Plague Years

by Ross A. Slotten, MD

  “Here,” he says, thrusting the phone at me. I talk to his wife. Her sobs during the last few months have devolved into whimpers, and she speaks in a cracking voice like someone who has cried herself into exhaustion. Despair has sharpened her sense of the world.

  “He don’t talk to me,” she says, her English as awkward English as her husband’s. “Guilt?”

  As I tell her that he’s withdrawing from the world, Manny listens, watching from the corner of his eye.

  “He’s there listening, isn’t he?” she asks. “We talk later about this, OK?”

  Manny stares at his feet. His hair is disheveled, and he reminds me of the heavy-lidded Woman before the Aquarium by Henri Matisse, a painting at the Art Institute of Chicago. Her chin resting on a forearm, the melancholic woman appears to be gazing at a goldfish bowl but clearly looks through it or, self-absorbed, doesn’t see the bowl at all.

  “Doc, I get nightmares,” he says. “I think medicine too strong. We turn it down, OK?”

  “Yes,” I say. “I’ll tell the nurse.” I get up to leave.

  “Thanks for comin’,” he says.

  During our early encounters I despised him for his carelessness with his wife. Now I feel more sympathetic toward him. Despite his irresponsible behavior, I admire his courage and wonder if I will be as graceful when my death looms. No doubt he infected his wife long before I warned him to protect her—or so I rationalize to let myself off the hook. He didn’t purposefully infect her. I’m not even sure he considered himself to be a person at risk, so powerful was the denial. In the 1980s antigay prejudice in the Greek immigrant community and in the United States compelled him to live a double life. In that regard he wasn’t much different from many gay men of my generation. There are a good number of Mannys in the world with equally unlucky wives, as proven by the epidemic in sub-Saharan Africa, where AIDS is a heterosexual disease. His life is tragic, not criminal, at least in my opinion. At worst, he is guilty of involuntary manslaughter. And even if he’s guilty of more, he’d already been given the worst possible sentence, without the benefit of a judge and jury. I reach out to hug him: who am I to judge? I ask. As healers, doctors must suspend judgment and not make choices in determining who shall or shall not be treated. Grateful for my sympathy, Manny embraces me, as if rebuffed and then reaccepted.

  “Doc, you’re a real friend,” he says, half-smiling.

  On a scale of human suffering, 1992 hardly differed from the previous eleven years of the AIDS crisis. My small triumphs—shifting the curve of death from months to a couple of years because we could now cure several opportunistic infections and prevent their recurrence—ultimately gave way to defeat as my patients died of some other untreatable opportunistic infection or cancer. Yet that shift in the curve signaled progress of a sort. Cancer specialists at the time couldn’t boast a similar record of success, if by success we meant putting off death for years instead of months. AIDS patients were living longer, even if we couldn’t treat the underlying HIV. I clung to the slimmest of slimmest hope that my patients with AIDS could survive just long enough for medications to cure them or put them into remission.

  Nevertheless, it amazed me how swiftly someone could proceed from initial infection to death from AIDS. In the late 1980s one of my patients, a chronically depressed man in his mid-fifties, convinced his reluctant HIV-positive boyfriend to fuck him without a condom. Like a wife who chooses to die on the funeral pyre of her dead husband, he expressed a wish to go down in flames with his lover. I pleaded with him not to be so reckless and pointed out that he had two grown children and a small number of friends who loved him and didn’t want him to die. It didn’t matter. He was determined to get AIDS. Refusing antidepressants and a referral for psychotherapy, he eventually got what he wanted and died miserably two years later.

