner. But each turn just reveals another silent corridor.

“Here we are,” she announces at just another door. She opens it. She in her long white coat and you in your sweat-impregnated shirt enter. The room is quiet and, like everything else, white. People in long white coats murmur greetings.

Finally. The Ghosts.

Three patients sit, awaiting exams, silent. You don’t want to stare, but can’t help it. Not as dramatic as you’d thought, their faces are pale. Their skin is lumpy, immobile and tight. Like masks. You realize how much we depend on that facial skin to show expression. Their lips are thin, stretched taut.

Lastly, you look at their noses. Noses are meant to cover the nares – the dark openings which, paradoxically, are necessary for life yet strike horror if visible. Only one of them has lost his nose architecture. The cartilage has collapsed and his nose caved into his face. His nares flare and contract with each breath. The pink inside of his nose pulses like a reptile’s throat.

“With this disease,” the woman in white begins, “the patients lose sensation. Even on their corneas. So if they get a speck of dust in their eye,” she pulls an ophthalmoscope from her pocket, “or even just an ingrown eyelash, it can scratch and ruin the cornea and there’s no pain to warn you.”

She smiles at a patient as if recognizing a friend, murmurs some comforting words, then begins the exploration of his eyes with her ‘scope.
You watch to see if she touches him – or if she skillfully avoids skin contact without being insulting. You see his hands politely cradled in his lap. Stubby, shortened fingers.

She examines all three, scribbles in their charts, explains a couple of things to you, but doesn’t offer to let you do an exam.

And she doesn’t touch.

They shuffle out of the clinic, into the silent corridors. You haven’t heard one word – one sound from them.

“Come with me to the lab,” she smiles. “We use armadillos.”

Occasional windows in the corridors reveal what you knew they would: deep emerald of grass, the swaying brown of Spanish moss, a pale blue Louisiana sky. If the windows were open, you know what you’d hear.

Then, one window is different. A half dozen people shuffle across the grass moving gradually in the same direction. Their clothes are pastel variants of colors which all feel white.

“It’s lunch time,” your guide explains.

You pass an open door.

“Oh!” your guide stops suddenly. “Let me show you this.”

Inside the room of the open door are many tables at waist height. Papers scattered over all of them. You see a printing press in the corner.

“This is where we write and print ‘The Star’,” she sweeps the room with her right arm. “It goes all over the world to tell people about the disease and our work here. The residents themselves produce it.”

Her face, all its muscles working in perfect harmony, beams.

She leaves the door open while we continue down the corridor.

Behind a door like any of the others, there is sound and movement. The lab has more activity than you’ve seen all morning.

“This bacteria grows at low temperatures,” she explains as you pass cages of armadillos. “It can’t survive at ninety-eight point six, unlike all other human pathogens. That’s why it never goes deep – just the skin. So to study it, we need a lab animal with cool soft tissue.”

She picks up an armadillo as someone would a pet rabbit. It curls into a bowling ball in her hand.

“His foot pad is exactly the right temperature. We grow our cultures of the Mycobacterium there. Now, we’ve got – for the first time in human history – an antibiotic that seems to work.”

She replaces the armadillo in its cage, and you observe: “Maybe someday Carville will be closed?”

She shakes her head slowly. Her moving hair actually makes noise.

“No. All the others may close, even Molokai, but the residents here, they don’t want to live outside. No one out there understands them. Even if they become non-contagious with the new antibiotics, they’ll always be treated as – well, outsiders,” she consciously avoids the obvious word. “They’ll die here,” her soft, pliable lips smile slightly. “This is their home,” her face muscles move to reveal her love for them. “But when they’re gone – when this generation dies off, that will be the end of Carville.”

You walk across the lawn again in the mid afternoon. The air buzzes and drips. You’re the only one visible on the century-old plantation. A car drifts slowly past on the road in the distance.

Maybe you’ll shuffle on over and find out what a levee is.

So you’ll have one thing, this afternoon, that you can understand.

