Take Me to Bellevue

When I was a boy growing up in Brooklyn in the years following World War II, I did not know that Bellevue was a hospital. I thought it was simply the name for a scary place that housed grotesque and terrifying crazy people. Later on, my brother Robert, a mental patient for most of his adult life, was sent to other infamous facilities, including a state hospital for the criminally insane, Rikers Island, and an insulin shock ward at Creedmoor State Hospital in Queens. I was Robert’s caretaker and advocate during these years, yet when, five years ago, I received a message telling me he had stuffed a toilet in his halfway house and caused a flood, for which act he’d been shipped to the emergency psychiatric ward at Bellevue, I felt a chill as deep as any I had felt during the previous fifty years.

I telephoned Bellevue and, to my surprise, was immediately connected to the psychiatrist who had examined Robert on arrival. “Your brother’s not psychotic,” she said, and—to my relief—laughed. “He’s mischievous, yes, but he’s not psychotic, and we’ll be sending him back home tomorrow.”

“Few hospitals are more deeply embedded in our popular culture” than Bellevue, David Oshinsky writes.

Tales of Bellevue as a receptacle for mangled crime victims, vicious psychopaths, and hopeless derelicts were always common fare, though the late-nineteenth-century circulation wars between William Randolph Hearst and Joseph Pulitzer churned out especially lurid exposés. The splashiest one—Nelly Bly’s Ten Days in a Mad- House—had an indelible effect.

From this point onward, Oshinsky notes, “the hospital became synonymous with bedlam, dwarfing its immense achievements in clinical care and medical research.”

Although Oshinsky gives generous space to events that made Bellevue synonymous with bedlam, he seeks in his richly detailed history to show how this public hospital’s remarkable achievements are connected both to the medical history of the past three centuries and also to the history of the city. “Bellevue,” he writes, “closely mirrors an ever-changing New York.”

By the time of the Civil War, Bellevue “had become both our nation’s largest hospital and its most important medical training ground,” and the reason, Oshinsky tells us, “could be summed up in a single word: immigration.” Early waves of immigrants were mostly Irish and Germans; after them came Italians and Jews; and after them, Hispanics, Haitians, Africans, South Asians, and Chinese. Most of Bellevue’s patients—the poor, the mad, and the despised—have been those who had nowhere else to go.

And yet, according to Oshinsky, in its more than 280 years of existence, Bellevue has never turned away a patient. Just as Irish immigrants were considered “dangerous foreigners” inflicting a typhus epidemic on New York in the mid-nineteenth century, so Jewish immigrants were later thought to have a “tailor’s disease” that was causing an epidemic of tuberculosis. In our own time, gays, blacks, Hispanics, drug addicts, and homeless people have been vilified as carriers of AIDS. But no matter which ethnic group is alleged to spread disease in New York, Bellevue has not only persisted in providing medical care for generations of the city’s residents, but has served as a model of how a public hospital—or any hospital—can survive and give excellent care. It has been the place where many of what Oshinsky calls “the better angels of medicine” have wanted to work. Lewis Thomas echoes this sentiment, shared by many doctors, when he writes in The Youngest Science: Notes of a Medicine-Watcher (1983): “If I were to be taken sick in a taxicab with something serious, or struck down on a New York street, I would want to be taken there.”

More than three million of New York City’s eight and a half million residents are foreign-born—more than the entire population of America’s third-largest city, Chicago—and of these three million, three quarters of a million are “undocumented” immigrants, people without a legal right to be here and who are now subject more than ever to fear of deportation. Part of the nation’s largest urban health care system, Bellevue handles nearly 670,000 nonemergency clinic visits, and nearly 116,000 visits to its emergency rooms each year. Approximately 80 percent of those it serves are either uninsured or poor enough to be covered by Medicaid.

While millions of residents benefit from public institutions such as Bellevue, undocumented New Yorkers provide, among their other gifts, practical benefits essential to our survival. “Although [illegal immigrants] broke the law by illegally crossing our borders or overstaying their visas, and our businesses broke the law by employing them,” former mayor Michael Bloomberg has said, “our City’s economy would be a shell of itself had they not, and it would collapse if they were deported.”

