Best and Brightest: Solutions for Female Incontinence

as told to Lisa Murtha — Thu, 29 Dec 2011 13:00:00 GMT

Pelvic floor disorders are extremely prevalent in women, almost to a point that every woman some time in her life will suffer from one. There’s a variety of different causes: The pelvic floor can be damaged by childbirth, heavy lifting, chronic disease, previous pelvic surgeries, and other causes that are not clearly understood.

There’s a tremendous overlap in symptoms related to things a gynecologist would see in a woman and things a urologist would see. You’ll have a patient who has a bladder control problem; maybe they’re having pain with intercourse, maybe a bowel problem. Historically they’ve been passed around—you need to see a gynecologist for this, a urologist for that, a colorectal specialist for that. It’s difficult for a patient to figure out, so you need this all-inclusive mechanism to guide the patient through the system.

The center’s been around less than a year [but] it’s been very well-received. It’s getting bombarded. It’s got state-of-the-art testing equipment; we can evaluate the most complex problems right there. Eleven percent of women who have a bladder control problem have a bowel control problem. Probably up to 40 percent of women who have a bladder control problem have a problem with pelvic organ support. Almost always, non-surgical treatment options such as medication, behavioral therapy, and pelvic floor rehabilitation are initially recommended. When surgery is necessary, it can often be done minimally invasively, on an outpatient basis. We get referrals from all over. We recently had a patient who came from Athens, Greece.

The good news is, for 95 percent of patients, it’s a quality-of-life issue—nobody ever dies of losing urine. But it’s a _significant quality-of-life problem. For example, most people aren’t aware of the fact that in the adult protective wear industry, the amount of money spent on pads to control a leaky bladder is about $4 billion a year. It’s a huge, huge problem that, unfortunately, women are still in the closet about. They buy their pads and they do their thing but they don’t talk about it. Christ Hospital has done a great job in promoting the center and getting the word out. There’s almost hardly ever a situation where we can’t help you and make your quality-of-life better.

Originally published in the January 2012 issue.
Illustration by Mario Wagner.

Best and Brightest: Treating Brain Tumors With Less Trauma

as told to Liz Bronson Rosenau — Thu, 29 Dec 2011 13:00:00 GMT

Philip Theodosopoulos: In terms of sinus surgery, even 10 years ago you couldn’t do most of what we do now. The old way involved opening the skull and sometimes breaking the jawbones to get to tumors.

Lee Zimmer: Now the process is much less invasive. For example, for a pituitary tumor we start by looking into the nose with a 4 mm diameter endoscope and watch the feed on an HD TV. We then find small openings in the sphenoid sinus wall [a paper-thin bone] and open that. We remove a little bit of the partition, or septum, deep in the nose. It’s then that we can see the tumor, and being careful not to nick the optic nerve or carotid arteries, we remove it. We don’t have to touch or move the brain at all. With the old way, we’d also have to put 10 yards of gauze up the patient’s nose to keep the surgical site sealed off so it could heal properly. That’s very painful to remove. Now, we simply seal off the surgical site with a gel spray and a small piece of fat from the patient’s belly.

Theodosopoulos: There used to be a lot more side effects too, including infection, pain, and scarring. The difference between the old approach and what we do today is honestly night and day. This isn’t only a better technique for surgeons; it’s producing better outcomes for the patients. It’s less risky and there’s no morbidity. That’s huge.

Zimmer: We’re able to look at more quality of life issues for the patient, too. We’re able to remove the tumor without affecting their sense of smell, and they wake up the next day able to breathe and go home.

Theodosopoulos: And psychologically, how you feel about your healing process has a big impact on your recovery. I’ve actually had patients come to me and say, “Doc, you’re sure you actually performed surgery on me, right?” I have to show them before and after scans to prove it to them. They can’t believe they feel as good as they do. Brain surgery is a major life event, and to feel normal afterward—you know that you’re winning.

Zimmer: I think it also has to do with the team-oriented approach. At the UC Neuroscience Institute, we have a tumor board where every patient is presented. At that tumor board we have radiation oncology, medical oncology, radiology, neurosurgery, ENT, pathology, endocrinology, and sometimes ophthalmology, so you have a wide scope of functions tailoring a patient’s treatment. That’s what makes UC special. You get the whole team’s expertise.

Theodosopoulos: It gives the patient hope. We don’t punt them somewhere else—the buck stops with us. If you come to us, we own your care. Very few people do the number and quality of tumors that we do here. We do 150 to 200 tumors a year, and I just did my thousandth tumor last week. There are years Lee and I do more tumors than the Cleveland Clinic altogether.

Zimmer: We’re still learning—it’s a continuum of improvement—but really, you don’t have to travel to get good care.

Illustration By Peter Ryan
Originally published in the January 2012 issue.

Best and Brightest: The Future of Breast Imaging

as told to Lisa Murtha — Thu, 29 Dec 2011 13:00:00 GMT

I love radiology because it’s like an investigation—the patient presents with certain symptoms, and imaging is a big piece of the puzzle. I also love the technical aspects of radiology and really enjoy patient interaction. We see patients year after year for their annual mammograms, so I get to develop relationships with them.

If one of our patients comes in for a mammogram and we see an abnormality, we have them return for different kinds of imaging to determine what it is. If it’s a lump, we send them straight to diagnostics to set up an appointment for a biopsy. A little over a decade ago, a patient had to go to the operating room to have a biopsy. Now with percutaneous biopsy, we mark the area, clean it, insert a needle and get the sample we need. The patient is awake and can watch what we’re doing the entire time. There’s no need for anesthesia, no incision, no visit to the OR. It’s also less expensive, less invasive, less overwhelming, has fewer complications, leaves less scarring, and it’s equally accurate. It’s changed the way I practice—now I get to manage my patients from the time they come in for their screening to the time I share their biopsy results.

It is amazing how much better we’ve gotten at detecting cancers because we can see so much more now. If I showed you mammograms from 10 years ago versus today, the difference would be startling. We can now shift our focus to identifying what we see—that is, whether it’s benign or malignant.

We’re also adding more tools to our toolbox. Tomosynthesis is a way of capturing a three-dimensional picture of the breast—instead of the traditional top-to-bottom and left-to-right pictures we get with mammography, tomosynthesis gives us a group of individual “slices” of the breast tissue. The breast is still compressed like it would be for a mammogram, but the machine moves in an arc. It improves specificity of normal versus abnormal, and gives us better visuals, especially for women with dense breasts. It’s still new and just got FDA approval, but there’s a lot of potential.

The future of radiology is molecular imaging. We won’t just be able to see the anatomy, we’ll be able to mark areas for targeted treatment. For example, with spectroscopy, instead of just looking at the size and shape of a tumor, we’ll be able to tell what compounds are in it and learn the physiology of the mass. That’s still in the research phase.

