Black Man in a White Coat

by Damon Tweedy, M. D.

  I wasn’t sure how to begin. If George had pancreatitis or an ulcer, it would have been easy to tell him and his wife together. But HIV would affect Janice and their marriage in a way that other medical disorders did not. For all we knew, it already had. I looked over at Adam for guidance. It was time for him to take over. His instinct was to break the news by separating them.

  “We’d like to look him over again closely and do some more neurological tests,” he said. “With the three of us examining him in here, it will be a little crowded. If it’s okay with you, we’d like you to give us a little time alone with him.”

  Janice seemed confused at first, but she didn’t put up a fight. “How much time?”

  Adam rubbed his temples. “Give us fifteen minutes.”

  “I’m going to go down to the cafeteria and get some food,” Janice said to George. “Anything you want me to bring you back?”

  George shook his head. Janice slung her purse over her shoulder and leaned down to kiss him on his forehead. I couldn’t help but wonder how long it would be before she kissed him again, if ever.

  After she left, Adam and I took a half-step toward George. Up close, his butterscotch complexion was sallow. Now that we knew he was HIV-positive, we examined him more methodically, looking closely for any signs of the complications that might accompany HIV infection. We felt for enlarged lymph nodes, peered into his mouth for signs of thrush, and searched his skin from head to toe for rashes or other discolorations, however slight. We shined a light into the back of his eyes. We didn’t find anything new.

  “There’s something else we need to tell you,” Adam said, retreating a half-step back.

  “What is it?” George asked. “Did you find out what is wrong with me?”

  “We believe so,” Adam said. “Sir, your HIV test came back positive.”

  George blinked twice and then looked away. After about fifteen seconds of silence, Adam spoke again:

  “Did you suspect that this might be possible?”

  The question seemed innocent enough, but he was basically asking George about the many not-so-innocent ways that a married man with an HIV-negative wife acquired HIV.

  “No, I actually can’t believe it,” George said, as his eyes briefly met ours. “Are you sure that’s what I have? It couldn’t be something else?”

  Adam told him that the chance for a false-positive test was nearly one in a million. George looked at the overhead television. “So what’s next?” he asked.

  Adam explained that we would need to check his CD4 count and HIV viral load, both markers for disease progression, and that these numbers would determine how to proceed. A small tear trickled down the bridge of George’s nose. “Damn,” he said.

  “I can imagine how difficult this must be,” Adam said. “I’m sorry about this.”

  George stared out the window. Adam had seemed detached outside of George’s room, but he’d turned into a caring doctor inside of it. I could see this skill serving him well in his future career as an oncologist.

  Adam stayed quiet for several seconds, giving George space to think. Then he said, “Your wife will be back in a few minutes. How do you want her to learn about this?”

  George turned toward us again. “Maybe you should tell her.”

  Adam nodded. We stepped outside the room to give George a few minutes alone. The nightshift nurses and nurses’ aides were on duty now, popping in from one room to the next, administering medications and checking vital signs. I opened George’s medical chart while Adam tested our medical student’s knowledge about HIV/AIDS. First, I entered orders for the lab to draw blood for a CD4 count and an HIV viral load. Then I wrote a short note to document our conversation informing George of his HIV status. These few words in his medical record—written in clinically detached language—gave no hint of their emotional impact.

  By the time I finished writing, Janice had returned. She walked in short, quick strides, her braids flopping back and forth with each step.

  “Can we speak to you alone?” Adam asked her. “There’s a room down the hall.”

  “What’s going on?” she asked, taking a deep breath.

  “He’s okay. But there’s something important we need to talk about.”

  We walked off the unit and found an empty conference room. The medical student, Adam, and I—all wearing our white coats—sat side by side at a table directly across from Janice. I sometimes wondered whether patients and their families might take bad news better coming from a single person, but medical care at a university hospital was a team effort.

  Adam wasted no time getting to the point: “Your husband tested positive for HIV. I’m sorry to tell you this.”

  “What!” Janice looked at me, perhaps seeking confirmation. I stared back solemnly. I didn’t know what else to say or do. She put her hand over her mouth. “That can’t be true.”

  Adam explained to her how rare it was to have a false-positive HIV test, but Janice was not convinced by the numbers. “I want the test repeated.”

  Adam said that we would do this, but that we’d also be taking the next steps so as not to delay treatment.

  “I just … can’t believe it,” she said. “We have lived a Christian life. I know he would not have done anything to jeopardize that.”

  Based on what we knew about HIV, George had to have contracted it during the course of their nearly twenty-year marriage. It would have been virtually impossible for him to have been infected before then and never have taken ill. Absent occupational exposure (George worked in a college office), blood or organ transfusion (none), or intravenous drug use (he denied), George had to have done something sexual outside their marriage. This was an awful way for her to discover his infidelity; the only thing worse would have been if Janice had learned of his cheating by being diagnosed herself. “What did he have to say for himself?” Janice asked, as a vein bulged on her left temple.

