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Physician, Heal Thyself

I HAD KNOWN TIM FOR 10 years before he came down with AIDS. He was somewhat younger than me, and had worked for several months as an intern and a resident under me during my first years on the faculty. He helped me care for Régis and the others from the early days and was one of our best residents. He was always compassionate, caring, optimistic, and hard working. I was pleased when he was appointed to the faculty. We collaborated on several projects. He was dedicated to teaching and creative with education. Tim always looked vaguely counterculture: slightly long hair, but thinning on the top, full cheeks, a small “spare tire” that betrayed an interest in the culinary arts. He usually dressed in jeans, a plaid shirt, and a wide flowery tie. Small talk with Tim centered on the clerkship for third-year medical students he coordinated. He was a friend. Not a best friend, but more than an acquaintance. We collaborated professionally and shared academic interests.

One of my secretaries, Anita, told me she had heard a rumor that Tim had told the entire first-year class that he carried the AIDS virus. This happened during a class entitled “Health and Human Values.” I never had thought of Tim as “gay” or “at risk” or, for that



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Physician, Heal Thyself I HAD KNOWN TIM FOR 10 years before he came down with AIDS. He was somewhat younger than me, and had worked for several months as an intern and a resident under me during my first years on the faculty. He helped me care for Régis and the others from the early days and was one of our best residents. He was always compassionate, caring, optimistic, and hard working. I was pleased when he was appointed to the faculty. We collaborated on several projects. He was dedicated to teaching and creative with education. Tim always looked vaguely counterculture: slightly long hair, but thinning on the top, full cheeks, a small “spare tire” that betrayed an interest in the culinary arts. He usually dressed in jeans, a plaid shirt, and a wide flowery tie. Small talk with Tim centered on the clerkship for third-year medical students he coordinated. He was a friend. Not a best friend, but more than an acquaintance. We collaborated professionally and shared academic interests. One of my secretaries, Anita, told me she had heard a rumor that Tim had told the entire first-year class that he carried the AIDS virus. This happened during a class entitled “Health and Human Values.” I never had thought of Tim as “gay” or “at risk” or, for that

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti matter, “straight.” He was Tim, a friend, a colleague, a neuter. Anita was well connected to the rumor mill at the medical center. She considered keeping me informed of campus gossip, particularly that related to sex and romance, as an important part of her job. Her opinions on AIDS and homosexuality were complex. She had not entirely escaped a cultural aversion to homosexuality. She once came into my office after a meeting with an openly gay faculty member and, after a long stare, arms crossed and extended foot tapping, declared, “I don’t like him. I think he’s trying to get into your pants!” As a person who saw most things in sexual terms, to her gay men were subliminally competitors. Yet she had close friends who were gay. She always lent them a sympathetic ear. She felt deeply and personally the suffering of my AIDS patients. One was the brother of a boy she had dated in high school. She wept for him when he came to my office. Tim and I had been meeting about establishing a teaching program for medical students in Key West. Tim liked spontaneous, unannounced meetings to present me with his creative ideas. The Key West proposal was just such a burst of creativity: Get the students away from the big city, let them see the kinds of problems they’ll encounter in a small town, and use the community physicians rather than full-time faculty as their teachers. He presented his ideas with his usual ironic wit and relaxed demeanor. After Tim left, Anita came in, looking despondently at the pictures on my wall. “Is Tim gay?” “What makes you ask that?” I answered, looking puzzled. “I don’t know. We’ve never talked about it. But I have no reason to believe so, and even if I did, it wouldn’t be any of our business, would it?” “They say he announced to the whole first-year class in lecture the other day that he had tested positive for the AIDS virus.” She moved from looking at my pictures to studying my diplomas. “Well, that’s one of the craziest things I’ve ever heard. You know how the rumor mill works. He was probably just acting out a role in

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti the course where the students learn how to talk to patients. I wouldn’t place any credence in that rumor until you hear it from Tim himself.” Two weeks later Tim and I met again to follow up on the Key West project. At the end of the meeting he matter of factly stated, “You know that I’ve got AIDS.” “I heard a rumor that you announced that to the freshman class, but frankly I gave no credence to it.” “It’s true. I see no reason to hide it. Having a disease is nothing to be ashamed of. Don’t you think our students should know that? I just want you to know because I don’t know how long I’ll be able to continue to work.” “Have you been feeling sick?” “Yes. For some time now I haven’t felt right. At first I thought it was just tuberculosis, something I had picked up on the Jackson Hospital wards. But when the cultures came back atypical tuberculosis, I got tested. They have me on five medicines, which is a pain, but I feel better now. The thing I worry about the most is the dementia. I think I may be getting that. I forget things all the time. I forget where I’m going, or what I’m supposed to be doing, or when my rent is due. I have to write myself notes.” “Sometimes if you worry about something too much, it comes true just from the worrying,” I said, attempting reassurance. I silently shuddered when I heard “atypical tuberculosis.” Despite Tim’s claims to be feeling better on five medicines, I knew atypical tuberculosis was a late complication of AIDS and incurable. He looked too well to be that far advanced. I promised him that I’d help keep him working for as long as he could, by supporting his salary through one of my grants. Tim liked that idea because the grant work would conform to the vagaries of his illness. It required a lot of written material. He could pick up his pen when he felt well and put it down when he felt ill. He had stopped seeing patients when he found out he had AIDS, but there was more than enough teaching and writing to keep him busy. He hoped to devote half of his time to the Key