VIII Home Stretch

Over the next three and a half years, although I studied and practiced and followed the Residents on rounds in the hospitals like everyone else, something was changing in how I viewed Medicine. My senior year, I spent three months in a clinic in South America.

“Why down there?” John asked. “You wanna be Dr. Schweitzer instead of Dr. Kildare?”

“Diagnosticians need to know Tropical Diseases, too,” was the best explanation I could mount.

I applied for Internship in California.

“Why California?” John asked again. “We have plenty of good hospitals here.”

That was a little harder to answer. The best I could come up with was:

“The Times, They are a’Changin’.”

VII Into the Real

I signed up for a class on writing, once a week downtown. If it ate into my studies, I could drop out. Meanwhile, I was doing something other than Med School. A diversion. I was unaware that another diversion had already been planned into the Med School curriculum.

A little man in a wool suit and a bow tie took the microphone.

“I’m Dr. Bottie,” he began. “Welcome to Preventive Medicine.”

No one even tried to muffle their groans.

“I know you aren’t all that interested in Preventive Medicine right now…”

… Snickers and snorts …

“… but it’s an important branch of Medicine.”

Guffaws …

“And to start the class off, we’ll be doing a field trip. The buses will be here Friday at this time. It’s not a vacation, so dress like professionals,” he warned us, providing a little insight into past field trips. “And no smoking on the bus.”

Hand up.

“Yes?”

“Where will we be going?”

He smiled with his thin little lips. “Harlem.”

I was a little nervous about the field trip, and I could tell, by the snippets of conversation, that I wasn’t alone.

“My parents don’t have insurance on me for death by gunshot. Make it look like an accident, OK?”

“Never been this far north in Manhattan before. Does Santa Claus live in Harlem?”

Out the bus’s left side windows, Central Park’s expanse of grass flashed my memory to my father’s farm, where he had once held a Civil Defense drill: dozens of people lying across the big lawn, pretending to have been burned by the Atomic Bomb. They tried to convince me it was a fun afternoon. Mushroom cloud: what fun.

So I forced my mind to conjure, instead, a grassy hillside from my long ago bicycle summers: where I lay back in a meadow like Central Park’s to look down onto cornfields; where I was immersed in the bizzing of insects hidden in the grass; where I watched crows slowly circle in the warm blue above me on an afternoon that felt like forever and was light years from this New York Med School craziness; where a puff of breeze had brought me the perfume of chlorophyll, late flowers, and just a hint of cow poop.

“Graze around me, cows,” I said aloud.

And the cadence of the bus’s tires fell into the rhythm of Grazin in the grass is a gas, can you dig it?

But, unlike that forever afternoon, Central Park abandoned us at 110th Street. Brick apartment buildings gave way to empty lots and century-old tenements. The faces of the pedestrians outside changed color.

We followed Dr. Bowtie off the bus.

“These people have invited you into their homes,” his eyes swept across all of us. “Be respectful.”

“Homes? These are slums,” Dolen sneered.

“Disrespectful,” Ralph observed.

Dolen snorted.

Then Ralph added, “unprofessional.”

“Yeah, go back to where you came from Weirdo. You don’t belong in New York.”

We followed Dr. Bowtie into a dank hallway, then climbed three flights of decaying stairs which creaked, threatening to decompose with each step. We waited while the Doctor knocked on a door.

A black woman, small child on her hip, opened up.\

“Mrs. Moore, these are the students. Thank you for letting us in.”\

“Yo’ welcome, Doctor. Ah jus’ got back from da Urgency Room. My boy done got his finger bit off.”\

“Bit off?” Bowtie sought clarification as we squeezed into her dark apartment. Three mattresses on a floor of peeling linoleum. Trash heaped up in the corners. Filthy windows admitting little light.

“Grayson!” she called.

A boy, maybe four years old ran over to her and grabbed her skirt with his unbandaged hand. He peered up at us in fear. The rest of us stepped back slowly, trying to dissolve our white faces into the shadows.

