[Paleopsych] NYT: Life at the Top in America Isn't Just Better, It's Longer

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Mon May 16 20:19:31 UTC 2005

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Life at the Top in America Isn't Just Better, It's Longer
[Second in a series of articles on class in America.]


    Jean G. Miele's heart attack happened on a sidewalk in Midtown
    Manhattan last May. He was walking back to work along Third Avenue
    with two colleagues after a several-hundred-dollar sushi lunch. There
    was the distant rumble of heartburn, the ominous tingle of
    perspiration. Then Mr. Miele, an architect, collapsed onto a concrete
    planter in a cold sweat.

    Will L. Wilson's heart attack came four days earlier in the bedroom of
    his brownstone in Bedford-Stuyvesant in Brooklyn. He had been regaling
    his fiancée with the details of an all-you-can-eat dinner he was
    beginning to regret. Mr. Wilson, a Consolidated Edison office worker,
    was feeling a little bloated. He flopped onto the bed. Then came a
    searing sensation, like a hot iron deep inside his chest.

    Ewa Rynczak Gora's first signs of trouble came in her rented room in
    the noisy shadow of the Brooklyn-Queens Expressway. It was the Fourth
    of July. Ms. Gora, a Polish-born housekeeper, was playing bridge.
    Suddenly she was sweating, stifling an urge to vomit. She told her
    husband not to call an ambulance; it would cost too much. Instead, she
    tried a home remedy: salt water, a double dose of hypertension pills
    and a glass of vodka.

    Architect, utility worker, maid: heart attack is the great leveler,
    and in those first fearful moments, three New Yorkers with little in
    common faced a single, common threat. But in the months that followed,
    their experiences diverged. Social class - that elusive combination of
    income, education, occupation and wealth - played a powerful role in
    Mr. Miele's, Mr. Wilson's and Ms. Gora's struggles to recover.

    Class informed everything from the circumstances of their heart
    attacks to the emergency care each received, the households they
    returned to and the jobs they hoped to resume. It shaped their
    understanding of their illness, the support they got from their
    families, their relationships with their doctors. It helped define
    their ability to change their lives and shaped their odds of getting

    Class is a potent force in health and longevity in the United States.
    The more education and income people have, the less likely they are to
    have and die of heart disease, strokes, diabetes and many types of
    cancer. Upper-middle-class Americans live longer and in better health
    than middle-class Americans, who live longer and better than those at
    the bottom. And the gaps are widening, say people who have researched
    social factors in health.

    As advances in medicine and disease prevention have increased life
    expectancy in the United States, the benefits have disproportionately
    gone to people with education, money, good jobs and connections. They
    are almost invariably in the best position to learn new information
    early, modify their behavior, take advantage of the latest treatments
    and have the cost covered by insurance.

    Many risk factors for chronic diseases are now more common among the
    less educated than the better educated. Smoking has dropped sharply
    among the better educated, but not among the less. Physical inactivity
    is more than twice as common among high school dropouts as among
    college graduates. Lower-income women are more likely than other women
    to be overweight, though the pattern among men may be the opposite.

    There may also be subtler differences. Some researchers now believe
    that the stress involved in so-called high-demand, low-control jobs
    further down the occupational scale is more harmful than the stress of
    professional jobs that come with greater autonomy and control. Others
    are studying the health impact of job insecurity, lack of support on
    the job, and employment that makes it difficult to balance work and
    family obligations.

    Then there is the issue of social networks and support, the
    differences in the knowledge, time and attention that a person's
    family and friends are in a position to offer. What is the effect of
    social isolation? Neighborhood differences have also been studied: How
    stressful is a neighborhood? Are there safe places to exercise? What
    are the health effects of discrimination?

    Heart attack is a window on the effects of class on health. The risk
    factors - smoking, poor diet, inactivity, obesity, hypertension, high
    cholesterol and stress - are all more common among the less educated
    and less affluent, the same group that research has shown is less
    likely to receive cardiopulmonary resuscitation, to get emergency room
    care or to adhere to lifestyle changes after heart attacks.

