class discussion

12 The Rigors of Kidney DialYsis for Robert Banes Laurie Kaye Abraham

Robert Banes' sloty reveals the daily rou,tine o'f' a patient vtho ntust luve dialysis or di.e. R<tbert's story tells ntore, however, thctn a saga ol'sickne-ss. Tltis chapter links the personal ex- perience of illness to Larger trends in incidence ol disease and diflbrerttials by race and class in receiving care. Like anyone else with a chronic tlhrcss, Rr,tbert experiences the vicissitudes of kidney dialysis within tlrc parcLntelers of a lilb. End Stage Renal Disease (ESRD) yvith sub- seqLtenl dia\,5i5 is iiot the crisis in Robert's life. Rather, it is one nrore crisis in a life riddenwith crises born out of poverty, lhnited education, and lacl< ofopportunity. For people like Robert and his wife, Jackie, disability and death are routine events. Pooled resources and shared housing ruith relatives help some but poverty and ill health prove to be relentless.

As yott read this selection, look for places wlrcre both Robert and Tbmmy could have 1 lbeett ltel1ted, wlrcre a further slide downhill could have been prevented. Note the contrast tn econorttic circutnstances between Robert and D r. lning. Assess the structure and quality ol treatment available to Robert.

D r\ober-t ivas thinking about frying some ba- con for breakfast when the driver who takes him to the kidney dialysis center sounded his horn foom the street. This was unusual be- cause it was iust a little after 5:30 A.M., and Robert is scheduled for a six o'clock pickup, Mondays, Wednesdays, and Fridays. Robert has knor,r,n drivers to be late, sometimes by

The Rigors of Kidney Dialysis for Robert Banes l13

hours; he has known drivers not to show. They are rarely early.

Still sleepy, he dropped down on the couch to pull on his leather high-tops. A lamp glowed orange in one corner of the living room; cltherwise, it was early-morning gray. Latrice slept next to him. Her long, brown legs stretched the length of the couch that does double-duty as her bed. She lay on top of a mst-colored throw that Jackie uses to cover the couchs thinning, stained uphol- stery. Jackie was zrlready up, washing in the bathroom. Her grandmother lay still in her bed: she had not vet called for her breakfast or a morning drink cllt waten

T h e l i v i n g r o o m i s s u b s t a n t i a l l y l o n g e r than it is wide ancl is divided into two rnain sections. The back area, where Robert sat and Latrice slept, holds Jackie s furniture, the couch zrnd a matching love seat she brought when she, Robert, and Latrice moved in with h e r g r a n d m o t h e r i n 1 9 8 6 . A d a r k w o o d h u t c h , br-rilt into the back wall, is filled with pictures of the family. Some of the photos are old and tattered, their frarnes tarnished, but none of that seems to matter mtrch. The pictures look as it they have been there for a long time and will remain for-a long time to come. A light- colored wood bookshelf next to the hutch is overflowing with knickknacks: ceramic figu- rines Jackie gave to her grandmother mixed with animals made from shells (souvenirs oF a craft project at a nursing home where Mrs. Jackson worked), mixed with a dozen basket- ball trophies that Robert won in high school and junior college.

Toward the front, outside Mrs. Jackson's bedroom doo4 sits a more formal-looking couch, upholstered in faded gold, that the olJ woman has owned since Jackie was a girl. De- Marest is an active little boy and has torn and poked through its plastic slipcover until it no longer provides much protection, but Jackie resists removing it. Her grandmother in- sisted on the plastic covel, and Jackie does not want her to think the family is defying her now that she cannot do anything about it. A low-slung credenza, about thirty years old, with a working radio and a broken turntable inside, is across the room from Mrs. Jack- son's couch. Three color TVs are stacked to- gether near it, although only one works.