All except Ralph. He squatted down to Grayson’s level.

“Hi,” he smiled at the boy. “I’m Ralph. What’s wrong with your hand?”

The boy held up his white bandage.

“Did you hurt your finger?” Ralph continued, softly, his voice a pitch higher than normal.

“It bit me,” the boy mumbled.

“Oh, I’m sorry,” Ralph soothed him. “Who bit you?”

“Da rat.”

“Rat?” Ralph’s voice betrayed surprise.

“Las’ nite. I was sleepin’.”

“Oh. I see. Where do you sleep? Can you show me?”

And Grayson let go of his mother to run over to one of the mattresses, stand beside it proudly, and declare:
“This one mine.”

Ralph walked over, squatted down to look closer at the mattress on the floor. “What a nice mattress you have,” he praised the boy. “Do you help your mother by making the bed?”

“Ain’t no bed,” Grayson educated him. “It’s a mattress.”

Later, as we boarded the bus, I heard Dolen sing song as he passed Ralph. “What a nice mattress.” Then his voice switched to its familiar sneer. “Fairy!”

I made a point of catching up to Ralph in the corridor of the school.

“Sorry about what Dolen said.”

He shrugged. “That’s his problem. I feel sorry for him.”

“You do? You’re the only one in the class, then.”

“Really? That’s sad.”

“Where are you from?” I took the most direct path to the answer of this human enigma.

“A little town near San Francisco. Why?”

“You seem more – – ah, – – – relaxed. Doing stuff other than studying. As if you were – – – I don’t know – – -.”

“Mellow?” he offered. “More laid back?”

“I don’t know what that means.”

That smile again.

“What’s your specialty gonna be?” I veered the discussion for my own comfort. “Preventive Medicine?”

“Pediatrics. But now that you mention it, Peds is pretty close to Preventive Medicine. You?”

“Internal Medicine,” I fear I may have puffed out my chest. “I’m gonna be a Diagnostician. A Detective. Preventive Medicine’s definitely not for me.”

“Uh huh.”

“I hate bowties.” I braced for an argument.

“Good. Do what feels right for you. That way, you’ll be really into it. But, for me, I’d rather prevent illness than clean up after it.”

Shock may be the most accurate explanation for why, in spite of what was a clear opening for obvious and easy rebuttal, I was briefly speechless. The whole purpose, after all, of going thru the torture of Med School and becoming a Doc is to treat sick people. Well people don’t need physicians. When I did respond, it wasn’t too clever.

“Bullshit,” I said.

Smile to laugh to smile again. “You ever see a kid with a finger bitten off by a rat before?”

I held my hands out, palms up.

“Me neither. Now, what was the cause, the etiology of that – – – disease?”

“Rat,” I smirked.

“Nope. It was,” he paused – – – “Poverty. Wouldn’t happen in our homes, huh?”

“Oh, I get it. You’re gonna cure Poverty.” I lost control of my sarcasm.

“No,” he spoke quietly, gently. “Poverty – – – AND War.”

“Ah HA! ” I exhaled my satisfaction at finally fitting one piece of this puzzle neatly into its vacancy. “That’s why you’re against this war!”

He shook his head. “Against all War. It’s just logical. Can’t imagine any physician thinking otherwise. Well, gotta go.”

I’ve got two stories for you about Hantavirus, and a greater story, which is information that will help you avoid this serious disease.

In 1993, we in Public Health discovered a new disease. This doesn’t happen very often. From the Four Corners area (where Colorado, Utah, Arizona and New Mexico are all near each other) reports came of a mystery disease that sickened some previously healthy people and killed several of them. Some were as young as 13 and several were Native American.

They got fevers, and then developed shortness of breath. One person described it as feeling like a tight band around his chest and a pillow in front of his face. By the time Public Health investigators had developed a full picture from all those states, they found twenty-four people who had become ill, many of whom lived in rural areas (like Mariposa County). Twelve of them died of Adult Respiratory Disease Syndrome (ARDS) in which their lungs failed to provide oxygen to their blood. Laboratory investigation implicated a new strain of virus: the “Sin Nombre” (Without a Name) virus in the Hantavirus family. All Hantaviruses are carried by mice and several cause human disease.

