Twelve Patients: Life and Death at Bellevue Hospital

Twelve Patients

Grand Central Publishing

CHAPTER 1

The One-Strike Law

The view from my office at Bellevue Hospital looks north up the East River. The south side of the UN building rises like a thin polished band, and it cuts through the arc of the 59th Street Bridge that reaches east over Roosevelt Island and then to Queens. On the southern tip of Roosevelt Island, I can make out the skeleton of the smallpox hospital now in ruins. FDR Drive pulses with white lights heading south as I look out at seven o’clock on a still-dark morning. Red taillights string north in the dark evenings as people head back to the outer suburbs locked in their cars.

The old Bellevue psychiatry building, now a men’s homeless shelter, frames my window on the left. The building is stained with water and neglect. Just to its right is the New York University School of Medicine with its laboratories, classrooms, and hospital beds. Hidden beyond the construction site exactly in the middle of my view is a small white tent. The site had been our northern parking lot until September 11, 2001, when air-conditioned freezer trailers were moved in and surrounded by a chain-link fence. Guards monitored access. The remains of the dead from 9/11 were brought to be identified, their DNA measured against the DNA extracted from toothbrushes and clothes. It reminded me of the ZAKA in Jerusalem (the Hebrew acronym of an Israeli organization that aids disaster victims), who came to the site of a suicide bombing wearing their tzitzis and collecting brain matter and fingers into plastic bags for burial, so that the souls of the dead would be able to join their people when the Messiah came.

The tent is still there as I look out my same window eight years later, though the refrigerated trucks and guards are gone. The view is being progressively obliterated. The Economic Development Corporation has taken over our north-side parking lot and leased the area to a California company to build a biomedical laboratory building. I figure I have about another three months before the UN disappears completely, and with it the medical school, along with the old psychiatry building cum homeless shelter.

When most people hear “Bellevue” today, they picture an old-fashioned insane asylum—but that is just one aspect of this city-within-a-city where I spend my days. For aficionados of Law & Order or Nurse Jackie, Bellevue is synonymous with psychotic killers perpetrating random acts of violence. But Bellevue is the oldest hospital in the country, 275 years old. It is also arguably the most famous public hospital in the United States. The first maternity ward, first pediatric ward, first C-section—Bellevue is full of firsts. Its public sanitation programs date back to the Civil War. Yellow fever, tuberculosis, typhoid, and polio epidemics were brought under control here. Famous for psychiatry, Bellevue also pioneered child psychiatry with the first inpatient unit complete with a public school for children. Two Bellevue physicians won the Nobel Prize for heart catheterization. The first cardiac pacemaker was developed at Bellevue. So was the early treatment of drug addiction.

Today, the hospital continues to work at the cutting edge of public health issues—HIV, lethal flu, potential terrorist epidemics. Bellevue also has a hundred-bed prison unit to care for prisoners of Rikers Island, the largest prison complex in the country. As part of the city hospital health system, we look after the needs of all New Yorkers—from Park Avenue to the tenement housing of recently arrived Fukienese immigrants, survivors of torture, and everything in between. With thirty thousand discharges and half a million visits in our hundred-plus different outpatient clinics, we see the effects of global problems often before most people know the problems exist: outbreaks, violence, climate change, tobacco, drugs, and the fast-food industry. We are known for many things, in particular our emergency room. If a cop gets shot in Manhattan, his first choice is often Bellevue. If a diplomat gets attacked at the UN, he gets taken to Bellevue. If an investment banker goes into cardiac arrest, his limo driver knows where to take him. If New York is a microcosm of the world, then the doctors of Bellevue are on the front line. We are a vibrant institution that moves to the same rhythms as the city we serve.

Where in colonial times there was a farm named Belle Vue now stands a vast hospital complex of several thousand beds with seven thousand employees, and several thousand new New Yorkers being born every year. The modern campus sits in Kips Bay, a few blocks south of the United Nations, flanked by First Avenue to the west and the FDR Drive snaking along the East River. The northern boundaries are the aforementioned men’s homeless shelter spun out from the old psychiatric buildings, and an intake center for kids in crisis; both were parts of the original sprawling hospital campus. The southern boundary runs into a nursing school and the Manhattan Veterans Hospital on 23rd Street. For the past 150 years, Bellevue has also been the teaching hospital for the New York University School of Medicine.

I arrived at Bellevue in 1997. After seventeen years as a physician at Dartmouth, I was ready to be back in New York and in public health. As a child growing up in the Bronx, I used to accompany my father, Dr. Robert Manheimer, as he made house calls at night. A rheumatologist and internist at Montefiore for more than fifty years, he took me on night rides in the family’s baby-blue Peugeot with an adjustable spotlight to find house numbers on Gun Hill Road or the little-known alleyways off the Grand Concourse. The sounds, smells, and rhythms of medicine entered my primitive brain’s limbic system. I had no choice. Though I loved everything else—history, languages, archaeology—medicine was my passion.

In the 1970s, when I was a medical student at Downstate, in Brooklyn, the city went bankrupt. Crime rates escalated. The city saw gigantic unemployment, a crack cocaine epidemic, racial tensions, and escalating economic and social disparities. As I made my way to pathology class Monday morning, the Brooklyn morgue was lined with bodies. The late 1970s, when I was a resident at Kings County, a huge public teaching hospital in central Brooklyn, were also crazy times for New Yorkers. The city was homicide capital of the world. Son of Sam was one of my more infamous patients of the time. There was nothing we had not seen after years working through all of the services, each with its own building on the campus. We had no on-call rooms, so we slept on empty stretchers. There was no air-conditioning, so in the summer we brought several extra shirts to change into. We would meet at midnight in the break room for peanut butter sandwiches and trade a CT scan for a barium enema before going back to battle. After ten years I had seen almost everything.

After a physician was stabbed to death in the parking lot of the hospital by a crack addict trying to rob him of five dollars, I answered an ad in the New England Journal of Medicine for a job in New Hampshire.

I met my wife, Diana, at Dartmouth—she was a young professor with Canadian parents and had been raised in Mexico, where her dad worked as a mining engineer. Diana’s work encompassed the world of the arts, theater, performance, literature, and politics, and I was seduced by it from the beginning. From her early childhood in Parral, Chihuahua, a dusty mining town whose only claim to fame was that Pancho Villa had been killed there, her family had moved to Mexico City. In 1997 I followed Diana back to New York City, where she was offered a position at NYU. I, like a true homing pigeon, started working in the city public hospital system again. Bellevue completed my inner circle, which consisted of Diana; my son, Alexei; and our daughter, Marina.

