Then she spat in my face.
A general practitioner’s task is simple. He doesn’t have to heal people, he only has to make sure they don’t sidestep him and make it to the specialists and the hospitals. His office is an outpost. The more people who can be stopped at the outpost, the better the practitioner is at what he does. It’s simple arithmetic. If we family doctors were to let through everyone with an itch, a spot, or a cough to a specialist or a hospital, the system would collapse entirely. Entirely. Someone did the arithmetic on that once. The conclusion was that the collapse would come more quickly than anyone expected. If every general practitioner referred more than one-third of his patients for further care from a specialist, the system would begin to creak and buckle within two days. Within a week it would collapse. The general practitioner mans the outpost. Just a common cold, he says. Take it easy for a week, and if it’s not over by then, well, don’t hesitate to come back. Three days later, in the middle of the night, the patient suffocates on his own mucus. That can happen, you say, but it’s a fluke. A rare combination of factors. We see it in no more than one out of every ten thousand patients.
Patients don’t realize that there’s strength in numbers. They let themselves be ushered into my office one by one. There I spend twenty minutes with them, convincing them that there’s nothing wrong. My office hours are from eight-thirty to one. That adds up to three patients an hour, twelve to thirteen a day. For the system, I’m the ideal family doctor. General practitioners who think they can make do with half the time per visit see twenty-four patients in a working day. When there are twenty-four of them, there’s more of a chance of a few slipping through the cracks than there is when there are only twelve. It has to do with how they feel. A patient who gets only ten minutes’ attention feels shortchanged sooner than a patient who gets the same song and dance for twenty minutes. The patient gets the impression that his complaints are being taken seriously. A patient like that is less likely to insist on further examination.
Mistakes happen, of course. Our system couldn’t exist without mistakes. In fact, a system like ours thrives on its mistakes. Even a misdiagnosis, after all, can lead to the desired result. But usually a misdiagnosis isn’t even necessary. The most important weapon we general practitioners have at our disposal is the waiting list. The mere mention of the waiting list tends to do the job. For this examination there’s a waiting list of six to eight months, I say. With that treatment your symptoms might be a little less acute, but there’s a waiting list … Half the patients give up as soon as the waiting list is mentioned. I can see it in their faces: relief. One of these days is none of these days, they figure. No one wants to have a tube the size of a garden hose pushed down their throat. It’s not a particularly comfortable procedure, I say. You could also decide to wait and see whether it goes away with a combination of rest and medication. Then we’ll take another look in six months’ time.
How can there be waiting lists, you might ask yourself, in a wealthy country like the Netherlands? For me, the association is always with the gas bubble. With our reserves of natural gas. I brought it up once during an informal gathering with colleagues. The waiting list for hip operations: How many cubic yards of gas would you have to sell in order to do away with that list within a week? I asked. How, for Christ’s sake, is it possible that in a civilized country like ours people die before they reach the top of the waiting list? You can’t look at it that way, my colleagues said. You can’t tally gas reserves against the number of postponed hip operations.
The gas bubble is huge. Even worst-case scenarios predict that there will be enough natural gas for the next sixty years. Sixty years! That’s bigger than the oil reserves in the Persian Gulf. This is a wealthy country. We’re as rich as Saudi Arabia, as Kuwait, as Qatar—but still, people die here because they have to wait too long for a new kidney, infants die because the ambulance that’s rushing them to the hospital gets stuck in traffic, mothers’ lives are endangered because we, we general practitioners, convince them that home-birthing is safe. While what we should actually say is that it’s only cheaper—here, too, it’s clear that if every mother claimed the right to give birth in a hospital, the system would collapse within a week. The risks of babies dying, of babies suffering brain damage because no oxygen can be administered during a home birth are simply factored into the equation. Every once in a great while an article appears in a medical journal, and sometimes a summary of that article will actually make the Dutch papers, but even those summaries show that infant mortality in the Netherlands is the highest in all of Europe and indeed the Western world. But no one has ever acted on those figures.