  Miraculous treatments didn’t appear imminent. In July 1991 I went to Florence to attend the Seventh International AIDS Conference, which had nothing to offer but gloom-and-doom predictions of how many more people worldwide would be infected with HIV by 1995. Like an unstoppable wildfire, AIDS swept the globe. HIV was no longer a gay man’s disease, except in the United States and Western Europe. Two-thirds of cases in the developing world were in heterosexuals. Every sexually active person not in a monogamous relationship was theoretically at risk of exposure to HIV, a fact that panicked a small cadre of heterosexual patients that showed up in my office obsessed with the idea that they’d contracted HIV, no matter how innocuous their sexual contact with a prostitute or woman picked up in a bar had been. Nothing I said, no reassurance about the impossibility (“a blowjob only?” or “you used a condom?”), no test I performed convinced them. I half-expected an expression of relief if they tested positive. As a self-flagellating person, I understood their obsession. Think the worst: that was my motto. Then you’ll be emotionally prepared for a bad diagnosis and prognosis. Yet I wasn’t so obsessive that I’d disbelieve evidence to the contrary.

  At the Florence conference one researcher, Dr. William Haseltine of Harvard University, described how HIV could invade the body through the mucosal surfaces of the genital and gastrointestinal tracts without trauma or direct entrance into the bloodstream. This reinforced the importance of condom use. It didn’t matter if a gay man topped or bottomed; both practices were risky. Dr. Haseltine’s research also underscored the difficulty of developing a vaccine, because generating an antibody response cannot by itself control HIV infection. If the body produced effective antibodies against HIV, a vaccine would have been developed in the 1980s, relegating HIV to a footnote of medical history. To stop the spread of AIDS, the only tool we had in 1991, besides screening the blood supply to prevent transmission through transfusions, was selling the idea of safe sex, and that wasn’t working.

  Florence was an interesting place to hold the conference. More than six hundred years earlier the bubonic plague, or Black Death, made a sudden appearance in the city, decimating its population and forcing those not afflicted to flee to the countryside or hole up in their homes in a vain attempt to escape its ravages.

  “Against these maladies the advice of doctors and the power of medicine appeared useless and unavailing,” wrote Giovanni Boccaccio in 1353. The same words could have been penned in 1981, at the onset of the AIDS epidemic in the United States. “Perhaps the disease was such that no remedy was possible, or the problem lay with those who were treating it . . . and since none of them had any idea what was causing the disease, they could hardly prescribe an appropriate remedy for it.”

  “Some of the people were of the opinion that living moderately and being abstemious would really help them resist the disease,” Boccaccio continued, as if he were describing the gay community and my patients once we all grasped the existential threat. “Others, holding the contrary opinion, maintained that the surest medicine for such an evil disease was to drink heavily, enjoying life’s pleasures, and go about singing and having fun, satisfying their appetites . . . while laughing at everything and turning whatever happened into a joke. . . . There were others who took a middle course between the two.” No matter how one responded, the Black Death didn’t discriminate.

  Deriving little pleasure from the conference, Gavin and I explored the old city’s cobblestone streets, majestic churches, and sculptural masterpieces. We crossed the Arno River by way of the Ponte Vecchio, the only bridge from medieval or Renaissance times to have survived aerial bombing during World War II. No visit to Florence would have been complete without viewing Michelangelo’s David, an idealized representation of young male beauty—with its disappointingly small penis (Michelangelo wasn’t a size queen)—not to be missed by any respectable gay man.

  Gavin and I weren’t the only Chicagoans attending the conference. There was a small contingent of fellow AIDS healthcare providers, and many of us met up afterward like warriors shooting the breeze in a smoky bar, sharing stories and showing off wounds. Tom was there too. In July 1991, five months before Henry’s death, we hir
ed another doctor, C., who’d barely settled into his office when Tom and I took off, leaving him alone for five days to manage a practice of staggering complexity. Having worked with us for three years as a family practice resident caring for our hospitalized patients, he was no greenhorn; and our nurse Maureen, as knowledgeable and capable as any doctor, helped. He relished the challenge, he said—but the builders of the Great Pyramid might have said the same thing before laying the first stone. He survived the ordeal but extracted promises from us never to leave him alone again.

  After seven years of practice, Tom and I were tired and irritable, sometimes snapping at patients, more often snapping at staff. When a patient with AIDS called me to spout a litany of complaints against one of my nurses, the receptionists, and me, I lashed out, remarking that I was sick of people projecting their frustrations with their own health problems onto others. He fired me, but in six months he called to apologize and begged to return to the practice. I accepted his apology and apologized in return for my intemperance.