Looking down out my window, I see a corrections van, “New York’s Boldest” stenciled on the side, pull outside the “Blue Room” (holding pen) between the emergency room and the adult psychiatric emergency room, which goes by the acronym CPEP—that is, the “Comprehensive Psychiatric Emergency Program.” The occupant of the van must be a high-value prisoner from Rikers Island—seven police and corrections vehicles surround it. The vehicles stop just below my window, and the corrections tactical squad members emerge in full body armor, carrying battlefield-level weaponry. They survey the perimeter, then create a human corridor through which two corrections officers (who must be captains, judging by their starched, formfitting white shirts) escort the shackled prisoner. He is Latino, with dark disheveled hair and a wispy beard, wearing the standard baggy orange jumpsuit. His skin is tattooed everywhere I can see. Blue, black, green, and red. His neck, arms, and hands.

He looks up toward my window. Las Maras have arrived in New York. They are one of the deadliest gangs. Their signature is extreme violence, no holds barred, unsentimental murder and mayhem. Their initiation rights involve peer beatings and an initiation murder or asesinato, as it is called in Spanish. Many of them grew up undocumented in the street gangs of Los Angeles, and were later deported as teenagers and young adults—some to El Salvador, where their parents had fled from the horror of civil war, and some to other countries of origin they had never known. Now they were back, more lethal than ever, with a spiderweb network of drug trade from Colombia and Peru all the way to Los Angeles and Long Island.

This guy’s hands and feet are bound with metal chains; another chain connects the hands and feet, and everything is connected to a strong leather belt around his waist. Is all this security to protect him from a rival gang that wants his territory, or is it to prevent his gang from helping him escape? This transport moment is the vulnerable point—he can’t escape from Rikers, though someone could kill him there. Given the gang’s power and codes, however, that’s unlikely. The guards push him into one of the cells in the Blue Room.

“¡Hola, jefe!” Patty, my executive assistant, walks in around eight a.m. and startles me out of my thoughts. “You have a full schedule today.”

“As opposed to every other day?” I ask.

“¿Quién te manda, jefe?” she rejoins. “You are your own taskmaster. So today, the UN Secret Service folks are coming in to make sure we’re ready for the upcoming General Assembly meeting next week. God forbid they take a shot at one of those world-leader types and he ends up here. The Mexican minister of health will pop in to discuss health care for Mexican migrants.” She goes down the list and finishes with: “By the way, Budd called down from the prison health unit asking if you would run up to say good-bye to Juan Guerra, who is to be discharged on compassionate release.”

I pause, speechless. “He’s finally going home? I can’t believe it.”

“Don’t believe it till you see it, jefe. You know how things are around here.”

Juan Guerra going home—unbelievable.

“I’ll go see Guerra before the UN guys come—I’ll be right down. Get them some coffee and donuts if I’m late, por favorcito.”

The first thing I ever noticed about Juan Guerra was his neck, which I recognized from twenty-five yards away.

I was making rounds with Budd, the lead physician on the nineteenth floor. Rail-thin, six foot six, Dr. Budd Heyman was an internist with a long history of working in correctional medicine from the Tombs, Manhattan’s prison adjacent to Chinatown. An indefatigable advocate for the disadvantaged, he knew that the game of life could change quickly for anyone and the only difference between the rich and his patients was that the rich had options. We usually began at one end and walked our way around. Even if the patients weren’t in their cells at the start of our rounds, they would magically appear by the time we got there. There was too little going on in prison to miss the opportunity to talk to someone new. There were twenty-five men, between the ages of seventeen and seventy-three, who had been there for as little as a few hours or for as long as five months plus. The corrections officers at their posts were a reminder that they were still prisoners, even though they wore hospital gowns. The gates were solid metal and locked; there was no decor and no color. Mesh screens covered all the windows.

With the guards, the gates, the IDs, more gates, it’s hard to “drop in” on that unit, and I am a drop-in kind of doctor and medical director who prefers to be on the floor rather than behind my desk. You get a feel for a unit. People in the know can actually size up a hospital in a few hours just by walking around it, talking to people, asking questions. You get a clear sense of what’s going on. You don’t need ten inspectors spending two weeks crawling through policies and procedures. A few sentinel scenarios tell you if the hospital is a Potemkin village or the real deal.

Guerra was a slight man under five foot eight, thin, with hospital-issued pajamas and slippers, short-cut pepper-gray hair, and a short goatee. And a neck I would know a mile away. The swelling told the full story immediately. I could anticipate every question, issue, side effect, treatment option, and alternative. I had no idea what his personal story was, where he was from, where he had been, or what his life trajectory had looked like so far. But I certainly had a fair sense of what his future possibilities might be. The left side had four golf ball–size tumor-filled lymph nodes that stuck out and left the skin over them stretched taut. They weren’t giving him any pain or interfering with his swallowing. He was thin but not gaunt and had a glass of water in his hand. His disease was advanced, and his chances of making it very slim. I wondered in what way I, as a physician, could have a positive impact on Guerra’s dwindling life.

Many physicians do not get into the boat at all and stay on the shore. Many become obsessed with lab values and the rituals of the white coat and stethoscope, the computer now safely between them and the patient so that hardly a glance is necessary before they can be off to the next. For this type of doctor, the loss of a patient is a narcissistic blow. It activates a primal fear of loss. It represents a deep professional failure. It makes a sham of what medicine is supposed to do. Regardless of the regimens, treatments, expenses—regardless of other specialists brought in, the surgeries, secondary options, drug trials, and rescue chemotherapies, the futile treatments themselves are a symptom of the physician’s inability to accept an ending. The doctor becomes frozen, protecting the illusion of power. But the illusion is untenable—it goes against the laws of physics. Everything dies. Nothing touches the inescapable outcome that is entropy itself. The Second Law will prevail, it always does, the house never loses.

I hesitated before approaching Guerra. Something else held me back: I was recovering from the same exact disease. My own treatment for SCC, or squamous cell carcinoma, from a peanut-size lesion near my right tonsil, had started on a Monday in mid-October a year earlier and finished with a final dose of radiation therapy and chemo in early December. The complications and recovery were still fresh. I had had a neck node that wouldn’t quit, that sat out the radiation and the chemo nearly to the end and then finally collapsed in a couple of days. Would his collapse? Would mine stay collapsed? Would his fate foreshadow mine? Seeing his neck created an anxiety in me I didn’t like to admit to myself and certainly couldn’t share. It’s painful to see your own worst fears made real and immediate in the person in front of you. It’s not simply a matter of the empathetic This could be me. It’s more like This could very well be me sometime soon. I pushed the thoughts as far back as they would go. I understood what lay ahead of him in a way no healthy physician could.

