Last updated on July 1, 2020
Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital
Bellevue.
What images does the title bring to your mind? Ten Days in a Mad-House?
Perhaps the most famous — and infamous — hospital in the United States.
In this well-paced, engrossing history and biography of the storied institution, David Oshinsky lays out how Bellevue gained — and earned — it’s ultimate reputation. That of our society’s most reliable of destinations for the ill — from the entitled to the poor.
But what I found most intriguing about the book was the story of social justice that emerges as Oshinsky chronicles the institution’s history and journey.
Especially in light of last month’s Twitter storm over the Wall Street Journal’s publication of the controversial op-ed piece (Sept 13, 2019) by Dr. Stanley Goldfarb, Take Two Aspirin and Call Me by My Pronouns. In his letter, the former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine laid out his argument against medical schools including any form of social justice in their curricula.
Medical education must train future physicians on these types of public-health issues, as they represent the reality of the world in which they will practice. Physicians have a responsibility to speak up when we can identify solutions for an issue harming our patients’ health.
Dr. Robert M. McLean, in letter to the WSJ
So, it was with all of this in mind that I read Oshinsky’s Bellevue, and was struck by the inescapable aspects of social justice that both drove and responded to the journey of the institution.
The history of Bellevue, is, in fact, a history of social justice and medicine in the U.S.
Starting with the introduction. Oshinsky writes,
Every immigrant group has availed itself of Bellevue’s protective umbrella over the centuries.
(introduction, bellevue)
Early on, he devotes time to the “lurid exposes” –including Nellie Bly’s Ten Days in a Madhouse —
“The hospital became synonymous with bedlam, dwarfing its immense achievements in clinical care and medical research.” (introduction).
–In order to then set all of that aside, to get to the real story of Bellevue.
He then brings to life through vivid prose each of those immense achievements.
The hospital played a giant role in the epidemics of history — including typhus fever, influenza, tuberculosis, AIDS, and Ebola.
He makes the case clear along the way that at Bellevue, “free hospital care is provided to the ‘medically indigent’ as a right, not a privilege.” (introduction).
The typhus fever epidemic led to the recognition by physicians that disease was associated with unsanitary living conditions (recall this was before germ theory):
It was only when high numbers of medical staff had died themselves from the epidemic, that “city officials in 1852 turned over the administration of Bellevue Hospital to a ten-member Board of Governors dominated by physicians and social reformers” (chapter 3).
This led to the creation of the “house staff.”
“…at the bottom of the ladder…five recent medical school graduates who would live at Bellevue and earn a nominal $130 for a six-month term.” (chapter 3)
As a result of these early physicians’ efforts, in 1866, The Metropolitan Health Act was passed.
It created a Board of Health for New York City and the surrounding area — the first of it’s kind in the United States. To tackle the “endemic diseases related to overcrowding, poor sanitation, and miserable working conditions– in short, the plagues of modern city life.” (chapter 6).
Led by Bellevue surgeon Dr. Stephen Smith, “the lonely health crusader versus New York City’s ever-expanding political machine” (chapter 6), the group of Bellevue physicians would successfully reverse the city’s alarming mortality rate by championing public health measures.
Dr. Smith pioneered preventive medicine, and “founded the American Public Health Association, which helped turn a well-meaning social cause into a highly trained profession.”
Another era where Bellevue and social justice were intertwined was during Prohibition.
“The flow of illegal whiskey…fueled a curious new specialty, developed in Bellevue’s pathology labs, to provide a scientific explanation for the manner in which a person died. Its founders called it forensic medicine.” (chapter 14).
Dr. Charles Norris, the first of Bellevue’s Chief Medical Examiners, would pioneer the field. He would set out to abolish the preexisting corrupt coroners system run by the city, using his own salary and personal fortune when his funding would be denied.
When the U.S. government decided “to scare the public into compliance by increasing the levels of poison in the denatured alcohol…being used in illegal whiskey” (chapter 14), Norris would point out the measure disproportionately affected the poor. Norris undertook an investigation into the full impact of poisoned alcohol on New Yorkers.
“The Norris Report” would claim “that alcohol poisoning was the greatest health menace currently facing the city…Prohibition hadn’t stopped the consumption of alcohol; it had simply made it deadlier.” (chapter 14).
Oshinsky later in the book walks the reader through the introduction of Medicare and Medicaid in the 1960s.
–And the resulting complexities of the New York City hospital systems and the disproportionate burden placed on the public versus the private hospitals. A problem that continues to exist to this day (in this physician-author’s experience).
The 1980s were then dominated by “the AIDS crisis at Bellevue; a place where doctors went the extra mile, as was the creed, to serve the most vulnerable and despised patients, whatever the cost to themselves. When others flinched or turned their backs, Bellevue stayed the course.” (chapter 17).
In the 1990s, the role of Bellevue came into question because of “the growing disconnect between the aims of the affiliated medical schools and the needs of the public hospital patient.” (chapter 19).
But a mayoral “panel concluded that ‘the city should remain in the hospital business, because of…its social responsibilities in this area, including the necessity of assuring that care be provided to all who need it.'” (chapter 17)
Oshinsky chronicles the only time in its history that Bellevue closed its doors on November 5, 2012 — due to Hurricane Sandy.
A Bellevue resident who helped to evacuate patients by carrying them down the staircase expressed “that night as the most rewarding experience of my career…The visceral feeling of ‘This is why I went into medicine’ is my most powerful sentiment left behind from the storm.” (chapter 19).
Oshinsky writes of the unprecedented closure of the hospital: “If there was a silver lining, it was the recognition of how valuable Bellevue’s services were, and how hard it was to get on without them. Doctors at other city hospitals were struck by the level of coordination and sophistication among the teams of Bellevue…It was a level of care, some acknowledged, rarely seen at their own institutions… Bellevue averaged 500,000 visits a year. Its closing had proved a grim reminder of its worth.”
In the epilogue, Oshinsky writes:
Several years ago, four NYU doctors with deep ties to Bellevue wrote a stirring defense of the role of the public hospital in American medical education. Where else, they wrote, could an aspiring nurse or physician ‘not yet accepting of the status quo,’ confront the ‘harsher inequities’ of modern life, from AIDS and substance abuse to homelessness and prison health care? Public hospitals embody a sense of mission. The core ethos of working in a place that exists to minister to the sick regardless of the walk of life or ability to pay is enormously influential in shaping the worldview of [those] in training.’
Bellevue, epilogue
These are just a few highlights from the history that Bellevue depicts going back to the 1700s. I encourage the reader to pick up the book for more, including the history of the first ambulance service (horse and carriage), and the impact of nurses improving postpartum/obstetric care for patients.
In conclusion, I found Bellevue to be an enjoyable read. It depicts the history of Bellevue Hospital as a mirror and metaphor for the inseparable missions of medicine and social justice. I would highly recommend it, not only to physicians, but anyone interested in social justice and the history of medicine.
want to know what the New York Times thought? here’s their book review.
Did you read Bellevue? What are your thoughts? Please comment below.