    "In the last 20 years, there have been enormous advances in rescuing
    patients with heart attack and in knowledge about how to prevent heart
    attack," said [2]Ichiro Kawachi, a professor of social epidemiology at
    the Harvard School of Public Health. "It's like diffusion of
    innovation: whenever innovation comes along, the well-to-do are much
    quicker at adopting it. On the lower end, various disadvantages have
    piled onto the poor. Diet has gotten worse. There's a lot more work
    stress. People have less time, if they're poor, to devote to health
    maintenance behaviors when they are juggling two jobs. Mortality rates
    even among the poor are coming down, but the rate is not anywhere near
    as fast as for the well-to-do. So the gap has increased."

    [3]Bruce G. Link, a professor of epidemiology and sociomedical
    sciences at Columbia University, said of the double-edged consequences
    of progress: "We're creating disparities. It's almost as if it's
    transforming health, which used to be like fate, into a commodity.
    Like the distribution of BMW's or goat cheese."

    The Best of Care

    Mr. Miele's advantage began with the people he was with on May 6, when
    the lining of his right coronary artery ruptured, cutting off the flow
    of blood to his 66-year-old heart. His two colleagues were
    knowledgeable enough to dismiss his request for a taxi and call an
    ambulance instead.

    And because he was in Midtown Manhattan, there were major medical
    centers nearby, all licensed to do the latest in emergency cardiac
    care. The emergency medical technician in the ambulance offered Mr.
    Miele (pronounced MEE-lee) a choice. He picked Tisch Hospital, part of
    New York University Medical Center, an academic center with relatively
    affluent patients, and passed up Bellevue, a city-run hospital with
    one of the busiest emergency rooms in New York.

    Within minutes, Mr. Miele was on a table in the cardiac
    catheterization laboratory, awaiting an angioplasty to unclog his
    artery - a procedure that many cardiologists say has become the gold
    standard in heart attack treatment. When he developed ventricular
    fibrillation, a heart rhythm abnormality that can be fatal within
    minutes, the problem was quickly fixed.

    Then Dr. James N. Slater, a 54-year-old cardiologist with some 25,000
    cardiac catheterizations under his belt, threaded a catheter through a
    small incision in the top of Mr. Miele's right thigh and steered it
    toward his heart. Mr. Miele lay on the table, thinking about dying. By
    3:52 p.m., less than two hours after Mr. Miele's first symptoms, his
    artery was reopened and Dr. Slater implanted a stent to keep it that

    Time is muscle, as cardiologists say. The damage to Mr. Miele's heart
    was minimal.

    Mr. Miele spent just two days in the hospital. His brother-in-law, a
    surgeon, suggested a few specialists. Mr. Miele's brother, Joel,
    chairman of the board of another hospital, asked his hospital's
    president to call N.Y.U. "Professional courtesy," Joel Miele explained
    later. "The bottom line is that someone from management would have
    called patient care and said, 'Look, would you make sure everything's
    O.K.?' "

    Things went less flawlessly for Mr. Wilson, a 53-year-old
    transportation coordinator for Con Ed. He imagined fleetingly that he
    was having a bad case of indigestion, though he had had a heart attack
    before. His fiancée insisted on calling an ambulance. Again, the
    emergency medical technician offered a choice of two nearby hospitals
    - neither of which had state permission to do an angioplasty, the
    procedure Mr. Miele received.

    Mr. Wilson chose the Brooklyn Hospital Center over Woodhull Medical
    and Mental Health Center, the city-run hospital that serves three of
    Brooklyn's poorest neighborhoods. At Brooklyn Hospital, he was given a
    drug to break up the clot blocking an artery to his heart. It worked
    at first, said Narinder P. Bhalla, the hospital's chief of cardiology,
    but the clot re-formed.

    So Dr. Bhalla had Mr. Wilson taken to the Weill Cornell Center of
    NewYork-Presbyterian Hospital in Manhattan the next morning. There,
    Dr. Bhalla performed an angioplasty and implanted a stent. Asked later
    whether Mr. Wilson would have been better off if he had had his heart
    attack elsewhere, Dr. Bhalla said the most important issue in heart
    attack treatment was getting the patient to a hospital quickly.

    But he added, "In his case, yes, he would have been better off had he
    been to a hospital that was doing angioplasty."

