treat themselves, but Howard Greenspan wasn't one of them. When he came down

with a persistent cough while completing work at Harvard University for a

master's degree in public health, he used the student health facilities. There

he saw a doctor who told him it wasn't serious, not worth bothering about.

Some months later, with the cough still hanging on, Howard

went to another doctor in New Jersey, where he lived, and this doctor delivered

the crushing news that Howard, who had never picked up a cigarette in his life,

had lung cancer. He immediately underwent chemotherapy, which did not put the

cancer into remission. But Howard survived the course in good shape, perhaps

because he specialized in nutrition, so he knew what vitamins to take.

He then went to Memorial Sloan-Kettering Cancer Center for

radiation therapy. At Sloan-Kettering, doctors have developed, according to

Howard, a unique procedure for delivering a maximum amount of radiation on the

cancer site or sites with a minimum amount of damage to surrounding healthy

tissue. Howard thus became one of thousands of people sent off by their

physicians to become outpatients for extended courses of cancer treatment at

hospitals specializing in such procedures.

At this point the local, recommending physician often loses

contact with the patient. Everyone presumes that the patient is now in the

hands of doctors with the minute knowledge of specialists, but it didn't work

that way in Howard's case. By Howard's estimate, he was in pretty good shape

when he got to Sloan-Kettering. "When I started, basically I'd say I was in

good health," he said. "I had lost some weight, I weighed 134 pounds, but I had

taken other tests, and it showed there was no cancer anywhere else in my body

other than the specific tumor sites, in one lung and some lymph nodes in my

chest and one lymph node above my right collarbone."

Howard began the course of treatment, which was to last

eight weeks. It turns out that doctors don't administer the treatments. As

Howard explained things, "Most hospitals that administer these kinds of

treatments have very well-trained and fairly extensive professional nursing

staff that can interface with you on your treatment level. In my treatment

area, there were no nurses to consult with. I will say that the technicians who

administered my treatment were like gold. Those women treated me well, they

were always concerned and always saying how progressively bad I was looking and

suggesting that I talk to the doctor. They were very caring and very giving,

but you know, they're technicians and they're limited to what they can do. They

just made my treatment time as easy as possible."

With the physician who recommended Sloan-Kettering out of

the picture, Howard came to realize that he now had a death-dealing disease and

no doctor. "The problem that I ran into at Sloan," he said, "is that you're

supposed to see a doctor every week. In order to see a doctor, whether you're

feeling sick or not sick, you're suppose to check in and see them; the typical

wait is about an hour and a half. Some days, you're feeling O.K., but you still

don't want to wait an hour and a half, especially when you have advanced cancer

and you're already spending five or six hours a day getting to the city, but

the way they run it they have only one or two teams that handle all of these

patients who are getting this type of treatment. They see patients on certain

days and the waiting rooms are always stacked with patients, and at

Sloan-Kettering, waiting is the name of the game … There were days when I'd

wait two hours for treatment, and the technicians would be there from 7 in the

morning until sometimes 8, 9 or 10 at night."

What Howard was talking about was not mere inconvenience for

people with busy, active schedules. He was talking about waiting rooms full of

people in pain, nauseated and so miserably weak that sitting around in waiting

rooms is a foretaste of life in the lower regions.

"There's an overwhelming number of patients," Howard

observed, "and I know that it's not necessarily the fault of the hospital or

the doctors that there's an overwhelming number. I know they have a waiting

list, and they're trying to help as many patients as they can, but I think

they're doing it totally understaffed without having the time or the manpower

to pay attention or to administer good patient care."

In a short time, the radiation's effect on Howard was

devastating. "I literally did not have any type of solid food for at least

three or four weeks," he said. "I did wind up with what was called a thrush

infection, which is a candida infection in my mouth and my throat and my

esophagus, the tube that goes down to your stomach. And that certainly

contributed, but it was only a piece of what was going on … it was turning out

that every night for five nights straight, I was up all night throwing up

nothing, but basically retching all night until 4 in the morning and just so

exhausted that I couldn't move, and I'm still going in for my treatments."

Howard could not get a doctor at Sloan-Kettering to address

what he was going through. Speaking as a physician himself, Howard said, "If

I'm a doctor and if I see a patient come in to me and over a four-week period

they've lost 16 or 17 pounds, I'm not going to wait for them to tell me that

they're not feeling well or that they think something's going on. I'm going to

see it, and I'm going to do something about it. I'm going to at least try and

find out what's going on and why it's happening.

"I'd wait an hour and a half to see the doctor for three

minutes, during which time he'd say, 'How are you feeling?' You're sitting

there and you're practically falling over, and you've lost 16 pounds, and

they're asking you how you're feeling, but you get into a state like that and

you kind of lose your will to object to what's going on, you just want to get

in, get out, get home and lay down.

"And I've always been a real advocate of patient advocacy.

You know, if you're not getting what you need, you should push for it. But, I

understand now, which I never understood before, that the time that you need to

do it most is often when you're least equipped to do it because you're in such

a debilitated state. This went on for weeks, and the main thing that they

stressed to me is that they didn't want me to miss treatments, that there were,

in their words, 'dire consequences' to missing treatments."

At the same time, Howard was beginning to doubt that he

would be able to make it through the treatments. "I understand they don't want

to turn anybody away. But if you're going to accept the responsibility of

treating a lot of people who are potentially seriously ill, then you have to be

able to support the patients in all aspects. You can't just be like a car wash,

where you go in, get your car washed and then you go get it serviced somewhere

else. You have to be involved in medical care, or you have to make it very

clear to your patients, 'All we're going to do is give you radiation. If you

want to be treated by a doctor for anything else, you'd better go somewhere

else.' I think that's where my confusion came in, because they never told me

that. They probably don't tell anybody that."

In desperate shape, Howard fled to the Cancer Institute of

New Jersey, where they began to feed him intravenously and administered

steroids to stop the nausea. Reflecting on the two places, Howard said, "When I

go into the Cancer Institute of New Jersey, the minute you walk in the door,

someone's there to greet you, they immediately take your vital signs, the nurse

sees you, a nurse who has experience and can talk to you, then you see your

doctor and he spends time with you. It's a really bright, cheery, loving

environment. I accept the fact that the Sloan is a big hospital, you know, it's

a busy hospital, it's in New York City, which puts a certain personality on

everything. It's a much more cavalier attitude than I've ever experienced

anywhere else."

Some of New York's most famous hospitals have become

infamous for their harsh impersonality, but Howard's case is a warning. If a

doctor can get lost in a system he knows and is at home in, what happens to lay

people? No patient bill of rights is going to address the problems of treatment

or nontreatment Howard ran into.

Howard Greenspan was the most humane of physicians.

Professionally, he earned his living working for a company whose efforts were

directed toward the invention of inexpensive solutions to Third World medical

problems. In his spare time, he used his remarkable knowledge of nutrition to

help scores of patients, none of whom ever received a bill from him.

Howard Greenspan died a few weeks ago.