I

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114 Section 2 * The Selfin Social Context

Robert finished tying his shoes' Eyes half shut, he pushed uiial a vinyl recliner the B".r"r", put in front of the door at night.for extra security and descended the stairs that lead down io a small front porch' "Heh, Banes, I knew I'd get you today," called the driven who has transported Robert before' Each weekday, private companies that con- tract with the Chicago Transit Authority take Robert and twenty-five hundred other dis- abled Cook County residents to medical ap- pointments and wherever else they need to go. In the summer of 1989, there were five iransportation companies working for the CTA (subsequently one of them was kicked out of the program for frar.rd, as another had been earlier in the year). Rober-t used SCR Transportation, which had the worst on-time record in the program. SCR arrived on time for about half of its I'ides; the rest of the time, drivers were anywhere liom ten minutes to m o r c t l r a n a r r h o u r l a t e . l

N o n e t h e l e s s , t h e r i d e w a s a b l e s s i n g b e - cause the dialysis clinic is a good hour away on tl-rc bus ot- train. Robert rvould have to leave for the clinic in the dzrrk, an unsettling proposition in a neighborhoocl irnprisoned b y n i g h t f a l l . T h e B a n e s e s r a r e l y g o o t r t a t night, and even zrt dusk, when Latrice wants to r-Lln down to her cousin'.s aptrrtment less than ur block away, Jackie watches her come and go from the tront porch. Roberl also ap- preciates the ride home al'ter dialysis because sometimes he f-eels weak and shaky, not at all i n t h e m o o d t o b e j o s t l e d o n t h e b t t s .

As soon as Robert got into the cal, he pulled a pack of cigarettes out of his jacket and lit one. "My wife doesn't know I sntoke," he said. Robert tries to curry Jackiei favor with small gestures such as pretending not to smoke and buying her-a box of candy when she gets mad. What Jackie wants most, though, is for him to stay away from cocaine, and that he has a harder time doing. He sometimes goes weeks, even a month or two, without using cocaine but then binges and spends every cent he can find on drugs. That leaves Jackie strainins to meet her household budget, and it canndt be good for Robert's health. Robert refuses to discuss drugs with anyone but Jackie and then only if she pushes the issue.

The twenty-minute ride to Neomedica Di- alvsis Center, located in the most exclusive arla of Chicago, had the feel of a boys' night out. The two men bantered about NBA stars they had met, gangsters the driver had chatrf- feured, and the high cost of dating.

"Give me some cash and I can go out, buy some drinks for the ladies," the driver boasted.

"So you can make things happen," Roben said with a vicarious thrill.

Robert wears a dialysis uniform of sorts: a navy and white nylon sweatsuit and a rcd Bulls cap. His arms are still sculpted lrom his basketball-playing days, but the muscles look as if they have been sanded down. All thats left are a few bulges covered by a thin layer of skin. He has lost twenty pounds in the srx months since he began dialysis, a big enough droo that the clinic nutritionist said she plzrns t o p u t h i m o n a s u p p l e m e n t a l d i e t . O n t h e warmest davs. Roberl sets cold, and whc'n he sees a *o-in walk clown the stt'ec't in shorts zrnd a sleeveless shirt, he often says, "I rvish I h a d h e r b l o o d . " L i k e m o s t d i a l v s i s p a t i c n t s , R o b c r t i s c h r o n i c a l l y a n e r n i c .

Neomedica'.s clerk calls patients back for dialysis two or three at a tin-re, so Roltert found a chzrir in thc rvaiting room ancl turned to tl.re Serrr-7.i/7?e-s sports pzrges. Othcr patients k i l l e d t i m e r v i t h t a l k o f t l r e B u l l s a n d h i g h b l o o d p r e s s u r e p i l l s , t h e C u b s a n d t h e r e s t r i c - tive diets patients are supposed to follow Robert was one of the last patients left when he was sumrnoned at 7:30. That is his regr-rlar dizrlysis tin're, but Roberl gets to the clinic a little after six becatrse he has found that the earlier the pickup, the n-rore likely the trans- portation company is to be on time. When patients are late getting to Neomedica, thev may wait hours to be dialyzed.