    Mr. Wilson spent five days in the hospital before heading home on many
    of the same high-priced drugs that Mr. Miele would be taking and under
    similar instructions to change his diet and exercise regularly. After
    his first heart attack in 2000, he quit smoking; but once he was
    feeling better, he had stopped taking several medications, drifted
    back to red meat and fried foods, and let his exercise program slip.

    This time would be different, he vowed: "I don't think I'll survive
    another one."

    Ms. Gora's experience was the rockiest. First, she hesitated before
    allowing her husband to call an ambulance; she hoped her symptoms
    would go away. He finally insisted; but when the ambulance arrived,
    she resisted leaving. The emergency medical technician had to talk her
    into going. She was given no choice of hospitals; she was simply taken
    to Woodhull, the city hospital Mr. Wilson had rejected.

    Woodhull was busy when Ms. Gora arrived around 10:30 p.m. A triage
    nurse found her condition stable and classified her as "high
    priority." Two hours later, a physician assistant and an attending
    doctor examined her again and found her complaining of chest pain,
    shortness of breath and heart palpitations. Over the next few hours,
    tests confirmed she was having a heart attack.

    She was given drugs to stop her blood from clotting and to control her
    blood pressure, treatment that Woodhull officials say is standard for
    the type of heart attack she was having. The heart attack passed. The
    next day, Ms. Gora was transferred to Bellevue, the hospital Mr. Miele
    had turned down, for an angiogram to assess her risk of a second heart

    But Ms. Gora, who was 59 at the time, came down with a fever at
    Bellevue, so the angiogram had to be canceled. She remained at
    Bellevue for two weeks, being treated for an infection. Finally, she
    was sent home. No angiogram was ever done.

    Comforts and Risks

    Mr. Miele is a member of New York City's upper middle class. The son
    of an architect and an artist, he worked his way through college,
    driving an ice cream truck and upholstering theater seats. He spent
    two years in the military and then joined his father's firm, where he
    built a practice as not only an architect but also an arbitrator and
    an expert witness, developing real estate on the side.

    Mr. Miele is the kind of person who makes things happen. He bought a
    $21,000 house in the Park Slope section of Brooklyn, sold it about 15
    years later for $285,000 and used the money to build his current house
    next door, worth over $2 million. In Brookhaven, on Long Island, he
    took a derelict house on a single acre, annexed several adjoining lots
    and created what is now a four-acre, three-house compound with an
    undulating lawn and a 15,000-square-foot greenhouse he uses as a
    workshop for his collection of vintage Jaguars.

    Mr. Miele's architecture partners occasionally joked that he was not
    in the business for the money, which to some extent was true. He had
    figured out how to live like a millionaire, he liked to say, even
    before he became one. He had worked four-day weeks for the last 20
    years, spending long weekends with his family, sailing or iceboating
    on Bellport Bay and rebuilding cars.

    Mr. Miele had never thought of himself as a candidate for a heart
    attack - even though both his parents had died of heart disease; even
    though his brother had had arteries unclogged; even though he himself
    was on hypertension medication, his cholesterol levels bordered on
    high and his doctor had been suggesting he lose weight.

    He was a passionate chef who put great store in the healthfulness of
    fresh ingredients from the Mieles' vegetable garden or the
    greengrocers in Park Slope. His breakfasts may have been a
    cardiologist's nightmare - eggs, sausage, bacon, pastina with a
    poached egg - but he considered his marinara sauce to be healthy
    perfection: just garlic, oil, tomatoes, salt and pepper.

    He figured he had something else working in his favor: he was happy.
    He adored his second wife, Lori, 23 years younger, and their
    6-year-old daughter, Emma. He lived within blocks of his two sisters
    and two of his three grown children from his first marriage. The house
    regularly overflowed with guests, including Mr. Miele's former wife
    and her husband. He seemed to know half the people of Park Slope.

    "I walk down the street and I feel good about it every day," Mr.
    Miele, a gregarious figure with twinkling blue eyes and a taste for
    worn T-shirts and jeans, said of his neighborhood. "And, yes, that
    gives me a feeling of well-being."

    His approach to his health was utilitarian. When body parts broke, he
    got them fixed so he could keep doing what he liked to do. So he had
    had disc surgery, rotator cuff surgery, surgery for a carpal tunnel
    problem. But he was also not above an occasional bit of neglect. In
    March 2004, his doctor suggested a stress test after Mr. Miele
    complained of shortness of breath. On May 6, the prescription was
    still hanging on the kitchen cabinet door.