In fact, the family doctor is powerless in the face of all this. He can put a patient’s mind at ease. He can see to it, for the time being at least, that a patient doesn’t seek the assistance of a specialist. He can convince a woman that home-birthing poses no risks whatsoever. That it’s all much more “natural.” Whereas it’s only more natural in the sense that dying is natural, too. We can give them salves or sleeping pills, we can burn away moles with acid, we can remove ingrown toenails. Nasty chores, usually. Like cleaning the kitchen, using a scouring pad to remove the goo from between the burners.
I lie awake at night sometimes. I think about the gas bubble. Sometimes it resembles a bubble like the ones you blow with soapsuds, only it’s right under the earth’s crust; all you have to do is poke a hole in it and it deflates—or blows up in your face. At other times the gas is spread out over a much greater area. It has permeated into the loose earth. The natural-gas molecules have mixed invisibly with the soil. You can’t smell it. You hold a match up to it and it explodes. The little fire becomes an inferno that spreads within seconds across hundreds of square miles. Underground. The earth’s surface becomes hollowed out, there is no more support for bridges and buildings, not enough solid ground beneath the feet of humans and animals, entire cities sink into the burning depths. I lie there with my eyes open in the dark. Sometimes our country’s undoing takes the form of a documentary. A documentary on the National Geographic Channel, with charts and computer animations, the kind of documentary they’re so good at: documentaries about dam bursts and tsunamis, about avalanches and mudslides that wipe whole towns and villages off the map, about the entire side of a volcano that breaks off from an island and slides into the sea, causing a tidal wave, which, eight hours later and thousands of miles away, reaches a height of almost four thousand feet. The Disappearance of a Country, tomorrow night at nine-thirty, on this channel. Our country. Our country consumed by its own reserves of natural gas.
On rare occasions, lying awake at night like this, I think about Ralph Meier. About his role as the Emperor Augustus in the television series of the same name. The role suits him to a tee; both his fans and his detractors are in total agreement about that. First of all, of course, because of his build, the corpulence he nurtured through the years. An obesity achieved exclusively by means of systematic pig-outs in restaurants with one or more Michelin stars. By lavish barbecues in his yard: sausages from Germany, hams from Bulgaria, entire suckling lambs roasted on a spit. I remember those barbecues as though they were yesterday: his hulking frame beside the smoking fire, single-handedly flipping the hamburgers, steaks, and drumsticks. His unshaven, flushed face, the barbecue fork in one hand, a sixteen-ounce can of Jupiler in the other. His voice, which always carried right across the lawn. A voice like a foghorn. A voice that tankers and container vessels might use to find their bearings in distant estuaries and foreign ports. The last barbecue wasn’t even that long ago, it occurs to me now, only about five months. He was already ill by then. It was still he who flipped the meat, but now he had pulled up a plastic lawn chair—he had to sit while he did it. It’s always fascinating, how an illness—an illness like his—attacks the human body. It’s a war. The bad cells turn against the good. At first they attack the body from the sides, a flanking maneuver. An orderly little attack is all it is, a glancing blow, designed
only to divert attention from the main force. You think you’ve won: You have, after all, repelled this first minor assault. But the main force is still in hiding, deeper inside the body, in a dark place where the X-rays, the ultrasounds, and the MRI scans can’t find it. The main force is patient. It waits until it has reached full strength. Until victory is assured.
The third episode was on TV last night. The emperor consolidates his power. He changes his name from Gaius Octavius to Augustus, and sidelines the Senate. There are ten more episodes to come. There has never been any suggestion of canceling or postponing Augustus just because its star is dead. Ralph Meier is formidable in his role, the only Dutch actor in a cast of Italians, Americans, and Englishmen, but he outplays them all.
Last night, I believe I must have been the only one who watched the series in a different way. Through other eyes, perhaps that’s the way to put it. The eyes of a doctor.