UC is an American College of Radiology accredited Breast Imaging Center of Excellence, the only hospital in Greater Cincinnati accredited for breast MRI. It’s great to go to national meetings and have people recognize UC as a great institution. With teaching, research, and busy clinical days seeing patients, the days can be very long. But I love the work I do.

Illustration by Victo Gnai
Originally published in the January 2012 issue.

Best and Brightest: Helping Kids With Asthma Breathe Easier

as told to Lisa Murtha — Thu, 29 Dec 2011 13:00:00 GMT

There’s a great metaphor by medical sociologist Irving Zola: Doctors are always so busy downstream trying to save the patients floating by they never have time to step to the side of the bank and look up at the bridge and see who’s throwing them all in. The challenge [in public health] is that doctors do doctor things, public health folks do public health work, lawyers do their lawyer work. It’s only when you start building bridges that you realize everybody has a common agenda.

The asthma study is an attempt to understand disparities in childhood asthma outcomes. From prior research we know that low-income children are four times more likely to be readmitted [with asthma symptoms]; we know minority children are two to three times more likely to be readmitted. But we really wanted to understand what the underlying factors were, what drove those income- and race-related differences. If we can identify key exposures that are leading to worse health, then we can begin to build collaborative programs to intervene.

We’ve begun to work with the Legal Aid Society of Greater Cincinnati and the Cincinnati Health Department. For Legal Aid we’ve placed a legal advocate in the Pediatric Primary Care Clinic five days a week. About one-third of the cases [that Legal Aid sees there] are around housing conditions, one-third relate to health insurance and benefit issues, and the last third are a basket of education-related and family law issues.

There was one young woman who had been admitted to the pediatric ICU twice in three months. But when she had additional difficulties, the real issues were revealed: The family was being put at risk of eviction and they had lost Medicaid. For a child with such fragile asthma to end up in a homeless shelter and uninsured would have certainly led her back into the ICU, with an outstanding bill in the tens of thousands of dollars. Legal Aid was able to help them get back onto Medicaid and to stabilize the housing. The patient subsequently went on to have six months with no further hospitalizations.

[Another time] we had referred 16 different children [with asthma] to Legal Aid for poor housing; the housing was all owned by a single New York developer. Legal Aid recognized that all these buildings were linked and began to work to get a new roof on two of the buildings. To me it was a perfect example: We were working downstream one by one, [but our] partner said, “Wait a second! You have a sick building, not just a sick patient.” And then suddenly we’re improving the conditions for dozens of children. This notion of recognizing patterns in the community of factors pushing children into poor health and trying to address it at that level just makes tremendous common sense.

Illustration by Scotty Reifsnyder
Originally published in the January 2012 issue.

Best and Brightest: Building a Team to Fight Diabetes

as told to Liz Bronson Rosenau — Thu, 29 Dec 2011 13:00:00 GMT

My focus is on inpatient diabetes. No matter what they’ve been admitted for—car accident, heart attack, having a baby—about one-third of our 500 hospital patients are diagnosed with diabetes; over one half will be diagnosed with hyperglycemia, or elevated blood sugar. With those who have diabetes, we want to help them get treatment, and with those who have hyperglycemia we want to see if we can intervene before complications arise.

You’d think that in a hospital feeding a patient is one of the easiest things to do. But if you’re trying to make sure the food is delivered, blood sugar is tested, insulin is administered, and the patient eats the meal all within a short period of time, it can be a challenge. I like the challenge and am working with a collaborative, multidisciplinary team to put policies in place to make all areas work together.

This is a relatively new concept in medicine. When I was in med school, the focus was doctor-to-patient. Now the patient has a whole team on her side. Our team includes people from food services, nurses, physicians, endocrine fellows, dieticians, pharmacists, and administrators. We measure metrics and meet weekly to see what other units are doing that affect our protocols. Our program provides the patient with survival skills—how to check her blood sugar at home, when to take medication, what kind of diet to follow, how to administer her own insulin. The goal is for the transition back to normal life to be seamless. It can be hard for patients to absorb it all, especially if they came in for an entirely different reason. So we’d like to expand the program to include communication with primary care physicians—to let them know their patient has the early signs of diabetes so they can intervene.

When I left Cincinnati to get my undergraduate degree at Columbia in New York City, there were so many misconceptions that the Midwest is not progressive. When I came back for medical school at the University of Cincinnati, I was blown away by how open they were to change and making things better. Every time I wanted to try something new I was met with enthusiasm. As a result, the work we’re doing here is having an impact on diabetes treatment nationally.

Illustration by William Varner
Originally published in the January 2012 issue.

Best and Brightest: Testing MRI-Safe Pacemakers

as told to Lisa Murtha — Thu, 29 Dec 2011 13:00:00 GMT

A traditional pacemaker’s job is to keep the heart from going too slow or to speed the heart up if the body’s asking for a faster heart rate. The most exciting new pacer technologies we have are pacers that are compatible with an MRI scan. Traditional pacers are considered contraindicated in MRI scanners for a variety of reasons, including pacer sensitivity to the electrical and magnetic fields emitted by the scanner—this can look like cardiac activity and thereby “fool” the device into pacing at the wrong rate—and pacer leads acting like antennae, concentrating energy to the heart, and adversely affecting the heart tissue. The design of both the hardware and software is modified to work around these issues in the MRI-compatible device. As a fella who’s had an MRI for torn knee cartilage, I know if I had told my surgeon that I couldn’t get an MRI, it would have made my care a little more difficult.

We were privileged here at Christ to be involved in the early research [of the original MRI-compatible pacemakers], which goes back to 2008; more recently we were the first in the country to put in the next generation device, sort of the 2.0 version.

The procedure from where the patient sits with MRI-compatible devices is very similar [to the procedure with traditional pacemakers]. They’re a bit thicker, but that doesn’t really translate into anything important to the patient that we’ve been able to discern. I tell my patients it’s the long-term track record—as with any new product—that’s not as well known. We don’t anticipate any problems, but that’s why we’re doing the trial.

It’s important for people to know that these pacemakers exist. I think it’s probably not common knowledge to patients that they may not be able to get an MRI if they get an implantable device. There may be times where their doctor, for good reason, would tell them: “You’re not the right patient for this.” Sometimes it doesn’t have the features that the patient needs. There is only one currently available manufacturer and model, so many patients opt to use a system that has a longer track record to mitigate risk. But to have it as a starting point in the conversation is really critical.

It’s early enough right now that we are really just starting to collect data. We had a patient who got the MRI as part of the research trial, and we found a tumor. It was a nice success story: We made an early diagnosis on something that would potentially have been life-threatening.

It doesn’t mean that everybody should be getting scanned. That decision is best done between the patient and the doctor who knows them well. But it’s nice to know you have the options and all the imaging available to you.

Illustration by Daniel Bejar
Originally published in the January 2012 issue.