As many as eight hundred languages are spoken in New York, making it the most linguistically diverse city in the world, and at Bellevue more than one hundred languages are translated, among them Mandarin, Cantonese, Polish, Bengali, French, Spanish, and Haitian Creole. Oshinsky writes:

Doctors and patients communicate on dual telephones through an interpreter trained in the nuances of regional dialects. The directional signs that guide visitors through the hospital are multilingual—the destinations now include a Muslim prayer room and a clinic for the survivors of political torture.

In one of the strongest sections of his book, Oshinsky tells of Bellevue’s response to Hurricane Sandy in 2012. After Hurricane Irene spared New York in August 2011, Bellevue, whose electric generators were on the thirteenth floor while the fuel pumps that supplied them were in the basement, took precautions, and “encased the fuel pumps behind ‘submarine doors’ of steel and rubber to withstand water damage from a future event.”

Sandy would be the largest storm ever recorded in the Atlantic Ocean, with a diameter approaching one thousand miles. And it hit New York City full on [on October 29, 2012], arriving at high tide on the night of a full moon. The damage from South Jersey to the eastern tip of Long Island was catastrophic, but the densely populated parts of lower Manhattan fared even worse. The storm surge of a major hurricane adds four to six feet to the East River; this one measured fourteen feet…an unfathomable event.

When the hospital became flooded and its elevators went out of service, the staff began carrying patients down stairwells lit by medical students and residents holding flashlights. Interns were dispatched with oxygen tanks to the beds of every ventilated patient, mechanical IVs were converted to “subcutaneous injections,” and prescriptions filled by flashlight were taken by medical student runners to various floors. The National Guard arrived, and together with doctors, nurses, medical students, technicians, and secretaries, they passed five-gallon jugs of gasoline hand-to-hand until the jugs reached the back-up generators on the thirteenth floor. If the jugs stopped moving and the generators died, so would patients.

But no patients died. The bucket brigade staved off disaster, and all seven hundred patients were saved—including surgical patients, alcoholics, drug addicts, hundreds of psychiatric patients, and sixty-one patients locked up on the nineteenth-floor criminal psychiatric ward who were chained together at the ankles, wore orange jumpsuits, and were surrounded by a phalanx of police. As one staff member recalled, “This being Manhattan, deliveries of pizza and Chinese take-out food never flagged.”

Oshinsky traces Bellevue’s origins to a small infirmary built in the 1660s for soldiers overcome by “bad smells and filth,” which was replaced in 1736 by a two-story almshouse that served nineteen paupers and included a prison and a room for the sick and insane. Constructed on the site of today’s City Hall Park, by 1795 the almshouse had become home to some eight hundred people, and its commissioners demanded larger budgets for “the prodigious influx of indigent foreigners.” A second almshouse was built, but its infirmary was soon overwhelmed by victims of a yellow fever epidemic.

“The yellow fever,” Thomas Jefferson wrote in 1800, “will discourage the growth of great cities in our nation, & I view great cities as pestilential to the morals, the health and the liberties of man.” New York City’s Common Council believed otherwise despite the fact that in a city of 33,000 the epidemic took 750 lives—436 of whom were buried at public expense—and it soon leased a property it had seen advertised:

For SALE or to be LET. That beautiful COUNTRY SEAT called Bel-Vue, situated on the banks of the East River, about 3 miles from the city, and as its properties in point of health and other advantages are well known, it is unnecessary to describe them.

Containing an almshouse, orphanage, lunatic asylum, prison, and infirmary, Bellevue Hospital opened on its present site—30th Street and the East River—in 1816. As Oshinsky chronicles its history, he shows that the hospital consistently served what in 1900 a city health official said were the “dregs of society.” As major teaching hospitals such as Columbia, Cornell, and New York Hospital were established in the city, Bellevue became, in effect, their stepchild, a dumping ground for poor patients who could not pay and for those who were dying: the teaching hospitals, one official said, sent their dying patients to Bellevue “in order to lessen their [own] death rates.” Oshinsky’s emphasis is on Bellevue as an exception, a hospital that gives first-rate care to the poor and vulnerable. But as will be seen, the teaching hospitals also sent their young doctors to receive valuable training at Bellevue that they might not get elsewhere, and to give resourceful medical care.

