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Ninja

1992–1994 OFTEN, THE FIRST THING I saw when I arrived to work at the homeless clinic each morning was Jennifer bathing herself. These daily ablutions took place in a curbside puddle next to the clinic. First she would glance in each direction to make sure that there were no police coming. She didn’t care who else watched her ritual; the other homeless people waiting for the kitchen to open for breakfast, the clinic staff arriving for work, or the motorists passing by on Northeast First Avenue. She would peel her tattered dress off over her head. She wore no underwear. Under other circumstances this activity might be seen as enticing or erotic to passers-by. But drugs, schizophrenia, and AIDS had turned Jennifer’s 34-year-old body into a parody of sexuality. Her breasts were drooping and narrow. Her buttocks were sunken inward. Her calves were wider than her thighs. The only part of her that was not withered was her pubis, which bulged forward from her lower abdomen like the puff of a dandelion attached to its stem, held upside down. She crouched with both feet in the water and splashed between her legs and under her arms. Next she rubbed muddy water across her chest, scooped some in her hands, and poured it down her back and over her shoulders. Finally, without drying herself, she would put her dress back on and



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Ninja 1992–1994 OFTEN, THE FIRST THING I saw when I arrived to work at the homeless clinic each morning was Jennifer bathing herself. These daily ablutions took place in a curbside puddle next to the clinic. First she would glance in each direction to make sure that there were no police coming. She didn’t care who else watched her ritual; the other homeless people waiting for the kitchen to open for breakfast, the clinic staff arriving for work, or the motorists passing by on Northeast First Avenue. She would peel her tattered dress off over her head. She wore no underwear. Under other circumstances this activity might be seen as enticing or erotic to passers-by. But drugs, schizophrenia, and AIDS had turned Jennifer’s 34-year-old body into a parody of sexuality. Her breasts were drooping and narrow. Her buttocks were sunken inward. Her calves were wider than her thighs. The only part of her that was not withered was her pubis, which bulged forward from her lower abdomen like the puff of a dandelion attached to its stem, held upside down. She crouched with both feet in the water and splashed between her legs and under her arms. Next she rubbed muddy water across her chest, scooped some in her hands, and poured it down her back and over her shoulders. Finally, without drying herself, she would put her dress back on and

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti return across the street to the parking meter she lived by. Some days she would repeat her baptism five or six times. Most homeless people manage to find shelter at night under bridges and in abandoned buildings. Jennifer slept out in the open, under a blanket, on the street corner opposite the clinic. Every night the police chased away the homeless hoping to sleep under the overhang in front of the shelter. Only Jennifer remained nearby. I believe the police were afraid of her. She was so emaciated that, if she pulled her blanket over her head, there was no visible evidence of a human being under the blanket. She looked like an abandoned crumpled blanket on the street corner next to a parking meter. I worried that a truck or bus would misjudge its turn, not care about running over an old blanket, and traumatically end Jennifer’s life. From this debris a human being arose each morning and repeated her ritual. If it rained, Jennifer would take her blanket and move under the overhang of the clinic until the rain passed. She was the only one the police never hassled when it rained. The clinic and the adjacent shelter were Jennifer’s protection. A security guard watched over her during the day and most of the night. The Brothers of the Good Shepherd, who ran the shelter, gave her breakfast and dinner. Although the shelter was officially for men only, on the few cold nights each year they would take her into the vacant clinic and allow her to sleep in the waiting room or on an examining table. I wish I had known about the shelter when Régis was alive. Brother Jack and Brother Harry would have protected him, too. They took in anyone, with no judgment passed. Jennifer had been living on the streets as long as anyone working in the clinic could remember. She had good days and bad days. On her good days, she would wish me a good morning as I walked from the parking lot to the clinic and ask me for quarters. On her bad days, she would wander up and down First Avenue, oblivious to the traffic, answering in obscenities voices only she could hear. She took no medicines for her schizophrenia or for her AIDS. Although the social workers tried to place her in various shelters, she