Best and Brightest: Keeping Hip and Knee Replacement Patients Healthier

as told to Lisa Murtha — Thu, 29 Dec 2011 13:00:00 GMT

Hip and knee replacement is the most common major joint replacement—or resurfacing procedure—in America. There are currently approximately 300,000 total hips done and 600,000 total knees done in America each year. These numbers will increase dramatically in the next five to ten years; it’s estimated that they could go up 200 to 300 percent. We have an aging population, which is a primary driver of arthritis of the hip and knee, and [high] obesity, which greatly accelerates arthritis.

The Joint Commission is an arm of the federal government that certifies centers of excellence in healthcare. The Gold Seal of Approval is granted to an institution that can show that they are able to achieve certain standards [of care] and that they have verifiable processes that can reduce adverse events and improve quality and safety. This is the first year we’ve received this award and we’re the first hospital in Cincinnati to get it.

The Joint Commission asks you to pick some clinical quality, like preventing urinary tract infections. Then they survey everyone involved with patient care, from the janitors to the president, so that they know your methods and best practices permeate the whole institution. They’re very interested in how you recognize and solve problems. That’s what led me, in cooperation with the other doctors in the hospital, to invent this new initiative called “Zero in on Zero”—an initiative looking at the 10 most crippling and costly adverse events that surround total hip and total knee. We looked at the rate of these across the country, and we said: “Let’s have a zero rate at Good Sam.”

The doctors and staff at Good Sam agreed to create what are called “best practice bundles” around these problems. And we built a total joint registry, a database that captures key clinical information about a patient’s experiences, their implant names, serial numbers, all of that. We’re the only ones with a registry in total joint replacement in Cincinnati.

We can tell in six months: What really is the rate of transfusion? What really is the rate of infection? Our current blood transfusion rate is about 2 percent—nationally it’s 30 percent. The Medicare published literature rate for infection in total knee [replacement] is 1.55 percent; ours is zero percent for the last nine months.

So some of these things are really producing concrete results—they’re really exciting. The adverse event rates in Good Sam’s Total Hip and Knee Replacement Program are just as good or better than those at the Mayo Clinic or the Cleveland Clinic. We’ve had more success.

Illustration By Jing Wei
Originally published in the January 2012 issue.

How Sick Is That?

By Linda Vaccariello — Thu, 29 Dec 2011 13:00:00 GMT

I don’t puke. Some people up-chuck at the slightest provocation. Not me. I’m not a puker.

I do not say this to brag, but simply to impress upon you how memorable it was when, sometime between midnight and dawn on Monday, September 14, 2009, I awoke with the feeling that “maybe” I was “coming down with something”—followed seconds later by the realization that there were no maybes about it, and that I was about to hurl like a freshman after a fraternity kegger. Which I did.

I will spare you the details of the cleaning-up and the exhausted clamber back into bed. Suffice it to say, that opening volley was just the beginning. For the rest of the night I took stock of the miseries as they swept over my prone body: muscles so sore they screamed, roiling guts, and a headache that made me pull my shoulders up to my ears and pray for death to take me.

What did I have? How did I get it? And who had I already given it to? I lay there pondering the possibilities between peristaltic assaults. For starters, I had, in the preceding 48 hours, been cheek-by-jowl with the weekend crowd at Kings Island. I had also dined out once, prepared food for a half-dozen people in my own home, and had—this was the worst thought—planted kisses on my grandchildren. Had I served family and friends a heaping helping of food poisoning or spread sickness among hundreds of amusement park visitors from all over southwestern Ohio? Were the adults who’d sat at my table destined to go through the same misery? Were the babies I’d anointed with my toxic breath already in an emergency room?

I called my doctor when morning arrived, expecting grave concern. The global pandemic of H1N1 was making its way across the nation, and even if I didn’t have that, I felt certain that I must be a festering pool of something. But my physician’s measured response suggested to me that he did not think there was sufficient cause to summon a Hazmat team for the disposal of my bedclothes. I don’t recall his exact explanation, but here’s what it came down to:

I had a bug.

Something ordinary. I was not at death’s door, nor was I a 21st century Typhoid Mary, spreading pestilence in my wake. He offered to phone in a prescription for the nausea and told me to drink Gatorade to stay hydrated. “You’ll feel better by tomorrow afternoon,” he said.

And I did. Almost like clockwork, I rose from my bed of pain the following midday and felt—if not perfectly fine—infinitely better. And rather sheepish at having catastrophized about something that turned out to be, well, nothing. At least nothing special in the world of disease.

Which is not to say that an unremarkable sickness like mine—or one such as your own household might be experiencing this very minute, as we enter the phlegm-coated heart of winter—goes unnoticed. Thanks to technology (and to the threat of bioterrorism), our sniffles and sneezes and intestinal vicissitudes are part of a landscape of malaise that’s being watched like a stock ticker to help health care specialists figure out the Who, What, Where, Why, When, and How to Stop It of illness.

Your first grader goes to the school nurse with a booger-clogged nose. Your neighbor stops at an all-night grocery to buy a new thermometer. You take your gurgling innards to the emergency room because your mother-in-law’s cabbage rolls aren’t sitting well. These things would hardly seem like worthy cinematic scenes in a remake of The Andromeda Strain. But in the world of public health, somebody’s watching.

Pretty sick, right?

It is early November, and the kids are all right. At least, that’s how it looks on the computer screen.

I’m in the office of Ted Folger, director of epidemiology and assessment for the Hamilton County Public Health Department, and we’re examining data from HealthWatch, an online surveillance system that tracks absenteeism in local schools. HealthWatch alerts the health department about a particular school when an unusually high proportion of the students don’t show up for class. “Ten percent is taken as normal,” says Folger. But, he allows, it’s a figure that epidemiologists must temper with input about whatever else might be going on at a school. Such as? “Senior skip day,” he says wryly.

We’re looking at a report from a suburban school (which shall remain nameless; confidentiality is part of the deal when schools agree to participate in HealthWatch). Today, the data does not indicate that absenteeism is higher than usual. The nurse’s report on kids’ symptoms indicates there’s hacking and coughing, but, Folger says, “The increase in respiratory illnesses are normal.” Around here, enteric (i.e., intestinal) diseases dominate in summer and respiratory symptoms rule in winter. Fall is the time of year when the switch-over begins.

HealthWatch doesn’t diagnose anything. It provides data that, combined with observations from school nurses about the symptoms they’re seeing when kids come through the door, can help the health department quickly spot a health problem, swoop in to ID the illness, and figure out ways to keep it from spreading. It was created in 2009 to prepare for the H1N1 influenza outbreak. “We knew that [H1N1] would disproportionately effect school-age children,” Folger says, so HealthWatch was used to point to the schools where the illness might be breaking out. Now it’s an established part of the county’s “syndromic surveillance” that keeps tabs on what ails us.

