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All Good Things

AND THEN THERE WAS SAM. As Sam loosened his overcoat, his hidden machete, held to one side by the cinch of his coat, slid down his pant leg. The tip buried itself into the rubber tile floor of the examining room with a musical ching. The fact that Sam was wearing an overcoat in the heat of Miami’s summer was the first clue that he had once again lost touch with reality. His chief complaint—“I want to kill somebody”—was the second. A gentle man when clean of cocaine, a homicidal paranoid schizophrenic when smoking crack, he had relapsed once again. Weapons, of course, were not allowed in the clinic. Carrying a concealed weapon into the clinic would result in Sam’s being banned from services for two years. My immediate concern was to make sure no one got hurt.

Fortunately, there was little real privacy in the examining cubicles, separated from the corridor only by a curtain that was impossible to completely close. I positioned myself on a stool where Ruth could see me. The machete ching caught her attention, and I was sure she could see it balanced against Sam’s shin under the curtain. I hand-signaled “911” to her while I engaged Sam in mindless banter. That was her clue to call the police; clear the students, staff, and



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti All Good Things AND THEN THERE WAS SAM. As Sam loosened his overcoat, his hidden machete, held to one side by the cinch of his coat, slid down his pant leg. The tip buried itself into the rubber tile floor of the examining room with a musical ching. The fact that Sam was wearing an overcoat in the heat of Miami’s summer was the first clue that he had once again lost touch with reality. His chief complaint—“I want to kill somebody”—was the second. A gentle man when clean of cocaine, a homicidal paranoid schizophrenic when smoking crack, he had relapsed once again. Weapons, of course, were not allowed in the clinic. Carrying a concealed weapon into the clinic would result in Sam’s being banned from services for two years. My immediate concern was to make sure no one got hurt. Fortunately, there was little real privacy in the examining cubicles, separated from the corridor only by a curtain that was impossible to completely close. I positioned myself on a stool where Ruth could see me. The machete ching caught her attention, and I was sure she could see it balanced against Sam’s shin under the curtain. I hand-signaled “911” to her while I engaged Sam in mindless banter. That was her clue to call the police; clear the students, staff, and

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti other patients out of the clinic; and station security on standby in case Sam suddenly turned violent. My job was to keep him calm until the police arrived. “What’s up, Sam? Long time no see.” I ignored the machete. “The FBI put a radio in my head. I can’t turn it off.” Sam was distracted by a bug crawling under the sink counter. “Well, I can see that would be a turnoff,” I deadpanned. “Huh?” said Sam, half listening to me and half listening to the voices in his head. The police arrived in a matter of minutes. They hid around the corner of the examining room until they heard Sam launch a particularly long and disjointed sentence. Before he could get to the direct object, they were on him, one officer hammer-locking his head and arms, another grabbing the machete. “Nice work, Doc,” claimed the arresting officer. “Not bad for an academic,” I replied. “Where’s my Baker Act?” In Florida the Baker Act allows a physician to treat a mentally ill person considered to be a danger to themselves or others involuntarily. “Gee, I’ve been kind of busy. I’ll have it for you in two minutes.” Ruth flashed me her “if anything had happened to you I would have killed you” scowl. Not waiting for the verbal zinger sure to follow, I retorted: “Hey, poor Sam’s slowed by drugs, mental illness, and AIDS. If I couldn’t outsmart him, I would have outrun him!” “It’s a good thing he didn’t come in while ABC News was here! Sam’s too scary. Our 15 minutes of fame would have been reduced to 10 seconds or less!” ABC had been by a few weeks before at the insistence of Joe, my former resident who founded the clinic. They put together a nice piece on the problems of the homeless, with some great sound bytes from the dean on how we were developing a “culture of compassion,” a small clip from my interview, and a lot of footage of Joe in his white coat and our medical students working out under the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti bridges. Conspicuously absent was Phil, who, in reality, was doing most of the work. He managed to find himself needed as far as possible from the camera on the day of the interviews. “What did you think of the news clip?” I asked him offhandedly the morning after it aired on the evening news. “It will be the death of our work here,” was Phil’s surprising answer. “What do you mean?” I responded, stunned by his candor. “That video went right to Joe’s head. Just watch. We’re no longer going to be about health care for the homeless. We’re going to be about Saint Joe.” In fact, Joe’s presence at the clinic was a rare event in the weeks prior to the news story. He was completing his fellowship in hepatology and planning on entering private practice. After the story we saw more of him for a while but always with an entourage of reporters or wealthy patrons. As a result of the news Joe generated about the clinic and our medical students’ heroic work after Hurricane Andrew, the University of Miami School of Medicine received the first-ever Community Service Award from the American Association of Medical Colleges. By the time the award was received, however, we were already sliding toward the dissolution of all we had accomplished. A new clinic administrator told us of changes mandated by the federal government. We’d have to reduce losses by enrolling patients in Medicaid and billing our patients for their copayments. Phil was beside himself with anger. Always outspoken, he told everyone who’d listen of the ridiculousness of billing homeless people. It was soon clear that Joe and the new administrator did not want to hear this, and Phil was targeted to be pushed out. In a preemptive strike, I reassigned Phil to a new free clinic we were starting in Overtown, a historically black community a few blocks away. Without Phil, my work at Camillus became impossible. I left a few months later. A week before I left, Jackie came to see me. “I heard you’re leav-

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti ing, Dr. Fournier. Who’s going to take care of me?” she asked as she gestured dramatically, with her hand pressing against her breast bone. “There’ll still be other doctors here,” I responded. “But they don’t know me like you know me. Inside out, if you know what I mean. What will happen if I don’t get my estrogen? I’ll just shrivel up and lose all my curves! Listen, I’ve got an apartment now and insurance—both Medicaid and Ryan White. Can I be your private patient?” I still had one half day each week during which I saw private patients. I liked Jackie’s idea. She would be the one patient I would take with me from the homeless clinic. Managing her problems really was too complicated to turn over to someone else. Besides, we had made a contract and she had kept her end of the bargain. She had kicked her drug habit, was no longer prostituting herself, and was no longer living on the streets. “You know Jackie that just might work. Here, take this number and call for an appointment. I’ll need to see you again to repeat your blood tests in four weeks.” Jackie kept her appointment. In fact, I followed her in my private practice for 12 years. She came faithfully every month, so that I could follow her HIV infection and renew her estrogen prescription. She was one of the first patients to become a long-term survivor of HIV infection—all told 15 years without requiring medicines. The office visits became like social calls. She would flirt in an innocent way and socialize with my office staff. When she died in 2004 (of a health issue that was not AIDS), I was both saddened and relieved. I had been faithful to the end to this most challenging patient. I viewed leaving Camillus Health Concern with ambivalence. On the one hand, the clinic really had raised the consciousness of Miami concerning its homelessness problems. In a moment of enlightenment, the citizens of Miami-Dade County voted to tax themselves to establish a comprehensive approach to homelessness. As a result, the number of homeless people in Miami has been drastically

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti reduced. And we succeeded in giving our students a window on the human condition that few doctors in training ever experience. On the other hand, with so many social problems—drugs, poverty, mental health issues—it was hard to convince myself that the health care services we were delivering amounted to much more than a Band-Aid. I asked myself over and over: Are we making a difference? Could we ever make a difference?