Chapter 2
The System

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    The long surgical incision extends laterally across the man's diminished body, causing a very slow seepage of blood through the severed tissue.  Someone who cannot be seen amidst the assortment of computer devices announces, "Dr. Earnshaw, pressure 90/60.  Heart rate 50."
    Modern medical science has taken a turn back towards the more conventional forms of surgery due to regulations that become more restrictive each year as the state's medical plan for the elderly shows larger and larger deficits.  Maintaining the rapidly changing camera equipment used in laparoscopic surgery is now something the state views as "an excessive expenditure not warranted due to more cost effective procedures."  What Howard Earnshaw sees on the operating table before his is not someone who once had hopes and ambitions for his life or even someone who is in the final weeks of that life.  He only recalls the medical charts of the digestive system as he probes through the tissue surrounding the pancreas within the curve of the duodenum and behind the stomach.  
    Impatiently, he snaps, "Nurse, sponge," even though RNs departed the OR years ago on hospital administration's supposition it does not take someone with 4 years of nursing school and the ensuing salary demanded by the medical labor unions for someone to wipe blood away, much the same as wiping grease from a plate before placing it in the dishwasher.  Consequently, much of the surgical staff consists of very young women who receive 8 weeks of instruction from a retired high school human biology teacher and now know how to align the patients under the OR lights and in what sequence to place the surgical instruments beside the operating table.
    Howard has performed  this operation many times and now compares the process to studying a road map before some trip over a route traveled many times.  If all the organs appear as they do on the medical chart, a number of very regimented steps follow but if something seems out of place, some degree of innovation is called for - much the same as following a detour to avoid street construction. 
    Mucus is accumulated around the pancreas.  The OR technicians stands there looking at one of the screens before receiving Howard's somewhat intolerant command, "Damn it, suction!  Pay attention to me and not that video game."
    She utters something in Spanish before clearing the organ of the obstruction.
    Howard stares at the massive malignant tumor that extends deep into the pancreas and has spread to the walls of the stomach.  Medical procedures scroll through his mind.  For a moment, he recalls the last time he filled his gas tank, standing there watching the numbers race by on the meter after failing to communicate with the Oriental attendant.  It was cold that day, and he hadn't taken off his white coat before leaving the hospital.  All the while, he was thinking how unprofessional he must appear to the drivers on the street who kept gazing at him as they drove by.  Most of the other doctors at Clairmont Hospital no longer wear white coats but dress more casually.  Hospital administration has it that a less formal appearance places the patients more at ease and was not amused at Howard's pointed comments that patients were more concerned with sound medical advice than seeing someone in tennis shoes and uncoordinated  colors who looks like someone from one of those situation comedies on television that have converted the natural attraction between a man and woman to a series of one-liners graced by dubbed-in laughter.
    He disregards customary surgical procedure and reaches for the scalpel rather than making another request to the OR technician.  It's almost as though all his medical books are there on the man's chest and he is studying for a test rather than trying to save a man's life or at least, give him back a portion of life he has lost to disease.  Again, he pictures himself standing beside the gas pump except dollar and cents are not rolling by.  Instead, he is seeing the instructions in the medical books, "make a cautions lateral probe along the walls of the tumor and evaluate the extent to which the organ is engaged."  First, he probes across the upper walls of the pancreas.  His eyes remain fixed on the larger portion of the tumor.  Tentacles stretch from the organ into the stomach.  The road map is still in his mind as he follows the diseased tissue extending to all sections of the middle abdomen.  Alternative steps interpose established procedure, much the same as the ringing sound on the gas pump each time a gallon is filled.  Incision into the pancreas offers no hope of removing all of the tumor.  Removing any of it along the spread course would expose too much tissue in the vital organs, certain to cause internal bleeding soon after closure.  He slowly shakes his head and glances at the 2 surgical residents who seem squeamish as they observe the patient's tissue expand and contract with each heartbeat.
    One of them asks, "Do you want me to close, doctor?"
    "No," Howard responds, still looking at the hopeless progression of the cancer.  "We just received notice from our professional liability carrier that each surgeon must complete all phases of any procedure.  It went on to say all sorts of things are being left inside too many patients."
    Several snickers are heard somewhere in the OR.  Howard hadn't intended what he said to be taken so lightly but recalls a statement he made at the last executive council meeting about what a joke performing major surgeries was with trainees having only 8 weeks training.  The chair, who is an accountant rather than a doctor, kept saying something about experience being the best teacher and with the "tight labor market," anyone who had a good job would be inclined to hold on to it.  This fact alone prevents the hospital from constantly training and retraining personnel due to high turn-over and is a means to achieve the progressive statistics axiom now ruling the business world.
    Howard has never used staples to close an incision and still uses stitches.  The same council meeting had described his procedure as "needlessly labor intensive and not cost effective OR management."  He didn't contest the observation since the person who had offered the observation was a business administration graduate and not a doctor.  He carefully pieces the layers of tissue and skin back together, and his presence of mind progressively moves from analytical to one ruled by emotion.  He recalls when he first saw his mother's x-rays and immediately knew, even without exploratory surgery, she was terminal.    
    Those years when he was at Georgia Research Institute, the group of scientists with whom he worked felt they were very close to discovering possibly not a final cure but at least a more effective means to treat cancer.  Just when they were at what they all agreed was a major breakthrough, their funds were withdrawn by the federal government due to what was described as "an outdated theory and concept plus the non-availability of funds to support such research."  What had really happened was that, due to efforts of gay rights organizations, much of the funds had been redirected into AIDS research.  What might have been available for cancer research was refunded to the states under the Republican-controlled congress's promise to return tax money to the states for distribution as determined by local government bodies.
    Due to worsening economic conditions throughout Georgia, the local officials decided to give all taxpayers a token refund on the premise the money would be immediately spent and assist the failing retail trade within the state.  That did not happen.  Everyone just held on to the money - especially those who feared their job was about to be outsourced to some foreign country or done locally by someone who could not document when, or even if, he or she had legally entered the country.  Most businesses maintain it is the responsibility of the government and not theirs to audit immigration records.
    He turns the soap over and over in his hands.  After such an unsuccessful surgery, he wishes he could wash away his mood with the patients blood - just like an auto mechanic after repairing a transmission.  Some of Howard Earnshaw is dying - not the same as the poor man in the operating room who has passed the point he can be helped but dying just the same.  His future treatment will be restricted to pain management with Sedateomoxifaine administered by another echelon of 8-week graduates who have yet to master the art of pushing the medicine carts down hospital halls - much less the delicate assignment of caring for someone who is close to death.
    The pharmaceutical company that developed Sedateomoxifaine pulled off a public relations masterpiece in relinquishing it's patent rights in order that all other companies could immediately begin producing generics.  The simple truth was that the discovering company had laid off so many employees, it lacked the capacity to meet all the orders.  After some sort of administrative study, the company determined greater progressive statistics could be achieved by this step as well as discontinuing further research projects as long as the profit line of Sedateomoxifaine kept the company stock rising to higher return on equity.  The demand was such that the company's stock rose 100% in 3 months and with that, it retained many of its pain-stricken customers as well as enlisting a substantial following on Wall Street.  Only some of such a thought process was revealed to the general public.
   Even with all his education, Howard does not understand what is happening to his life.  What has happened to his marriage?  He remembers that day at Mass when he and Charlotte were engaged.  During the sign of peace, both of them had faced an elderly man behind them; and as Charlotte extended her hand to say, "Peace be with you," the old man smiled and said, "You look like you belong together."
    Charlotte always loved his mother who many times had told them the same thing.  This love continued to build all through the years of their marriage, especially after his father met that younger woman who was more attracted to his bank account rather than the fact she would always achieve an organism during one of their frequent meetings, always at one of those upgrade hotels that somehow added an enhancing degree of decorum to the encounters.  Her account of the sex life with her husband lacked tact when she evaluated it on the ultra-objective basis that, "His gut is too big, and he can't get it all the way in."  His father must have been quite a lover.  Sometimes, they would meet in a dingy motel, he would assume a rough technique, and it  made the process much more adventurous for her and increased her drive all the more.
   Marriage follows such a different course for many people.  Some grow happier with the passing years, knowing their love is consummating a higher dimension the longer the marriage continues.  For others, the love gradually begins to fade away until there is only regret and even hate for someone who has taken what was once a happy life and turned it into an assorted variety of misery leaving divorce as the only charitable alternative.  This unfortunate demise is happening to Howard.  There is no other woman.  The career he once had is coming down all around him.  It's so unfair that the disenchantment that now owns him is ruining Charlotte's life as well as his own.  That happened to his mother.  No one was sure how she found out about the other woman but her downfall wasn't gradual - it came in a single day.
   As he drives towards his mother's house, his eyes are trained on the street before him.  He sees nothing but images of those nameless faces on operating tables and that terrible expression on their faces when they learn they are terminal.  After so many years as a surgeon, he has yet to perfect the way to tell someone he has only so long to live but always avoids something like, "You're terminal," or "There's nothing we can do."  Such explanations only add to the impersonal system that has contaminated his profession.  Some of the other doctors often speak of the time when a series of tests were conducted to determine the cause of a patient's symptoms.  Now, most such tests are disallowed by the insurance system until the illness progresses to the point a diagnostic test is unnecessary.  By then, the patient may well be terminal but still, progressive statistics have proven the resultant lawsuits do not exceed hospital expenses in maintaining the staff and equipment to administer the battery of tests that were once established procedure.
   Something strikes the back of his car, and he snaps out of his trance-like stare.  Only now does he realize he is in the Puerto Rican section of the city and the 2 men standing on the street corner are Chytinos, a racial mix between Spanish and Oriental, who have thrown a beer can at his car.  Their one obsessive characteristic is a consuming hate for white people as well as the Indicos, a racial mix between Indians and Spanish, a few blocks over.  The sight of a well-dressed man in an expensive vehicle incites all sorts of emotion from what the Descendants of the World congressional lobby calls "the oppressed people of the Earth."  There is no longer an interest in what little power remains in Congress to address illegal immigration, because the condition is so widespread, it is beyond legislation.  They shout something in Spanish as he passes.  Recently, the local newspaper reported a number of instances where what seemed innocent passers-by were attacked, apparently for no reason other than they were Caucasian.  Hate does that.  There is a need to strike back at something, and it's easier if the victim is nameless and more easily forgotten.
   Now aware he should be more concerned with the perils of driving through Atlanta, he looks across the railroad tracks at the Patron of the Hopeless Church which, after the terrorist attack last week, is surrounded by a 7 foot fence with 2 layers of concertina wire on top and patrolled by several armed guards in khaki uniforms with large, black dogs at their sides.  He is restless and turns on the car radio.  After a few commercials for some preparation applied to the sin twice a day to remove the signs of aging, there is the booming voice of Horace Hastings.