    An important link in the safety net that caught Mr. Miele was his
    wife, a former executive at a sweater manufacturing company who had
    stopped work to raise Emma but managed the Mieles' real estate as
    well. While Mr. Miele was still in the hospital, she was on the
    Internet, Googling stents.

    She scheduled his medical appointments. She got his prescriptions
    filled. Leaving him at home one afternoon, she taped his
    cardiologist's business card to the couch where he was sitting. "Call
    Dr. Hayes and let him know you're coughing," she said, her fingertips
    on his shoulder. Thirty minutes later, she called home to check.

    She prodded Mr. Miele, gently, to cut his weekly egg consumption to
    two, from seven. She found fresh whole wheat pasta and cooked it with
    turkey sausage and broccoli rabe. She knew her way around nutrition

    Ms. Miele took on the burden of dealing with the hospital and
    insurance companies. She accompanied Mr. Miele to his doctor's
    appointments and retained pharmaceutical dosages in her head.

    "I can just leave and she can give you all the answers to all the
    questions," Mr. Miele said to his cardiologist, Dr. Richard M. Hayes,
    one day.

    "O.K., why don't you just leave?" Dr. Hayes said back. "Can she also
    examine you?"

    With his wife's support, Mr. Miele set out to lose 30 pounds. His
    pasta consumption plunged to a plate a week from two a day. It was not
    hard to eat healthfully from the Mieles' kitchens. Even the "junk
    drawer" in Park Slope was stocked with things like banana chips and
    sugared almonds. Lunches in Brookhaven went straight from garden to
    table: tomatoes with basil, eggplant, corn, zucchini flower tempura.

    At Dr. Hayes's suggestion, Mr. Miele enrolled in a three-month
    monitored exercise program for heart disease patients, called cardiac
    rehab, which has been shown to reduce the mortality rate among heart
    patients by 20 percent. Mr. Miele's insurance covered the cost. He
    even managed to minimize the inconvenience, finding a class 10 minutes
    from his country house.

    He had the luxury of not having to rush back to work. By early June,
    he had decided he would take the summer off, and maybe cut back his
    work week when he returned to the firm.

    "You know, the more I think about it, the less I like the idea of
    going back to work," he said. "I don't see any real advantage. I mean,
    there's money. But you've got to take the money out of the equation."

    So he put a new top on his 1964 Corvair. He played host to a large
    family reunion, replaced the heat exchanger in his boat and
    transformed the ramshackle greenhouse into an elaborate workshop. His
    weight dropped to 189 pounds, from 211. He had doubled the intensity
    of his workouts. His blood pressure was lower than ever.

    Mr. Miele saw Dr. Hayes only twice in six months, for routine
    follow-ups. He had been known to walk out of doctors' offices if he
    was not seen within 20 minutes, but Dr. Hayes did not keep him
    waiting. The Mieles were swept into the examining room at the
    appointed hour. Buoyed by the evidence of Mr. Miele's recovery, they
    would head out to lunch in downtown Manhattan. Those afternoons had
    the feel of impromptu dates.

    "My wife tells me that I'm doing 14-hour days," Mr. Miele mused one
    afternoon, slicing cold chicken and piling it with fresh tomatoes on
    toast. "She said, 'You're doing better now than you did 10 years ago.'
    And I said, 'I haven't had sex in a week.' And she said, 'Well?' "

    Just one unpleasant thing happened. Mr. Miele's partners informed him
    in late July that they wanted him to retire. It caught him off guard,
    and it hurt. He countered by taking the position that he was
    officially disabled and therefore entitled to be paid through May 5,
    2005. "I mean, the guy has a heart attack," he said later. "So you get
    him while he's down?"

    Lukewarm Efforts to Reform

    Will Wilson fits squarely in the city's middle class. His parents had
    been sharecroppers who moved north and became a machinist and a nurse.
    He grew up in Bedford-Stuyvesant and had spent 34 years at Con Ed. He
    had an income of $73,000, five weeks' vacation, health benefits, a
    house worth $450,000 and plans to retire to North Carolina at 55.

