Twelve Patients: Life and Death at Bellevue Hospital (27 page)

This experience in my office was repeated in millions of office visits by millions of patients with similar efficacy. The zero-effect dilemma. The magnitude of the obesity epidemic and the failure of medical weight reduction interventions has outsourced the “problem” of dieting and weight management to the innumerable diet “authorities.” It has spawned a multibillion-dollar industry that is ballooning as fast as the obesity epidemic itself. With depressing and predictable regularity, studies have replicated the irrefutable facts. Dieting has a very limited effect on weight loss that is at best modest and transient. The traumas and stresses of everyday modern life can be assuaged by instantaneous food gratification. For anyone experiencing a bad day at the office, domestic tension, parenting challenges, and financial downturns, food is one of the sure ways we can get some relief no matter how transient. Then we push Repeat a few hours later.

Months passed and then the insistent buzz of a text message cryptically reminded me,
coffee marta lobby don’t forget!!!!
I sat stuck in traffic in Lower Manhattan as half of the streets were barricaded off for either a presidential visit or the relocation of a high-security prisoner. The ubiquitous black police helicopters reverberated loudly overhead. I wondered when domestic drones would provide surveillance.

Marta waved me over to a corner seat as I walked across the polished granite floor. “
Hola, mi amor
…” We smiled. “I’m going to check out the surgery,” Marta said. “I can’t afford not to, not with my three babies—you know, including Mama.”

“They need you,” I said, taken aback by the starkness of her situation.

“Ha,” she laughed, though it was not her old, open laughter. “Before I couldn’t afford the operation and now I can’t afford not to
try the operation.” The doors to the auditorium where the bariatric surgery session was starting had just opened. “I’ll go with you for the first part,” I said as we walked toward the doors.

There were a hundred people milling, all oversize, two-thirds female, young folks in their early twenties and middle-aged men and women and partners. The English/Spanish buzz continued as people moved to fill the seats and lined the walls around the room. The community needed lots of room to spread out. Oversize arms hung over the backs of chairs as the slim young surgeon in a crisp white jacket took the microphone and welcomed everyone to the bariatric surgical open house.

There was simultaneous Spanish translation. This was no accident, and not only because a large part of our population was native Spanish speaking. The Latino or Hispanic health paradox suggests that first-generation immigrants have healthier children—despite relatively lower socioeconomic status and lower educational attainment—than comparable white populations in the United States, probably due to breast-feeding and stronger social networks or other “mechanisms,” but second-generation immigrants lose the advantages of the first. The data showed that Latinos had obesity rates second to none in New York City. The Mexican immigrant group was at the top of the list. The issues were as varied as the Latino populations themselves but seemed to suggest that cultural norms optimized chubbiness and size as desirable in young children. Throughout Latin America, obesity was looming as an enormous public health issue. Fast foods, high-fructose snacks at a four-year-old’s eye level in every conceivable store across the continent had created in a generation a nightmare health debacle.

Dr. Parikh spent half an hour running through a series of slides that spoke directly to obesity and its effects on health. I glanced over to get a sense of whether Marta recognized him from when Irene’s baby was delivered, but she showed no signs of it.

“There are several types of operations for obesity now. We operate using special techniques that make only small punch-like incisions in the abdomen. We insert instruments and operate using a movie camera on a big screen. There is no need for a big incision, and the healing
time is much shorter. You are in one day and home that night, or at the latest the next morning.” He showed some real slides of actual surgeries being done, with the instruments alternating with colorful cartoons. “But the most important thing to show you are the different kinds of procedures and why you might choose one or another. I will help guide you to the right one for you but ultimately it is a personal decision. We have three guests here today who have had the three types of surgery, and they will explain to us why they chose a particular type of procedure.”

Two women and a man came out to the front of the room and sat in chairs facing the audience. “Mr. Clark had the band two years ago,” the surgeon said by way of introduction. “Can you tell us about why you chose it and a little about yourself before and after the surgery, Isaiah?”