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti West project. The other half would be devoted to teaching about AIDS. Despite the advanced state of his illness when he was first diagnosed as having AIDS, it took two years for Tim to die. His tuberculosis caused fevers, weakness, and poor appetite. The relentless course of his infection was slowed by antibiotics but never reversed. Once, in despair, he stopped taking his medicines altogether but he felt so much worse, with higher fevers and less appetite, that he started back on them shortly thereafter. I found it difficult to avoid clinically assessing how far Tim had declined each time I saw him. The first outward sign of illness was how he trimmed his sideburns. He trimmed them unevenly, leaving a large patch of white skin on the left side of his face. This suggested either a problem in coordination or an inattentiveness to detail. Perhaps he just didn’t care about his appearance anymore. There were subtle changes in his hair. It became thinner and straighter. The fullness of his cheeks and waist slowly disappeared. His enthusiasm for work, however, masked many of these physical changes. He was always smiling. We rarely talked about his illness. The Key West project was going well, and we were collaborating on a new course to introduce first-year students to clinical medicine. Some cynics on the faculty were already dubbing this course “The Tim ______ Memorial Clerkship.” Tim conserved his intellectual faculties for teaching and writing. His only complaint was his repeated conviction that he was losing his mental powers. I began to realize that this was, in fact, slowly but surely happening. He would refer to me by other people’s names or stop a sentence in the middle of a thought. Strangely, he would usually become aware of these lapses shortly after he committed them and would then apologize with a matter-of-fact disclaimer: “See, I told you I’m losing my mind.” Major and minor lapses in judgment were also present. “I know he is not well, but he is driving us crazy,” sighed Anita. “He doesn’t follow university procedure. He doesn’t bring us back his receipts for his trips to Key West, and he wants to be paid cash in advance. He

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti claims not to believe in credit cards, and if we don’t pay him in advance, he’s too poor to go.” I later learned that the reason why he didn’t have credit cards was that he had overcharged and refused to pay his bills. “Let them go after my estate,” he was quoted as saying. Yet with me he always seemed in control of himself. He somehow managed to be, if not optimistic, somehow unaffected by the fact that he had AIDS. I had seen this attitude in others, most notably Previlus. In Previlus’s case, I attributed it to poor understanding of his disease. Yet here was Tim, for whom the burden of his disease was compounded by the burden of knowledge of his own fate, and he could still think about ideas and things that had nothing to do with dying of AIDS. I could not understand this. If I found out I had AIDS, I would quietly consider suicide. The knowledge of what was ahead would have been too frightening. Didn’t Tim have similar thoughts? Being a physician would have made it easy for him. Before his pronouncement, I had heard him once express vaguely Buddhist ideas. Perhaps that was his secret. The cause of all suffering is desire. Freedom from suffering is freedom from desire, even if that includes a desire to keep on living or to die. We traveled to Key West so he could introduce me to the doctors he had recruited there to teach our students and plan for the health fair that was scheduled in the next few weeks. We had lunch at a restaurant overlooking the Gulf of Mexico. Tim was openly nostalgic about the city, telling me about the best restaurants and the best places to stay. The thought crossed my mind that this might have been where Tim acquired his infection. Living with AIDS was worth it, he seemed to be saying, as long as it included one more visit to Key West. With places like this, life couldn’t be so bad, could it? The gulf glistened under the December sun, forcing me to squint as I looked into the shadow of Tim’s face. Although I could not make out the details, I could see he was smiling, perhaps dwelling on a fond memory. Between the sun, the water, the perfect temperature, and the clapboard storybook houses, it was hard to believe there was any evil or suffering in the world.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “What’s it like to be gay, Tim?” I blurted spontaneously. It seemed like a natural question at the time but was followed by an immediate sense that it was the dumbest question I had ever asked. Had I spoken too loudly? Had others in the restaurant heard me? Anyway, it was out now. Tim had always been so open with me. I did not mean the question pejoratively. I just wanted to understand. I might never have another chance to ask it. “Forgive me, Tim,” I said softly in order to explain, “but when I was growing up, no one admitted to being gay. When I was 13 and my father had to tell me about “the birds and the bees,” he told me only two things. When I was married, I would ‘plant my seed’ in my wife and we’d have a baby, and if any other guy ever touched me, to run away as fast as I could. Gays were called ‘queers’ when I was in high school and college. Even when I was in medical school, homosexuality was taught as a ‘perversion.’ It was only taken off the psychiatric diagnostic code a few years ago. I’m over 40, and this is the first time I’ve ever felt comfortable asking someone the question.” “Well, right now that name has a hollow ring to it. I’m not feeling particularly gay right now and haven’t for months. ‘Resigned’ is a more accurate adjective to describe me. There are a lot of us ‘resigned’ around now, so you better be careful. It might be catching.” “I’m sorry, Tim. I don’t want to spoil your day. Am I the first person to ask you that?” “Before I came out about having AIDS, I don’t think people thought of me in sexual terms. I’m kind of nondescript. Besides, I’m a doctor. No, it’s really never come up. So, what do you mean? What’s it like to be gay and have the whole world stereotype you, or what’s it like to have sex with a man?” “No, not the stereotype. I think I understand that, among other things, I’m left-handed, you know—we southpaws consider ourselves the world’s most misunderstood minority. Why do you think you are the way you are?” “Well, Art, why ask me? If you want to know what it’s like to desire a man, why don’t you ask your wife what that’s like? To be on