    Mr. Wilson, too, had imagined becoming an architect. But there had
    been no money for college, so he found a job as a utility worker. By
    age 22, he had two children. He considered going back to school, with
    the company's support, to study engineering. But doing shift work, and
    with small children, he never found the time.

    For years he was a high-voltage cable splicer, a job he loved because
    it meant working outdoors with plenty of freedom and overtime pay. But
    on a snowy night in the early 1980's, a car skidded into a stanchion,
    which hit him in the back. A doctor suggested that Mr. Wilson learn to
    live with the pain instead of having disc surgery, as Mr. Miele had

    So Mr. Wilson became a laboratory technician, then a transportation
    coordinator, working in a cubicle in a low-slung building in Astoria,
    Queens, overseeing fuel deliveries for the company's fleet. Some
    people might think of the work as tedious, Mr. Wilson said, "but it
    keeps you busy."

    "Sometimes you look back over your past life experiences and you
    realize that if you would have done something different, you would
    have been someplace else," he said. "I don't dwell on it too much
    because I'm not in a negative position. But you do say, 'Well, dag,
    man, I should have done this or that.' "

    Mr. Wilson's health was not bad, but far from perfect. He had quit
    drinking and smoking, but had high cholesterol, hypertension and
    diabetes. He was slim, 5-foot-9 and just under 170 pounds. He traced
    his first heart attack to his smoking, his diet and the stress from a
    grueling divorce.

    His earlier efforts to reform his eating habits were half-hearted.
    Once he felt better, he stopped taking his cholesterol and
    hypertension drugs. When his cardiologist moved and referred Mr.
    Wilson to another doctor, he was annoyed by what he considered the
    rudeness of the office staff. Instead of demanding courtesy or finding
    another specialist, Mr. Wilson stopped going.

    By the time Dr. Bhalla encountered Mr. Wilson at Brooklyn Hospital,
    there was damage to all three main areas of his heart. Dr. Bhalla
    prescribed a half-dozen drugs to lower Mr. Wilson's cholesterol,
    prevent clotting and control his blood pressure.

    "He has to behave himself," Dr. Bhalla said. "He needs to be more
    compliant with his medications. He has to really go on a diet, which
    is grains, no red meat, no fat. No fat at all."

    Mr. Wilson had grown up eating his mother's fried chicken, pork chops
    and macaroni and cheese. He confronted those same foods at holiday
    parties and big events. There were doughnut shops and fried chicken
    places in his neighborhood; but Mr. Wilson's fiancée, Melvina Murrell
    Green, found it hard to find fresh produce and good fish.

    "People in my circle, they don't look at food as, you know, too much
    fat in it," Mr. Wilson said. "I don't think it's going to change. It's

    At Red Lobster after his second heart attack, Ms. Green would order
    chicken and Mr. Wilson would have salmon - plus a side order of fried
    shrimp. "He's still having a problem with the fried seafood," Ms.
    Green reported sympathetically.

    Whole grains remained mysterious. "That we've got to work on," she
    said. "Well, we recently bought a bag of grain something. I'm not used
    to that. We try to put it on the cereal. It's O.K."

    In August, Ms. Green's blood pressure shot up. The culprit turned out
    to be a turkey chili recipe that she and Mr. Wilson had discovered:
    every ingredient except the turkey came from a can. She was shocked
    when her doctor pointed out the salt content. The Con Ed cafeteria,
    too, was problematic. So Mr. Wilson began driving to the Best Yet
    Market in Astoria at lunch to troll the salad bar.

    Dr. Bhalla had suggested that Mr. Wilson walk for exercise. There was
    little open space in the neighborhood, so Mr. Wilson and Ms. Green
    often drove just to go for a stroll. In mid-October he entered a
    cardiac rehab program like Mr. Miele's, only less convenient. He would
    drive into Manhattan after work, during the afternoon rush, three days
    a week. He would hunt for on-street parking or pay too much for a
    space in a lot. Then a stranger threatened to damage Mr. Wilson's car
    in a confrontation over a free spot, so Mr. Wilson switched to the

    For a time, he considered applying for permanent disability. But Con
    Ed allowed him to return to work "on restrictions," so he decided to
    go back, with plans to retire in a year and a half. The week before he
    went back, he and Ms. Green took a seven-day cruise to Nassau. It was
    a revelation.