  Every other week Tom and I had taken call, and we covered for each other when one of us went out of town. Taking call meant interruptions while at dinner or a concert, in the middle of the night, or at any time during the weekend. In the concert hall or opera house we vied for access to the pay phone during intermission, mindful of the clock, the time crunch threatening to ruin the evening’s enjoyment. When paged while on errands, I hunted for the nearest phone booth and hoped I could find a parking space without getting a ticket. And after returning from a vacation we’d have to make up for the time by taking call for two or three weeks in a row, which left us questioning whether it was worth leaving town for more than twenty-four hours.

  There were nights when I got little sleep because the phone rang or pager beeped multiple times, at first from a frantic ill patient, followed by the ER doctor when that patient showed up for evaluation, and hours later from the intern or resident after admitting him. And the patient could be one of several admissions. I’m a poor sleeper. If I expect a phone call or page, I lie in bed full of anxiety, unable to sleep—will it be midnight, 1:00 a.m., 2:00 a.m., or later before my phone shrieks or pager reverberates like a high-pitched drill? If I somehow do drift off to sleep, later I won’t be able to fall back asleep after discussing the details of the case because of the rush of adrenaline. It was worse than being an intern and resident—at least those years had time limits. This was the life of a doctor, of course; but in a war there are more casualties than during peacetime. The war against AIDS appeared to have no time limit; the prospect of sleep, I absurdly thought, would have to wait until my death. Tom and I desperately needed a third partner to give us time to recuperate, and to continue to absorb the increasing number of patients flocking to our practice like refugees.

  Gavin’s call schedule did not always dovetail with mine. There were times when I would be on call but he wasn’t or vice versa. When I was paged, he woke up too. In a huff, he would pull the blankets over his head. When the shoe was on the other foot, more than once I growled at him for not moving to the bathroom out of earshot instead of talking, even yelling when frustrated, on the chaise longue a few steps from our bed. He relaxed there as if on a beach chair, left ankle crossed over his right knee, head hanging over an arm as he gesticulated with a free hand. The bedroom in our house in Bucktown was capacious, with twelve-foot ceilings and thick curtains hiding a wall of windows, which amplified Gavin’s voice as if in an amphitheater. The image of him on the chaise is funny to me now. It wasn’t then.

  Gavin and I had moved to Bucktown in February 1991 because we were tired of the politics of a condominium association. We wanted a free-standing home we could afford in the city. Bucktown had seen better days, and a number of oldtimers, mainly people of Polish or Ukrainian descent, still occupied some of the houses. In the 1960s, when many white families like my own had fled the city for the suburbs, ostensibly for a better education for their children, Bucktown declined and buildings were abandoned. Poor families (mainly Hispanics) and artists moved in, followed by developers. In its crumbling state, Bucktown had charm. Funky restaurants doubling as art galleries had sprung up; Gavin and I were amused to be the two square people in a space where everyone else had multicolored hair, paint on their fingers, tattoos on exposed skin, and nose rings. One acquaintance in Bucktown who out of curiosity posted a sign inviting anyone gay in the area to his house for a party was surprised that more than a hundred people showed up, which was refreshing. Boys’ Town no longer had a monopoly on gay life in Chicago, if it ever had.

  Our three-story brick and glass house didn’t resemble the A-frames, bungalows, or brownstones around it. The first floor sat sunken halfway below street level and was set back to permit a small front garden. For privacy and protection, an elegant wrought-iron fence enclosed the property. At the top of the facade the architect had appended whimsical flourishes, a central cement half-circle flanked on each corner by a pyramid. A skylight and glass block on one wall of the dining room made the interior light and airy. It was love at first sight for me; Gavin needed convincing because even in an up-and-coming neighborhood, the list price stretched our budget. A similar house on the Gold Coast would have cost two or three times as much.