The big picture of all things infectious is Hamilton County’s most recent Communicable Disease Report, which came out last August. It covers everything from Amebiasis (that’s amebic dysentery, in layman’s terms) to Yersiniosis (a rare disease, but a good reason not to eat raw meat). It takes time to gather, confirm, and certify this information, so the most recent report only covers 2004–2008. In contrast, syndromic surveillance is a snapshot of what’s happening right now.

Folger takes me to another recent online eye-on-malaise: a report from a suburban hospital’s emergency room generated a few days before our meeting. All the patients are de-identified, but each one is described, along with his/her complaints. There’s an “SOB [shortness of breath] and Cough”; also an “SOB, panic.” There are patients coming through the door with ILI (influenza-like illness), abdominal pain, fever, and other assorted concerns. The area’s hospital emergency departments transmit this information to the county’s EpiCenter system, and EpiCenter issues alerts when there are higher than expected visits for a particular complaint. Epidemiologists can drill down into the information, slice it and dice it by symptom, by neighborhood, by hospital, by gender or age, looking for “who is getting what,” Folger says. “Then we try to figure out what is driving it.” And, of course, what to do about it.

Case in point: Last summer, data from EpiCenter and other systems helped identify the swimming pools in the region linked to a cryptosporid-iosis outbreak. Cryptosporidium is a nasty parasite that can bring on diarrhea and dehydration in healthy individuals; for those with poor immunity, it can be very serious. And it spreads readily where kids and water mix. “A kid goes to a lake on vacation, takes in a gulp and becomes infected with crypto,” explains Folger. “Then they go back to the pool and have a diarrheal accident. Now all the children are swimming in feces!”

Folger, who is putting the finishing touches on a PhD in epidemiology and biostatistics, is the father of a toddler and has a second baby on the way, so his infection scenario may be somewhat colored by parenthood. But to his point: crypto parasites are chlorine-resistant and they persist in stool for a long time, so a kid who goes into the water with a soiled bottom or a mom who rinses her hands in the wading pool after changing a diaper can be an effective delivery system. “I love taking my daughter to the pool,” Folger adds with a note of glum irony.

There was a major crypto outbreak here in 2005; so when the first case appeared last summer, the health department asked physicians to start testing their symptomatic patients immediately and began interviewing the parents of infected kids about the pools where they swam. As the data rolled in, the department posted signs at pools connected to the infections—not something pool managers were thrilled about, but they cooperated, Folger says. He shows me a map pinpointing the aquatic hotspots. Traditional media and family-centric social media helped educate people about crypto (don’t swim if you’ve been sick in the past two weeks; don’t change diapers poolside; wash your kids with soap before letting them dive in). Some pools were closed temporarily and the water super-chlorinated in hopes of killing off the resilient parasite. In 2005, the disease shifted from pools to daycare centers by summer’s end; the department worked to short-circuit that transfer during the outbreak in 2011. If your kid’s nursery school got rid of the water table this fall, this may be the reason.

When school is in session, HealthWatch data can be used alongside EpiCenter for a more nuanced picture of the disease landscape. In the fall of 2011, for example, there was a HealthWatch alert about a school with high absenteeism. So an epidemiologist went to EpiCenter, searched by zip code, and found that there were higher than expected pediatric ER visits for respiratory complaints involving children from that school’s neighborhood. A call to the hospital’s infection control specialist revealed that those sick students had parainfluenza—a not-so-scary virus for school kids, but dangerous for infants. Connecting the dots made it possible to alert local doctors about the outbreak.

You can thank 9/11 for EpiCenter. The system was adopted in Hamilton County (and in many other places) in the wake of that terrible event—built as an early warning system for bioterrorism. It’s the epidemiological equivalent of the DEW Line, with data instead of radar scanning the horizon for symptoms that might be the first clue of, say, an anthrax attack.

The information provided by syndromic surveillance doesn’t necessarily speak for itself. For example, there’s a database about over-the-counter drug store and grocery purchases—thermometers, cough medicine, Pepto-Bismol, et cetera. Hypothetically, an alert about bottles of Pedialyte flying off the shelves in Hyde Park on November 1 could be a heads-up that an intestinal virus is poised to tear through east side toddlers like a tsunami. Or that a bioterrorist with a syringe is injecting pathogens into juice boxes. Or it could just be the result of widespread Halloween candy pigging-out. Without built-in “subject matter experts,” Folger says, it’s hard to tell what’s going on with OTC purchases. Essential are what Folger calls “sentinel clinicians”—the ER docs and nurses, hospital infection specialists, local physicians, and school nurses who are actually seeing the runny noses and strange rashes, and who can help the health department quickly suss out what a spike in symptoms might mean. “School nurses are the front line,” says Folger. “And they’re slowly disappearing.”

It doesn’t always take vast numbers to get the attention of officials; sometimes one will do it. Last fall Pat Allingham, a public health nurse and director of disease prevention for Hamilton County, got a middle-of-the-night call from a hospital about a young woman who’d arrived with a suspected case of Neisseria meningitides—a serious bacterial meningitis. She got on the phone with the patient’s family, found that the woman’s sweetheart and child were at risk for infection, and put them on antibiotics immediately.

“Different diagnoses have different laws that guide our response,” Allingham says. Reportable diseases are those communicable infections that are of high public health concern. Food-borne botulism, for example, must by law be reported to the health department immediately; ditto anthrax, rabies, and any one of the epic ills that wiped out whole populations back before vaccines and antibiotics existed—cholera, measles, diphtheria, smallpox. What happens next depends on the law, the disease, and how much investigators are able to find out.

Allingham began her nursing career back in the 1970s, back when government support for public heath programs was broad and deep. “We visited every newborn and new mother and every pregnant woman,” she says. These days her one-on-one interviews are often focused on matters that are even more intimate than childbirth.

Take the case of the church festival salmonella outbreak. In the summer of 2010, the health department got a call from a person claiming that she and her family got sick from something they ate at a church festival. The symptoms—vomiting, stomach pain, diarrhea—sounded like it might have been a norovirus. A norovirus is a common intestinal menace. Highly contagious, you can catch it from another person—or from the food they’ve handled. It’s not a disease your doctor needs to report to the health department, but when someone says they got “a little food poisoning” or “a stomach bug,” odds are it’s a norovirus. Still, Allingham can’t assume that because there are other food-borne illnesses that are too dangerous to dismiss. So she phoned the church secretary—“Who knows everything,” Allingham jokes—and asked if there were any reports of illness after the fete. “And the secretary says, ‘Oh my gosh, I’ve had about 20 calls!’”

The church provided the names of everyone who was—literally—bellyaching as well as a list of every food served that weekend. Then Allingham and her staff set about contacting the households, running through a long list of questions about what each family had been up to (Camping? Fishing? Petting zoo?), what they’d been eating (Runny eggs? Shellfish? Rare hamburger?) and inquiries about their symptoms—the vomiting, the diarrhea, the abdominal pain. Then she had to request a stool sample. These are never easy conversations to have. “It’s a science and an art,” Allingham says.