    "Sort of like helped me to see there's a lot more things to do in
    life," he said. "I think a lot of people deny themselves certain
    things in life, in terms of putting things off, 'I'll do it later.'
    Later may never come."

    Ignoring the Risks

    Ms. Gora is a member of the working class. A bus driver's daughter,
    she arrived in New York City from Krakow in the early 1990's, leaving
    behind a grown son. She worked as a housekeeper in a residence for the
    elderly in Manhattan, making beds and cleaning toilets. She said her
    annual income was $21,000 to $23,000 a year, with health insurance
    through her union.

    For $365 a month, she rented a room in a friend's Brooklyn apartment
    on a street lined with aluminum-sided row houses and American flags.
    She used the friend's bathroom and kitchen. She was in her seventh
    year on a waiting list for a subsidized one-bedroom apartment in the
    adjacent Williamsburg neighborhood. In the meantime, she had acquired
    a roommate: Edward Gora, an asbestos-removal worker newly arrived from
    Poland and 10 years her junior, whom she met and married in 2003.

    Like Mr. Miele, Ms. Gora had never imagined she was at risk of a heart
    attack, though she was overweight, hypertensive and a 30-year smoker,
    and heart attacks had killed her father and sister. She had numerous
    health problems, which she addressed selectively, getting treated for
    back pain, ulcers and so on until the treatment became too expensive
    or inconvenient, or her insurance declined to pay.

    "My doctor said, 'Ewa, be careful with cholesterol,' " recalled Ms.
    Gora, whose vestigial Old World sense of propriety had her dressed in
    heels and makeup for every visit to Bellevue. "When she said that, I
    think nothing; I don't care. Because I don't believe this touch me. Or
    I think she have to say like that because she doctor. Like cigarettes:
    she doctor, she always told me to stop. And when I got out of the
    office, lights up."

    Ms. Gora had a weakness for the peak of the food pyramid. She grew up
    on her mother's fried pork chops, spare ribs and meatballs - all
    cooked with lard - and had become a pizza, hamburger and French fry
    enthusiast in the United States. Fast food was not only tasty but also
    affordable. "I eat terrible," she reported cheerily from her bed at
    Bellevue. "I like grease food and fast food. And cigarettes."

    She loved the feeling of a cigarette between her fingers, the rhythmic
    rise and fall of it to her lips. Using her home computer, she had
    figured out how to buy Marlboros online for just $2.49 a pack. Her
    husband smoked, her friends all smoked. Everyone she knew seemed to
    love tobacco and steak.

    Her life was physically demanding. She would rise at 6 a.m. to catch a
    bus to the subway, change trains three times and arrive at work by 8
    a.m. She would make 25 to 30 beds, vacuum, cart out trash. Yet she
    says she loved her life. "I think America is El Dorado," she said.
    "Because in Poland now is terrible; very little bit money. Here, I
    don't have a lot of, but I live normal. I have enough, not for rich
    life but for normal life."

    The precise nature of Ms. Gora's illness was far from clear to her
    even after two weeks in Bellevue. In her first weeks home, she
    remained unconvinced that she had had a heart attack. She arrived at
    the Bellevue cardiology clinic for her first follow-up appointment
    imagining that whatever procedure had earlier been canceled would then
    be done, that it would unblock whatever was blocked, and that she
    would be allowed to return to work.

    Jad Swingle, a doctor completing his specialty training in cardiology,
    led Ms. Gora through the crowded waiting room and into an examining
    room. She clutched a slip of paper with words she had translated from
    Polish using her pocket dictionary: "dizzy," "groin," "perspiration."
    Dr. Swingle asked her questions, speaking slowly. Do you ever get
    chest discomfort? Do you get short of breath when you walk?

    She finally interrupted: "Doctor, I don't know what I have, why I was
    in hospital. What is this heart attack? I don't know why I have this.
    What I have to do to not repeat this?"

    No one had explained these things, Ms. Gora believed. Or, she
    wondered, had she not understood? She perched on the examining table,
    ankles crossed, reduced by the setting to an oversize, obedient child.
    Dr. Swingle examined her, then said he would answer her questions "in
    a way you'll understand." He set about explaining heart attacks: the
    narrowed artery, the blockage, the partial muscle death.