   "Hello out there in America.  Well, it had to happen but even I, with all my astute political insight, was surprised when it happened so soon.  The Restoration had barely begun when someone was gunned down on the steps of the Church that claims its immediate goal is to reunite America under some sort of 11th Century dogma that only a common religion can repair all those things it claims is wrong in America.  The Atlanta Police apparently did not share this belief when they arrested the trigger man for possession of a weapon outlawed by the Firearms Deterrence Act which disallowed private ownership of guns to no more than .22 caliber.  So what does The Restoration do?  It looks in one of its pews and finds some lawyer who gets the case thrown out on the technicality The Restoration is not a private entity.  Now, we have armed guards patrolling a church premises which looks more like a Nazi concentration camp than a place where someone is supposed to find himself or discover some other nonsense that a common belief in a God that doesn't even exist in the view of many educated above the 8th grade who can do everything from saving your marriage to finding you a job that will place you back on the economic ladder where you know you belong.  You don't have to be an atheist, as I am, to see what The Restoration really needs is a public relations agent and not a bunch of priests and parishioners who are too stupid or lazy to do anything but blame everyone else for, what do they say, 'what America has become.'"
   "You nitwits down there in Atlanta - or anywhere else this cancer is spreading.  Don't let your lack of self-respect lead you to some unholy rebellion against your own failure.  All you're going to do is create hate of the type that prompted that man who was gunned down trying to destroy your little Gestapo.  Hell, they should build a memorial to him right out there on the railroad tracks - the same as the Germans should have done to those officers who tried to assassinate Hitler.  Oh, I just had a better idea.  They could go inside that museum they call a church with all those silly statues and hang the fire bomber on the cross instead of old what's his name - Jesus."
   Howard stops in front of his mother's house and remains in his car for a few moments.  He feels ashamed in almost wishing he did not have to face her and that most of his sadness each time he sees her is concern for his own feelings rather than the pain and heartbreak that has so ruled her life for all this time.
   The steps creak under his feet as he slowly finds his way to her bedroom.  It seems as if he is walking as slowly as he can to delay entering her room as long as possible.  Leonard and Franklin are seated at her bedside.  Some weeks ago, she told them she enjoyed it so much more when they all visited her at the same time.  Immediately, Howard's eyes fall on the armband now on Leonard's arm. and the maple leaf on each collar.  His mother is sitting up in bed, leaning back against 2 pillows.  A warm smile comes to her face as she extends her hands and in a weak voice, says, "Oh, good.  It's Howard."
   There's already a chair for him, and the caregiver departs the room.  As he sits down, he grasps her hand, brings it to the side of his cheek before gently kissing it and placing it at her side.
   "We didn't expect you so soon," she says, still with the broad smile.
   Her eyes are fixed on Howard.  How many times has she told him how proud she was of him.  He only hopes she never knows the true feelings he has about himself and never knows the obstruction that now exists between him, Charlotte, his profession and nearly everything else in his life.  That would deprive her of just about all she has left.  "The operation didn't go as long as I thought because...."  A searing jolt in his throat stops him just before he says something like, "The patient was terminal," or "There was nothing I could do."  That was how her Oncologist had described her condition.  The last time Howard spoke with him,  he seemed almost embarrassed that his mother had lived a full year longer than he had predicted after she entered the "terminal" stage.  Trying not to change his expression, he adds, "Because you never can be sure how you can communicate with an OR staff when many of them only speak broken English."
   Franklin can't conceal a disgusted sneer as he says, "Don't tell me the social justice system has found its way from the assembly line all the way into the operating room."
   Leonard glances at him and angrily shakes his head.  As unpolished as he is, Franklin realizes bringing up such controversial subjects will do little to console his mother and thankfully, he shuts up.
   "I'm feeling much better," Alma says as she reaches for a medicine bottle and hands it to Howard.  "This is a good product.  The pain has almost gone away."
   Howard looks at the label which reads "Sedateomoxifaine 100 mg.  Take 6 capsules daily," and immediately realizes the dosage is nearly large enough to result in toxicity for someone whose body weight has declined to 80 pounds.  Just before making such a clinical observation, he knows her condition must have worsened to the point such a massive dosage is the only remaining treatment.  He places the bottle back on the nightstand and says, "This is a new drug.  Many of my patients are taking it before they come into the hospital."  Just then, he realizes he has never prescribed it himself, because when a patient such as the one he scheduled today leaves the OR, he goes to that God-awful hospice ward where the only treatment for anything is pain management.
   She looks at Leonard with the same smile on her face and asks, "Did you bring me Communion?" without the presence of mind to notice his armband or even recall Vatican Council III declared communion was no longer looked on as the actual body of Christ, the same as the Protestants,  and is now only a representative custom.
    Leonard removes the small circular container from his coat pocket and holds one host in front of her eyes as he quietly says, "This is the Lamb of God that takes away the sins of the world.  Happy are those who are called to his table."  He breaks off a portion, knowing she cannot swallow it all and gently places it on her tongue.  Again looking directly into her eyes, he says, "The body of Christ."  He reaches for her hand and begins his prayer.  "Thank you, our Father, for warm memories contained within this room and indeed within our hearts as we find our thoughts reaching back, back across the years when we were all together in this house.  Thank you for a mother's love that has remained with each of us for all those years and will remain with us always.  For each of us, it has been a gift that has always told us what we should do.  May we always seek out what we know is right, what we know we must do and so become those of whom our mother can remain proud.  Her love and precious memory can lead us to what is right, and what a wonderful gift that is for anyone to receive.  Amen."  
    She always seems to better appreciate prayers that do not dwell on her illness, and the warm expression written on her face is far more comforting to him than any words she could speak.
    Her private night nurse has just come on duty and enters the room. Howard asks, "When did she last take her medicine?"
    "About 30 minutes ago," as she quietly closes the door, knowing Alma wants to be alone with her sons.
    Howard again has that feeling resembling one of shame when he begins to think of the properties of Sedateomoxifaine instead of the fear his mother must be feeling.  He knows the effects it has on the brain and central nervous system, and for the next few minutes, he watches his mother aimlessly speak of persons she hasn't seen in 40 years.  Gradually, her voice declines to only mumbling but before she drops into the sound sleep the medicine is now intended to produce, there is obvious hate in her faint and delirious words.  "That son of  bitch husband of mine.....What about the boys?  I....I always had the boys....They can never take them."
    The 3 brothers quietly step out of the room and go down the creaking stairs.  Each of them sees his mother when he was a child, standing there at the bottom of the steps with that same warm smile they have just seen and saying, "Get ready for supper.  Daddy will be here soon."
    Before they got out of grammar school, the high level of success of their father's medical practice caused him to undergo what political historians at one time called a "revolution of rising expectations," not intended to refer to successful people but suggesting such a phenomenon is only observed in impoverished countries first experiencing a higher standard of living, primarily resulting from past foreign aid from the United States.  Strangely, there was never a substantive explanation as to why these same countries ultimately developed a hatred for the same hand that fed them.  The question finally solved itself when there was no longer adequate money in the federal budget to continue foreign aid.  Some people undergo the same change when they find their success beckons them away from what they come to view as a mundane existence.  Something like that must have happened to their father -  not to mention the fact that other woman always said she had a wet pussy for him.
    The 3 of them stop beside Howard's car.  Franklin takes out his handkerchief, begins to rub the hood and says, "Where's your chauffeur?"  Through the years, he has made something of a game in taunting his brothers about how they always keep their hands clean in their work.  He seemed to especially enjoy ragging Leonard about those puritanical bumper stickers which read "My child is an honor student at Christ The Redeemer School."
    Howard looks at Franklin's 15-year-old pickup truck parked at about a 45 degree angle at the curb.  The hubcaps are missing, the rear tires are caked in mud and there is a bumper sticker reading, "If I had children, they would probably be drop-outs."  
    Howard walks over to the truck, starts rummaging through the various things in the cargo bed and making a terrible rattling noise before saying, "My chauffeur is over on Highland Avenue trying to pick up that painted woman you brought over here last week."
    Leonard laughs and steps between them as he says, "Damn, sometimes you amaze me as to how far behind the times you are.  Bar room pickups are a thing of the past.  All the good whores now work off the Internet."
    Franklin's mouth drops open.  "How does a man of the clothe know how to locate a whore?"
    Then, Howard steps between them and asks Franklin, "What's about to happen at the plant?  There's been all sorts of stories on the news."
    Immediately, Franklin looses interest in ridiculing his brothers and snaps, "I think the bastards are going to close it.  It's those damn workers who can't speak English.  Hell, it takes 2 quality control people walking around behind them all day, picking up the loose parts they can't figure out where to put during the 20 seconds the chassis stops in front of them on the assembly line.  They've got their own labor union now.  About every 2 weeks, someone from some fucking organization called Descendents of the World comes by and gets them all pumped up about something."
    "Something?" Howard asks.  "What is it?"
    "Nobody knows."  He remembers Leonard prefers to be called father rather than reverend, because reverend sounds like some damn Protestant as he puts it.  "You see, reverend, that low-class white trash on the assembly line don't speak Spanish and don't give me any of that silly shit about everyone in the world is supposed to love everyone else.  If you could see those cars rolling off the line half-assembled, you might start to see what's really happening."
    Being addressed as reverend annoys Leonard.  "How many years did you threaten strikes in your own labor union?  That white trash on the assembly line fumbling around in tool boxes with greasy hands ended up making more money that first year residents at the hospital.  It's your own fault Detroit turned to immigrant workers.  The American cars couldn't compete with the imports.  Didn't you have sense enough to see that?"
    Then, Howard steps between the two of them.  With something of a laugh, he says, "Let's resume this conversation when we have a sociology professor to take notes."
    Franklin asks, "What about mother?" looking at Howard as though it were he who was treating her.
    "I saw her x-rays last week," he replies just as the images flashes into his mind of the advanced stage of cancer in that patient on whom he had attempted surgery earlier in the day.  He feels so very sad when he visualizes the same disease is about to claim his own mother.  Often, he has asked himself how a terminal patient must feel, knowing he or she is near death and the only assessment remaining is "we've done all we can."  He embraces both his brothers, not wanting them to see the tear forming in his eye and only says, "It's hopeless."  Suddenly, he realizes he has used a term he always tries to avoid.  "All they can do is give her Sedateomoxifaine to keep her out of pain."
    Angrily, Franklin grabs him by the arm and stands there staring at him before throwing it back to his side and mumbling, "Mama don't deserve this," as he gets into his truck, abruptly drives away and leaves 24 inches of skid marks on the street.
    Howard makes a more collected departure but is tortured by the same thoughts as his brother.  As he starts for his home, he glances at his watch and notices it's only 2:00 pm.  Sometimes, during these past few years, he has dreaded going home only to see that wanting expression on his wife's face.  He almost wishes she would "start bitching at him" the way some of the other doctors describe their wives and depleted marriages.  Each knows the other wants a divorce, but they have never discussed it.  Perhaps neither is willing to admit failure - not to each other but to anyone who still thinks they have a loving marriage.
    There is a police car behind him, flashing its blue light.  Howard stops at the curb and watches a short, plump Korean officer slowly walking towards him.  In broken English, he says, "Get out of the car and open the trunk."
    The officer searches through the trunk, opens all doors of the car and looks under the seats and in the glove compartment before seeing Howard's white coat with the black letters "Howard Earnshaw, MD - Clairmont Hospital" embroidered above the left pocket.  Something of a smirk comes to his face, and there is obvious resent in his voice as he says, "The only people we ever see around here in a vehicle like this are pimps and drug pushers."  He motions for Howard to get back in the car, stands beside it and leans down into the window.  His eyes are squinted and almost closed when he says with tight lips, "Maybe you ought to find another route.  See that traffic light up there?  Two whites were mugged last week because they didn't belong here.  Stay where you belong unless you decide to become a pimp."
    Howard waits for him to say something else but he just stands there, still with that contemptuous expression on his face.  As Howard drives away, only then does he realize he is in the Korean section of the city.  There at the corner is a group of young men who shout something in Korean as he passes by.  He looks up and down the street.  No Caucasians are in sight - only Orientals.  There at the traffic light the officer had mentioned is a billboard with a picture of a young Oriental and large, black letters reading "Wo for you in Congress."  Just then, the young men begin to shout - this time in English.  "Get out of here, nilla!"  A few weeks earlier, Franklin had told him "nilla" is the term immigrants now affix to those of vanilla color.