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti refused to go voluntarily. There had been a time when she was addicted to crack and supported her habit by selling sex for drugs. Now she couldn’t afford her former addiction. She was too ill and too unattractive, and word was out among the street people that “Jennifer’s got the ‘Ninja’.” Ninja is the Miami street name for AIDS. Occasionally there would be a man leaning against her parking meter, usually facing the opposite direction but talking to her. Most of these men had backpacks or bedrolls, suggesting they were new in town. Most of the time, however, she was alone. She knew she had AIDS but did not understand. Several times since I had started working at the clinic, Jennifer was absent from her corner for prolonged periods. Each time she returned, I asked her where she’d been. “I was in the hospital. I got pneumonia,” she would respond nonchalantly. She came to the clinic only when she was in pain. She had sores on her feet that occasionally became infected and needed to be cleaned. Jennifer was one of 8,000 people living on the streets of Miami at that time. Many had serious substance abuse and mental health issues. These patients were in a medical no-man’s-land: deinstitutionalized but not capable of managing their own affairs, lost in their own inner world, and easy prey to pushers and pimps. Treating their medical problems was next to impossible. Others were immigrant women and their children who, upon losing their marginal jobs, were only one paycheck away from living on the streets. The Camillus Health Concern was located in an older building of vaguely mission architecture. The skyscrapers of downtown Miami were easily visible from the front door. If the building were one story higher, you could see Biscayne Bay and the cruise ships lined up at the port of Miami four blocks to the east. The immediate neighborhood was surrounded by vacant warehouses, abandoned buildings, parking lots, and pawn shops. Litter was everywhere. Rats scurried around the parking lot, ignoring their human neighbors. Two blocks to the west was the Miami Arena, home at the time of our professional basketball and hockey teams. The arena was built

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti there in an attempt to revitalize the area. Many of my patients worked intermittently at the arena, parking cars, setting up staging, and assisting with the concessions. Those who couldn’t find these kinds of jobs tried washing the windows of cars passing by or just plain panhandling. The city fathers very much wanted to move the shelter and the clinic away from the arena. No other neighborhood in the city wanted it though. Every day the food line stretched for two blocks from the kitchen. Every day, when I arrived at work, there were already 15 to 20 patients lingering outside the door, even though the clinic would not officially open for another hour. The windows of the clinic were papered with messages to patients: John Smith, see Joan about your lab tests. Jorge Gonzalez, speak with Wilfredo about your disability claim. Inside, the clinic had a well-used, chaotic look. Boxes of donated medical equipment, supplies, and clothing were piled in corners and corridors. The furnishings of the examining rooms and waiting area had been donated and ranged from the merely old to the archaic. An antique x-ray machine gathered dust in one room of the clinic. We couldn’t figure out how to use it. The setting would have been depressing if it were not for the staff of nurses, social workers, and support people who assisted Phil, Jill, Bill, and me in caring for the patients. I’m not making up the rhyming names. In fact, we used to joke about the “Phil, Jill, and Bill” show. Phil looked a lot like Willie Nelson, right down to the ponytail. Professionally, he was an interesting story. A “young Turk” pediatric infectious disease specialist, he had had a falling out with his chair, resigned from the faculty, and entered private practice. He made a lot of money, sold the practice, sailed for two years around the Caribbean, and started to volunteer at the clinic during a refitting layover in port. His volunteering soon became a full-time job—the only job he ever loved, he later claimed. His trademark was a hug. He hugged patients, staff, and medical

