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  Until this point, the American hospital had been the province of the lower classes. Those with the means to avoid one happily stayed away. There was nothing a hospital could do for the upper and middle classes that couldn’t be done better at home. But advances in technology, sanitation, and nursing were changing that perception. At Bellevue, for example, the chance of dying from a postoperative infection following surgery in 1865 was almost one in two; by 1900, that figure had dropped below 10 percent. As hospitals became better at saving lives, a serious competition emerged for “paying patients”—those wanting the benefits of modern medicine without sacrificing personal comfort. Bellevue was not a serious option for these people unless a city ambulance plucked them unconscious from the gutter. But as “voluntary” hospitals began to convert some of their charity wards into private and semiprivate rooms, crowding in public hospitals became ever more intense.

  The results were predictable. During the Great Influenza of 1918–19, Bellevue quickly ran out of beds, forcing the patient overflow to sleep on doors ripped from their hinges and piles of damp, fetid straw. Similar scenes appeared throughout the Great Depression, when a third of the city’s workforce was unemployed. With far fewer New Yorkers able to afford a stay at a voluntary hospital, Bellevue bulged at the seams. Many of these patients were members of the “better classes” who had never set foot in a public hospital before.

  And rarely would again. The return of prosperity following World War II revived the struggling voluntary hospitals, as group insurance plans like Blue Cross, often written into employment contracts, afforded the working classes access to amenities that a place like Bellevue couldn’t possibly match, despite the excellence of its medical staff. Why put up with the indignities of peeling paint, miserable food, crowded wards, and perhaps a stabbing victim in the next bed when a semiprivate room in a well-appointed private facility could be had? The coming of Medicare and Medicaid in the 1960s—programs that funneled billions of tax dollars into the health care sector—further diminished public hospitals by giving poor and elderly patients greater freedom of choice.

  In the 1960s, both Cornell and Columbia departed Bellevue, leaving NYU physicians to provide the medical care. The quality remained high; NYU had long been closest to the hospital because so many of its faculty and house staff were native New Yorkers from the working and middle classes who viscerally grasped Bellevue’s importance to the city. In 1973, an enormous addition was opened—a partly finished twenty-five-story patient tower, two decades in the making—just as national economic stagnation took hold. The impact on New York City was dramatic. Vital public services, including free hospital care, were now in jeopardy. Crime and drug addiction flourished against a backdrop of white flight, a declining tax base, and the threat of municipal bankruptcy. For Bellevue this meant staff shortages and budget cuts in the midst of jam-packed emergency rooms and soaring psychiatric admissions. One crisis flowed into the next, the bottom reached in 1989 when a homeless psychopath raped and murdered a pregnant physician in her Bellevue office. The killer had not only been wearing stolen doctor’s scrubs, complete with an identification badge and a stethoscope, he’d been brazenly squatting for weeks in a machinery room in the hospital, entirely overlooked.

  Amidst the growing calls to close down or privatize the entire public system, a familiar truth reemerged: New York needed these hospitals, especially its flagship. When AIDS descended in the 1980s, Bellevue again became ground zero for an epidemic targeting those on the margins of public concern—in this case gay men and intravenous drug users. Many more AIDS patients would be treated (and die) there than at any other hospital in the United States. The story of AIDS at Bellevue is a complicated one, as we shall see, but nothing better defined the hospital’s mission—its indispensable service to society’s most vulnerable members—than its response to this seemingly endless medical nightmare.

  Bellevue today remains a buttress against unforeseen crises that periodically arise—the successful treatment of New York’s lone Ebola victim in 2014 being the latest example. And its resilience was displayed again in the heroic patient evacuation during Superstorm Sandy, which closed the hospital for the only time in its storied history. Bellevue reopened a few months later, its mission unchanged. The old ethnic groups have moved on—Irish, Jews, and Italians replaced by Hispanics, Haitians, Africans, South Asians, and Chinese. The patients it currently serves are every bit as poor and needy as the patients who preceded them in centuries past. And those with viable options almost always wind up going somewhere else. That’s what makes Bellevue so comforting and so disquieting. It stands, for all its troubles, as a vital safety net, a place of caring and a place of last resort.