I walked over to him, holding out my hand: “Buenos días, soy médico, parte de tu equipo de médicos en el hospital. ¿Tienes un ratito para platicar?”

Patty is ushering the two Secret Service men into my office through the front door as I enter through the back. I intended to see Guerra first thing this morning, but was stopped in the hall by one of the chiefs telling me there was a problem in an operating room. Figuring out a solution has taken the best part of an hour, and I need to get back. I ask Patty to find out what’s happening with Guerra ASAP, and then greet the two men.

They are standard government issue. Beefy, short haircuts recently clipped, cheap gray suits off the rack, plastic white earpieces with a cord disappearing down their necks, and the omnipresent clipboards. The president and other heads of state are due to meet at the UN next week, so these men are here to check the hospital security and trauma and cardiology readiness, as Bellevue is the receiving hospital for heads of state. They are here for a walk-through, very hands-on. As part of the emergency-management system, we rehearse a variety of different activations such as biological attacks, mass trauma, and dirty bombs. I make them coffee with my new espresso machine that Diana gave me. A box of Dunkin’ Donuts has miraculously materialized on the polished wooden conference table. This is not the quiche-and-Perrier crowd. Even though they come every year, we always go down the same checklist.

Randy, the senior Secret Service officer, says, “You have 24/7 in-house trauma attendings?”

Check.

“Dedicated trauma operating room?”

Check.

“Examples of current emergency escalations?”

“We had a gunfight two weeks ago with three cases in the trauma slot and in the OR in a few minutes,” I responded. “Rival gangs involved in narcotics turf warfare. Fifty units of blood and product for the cases. We can access an enormous quantity from the blood bank and sister hospitals quickly.”

Randy looks up and smiles: “Like Maryland. Except their business is car crashes, not the knife and gun club. Do you have helicopter access?”

Check.

Jim, the junior guy, texts on his BlackBerry throughout the meeting. We schmooze comfortably and eat donuts as they complete their paperwork.

We then take the walk around the central administrative hub of the intensive care unit (ICU), where a safe space is secured in the event a high-profile politician or diplomat comes in with trauma or another life-threatening condition. I stop to introduce them to Maria, the secretary to the surgical intensive care unit, and the chief resident on neurosurgery. I look in on the fifteen members of the trauma team that surrounds the bed of a young woman who lies in a coma after her motorcycle was hit by a distracted octogenarian behind the wheel. She was launched into a low orbit that caused multiple cranial fractures, internal bleeding, and swelling that killed all tissue above her brain stem. The doctors are carrying out some of the tests we relied on completely before the age of CT scans. Do the pupils react to light? Are they equal in size? Do you see doll’s eyes moving together when you rotate the head to one side and the other? She has fine features and long dark hair. For an instant she reminds me of my daughter, and I look away. They are around the same age. Too painful to think about.

My cell phone goes off, and I check it as I walk the Secret Service men to the elevators. It’s Patty—the Mexican minister of health has been delayed at the mayor’s office. We have a meeting to discuss the partnership that Bellevue has developed with the Mexican consulate to provide health care for the influx of documented and undocumented Mexican immigrants—more than five hundred thousand of whom live in the greater metropolitan area alone, and twelve million in the United States. I ask her to call me when he arrives.

She assures me she’s on the Guerra case. “Jefe, thought you’d like to know that Dr. Faruz is waiting here to see you. I told him you’re busy upstairs but he says he’ll wait. He wants to complain to you about…” I pray for patience and hang up.

“A happening place,” says one of the Secret Service men.

Juan Guerra is going home—unbelievable. After half a life in prison, his throat cancer might actually save his life. Maybe. I think back on my earliest discussions with him, a fifty-nine-year-old man born in New York of Dominican parents.

As a child in the Bronx, Juan Guerra had made several lengthy trips to the Dominican Republic, first living on a ranch, riding horses near the Haitian border, and later in the capital city, Santo Domingo. Timing was everything, Guerra had told me. And his timing had always been terrible. Coming of age when Vietnam was exploding like a grenade with the pin pulled, his lottery number had been 11 and he went to war with the neighborhood. This was not a Crawford, Texas, neighborhood with street names like Harvard and Princeton Place. There was no question of a deferment for an injury or conscientious objection or a family that could stash him safely in the National Guard to ride out the waves of Hue that would bring the nightly death counts onto living room televisions across the country. Guerra and his family knew he was the one who would always be caught. A black cat had walked across his mother’s path when she was pregnant, he said.

Guerra had served in Vietnam in a combat unit, though in fact he was in Cambodia ferrying U.S. troops illegally into the border areas to find and destroy Vietcong storage tunnels. What he didn’t know was that not all the risks in the army were booby traps in the jungle or black-pajama-clad locals who might be soldiers, sympathizers, or just villagers trying to survive one side or the other depending on the time of the day. What he didn’t know was that a pure white powder would claim his future and, in many ways, remake him into another person before he was twenty-one years old.

He came back, like many in his unit, addicted to heroin, and for the next thirty years tried dozens of times to kick the habit, relapsing regularly. He was caught in possession of drugs, sent to Rikers and occasionally upstate for longer sentences of over a year, and put on parole again and again. The last time he was sentenced to prison was for being fifteen minutes late for a meeting with his parole officer. His adult life post-Vietnam had been one extended coda with the Department of Corrections of New York State. It was like his second family—maybe even his first at this point. He had a wife and a son whom he missed terribly and who’d supported him unconditionally through thick and thin over decades, an aging mother and father, and an extended family in the Dominican Republic. In fact, a lot more than many non-felons could claim.

Guerra and I had talked about this often over a hospital meal at his bedside. I asked him why he would make such bad decisions knowing the consequences—and how the police needed to make their arrest quotas. These were minor drug offenses, possession or selling tiny amounts of methadone. How could he take the risks?

He said that he was an addict and had been one for thirty-five years courtesy of the U.S. Army. His entire social network was made up of addicts, dealers, and minor neighborhood drug types who couldn’t get any type of employment.

“I made a lot of bad decisions and pay the piper every time. After a certain point it doesn’t matter. You will get picked up and charged with someone else’s crimes since they know you cannot say no and you plead down so you don’t have to go upstate.”

“So can’t you play it extra safe, knowing that?”