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    The hospice ward serves a dual purpose in the view of hospital administration.  It "centralizes those requiring pain management in addition to removing the terminal from the sight of regular patients."  Recently, there was even a lecture by some psychologist as to how recovery can be thwarted in a "non-promising atmosphere."
    Howard stops at the nursing station but does not ask anyone to access the central data base, not as a matter of choice but only because everyone dresses alike, and it is impossible to determine who does what job.  At times, a sufficient level of motivation does not exist for anyone to admit to any task, and Howard has found better reason to dictate he do as much as possible himself.  He sees his last surgery never went to the recovery room, because there was very little from which to recover, since the surgery ceased very soon after the initial incision and probe. 
    Walking down the aisle, he hears a number of suppressed moans intermingled with an occasional painful cry.  He begins to wonder if he has permitted his work to become so mechanical, so driven by pre-determined surgical procedures that he never stops to recognize what it must be like for those in this God-awful hospice ward who are waiting, and even wanting, to die.  He sees his patient at the corner bed, awake and wrenching in pain.  Only then, does he realize he doesn't know how he should explain there is no hope and all that can be done is pain management.  He remains intent on not using those precise words and starts to speak, but he doesn't remember the man's name.  Relief sweeps over him when the patient turns his head towards him and weakly says, "They told me there was nothing that could be done."
    "That isn't exactly true," Howard says, finding himself gratified someone else has done what he should have.  "We have an advanced pain medication that can remove near all the symptoms you are experiencing."
    The man's head turns away.  "Do you mean Sedateomoxifaine?" he asks.
    Howard realizes he has completely forgotten what medicine the patient is presently taking but is reluctant to fumble through his chart.  He simply asks, "How long have you been taking Sedateomoxifaine?" on the unqualified assumption the patient is already on the drug.
    "About 5 months."  He continues to grimace in pain and says, "My doctor said that....that it was a new drug and....and....he wasn't sure if the body would form a tolerance to it.  I've had to increase my dosage to 600 mgs per day.  They said I....I couldn't have any more today, because I've already taken that much."  His expression becomes very stern, his eyes widely open and in a stern voice, completely different from the painful whining Howard has just heard, says, "Doctor, will you do something for me?"
    "Anything I can," Howard responds, thinking how much better that sounds than "We've done all we can."
    He looks Howard directly in the eye and in a short, demanding voice, utters, "Kill me."  Howard does not respond.  The man reaches out and firmly grasps him by the wrist.  "Did you hear what I said?  Kill me!  Damn it, kill me!"
    No one has ever made such a request, and Howard doesn't know what to say.  The first thing that comes into his mind is the Catholic Church's position on euthanasia but he recognizes now is no time to discuss religious philosophy on what is one of the few traditional beliefs remaining in the Church.  Finally, he manages what he hopes is not and unduly analytical response and without looking him directly in the eye, says, "You know we can't take a life.  I....I mean we're supposed to treat an illness and not wash our hands of it."
    The patient's expression becomes more stern.  "Doctor, I hope you or no one you love ever finds themselves in the shape I'm in but if you do, you're going to find yourself asking where does meaningful life stop?  Where does life cease and become a curse not only to the sick and dying but also those who must watch a loved one wither away - not to mention how much it costs a day to stay in this wretched place.  Killing someone like that is an act of mercy.  If you won't kill me, then god dammit, do something.  I can't stand the pain and I can't stand the worry I'm causing my wife anymore!"
    "I'll change your medication," Howard says, just as an elderly lady comes to the bedside.
    Immediately, the man's face assumes a broad smile.  He extends his hands to the woman and if for only a moment, there is no sign of pain, no sign of resignation.  His eyes sparkle as he says, "This is my wife, Mary."
    She leans over the bed, places her hand on top of his head and gently kisses his forehead before looking at Howard and saying, "May I see you a moment?"  She moves towards the hallway and glances back at her husband saying,  "I'll be right back, darling."
    They reach the hallway, and she abruptly turns around.  Her expression changes from loving concern to one of scorn.  "You've got to do something for him. I can't stand to see him suffer any longer.  I can't even get anyone to change his diaper, and he's laying there in feces and urine half the time."
    Howard looks above the doors on the adjacent hallway and sees the flashing white lights but there is no one in the hallway other than the 2 of them.  Tears begin to stream down her cheek.  "They don't care," she says, searching through her pocketbook.  Finally, she produces a piece of paper containing the names of 5 different medications.  "He's taken all of these but none of them did any good until they put him on that."  She points to Sedateomoxifaine, and adds, "That worked for awhile but now, he's back in the same pain."
    Howard reaches for the paper and sees the other drugs are intermediate pain killers and muscle relaxers.
    "Why did he wait so long for surgery?" he asks, looking her straight in the eye for the first time.
    "When we retired, we got to keep our group insurance for awhile but then, some accountant got the idea they could save a lot of money if they cancelled everyone eligible for Medicare.  That damn governor bankrupted the state Medicare fund, borrowing from it to enact all that stuff he's got to do to get re-elected.  Medicaid wouldn't do a damn thing until our money ran out and by that time, all anyone would say was 'There's nothing we can do.  He's terminal.'"
    "Then why was he in surgery this morning?" Howard asks, finding his concern leaning towards technicalities rather the pain both of them are experiencing.
    "I....I wanted to be sure there was really no hope.  We've been hoping and praying for a miracle."
     Even his brother, Leonard, never subscribed to the idea that prayer should be an effective substitute for sound medical advice or procedures, and Howard has always felt such encouragement from the priesthood often did more harm that good, sometimes leading patients into an untenable belief they could recover, only making the final stages of their lives all the more punishing.  Many died feeling God had abandoned them as well as the medical system.  He knows the state would not pay for the ill-advised surgery, even if funds existed, and struggles for what he should tell her.  Finally, he says, "When you receive your bill, don't worry about it.  Just send it to my office."
    A thankful smile briefly comes over her face before she asks, "How long does he have?"
    Speculating on the length of a patient's remaining life is a practice Howard discontinued years ago.  Cancer reaches a point where the patient, everyone in the family and everyone who knows him find themselves just hoping for a merciful death.  His experience has been that if a suffering and terminally ill patient outlived the forecast, everyone held the doctor responsible.  Often, it upset the business aspect of settling the estate, produced additional attorney fees and worse of all, additional medical bills eventually finding everyone praying for death rather than a miracle.
    "That can only depend on the will of the patient," Howard responds, trying to avoid an overly clinical explanation but immediately realizing he has only created a need for additional clarification.
    Her voice seems almost resentful when she says, "He doesn't want to live like this."  Becoming more intolerant, she adds, "I can't get anyone's attention around here.  What are you going to do?"  Her eyes remain fixed on him in an appalling stare.
    Her pain is one Howard has seen so many times and in fact, is what led him into medical research after spending quite a few years practicing in the suburbs where most of the patients only experienced conditions brought about by some level of success which ultimately turned them to assorted indulgences producing the attendant and self-inflicted conditions of hypertension and obesity.  Looking back at the dying man, statistics and medical information outlines roll through his mind.  He knows if the dosage of Sedateomoxifaine is increased, an induced coma will result.  Finally, he manages an impromptu plan.  "I'm going to add an energy-producing IV and try to keep him hydrated.  Hopefully, this will improve his strength to the point he can develop some level of encouragement.  To some extend, illness is a frame of mind.  I'm not going to tell you what I can't do.  I can tell you've heard that enough already.  We need to pursue what can be done."  
    He cannot read the expression on her face and isn't surprised when she abruptly walks back to her husband's side, leans over the bed and whispers something to him.
    There is only one person in the chart room.  She is frantically fumbling with the telephone.  All lines are on hold.  As he removes his patient's chart, he watches the middle-age woman for a few seconds.  Each time she answers one of the flashing lines, she takes a breath, shuts her eyes for a moment and in the most pleasant voice, responds to a number of questions about patients in the ward who are too weak to receive their own calls.  She seems to know all the patients' first names and refrains from referring to them by bed numbers, a practice more commonly used to correlate condition with location.  There is obvious concern in her voice.  Howard gets the impression she has visited every patient on the floor sometime during the day, especially when she knows the name and relationship of each caller.  He notices she is not wearing a wedding ring but she doesn't have the appearance of a spinster.  His scientific mind automatically begins to analyze the possibilities that would place someone her age in a starter job normally occupied by some 18 year old with dirty hair and facial ornamentation.  That line of speculation ceases when he realizes here is someone doing more to console the dying and those who love them than he is doing with all his years of training and experience.  Many times, kindness and concern is independent of education.  She glances at him with a pleasant smile as he enters the IV instructions on his patient's chart.
    He leaves the chartroom and begins walking towards his office.  Troubling images invade his mind.  There is the professor handing him his medical diploma.  He can see himself among the procession of interns making rounds with the residents and those terrible expressions on some of the patients' faces when the resident would quiz the interns at the bedsides regarding their conditions and treatments.  He recalls the final years of his private practice, feeling more like a marriage councilor than a medical doctor, listening to all those women complain about how their husbands had become "couch potatoes," thus inflicting every encumbered fulfillment from clothes that do not fit to sexual intercourse.  Then, there was such an invigorating spirit when he entered medical research.  It continued to build as the Cancer Research Component of the Georgia Research Institute drew closer and closer to what they all were sure would be a breakthrough in cancer treatment.  But then, the grant was withdrawn in favor of more pressing needs for "available funds" such as further research on AIDS which then was nearing the same mortality levels as cancer and heart attack.  All that remained was for him to become a staff surgeon at this hospital.
    All those certificates on the wall of his office imply his career has been a resounding success but he feels anything but that as he sits there staring at them.  His next surgery is 2 days away - not a result of lack of patients but lack of funds within the system.  All on his schedule until then is morning rounds with the interns.  Briefly, he feels a flickering of his lost motivation as he re-reads a portion of his request for an additional research grant to the Georgia Department of Health Benefits, an entity formed under the prevailing idea that as much power as possible should be returned to the states rather than centralized in Washington.

