I stood silently in the cold, dark room, the shadows and
light of the X-ray film playing on my face, and I knew that this day would be
the border between Before and After in my life, that everything had already
changed.
In the summer of 1981 I was beginning my pediatric residency
at Lenox Hill Hospital in New York City.
It was a small program, only four residents in each of the three years,
so we each spent a great deal of time at other institutions doing specialty
rotations. In August of that year I was
at Memorial Sloan-Kettering, then as now, one of the premier cancer hospitals
in the country, doing my intern-year pediatric Hematology-Oncology rotation. I was taking care of kids from all over the
world with cancer and leukemia, many of them there because they couldn’t be
treated in their home cities. Memorial,
for many, was the hospital of last resort, the place where the mysterious cases
were sent and where a few, even kids, came to die.
Each morning our team – the attending physician, the senior
resident, myself and the other interns, and the medical students – would go
down to the radiology department to look at any X-rays that had been done on
our patients in the past 24 hours and discuss them with the radiologist. We had finished going over all our films when
the radiologist said, “Wait a minute. I
know you guys are peds, but I want to show you this one film. It’s really interesting.” He sifted through a pile of X-rays on the
desk in front of us, held up a film, and slapped it up on the backlit
viewbox. “Take a look at this. What do you think?”
We all stood in perplexed silence for a moment. I looked at the chest X-ray on the box in
front of me and systematically began to analyze it. Based on the size of the chest it looked like
an adult, probably male since no breast shadows were evident. Good quality film, no rotation. Heart normal size. Lungs…
Something about the lungs. They
were clear for the most part: Black fields indicating that the X-rays were going
clear through the mostly-air of the lungs to expose the film behind, blocked at
regular intervals by the gentle white arcs of ribs bordering and encircling the
chest. But in the blackness where there
should be nothing – more white, something, some things, in the lungs blocking the X-rays, things that looked like
huge cotton balls. “Fluffy infiltrates”
is the term radiologists use for lesions such as these. I thought I could rattle off a few things
that did this, but it would help to know more about this patient. I knew my place so the resident was the one
who asked the question.
“What’s the history?”
“27-year-old white male,” the radiologist answered, and as he
said it, I thought, 27? Makes no
sense. These sorts of infiltrates are
usually seen in fungal infections in really old people. But 27?
He was still talking. “He’s been
coughing for a couple of months, losing weight, no energy. Anyone want to guess what this is?” The attending mentioned fungal
pneumonia. Cool, I thought. Nailed that one!
“No,” the radiologist answered, clearly pleased at having
stumped a clinician. “Anyone else?” Silence.
After a moment he looked over the crowd and said, with a sly smile, “Pneumocystis
carinii pneumonia.” His audience didn’t
disappoint. This revelation actually
brought a gasp from the attending. For
myself, I thought: That’s impossible. Pneumocystis carinii was thought
to be a protozoan and a very rare cause of disease in healthy humans. My only past experience with Pneumocystis pneumonia had been
the year before during an internal medicine rotation when I had taken care of
an extremely ill, immunosuppressed woman in her late 80’s. For Pneumocystis pneumonia to be present in an
otherwise healthy man in his 20’s was almost inconceivable. My thoughts were being echoed by the
attending who was asking the radiologist about this case. “How do you know that’s it?” he asked.
“Pulmonary did a biopsy,” he said. “But shouldn’t your next question be, what’s
a pneumonia doing at Memorial?” We
looked at each other. Yes, it
should. Why indeed would someone with an
infectious pneumonia be admitted to a cancer hospital?
Scanning the crowd, the radiologist finally said, “Because
the patient was originally referred here for Kaposi’s sarcoma.” Again, his audience was thunderstruck. I’d read about Kaposi’s sarcoma but had never
actually seen it. It was a form of skin
cancer that looked like a bluish-purple bruise.
Indeed, it was often assumed to be a bruise for weeks until the patient
noticed that it hadn’t gone away. But
again, it was only seen in very old, very frail people whose immune systems
were not working. What was going on with
this 27-year-old?
“Here’s the thing,” the radiologist continued, answering our
unspoken question. “This young man gets referred here for Kaposi’s by his
private doc, and then they find out he’s been coughing and losing weight so
they get this chest X-ray and see this and call in pulmonary to get a
biopsy.” I looked at the date on the
X-ray film and saw that it had been done almost two weeks earlier. “So the pulmonologists are stumped, and they
start talking to other docs around town.
Turns out this guy’s not the only one with this stuff going on.” He paused for a moment. “There’ve been about 5 or 6 cases pretty much
like this, healthy young men who suddenly get sick with diseases that only
older, immunosuppressed people get. And
you know what they all have in common?”
Again he paused. “They’re all
homosexual.”
I don’t remember if I broke into a sweat. I do know that my face flushed, and I could
feel my heart pounding like one of the jackhammers out on York Avenue. I looked at the film again, for something,
what?
“Wait a minute,” the attending said. “I think I read something about this in
Morbidity and Mortality Weekly Report.
Clusters of homosexual men coming down with these weird diseases. Here, San Francisco, Atlanta…”
“This is one of them,” the radiologist said triumphantly, as
if he were displaying a rare white tiger.
Fluffy infiltrates, Kaposi’s sarcoma, Pneumocystis. Words I’d
heard. Things I’d seen, but in the pit
of my stomach I knew that I would hear these words over and over and over
again, in hospitals, in bars, in community meetings, from friends, on TV. Something bad was happening… This X-ray, this guy I’d never met: He could be me. Someday, I wondered, would I be him?
I don’t remember much more of the discussion that followed as
the attendings, resident, other interns, and students talked about what they
did and didn’t know, what they’d heard and hadn’t heard, about this cluster of
cases. Someone said something about
sexual spread, someone else a tentative name she’d heard for it called gay lung
disease, another made a wisecrack. I was
silent, staring at patterns of shadow and light.
Once we got back to the inpatient floor, there were a lot of
sick kids to take care of, and I didn’t have much time to think about the X-ray
or the man with – what? This thing with
no name. It wasn’t until much later, as
I walked the 15 blocks to my apartment on 2nd Avenue between 80th
and 81st in the dark, still-hot August evening, that the unease of the morning
returned.
I got home late that night.
Bob was there. He’d already
eaten. “I saved you some,” he said,
fixing a plate for me. We’d been together
for over a year but had just moved in together two months before. “Long day, huh?”
“Yeah,” I said quietly, looking up at him as I poked at my
food, almost examining him. “Yeah, long
day.”
In bed that night I held Bob as he slept, listening to his
breathing – his strong healthy breathing – and I wondered about the
future. I wanted this moment to last
forever. I didn’t know then that Bob and
I would split up three years later, that we would become best friends very quickly
afterwards, and that we would remain best friends until he died at the age of
36 on Thanksgiving weekend 1994. I
didn’t know then that he would come to me in a dream in 1997 to tell me that
death is nothing to fear and that he would always be with me. I didn’t know then that – though I would be
spared the virus – this day would give my life focus and that I would be one of
the survivors to tell the story of my people in the time of plague.
I didn’t know any of this on that night in 1981, holding my
lover in the August heat as he slept, or earlier that morning standing frozen
in the dark, staring at the chest X-ray of a nameless 27-year-old gay man, but
I did know as I finally fell into a troubled sleep that life as I knew it had
changed forever.
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