Upon hearing his name, Robert pitched his paper and walked to his reclinel, past a sco.e of patients tethered to blinking, beep- ing machines. Two thin plastic tubis, red' d#ed by, steady ,t."u-r'of blood, sna.ked trom each of the patients' forearms. On.their inner arms, diaiysis patients have knots called fistulzrs, rvh-ere cloctors connect a.veln and an artery to enable them to receive dtatl- sis. The arteiial tube feeds blood into the dta- Iyzeq where a six-inch filter composed of doz' ens of tiny strawlike tubes draws out \\'astes

qi ! nger expel. The cleansed) r h e k i d n e Y s c a n n o I o l It t^.,d is then pumped Sack into patients'bod-i iJl,''*l; n ;' t'd ialys i s.-R:b"X ii$^ :le other

kidnev failure cattsed by hypertension, a dis- ease that usually can be controlled by medi- cation. In other words, a significant portion of the kidney failure among blacks is largely preventable with r:egular care. For those who or. p,ror, thc reasons they do not receive care range l'ron-t inadeqtratc or nonexistent insur- ance, to :r misltndet'stzrncling of the serious- n e s s o f t h e c o n d i t i o n , t o a n i n a b i l i t y t o c o p e u , i t h a n y t h i r - r g o t h e r t h a n i m m e d i a t e t h r e a t s t o t h e i r w e l l - b c i n g . A s a d m i x o f a l l t h r e e causecl Jackie'.s lather, Tommy Markham, to suffer another of the conseouences of uncon- trolled high blood presslrre, a stroke, when he was only fbrtv-eight.

Tommy givcs only sketchy details about his youth, br-rt he apparcntly had a conten- tior-rs relzrtionship with his parents, Mrs. Jackson ancl her first husband. He stayed be- h i n d i n M i s s i s s i p p i w h e n t h e c o u p l e ' m o v e d north, to Garry, Indiana, though his young daughter, Jackie, went with them. Jackie's teenage mother had given her daughter to Mrs. Jackson to raise. After Tommy got into trotrble for car theft, he moved to Chicago, where Mrs. Jackson had gone after she split from her htrsband. Tommy's mn-ins with the law did not stop, howevei. The way Tommy tells it, he got led up with a man who wrongly acclrsed hirn o[ "going with his woman" and "beat the shit otrt of him." He was convicted of armed lobbery and spent seven years in Illinoiss Stateville Correctional Center dur- ing his trventies. (Tommy huffily denies the robberv': "I didn't rob the dude. I just beat him up. . . . He r.r'as laying there in the gangway, and peoples from the lounge ran out. They took the money off him.")

The Rigors of Kidney Dialysis for Robert Banes ll5

When Tommy was released in 1971, Mrs. Jackson continued to raise Jackie. He lived with his mother and ten-year-old Jackie for a few days, but Mrs. Jackson threw him out be- cause of his "attitude," Jackie said, and he re- turned to the West Side's streets. He worked off and on as a bartendet', butcher. and exter- minatol all the while guzzling beer, whiskey, and cognac. Six feet, two inches tall, with muscle built in the prison gym and still evi- dent today, Tommy was menacing to Jackie and, evidently, to a lot of other people. "Everry- body would be scared of Tommy, Tommy, Tommy," Jackie chanted. So intimidated by her violent father was Jackie that she hzrs fonder memories of him when he was impris- oned than when he came ollt. She ancl her grandmother took the Greyhound bus to visit him in Joliet once a year. "I remember my father giving me bottlecl pop and peanlrts," she said. "It used to be a nicc ritual fior me, The prison hacl beautifurl f-lower gardens arrd aftenvard we'd go shopping in Jolict."