Summary:  Study on Reverse Metastasis
and Alteration of Deoxyribonucleic Acid Tissue Content
______________________________________________________________

    Although the accompanying documentation represents a departure from the more recent direction of cancer research, this organization believes that the formation of malignant cells, especially in carcinomas, can be reversed through the induction of a series of protein enzymes created by the ingestion of disproportionate  levels of amino acids and non-protein coenzymes creating a controlled triple helix and markedly increased levels of Collagen.  When this therapy is combined with moderate radiation after surgical removal of a malignant tumor, it is possible the combined effect will result in anabolism in all forms of tumors and produce a feedback inhibition of high protein molecules, thus altering the deoxyribonucleic acid content of the diseased tissue and disabling its ability to produce new malignant cells.  Through the protein synthesis of the altered enzymes, the body will produce healthy tissue at an enhanced rate, eventually overpowering the diseased tissue.
    With the application of previously established facts regarding metabolism and the rate at which the body naturally reproduces healthy tissue, the adverse effects of chemotherapy, which often obstructs normal digestive processes and tissue formation, are avoided.  Indeed, the natural progression of cell formation at the increased rate results in the body's becoming its own healer instead of the radically invasive processes currently in use which, more times than not, reduce the patient's blood count, tissue content and ability to heal.  The most distinguishing characteristic of such treatment is that it can be administered with varying levels of intensity, sometimes following surgery in the case advanced stages,  at anytime from the completion of tumor induction to terminal diagnosis.

    He faces his computer and sees he has one e-mail.  Before he opens the program, somehow he knows it is the reply from the Georgia Department of Health Benefits.  He clicks the marker.  His face draws tight as he begins to read.

Response to Request for Additional Research Grant - Reverse Metastasis
____________________________________________________________________________

    While this institute receives many research grant requests, our staff does its utmost to review the content and merit of each proposal and then with learned guidance, weigh each request against it practicality, available funds and where the proposal stands among all undertakings of the department.  Your recent transmittal, although not without some intellectual merit, is viewed as a peculiar combination of outdated processes and theory-based concepts formed without the benefit of extended test periods now recognized at all levels of health treatments and medical research.  Our evaluation of your request led us to consultation with the Georgia Medicare Administrative Agency.  Should that agency become financially solvent, an event that is anticipated will take several  years, speculative treatments of this nature would be ruled ineligible for coverage.  The failure of Medicare has driven the costs of private insurance among the few HMOs that are now accepting new members beyond the reach of most citizens of this state.  Again, due to over-extended resources and mounting claims costs, no HMO with which we consulted would view such treatment as eligible.  Of necessity, medical research must remain in the area of genetic engineering in cancer-free citizens and directed towards the formation of genes resistant to cancer rather than treating those who are often beyond hope.  The massive costs of radiation, multiple surgeries and chemotherapy can only deplete the private insurance system beyond where it now stands - in a position of extreme weakness requiring well-managed cost-cutting procedures directed only towards pain management for fully developed cancers.  After proper evaluation, the department was unanimous in belief that it would be misuse of existing resources to fund and untested treatment theory that even if proven successful to some extent, could then not be put in use due to insurance limitations at any subscribing hospital.  Your request is, therefore, denied with the suggestion you take note of the facts in this transmittal and direct your future efforts into areas approved by the system.