  1

  BEGINNINGS

  At the southern tip of Fifth Avenue, in the heart of Greenwich Village, sits the leafy oasis known as Washington Square. A cherished landmark for New Yorkers, its iconic arch, imposing fountain, and flowered walkways provide no hint of its tumultuous past. At various times Washington Square has served as a military parade ground, a gallows, a haven for ex-slaves, and a magnet for artists, hustlers, street performers, and protesters of every stripe. After the American Revolution, it became a mass grave for the victims of epidemic disease.

  All large cities have a “Potter’s Field”—a cemetery for unclaimed corpses. The term comes from the New Testament: “And they took counsel and bought…the Potter’s Field, to bury strangers in.” New York established its Potter’s Field in 1795 in response to a devastating yellow fever outbreak. Covering 9.5 acres, it created a furor because it abutted the country homes of New York’s financial elite. “The field lies in the neighborhood of a number of Citizens who have at great expense erected dwellings…for the health and accommodation of their families during the summer season,” read a letter of protest signed by Alexander Hamilton, among others. But Mayor Richard Varick stood firm, ruling that a medical catastrophe trumped the interests of a few dozen landowners, who included some of his closest friends.

  It’s estimated that twenty thousand people were buried in Washington Square between 1795 and 1826, when the Potter’s Field was moved farther north to Fifth Avenue and 42nd Street, where Bryant Park stands today, and then to Hart Island, in the outer reaches of the Bronx. Most of the victims were recent immigrants who lived in squalid boardinghouses near the downtown wharves. Each summer and fall—yellow fever season—their bodies would be dumped into wagons and carted uptown. “The wheels of these chariots of death rolled heavily,” a witness recalled, “the springs and timbers screeching and groaning as if chanting the requiem of friends departed.”

  Over the years, workers digging in Washington Square have routinely come upon human remains. But in 2009, a construction crew encountered something odd: a three-foot grave marker with the inscription still intact. “Here lies the body of James Jackson,” it read, “who [left] this life the 22nd day of September 1799, aged 28 years, native of the county of Kildare, Ireland.” The discovery raised a pointed question: Why would someone with the means for a headstone wind up in Potter’s Field?

  City records told the story. James Jackson had achieved some modest success in New York City as a grocer, leaving behind a wife, several children, and a personal estate valued at $262. He had also applied “to be a citizen of the United States.” In normal times, a man of Jackson’s standing would have been interred in a church cemetery. But New York was a city under siege in the 1790s, overwhelmed by yellow fever. In a desperate attempt to contain the disease, the dead bodies, believed by many to be contagious, were buried together in a single place. As a contemporary newspaper explained: “It is important to remark that no persons dead of fever are admitted to any other cemetery, which has not been the case heretofore.” And that is how the body of James Jackson, the Irish grocer, came to rest in Washington Square.

  But Jackson was fortunate in one respect: he almost certainly died at home. Dozens of others were brought to a place specially created for yellow fever victims
who had nowhere else to go. Little more than a pesthouse—a way station, truth be told, on the path to eternity—it would earn a grisly reputation as New York City’s dumping ground for the terminally ill and unwanted, taking its name from the deceivingly placid acreage on which it stood: “Bel-Vue.”

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  A number of cities claim the honor of establishing the first hospital in North America. The problem is one of definition. Many of the almshouses in colonial America contained a small infirmary to care for the destitute. In 1752, however, Pennsylvania Hospital in Philadelphia opened its doors to medical patients alone. Founded by Dr. Thomas Bond, with a charter from the Pennsylvania legislature and the financial support of Benjamin Franklin, it was intended for “the reception and cure of the sick poor,” not for those seeking food or shelter or a place to die. In this sense, Pennsylvania Hospital holds a very strong hand.