“I need methadone. Once the clinic shut me out, paperwork they forgot to file. They told me to come back in five days. I had to choose between withdrawal and getting some drugs to tide me over. There is no slack. You do anything not to withdraw.”

Guerra paused, then continued. “A year ago I was arrested for walking Tiger off a leash. He weighs four pounds. He is my grandkid’s Chihuahua. It was the end of the month and the rookie needed to fill his quota. The senior cops all laughed at the rookie for such a stupid arrest. I went to prison and they laughed at him.

“Doc, try living in the stop-and-frisk world of the NYPD. Just for a week.”

“How does your family take it?”

“Es una locura. And why my wife has stayed with me for over thirty-five years. Who knows! She knows hard time with her brother for the real bad stuff. Mine is petty stuff and I am faithful and I love her and our kids. Our world includes prison time and probation and the likelihood you will be back again.”

After his latest incarceration, Guerra’s disease was diagnosed, and he began his treatment with radiation therapy. Every morning at ten thirty the guards would escort him per protocol in handcuffs and leg shackles through the metal gates to the elevator bank for supplies. They would go down to the ground floor and walk out to the Blue Room. He would wait there until a prison van arrived to take him three blocks north to the basement of the university hospital. Two officers would escort him to the radiation therapy area. He would be unshackled and assisted onto the table, where he would lie back on the thin metal gantry covered by a sheet.

The technician would fasten the plastic gridded molded mask over his face and screw it into the table. His throat was burned raw by the radiation treatments. Two circles of hair loss on the back of his head marked the radiation fields. To relax him during the procedure, a nurse injected him with Ativan, a sedative to take the edge off the anxiety and discomfort of being locked down on a metal table with stomach acid lapping up his esophagus, the nausea from the chemotherapy threatening spontaneous spasmodic vomiting. His stomach tube dangled down the table, almost touching the floor.

Very few people in the United States know that the largest penitentiary system in the country is in New York City. For most, Rikers Island exists simply as a TV set. Only the guards who go there and the prisoners and their families have a clue about the scale and operational routines of the place. There are eleven prisons on Rikers, an island about the size of Central Park, a short distance from the takeoff corridors of LaGuardia Airport. The only access is by a bridge from Queens that is heavily controlled by the Corrections Department. Family members, lawyers, guards, and prisoners are ferried back and forth in vans and buses to the eleven prisons, infirmaries, and miscellaneous outposts on the island where thousands of people are warehoused out of society’s view. There is a supermax prison for the extremely predatory and violent prisoners, a prison for women with room for their infants (if the women have the capacity to care for them), and a prison boat when the census gets extremely high. A smattering of high-value prisoners, such as the corrupt cops and Madoffs of the world, are kept segregated—otherwise, imagine.

The general population of Rikers consists of short-stay prisoners awaiting trial or sentencing, or prisoners sentenced for under a year. Longer terms are served in more than sixty upstate prisons holding more than fifty thousand prisoners, most of them from New York City. The state legislature in Albany has lobbied hard to bring prisons to the poorer rural communities in the northern reaches of the state, providing economic benefits to dying industrial communities. The fact that prisoners are separated from their loved ones and the fragile human ecosystem that sustains them when they finish their time is an “externality,” an unfortunate side effect. It’s an economic and social cost that is not factored into the “benefits” of rural development and keeping society safe thanks to the mass incarceration model. The rotating prison door of re-incarceration is good for certain businesses.

After I reach 19 South, our med-surgery prison unit, it takes me about ten minutes to make it through the elaborate security apparatus run by the Department of Corrections. Metal detectors, sequential electronic gates, and a Plexiglas-enclosed lookout monitored by several officers dressed in blue uniforms review all incoming and outgoing activity in this hospital prison. I call Patty to tell her that I will now be incommunicado, and then place my cell phone in a mailbox-size locker and pocket the key, supervised by a seated, attentive corrections officer.

“Gate,” I shout. A very large guard approaches slowly and without affect, dangling a huge key in his hand. He lets me into the unit without looking at me—his eyes floating to some invisible place right over my head. When I finally enter, I am really in Corrections’ space. This is not a civilian universe, though we have made an effort to bridge the cultures of medicine and corrections, to achieve a balance of security and a health-supporting environment. As I enter the conference room, Juan Guerra looks up and smiles. He and his twenty-two-year-old son are in deep conversation. His wife, a lively, strong woman, looks worried.

This dingy “conference” room at least offers a modicum of privacy and, most important, some freedom from the constant barrage of noise, the shouting, the bright fluorescent lights, and the call for “gate” that punctuate the air like a slap in the face as nurses, aides, doctors, corrections officers, pharmacy techs, dietitians, therapists, administrators, supervisors, regulators, and wardens make their way in and out of the unit. Still, the windowless room is depressing with its dead color, the echo of metal on metal, the scratched Plexiglas, and the omnipresent guard in the corridor outside.

I am glad to see Guerra looking relatively strong. He is about to get up when he sees me. I urge the family to go on. I pretend to look for something in the chart to give them time to speak.

“The pandillas [gangs] are death for you, m’hijo. You have to make a choice soon, or it will be made for you.” Guerra waves me into the room, but I step outside the door and signal that he should take his time.

“My friends are who protect me,” his son says.

“That type of protection is a death trap.”

“Without them I am dead.”

“Then you will go to the DR this week and stay with Tio Juanito,” Guerra’s wife interjects. “We used to leave Santo Domingo to avoid Trujillo and his butchers, now I have to send my son home to avoid the gangs here.”

“Tio Juan’s is bullshit. I am too old for horseback riding and cleaning the stables and driving a tractor.”

“When I was your age it was the Lords or the army,” Guerra says.

“So what are you saying?”

“I am saying, Javie, that for you it is the same choice.”

Javie laughs. “The army will save me? Look at you!”

“Learn from me. You go in, you enlist and choose carefully who you hang with, and you stay away from drugs—nothing in the vein, up the nose, nothing. You do that and the odds shift right away.”

I sense a pause and lean my head back in the room. Javie looks at me straight in the eyes without anger or hostility. He knows I am on his father’s side. After decades of being in and out of the system, Guerra has learned to use his smarts and humor to get people to help him. He is not completely powerless, even though he has cancer and is in prison. He is trying to teach his son to survive in what suddenly strikes me as a nearly hopeless situation.