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti the receiving end of sex? Again, ask your wife or your girlfriend if you have one. If you think of it that way, those of us who prefer loving men are a majority, and it’s me who should be asking you, ‘what’s it like to be straight?’ Stop trying to understand it, Art. Anyway, you’ve got too much lingering Freudian baggage. Just accept the fact that gayness exists. Always has, always will. Not even AIDS will get rid of us.” We were silent for a while, sipping our beers, me thinking the question had gotten all the answer it deserved, when Tim started talking again. “Your left-handed analogy is a good one. To me, my ‘gayness’ is natural. Biologic. It’s just that the rest of the world is sexually right-handed, with a few ambidextrous people thrown in for good measure. The interesting thing, though, is when people don’t know you’re gay. They let slip out some of the most outrageous things.” “How do you suppose my Haitian patients got HIV? Do you believe that stuff about gays from New York on vacation buying the services of poor island boys?” “I don’t know. That may have happened, but I don’t think it explains all of it or even most of it. I read a poster presentation at a meeting once that claimed Haitian women allowed anal intercourse during menses as a form of birth control. I never saw that presentation published, thank goodness. It was bad science, with a hefty dose of what I call medical voyeurism. Anyway, I’ll bet a lot of straight couples practice anal intercourse, or at least experiment with it just for variety’s sake, but aren’t honest enough to admit it. That’s the problem with any research that has to do with sex. The honesty factor. But I don’t think anal intercourse causes AIDS, per se, so I don’t think that’s how the Haitians got it. And then there’s the whole issue of sex during menses. I mean, think about that for a minute as an exposure risk. I think we’ve just got to realize there’s a lot we don’t understand. If you threw me on the floor, sat on my chest, and didn’t let me up until I told you something, I’d probably say they got it from sex, pure and simple. But maybe it’s from medical injections