Tommys stroke did not come out of the blue. He knew he had high blood pressLu'c, but he stopped taking antihypertensive rnedi- cation becausc of its side el'fects-impotence, for one. IIis alcoholism and smoking also arl- most certainly contributed to the stroke. Br"rt high blood pressure does not cause any dis- comfort for most people, which is why doc- tors call it the "silent killer," and so Tommy, who generally cloes not look past the r-rext day, paid no attention. "Nature will takes its course," he likes to say. And it did. The left side of his body is now paralyzed, and he spends most of his time in a wheelchai4 though he can walk very slowly with the as- sistance of a brace and cane. As Tommy tells the Currency Exchange clerk with whom he flirts when he picks up his welfare check, "I can't rarn no more yards; the All-American Tom Cat done slowed down."

The casualties that high blood pressure in- flicts on blacks are enormous: thev suffer strokes at twice the rate of whites,a und the.e are sixty thousand excess deaths a year among blacks from hyperlension-related dis- eases.5 In Chicago, where the population of blacks and whites is roughly equal, there are more blacks with kidney failure caused by

l'^'' ;;;;"tld di'e within a few weeks'P" ")-,,i""" of

the patients on Robert's morn- ,."'."n]t u, Neomedica are black, five are His- ir^?i.],*t are white, and one is Asian' The i^.i"r'"ti^ of the group nearly matches that oT'chi.ugot dialysis population, though the i""r.. his fewer whites than the city as a ,-fr.i".' Nation-wide, the incidence of kidney ioll,rr" among- blacks is four times that a m o n g w h i t e s ' r

Much of that racial difference results fi-om

116 Section 2 i The Self in Social Context

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,-r.o.i Robert through his first kidney

il]i"nr""i i" 1e82. rn January 1989, his bodv ::i.,'"",t the transplanted organ' and Barber l,','""p'" p "' i" e h i m 9- qe1 :1t

t""3:]:A'-Y].1l l : ]l:,i i,tr iirt fol' a second time' "when patients r l].],... irtt Cook County with chronic renal ' ij'i,".' ""a

say' 'Nobocly ever to,ld me this , i.,ri.r rt^ppen,' the,v're partlv right'. Thelr've

i.i.ltr ,ota but not in a way that sticks," says t: iu t ... "Robert was t'efet-r'ed back for treat- I l.'rt, btrt being.young and feeling well, he .: Ji,l not have a lot of motivation to follow

thlrlr-rgh'" Then, too, people who can barely afford

f 6 o d a n d s h c l t e r n l a Y n o t t h i r - r k t h e y h a v e nruch to gzrin From sper-rding scarce dollars fur cl<lctors' visits. "For s()meone who is poor, h e a l t h c : r r c i s n o t t h e h i g h c s t p r i o r i t y , " D r . Corru,zrv said, an obscrvation offeled repeat- edlv by doctcir-s ancl nttLses who work with p ( x ) r p i l t l e n t s .

It'.s al.so possible thart l'riends and family \\'ere nol purshing Robert to go to the doctor, Dr: Conway continrlccl. "People in Chic:rgois poorer ncighborhoocls arre used to zr lot of sick people arouncl. Wherr someone says 'Some- t h i n g l s w r o n g w i t h r n v k i d n e y s , ' t h e a u t o r n a t - ic lesponse is not 'Wcll, what dcictor arc you g o i n g t o / ' W h c n y o t r l i v e o n t l - r e N o r t h S h o r e I t h e a f f l r r c n t s u b u r b s n o r t h o f C h i c a g o ] , t h a t ' s thi: first thing pcr>ple ask yor-r."