Through every major epidemic, Bellevue’s difference from the uptown hospitals—and its uniqueness—lay in its commitment to providing free care to the “medically indigent,” thereby insisting by its practices that health care was not a privilege, but a right. From the yellow fever outbreak at the end of the nineteenth century to the AIDS epidemic of the 1980s, when Bellevue treated more AIDS patients than any hospital in America, the hospital “has borne witness to every imaginable disease and public health scare, every economic swing and population surge, every medical breakthrough and controversy.”

During the great influenza epidemic of 1918–1919, no one was turned away, “forcing the patient overflow to sleep on doors ripped from hinges and piles of damp, fetid straw.” Bellevue doctors and nurses became sick in such numbers that city officials considered—then rejected—limiting admissions. Meanwhile, the city’s voluntary hospitals such as Columbia Presbyterian—funded by charitable foundations or private funds—accepted only as many patients as their charity wards could hold. At these hospitals “there would be no doubling up, no cots in the hallways, and no invasion of the rooms set aside for private patients.”

Public hospitals, financed by the city budget, Oshinsky writes, “reflect the social ills of the inner cities that surround them.” On January 7, 1989, for example, Kathryn Hinnant, a thirty-three-year-old pregnant physician—Bellevue’s chief resident in pathology—was in her office preparing slides for a lecture. Four years earlier, the city had moved its psychiatric patients to the top floors of the main hospital, and turned the crumbling six-hundred-bed psychiatric building into an eight-hundred-bed shelter for homeless men.

Steven Smith, a homeless cocaine addict living in a machinery closet on Bellevue’s twenty-second floor and wandering the hospital freely in stolen doctor’s scrubs, found Hinnant alone in her office. “By his own estimate,” Oshinsky writes, “Smith spent no more than twenty minutes in Hinnant’s office. In that time, he beat her unconscious, raped and sodomized her, and strangled her to death with an electrical cord.”

Smith—called “The Beast of Bellevue” by newspapers—was caught, found guilty, and sentenced to life in prison. But the murder added to Bellevue’s reputation as an infernal madhouse. While not exonerating Bellevue for security lapses, Oshinsky observes that its psychiatric wards were running at more than 100 percent of capacity. Of the hospital’s adult inpatient population, 43 percent were classified as homeless, the figure rising to 70 percent in the psychiatric division.

Columbia Presbyterian, a voluntary hospital with fewer beds, had three times the number of Bellevue’s security staff—250 as opposed to eighty. During the 1980s, “Bellevue, by contrast,” Oshinsky writes, “could barely pay the salaries of its bare-boned security force.”

In truth, Bellevue had become hostage to circumstances it couldn’t hope to control. The AIDS crisis, the crack cocaine epidemic, the deinstitutionalization of state mental patients, the adjoining men’s shelter…each took a heavy toll. “I hate to put it this way, but we’re sort of the waste basket for the rest of society,” said the head of Bellevue’s psychiatric emergency service.

Today, the hospital’s troubles may be even more dire. Due to federal budget cuts and increased expenses, the New York City system of public health care faces a projected cash shortfall of $6.1 billion between 2016 and 2020, “the steepest fiscal challenge it has faced in memory,” according to the city budget office. Eighteen hospitals have closed in New York since 2003, and the de Blasio administration has said that there’s “likely to be a net loss of hospital-based jobs in city hospitals.”

Bellevue is one of eleven remaining city hospitals, all of them operated by NYC Health + Hospitals (H+H), a public benefit corporation, a majority of whose board of directors is appointed by the mayor. The projected shortfalls will be especially acute at Bellevue because, as ever, it serves an inordinately high percentage of people who are homeless, undocumented, and uninsured. The situation is further complicated since, for many years, Bellevue and other hospitals that serve this population received supplementary federal funds—called Disproportionate Hospital Share (DHS) and Upper Payment Limit (UPL).