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti students—“an equal opportunity hugger,” he used to say. The students were soon voting him “best teacher” annually. His gentleness with patients was balanced by his intellect and, when necessary, his acerbic wit. Jill and Bill were both recent physician assistant graduates. They added the idealism of youth to the experience of Phil and myself. Looking back, these were the halcyon days of my career. My students used to ask me, “Dr. Fournier, why are you smiling all the time?” My quick answer, “Are you kidding? They actually pay me for the joy of caring for these poor people and teaching you!” In our day-to-day work, the faculty and staff all aimed to inspire the medical students by communicating without words that it’s okay, even rewarding, to care for those that nobody else cares about. Many of the staff were former street people themselves, like Roscoe, a huge teddy bear of a man who had kicked his drug habit and become a counselor. The clinic was founded by Joe, one of our residents, who started volunteering at the shelter when he wasn’t on call and who was starting to make a name for himself for having the courage to go out under the bridges and expressways, encounter the homeless face to face, and invite them into the shelter and makeshift clinic. Alina volunteered to write a federal grant, which allowed the clinic to expand and which paid for doctors and staff. She also asked me if I would volunteer on Tuesday and Thursday nights. At first I was reluctant—homelessness wasn’t one of my issues—but how could I say “no” to Alina? Once I started, I actually enjoyed it. There was a core group of medical students who came every night—clearly our most dedicated—and lots of patients with interesting problems. After Joe had some difficulties finding a full-time physician, I suggested I’d be willing to work there if he’d also hire Phil. Phil and I could work as a team and bring in medical students to work with us during their primary care clerkships and as evening volunteers. I had received a large grant to move primary care education into the community, and Camillus Health Concern seemed a good place to start. Moving my

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti office into the clinic was a radical move for a tenured professor. I told Margaret I’d have to give up my sessions in special immunology. She and I had been the only ones of the original group left. In truth, I was no longer needed. Her research grants allowed her to fund several new faculty positions, all specializing in AIDS. We had 10,000 charts in the clinic. Each chart represented a patient who had been seen at least once, a life that had fallen through the cracks of society. Some, like Jennifer, were mentally ill or severely addicted to alcohol or crack cocaine. Others were merely poor or were the victims of bad luck. The patients coming to the clinic reflected Miami’s diversity—black, white, multiethnic, Latino—with one notable exception: There were very few Haitians. In fact, in the six years I worked at the clinic, I had only two Haitian homeless patients. One was a lawyer with bipolar disorder who was too proud to tell his family that he had lost his job. Instead, he just disappeared into the streets. The other had AIDS but didn’t want his family to know. I asked the social workers at the clinic how they might explain this. After all, Little Haiti was by far Miami’s poorest community. Their consensus: First, there was a very low incidence of alcoholism and drug use among Haitians. It wasn’t just that they couldn’t afford the alcohol or drugs; their culture didn’t condone them. Second, family was the ultimate Haitian safety net. If you fell on hard times, someone in your extended family would always take you in. Finally, as a last resort, returning to Haiti was preferable to life on the streets. The clinic offered comprehensive services to homeless people, including HIV counseling and testing. Every month Ruth, the head nurse, would give me a copy of the monthly report on counseling and testing activities. For several months they passed in front of my eyes but did not register in my conscience. Then I started to notice. “Uh, Ruth, are these numbers right?” I asked her as she passed by my open office door. “Which numbers, Art?”

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “The counseling and testing numbers for January, February, and March.” “What’s the matter with them?” Ruth was a meticulous person who carried the day-to-day activities of the clinic on her shoulders. She took pride in the counseling and testing program. No other clinic for the homeless had one, and she had developed it from scratch. She stopped making copies at the Xerox machine and came into my office. If there was a problem, we needed to fix it immediately. “The numbers testing positive seem awfully high. Seven out of 40 for January, 10 out of 53 in February, 12 out of 42 in March. That’s going to average somewhere between 15 and 20 percent.” “That’s what we’ve been averaging since we started testing. Is this the first time you’ve read my report?” “I must have made a mental error with my decimal points. But could this really be true? Nobody has numbers this high. Fifteen to 20 per thousand is high, but 15 to 20 per 100? Could there be a bias? Do only those who feel sick ask to be tested?” “I don’t think so, since the Centers for Disease Control gets pretty much the same numbers from their seroprevalence study. The interesting thing is that it’s pretty much all heterosexual transmission. I’ll show you.” She got up, went to her office, and returned with more data. “You see, we have very few gays, and surprisingly few IV drug users. The prevalence in men and women is essentially the same.” “What’s this ‘sexual assault’ category?” “Oh, those are guys who had nonconsensual sex in prison. But even if you factor that in, it’s still mostly heterosexual sex.” “How do you explain it?” “Crack cocaine, sex with prostitutes, lots of unprotected sex. The price of a ‘basic service’ by a street prostitute is the same as a ‘nickel bag’ of cocaine—$5. That’s not an accident. For the drug dealers, crack is literally money that grows on trees. They give a huge discount for volume. Sex and crack, the opiates of the homeless. I saw oral sex performed for bus fare—75¢—right on the sidewalk in front