Her office talked to 60 people after the church festival; only three agreed to provide a sample. The samples established that the problem was not a relatively benign norovirus—it was the bacterial infection salmonella. That meant rapidly re-interviewing households, talking to family members who didn’t get sick about what they didn’t eat, and by process of elimination identifying the source—a pulled pork sandwich. The pulled pork vendor was located, but since the meat was all gone, the Case of the Tainted Barbecue was over.

It’s a process that’s repeated in some form whenever there’s suspicion of a food-borne illness. And it doesn’t always end so quietly. In September, children from a family in Butler County got E. coli from Tyson’s ground beef, setting off an investigation that involved the county, the state, and the USDA—an investigation that ultimately prompted a recall of 131,300 of pounds of meat in 14 states. It happened as the illness and death toll was rising from the listeriosis outbreak caused by tainted Colorado cantaloupes, and for a moment it looked like it might be another catastrophe besetting the U.S. food chain. “You take a deep breath and think, ‘We could be in the middle of something severe,’” says Patricia Burg, director of the Butler County Health Department. Amazingly, no other cases were reported.

Burg says modern technology helped: “[Recall information] can be shared so easily across states that we can get a handle on it.” And perhaps anxiety about listeria had already put everyone on high alert. “When the recall was announced, the news media was on it immediately,” she says. “We were very fortunate.”

Database technology has transformed our ability to pinpoint contagions. But computers haven’t taken all the mystery out of epidemiology. Consider Southwest Ohio’s STD problem.

Between 2004 and 2008, Hamilton County saw an increase in the rate of gonorrhea—even though the sexually transmitted infection was decreasing in the United States at the time. The county also has the dubious distinction of having the highest chlamydia rate in the state—about 6,000 cases diagnosed in 2010, according to Dr. Lawrence Holditch, medical director of the Cincinnati Health Department, which handles STD statistics for the region.

Neither trend is good news, but the most worrisome conundrum is syphilis. In 2009, the county leapt from having 72 cases to 197 in a year. In 2010 there were 257 acute cases of syphilis—including eight babies born with it, at grave risk for disability and death. “We should have none,” says Holditch grimly. “It’s very concerning.”

The local syphilis surge is especially puzzling, Holditch says, because the pattern is unusual. Nationally, when the disease is on the rise it’s usually associated in large part to male-to-male transmission. And often sex for money or drugs plays a role. But investigators say that’s not the case here. “In Hamilton County, it’s much more heterosexual, and disproportionately impacting the African-American community,” he says. It’s young adults and “party sex,” as he describes it.

In 2010, the situation in Hamilton County was concerning enough that the Centers for Disease Control sent two teams of investigators here for several weeks to attempt to help the city health department get a handle on the outbreak. Holditch says investigators have gone door to door in targeted neighborhoods offering free testing; the department works with WIZ-FM to get information to that station’s listeners and is using social media tools such as text messaging to alert partners. Then there’s the old-fashioned shoe leather/phone call attempts to make contact with people who may have been exposed—“sometimes to the point of making ourselves quite obnoxious,” Holditch says.

For the moment, Holditch can only conjecture about the reason for the sudden rise: Perhaps it has to do with young adults being less concerned about HIV and failing to practice safe sex. Or maybe it’s the ease of hooking up in the age of social media. “Maybe,” he says, “in times of economic instability, all forms of recreational activity go up.” That still doesn’t explain why here and why us, but syphilis has a tendency to throw public health gurus curveballs. “In 1990 there was a big outbreak here and nationally,” he says. It’s two decades later “and no one has been able to explain that.”

When we talked in the fall, Holditch told me the case count for the year was 178; “So,” he said with a touch of don’t-want-to-jinx-it caution, “a downward trend.”

Remember my misery on that September night when I was—I swear—as sick as Gwyneth Paltrow right before she bit the dust in Contagion? Considering my symptoms, Ted Folger speculates that I probably had a norovirus—one of the ubiquitous stomach bug/food poisoning/touch-of-something illnesses.

I am willing to concede that it could have been something thoroughly ordinary. But, I wonder, was it “going around” in sufficient numbers to get noticed? Even if my diligent (OK, semi-hysterical) call to the doctor and my palliative purchase of Gatorade didn’t register on the we’re-sick-o-meter, surely there were other people who had what I had—enough of them who were miserable enough to show up in emergency rooms barfing and dehydrated and causing a spike in EpiCenter’s survey of the landscape.

Folger pulls up a report from the fall of 2009—a graph from September, when I was sick. He can find nothing unusual in terms of gastrointestinal complaints; no alarm bells set off by headache-debilitated hoards either. Yes, people were showing up in the emergency room with those symptoms, but they were barfing and cradling their noggins in predictable, average numbers.

Then he switches to data tracking different symptoms: respiratory complaints. We follow the steep graph line from a gentle rise in the summer to a steep ascent in September to its apex in October 2009, when 450 people were showing up each day in emergency rooms.

That’s when H1N1 peaked here, he says. That’s what sick looks like.

Photograph By Kevin Miyazaki
Originally published in the January 2012 issue.

The Future of Medicine: Testing Hot-From-The-Lab Cancer-Killing Drugs

as told to Lisa Murtha — Wed, 21 Dec 2011 18:30:00 GMT

The university asked me to develop this Phase I program, the first [step] in human clinical trials, as part of UC’s cancer institute. There are few Phase I centers in the United States, maybe 10 to 15. We have new drugs, new strategies [researchers] want to investigate, and I am here to run the trials and to translate this knowledge from bench to bedside.

Most patients in the trials failed other therapies—chemo, radiation. They are resistant to most of them. We see patients very, very, very motivated. It’s the last opportunity to get treatment and hopefully to have some benefit.

Currently we are developing Antibody Drug Conjugates. It’s a very specific way to deliver anti-cancer agents. We identified some very specific protein targets [that appear in] cancer cells; we designed antibodies to recognize those targets, and they are loaded with some bombs—toxins. When we inject those toxins, we deliver [them] directly to the cancer cells. So we move from a nonspecific treatment, chemotherapy, to a very specific targeted molecular therapy. We are at the very initial step. This is one of the most promising avenues of the future. Only two centers in the U.S. are doing this trial—one in San Antonio and the other, here.

Soon we will develop this fascinating approach for treatment of primary brain tumors, called gliomas. And we have a drug coming from [UC’s research that] is a kind of nanotechnology: We can deliver a very toxic drug for the cancer cells to the primary brain tumors in a very specific way and induce “cell deaths.” The results are very impressive in animals. We are waiting for FDA approval to move to Phase I. This is going to be a UC story, from basic research to general hospital to clinical development.