  When I showed the house to my parents, my mother reacted with skepticism and my father kept his thoughts to himself.

  “It’s a beautiful house,” I said defensively.

  “Yes, it is,” she agreed.

  “It’s only about two miles west of my office near Cabrini Green, and it’s an easy drive to your house in Wilmette,” I rationalized.

  “But look at the neighborhood,” she pointed out, like a dentist noting that one good tooth beside a row of rotting ones didn’t brighten the smile.

  One Saturday afternoon that first fall, I was in the front garden planting tulips. As I squatted in the dirt digging six-inch holes, inserting a papery bulb into each one, and adding fertilizer before burying it, I heard a distant popping sound. I stopped and stood up to listen with ears twitching forward and fine hairs on my neck standing upright like those of a stalked animal. No one else seemed perturbed. Children on a nearby street didn’t cease playing. Our three-month-old puppy Monty dashed around the yard throwing up dirt as he ran in circles. Like a fever heralding the onset of a dangerous illness, the pops portended something ominous to me. As I was about to resume my gardening, shooing Monty away, I looked up and observed a young man slinking by my fence, glancing behind him and paying no attention to me. Later I noticed a trail of blood along the fence line. Within minutes, hysterical screams emanated from a nearby house.

  “He’s been shot, he’s been shot!” someone cried.

  I grabbed Monty and asked myself, What should I do? Should I shout “I’m a doctor” and rush to help? Should I call the police? Should I lock myself in the house and hide from any stray bullets?

  Before I could make a decision, a car with big wheels pulled up, the wounded teenager was shoved inside, and the driver raced away, hopefully to a hospital, leaving me to ponder the severity of the boy’s injury. And like a pond whose surface has been disturbed by the toss of a stone and then returns to placidity, life went on as if nothing significant had happened. The children continued to play, old ladies strolled by with their pushcarts, and I finished planting. But the incident unnerved me. What kind of neighborhood was this? Moreover, had I been cowardly, equivocating rather than thrusting myself into a potentially dangerous situation, concerned more about my life than about that of the wounded boy?

  When it came to AIDS patients, however, I didn’t equivocate. I never shunned an AIDS patient or hesitated to treat someone because of fear for my own health or safety. There were times when I put myself in harm’s way. In the earliest days of the epidemic, when we didn’t know if AIDS, like the Ebola virus, could be transmitted through sweat, saliva, or other bodily secretions besides blood, I often hugged my patients to reassure them that they weren’t “lepers,” as they often referred
to themselves. Because of my habit of sitting on the side of a patient’s bed, holding his hand as we talked, I’ve even sat on urine-soaked sheets. Once when I was drawing blood on a patient with HIV, the seal around the needle in a syringe broke and blood leaked onto my ungloved hand. We looked at each other in stunned silence. That was in the mid-1980s, before the CDC issued the policy of universal precautions in which everyone should wear gloves and protective eyewear or a mask when dealing with potentially infectious body fluids. Later I stuck myself several times while performing a procedure in the office, like draining an abscess, performing a spinal tap, or taking a biopsy of a skin lesion. Each time I panicked a bit, but I didn’t get infected.

  Now and then I felt physically threatened as the bearer of bad news. The boyfriend of a patient who’d failed all treatments for PCP, including an experimental one, ambushed me one morning during rounds. Furious that his lover was dying, he came up from behind, fist raised as if to punch me, rage in his eyes, but I defused the situation by reminding him that we were all on the same side. I wanted his partner to get better just like he did, and was doing everything in my power to rid him of PCP, but I couldn’t restore the health of his immune system. The virus was the enemy, I said, not me. He broke down in tears and we embraced.

  That moment, sometime in 1990 or 1991, seemed like a revelation to me because I spoke the truth: the virus was the enemy, not I. I could forgive myself, I thought, for losing patients to this dreadful disease; their deaths were not my fault. Yet that revelation provided no consolation for me. It didn’t make the losses less dreadful or depressing, nor did it make my days brighter or nights less tortured.

  : 10 :

  Dead Men Walking (1992)