Since then, this disease (Hantavirus Pulmonary Syndrome) has hit people sporadically: individual cases from various widely scattered locations, rather infrequently. There have only been approximately 60 cases in California since we began watching in 1993.

Now we have another “cluster” of cases which, as the whole world knows, are strongly suspected to have come from a specific area in Yosemite Park. When, in early August, I went to Yosemite to inspect cabins in the Camp Curry area, all of us there found evidence of mice inside many of the cabins. But the epidemiological connection was with the fancy tent cabins which have hard wall interiors and stoves for heat. It appears that, in those tents, the mouse infestation may have been heavier than in other tents and cabins. Perhaps we’ll find that the space between the tent canvas and the walls has something to do with it. The exposure for campers could have been greater in those tents.

Here’s the greater story: the mice that carry Hantavirus are all over the California mountains. We have been warning people for years about this. Your house, garage, crawl space or attic could be infested with deer mice and, therefore, possibly have Hantaviruses in the mouse poop in your house. Testing has shown that about 14% of these mice carry Hantavirus.

You should prevent mice from getting into your house and other buildings. And if you find evidence of mice (feces, nests) you must protect yourself when cleaning up. Here is how to safely clean up a room with mouse feces:

1. Open all windows and doors to let air circulate through for several hours.

2. DO NOT SWEEP or VACUUM mouse feces.

3. Spray the feces well with a disinfectant solution.

4. Let the disinfectant soak into the feces for at least 15 minutes.

5. Wearing gloves, wipe the wet feces and dispose of in a plastic bag.

For more information, see our website at http://www.mariposacounty.org/health/hantavirus.

VI. Our Isolation, Invaded

A few weeks into the first semester, with mid-term exams looming like Godzilla over our little Manhattan Med School, the bald Dean took the podium again.

“Yesterday,” he seethed, “some students” (he almost spat this word) “from this Medical School walked down Fifth Avenue in a demonstration. A political demonstration.”

We all glanced left, then right.

“Now, I admit,” he admitted, “That you have the right to express yourselves. Even when you’re wrong. Very wrong. But you do NOT have the right to wear white coats with the school’s insignia on it. You do NOT.”

We were all looking only forward now. All looking innocent. Who would risk his medical school career doing that? I wondered.

“It was Ralph,” John later told me as we all buzzed about it. “Some anti-war demonstration downtown.”

“That’s a hell of a risk,” I shook my head.

“No kidding. For the next four years the only places you’ll find ME are in class, in lab, and in the library,” he said as he turned toward the library.

That afternoon, in Bio-chem lab, I leaned toward Ralph and asked him.

“Yep. I was there. So were some other students and even some faculty,” he added. “And people from every other Med School in town.”

“Aren’t you afraid they’ll throw you out? You’re risking your entire career.”

He looked at me a long time with his easy, natural smile.

“Don’t you think our involvement in Viet Nam is immoral?”

I waited for him to say more. But he was done, apparently.

“That’s for other people to decide. In Washington. My job, right now, is to get through Med School. Without flunking out or getting drafted.”

“If you do get drafted, what will you do?”

“Whadda you mean, ‘what will I do?’ It’s not like I’d have a choice. They’d order me to go, and I’d have to go.”

His smile, soft and gentle as it was, bore into me like a blowtorch. “You don’t have to do anything. You – all of us – choose what to do. Choose to support the war or choose not to…”

I snorted derisively.

“As someone who cares about people’s health, I’ve made my decision. Don’t you think war is bad for people’s health?”

“Sure. So’s smoking. But I’m not gonna quit ‘til I graduate and neither is anyone else,” I snapped. “Back to work.”

From the corner of my flask-focused eyes, I watched Ralph carefully remove his jacket and slide into his lab coat. Dylan. That’s who he looks like. Bob Dylan.