“Can I go, anyway?” he’d asked me at the time. “It’s a two-month shoot. If I have to pull out halfway through, it would be a disaster for everyone involved.”
“Of course,” I told him. “Don’t worry. It usually doesn’t amount to anything. We’ll just wait for the tests to come back. There will be plenty of time afterwards.”
I watched the Emperor Augustus as he spoke to the Senate. It was an American-Italian coproduction, and they hadn’t cut any corners. Thousands of Roman soldiers, entire legions cheering from the hillsides around Rome, tens of thousands of swords, shields, and spears raised high, fleets of hundreds of ships before the port of Alexandria, chariot races, gladiatorial contests, roaring lions, and mangled Christians. Ralph Meier had the illness in its most aggressive form. It was something you had to act on immediately; otherwise it was too late. Radical intervention: a first strike, a carpet bombing to knock out the malignant cells at a single blow. I looked at his face, his body. Inside that body, in all likelihood, the main force had already begun its offensive.
“Senators!” he said. “From this day forth I am your emperor. Emperor … Augustus!”
His voice carried, as always—at least it still did then. If there was anything wrong with him, he didn’t let it show. Ralph Meier was a real trouper. If need be, he could upstage anyone and anything. Even a fatal illness.
Over the years, one by one, the normal people have disappeared from my practice. By which I mean: people who work from nine to five. I still have a couple of lawyers and the owner of a fitness club, but most of my patients work in what are called the “creative professions.” For the moment, I’m not counting the widows. There are quite a few of those. One could refer to a widow surplus. The widows of writers, of actors, of painters … The women hold out longer than the men; they’re made from other, sterner stuff. You can reach a ripe old age standing in the shadows. A whole life spent making fresh coffee and running to the wine shop for the geniuses in their studios. Fresh Norwegian salmon for the writers in their studies, where you always have to walk on tiptoe. It looks like a real chore, but of course it’s a cakewalk. The widows grow old. Old as dirt. As soon as their husbands die, they often enter a brief, second bloom. I’ve seen them here in my office. They’re sorrowful, they dab at their eyes with a hankie, but they’re relieved as well. Relief is an emotion that’s hard to hide. I look with the eyes of a doctor. I have learned to see through the tears. A prolonged illness is not an easy thing to endure. Cirrhosis of the liver is a drawn-out, painful affair. The patient is often too late; he goes for the bucket beside the bed, but the blood is already welling up. Changing the bedclothes three times a day, sheets and blankets heavy with puke and shit—that’s more demanding than fixing coffee and making sure there’s enough gin in the house. How long is this going to last? the prospective widow wonders. Will I be able to hold out till the funeral?
But then the day comes at last. The weather is beautiful, blue skies with fluffy clouds, birds singing in the trees, the smell of fresh flowers. For the first time in her life, the widow herself is the center of attention. She’s wearing sunglasses, so no one can see her tears; this is what everyone thinks. But in fact the dark lenses serve to hide her relief. His best friends carry the coffin to the grave. There are speeches. There is booze. Lots of booze. No watery coffee at an artist’s funeral, just plenty of white wine, vodka, and old gin. No slices of cake or almond pastries with the tea, but oysters, smoked mackerel, and croquettes. Then the whole club goes to their favorite haunt. “Well, here’s to you, old boy, wherever you may be! Old bastard! You old goat!” Toasts are made, vodka is spilled. The widow has taken off her sunglasses. She smiles. She beams. The puked-on sheets are still in the hamper, but tomorrow they’ll go in the washing machine for the very last time. Life as a widow, she thinks, will always be like this. The friends will go on proposing toasts for months (for years!). To her. To their new center of attention. What she doesn’t know yet is that, after a few courtesy calls, it will all be over. The silence that will follow is the same silence that always falls after a life in the shadows.
That’s usually the way it goes. But there are also exceptions. Rage makes for ugly widows. This morning there was suddenly a ruckus at the front door of my office. It was still early; I had just ushered in my first patient. “Doctor!” I heard my assistant call out. “Doctor!” There was a sound like a chair being knocked over, and after that I heard a second voice. “Where are you, you piece of shit?” the voice shrieked. “Are you scared to show your face?”