Guerra stands up, a bit shaky, and introduces me to his family as the “mero mero” or the man who would help explain his treatments. We shake hands and trade the bachata CDs we’ve both brought, the rhythmically contagious music from the Dominican Republic. In fact, Juan Guerra and I like to joke about his tocayo or namesake, Juan Luis Guerra, one of the most popular bachateros in the world, who sells out Madison Square Garden in an hour.

Juan Guerra’s family has visited him in jails and prisons from New York City to the upper reaches of New York State near the Canadian border. They have sustained him and, in a way that is not immediately obvious, he has sustained them. I lay it out slowly and carefully, what to expect from the chemo, the radiation, the fatigue, the pain medications, and so on, taking a lot of time for questions, drawing diagrams and a time frame on pages ripped out of my black-flecked notebook. The treatment will take another two months, and the recuperation another four months after that. To return to a sense of well-being takes at least a year—really two years. During that time, quarterly surveillance in the form of PET scans will determine his future (or if he will have one). The disease and the treatment will test the whole family’s limits—they will need as much backup from family and friends as they can muster.

Guerra blocks me when he thinks I am saying too much. It’s interesting because I thought he hadn’t been paying too much attention, but he has taken in everything and has been weighing it against what his wife and son can handle. I am struck by his subtle calibration of his family’s ability to handle stress in its protean forms.

For years, I had been at the tail end of discussions about compassionate release for terminal prisoners, those who were so ravaged by disease that they posed no threat to society regardless of their crime. Guerra, who had never committed a violent felony and was struggling against a life-threatening disease, was a good candidate for release.

Humanity dictated that people like him could and should spend their last days with their families. The hard-line punitive thirty-year-plus political environment demanded time served without mercy. Many patients, unfortunately, had no family left and many families were dysfunctional remnants, incarceration’s other silent victims. For others, this basic social unit proved remarkably durable. Most patients released under the compassion rubric could not walk. Others had progressive neurological diseases and couldn’t breathe without oxygen being forced into their lungs. Most had only a few weeks or a month to go. Still many critics of the humanitarian program clamored for revenge—“Let them rot in prison and die alone!”

But I can’t help but think of the old expression: If one is intent on revenge, one should dig two graves. One for one’s victim and one for oneself.

Why was Guerra still in limbo regarding compassionate release? Yes, he was a recidivist and still addicted to heroin. He had a possible terminal disease with a generous 30-plus percent chance of a cure. It was all numbers, statistics, and probabilities. The treatment was protracted; if he could complete it, he had a chance. If he could not, then he had no chance and the inexorable growth and expansion of the cancer would kill him in a year max.

We’d filed the papers for compassionate release with the prosecuting attorney, a recent Harvard Law School grad (as she let me know in the first three minutes of our conversation), and we attempted to call her office a dozen times without a response. Finally, I called on connections. The husband of one of my attending physicians was a prosecuting attorney with a bright political future. He was eventually successful in getting his colleague to return my call.

She was tired, grouchy, and clearly did not know much about the case in question. This was not a highlight of her day. The scorecard for her life after the DA’s office was about putting prisoners behind bars, not letting them out. That was her ticket to partnership and a lifetime in elite legal circles. I got that, so I put my argument in terms of not compassion, which would have netted zero results, but rather cost efficiency. Juan Guerra’s care in jail would cost $350,000-plus; he had a wife and son and a stable home situation. I also reassured her that the Guerra case would not come back to haunt her as she moved up professionally. Guerra’s Vietnam War record and the fact that he had no felonies for weapons possession or violent acts of any kind were predictors in his favor.

We still heard nothing for well over a month. During that period I would pop in to talk to Guerra from time to time, to check his neck and mumble reassuring nothings. He was losing weight, losing hair, and, indomitable as he was, beginning to lose hope. He was not angry talking about prison or his life. He did it half laughing and with a partial smile. It was life as he knew it. The prison routines, the judicial system, the court-appointed lawyers, the shitty food, indignities, risks and violence, gangs, protection were all kept in a part of his brain he shared only occasionally. The trick was appearing confident and not vulnerable when he spoke of his life behind bars. This was survival strategy number one. Knowing how to wait. But now, of course, waiting was not a survival strategy. Hope was not a plan.

As I leave the conference room to go back to my office, Budd finds me. “There’s been a glitch,” he says.

“No!” I say, surprising even myself by the tone of surprise in my voice.

“Yes.” Budd’s matter-of-fact tone does not hide his frustration. “Apparently the clerk faxed in the wrong form and the lock-them-all-up-for-life guy in Albany got wind of the release so it’s all touch and go now. We can’t release him without the right document. We’ll have to get the right one signed ASAP if he’s going home.”

“Guerra doesn’t know. Can you stall a bit?”

“Yes, we’ll have to. Let me figure something out.”

“Okay. I’ll be back up later. Call me if you know anything.”

“ ’Kay. Later.”

Getting out of the prison unit is a lot easier and faster than getting in—if you’re a doctor and not a prisoner, of course.

I check in with Patty to learn that the Mexican minister of health has been delayed. I climb the two flights of stairs to the male psychiatric ward to take a look. Some patients sit at the round tables in a large room chatting with the aides, nurses, and doctors or sit quietly by themselves or pace. Coffee and cartons of apple juice and packages of cookies have been handed out, like a break at summer camp. Uniformed guards stand at both entrances. There are about thirty patients, mostly black men, a few whites, and some Hispanics. They are schizophrenic, bipolar, depressed, anxious, suicidal, schizo-affective, and have personality disorders. Many have been abused, many are ex-felons, many have drug problems, some have AIDS, and many have all of the above.

The psych ward brings up a memory of my medical school training years in Brooklyn.

A twelve-year-old had been found in the psychiatry emergency intake room by a clerk, who noted that he had been there for several days sitting in the same chair. The boy was wearing a pull-down gray winter hat and sunglasses. He was brought into the triage area for questioning. When the nurse removed his hat and sunglasses, the bruises around his head—black eyes and a swollen-shut right eye—made it clear in a microsecond what the issue was. His story emerged in stages over weeks. His mother and her boyfriend would tie him to the steam heating fixture in their apartment. He was fed from two dog bowls on the floor, one for water and one for dog food. He was beaten if he cried and if he didn’t cry. He was whipped and watched this couple smoke crack. His mother would bring up other men for ten dollars. He would whimper and they would beat him. One day they dropped him in front of the hospital. After he was admitted, we fed him ice cream, candy bars, McDonald’s hamburgers, Rice Krispies, and anything else he wanted. Then he was sent to the ACS, Administration for Children’s Services, for disposition to a family that would look after him. That was it.