It’s fascinating to work with the cancer cells. Those cells are so small, they can develop resistance. They can adjust, adapt to our strategies. So who is going to be the smartest? We don’t know, but those drugs are very smart, so we’ll see. As an oncologist I must be an optimist. There is no alternative.

What is extremely emotional is sometimes you see some positive effects. You are the first to see some shrinkage, the strategy seems to be promising, and then you say: “OK, I think I found the dose and we are ready to move to Phase II and Phase III, and maybe one day to get the drug approved.” It’s amazing to bring something new and to see the drug having its own life.

I have just one real enemy: cancer. That’s why we are here.

Illustration by Grady McFerrin
Originally published in the January 2011 issue.

Another Day in Cancerland

By Dennis O'Connor — Mon, 09 Apr 2012 12:44:00 GMT

I thought I was in the midst of a dream. Although I couldn’t see it, I could sense this monster hovering near my feet, massaging my legs, from my ankles to my knees; each squeeze from its spongy hands pulling me back to consciousness. Why won’t it stop? I thought.

I was lying on my back, and although I was not tied down, I found that I could not move. Something was on my face, too. But caught somewhere between the hazy dreamworld of semi-consciousness and being awake, I could not make sense of anything. I tried to ask for help, and although my mouth was open, I could not utter a word. I closed my eyes again, feeling the monster working my legs, the only discernible noise a whoosh-shush, whoosh-shush as I drifted off to sleep again.

After what seemed to be an eternity, the haze lifted and I could see the tubes coming from my mouth and nose. What I thought was a monster was in fact a pneumatic contraption designed to keep the blood circulating in my legs. The room was fairly large but spare, with only my bed, electrocardiogram leads connected to a cardiopulmonary monitor above my head, and an IV tower holding bags of saline solution. There was a single wooden chair at the foot of the bed, empty. I was in a post-operative recovery room at St. Elizabeth Edgewood in Northern Kentucky. Slowly, a palpable sense of relief washed over me. I remember thinking: Hey, I’m alive, after all.

I had awakened, mostly intact, in Cancerland.

Just days before, I had been bouncing around in the back of a pickup truck, maneuvering up a glorified goat trail to the village of Las Mesas in the tiny Central American country of El Salvador, joined by staff and board members of Christians for Peace in El Salvador (CRISPAZ), the nonprofit agency that I had served as executive director for the last year. I’d traded in a 25-year career as a journalist and religion writer to head up an organization founded during the civil war in El Salvador a quarter-century ago with the hope of doing some good in a country that had historically suffered as a result of United States foreign policy during the tumultuous 1980s. Part of the job required me to travel several times a year to Central America to keep an eye on the operations there, where our most important work was bringing students and church groups from the U.S. to El Salvador for short-term mission trips.

As we worked our way up the hillside to Las Mesas, I began to experience deep abdominal pains that, at first, I attributed to either the plethora of red and black beans I’d been having for breakfast, lunch, and dinner during the weeklong board meeting we were conducting in the capital city of San Salvador, or the constant jabbing I was getting as the truck lurched from stone to stone on the nearly washed out road. But a day passed, then another, and finally one of the members of the CRISPAZ board convinced me that, with the meetings over, I really ought to return to the states and see a doctor.

I half-entertained the idea of going to a hospital in El Salvador until I learned that the preferred destination for Central Americans seeking serious healthcare is Houston and parts north. I booked an early departure on Continental in the only space available—a first class seat alongside members of the Houston Dynamo Major League Soccer team, which had just played an exhibition match against the El Salvador national squad. I tried to smile and carry on brief conversations with the soccer players even while I was bent over in pain, unable to enjoy a glass of champagne or the gourmet meal prepared for those of us in the front of the 737. So much for the glories of flying first class.

The severe pain I’d begun to experience in El Salvador was due to a fist-sized tumor that had lodged in my lower intestine, ultimately blocking any waste or gas from moving through my GI system. The tumor had blocked my descending bowel and caused a monumental plumbing backup. Dr. Mike Davenport, the general surgeon on duty when I was admitted for the emergency procedure, put it to me this way: my descending bowel had acted like a garden hose, forcing liquid and solids through the small space with enough pressure that my cecum—the first part of the colon, which connects to the small intestine—burst, causing the peritoneal cavity around my stomach to fill up with the contents of my colon. I equated it to the levies and retaining walls in New Orleans giving way to the high waters from Hurricane Katrina: Lots of foul stuff floating around where it shouldn’t be. Davenport told me that he went through 20 liters of saline solution to clean out the peritoneal cavity of the waste products.

“It was a mess. A mess,” he said. He wasn’t smiling when he gave me that report.

As an added bonus, I was given a colostomy along my descending colon, with the opening for a colostomy bag placed on the left side of my lower abdomen. A couple of matronly nurses visited me in the hospital a few days after surgery to give me training in the care and operation of the colostomy bag, but I can tell you there is no rosy way to deal with the fact that you carry your own feces around in an opaque bag just above your belt line. Everything was held in place with an elastic belt and something like plumber’s putty, and no matter how hard you try, once in a while the whole shooting match is going to fail and you have poop dripping down your belly. My colostomy apparatus was also a noisy thing: When gas accidentally passed, it came out in a kind of squealing, almost lifelike pitch. I began to call it Kuato, after the deformed character growing out of the stomach of a terrorist in the Arnold Schwarzenegger Mars movie Total Recall. My kids, nieces, and nephews loved the concept of Kuato. They didn’t, however, like it when I popped the seal on the bag to let a little gas loose for comfort (and some mischievous fun).

I suppose the natural thing to do when you have just had major cancer surgery is to worry. But, strangely, I was not having any of that. Not enough time, really. Within a day or two of regaining consciousness, still lying in my hospital bed, I was processing payroll for CRISPAZ, fielding calls on my cell phone, and talking to board members about how I was doing, when I planned to be back to work and so on. Worries about the nonprofit were really a blessing in disguise, since I spent a lot more time concentrating on making payroll and other deadlines than I did on my own condition.

Early on I was comparing notes with a friend in Chicago, a stockbroker who had been diagnosed with kidney cancer a couple of years earlier. One thing he told me I found particularly calming. “If you gotta get cancer,” he said, “colon cancer is the best kind to get. It has better cure rates.”

Friends and family let me know they were thinking of and praying for me, and a group of folks from Cincinnati who had made a visit to El Salvador joined hands and prayed for me at the tomb of Archbishop Oscar Romero, the Roman Catholic prelate who was murdered at the beginning of the Salvadoran civil war in 1980. Some have scoffed when I tell them this, but I truly believe that I’m here today because of modern medicine and the saintly intercession of Oscar Romero.

