CITY JOURNAL, April 14, 2017
The story of Bellevue is the history of public health.
A review of Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, by David Oshinsky (Doubleday, 400 pp., $30)
The milestones of the modern city are not always measured in building heights or population numbers: sometimes they are recorded in epidemics and how the city confronts these crises of public health. For New York City, where urban density and the diseases borne by international travel have often collided, with catastrophic results, this has meant a history of fighting varied and deadly human pathogens: from the yellow fever epidemics of the 1790s to battles against cholera, typhus, puerperal fever, influenza, tuberculosis, and AIDS. Since its founding in 1736, New York’s Bellevue Hospital has been at the center of all these struggles. In Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, David Oshinsky, a professor of history at New York University and the director of the Division of Medical Humanities at NYU’s Langone Medical Center, applies his talent for storytelling—he won the Pulitzer Prize in 2006 for his book Polio: An American Story—along with a taste for the macabre to deliver a remarkably compelling history of New York as seen through one medical establishment.
“Few hospitals are more deeply embedded in our popular culture,” Oshinsky writes of Bellevue. “The flagship institution of America’s largest city, where free hospital care is provided to the ‘medically indigent’ as a right, not a privilege,” Bellevue continues to stand, “for all its troubles, as a vital safety net, a place of caring and a place of last resort.” The “three centuries” of the subtitle describes not just Bellevue’s history but that of the institutions of public health as a whole. In a city where an outcry over the “body snatching” of cadavers by medical students led to the deadly “doctors riot” of 1788, and where the upper classes long sought refuge from their infirmities at home rather than in a hospital, Bellevue grew out of a pest-house, or ward for those who were often terminally ill, established in what was then New Amsterdam. “Citing records from the West India Company, when the Dutch ruled Manhattan Island,” writes Oshinsky, Bellevue’s existence can be traced to “a small infirmary built in the 1660s for soldiers overcome by ‘bad smells and filth.’”
The institution that became Bellevue was first used more as a quarantine for those dying from “periodic eruptions of measles, influenza, scarlet fever, and ‘throat distemper’ (diphtheria)” than as a place for fighting what were then misunderstood infections. By the 1730s, the primitive hospital had advanced north from the downtown population center to an almshouse on the city common, near what is now City Hall. In 1798, New York secured the land of the remote Belle Vue farm, on what was then a bucolic hill overlooking Kips Bay. When the city grid was laid down in 1811, this became the block of land east of First Avenue between 26th and 28th Streets, where the hospital has been in near-continuous operation. Today, from this same quadrangle, NYC Health + Hospitals/Bellevue annually handles some 650,000 clinical visits, 110,000 emergency calls, and 25,000 inpatients each year, with an attending physician staff of 1,800 and 5,500 nurses, assistants, and clerical employees.
Early on, Bellevue helped protect a swelling immigrant (and often indigent) population from the diseases that plagued their slums. In the nineteenth century, New York became one of the world’s most densely populated places. With half its population living in infested and overcrowded tenements, the city for a time suffered a mortality rate exceeding that of London and Liverpool. “In 1870, one child in five in NYC would not live to one,” Oshinsky writes, and “25 percent who reached adulthood would not live to thirty.”
Bellevue doctors played a central role in writing Sanitary Conditions of the City, the groundbreaking 1865 study that led to the creation of New York’s first official Board of Health. Even without fully understanding the vectors of disease—such as mosquitos, lice, fecal waste in tainted water, and vermin—they installed new sanitary measures to replace fetid wells with fresh water conveyed through the new Croton Aqueduct. The Board of Health also cleared livestock from city streets and banned the driving of cattle through residential neighborhoods. Out of the necessity of its urban circumstances, Bellevue shepherded other innovations, in particular the science of modern pathology. New York’s Office of the Chief Medical Examiner originated on Bellevue’s second floor and soon became the “gold standard for detecting intoxicants, barbiturates, and poisons.”
Oshinsky traces the emergence of the many private hospitals that began opening around Bellevue, paralleling the city’s diverse ethnic communities and their desire to attend to their particular religious customs in illness and death: St. Vincent’s, the city’s first Catholic hospital for a growing Irish population; German Hospital, which became Lenox Hill after the First World War; Jews’ Hospital, which became Mount Sinai; Presbyterian Hospital, St. Luke’s for Episcopalians; St. Francis for German Catholics; Columbus for Italians.