  Some, however, consider Bellevue to be first. Citing records from the West India Company, when the Dutch ruled Manhattan Island, they trace Bellevue’s existence to a small infirmary built in the 1660s for soldiers overcome by “bad smells and filth.” Under British control, a permanent almshouse was constructed in 1736—a two-story wood-and-brick structure costing £80 for building materials and fifty gallons of rum for those who “laid the beams and raised the roof.” It contained a workspace for the able-bodied, a room for the sick and the insane, and a prison in the cellar for the “unruly and obstinate,” complete with a whipping post. Those found “to be Lousey or to have the Itch” were segregated “til perfectly Clean.” This one-room infirmary, we are told, is “the seed from which grew the mighty oak of Bellevue.”

  Built on the site of today’s City Hall Park, the almshouse became a vital public institution. Serving just nineteen paupers in 1736, it housed close to eight hundred of them by 1795, as New York’s population soared. To stem the tide, city officials took to rounding up vagrants and prostitutes and paying their transportation out of town—but it barely made a dent. The almshouse commissioners demanded ever-larger budgets, blaming their costs on “the prodigious influx of indigent foreigners,” mainly from Ireland. In the 1790s the city opened a larger almshouse financed by a municipal lottery, a common money-raising device. But its infirmary was soon overwhelmed by yellow fever, which brought dozens of sick and dying victims to its door. As panic spread, the Common Council leased a vacant property along the East River, far from the city center, to house the “wretched overflow.”

  The land they chose had a checkered past. Once prized for its lush gardens and freshwater breezes, it had first belonged to a prominent Dutch settler named Jacobus Kip, who built a house there in 1641—the Kip’s Bay Estate—using bricks imported from Holland. In the 1700s, Kip’s heirs had divided the land, selling one parcel to a local merchant who named it Bel-Vue for its rolling fields and river vistas. A grander home was soon constructed—one so impressive that it played host to both the fleeing General George Washington and his British pursuer, General William Howe, during the darkest moments of the Revolutionary War. Shortly thereafter, it passed into the hands of Lindley Murray, an eccentric scholar whose popular books about the English language had made him a spectacularly rich man. Murray wrote lovingly of a mansion “delightfully situated” on lush farmland overlooking “a grand expanse of water.” In truth, he barely set foot there before sailing off to London—the proper place, he believed, for “the father of English grammar.”

  An advertisement soon appeared:

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

  The price being steep, it didn’t sell quickly. Five years passed before Henry Brockholst Livingston, a prominent New York attorney and future U.S. Supreme Court justice, paid £2,000 for the six-acre estate.

  Livingston, it turned out, had no intention of living there, either. The property—referred to interchangeably as “Bel-Vue,” “Belle-Vue,” and, finally, “Bellevue”—passed from one renter to the next before the Common Council leased it in 1795 “to serve as a hospital for the accommodation and relief of such persons afflicted with contagious distempers”—or yellow fever. Described by nervous officials as “a proper distance from the inhabited part of this city,” it was accessible by road and river, with a dock already in place. The plans called for hiring a steward, a matron, a resident physician, and “as many nurses as may be wanted.” There would be “two men to transport the sick to Bellevue” in wagons and “a Boat with good oars-men” to ship in needed supplies. Port, brandy, and “assorted spirits” headed that list, with detailed instructions for the doctor. “Sherry wine, the most natural stimulus, should be given freely,” he was told, and “beer, for those who are accustomed to its use, is a very valuable remedy.”