Those funds, however, have been cut back in recent years, and will continue to be reduced in 2017. The federal government made the erroneous assumption that under the Affordable Care Act, with increasing numbers of people being insured, hospitals would no longer need supplementary payments. Undocumented aliens, however, are ineligible for insurance under the ACA, and in New York, homeless and uninsured people have yet to participate in the ACA in large numbers.

On April 26, 2016, NYC Health + Hospitals announced a “Transformation Plan” to address the $6.1 billion expected shortfall. In mid-September—a sign the system was in “deep hot water”—Ramanathan Raju, CEO of H+H, announced his resignation. In his place, the mayor’s office appointed Stanley Brezenoff, who had served in Raju’s position from 1981 to 1984 and as CEO of Maimonides Hospital in Brooklyn. He has also, in recent years, overseen the closings of Long Island College Hospital in Brooklyn and Beth Israel Hospital in Manhattan.

Because hospitals such as Bellevue have become increasingly dependent on government funds that are decreasing rapidly, the crisis has become more acute. Whereas, for example, total DSH and UPL payments increased from 3 percent of H+H’s budget in 2003 to 33 percent in 2015, Medicaid receipts are estimated, because of government policy, to decline from $2.4 billion in 2015 to $1.4 billion in 2020. And the prospects for Bellevue and other public hospitals becomes even more grave when one considers that Tom Price, the incoming secretary of health and human services, has promised to eliminate the ACA and to do all he can to gut and privatize Medicaid and Medicare.

Facing a mayoral election in 2017, the de Blasio administration is not likely to eliminate jobs or hospitals until next November. But no matter what he or a possible successor does—or what the Trump administration does—what is clear is that nobody knows where the money will come from to prevent the $6.1 billion shortfall from becoming larger, and nobody knows just how damaging the effects of an increasing shortfall will be on the city’s public health care system.

“Still, Bellevue, like the city, is nothing if not a survivor,” David Oshinsky says, and what is also clear, he argues, is that because of the quality of its medical care, the fact that it provides unique services to the city (e.g., the Medical Examiner’s Office and forensic labs), and because of its ongoing relation with NYU Medical School—an affiliation that has served both well for over a hundred years, “Bellevue is not going away.” (NYU’s doctors, medical students, residents, and attendants train and work at Bellevue, and Bellevue pays NYU an annual sum for these services.) Still, Bellevue’s increasing lack of funds remains a major concern for the city right now.

“There was never a time when Bellevue appeared even remotely trouble-free,” Oshinsky writes, yet while caring for millions of patients other hospitals turned away—and often on the verge of being closed down by the city—it was also among the nation’s leaders in medical research and innovation. In wonderfully engaging tales, Oshinsky describes some of the most important achievements and the doctors who brought them about.

Bellevue was the first American hospital to establish a maternity ward (1799), a nursing school (1873), a children’s clinic (1874), an emergency department (1876), a psychiatric ward (1879), an ambulance corps (1869), and a pathology lab (1884). It produced lasting innovations in amputation, anesthesia, antisepsis, and the treatment of tuberculosis, heart disease, AIDS, and Ebola. And throughout its history, its doctors constantly demanded that the city provide decent conditions for their patients and humane conditions for the city’s poor and underserved citizens.

When, in pre–Civil War New York, Stephen Smith visited tenements in which the typhus victims he was treating lived, he discovered there were no laws to protect tenants from neglect by well-to-do landlords who were supported by some local politicians. He enlisted William Cullen Bryant and Bryant’s Evening Post as allies in his fight against “Boss” Tweed and Tammany Hall. Drawing on a variety of writers and sources, they assembled a 367-page report (with seventeen volumes of accompanying data), Sanitary Conditions of the City, that portrayed New York as having two distinct populations—one well-to-do, healthy, and native-born, the other diseased and foreign-born.