Dt'. Conr,vay also speculated that since Robcrt'.s clisezrse is zr chronic one, doctors may have told him that "there was nothing t h c v c o r r l c l t l o , " a p h r a s e t h a t c a n m e a n o n e t l t i n g t o p a t i e n t s a n d e r n o t h e r t o d o c t o r s . " I t souncis blzrck-ancl-r,r,hite, but it'.s not. We can't cure AIDS, but we don't say 'You're on your o l n . D o n ' t c c l n t e b a c k . ' W e c a n d o t h i n s s t o p r i r l o n g l i t e . "

Doctors mav face er particular challenge gettirrg that message across to people as fa- talistic as Robefi ancl Jackie. Asked at least a half-clozen times to discuss her feelinss about h e r f a m i l y s u n r e l e n t i n g i l l n e s s - E i d s h e think they were Lrnusual or especially cursed? _-Jackie got exasperated. "Look," she finally said, obviously hoping to close the subject, "I just sav it happens."

The f:rntastic and horrid deaths that mark their daily lives feed such fatalism. Perhaps onlv the most stout-hearted-or delusional-

The Rigors of Kidney Dialysis for Robert Banes ll7

could retain a sense of control over their des- tiny. One day, a thirtyish-looking man spotted Jackie in a car and ran up to the side window, puckering his lips in an exaggerated kiss. "I w,ent to school rvith him," Jackie said, lar"rgh- ing at his foolishness. Then, without skrpping a beat: "Thev fbund his brother dead right up uncler the house, this tall building right up on the corner'. I heard rllmors when I was rl g r a m m a l s c h o o l . T h e k i d s w a s p l a y i n g a n d they kept saying the,v smellecl something toul, like dead rats, and it was his brothers body down in the server."

Then there is the death of Robeft s beloved mother-. Thc official version of her story is that she went out clrinkins with friends after work on a Friclay, returnecl home, zrncl passed out in the garagc with the car running. The unofficizrl vcrsion is considerably more vivicl. "She rvas rnurrclcrcd," Jackie said once. Then s h e c o r r e c t e c l h c r s e l f . " C a r b o n m o n o x i d c , that'.s ',vhat'.s cln the cleath certificzrte. Btrt I R o b e r t a n d h i s f a m i l y ] s a y t h e r e w a s scratches zrncl blorid. And I've heard that she wers disrobecl halfrvav. And I remember Robert gctting hcl bra and there wzrs blood stains or.r it, so rve feel like, the family felt, therc was foul play somewhere."

It wor-rld be easy to dismiss this as an ex- ample of devotccl chilclren unable to face the m u n d a n e b u t u l t i m a t e l y t r a g i c c i r c u m - stances of their mother'.s death. And that may be all it is. But in a neighborhood where the clich6 "tmth is stranger than fiction" takes on pointed meaning, who knows for sure?

There has been little rigorous study of how fatalism and other accompaniments of pov- er.ty influence commllnication between doc- tors and patients, but at least one investigator of the subject found that doctors spend more time discussing diagnoses and treatments with well-educated people, resulting in a "paradoxical situation whereby patients most in need of education receive the least."8 At the same time, blacks reporl more often than whites that doctors do not adequately explain the seriousness of their illnesses or how medications work.e Robert, for one, is often confused by doctors, but he rarely if ever asks them for more information.

Several days before he was admitted to University of Illinois Hospital because of the

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118 Section 2 * The Selfin Social Context

blood in his urine, Robert had visited a urolo- sist at the university's outpatient clinic' He f,ad nel er seen the doctor before, but Barbel the transplant nurse, made him an appoint- ment beciuse of the unusual bleeding. At that appointment, the doctor told him he would haie to be hospitalized. He also told Robert that before he could be admitted to the hos- pital he wor-rld need blood tests and an ultra- iound study of his kidneYs.

"When am I going to have to have sur- gery?" Robert asked, certain of that eventual- ity though the doctor had not mentioned it.

"That'.s only if the ultrasound shows us something like a cyst, like cancer on the kid- nevs," the doctor said flatly.""Don't

tell rrle that, please," Robert pleaded. The doctor smiled sympathetically a n d w a l k e d o u t o l ' t h e e x a m i n i n g r o o n r w i t h - out explaining ftrrther.