Today he would be forty-six years old. I was twenty-four when I met him. I have never gotten the image of his baby face out of my mind. Every time I see a bruise, I see his face. Was he in the prison ward? Was he in a unit like this somewhere, having orange juice? Was he alive?

Many if not the vast majority of the individuals in the psych unit were subjected to extremities of violence themselves as children. If there is a laboratory experiment in how to create people at the margin of functionality by eliminating all resources and social supports, education, medical care, and community involvement, these are the guinea pigs who have been dumped out of their cages and turned loose on the streets. The prosecuting attorneys lock them up in the city’s penitentiaries, and we treat them for the medical and psychiatric problems that flourish in the hothouse atmosphere of a prison system. In forty years, that system has gone 180 degrees from rehabilitation to punishment, without regard for the long-term self-inflicted collateral damage.

My cell phone rings, and Budd’s name appears on the screen. “Nothing yet. The Guerra family is getting agitated.”

“Okay. We’re working on it.”

I decide to go back up to the prison unit until I hear from Patty. I want to be useful to Guerra and his family and smooth over the discharge. Plus, I remind myself, I have other patients there that I need to talk to.

I see Marlene Scott, the head nurse for over twenty-five years, bending over a file at the nurses’ desk. A middle-aged, diminutive Afro-Caribbean woman, she emanates calmness and authority. The escalating curses of a patient being wheeled to his room/cell down the hall behind her do not even seem to register. She looks up and smiles at me. “Budd’s in with a patient.”

We reminisce about the old prison unit in the administration building at Bellevue, before the new hospital was built. No one wanted to go there. It was made of wide-open wards typical of the time. Kings County, where I trained, had the same setup. Everyone was in one big room with only curtains to protect their privacy. And the curtains didn’t work! On my first day as resident, I was on rounds and tried to pull the curtain shut. Dozens of baby cockroaches fell on the patient’s huge cirrhotic abdomen filled with tense ascites, fluid from a scarred and marginally functioning liver. His yellow hue was the same as the stained sheets. He didn’t move when the roaches scrambled off him onto the bed.

I ask her about Guerra. “No news,” she says, “but they’ve got a whiff of the problem. It’s hard for them, after everything they’ve been through. The possibility now that he won’t get out seems more than they can bear.”

“I’m going to see him now.”

She decides to walk with me through the unit to the waiting room. As we go, she tells me about a retirement party a few weeks earlier at Bellevue where a woman spoke of her first job on the prison unit when she was eighteen. She had called a prisoner by a number. Her supervisor asked her to step outside. He told her this was a human being and to call him Mr. Jones. She never forgot that lesson. She used it as an example of the many contradictions that crop up in trying to treat people as human beings in systems that degrade their humanity.

I see Guerra’s wife speaking intently to her son. I wonder for a second who comforts her.

I put my hand on Guerra’s shoulder and assure him we’re working on the release. Guerra just shrugs. “I was an idiot to hope. What a pendejo!” He looks old. In prison, everyone looks ten to twenty-five years older than they are, except the teenagers.

I check my watch and go to the nurses’ station to call Patty. No beeps, so that’s a good sign. She picks up immediately and tells me something has come up in the Mexican consulate; the minister is delayed again. He will make it in by late afternoon. He’ll call. She got the Guerra release files again and hand-delivered the right form back to the prosecuting attorney’s office. She wants me to call them to expedite it, sign it, and return ASAP. They won’t pay attention to her.

My beeper goes off several times and I retreat to the nursing station for a phone, a computer, and a modicum of quiet. Medical Director Ed Fishkin from Brooklyn’s Woodhull hospital is on the line about our lack of ICU beds and their inability to transfer three patients who have been waiting for more than a day. A young woman has falciparum malaria after returning from Southeast Asia. And she is in her third trimester of pregnancy and cannot breathe. We need an ICU bed and a team from high-risk OB, pulmonary, and critical care medicine right now.

The next call is from my daughter, Marina, inviting me out to dinner at a small bistro on First Avenue, our usual place when Diana is out of town giving a lecture. Marina was back after a post-BA year studying in Israel and was settling into a new job in Midtown. Sometimes the five of us would go out, including my son, Alexei, who lives in Brooklyn with his wife, Gladys. Diana complained that all the best family dinners happened when she wasn’t around, but she understood and appreciated the family support system.

After getting an ICU bed, I make a call to the prosecuting attorney’s office and tell her assistant about the urgency. I promise to email the attorney. I put in a few words like “justice” and “the American way” and “my friend at the New York Times” in the hope of hurrying this along.

I report in to Patty.

“Jefe, I have a turkey sandwich on your desk for when you get back down here.” She then puts through my voice messages—all routine except the one from Diana sending me hugs and kisses from Santiago, plus she’s found me the perfect novel by Faciolince and pulsating vallenato recommended by her friends in Colombia. Our long-standing tradition from her innumerable travels: She finds the most interesting book everyone is talking about and the CD that you can’t live without.

I wind my way back through the gate and pick up my cell phone, then head back to my office. Too late I remember that sanctimonious Dr. Faruz is waiting. He’d been in several times in the past couple of weeks already, complaining that another department was poaching on his area. As new technologies have developed, several departments (not infrequently with a monopoly source of income) have been losing ground on what they see as their immutable rights to turf. Interventional cardiology with catheterization has reduced the volume of bypass surgeries dramatically worldwide. There are medical winners and losers in the financial game. This is why Faruz was waiting for me, though inevitably the tensions would be expressed in terms of quality and patient safety, competency, and so on. I was not sympathetic. Times change, new procedures come online all the time. Departments that try to hold on to things using technical and bureaucratic stratagems to control their monopolistic practices are not just hurting themselves. In the long run, they limit the institution’s ability to stay vibrant and adaptive and will ultimately hurt our patients.

I’m not in the mood for Dr. Faruz—I just want my turkey sandwich.

As I put my hand on the back door to my office, I hear my name called from behind. Beth, the head of the forensics unit, is on her cell phone and waves at me to wait. She listens intently into the phone. When she hangs up, she asks me if I have some free time to go with her to CPEP to see a new prisoner who was brought in recently. I think about my sandwich, then look at my phone and see that Patty has moved the appointment with the Mexican minister of health until the end of the day. I think of Dr. Faruz and turn to follow Beth back down the stairs to the ground floor.

We wind our way through the back corridors and are stopped by a phalanx of corrections officers. There are the usual officers in blue with holstered guns, but now there are also many in white shirts and the entire area is blocked off from every direction. We see a single prisoner being led between a squadron of blue and white shirts in front of us down the hall from the Blue Room to the CPEP entrance.