Within a year of the report’s publication, New York created its first Board of Health, and passed a Metropolitan Health Act (the first of its kind in the United States) that Smith declared “the most complete piece of health legislation ever placed on the statute books.” (Like the list of Bellevue’s “firsts,” the list of well-known people who spent time on Bellevue’s psychiatric wards is also long, and Oshinsky mentions a few among them such as William Burroughs, Norman Mailer, Delmore Schwartz, Mark David Chapman, Sylvia Plath, Charlie Parker, and Charles Mingus.)

In 1956, André Frédéric Cournand and Dickinson Richards, doctors in Bellevue’s Chest Service who had done original work in viewing the circulatory system, heart, and lungs as integral parts of a single unit, won the Nobel Prize for their work in cardiac catheterization: the ability to thread catheters into the heart’s chambers. Eighteen years ago, I was a beneficiary of this technique when, via catheterization, I was diagnosed with coronary artery disease, and my life was saved at Yale–New Haven Hospital by emergency quintuple bypass surgery. This was made possible by four doctors, three of whom received their medical training at Bellevue.

“What set Bellevue apart, even in the worst of times,” Oshinsky writes, “was its powerful connection to New York City’s top medical schools.” By the mid-nineteenth century, the Columbia College of Physicians and Surgeons and the Medical College of New York (later NYU) were sending their students to Bellevue, and the city’s “elite physicians for whom the lure of ‘interesting’ patients outweighed the fear of deadly ‘miasmas’ and physical blight” were applying for visiting positions. Soon after it opened in 1898, Cornell Medical School joined Columbia, NYU, and “elite physicians” in sending its medical students to Bellevue. Oshinsky explores Bellevue’s “byzantine arrangement” with these schools. In four “separate fiefdoms” sponsored by the schools, “students were trained; research flourished; patients got free care; and the city fulfilled its obligation to the poor.”¹

My friends describe the training they received at Bellevue in the early 1960s as the best any physician could receive, largely because of two elements—the dedication of many faculty members and the fact that the hospital was “a virtual war zone.” Because the patient population came largely from New York City’s foreign-born residents and its underclass—immigrants, alcoholics, derelicts, addicts, the homeless, the mad, and the discards and dying sent from other hospitals—they became familiar with a range of illnesses few medical students would ever see elsewhere. The medical training, they said, was not for everyone. They worked under conditions so abysmal that, for example, more than a hundred TB patients were often stacked in corridors awaiting beds. Surgeries were routinely canceled during heat waves because there was no air conditioning. Stray cats roamed the doctor’s basement dining room to ease the invasion from the hospital’s maze of rat-infested underground tunnels.²

Yet it was also, they say, an environment that, as on a battlefield, taught them survival skills by encouraging both self-reliance and a sense of camaraderie. What they remember and what other doctors recall is the resilience and humor of staff, not only of patients themselves. Jerry Friedland, for example, one of the world’s most prominent AIDS doctors, worked at Bellevue. At the beginning of the pandemic, his team at Montefiore Hospital in the Bronx made the game-changing discovery that AIDS could be transmitted only by blood, semen, and vaginal fluids. He says that it was his training as a medical student and resident at Bellevue that prepared him for being at the center of the AIDS epidemic, and for having the survival skills to go on treating AIDS for four decades, here and in South Africa.

Bellevue “gathers the dead and dying from the rivers and streets and is kept busy night and day with the misery of the living,” a New York Times reporter wrote in the first decade of the twentieth century. Oshinsky says much the same thing:

One could chart the severity of a New York winter by counting the pneumonia victims on the hospital’s Chest Service, or measure the dangers of Prohibition liquor by totaling up the poisoned bodies in the morgue. If tuberculosis was running rampant through the city, then tuberculosis was what Bellevue treated. When AIDS arrived, when violent crime spiked, when addicts turned to crack cocaine, when released state mental patients became homeless, Bellevue usually saw it first.

Despite three centuries of wars, plagues, and natural disasters—and despite the near infinity of problems involved in running the nation’s largest public hospital in the nation’s largest city—David Oshinsky’s excellent book reminds us that the wonder is not that this public institution has continued to work, but that it has continued to work so well.