Through the open door, Robert cotrld see but not hear the doctor confer:ring with a nurse who was holding a srnall plastic cup of blood that seemed to be Robert's.

"Don't be whispering," l're said to himself. "Tell me, too."

B u t w h e n t h e d o c t o r r e t u r n e d m o n l e n t s later, Rober-t did not ask lrinr what he had been tzrlking about. FIe lay bzrck on the exanr- i n i n g t a b l e a n d o l T e r e d u p h i s a r m f o r h i s blood pressure to be taken. If Robert won- dered wl-rat the chances lvere of his having c a n c e r , h e s a i d n o t h i n g .

Robert says he is not angry that no one ef- fectively explainecl to him that his kidneys were failing. Then again, Robert does not ad- mit that much of anything disturbs him. "I look at dialysis like a setback. Why should you get dorvn? It jusl makes you sicker."

It's understandable, perhaps admirable, that Robeft does not want to dwell on his ill- ness. But Roberl is so matter-of-fact and pub- licly emotionless about how he got sick-and even the most devoted doctors and nurses are so used to situations like Roberts-that it is easy to be lulled into taking it all for granted. Whose fault is it that Robert did not have health insurance, and that at least thirty-five million Americans are without it todav?10 What about doctors' inability to communi- cate to patients in a way that makes them understand their illnesses-whose fault is

that? Who is responsible for the many poor minorities who are so socially and economi- cally isolated that they cannot take advantage of the medical system in the same rvay tirat many whites can?

No one is forced to take responsibilit-t' for these inequities. Medical ethicist Larry Chur- chill describes well the forces that allor.v the United States to remain the only industrial- ized country other than South Af ica that does not provide at least basic health care to all of its citizens, "Access to health care rs mostly contingent on having a way to pay for it, either out of one's own resources or rvith some form of insurance," he writes. "The es- sential point is that lthis] allocation by price is a rationing scheme-one which we have easily accepted in health care as an extension of a basic economic philosophy, ancl one which largely absolves any particular person lrom responsibility for the results. Since no one actually decided to exclude the poor (as it is their lack of money that excludes them, not our actions) no one is responsible and no o n e i s t o b l a m e . " l l

The morning the dialysis driver arrived early, Robert fell asleep rvithin minutes after his blood began cycling thror-rgh the dialysis machine at Neon-redica. Belorc settlir.rs in for a nap, he covered himself rvith a blue bed- spread he'd brought from home to ',vald off the chill he gets during dialysis. The elderlr Hispanic *J-un who iat n"*t to him had the opposite problem: she brought a small fan lo cool her is she slept. Cigarette smoke c.urled over the backs of several of the recltners spread across the room. Some patients watched a TV that huns firom the ceiling;otn'

i ' - r , , , 1 ; r l v s i s c h a i n , w h i c h i n 1 9 8 9 i n c l u d e d

, llili'rir-';i Chicago-area dialvsis units'

' ''"Dir,lrri, is one of few areas. of medl:"].t'll: ari,l'-r"i"a ny for-profit

providers' and,it has il""r, ",

the center o1' a nationwide debate 1i",,, ,ft" costs and quality. of ploprietary l , . , i i . i n " . M e d i c a r e . p a y - s d i a l y s i s u n i t s a i l - , , r [ e e l o r - e a c h d i a l y s i s s e s s i o n - X . , , n r " a i . u c u t - r c r t l v g e t s $ 1 3 1 . p e r t r - e a t - r.nil'-1,u, exerciscs little control over how , 1 , ^ , n r , r n c v i s s p e n t . O f f i c i a l s a t t h e H e a l t h i , ; ; ; F i " " " . i n g A d m i n i s t r a t i o n , w h i c h z r d - ministers Meclicare, chargc that, to preselve h i g h p l o i i t m l r r g i n s ' n l z r n y c e n t e r s c o m p r o - , n i r " ' p o t i " ' . t t s ' c e l e b v r e d u c i n g s t a { T a n c l shortening tl'ezlt lrell I ti mes.