Somewhere in all this I started reading the essays of Christopher Hitchens, the English journalist and writer based in Washington, D.C., whose polarizing works, such as God Is Not Great, have served to energize a legion of haters who publicly cheer against him now in his battle against cancer of the esophagus. I’ve read several of his books, most recently his atheistic tome, and it has made me wonder how someone can deal with all of the black nights of the soul associated with cancer and not have at least some hope for a divine destination on the horizon. I feel a little sorry for Hitchens, although he warns in his most recent columns in Vanity Fair that he doesn’t really need the pity nor the prayers. Still, I think you have to have faith along with that hope. And most important, you have to have the support of your family, who remain at the center of your struggle. Throughout my own journey through Cancerland, I have been bolstered by the courage and support of my wife and two children, who have stayed constantly positive about me and for me.

My first real foray into the deepest jungles of Cancerland, where I seriously began to face the unknown and the difficulties that loomed ahead, occurred soon after my initial visit with my oncologist. I was still pretty much flat on my back and recovering from an incision that ran from below my navel to my breastbone. Davenport, the surgeon, had worked regularly with a young doctor named Doug Flora, a 39-year-old physician with a wonderful bedside manner and an air of assurance; if anything can be done, he’s going to get it done for you.

Flora—dark-haired, slender, always smiling—is part of a large cancer practice called Oncology Hematology Care, with doctors and operations on both sides of the Ohio River. I liked him immediately. He reminded me (often) that he is from the new generation of oncologists, not one of the “old guys.” I guess it was a way for him to let me know that I can have experience, sure, but if I’m looking for the guy who is at the front of the pack digging up the latest research and trial findings, he’s my guy.

Well, he definitely is my guy. In fact, I feel very lucky in my choices for doctors. It was simple chance that led me to Mike Davenport, and thus to Flora. But like it or not, this is very much how we find our cancer specialists in Cincinnati—or anywhere else in the country, for that matter. Your family doctor will recommend someone they know, whom they believe has a great reputation for working on the type of disease you suffer. And you try to go with the flow and hope you are getting the best care you can get, which is usually the case. But sometimes those referrals don’t work: My friend from Chicago, an Ohio State graduate, told me that his first cancer doc was a graduate of Michigan, and try as he might to like the guy, he ultimately changed doctors because of the ancient rivalry of the two football programs. (I know, it didn’t make any sense to me either. But who am I to judge?)

My diagnosis was pretty good at this point: Although I had been told I had Stage III colon cancer—because the cancer had spread from the tumor to my lymph system—the entire tumor appeared to have been removed, and a follow-up with chemotherapy would push any reappearance of the cancer off for many years. Flora told me that data on colon cancer over the years had shown that surgery not followed by chemo resulted in a higher chance of tumors coming back.

It was an easy call for me. The plan was that I would let my body recuperate from surgery for about six weeks, and then I would launch into the chemo routine that Flora would design for me: Nine treatments of a lethal cocktail that would zap my body of existing cancerous cells. The regimen, called FOLFOX, consisted of two cancer drugs: 5-FU (fluorouracil), a drug that has been used in cancer treatment for more than a quarter century, and oxaliplatin. I was given the oxaliplatin intravenously, but I took the 5-FU in tablet form in a drug called Xeloda, so that I would be able to travel more easily and meet the requirements of going to El Salvador several times a year. I didn’t lose any hair—at least not with this regimen—but the oxaliplatin made me hypersensitive to the cold and brought on a numbness in my fingers and toes that took a long time to pass.

There were, of course, adjustments that had to be made. I became so ill at one point that the mere sight of the pills made it hard to eat without getting sick. I lost a bunch of weight—going from 230 pounds when I was first diagnosed to 195 pounds after surgery and now down to 180 in the wake of the chemo—and I was completely lethargic.

This down cycle lasted for about a month. But a few days after the doctors lowered my dosage of Xeloda, I was lying on the couch and smelled a pot of chicken soup my wife was making. I went to the kitchen and had a bowl of the soup. And then another. Then I drained the pot. I ate and ate everything in the house for what seemed like a week, and finally, sated, sat up and decided that I was finally feeling pretty good. When that particular chemo regimen finally ended, I was very much ready to leave Cancerland behind and flip the switch on my life back to “normal”—as much as that was possible. Easier said than done.

In March 2009, nearly six months after surgery and almost immediately following the end of my first round of chemo, I packed my bags and headed south to El Salvador for a series of meetings. By then I had a routine down pat about how to change the colostomy bags (every two days), and the connector ring that was glued to my stomach (once a week). But because I was going to be very far away and I didn’t want to chance not having all the right stuff for my trip, I brought along a bag a day, two boxes of rubber gloves (I’ll leave that reasoning to your imagination), and enough “O” rings to hang a long shower curtain. The only fun I had with the colostomy bag was in the Houston airport, where a security guard opened my suitcase and asked what all the stuff was I was bringing along. Rather than explain, I simply pulled up my shirt and showed him my bag. Almost as if on command, the elastic belt that was holding the whole affair in place snapped off in his direction. “Go ahead,” he said, leaning ever so gently back and away from me and my colostomy gear.

Because El Salvador is such a religious country, it was no surprise that my staff there was concerned about my well-being and told me about the various prayers offered for me. I decided I needed to go to the source of the divine intervention that I believe had a part in saving my life: the tomb of Oscar Romero. Located in the undercroft of the Metropolitan Cathedral in San Salvador, Romero’s tomb is a bronzed tableau with his effigy holding the bishop’s staff, a pointed miter crowning his head, and a bright red ball resting where his heart would be. I marveled at the peasants who wandered into the crypt, an upstairs/downstairs world where the poor were relegated to the basement while the rich churchgoers worship in the main level of the cathedral. Each person seemed to have his or her own ritual but they all stopped for a moment to whisper in the ear of Romero’s bronze figure.

Eventually, I, too, walked around his effigy and whispered a hello in his ear: “Thanks. I’m still here, still working for the people of El Salvador. So keep me on your radar.” It’s become my ritual, something I do every time I go back.

Perhaps the most important thing I’ve gained over my 26 months in Cancerland is a better understanding of the disease. From the beginning, this has been Doug Flora’s mantra: Each treatment, each test is going to tell us how the cancer reacts to chemo, whether there is going to be metastasis, and what kinds of odds I will have going forward. Part of that process of understanding—for me at least—involved getting a second opinion about my treatment. Flora listed his recommendations: Sloan Kettering in New York; the Cleveland Clinic; MD Anderson in Houston; University of Pittsburgh Cancer Institute; and the Mayo Clinic in Rochester, Minnesota.

I opted for a visit down the road at the University of Kentucky’s Markey Cancer Center, where I received the unwelcome news that the original scans done in October 2008 actually showed hints of a spot on my liver. A CT scan in February 2009 showed nothing; but after another test, there indeed was a spot—a tumor that had been there from the beginning but had not been detected by the surgeon nor immediately identified by the radiologists. I remember exhaling, and then recalling that I rushed into the hospital as an emergency patient, and that in the clamor to get me up and running, things like this could be missed. Plus, we did find the spot in time to treat it, and that was good news. So we were on to Plan B.