I smiled broadly at my patient. “Excuse me for just a moment, would you?” I said, and stood up. Between the front door of the practice and my office is a corridor; first you have to walk past a desk where my assistant sits, then past the waiting room. It’s actually more of a waiting area than a waiting room; there’s no door separating it from the hallway.
I glanced over as I went by. As I said, it was early, but there were already three patients flipping through old copies of Marie Claire and National Geographic. By that point, however, they had stopped their flipping. They had lowered their magazines to their laps and were staring at Judith Meier. Judith had not become any prettier after her husband’s death, and that was putting it mildly. The skin on her face had reddened, but not everywhere, making it look spotty. Behind Judith’s back, my assistant was gesturing that there was no way she could have stopped her. Farther back, behind my assistant, a chair was lying on the floor.
“Judith!” I said, opening my arms as though I were pleased to see her. “What can I do for you?”
For a couple of seconds my greeting seemed to stun her—but no longer than a couple of seconds.
“Murderer!” she screamed.
I glanced over at my patients in the waiting space; I knew all three of them by sight. A film director with hemorrhoids, a gallery owner with erectile dysfunction, and a no-longer-so-very-fresh-faced actress who was expecting her first child—albeit not from the blond, hulking, and permanently unshaven actor she had married seven months earlier in a Tuscan castle, all paid for by the society program on the commercial TV channel that had been granted exclusive broadcast rights to the entire ceremony and after-party. I shrugged and winked at them. An emergency case—that’s what the shrug and wink were meant to say. A typical case of acute hysteria. Alcohol or drugs—or both. Just to be sure they’d seen, I winked again.
“Judith,” I said as calmly as possible. “Why don’t you come with me, then I’ll see what I can do for you.”
Before she could reply, I turned and strode back into my office. I placed my hands on my patient’s shoulders. “Could I ask you to go to the waiting room? My assistant will write out a prescription.”
Judith Meier was sitting across from me at my desk. I looked at her face. The red blotches were still there. It was hard to tell, in fact, whether her face was white with red blotches, or red with white.
“You’re finished,” she said. Then she went on: “This whole flea circus is going to shut down so fast it will make your head spin.” She nodded toward my office door, with the
full waiting room behind.
I put my elbows on the desk. Then, forming a tent with my fingertips, I leaned forward slightly. “Judith,” I said—but suddenly I didn’t know how to go on. “Judith,” I tried then, “isn’t it a bit early to draw such drastic conclusions? Maybe I did diagnose Ralph’s illness incorrectly at first. I’ve admitted that possibility already. And that will come up tomorrow at the hearing. But I never intentionally—”
“Why don’t you just save it and see how the Board of Medical Examiners reacts when I tell them the whole story myself?”
I stared at her. I tried to smile, but my mouth felt the way it had the time I broke my jaw in a cycling accident. A pothole. Men at work. A little barrier had been set up to alert oncoming cyclists to the hole in the road, but some joker had removed it. At the emergency room they wired my upper and lower jaws together; for six weeks I could neither talk nor consume anything but liquids, through a straw.
“Are you going to be there, too?” I asked as calmly as I could. “That’s not exactly custom—”
“Yes, that’s what they told me. But they thought the charges were serious enough to make an exception.”
This time I really did smile. Or at least I succeeded in twisting my mouth into something that could be said to resemble a smile. But it felt as though I was opening my mouth for the first time after remaining silent for a whole day.
“Wait, let me check with my assistant for a moment,” I said, rising from my chair. “I’ll get together all the test results and the files.”
Now Judith started to her feet, too. “Don’t bother. I’ve said everything I have to say. I’ll see you tomorrow at the hearing.”
“No, really, I’ll only be a moment. I’ll be right back. I have something that might interest you. Something you don’t know about, either.”