He’s the prisoner I saw come in early this morning from my office window. He is shuffling in his leg shackles. He looks over at us since we are the only non-guards in his field of vision. He is totally expressionless. His eyes are alive, but he gives away nothing. His tattoos are obvious now, even more chilling since they cover every inch of exposed skin except the front of his face. His neck bears the letters MS and a number 13.

Las Maras Salvatrucha. The Maras are leagues away from the Crips and Bloods. They’re relatively new to New York. I am familiar with them from my trips to Chiapas, the southernmost state in Mexico near the Guatemalan border. The Maras prey upon undocumented immigrants fleeing north. They will steal and extort everything. They will cut off arms, disembowel, or behead someone for nothing. When the Maras are sent to prisons, they take them over, organize them, terrorize the guards, and train their fellow inmates in their particularly vicious brand of violence.

CPEP, where the Mara gang member is taken, is a very controlled space. New York City police and hospital police stand right outside the doors and glass windows. The many staff members inside this prison wing are used to dealing with all kinds of difficult situations, particularly violent and unpredictable patients. “Tako”—as he is nicknamed according to his file—swallowed some silverware at the supermax prison on Rikers, and needs some X-rays and a surgical consult. We have to observe him for a couple of days while things work their way through his system and out the other end. This is a fairly common practice, and we call the patients “swallowers.” Inmates use this little trick as a way to get off the island and break up the boredom. Our Mara friend says nothing. I’m glad to get out of there and thank my colleague for taking me down with her, though I will have Maras pesadillas, nightmares, for a few weeks afterward.

I head back to my office as my beeper goes off. Budd. I call up. Guerra isn’t eating. Won’t allow anything in the tube, either. His wife and son are beside themselves. I say I’ll be up.

Late in the afternoon, the ritual of getting into 19 South is compounded by the rush for elevators, the waiting, pushing, shoving off all those in a hurry to go up or down. After I make it to the floor, Budd takes me to Guerra. He looks gray. If anything, he has aged since this morning. He looks up at me, weary, and looks down at his shoes again, bent over as he is with his shoulders on his knees. His wife and son look alarmed.

“What’s up?” I ask him.

“I’m sick, Doc.”

“How come you’re not eating?”

“I’m afraid to throw it up. It’ll hurt.”

“You have to eat, Guerra, or you’re going to get weaker. You need all the strength you have for this. We will use the stomach tube now exclusively to feed you, so no worry about swallowing at all. You will reteach yourself how to swallow when you’re stronger. Your throat muscles will learn again.”

He looks at me. “It doesn’t matter.”

“Guerra, don’t give up now. You’ll be home soon. You have to save your strength for your treatment. Don’t make it harder for your wife or for your son.”

Guerra looks up again, and stares at each of them.

“Okay. Bring it on.” His wife attaches the syringe to the plastic outlet on the tube that dangles from just above his belly button—her first time feeding him, and pours in the Ensure. He holds her hand as the liquid goes in.

“Good,” I say. “You’ll both have to learn how to do the feedings and look after the equipment. It’s not hard. You’ll get the hang of it. Small amounts six times a day and slow feeds overnight by the pump. That’s it.”

I smile at them as I leave.

Back in my office, I put on some music and make myself a coffee. I email Patty for an update, but ask her to give me a few minutes if possible. I sit and look out the window, and am suddenly furious. Why is someone like Juan Guerra treated the same as the Mara? When did mental illness and petty drug possession offenses become equivalent to major crimes? The psychiatric patients need mental health care, Guerra needs cancer treatment at home with his family, and “Tako” needs to be locked away in the supermax—not that imprisonment will deter him from continuing the terrible things he’s done. There are now at least tens of thousands of Maras and their deadly offspring spread from LA to Long Island. Do we really need to finance an incubator for more? Why are so many people, with such a wide range of problems, sent to prison as the one-size-fits-all solution?

If our goal as a society is to lock people up and throw away the key, then there is a genius to the three-strikes laws. If the goal is to make us feel safer and to create a society that is healthier and more productive, then we have failed miserably.

I pull my thoughts back to the present when Patty calls. Guerra’s papers have been signed and he is being released within the hour. She also tells me that the young woman in the SICU with a severe brain injury from her motorcycle accident has died. Normally Patty wouldn’t call me about this, but the body was left in the room for six hours before being claimed by the medical examiner, headquartered just a block north of the hospital. The family flew in from Italy, not only bereaved but irate over the lapse. They are saying they won’t be able to get their daughter home for a proper burial. I tell Patty I’ll phone the parents and apologize profusely after speaking with the attending and getting details from him. The ministro de salud of Mexico has arrived, she adds, and will be up in five minutes. I look at the building encroaching on my view, the steady thread of cars heading north on the FDR. One of them will soon have Juan Guerra in the backseat with his wife and son on their way to the Bronx and a future they can’t anticipate. Will he even complete the treatment? This thought starts to burrow its way into my brain. I reel it in and turn off the heart-aching fado music of Dulce Pontes as I get up to greet Mexico’s minister of health.

CHAPTER 2

Tanisha

The walk from Bushwick in North Brooklyn had taken several hours. Ice-cold air and slushy snow on the streets had the effect of another dose of adrenaline for Tanisha. She had climbed down the fire escape outside the window in her room when commercial garbage trucks were making their predawn rounds. Her hands were freezing against the oxidized and flaking bare metal that scraped raw the skin on her palms. Three flights down and then a fifteen-foot drop to the sidewalk. By the time she was at the bottom and hanging from the rusty bottom rung, her five-foot-one frame left her with a mere ten-foot controlled fall. It was four o’clock in the morning, and the streets were empty. A flickering streetlight reflected off the snow and ice. She could see the barbershop sign as she hung for a few seconds. The lights of a 24/7 Bodega “El Amanecer” on the corner were nearly hidden in a cloud of steam from a sidewalk vent. She let go and dropped, hardly making any noise when her Converse All Stars hit the cement. She remained in a crouch, rubbing her ankles, for a few seconds.

Tanisha was sixteen, pretty, with braided hair that hung to her mid-back. She had bundled herself in several T-shirts, a sweater, and an extra-large Yankees sweatshirt along with jeans layered over pajamas. She headed toward Myrtle Avenue a few blocks away, carefully scanning the streets. A few lone cars drove past her as she made her way, her breath turned white. She was glad it was freezing, unlikely anyone would be hanging outside.