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti of the clinic the other night. I surprised them as I was leaving. Sex is one of the few things with a value that they can’t take away from you when you’re homeless. Lots of our guys work—in the labor pool, crushing cans, windshield washing. It’s not enough to rent an apartment, but it can buy you a few minutes of release. Fifty pounds of aluminum cans will get you five bucks and that will get you laid. Unfortunately, the cheaper the prostitute, the more likely she has the Ninja.” I thought about what Ruth was saying and intuitively knew she was right. I knew many of the prostitutes she was talking about, since they frequently used the services of the clinic. They were not Hollywood-image prostitutes. No Julia Roberts look-alikes. They had been burned out, frequently abused, and physically changed by the pathological effects of their addictions. A few were men in drag. Some gave up prostitution when they found out they were infected with the AIDS virus. Others continued selling themselves to support their habit or merely to keep from starving. Other women were not strictly speaking prostitutes but bartered sex for crack cocaine or simply got screwed while high. Crack became so popular in Miami because it was cheap and gave a powerful high, and the word on the street was that IV drug use could give you the Ninja. Crack is smoked, not shot up. Once addicted to crack, few cared about the future anymore, so every day and night the games of Russian roulette were repeated in alleys, vacant buildings, and on old mattresses all around the clinic. We had over 100 patients known to have AIDS that we followed on a regular basis. Fortunately, there were enough minor victories among these patients to keep us going. Juan got a job as a house painter. He was one of a special group of patients. He discovered he had AIDS while recovering from drug addiction. There were 20 such patients living at the shelter at any given time, as part of a substance abuse recovery program. They got a single room, worked in the kitchen or on “crew,” supported each other, and eventually got set up with a job and an apartment of their own. I was proud of Juan because he didn’t cave in and start using