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti with unsterile needles. Who knows? I’ll tell you one thing. That stuff in the Herald about blood and Voodoo—that was truly outrageous! Now Régis—he was the exception. He got it from pulling teeth without gloves. Anyway, if you want to find out the answer, my advice is wake up and think out of the box. Don’t think like everyone else is thinking. Think left-handed. Think gay. Think Haitian. Otherwise, the virus will always be two steps ahead of you.” Although he was still in the shadows, I could tell that the smile was gone from Tim’s face. I suggested we walk to Mallory Square to take in the sunset and the street performers. I noticed an occasional stare from the straight tourists as we left the restaurant and headed down Duval Street. Meanwhile, Tim kept spending or committing grant funds without accounting for them. My office had to track these expenses surreptitiously. During a one-day visit to Key West he ran up a $100 tab in cab fares. “Why didn’t you rent a car?” I asked in frustration. “I had to give up my license,” he mumbled. “I can’t afford the insurance.” He recommended an administrator for the Key West project who did not do a good job. The administrator “retired” to Spain with no notice. The project checkbook was missing for two weeks before it was finally found in a drawer by a secretary. Those two weeks were my worst two weeks on the faculty. Fortunately, there were no funds missing. These problems with judgment tested my commitment to keep Tim working for as long as possible. “Have you thought about retiring on disability and going home to be with your family?” I asked. Tim’s parents had died in an automobile accident when he was young. He was “somewhat estranged” from the other members of his family, except for one sister in Stuart, and he didn’t want to be a burden to her. She had young children. Most of his close friends were either already dead or more debilitated than he was. I could see that without his work Tim had little to live for.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Work sustained him. He was hospitalized occasionally to diagnose and treat new infections. Sometimes he would call me from the hospital if he was concerned he would miss a deadline. At other times he would just disappear for two or three weeks and then return, as if those two or three weeks had never existed. These absences were always terminated with spontaneous, unscheduled visits to my office, during which Tim would try to “sell” me on a new educational idea. The times in the hospital took chunks out of his body and soul. Between hospitalizations, his decline was subtle and slow. With each stay in the hospital, however, he looked more and more like a victim of a concentration camp. He gave up his apartment and moved to Genesis House, a home for homeless AIDS patients. Why did he do this? I asked myself. It was probably more from loneliness and a desire for company than an inability to care for himself. He was still writing, teaching, and going to work each day. Or was this the judgment problem, again? Genesis House didn’t work out. The home was not close to public transportation, and the companionship he had hoped to discover among fellow AIDS patients just did not materialize. He found it depressing—all these people with nothing to do, waiting to die. He then became truly homeless. He spent some time with his sister in Stuart. If he needed to lecture, he would rent a hotel room within walking distance of the location of his lecture and stay there the night before and the night after, to conserve his strength. He finally found another apartment and moved in alone. There was a small group of students who were devoted to Tim. They admired his honesty and openness about his illness. They worked with him in preparation for the health fair in Key West. Tim had directed the fair for eight years. It was his favorite project. For the year prior to each fair, the students learned how to do screening procedures such as Pap smears and breast examinations. On the day of the fair, people in the lower Keys came for health checkups performed by over 100 medical students. No one on the faculty but

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Tim knew the organization and planning necessary to pull off a successful health fair. As the 1990 fair approached, Tim’s decline began to accelerate. His gait became slow and feeble. He added new notches to his belt, which bunched up the top of his pants like a drawstring, similar to what Herminio had done. The students assumed more and more responsibilities. Meetings with Tim were painful. I asked myself, How much longer can this go on? Death would have been a blessing six months ago. The administrative part of me wished very much for Tim to retire on disability. Tracking his grant-related expenses had become an office project. The office staff began planning errands around his scheduled visits, not because they were afraid to see him but because they didn’t want to cry in his presence. The health fair went off flawlessly. The students did a great job. Tim summoned what would have been an enormous amount of energy even for a healthy person; finding extra examining gowns, setting up examining rooms, directing students to the screening stations where they were needed the most. Five hundred people came. Three other faculty members, besides me, came down to supervise the students. In general, most faculty members avoided Tim and his projects after he made his announcement. Tim went into seclusion after the fair. We talked on the phone one time before he died. He told me matter of factly that he thought it was time to go on disability. He didn’t think he could work anymore. I told him I understood, thanked him for all he had done, and offered to help in any way that I could. “Art, one more thing.” Tim’s voice was faltering. “Sure Tim, anything.” “Promise me you’ll keep the health fairs going.” “I promise, Tim. Don’t worry.” I heard from Anita two weeks later that Tim had been admitted to a community hospital. Although he had been public about his illness, he was very private about his death. He didn’t want to die at

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti the medical center. He didn’t want his students to see him dying. His death was mercifully painless. After a few days, he lapsed into a coma and did not wake up. Tim chose to be cremated and requested that his ashes be spread over the waters near Key West. There was no funeral, but there was a memorial service in the medical school library. Present were his four sisters, their families, several medical students, and a handful of faculty. I was proud to see my office staff standing in the back. Tim’s chairman had brief and kind words to say. All of Tim’s sisters had tears streaming down their faces. I spoke with one of them afterward. I introduced myself as someone who had worked a lot with Tim. She told me that until that day she had no idea of what Tim actually did or what his work involved. “He never talked about work,” she said, “and we just thought he was a regular doctor.” “This is so strange,” I thought. I both wanted and didn’t want to be there. Death was overdue for Tim. I was relieved for him when he finally died. But the low turnout punctuated how ephemeral his memory would be. He had worked until two weeks before he died. He had made a significant contribution to teaching. I had rarely witnessed such a courageous facing of death. He never complained. Yet now that he was dead, what did it mean? It was as if he expected his peers and his students to learn from his example, but he would not intrude on our consciousness. We had to choose whether we would learn from his experience or continue in our ignorance. He tested us, and most of us failed. Walking back to the office, I heard Anita mumble, “What a waste.” In the past she had used that expression as a put-down, upon learning that someone was gay. “How dare they deprive some needy woman of a husband or lover? How dare their attractiveness be wasted on other men?” I knew, this time, it was AIDS she was indicting, so I let the comment pass, unanswered.