I 3 Sr-tch cclst -ctt t- ting ctrangcs havc becn nrzlcle at Neclrnediczt, D r . L a n g I r - e c l y a d n i t s , b t r l h c s a i c l t l i c y d r r n o t t h r e a t e t t p a t i e n t s ' l l c z r l t h . N e i t h c r , t r e s a i c l , d o N c o r n e c l i c z r ' s p l r y s i c i a l t - o \ v n e l ' s c i l r l l c - x - ccssir,c ttroltit.s.

D r : L : r n g f o t r n c l e c l N e < i r l e c 1 i c a w i t h a r r o t h e r doctor rvhen Mcclicare began t() pny for clialy- s i s i n I 9 7 2 z u r c l t o c l a y o r t ' t t . s I 4 p e r - c c n t l + t ' l t h c S 6 . 7 n r i l l i o n c l r a i n . l s P r - r b l i c c k l c t r n t e n t s c l < r not shorv trow rnnclr Dr. Lerng nreikcs ars the c o l p o r a t i r . r r - r ' . s c h i e l c x c c t r t i v c , b r - r t h i s . j o b a s z t mcdical clircctor ol' Rober-t'.s trnit, rvlrich Dr. L a n g e s t i n - i z r t e c l c l c c t r p i e s h i m f i l r t h r e e o r f o u r - h o u r s a w e e k , p a y s r , v c l l : $ 6 8 , 4 8 0 i n 1 9 8 9 , a c c o r d i n g t o M e d i c a r - c c ( ) s t r e p o r - t s . l 6 C o m - pletelv npart f lonr u'hnt hc mzrkes for rr-rnning Neorncclica, lre czrr-ns a nronthly fee as the nephrrilogist lbr Robert ancl Forty-five to fifty o t h e r c l i e r l v s i s p a t i e n t s . l T F o r t h a t w o r k , M e d i - c a l ' e p a y s c l o c t o r s a n a v e r a g c o l ' $ 1 7 3 p e r p a - tient per rnor-rth, r,vhich wrtr-rld ntean Dn Lang e a r n s r o r - r g h l y z r n o t h e r $ 1 0 0 , 0 0 0 e a c h y e a r irom Medicare.l8 Finally, a medical practice h e n t a i n t a i n s o u t s i d e o f t h e d i a l y s i s u n i t f u r - t h e r e n h a r r c e d h i s i n c o m e . D r : L a n g w i l l n o t sav hou' much he clrrrentlv makes a yeal, but accot-cling to thc Internal Revenue Service, h i . s t a x a l : i l c i n c o m e i n 1 9 8 5 w a s $ 3 6 2 , 9 6 4 . 1 e (That figurre comes flom a suit Dr. Lang filed agiiinst the IRS to block the agency'.s attempt to recor,'er g 160,000 for alleged improper de- dltctions he took on a ski resorl condomin- t u m i n U t a h . )

Dr. Lar-rg's manner with the dialysis pa- tients at Neomedica's downtown Llnit was brisk and etficient if not cursory, but for

The Rigors of Kidney Dialysisfor Robert Banes ll9

R o b e r t , a t l e a s t , h e i s " t h e m a n . " T h o u g h R o b e r t a n d t h e o t h e r p a t i e n t s r e g u l a r l y g m m b l e a b o u t e v e r J a s p e c t o [ d i a l y s i s , l i t t l e o f t h e i r a n g e r s e e m s d i r e c t e d a t D r . L a n g . T h e t e c h n i c i a n s a n c l n u r s e s t a k e t h e b m n t o f i t , e v e n t h o u g h i t i s D r . L a n g w h o h a r s u l t i n t ; r t e r e s p o n s i b i l i t y f b r t h e r v a y t h e u n i t i s r L r n . . . .