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  New York City had seen its share of epidemic disease. From the Dutch settlement forward, infectious outbreaks were a common part of daily life. The first Europeans had praised New Amsterdam’s “sweet and wholesome climate”—more forgiving than the brutal cold to the north in Boston, less treacherous than the fetid swampland to the south in Jamestown. But Manhattan’s bustling harbor soon became a magnet for the world’s microbes and maladies. Periodic eruptions of measles, influenza, scarlet fever, and “throat distemper” (diphtheria) killed untold numbers in the colonial era, especially children. Barely a decade went by in the 1700s without a serious outbreak of smallpox. New York recorded more than five hundred deaths from this disease in 1731, a staggering total in a city of barely ten thousand people. While the threat of smallpox would recede by the early 1800s—due mainly to the introduction of Edward Jenner’s revolutionary vaccine—other diseases proved more difficult to contain. The most frightening one, by far, was yellow fever.

  It seemed odd that a disease associated with the tropics would find a home this far north. Yellow fever—commonly known as “Yellow Jack” for the warning flags flown on infected ships—is transmitted by the bite of the female Aedes aegypti mosquito. In mild cases, the symptoms include a headache and moderate fever, similar to the flu. But the more severe ones can produce delirium, jaundice (lending skin a yellow tinge), and massive bleeding from the mouth, nose, and ears. Most early accounts of yellow fever refer to the victim’s horrifying “black vomit,” the discharge of blood-soaked material from the stomach. Case mortality in a serious epidemic can reach upward of 50 percent. The only good news is that the surviving victims are rewarded with immunity for life.

  Yellow fever came to the Americas from Africa, carried by slave ships that docked in the West Indies. Water barrels on board provided an ideal breeding ground for the Aedes aegypti. Over time, as trade routes expanded, yellow fever reached North America’s eastern ports. In the summer of 1793 it struck Philadelphia, the young nation’s capital, with a fury that shook the national government to its core. By November, the streets were deserted and more than 10 percent of the city’s fifty thousand residents were dead. Most of Congress was gone, along with President George Washington and Secretary of State Thomas Jefferson, who fled to their native Virginia. For Jefferson, a defender of rural values, the epidemic was a mixed blessing, with a powerful lesson attached. “The yellow fever will discourage the growth of great cities in our nation,” he confidently wrote a friend, “& I view great cities as pestilential to the morals, the health and the liberties of man.”

  Jefferson was wrong, of course, though the enormous damage done to Philadelphia did dramatically slow its growth. Yellow fever reached New York City in the summer of 1795 on a brig from Haiti with a very sick crew. A port officer who boarded the infected vessel died a few days later, the first of many to come. While hardly matching the carnage of Philadelphia, the disease proved deadlier than anything the city had seen before.

  What caused yellow fever was a matter of debate. Medical opinion in this era endorsed the so-called Miasma The
ory, which blamed illnesses on chemical agents from decayed matter—corpses, rotting fruits and vegetables, swamp and sewer gases—that formed dangerous airborne clouds. Those who studied disease spent much of their time minutely analyzing atmospheric conditions: sunlight, humidity, temperature, rainfall, lightning, cloud cover, and wind direction. As late as 1888, Bellevue’s specialist in childhood diseases insisted that diphtheria, a deadly bacterial infection, resulted mainly from inhaling the damp gases that rose from the sewers. (He also warned against the danger of kissing a cat.)

  Yellow fever split the medical community into warring factions. One saw it as a contagious disease, much like smallpox or influenza, which could spread from person to person through the victim’s breath or clothing—or corpse. How this occurred was still a mystery; one physician described the process as “effluvia arising directly from the body of a man under a particular disease, and exciting the same kinds of disease in the body of the person to whom they are applied.” This camp viewed yellow fever as an imported illness, reaching New York harbor on West Indian ships. The solution, therefore, was to quarantine arriving vessels in order to isolate the carriers—an expensive process that severely restricted trade.

  The competing group blamed local conditions for the disease, especially the “noxious smells and vapors” along the wharves. Person-to-person contact made little sense, these doctors argued, because they “continually touched the sick, lived in the midst of them, and breathed the same air” without personally contracting yellow fever. Their solution was to destroy the noxious miasma clouds by scrubbing the city clean; they saw no reason to quarantine its vital harbor.