    He stares at the computer and feels as though what little determination remains within him is seeping from his body, much the same as dirty dish water makes a sucking sound before disappearing down a drain.  Watching ambition and purpose bleed away is a terrible thing, often leaving one so much a different person than had been the design of a younger man so ill-informed on the ways of the world, now measuring success solely on progressive statistics and resultant stockholders' equity.
    As he slowly drives home, Howard Earnshaw now feels he is a failure but what is really impounding all those hopes, all those ambitions isn't the failure itself - it is resent and hate that often leads so many away from what were once worthwhile hopes to a life of rebellion that ultimately confiscates them into a meaningless subsistence and tragically, all those around them.
    Living in the suburbs isn't the presumed escape it was once represented by all those real estate agents and builders who constructed the mass of cluster home communities around Atlanta at such a hectic pace they eventually found themselves with scores of unsold houses sitting there as a grim testimonial that social standing had yielded to the impracticality of being trapped in grid-locked traffic for hours during the day.  In time, the buying public became intolerant to that and those hokey names such as "Paradise Cove" and "Placid Glen" no longer appealed to whatever superceded sense a person had in moving to the suburbs.
    When he and Charlotte moved to "The Summit," they both liked the subliminal confirmation of success, such as the statue of some type grotesque animal at the entrance -  much the same as an upgraded billboard announcing such success.  But that was when Charlotte looked on her success as remaining home where she could care for the children and avoid excessive dust accumulation on the furniture between by-weekly visits by the housekeeper - certain to be noticed by their frequent guests who no doubt would have been delighted to see such tell-tale evidence that such infrequent visits by a housekeeper detracted from the accruements of a prominent bank account.
    Franklin is a good bit younger than his brothers and has always delighted in ragging them about their careers where they don't get their hands dirty.  When Howard bought the house in The Summit, he asked them if the owners' association would permit them to have a clothesline and went on to say that if such an obvious statement of ill-breeding were permitted, his advice was to move further away from Atlanta.  He later retracted the suggestion on the premise that the further a suburbanite moved from Atlanta, the worse the traffic became and it would then be necessary that Howard move his medical practice from Atlanta to Chattanooga, unless his OR moved into his basement and his patients were then required to come to him.
    It wasn't so very long ago that The Summit was indeed the mark of success so alluring to its residents.  Franklin came up with the formula to measure levels of success.  Howard wasn't nearly as amused as Charlotte that day when he sat down with them at the dining room table with his calculator he got at the drug store for $3.98 and explained how each owner could evaluate himself - or more realistically, how the other owners would evaluate him.  His theory was to divide the number of houses in the complex by the number of lawn care companies observed in the subdivision at noon each Wednesday and then divide that into the square footage of each house.  The lowest result would indicate the highest levels of success except in the cases of those who did their own lawn work who were to be excluded from the study since they obviously were too low class to even be there in the first place.
    Lawn care companies are now one of a number of things that have departed The Summit.  Once there were 50 lavishly appointed houses complete with clubhouse, swimming pool and tennis court.  Now, the clubhouse is closed, the swimming pool is drained and only occasionally is someone seen on the tennis court that is the only remaining amenity the association can afford to maintain since a number of the houses have been repossessed and others stand in varying stages of disrepair, all victims of what those who are expected to have an explanation for economic decline describe as "the repositioning of the American populace to more accurately represent the present economic and racial distribution."
    He remains in his car for a moment and stares at the garage door which is open, revealing a number of storage boxes and lawn equipment in strict violation of association requirements that garage doors remain closed at all times except when receiving or dispatching vehicles, to avoid the unkept appearance he is now viewing.  But he really isn't concerned with boxes or association mandates, as his thoughts reach back over the years when he was so eager to come home each night and see his wife and children.  The children now have their own lives and ever so gradually, his marriage has faded into what it now is - one that retains little of its former enchantment.  He can see that priest who conducted the pre-marriage counseling, then required by the Catholic Church, who kept telling them a marriage could not be maintained on sexual attraction alone.  Ironically, now sex is all that is keeping what remains of their marriage together.
    As he opens the door, most of his troubling thoughts are centered on himself.  His career, failure to obtain the research grant and what he can do with this damn house that has lost half its value but even at that, there is hardly anyone within a 50 mile radius that can afford to buy it.  He remembers when the children would come running to meet him, and there always was Charlotte in one of those cute little aprons preparing supper, much the same as any woman who had set aside whatever career ambitions she might once held, placing her family ahead of everything else.  She still greets him but there is always that withdrawn and evasive temperament that can no longer conceal her unhappiness.  When the children left, her life became a vacuum, desperately reaching out for something to fill the void created by her own thoughtfulness in thinking of others before herself.  Now, she is a 55 year old woman whose thoughts can only constantly dwell on the past.
    On this night, that damning expression, those empty eyes and the polite kiss on the cheek with some meaningless greeting is not there.  She is in the hall in front of the full-length mirror.  Her waistline remains trim, her legs still have that sculptured athletic appearance and she has never changed her hair style from the short, ducktail type that went out of vogue when those women in the television situation comedies quit combing their hair and began wearing rings in their noses and various things in other parts of their bodies.  Charlotte never let herself go physically as so many others do when they find themselves in such an unfulfilling existence.  With that, Howard has always remained in good physical condition, telling himself it would make his insistence that his patients take some form of regular exercise more rational.  In fact, however, it was really his own ego, not wanting to become some flabby slob on the arm of a shapely woman at some social event producing all sorts or under-breath observations and inviting the advances of any stud encouraged by the unharmonious coalition.
    Charlotte is wearing a dark blue mini-skirt with a white blouse with matching blue vertical stripes and a visor cap.  She takes a few steps towards him and turns around a few times before facing him and announcing with a vitality long absent from her voice, "I got a job at Burger Buster."
    "Doing what?" Howard asks.
    "Waiting tables."

________________

    Hospital rounds are among those mounting tasks that Howard dreads.  The procession of interns and first-year residents parades down the hospital hallway like a battalion of soldiers marching in a 6-man front.  The procession turns towards the hospice ward; and as they pass the chartroom, all eyes turn towards the very attractive technician, much the same as though they were passing in review in some parade to recall some memorable event in military history that no longer is mentioned in the evening news, now consumed with what reporters call "the pressing issues of a diverse society."  More times than not, this involves a robbery, an unexplained shooting or rape.  They make a left turn, all still in step, and advance to the bedside of the man on whom Howard performed the exploratory surgery a few days earlier.  Howard still can't recall the patient's name until he sees it on the band around his wrist.  Howard no longer directly supervises the rounds, feeling it better training for the residents and interns to speak among themselves and with the patients and outline the future treatment with the other doctors.  Usually, this takes very little time in a hospice ward.  The treatment is always the same - pain management.
    The resident at the head of the delegation says, "Good morning, Mrs. ...."
    She responds, "Davis," seeing the doctor doesn't know her husband's name.
    They surround the bed as the same doctor begins fumbling through some pages on a clipboard before saying, "Oh yes, this case involves...."
    Mrs. Davis reaches out and firmly grasps his wrist.  There is a demeaning glare in her eyes as she shakes her head but says nothing.
    The young doctor seems somewhat offended at her objection that her husband be used as training material for the advancement of their careers, some of whom can't get the image of the attractive technician out of their minds and appear to be wearing partial erections.
    Without proper ritual, the delegation moves on in the direction of the next patient, or "case," on the agenda.  As they walk along, Howard studies the lead doctor's loose, wrinkled clothing, his waving ponytail, swinging from side to side with each step, and the earring in his right ear.  He tries to remember if homosexuals wear such things in their left or right ear and finally decides it is the left ear.  Such ornamentation, worn in the proper place implies, but does not guarantee, the person is heterosexual.
    Suddenly, his attention is drawn from the procession.  He notices an unusual undertone of painful moans throughout the hospice ward.  As they pass each bed, he sees patients in varying stages of disease with different levels of pain written all over their faces.  Some are alone and some have love ones standing at their sides.  Always, there is that same hopeless expression on their faces.  He has seen it so many times.  They search their souls for something they can do for the dying.  At some point, they will all find themselves knowing the only remaining solace rests in death.
    Howard tries to turn his attention to the rounds and glances down at his chart for the patient in bed 3307.  He hardly hears the lecture-like observation made by the lead doctor or the elementary grammar school-like questions from the interns.  He sees Sedateomoxifaine is the only medication the patient is taking and studies the expressions on the faces of the 3 family members at the bedside as they listen to the classroom atmosphere that has suddenly descended upon them.  An unsettling feeling comes over him as he holds his pen to the chart and slowly reads the diagnosis.  