Notes

l . C h i c a g o l - r a n s i t A u t h o r i t y , o n - t i m e p e r f o r m - a n c e o f C T A S p c c i a l S e r u i c e s t r a n s p o r t a t l o n c o m p a n i e s I 9 8 9 - I 9 9 1 , o b t a i n e c l t l t r o u g h a F r e e d o m o l l n f o r m a t i o n A c t l e q u e s t , D e c e r n - b e r ' 1 9 9 l

2 . R e n a l N e t r w r r k o [ [ l l i n o i s , " C h i c a g o D i a l y s i s P o p r r l : r t i o n : R a c e r v i t h i I - r A g e , " s p e c i a l c [ : t t : t t r - t r r o l r t : r i r r e d t l r r o r - r g l ' r a F r e e c l o m o f I n f o r m z t t t o n A c t r c q t r e r s t , J t r l v 1 9 8 9 .

3 . C o m r r i t t c c l o r t h c S t u c l v o f t h e M e c l i c a r e - E S R D P r o g r a n ' r , I n s t i t u t e o l M e c l i c i n e , p r - c - p r r b l i c a t i o n c o p v , K i r l r r e . r , F a i l u r e a n d t l t e F e d c r a l ( l < ' ; t , c n t r n t ' r r t ( W a s h i n g t o n , D . C . , N a - t i < r n z r l A c a c l e n r v P r e s s , l 9 9 l ) , p . 1 2 2 .

4 . N : r t i o n a l C c n t e r f t l ' H e a l t h S t a t i s t i c s , " A c l - v a n c c d R c p o r t o 1 ' F i n a l M o r t a l i t y S t a t i s t i c s , 1 9 8 9 , " i n M t ; t t t h l y V i t a l S t a t i s t i c s 4 0 , n o . 8 , s t r p p l . 2 f l v a t t s v i l l c M c l . : P u b l i c H e a l t l ' r S e r - v i c e , 1 9 9 2 ) . T l i e r 1 9 8 9 a g e - a d j u s t e c l s t r o k c r a t e f o r r v h i t e s r v : r s 2 5 . 9 p e r 1 0 0 , 0 0 0 p o p u l a t i o n , f o r b l a c k s , 4 9 . 0 p e r 1 0 0 , 0 0 0 .

5 . E l i i a h S z u n d e r s , " E p i d e m i o l o g i c F a c t o r s i n t h e M a n a g e m e n t o f H y p e r t e n s i o n , " . / o l . r n n l o l t h e N a t i o n a l l V l e d i c a l A s s o c i a t i o n 8 1 , s u p p l . ( A p r i l 1 9 8 9 ) : 9 . T h e e x c e s s d e a t h r a t e i s t h e number of deaths minorities '"vould not have suffered had they clied at the same rzrte as w h i t e s .

6 . R e n a l N e t r v o r k o f I l l i n o i s , " C h i c a g o D i a l y s i s P o p t r l a t i o n : R a c e w i t h i n A g e w i t h i n Z i p C o d e , Diagnosis Hypertension," special data r-un ob- tained through Freedom of Inlbrrnation Act r e q u e s t , J u l y 1 9 8 9 .

7 . C o m m i t t e e f o r t h e S t u d y o f t h e M e d i c a r e ESRD Program, Kidney Failttre and the Federal C o v e m n r e n t , p . 1 2 6 . D.R. Ler,y, "White Doctors and Black Patients: Influence of Race on the Doctor-Patient Rela- tionship," Pediatrics 7 5, no. 4 (April 1985) 639- 4 3 . R o b e r t J . B l e n d o n e t a l . , " A c c e s s t o M e d i c a l Care for Black and White Ameicans," Jottmal o f t h e A m e i c a n M e d i c a l A s s o c i a t i o n 2 6 1 , n o . 2 (13 January 1989): 27 8-81.

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