A black man in his midforties stood in front of the room. He wore a dark chocolate-brown suit, brown shirt, and tie. His head was shaved and shiny under the lights. He carried himself with dignity and looked fit. His deep voice resonated off the four walls. He didn’t need a microphone. We all wondered where the patient was.

“I was a bus driver for New York City in Queens and Brooklyn for nearly twenty years and loved my work. I am a big man, over six feet as you can see, but I weighed more than three hundred pounds and had to go on disability over five years ago. Back pain, arthritis in my knees, hypertension, and diabetes. No smoking and no drinking. But I aged twice as fast as anyone else, like I was in a movie at double speed.” He smiled and the audience laughed with him.

“Not working got me pretty depressed. It affected my marriage and my relationship with my kids and grandchildren. I was totally useless. The more sedentary I became, the more weight I put on. No job, nothing to do but watch television and sit. My only satisfaction was cooking and eating. I was worthless in my own eyes. My doctors treated me well. They had visiting nurses in to check on me and I had the latest medications, all six of them, computerized instructions and phone calls from a case manager twice a week. My life was all about medicines, doctors, nurses, and the constant threats and fears about
strokes, heart attacks, and cancer. The first took my mother and the heart attack my father when he was my age. His first of four heart attacks. Until he was on oxygen and his legs were the size and appearance of a fireman’s legs with the pants on.” The eyes of everyone in the room were glued to Isaiah. He was speaking to and for all of them.

“I read about surgery for obesity in a magazine and didn’t think anything of it. An interesting article, but it sounded like an experimental treatment. Surgery for obesity? Not for me. I was not going to be a guinea pig. Then one day coming here for a routine checkup—my monthly therapy session, as my wife called them, because it got me out of the house and out of her hair—I saw this flyer, the one you have in your hands about this meeting. We came together and we listened and I set up an appointment to meet the surgical team two weeks after that meeting. I saw them many times over six or eight months before they put me on the surgical schedule. They made it clear this was serious surgery and it would not work unless I was dead serious about it myself.” He looked at Dr. Parikh, who was sitting off to the side listening as if it were the first time he’d heard the story.

“It took me a little time to get used to the idea since I was a full-time patient by then. I mean a professional patient, my new job. No pay and no benefits but full-time job. With high blood pressure. With diabetes. With high cholesterol. With arthritis. Even with depression and anxiety. The whole shooting match. ‘What don’t you have, Isaiah?’ Minerva my sister asked one day as I was going through my medication list and blood test results. That did it.” He paused a minute and sipped some water from a Poland Spring bottle.

“During the time of coming to see the surgeons and their team, I met a lot of patients who were coming back for checkups after their surgery. They were getting checkups, adjustments, having their weight monitored. They were all losing weight, some faster than others, and some were struggling. But what got me was when I talked to several who were a year out already. One gal, she was my daughter Mona’s age, had lost a lot of weight and then was off her medications by twelve months. She was working again as a secretary, looking after her kids, and wearing her wedding dress around the house, because she could.
And you will hear from Adriana in a minute.” He pointed to a lovely dark-haired woman sitting two chairs to his left. She nodded and smiled to the audience. Isaiah had the group in his hands.

He turned to the screen, and the projector flipped on. Isaiah showed the group on some cartoon slides how the band worked. The deceptively simple idea involved putting an adjustable plastic ring, like a small dog’s collar, around the top of the stomach, creating a much smaller pouch for food. Saltwater solution would be injected by a syringe into a reservoir every four weeks, through the skin in the abdomen, tightening the ring and making the stomach pouch smaller and smaller while still allowing food to pass through into the intestine to be digested. It usually took about eight months to get to the right size for a particular patient.

“So after half a dozen adjustments, which were done at home by a visiting nurse, my meal sizes dropped drastically and I was feeling full. The weight came off regularly, and with it the pills I was taking came off as well. First the meds for depression and anxiety. I was doing something for myself and didn’t feel dependent and useless. Then my blood pressure was normal. My cholesterol came way down and I only needed a small amount of the Lipitor—and even that is being negotiated with my internist. But the most important is, I don’t need the meds for diabetes. I mean I don’t have diabetes now. Talk about free at last!” He was a natural preacher and enjoying sharing his success with the group.