            Age:  73
            Diagnosis:  Kaposi's Sarcoma
            Condition:  Terminal

    He looks at the last blood work and notices a serious depletion of CD4 lymphocytes in the white cells just as the medical team resumes the march.  He steps to the bedside, holds the patient's hand and looking at his love ones, softly says, "I'm Doctor Earnshaw."  
    They all simply nod and look down on the patient whose eyes are firmly focused on Howard with the typical pleading glare of the dying.  He feels it unnecessary to expand on the patient's condition and only asks, "How is your pain?"  He drags his fingertips across the patient's frail forearm and notices the lymph nodes are quite noticeably swollen.
    The patient says nothing but the woman, who must be his wife, showing the same pleading expression, says, "He's been in terrible pain for a week."  She points to the Sedateomoxifaine at his bedside, begins to sob and adds, "That helped for awhile but it doesn't do any good now."
    Howard picks up the bottle and sees the dosage is near a coma inducing level.  He asks, "How long has he been taking this?"
    "About 6 months."
    The patients eyes remain fixed on him, yet he doesn't utter a word.  Howard manages a faint smile and says, "We'll need to keep him sedated with another medication," feeling it unnecessary to mention an induced coma will at least stop his pain.
    As he walks back to the chartroom, he realizes this patient's illness and symptoms are very similar to those of Mr. Davis, his patient in the OR a few days earlier.  Both of them are terminal, have taken Sedateomoxifaine for the same period and now seem to have developed a tolerance to the pain-killing properties of the drug.  He enters the new medication on the patient's chart and walks back to his office where he sits down and again reads the denial of his request for a research grant.  He stares out the window for a few minutes, trying to remember the doctor's name who conducted the rounds.  Finally, he picks up his telephone and for the first time, uses the new paging system that makes it unnecessary to go through the hospital switchboard, no longer manned by a person but an automated answering device that has so many options the caller usually forgets why he called when, or if, the correct option is recited by the machine.  He says, "Paging Doctor Kramer.  Please report to Doctor Earnshaw's office."
    After some few minutes, the young doctor walks into Howard's office, says nothing and flops down in the chair in front of his desk.  Howard stares at him and begins to pat his desk with his pen before saying, "I've always remembered something my professor told us in medical school.  It had to do with treating the terminally ill.  He discouraged any emotional involvement with the patients but simply suggested that in conversing with them, we imagine how we would feel, if we were in their condition.  You might find it advisable to consider that and particularly cease referring to them as 'cases.'  But that's not why I paged you.  I was concerned with 3307's chart; and by the way, his name is James Arnold."
    Some degree of casual interest enters the young doctor's eye before he calmly says, "He's terminal.  Three weeks at the outside."
    Again, Howard taps the desk with his pen before abruptly saying, "I made a copy of his chart."  He hands it to Doctor Kramer.
    Without looking at it, Kramer says, "I know what it says.  There's nothing that can be done other than pain management.  Everyone already realizes that."
    Howard leans back, throws his pen on the desk and says, "I think you need to take a closer look at his blood work.  Haven't you noticed the deficient CD4 T?"
    "Chemotherapy does that," he responds, becoming intolerant to the elementary nature of the discussion.
    "Have you noticed the swelling of the lymph nodes?" Howard asks, leaning forward and folding his hands on his desk.
    Kramer's mouth comes slightly open as though he were at the point of demanding some explanation for the polite down-dressing he is receiving but he says nothing.  He shakes his head.
    Sensing he has said all he intends, Howard' voice becomes more pointed.  "Here's what I want you to do, and do it today.  I want a RNA reverse transcription blood study.  Get that done and bring it to me no later than tomorrow."
    Kramer slaps his legs with his palms and says, "What are you telling me?"
    There is a long pause before Howard snaps, "I'm telling you that Kaposi's Sarcoma, depleted CD4 T and swollen lymph nodes strongly suggest the presence of AIDS."
    The young doctor's mouth opens even wider except this time, there is a muffled laugh and demeaning sarcasm when he says, "Come on, doctor.  That old man is 73 years old and probably hasn't screwed any strange stuff in the last 50 years.  Don't tell me you think he's been exchanging needles with some 20 year old whore."
    "Just order the test," Howard says.  His eyes remain fixed on him until he hastily gets up and slams the door behind him.
    Howard faces the window and begins gazing into the parking lot.  Thoughts and facts begin forming in his mind as he recalls a number of patients in the hospice unit over the past year.  As a surgeon, he wasn't the primary doctor for any of them but a vague similarity of symptoms, medications and death certificates flash before him, all punctuated with the same pleading stare he has witnessed this very day.  He faces his computer and stumbles through the program that eventually leads him to archive records.  After several unsuccessful attempts to click on the correct icon, he finally selects "mortality category designation," thinking that is where his haunting feeling is leading him.  Names, dates, ages and all sorts of data roll across the screen.  He clicks on the cancer icon and is startled at what he sees.  All neatly arranged in a number of evenly spaced columns, that resemble the flower beds that once graced his subdivision, are the records of each patient who died (or expired as hospital administration prefers to say) in Clairmont Hospital for the past 5 years.  Momentarily, he is lost within the maze of information but sees another icon at the right of the screen - "specific tabulation."  He clicks on the 70-80 age group.  Another color comes up on the screen but in the same format.  Slowly, he scans what the program calls "attendant conditions" - "pneumonia, toxoplasmosis, cryptosporidosis myco bacteria," all of which are AIDS related complexes and provide the avenue for formation of a defective Golgi Apparatus in the cells.  He clicks on the column headed "initial diagnosis."  There are scores and scores of entries - "Hodgkin's Lymphoma.....Hodgkins Lymphoma.....Kaposi's Sarcoma....Kaposi's Sarcoma."  Over and over in the "secondary diagnosis" column, there is "terminal....terminal....terminal....terminal."
    He stares at the screen for some few moments before calling up the central data base screen for the Georgia Research Institute where he has done some of his past research.  He has maintained contact with some of the doctors at the Institute who were working with him on the cancer research and still has access to their computer records.  Hurriedly, he goes through the log-on process but at the final step, a black screen appears with large white letters:  Security Violation.  Access Denied.  User Code And Password Withdrawn.
    He leans back, brings one hand under his chin and utters, "What in the hell....?"  He picks up his telephone to call the Georgia Research Institute.  There is the customary automated message directing him to press a series of numbers, none of which seem to suit the intent of his call.  As he tries to determine what number followed by the pound key to press, there is a very pleasant, although automated female voice, "Thank you.  Goodbye."  Then, there is a click followed by the dial tone.  He slams the received down and begins to go through his correspondence records with Dr. Harvey Russell.  He finally locates the doctor's letterhead that provides his direct telephone number and is somewhat surprised when a human voice answers with the added compensation it is the very person he is trying to contact.  Howard remembers when the telephone system was installed at the institute and the 2 hour period of training everyone received on how to use it as well as how to "screen your calls and establish priorities for your valuable time which may well not warrant returning a call."
    "Doctor Howard Earnshaw," Russell says.  "Now there's an exulted name I hadn't expected to hear today, or any other day for that matter, since you moved to the higher echelon of the profession.  What did you do - dial the wrong number?"
    Howard isn't interested in trying to psychoanalyze his demeaning tone which could result from the loss of many research grants or the fact he lacked the determination to move on to something worthwhile when the institute ceased to serve any valid purpose that anyone could assert or even imagine.  Carefully, he politely says, "I just tried to access your data base but found my access code has been withdrawn."
    "We haven't changed any codes since the last upgrade.  You should be able to enter the system the same as you always have," Russell says in a voice of disinterest implying he has more important things to do than discuss computer science with someone he isn't sure he resents, envies or guardedly admires.  "What were you trying to find?"
    "AIDS archive records."
    There is a long silence before Russell says in a non-committal pitch, "Well, we have made a few changes.  Now, these damn machines are programmed to automatically void anyone's code who tries to gain certain information without the proper authority.  That takes a whole new set of user names and passwords."
    "Proper authority?  I've got blanket authority for the complete system."
    "What do you need to know?" Russell asks with his voice cloaked in what Howard feels is a safekeeping mechanism.
    "I've come across something that makes no sense at all.  Clairmont has scores and scores of patients who have died over the past few years with complications that strongly suggest the presence of HIV or AIDS but most of them were elderly and not in the jeopardy categories that are even remotely related to these conditions."
    Again, there is a long silence before Russell says, "Maybe you'd better get over here.  What about 3:00 o'clock tomorrow?"