The greatest strength your doctors can have, outside their own expertise, is their ability to place you with the best specialists for what ails you, and here Flora did his job once again. I was sent to see Dr. Steven Rudich, head of liver transplant surgery at the University of Cincinnati Medical Center. Drs. Rudich and Flora had been engaged in patient referrals for a number of years, a fact that the quick-talking, fast-moving Rudich confirmed to my wife and me during our first consultation. The good news, as they both told me, was that this cancer is a curable thing if gotten in time (curable equating to long-term survival in this context). But that might mean actually cutting off the cancerous part of my liver, along with some additional tissue for safety’s sake. The spot in question was on the left lobe of my liver, which is the operable portion of the organ. And the best news, I guess, is that the liver can actually grow back.

And so I was running the radiological gauntlet, getting PET scans and CT scans and an MRI. Plan B was going to involve two surgeons: Dr. Brad Davis, a colon and rectal surgeon and associate professor of surgery at the University of Cincinnati College of Medicine, would take down my colostomy and reconnect all my pipes, while Rudich would go in and poke around to see if he could cut away the spot in question.

None of the planning or scanning or additional surgeries would be available to me if not for the top-notch insurance plan I have through my wife’s work. When I first got sick, we were able to opt into the higher-priced coverage component of the plan, which has allowed me full access to the state-of-the-art treatments that are available. My most recent round of chemo was something of an experimental application of known effective drugs. (In fact, I’m told there is a study under way of the exact regimen I was using, so it is possible my results will be added to that study.) Thus far, our insurance company has not denied us any reasonable requests.

Which brings me to Peggy Hollingsworth. Peggy is a nurse advocate for me. She has been assigned by the insurance company to follow my case and make sure I am getting the treatment I should be getting, and to motivate me to help my own cause as much as I can. During my first round of chemo, when I was unable to keep food down and I was battling with the newness of the colostomy bag, Peggy suggested I start eating pretzels to soak up any liquid that might be zipping through my system, which also would help me keep some weight on. It worked like magic. She has access to all my medical records and asks questions when she sees something that bugs her. Peggy has been a key liaison between our doctors and the insurance company, and has gone to bat for me more than once with her bosses. But beyond all of that—and that is a lot—Peggy also reminds me that I have to go through with the chemotherapy and the surgery if I want to live.

“You do great work for CRISPAZ,” she has told me several times. “But you can’t do it if you’re dead.”

Ground zero in Cancerland ultimately becomes the treatment ward where one hooks up to an IV and receives chemotherapy. The offices of Oncology Hematology Care in Crestview Hills, Kentucky, are tucked inside a two-story red brick building that looks a lot like the other red brick buildings in the medical services park near St. Elizabeth Edgewood. The ground level is fitted out with radiology equipment and scanning gear; the second floor is where I check in with Dr. Flora and get my chemo treatments. The waiting room is always interesting.

Although I traditionally have received treatments on Fridays (which gives me the weekend to recover from the immediate effects of the drugs), I rarely see the same people in the waiting room more than once or twice—testimony, I guess, to the sheer number of patients seeking treatment at this one facility, a group so large you don’t really recognize your neighbors, let alone get to know them. Newbies in Cancerland are almost always joined by a small entourage of family and friends, and you can see the worry on their faces: They are fearful about the unknown, about taking the first steps on this journey. Whereas the regulars, like me, bring along newspapers or knitting or paperbacks, ready for the sessions that last from one to three hours, depending on the amount of chemo to be taken that day.

I think one of the hardest jobs in the world, second only perhaps to working in hospice, is that of an oncology nurse. I’ve gotten to know almost all the nurses on the floor because virtually all of them have given me chemo drugs at one time or another. No matter how bad you feel, they are cheery and helpful, ready to give you a mental boost so you can get through the process. You see people napping, their bald heads covered with knit caps; others watch reruns of The Andy Griffith Show or Gunsmoke or Bonanza (I never get enough of Hoss and Little Joe yukking it up with Pa Cartwright).

The nurses talk you through the drugs you are about to receive and they monitor the flow. You get a countdown: “Just another half hour to go, Mr. O’Connor. Then you’ll be on your way home.” When I was unable to keep any food down a year ago, one nurse, Veronica, sat with my wife, Paula, and me and offered suggestions on what I might be able to ingest. Still, no matter how kindly they are, the best words you can hear are: “OK, you’re done for the day.” And so you leave, pumped full of the poison that, you hope, will keep your cancer in check.

Living in Cancerland is a lot like being stationed on some demilitarized zone where there is still plenty of gunfire going off all the time. You have to constantly be vigilant or the enemy—the disease—will gain higher ground. And then you are doomed.

My own condition is such that my team is trying to stay far enough ahead of the cancer so that at some point we can say This thing is stopped for now. The reality is that we aren’t there yet. As I write this, I have two scans scheduled for next week to see how well a new chemo cocktail has done at keeping the cancer at bay.

Can I leave you with some good news? Well, yes. My hair is growing back, little by little. My wife says I look more like my “old self,” which I guess is good news. I’ve been following Hitchens’s reports on his disease in Vanity Fair and I seem to be doing better than he is, although thus far my cancer is more garden variety than his. That said, whatever disagreements I may have with him about God and religion, I do wish him the best.

Of course the news from Cancerland is not—in fact, cannot be—all good. My buddy in Chicago died recently after fighting his kidney cancer over the course of four years. A relative close to my age succumbed to a rare form of cancer in the spring. A cousin wrote to me on Facebook saying that her husband has been battling colon cancer but he hasn’t had to do chemo. Yet. A fellow I did contract work with about a decade ago has had a recurrence of his colon cancer, and he’s now on chemo. But then I read in Monday’s Enquirer that a new cancer therapy developed at Children’s Hospital is showing promise in causing cancerous cells to self-destruct. Not a moment too soon...

Maybe I wasn’t paying enough attention before, but now that I am living in Cancerland I can’t escape its ubiquity in the larger culture. So instead of fleeing it, I embrace it. I live my life on a day-to-day basis, a kind of warrior in a battle that has obvious deadly consequences and frequently ends badly. I pray a lot. I spend as much time as I can with my family. I think about Romero and my work in El Salvador. I listen very carefully to my doctors and nurses, trying to do what they say I need to do. And when people ask me about the experience, I like to explain to them what a blessing cancer can be. Nothing gets you more focused about living than walking out of that chemo ward and witnessing another beautiful sunny day.

Or any day, for that matter.

Originally published in the January 2011 issue.
Illustration by Michael Byers

Editor's Note: In April 2012, Dennis O'Connor lost his battle with cancer. We're saddened by his loss.

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