The one institution among these that comes out as a villain in Oshinsky’s story is New York Hospital. Chartered by King George in 1771, it opened in 1791 as a “‘handsome structure set amid shaded lawns,’ a few short blocks, yet a world away, from the almshouse where Bellevue was born.” The contrasts between the public mandates of Bellevue and the private privileges of New York Hospital were stark. “By law, private hospitals can unload on Bellevue, and Bellevue must receive them,” Oshinsky writes. So New York Hospital would turn away “drunks, vagrants, and those with smallpox, ‘the itch,’ and ‘contagious distempers.’” Or, in what is known as “patient dumping,” it would redirect its sickest patients to Bellevue, as it did well into the twentieth century.
Yet just as often, Bellevue proved its own worst enemy, as both disease and mismanagement frequently overran the institution. “There never was a time when Bellevue appeared even remotely trouble-free,” writes Oshinsky. In the 1848–49 epidemic of Typhus or “Irish Fever,” a bacterial disease that “thrives in close, filthy quarters” and is spread by a body louse, the patient death rate at Bellevue topped 40 percent; it was even worse for staff. In the 1850s, a sensational story spread of Bellevue’s rat infestation, as a woman was discovered in a hospital bed with a lifeless child whose face had been eaten by vermin (posthumously, it was determined).
In 1887, a young reporter named Nellie Bly feigned insanity and was involuntarily committed to the city’s system of institutions for the mentally ill. Her story, “Ten Days in a Mad-House,”published in the New York World, became a sensation for its depiction of brutality and neglect. Yet while her tale mainly focused on the city’s asylum on Blackwell’s Island (now Roosevelt Island), the psychiatric unit of Bellevue also became associated in the subsequent public scandal and investigations, cementing a “connection between Bellevue and insanity.”
Sensational episodes persisted into modern times. In 1989, a “homeless cocaine addict” named Steven Smith, who had been released from psychiatric care against his wishes, took up residence in the machinery closet of the hospital’s 22nd floor. Wearing stolen doctor’s scrubs and bearing a stethoscope and security badge, Smith was free to roam the hospital. He entered the office of Dr. Kathryn Hinnant, who was five months pregnant, and over 20 minutes “beat her unconscious, raped and sodomized her, and strangled her to death with an electrical cord.” The investigation of the “Beast of Bellevue” uncovered “at least three reports of unauthorized persons living in the fourth floor locker room and at least five reports of persons sleeping in other common areas and in stairways around the hospital.”
Still, these incidents to the contrary, Bellevue’s reputation as an out-of-control hospital for the mentally ill might be exaggerated, argues Oshinsky. “Bellevue’s hold on our popular imagination has come at a price,” he writes. “The relentless focus on its eccentricities has obscured its role as our quintessential public hospital.” Bellevue was a leader in psychiatric research and treatment, he maintains, yet here again, the hospital eventually became embroiled in controversy. Recognizing a connection between seizure and the treatment of schizophrenic symptoms—still not fully understood—Bellevue inaugurated the practice of electroconvulsive therapy, or ECT. “Thousands would undergo ECT at Bellevue,” writes Oshinsky, “many of them children. Indeed, few units employed it as systematically.” Bellevue largely abandoned ECT after its lead practitioner, the child neuropsychiatrist Lauretta Bender, left for Creedmoor State Hospital in 1956, where her psychiatric research turned to the experimental use of LSD.
For Bellevue, the “medicine and mayhem” of Oshinsky’s subtitle came together, triumphantly as it turned out, in its confrontation with a new illness beginning in November 1980, when “a man arrived at Bellevue with a fever and shortness of breath.” Detecting “Pneumocystis pneumonia with profound cellular immunodeficiency,” a team that included doctors Fred Valentine, Alvin Friedman-Kien, and Linda Laubenstein raced to understand the nature and vectors of a new urban epidemic. Originally called “gay cancer,” then Gay-Related Immune Deficiency (GRID), the disease was eventually renamed Acquired Immunodeficiency Syndrome, or AIDS.
Even as “nobody knew what precautions to take or how long the epidemic would last,” writes Oshinsky, “Bellevue became the epicenter of the spreading epidemic,” as it served “both the gay neighborhoods of Greenwich Village and the drug-plagued streets of the Bowery and the Lower East Side.” The heroics of the city’s medical professionals, many of them involved with Bellevue, became the subject of Larry Kramer’s play The Normal Heart. “The challenge of battling AIDS held a strong appeal to those steeped in the Bellevue tradition,” writes Oshinsky in a moving closing chapter. The story serves as the model for the next time Bellevue confronts an urban epidemic that will, inevitably, arrive at its doors.