The other speakers covered the other procedures in the same personal way. The question period took a long time. Dr. Parikh spent as much time as was needed going over the complications and how the team customized the procedure for each person. “It takes time to figure this out, and people change their minds at the beginning. That is normal and part of the process. There is no rush. The day you are wheeled into the operating room, you need to know it is right for you. That is the test. Just like the folks here did this morning. I won’t operate on anyone who is not ready. It is not fair to them or to my team.”

He finished more somberly than I had remembered. “You have heard the success stories here today. There are complications. We have
done well, but there will be problems. That is why we take our time and don’t rush anyone ever.”

While Marta Sahagún cornered Dr. Parikh, a line behind her rapidly accumulated oversize patients clutching their handouts, medical records, and X-ray files, stretching toward the exit.

After Marta’s surgery and recovery, I met her again for coffee. Months had passed. Isabela, her granddaughter, was starting to walk. A photo on Marta’s phone showed a smiling and thriving little person. “She’s my little girl,” Marta said, bittersweet. Doña Olimpia was doing well, she told me, and Jaime was okay, though he still had weight issues. Marta had slimmed down somewhat. She looked younger, nicely dressed, and oddly optimistic, considering everything she had been through. “I stopped smoking, Doctor,” she said proudly.
How do people survive?
I wondered. Resilience. We would prescribe it, if only we knew what it was and how to get it.

“You know, Doctor, Irene took Jaime to the WIC program, the Women, Infants and Children program, until he was five years old. She’d wanted to breast-feed but they gave us free cans of infant formula from Carnation. What can you do when you have to work and you have the cans sitting there? You get hooked on convenience. And your baby is hooked on Carnation!” The Carnation “wars” were international, playing out in Africa as well as the kitchens of middle America. WIC’s forty-year mandate was to provide calories for poor people. Ten years ago it was waging a battle with the food lobby to provide fewer calories for a large percentage of its mothers and kids as the “first responders” of an obesity epidemic sat in WIC’s waiting rooms.

Marta looked up and around. “You have Pepsi here at the hospital, Doctor. Exclusive contract?” I nodded and rolled my eyes. She added: “Just like in the public schools. I heard the mayor signed with Snapple an exclusive contract for the city of New York. A way to bring in money to pay for education. Snapple and education? Our neighborhood hospital has a Burger King sitting in the lobby. You can smell the fries when you go through the revolving doors.” The near-vegan, thin to anorexic, jogging, calorie-counting physician workforce promoted prevention and über-nutrition in the small outpatient cubicles, took
care of the heart attacks, kidney failure, and foot infections on the inpatient units. And we contracted for a few bucks with the omnivorous industry that was the problem on the ground floor.

I looked at Marta. This was not the typical
mi amor
stance. This was a different woman, not just because she’d lost some fifty pounds. There was a new look to her—not determination. She had always been determined, determined to survive, to care for those she loved, to connect affectively with the world around her. This was different—a new focus maybe, a new intensity.

“How much did the hospital make?” she asked directly. I was taken aback.

“Hm,” I said, thinking back. “The public hospital system signed a multimillion-dollar ten-year contract with PepsiCo in 2002.”

“How much do you guys get?”

I did the mental math. “In a six-plus-billion-dollar corporation, this would amount to less than two hundred thousand per year for each hospital.”

“How much does it cost to treat diabetes?” She was not going to let it go. I smiled at her—I could see now what was different.

“Well, let’s see. Two hundred thousand dollars would cover the cost of one laser in our clinic for diabetic eye disease, the number one cause of blindness. Each treatment costs nearly a thousand dollars in a private doctor’s office. And you need a lot of treatments to prevent the blood vessels from oozing and blinding the patient.” I got her point.