Then my brain was assaulted by “The Times They Are a – Changin.” That really pissed me off.

I don’t care about Changin’ Times and neither should any of us. Just study. Just become a doctor.

I tried to bump Dylan out with a different tune:

I said I’m gonna mix it up right here in the sink
I’ll slip it in his wine to cover up the bad stink

But Dylan wouldn’t shut up and it was all Ralph’s fault. I felt a really powerful need for a Marlboro, but I was trapped in lab. I tried to fit a glass tube into the rubber stopper of a flask. You better start swimming or you’ll sink like a stone – – – It wouldn’t go. So I pushed a little harder. Don’t criticize what you can’t understand – – – The glass tube snapped, the flask shattered, my Bunsen burner sizzled out.

“A little frustrated, are we?” the professor’s voice clawed against my neck like ice water.

My impulse was to whirl, slash his face with the broken shard of flask, then to slit Ralph’s throat. The fact that I’m telling you this story is your clue that I did neither. I did something else. More accurately, something else happened to me.

I began to laugh. I realized it was inappropriate, but I couldn’t quit. I began to slide to the floor, laughing so hard my abdominal muscle began to spasm. I stumbled, still laughing, out of the lab, down the hall, into a bathroom. A laugh room. The stupid pun made me laugh all the harder.

It took half an hour until I was able to stop it. A handful of my fellow students stood at the bathroom door, staring down at me.

“You OK?”

I stood up, smoothed out what wrinkles I could in my lab coat and said. “Yeah. I feel better.”

“What caused that?” John asked, very concerned. I could imagine him calling the psych unit.

“Don’t know,” I shook my head. “Too much library, maybe.”

* * *

Now, the hippocampus is important, but hidden deep in the brain. The visual cortex is crucial to what makes us human, but is all wrinkled into strange shapes. The ‘Tahl-a-moose’ as our Neuroanatomy prof pronounced the Thalamus is about as basic as a brain can get, but is impossible to differentiate visually from surrounding brain tissue. These, and about seven hundred other structures make up the human brain. And, they would also make up my final exam in Neuroanatomy. Which course was I most likely to flunk? It was a race between Physiology and Neuro. So I called my parents to tell them I wouldn’t be home for Christmas. I spent the week in the library. And I wasn’t alone in there, either.

“If I’m gonna flunk out of Med School, it’s gonna be next week,” I confided in John. No need to worry about next semester.”

“Aw, you’ll do fine,” he said in his Polly-Anna way. He’d bolster anyone. He’ll probably be a great doctor. “Just try not to do that laughing thing again, okay?”

“Laughing? At Neuroanatomy? There is definitely no synapse in the human brain that connects those two processes.”

The sun rose on January sixth. That may not have been news to most of the world, but it was a major miracle in my life and helped me go a long way toward understanding that Resurrection phenomenon the priests and nuns had been trying to explain to me.

Sunrise illuminated the 8-1/2 by 11 sheet on the bulletin board declaring that I had, unbelievably, made the Dean’s list that first semester.

“How’d you do?” Marshall asked me with his Zappa voice.

“I passed,” I said in a very long exhalation.

“Me too. One semester down and seven to go!”

“Actually,” I smiled broadly, “It’s all downhill from here.”

“How do you figure?”

“Now I know I can do it.” And I went away whistling.

Four hadn’t made it, and were gone. That news spread rapidly.

“Wonder if Ralph’s one of them,” I mused to John.

He looked at me with a cocked eyebrow. “Why’d you say that?”

“Well, if he’s not downtown doing demonstrations, he’s off at meetings about getting more Black and minority students into Med School. Not spending all his time studying, you know?”

John shook his head. “Straight A’s,” he pronounced. “Dean’s List.”

“Hm-m. So maybe it pays to broaden your horizons.”

“Not me. I got a job at the library, so I’ll be there until eleven every night. And I get paid for it!”

“Lucky you,” I said probably way too half-heartedly.