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti again when he found out he had AIDS. Four other members of his group were in a similar situation. He wanted to use the time he had left to make peace with himself and feel good about himself. He didn’t look ill. Many recovering addicts turn to weight lifting and other sports to build their self-esteem and help them cope with withdrawal. Juan was barely five feet two inches tall, but had a physique resembling Arnold Schwarzenegger’s. His platelet count was low, and he had to take medicine to keep from bleeding or bruising spontaneously. It took five pages of forms and four visits to various social agencies to get him to qualify for zidovudine, under the newly funded Ryan White program. Politically astute legislators had named their ambitious program to provide treatment for everyone with AIDS after a well-publicized boy with AIDS and hemophilia—an “innocent” victim. Hemophiliacs need lots of concentrated blood products to stop them from bleeding, and before a blood test for HIV was developed, many received blood products that had been contaminated by the virus. I would later discover there was a bizarre Haiti connection to poor Ryan White. The Miami company that manufactured the concentrated product (called cryoprecipitate) needed lots of whole blood. Where better to harvest it but in Haiti, where there were plenty of people desperate enough to give until they passed out, at $10 per unit? Some of that blood was contaminated with HIV virus. The contamination of cryoprecipitate with HIV wiped out a generation of hemophiliacs. A year of zidovudine cost about $3,000. Usually by April the program that funded zidovudine for poor people in Miami ran out of money, and we couldn’t enroll new patients until July. Juan found a job. He moved into his own apartment. He “adopted” one of our older patients with cancer, took him to the hospital for his radiation treatments, and translated for him there. Far and away, our biggest success was Jackie. If ever there was a person who played to all the stereotypes of the AIDS epidemic, it was Jackie—a six-foot-two, 200-pound black gay transsexual. “Her breasts are bigger than mine,” said Ruth, somewhat jealously.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “It’s the estrogen she takes” was my comeback. “If you had that much estrogen flowing through your veins, your breasts would be huge, too.” Jackie was well known to the clinic even before I started working there. She was one of the first patients Ruth had persuaded to be tested for HIV. Not only did she test positive, but her blood counts said she was not far away from full-blown AIDS. She had been living on the streets for years, prostituting herself to support her drug habit—not just the usual crack habit but extraordinary amounts of estrogen, the feminizing hormone. The ultimate outcast and proud of it, she would come to the clinic wearing a blonde wig, a tank top, no bra, the shortest of skirts, and high heels. She was all about attitude. Once I slipped and referred to her as a “he.” Her stare was withering. But she needed us. Without estrogen she could not be the woman she wanted to be. I was her only legal source for estrogen. Ironically, in Miami it was getting harder to get estrogen on the street than it was to get crack or heroin. “Jackie’s here to see you, and only you, Art,” announced Ruth. “I think she’s in love with you.” “Now Ruth—you’ve just got issues with her cup size.” “Well, it just doesn’t seem fair.” In addition to HIV, Jackie had high blood pressure. She adamantly did not want to take AIDS medicines and insisted on taking one and only one medicine for her blood pressure. She knew she was different—I’m sure her attitude was a defense mechanism—but we had leverage: She really wanted estrogen. “Look, I’m not going to prescribe estrogen to someone who’s living on the streets, prostituting herself, maybe infecting others with HIV just because you’ve got body image issues,” I stated, matter of factly, in the semiprivacy of an examining cubicle. “On the other hand, I’ll meet you halfway. Kick your habit, come in for regular visits, and give up your life on the streets, and we’ll work with you.” Jackie was used to bargaining with clients but never about her health. “You would do that for me? I could come here rather than

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti going to the Jackson Clinic? I hate it there. People are always staring.” As she said this, she herself was staring down at her own cleavage. “Sure! Let’s get the ball rolling. Start by talking to one of the social workers. We’ll get you in a drug program and follow your HIV infections here. You’re in luck. Someone actually donated some Premarin to our pharmacy. Who knew? I never thought we’d use it, but why not use it for you?” I had taken a basic negotiating skill we teach our students—establishing a therapeutic contract—and applied it to a homeless, black, HIV-positive, prostituting transsexual. It worked. She came every month. I knew that in the beginning she came for the estrogen alone, but slowly, surely, she started to take her health seriously. Curiously, her blood counts did not deteriorate appreciably from month to month. It was almost as if she had partial immunity to the effects of the virus. “You’d better watch your blood pressure,” I told her during one visit in which she confessed she had been lax about taking her medicine. “Mark my words. Something other than the AIDS virus is going to do you in if you don’t take care of yourself.” For every temporary gain or spiritual healing, however, there seemed to be 10 medical and spiritual failures. For example, I had to find a way to tell Charisse she would die soon. She and her two children had been living on the streets. Her family threw them out when they found out she had AIDS. She felt well, but her T cell count was down to 30. At that level, death is usually just a short time away. “Have you made plans for your children?” I asked when the medical student assigned to her faltered. One of them was with her, a waif under 2, playing obliviously with her shoes. He most likely had AIDS also. “You’re at a stage of your illness where you will become ill soon. It’s time to think about these things.” Charisse burst into tears. The student looked as if she might cry also. “No, I haven’t made any plans. I’m just going to Hell. I guess HRS [Health and Rehabilitative Services, Florida’s welfare program] will take my children.”