    Ms. Gora looked startled.

    "My muscle is dead?" she asked.

    Dr. Swingle nodded.

    What about the procedure that was never done?

    "I'm not sure an angiogram would help you," he said. She needed to
    stop smoking, take her medications, walk for exercise, come back in a

    "My muscle is still dead?" she asked again, incredulous.

    "Once it's dead, it's dead," Dr. Swingle said. "There's no bringing it
    back to life."

    Outside, Ms. Gora tottered toward the subway, 14 blocks away, on pink
    high-heeled sandals in 89-degree heat. "My thinking is black," she
    said, uncharacteristically glum. "Now I worry. You know, you have
    hand? Now I have no finger."

    If Mr. Miele's encounters with the health care profession in the first
    months after his heart attack were occasional and efficient, Ms.
    Gora's were the opposite. Whereas he saw his cardiologist just twice,
    Ms. Gora, burdened by complications, saw hers a half-dozen times.
    Meanwhile, her heart attack seemed to have shaken loose a host of
    other problems.

    A growth on her adrenal gland had turned up on a Bellevue CAT scan,
    prompting a visit to an endocrinologist. An old knee problem flared
    up; an orthopedist recommended surgery. An alarming purple rash on her
    leg led to a trip to a dermatologist. Because of the heart attack, she
    had been taken off hormone replacement therapy and was constantly
    sweating. She tore open a toe stepping into a pothole and needed

    Without money or connections, moderate tasks consumed entire days. One
    cardiology appointment coincided with a downpour that paralyzed the
    city. Ms. Gora was supposed to be at the hospital laboratory at 8 a.m.
    to have blood drawn and back at the clinic at 1 p.m. In between, she
    wanted to meet with her boss about her disability payments. She had a
    4 p.m. appointment in Brooklyn for her knee.

    So at 7 a.m., she hobbled through the rain to the bus to the subway to
    another bus to Bellevue. She was waiting outside the laboratory when
    it opened. Then she took a bus uptown in jammed traffic, changed
    buses, descended into the subway at Grand Central Terminal, rode to
    Times Square, found service suspended because of flooding, climbed the
    stairs to 42nd Street, maneuvered through angry crowds hunting for
    buses and found another subway line.

    She reached her workplace an hour and a half after leaving Bellevue;
    if she had had the money she could have made the trip in 20 minutes by
    cab. Her boss was not there. So she returned to Bellevue and waited
    until 2:35 p.m. for her 1 o'clock appointment. As always, she asked
    Dr. Swingle to let her return to work. When he insisted she have a
    stress test first, a receptionist gave her the first available
    appointment - seven weeks away.

    Meanwhile, Ms. Gora was trying to stop smoking. She had quit in the
    hospital, then returned home to a husband and a neighbor who both
    smoked. To be helpful, Mr. Gora smoked in the shared kitchen next
    door. He was gone most of the day, working double shifts. Alone and
    bored, Ms. Gora started smoking again, then called Bellevue's free
    smoking cessation program and enrolled.

    For the next few months, she trekked regularly to "the smoking
    department" at Bellevue. A counselor supplied her with nicotine
    patches and advice, not always easy for her to follow: stay out of the
    house; stay busy; avoid stress; satisfy oral cravings with, say,
    candy. The counselor suggested a support group, but Ms. Gora was too
    ashamed of her English to join. Even so, over time her tobacco craving

    There was just one hitch: Ms. Gora was gaining weight.

    To avoid smoking, she was eating. Her work had been her exercise and
    now she could not work. Dr. Swingle suggested cardiac rehab, leaving
    it up to Ms. Gora to find a program and arrange it. Ms. Gora let it
    slide. As for her diet, she had vowed to stick to chicken, turkey,
    lettuce, tomatoes and low-fat cottage cheese. But she got tired of
    that. She began sneaking cookies when no one was looking - and no one

    She cooked separate meals for Mr. Gora, who was not inclined to change
    his eating habits. She made him meatballs with sauce, liver, soup from
    spare ribs. Then one day in mid-October, she helped herself to one of
    his fried pork chops, and was soon eating the same meals he was. As an
    alternative to eating cake while watching television, she turned to
    pistachios, and then ate a pound in a single sitting.