________________

    Howard slowly washes his hands after his morning surgery.  He stands at the sink and with uncertain thoughts, watches the water until it is completely drained, trying not to become unduly apprehensive about his discussion with Dr. Russell the day before.  Momentarily, an invigorating sensation fills his body as he looks at his patient being wheeled down the hall towards the recovery room before he goes into the surgical waiting area.
    The patient's love ones see him the moment he enters the long hallway leading to the room.  They restively glance at one another before standing and slowly walking to the door.  The elderly lady must be his mother, and tears are in her eyes.  She starts to say something but only stares at Howard with an expression that can only mark love and concern in its purest form. 
    As they gather around him, he smiles and says, "I think we're going to be OK.  The tumor hadn't engaged any major organ, and the lymph nodes were clear.  Only a slight tissue removal was necessary, and there was no remaining sign of cancerous tissue."
    The mother finally breaks down and asks, "You mean my boy is going to be all right?"
    Howard tactfully makes no assurance but says, "Simply as a precaution, I'm ordering a mild battery of chemotherapy.  After that, we'll need to do a few tests every 6 months."  He reads the relief on everyone's face and feels it necessary to qualify his appraisal, quickly adding, "Cancer is a disease we still don't fully understand.  Today, there's no longer outward signs of malignant tissue but we must recognize that for someone who has experienced his condition, there is always a chance of re-occurrence."  He reaches for his pad and starts to write a prescription for Sedateomoxifaine but suddenly recalls Mr. Davis and the moaning patients in the hospice ward.  He lists 2 other drugs and says, "He'll remain on these for a few days.  Only give him the medicine if he experiences unusual pain that does not subside in a few hours.  If there is any pain level after a week, ask his primary physician to contact me.  The way this medical insurance is, we must first go through the primary physician or the HMO will deny coverage."  Hoping he hasn't left them confused, or unduly criticized the need that HMOs maintain progressive statistic, he shakes everyone's hand.  Immediately, his concern turns to his meeting with Dr. Russell.
    When he returns to his office, there is Dr. Kramer semi-reclined in the guest chair with his legs stretched out revealing God-awful urine-color socks that do little to coordinate with his dirty, white tennis shoes.  He has one of those green and white computer pages in his hand and waits until Howard sits down and faces him before he says, "I've got the lab report for the HIV study on James Arnold."  He pauses, slightly shakes his head and says, "It isn't especially conclusive but does suggest a depletion of T4.  For someone in his condition, we'd need to do several comparative studies to confirm the copy of RNA."
    He hands the page to Howard who for a moment, waits for him to say something else but he just sits there in his wrinkled clothes with the small rhinestone in his left ear gleaming in the overhead lights. 
    Howard scans the lab report, places it on his desk and looks at Kramer whose contempt for staff surgeons overrides any need that he offer a more detailed prognosis.  "Have you ever seen anything like that?" Howard asks.
    Kramer shakes his head and says nothing.
    Howard realizes he feels an unusual amount of dislike for the arrogant doctor and only says, "Thank you."  He watches him quickly get up but before he reaches for the door, Howard asks, "By the way, doctor, did someone piss on your socks or did you find them in the toilet somewhere?"
    Kramer slams the door behind him without uttering another work, either on medical science or fashion design.

________________

    Howard remembers Boulevard as it was only a few years ago but as he drives down the central city street, there is such a change.  Many of the older buildings have been torn down, and a series of cluster condominiums have been constructed side-by-side that at first sight, give the impression one has entered a military post with everything dressed right and covered down instead of driving through what is supposed to be an upgrade neighborhood for those who have somehow managed to maintain their bank accounts within an economy that has been in decline for months and months.  Now, what exists is blocks and blocks of buildings with many vacancies never filled by the suburbanites who were supposed to move back closer to the city after what many financial advisers suggested was "an ideal time to capitalize on the emerging trend towards urban residence."  There is such a trend but the developers, advisers, real estate agents and even some of the present so-called economists did not visualize the massive layoffs within the past several years or speculate on how much of the retail market would move towards the Internet - not as a matter of consumer choice but of necessity, because those who were previously retail sales clerks found themselves at the top of the list of those who were laid off in order to reduce operating expense, increase stock holder equity and achieve greater progressive statistics.  This is not to mention the enormous balance of trade shortcoming resulting from outsourcing much of the manufacturing trades to foreign countries and the importing of foreign-made commodities. 
    Howard parks in the same spot that was reserved for him when he was employed at the Georgia Research Institute and is not surprised at the number of vacant spaces, considering the layoffs after much of the research funds previously supplied by the federal government were returned to the states. Due to declining state income tax collections, these funds eventually found their way into projects to prevent crime such as the purchase of television adds trying to sell the idea of peaceful co-existence in a multi-racial society.
    Dr. Russell is seated at his computer, glances up at Howard as he enters the room and with no change in facial expression, goes back to the computer for a full minute before finally facing forward and curtly asking, "How much do you know....or how much do you think you know?"
    Russell is a few years older than Howard and has been at the institute since it was formed.  Strangely, his expression displays the same contempt for him as the last doctor he viewed exiting his office with a 10 inch ponytail and urine-color socks.  Russell is much too conservative to be taken in by those broom-straw male models that have found their way into the medical journals to advertise the current trend which blends urine-color socks, earrings and gaunt physiques, often leaving the reader confused as to if the target market is a doctor, a homosexual or a drug addict.  His white coat is starched and goes well with his light blue shirt and black tie with coordinating oblique stripes the exact color as his shirt. 
    When Howard was at the institute, the 2 of them were at odds on nearly everything except their taste in clothing.  Trying to avoid the controversy that erupted almost daily when they were working together, Howard politely asks, "Very little....Only enough to think there may be something very serious developing in HIV transmittal."
    Russell places one hand on the back of his neck, looks to the side and exhales.  He seems laboring over what, if anything, he should say.  "How many AIDS patients have you treated?" he finally asks.
    "Very few, especially since all those drugs were developed a few years back that arrested the symptoms in most cases," he replies, noticing a sarcastic smile on Russell's face.
    Again, Russell hesitates but as his smile becomes broader, he asks, "Do you still use penicillin to treat an infection?"
    "Not anymore."
    "Why?"
    Howard sees Russell is enjoying playing with him as though he were a fish on the line of one of those persons who considers himself a sportsman by going out somewhere in the woods, hiding behind a bush and shooting the first helpless animal he sees.  "Because it's been used so long, much bacteria has developed an immunity to it.  Hell, every 4th grader that wants to be a doctor knows that."
    With a slight laugh, Russell faces his computer, pushes a few buttons and says, "Let me show you something.  I can see you're going to find out anyway."
    Howard walks to the computer and watches the program options roll across the monitor until "deceased" appears.  Russell clicks on the icon, which is in the image of a tombstone, and asks, "Tell me if you see anything similar in all these cases."  He allows Howard time to view the screen before scrolling forward to several other pages.
    Howard searches up and down the screen. Over and over there is Non-Hodgkin's Disease, Hodgkin's Lymphoma and Kaposi's Sarcoma, all diseases that are often associated with AIDS and remain undiagnosed for long periods, because the types of AIDS that result in these diseases often produce very little symptoms.  Most of the "deceased" were over 70 years old.  "Go back to the 1st screen," he asks.  He nods for Russell to proceed on the the next and the next.  He goes back to his chair, sits down and says, "At the risk of appearing overly simplistic, most of them had the same zip code."
    Russell leans back, laughs aloud and in a rather loud voice, almost shouts, "Exactly!"  He leans forward, places his hands on his desk and in an even less dignified manner, says, "Do you know how long it took that bunch of wet-backs in the records department to recognize that?"
    Momentarily, Howard is more captivated by his former colleague's harsh attitude than with the medical records of the deceased.  He simply shakes his head.
    Suddenly, Russell's mannerism changes from outspoken resent to cautious reservation.  His face comes completely blank as he tilts his head to the right and almost whispers, "You realize what you have just seen requires a top secret security clearance."  Abruptly, he stops and says, "Damn.  You no longer have the clearance." 
    Again, Howard is bewildered.   Guardedly, he asks, "Are you frustrated with lost of grant funds or do you want to leave the medical profession and become a postman to look into those zip codes?"
    Russell stares at him for a moment but does not respond with the derision that seems to have become the dominant form of his personality.  Instead, he adopts something of a cautious temperament and quietly says, "Can I have your word you will keep what I'm going to tell you to yourself?"  His eyes are stern and glaring.  He waits until Howard nods before leaning back in his chair and saying, "Since you moved to the suburbs, you might have forgotten or chosen to ignore what's happened to Atlanta.  You must still have the analytical mind I recall, because you noticed most of the patients had the same zip code.  He is restless and again leans forward, again adopting what has become his natural cynicism.  "What should the analytical mind tell a researcher about such a phenomenon?"  Still again, he leans back and is outwardly amused at the quizzical expression on Howard's face.
    Howard begins to resent being questioned like some 3rd grader and impatiently responds, "The first step in any such research is to determine what factors link the subjects.  We don't seem to be speaking of pollution-related causes.  I can't see how the zip code...."
    Exhaling, Russell again leans back and stares at the ceiling.  "How long has it been since you've been over there on North Midland Avenue?"
    "Charlotte and I used to like to go over there to those antique shops.  We haven't been there in quite awhile."
    "Did you notice anything strange?" he responds, again facing Howard and placing his hands back on his desk.
    Becoming more impatient, Howard shakes his head but then says, "There's a lot of gays over there.  Most of the people in the shops had high-pitched voices and all sorts of ornamentations on their bodies."
    "What else?"  The ridiculing smile begins to trickle over his face as he watches Howard struggle with the bizarre direction of the conversation.  Finally, he says, "Doctor, I'm supposed to be a research scientist and not a member of the census bureau but let's see, what do those monkeys down there at City Hall say?....Oh yes, 'the dynamics of the neighborhood have brought together an expanding homosexual community among a population of older residents.'  What they really mean by that bull shit is some of the older people have lived there all their lives and are still trying to hold on to a neighborhood they once loved because they can't afford to move away from it."  He gets up, walks to a filing cabinet and goes through some sort of password process to open the top drawer.  He removes a folder and walking back to his desk, drops it in Howard's lap.  He sits down and resumes the same stare without saying a word.
    The "AIDS MUTATION" label strikes Howard.  He looks at Russell who still says nothing.  Howard recalls Russell as a very detail-oriented researcher, so much so, he often lost himself in lengthy dissertation of medical facts not related to the project at hand.  He looks at the 2 1/2 inch content of the folder, goes to the index and sees the summary is on page 150 where he begins to read.