She had stayed too long at this foster family’s apartment. She knew it from her placement there exactly four weeks ago. The caseworker from the Administration for Children’s Services had taken her in a car with another worker. It had been her twelfth foster care placement, almost one a year since she was born in Kings County Hospital sixteen years earlier. They had arrived in the late morning and a middle-aged woman opened the door, smiled, and welcomed them inside. Tanisha had dropped her guard slightly when the woman, Letitia, spoke with a Spanish accent. It had brought her back momentarily to the one foster placement that had been a home to her several years earlier.

The warmth of the apartment—the radiators that had no controls—and the steamed windows made it seem almost friendly. The caseworkers had stayed for over an hour, talking with Letitia, introducing Tanisha, and helping unpack the small backpack of what remained of her worldly items. She had a few changes of clothes and a small zipped bag for her toothbrush and hairbrush. The senior caseworker Anna had given la puertoriqueña Letitia two plastic pillboxes and gone over the instructions for the timing of the medications and possible side effects. There was a sheaf of papers she had in a plastic binder. She gave Letitia a copy of some documents and asked her to sign and date a form. The workers turned to Tanisha, who was sitting quietly at the dining room table, came over to give her a hug, and told her she would be fine here and they would be by to visit in a few days.

The problem started that night. In the late afternoon, Letitia’s daughter had come home with her boyfriend. They put on the television and ate pizza while talking and ignored Tanisha after a perfunctory introduction by Letitia, who promptly left to do some errands. The boy was around twenty and lived upstairs and didn’t appear to notice that Tanisha was even in the room.

It was after midnight when Tanisha was in bed. She had left the window open a few inches since the only way to control the temperature was to let in some cold air. She heard the window scraping against the frame and saw a sneaker and leg enter the room, followed by the young man from the afternoon. The light from the street made it clear who he was even in the shadows. He slid the window down, looked over at her, and took out a switchblade.

This wasn’t the first time Tanisha had been raped, violated, or abused in foster care, but she had decided it would be the last time. She said nothing to the family the next morning after they banged on the door to the bathroom as she showered under near-boiling water for fifteen minutes to cleanse her mind and body. The window didn’t have a lock. She jammed it shut that morning and rigged a wooden bar so that it could not be opened. She also took a knife from the kitchen and kept it at the side of the bed. She heard rattling at the window a few nights later, again after midnight. The young man came over several days a week, and one night she noticed that the piece of broomstick keeping the window secure was gone. It was time to get out.

When she got to Myrtle Avenue, she turned right under the elevated train. She had gotten directions on the walk to Manhattan from a friendly counterperson at the White Castle all-night diner. “You go to Myrtle,” he’d said, pointing out the window, “and make a right turn. It is another fifteen minutes until you hit Broadway. There is another elevated train there and you make another right turn. You just walk the length of Broadway and stay under the elevated train. It runs right into the Williamsburg Bridge. You can’t miss it. You are practically in the East River. It is another world there. You are in another country.” He smiled enigmatically while handing over two hamburgers and french fries “on the house, chica. Suerte, good luck.”

By the time she got to the hundred-year-old bridge it was past five a.m. and the streets were starting to fill up. At first she was anxious, but she could hear the trains squealing overhead. The early-morning risers were going to work. Bundled up against the cold, they barely gave Tanisha a glance, walking quickly to the steep stairs to the M train platform or ducking into the coffee and donut shops that lined Broadway in a shadowy sunless netherworld. She knew she was near the bridge when several men walked along the early-morning streets of Williamsburg in long black coats and round brown fur hats with white socks. She had heard about this group of Hasidic Jews, the Satmars. They ignored her and spoke among themselves in a guttural foreign language. An orange school bus idled at the corner, plumes of white exhaust exiting the rear like a surreal post-apocalyptic beast. The door opened and long black coats and fur hats got inside.

It took Tanisha awhile to find the pedestrian walkway across the bridge. She waited until a group of middle-aged workers, black metal lunch pails in hand, started across and trailed them by fifty feet. They would be her safety net to the other side. The morning was sparkling clear and very cold. The wind whipped through her layers. She tucked the hood tightly around her head and put her hands underneath her armpits. Traffic was picking up. Red taillights zipped by. Tugboat lights headed north up the East River toward Roosevelt Island. Sparkling yellow lights from Manhattan stretched as far to the north as you could see. Once she was across the bridge, she was in known territory. She had been “placed” on the Lower East Side two years earlier. There wasn’t a block, bodega, or pizza shop she didn’t know in the area, from Delancey Street to 14th Street. Avenue C in Alphabet City had been her home base. It would be good to be out of a Brooklyn she was unfamiliar with—each neighborhood a crazy quilt of angled streets, different languages, street gangs, drug dealers, hustlers, hipsters, and old folks sitting on their stoops. You had to have your wits about you and stay in your safe zone or it was a game park.

As Tanisha wound her way past the midpoint of the bridge and began the downward slope into Manhattan, her thoughts changed into Spanish. She was back in the house of her abuelita. Mama Lola as her family called her and abuelita (little grandmother) as the six young girls called her, wards of the state in foster care in a group home run by Mama Lola and her adoring husband, Hugo. He drove a livery car or gypsy cab fifteen hours a day, as the price of gasoline had inched its way up and cut into his weekly take-home pay. Abuela always said her husband “was an exception to Dominican men. He has one wife and one family, and he is a loving man. I found the one in my town.”

As her legs carried her down the slope, she ran through in her mind the families and group homes she had lived with over the years since she had a memory. Of her mother she had no recollection, and there virtually no information was shared with her or perhaps known. All Tanisha knew about her mother was that she was a Latina drug addict; crack was her drug of choice. She had several other children all in foster care removed by ACS. She had left Tanisha when she was a child with some “crack sisters,” and a neighbor called 911. After the police arrived and found a six-month-old girl in a filthy rug, they brought the baby to St. Barnabas hospital in the Bronx. ACS was notified and traced the mother to the Rose M. Singer women’s prison at Rikers Island. They worked through the legal system to have Tanisha removed permanently from the mother’s custody given her long record of drugs, abandonment, and prostitution. Tanisha’s mother had been a victim herself of a mother who had been a gang member, drug user, and petty dealer who didn’t actively abuse her children so much as neglect them. Feral was the term ACS used in a report that had been shared with Tanisha by a social worker when she was a young teenager. Tanisha had no idea what feral was. She had thought it was an animal, a pet tiger.

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Excerpted from Twelve Patients by Eric Manheimer Copyright © 2012 by Eric Manheimer. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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