    Cruising the 99 Cent Wonder store in Williamsburg, where the freezers
    were filled with products like Budget Gourmet Rigatoni with Cream
    Sauce, she pulled down a small package of pistachios: two and a half
    servings, 13 grams of fat per serving. "I can eat five of these," she
    confessed, ignoring the nutrition label. Not servings. Bags.

    Heading home after a trying afternoon in the office of the apartment
    complex in Williamsburg, where the long-awaited apartment seemed
    perpetually just out of reach, Ms. Gora slipped into a bakery and
    emerged with a doughnut, her first since her heart attack. She found a
    park bench where she had once been accustomed to reading and smoking.
    Working her way through the doughnut, confectioners' sugar snowing
    onto her chest, she said ruefully, "I miss my cigarette."

    She wanted to return to work. She felt uncomfortable depending on Mr.
    Gora for money. She worried that she was becoming indolent and losing
    her English. Her disability payments, for which she needed a doctor's
    letter every month, came to just half her $331 weekly salary. Once,
    she spent hours searching for the right person at Bellevue to give her
    a letter, only to be told to come back in two days.

    The co-payments on her prescriptions came to about $80 each month.
    Unnerving computer printouts from the pharmacist began arriving:
    "Maximum benefit reached." She switched to her husband's health
    insurance plan. Twice, Bellevue sent bills for impossibly large
    amounts of money for services her insurance was supposed to cover.
    Both times she spent hours traveling into Manhattan to the hospital's
    business office to ask why she had been billed. Both times a clerk
    listened, made a phone call, said the bill was a mistake and told her
    to ignore it.

    When the stress test was finally done, Dr. Swingle said the results
    showed she was not well enough to return to full-time work. He gave
    her permission for part-time work, but her boss said it was out of the
    question. By November, her weight had climbed to 197 pounds from 185
    in July. Her cholesterol levels were stubbornly high and her blood
    pressure was up, despite drugs for both.

    In desperation, Ms. Gora embarked upon a curious, heart-unhealthy diet
    clipped from a Polish-language newspaper. Day 1: two hardboiled eggs,
    one steak, one tomato, spinach, lettuce with lemon and olive oil.
    Another day: coffee, grated carrots, cottage cheese and three
    containers of yogurt. Yet another: just steak. Ms. Gora decided not to
    tell Dr. Swingle. "I worry if he don't let me, I not lose the weight,"
    she said.

    Uneven Recoveries

    By spring, Mr. Miele's heart attack, remarkably, had left him better
    off. He had lost 34 pounds and was exercising five times a week and
    taking subway stairs two at a time. He had retired from his firm on
    the terms he wanted. He was working from home, billing $225 an hour.
    More money in less time, he said. His blood pressure and cholesterol
    were low. "You're doing great," Dr. Hayes had said. "You're doing
    better than 99 percent of my patients."

    Mr. Wilson's heart attack had been a setback. His heart function
    remained impaired, though improved somewhat since May. At one recent
    checkup, his blood pressure and his weight had been a little high. He
    still enjoyed fried shrimp on occasion but he took his medications
    diligently. He graduated from cardiac rehab with plans to join a
    health club with a pool. And he was looking forward to retirement.

    Ms. Gora's life and health were increasingly complex. With Dr.
    Swingle's reluctant approval, she returned to work in November. She
    had moved into the apartment in Williamsburg, which gave her a kitchen
    and a bathroom for the first time in seven years. But she began
    receiving menacing phone calls from a collection agency about an old
    bill her health insurance had not covered. Her husband, with double
    pneumonia, was out of work for weeks.

    She had her long-awaited knee surgery in January. But it left her
    temporarily unable to walk. Her weight hit 200 pounds. When the diet
    failed, she considered another consisting largely of fruit and
    vegetables sprinkled with an herbal powder. Her blood pressure and
    cholesterol remained ominously high. She had been warned that she was
    now a borderline diabetic.

    "You're becoming a full-time patient, aren't you?" Dr. Swingle


    2. http://www.hsph.harvard.edu/faculty/IchiroKawachi.html
    3. http://chaos.cpmc.columbia.edu/sphdir/pers.asp?ID=599

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