Urgent Transmittal To Georgia Department Of Public Health
Subject:  Destruction of P53 Gene and Parallel Metastases
______________________________________________________________________

    The conclusion of this study is that through a mutation process not fully identified, the AIDS virus is now spreading by other than blood to blood contact.  In a creditable number of case studies, the condition is limited to persons over 70 years old who have naturally undergone some depletion in the immune system.  The mutation has, however, shown a very rapid evolution and should be expected to eventually expose all age groups.
    Specifically, the virus is attacking cell receptors producing a distorted growth factor in proto-ontogenesis which are very rapidly mutating into oncogenes.  Once the cell is attacked, p53 gene production is repressed, apoptosis is inhibited increases and expands the production of telomerase at a rapid rate, thus producing a well-developed angiogenesis and ultimate metastases.  Initial indicators were that this process was largely confined to vascular tissue but more recent studies show such progression is now occurring in all organs of the body, primarily the pancreas and liver.
    Through the course of this study, one glaring fact was noted which has never appeared at any level of all previous medical research.  The incident rate in the state of Georgia was 90% in the city of Atlanta and further defined to 85% in a small geographic area consisting of less than one square mile.  The area is largely populated by homosexuals where a greater incidence rate of AIDS and related illnesses could reasonably be predicted; however, of the 85% in this small area, 75% of the infected individuals were over 75 years old and none were homosexuals or members of any high-risk category in contacting these diseases.
    It is the undisputed and unanimous opinion of the research center that a grave public health issue exists that commands immediate public notification and bold measures to prevent the spread of these diseases until the contributory causal effect can be more specifically identified.  At present, it is believed the virus has mutated to a strand that can be transmitted by the most casual contact with perspiration, skin oil and saliva.

________________

    Howard slowly shakes his head, closes the folder and places it on Russell's desk before exhaling and faintly saying, "Damn."
    "A very astute observation, doctor."  Russell picks up the folder and immediately places it back in the filing cabinet and then goes through several steps to encode the security lock.  As he walks back to his desk, he says, "Now, I'm going to tell you something else you probably won't believe.  Do you know what those idiots at the state told us to do?"
    "Since a certain amount of theory exists as to the transmittal mode, they probably told you to keep this under your hat.  Releasing only what you know now probably wouldn't accomplish much."
    That same defiant smile comes over Russell's face before he breaks out in a stifled laugh.  "That's exactly what they told us, among other things."
    "What other things?"
    "They said our data base was far to small to draw any such far-reaching conclusions."  Before Howard can respond, he holds up his hand and pointedly says, "No, we haven't asked any of the other states if they have noted similar trends."
    "Why?"
    Russell leans back, places his hands behind his neck and again starts staring at the ceiling.  "Doctor, you've been away from here a long time and probably don't know how fucked up things are over there at the Capital.  What do you think happened when Congress turned medical research over to the states?"  Immediately, he leans forward.  "I'll tell you what happened!  Research is galloping in 50 different directions with no co-ordination, severely reduced funds and almost no exchange of information."  His emotion rapidly alternates between defiance and sarcastic amusement as he adds, "Do you know what the number 1 priority is in the state legislature?"  Before Howard can venture a guess, he blates out, "They've got to teach these squint-eyes and wet-backs, most of whom are here illegally, how to speak English.  And I'll tell you something else.  They told us all these privacy and human rights laws those imbeciles have passed in the last few years would deny us access to the medical records we need to get the conclusive proof they want."
    Howard's mouth drops slightly open.  "What?"
    Russell doesn't repeat himself and only adds, "The Descendents of the World organization has got all those frigging politicians so brainwashed on all this diversity horse shit, that's all they ever talk about.  Everyone's trying to clothe himself as a human rights crusader.  All they're trying to do is stay in office.  In some districts, immigrants are now the majority of the voters."
    Finally, Howard manages a slight smile and says, "I really don't see how...."
    "Of course, you can't see how," Russell responds, appearing he is about to leap across the desk.  "Maybe you ought to take a few days off and sit around here for awhile.  It's comical.  You could probably sell tickets to it."
    The records on the hospital computer system reenter Howard's mind.  "What are you going to do?"
    "Not a goddamn thing!" he snaps.  "We're just going to have to teach everyone to speak English first and then look at the lesser priorities."  Somehow, he immediately becomes more restrained and calmly utters, "I suppose the state might be right to some extent.  If we went public with what we know, we'd look like some of those damn politicians bitching about all the things that are wrong in America and getting everyone so stirred up, they'd expect we come up with a solution overnight."  He pauses, leans back and places his hands on top of his head before sarcastically laughing and saying, "Even if we had this goddamn sufficient data base, we'd  have the Gay Rights Alliance on our doorstep and on the evening news making all sorts of ridiculous charges of discrimination.  Hell, there're more concerned with the right of a bunch of dirty little queers to stick their pricks in each other's asses than they are such a trivial matter as public health."  His emotional outburst ceases, as he keeps leaning forward and backwards in his chair.  In a very serious tone, he says, "Of course, you realize how important it is that you keep this to yourself, at least for now.  I guess I'll have to keep you informed, even though you no longer have the clearance.  In the meantime, if you run across any woman with $5,000,000 dollars who has low standards and is looking for a husband, let me know.  My wife, I'm sorry to say, left me.  She couldn't put up with what all this is doing to me."  Abruptly, he turns around, picks up his telephone and gets an outside line.  He seems to be listening to a recorded message, slams down the receiver and remains motionless, staring out the window.

________________

    It is troubled thoughts that rule Howard's mind as he aimlessly drives back to the hospital.  It isn't only what he has just heard.  There are the faces of those in the hospice ward, the tears in the eyes of their love ones - all denied anything but pain management due to the financial limitations of the health care system.  There is the denial of his research grant because the same financially depressed system cannot fund "highly speculative research" and adhere to the prevailing attitude nearly everywhere that progressive statistics must determine what is done and what is not.  He sees Charlotte as a young woman and those happy expressions on her face when the children were in the house; but as his career moved towards what he had always thought would be success and fulfillment, her life began to wither, much the same as a leaf in the final days of autumn, waiting to fall to the ground where its past beauty is forever lost to a new season, changing times and those such as himself who have placed their own hopes and ambitions ahead of loving concern for another person's feelings.  He wonders what he can do, what must he do to give her back the happiness he has destroyed.
    Slowly, he walks through the hospice ward.  Several patients, their bodies diminished by disease, pain and worry fix their eyes on him as he passes.  There is an unspoken pleading indelibly written across their faces as if each is begging, begging.... please, please do something for me.  He is at Mr. Davis's bed and comes to a dead stop.  His wife is standing there at his side with the most composed expression on her face.  Her eyes convey a gentle and loving sentiment, and there is a tender smile as she looks down on her husband.  Lovingly, she holds his hand.  Howard looks at him and immediately, knows he is dead.  She glances up at Howard before placing her husband's hand on the bed, still standing there and gazing down at him. 
    Cautiously, Howard walks forward and suddenly is seized with the most startling apprehension.  Quietly, he asks, "How did you do it?" 
    Her eyes remain fixed on her husband for a moment before she says, "That medicine you prescribed to replace Sedateomoxifaine - I saved it up for a few days and gave it to him all at once.  That's what he wanted.  No one here would do anything for him.  Somebody had to do something.  He's at peace now."