  “He seemed just as shocked,” Adam replied. “We didn’t get into the how or why.”

  “There’s just no way,” Janice said, looking down in her lap. “This can’t be happening.”

  Adam advised Janice to get tested herself as soon as possible and then again six months after their last unprotected sexual encounter. He told her that condoms were essential from this point forward. He also mentioned that a social worker would be talking with them the next morning, and that other counseling supports were available to them too. Janice listened silently, her hands firmly gripping the chair armrests. She appeared to be trying to hold herself in place, as if any movement might unleash an emotional torrent.

  As we left the conference room, Janice headed toward the elevator instead of rushing to comfort George. Maybe she needed fresh air or time alone to process what we’d told her. We walked back to the ward in silence. Our initial excitement for the case had vanished. What was salacious in the abstract was heartbreaking when seen up close.

  Back on the unit we found Laura, the overnight nurse assigned to George. She was in her late thirties, highly organized and detail-oriented yet friendly and calm at the same time. We told her the story and asked her to keep a close eye on them. “Will do,” she said. “That poor woman. What an awful situation.”

  We nodded before moving on to our other work; we had no time to dwell on the cruel twists of life. Adam and the medical student went down to the ED to see a new patient being admitted to our team, while I tended to the usual array of intern duties—managing various medical complaints, reviewing lab tests, and drawing blood samples on feverish people—that kept me up most of the night. The basic tenet of such work is to help people. In the life of an intern, however, practicing medicine felt more like trying to stay afloat without hurting anyone.

  The next morning before she left, Laura gave us an update on George. “His wife came back about an hour after my shift started. There was a lot of crying and arguing at first, but nothing that got me or anyone else worried,” Laura said. “She stormed out around ten o’clock. We figured
maybe it was all too much for her. I went in and talked with him for a while. He said he’d let her down.”

  According to Laura, he didn’t offer other details, but this seemed to be a tacit admission that he’d cheated on Janice.

  “She came back again around eleven and stayed the night,” Laura said. “I talked with her too. She’s mostly in denial right now. I left a message for the social worker to see them first thing. I just hope he didn’t give it to her.”

  Great nurse that she was, Laura had done the emotional heavy lifting that made our jobs easier. When we checked in during our morning rounds, George and Janice were in the same positions that we’d seen them the previous day before breaking the news. They had little to say other than wanting to know if the results from the second HIV test had come in. They hadn’t, but we were certain that this test was going to be positive too. We were also awaiting the results of his CD4 count and HIV viral load before starting treatments. Nothing had changed, and yet everything had changed.

  Later that morning, I caught up with the social worker assigned to the case. He was in his early forties, balding on top, with freckled skin that looked as if it would sunburn easily. In addition to his work at the hospital, he also had an evening psychotherapy practice in town. He pulled me aside. “You didn’t hear this from me, and don’t put it on the chart, but I’m pretty certain our guy is gay. The wife doesn’t know it. I’ve seen a fair amount of this in my practice. Besides, as a gay man, I’m pretty good at picking out other gay men who are in the closet.”

  I wasn’t sure what to say or how to respond. George did not appear gay to me, certainly not in the stereotyped manner that gay men were so often depicted in the popular culture. But in the past, I had incorrectly assumed that some men were gay who weren’t, and vice versa, so I had no reason to dispute the social worker’s assessment. His judgment made sense: It explained how George could have acquired HIV in the absence of any other risk factors. I filed the social worker’s theory away as the most likely explanation. We never got a better one.

  We could only go so far with our inquiries with George. Now that Janice knew that her husband had HIV, it was up to her to get an HIV test and use condoms if she decided that she could move beyond George’s secrets, whatever those turned out to be. As his physicians, the way he had acquired HIV would have no effect on how we treated him now that he had been diagnosed. Yet as we prepared to hand over the case to the infectious disease specialists, George stood out in my mind. His story pointed to something I’d read and heard so much about—black men leading a “down-low” lifestyle—but had yet to see up close.

  * * *

  When I began medical school in 1996, I expected HIV/AIDS to be a centerpiece of my education. AIDS first became known to the medical community in June 1981 when the Centers for Disease Control published a case report of five gay men in Los Angeles who developed the rare infection Pneumocystis carinii pneumonia. The following month, the New York Times printed an article about forty-one gay men in New York and California diagnosed with the previously uncommon cancer Kaposi’s sarcoma. Initially called gay-related immune deficiency, in late 1982 the underlying condition that led to these unusual infections and cancers was renamed acquired immune deficiency syndrome (AIDS). By the spring of 1984, it had an identified cause: infection with the human immunodeficiency virus (HIV).

  These developments took place when I was between the ages of seven and ten years old, and were unknown to me. It was not until movie icon Rock Hudson’s 1985 announcement that he had AIDS that I became aware of the disease. My mom was a fan of his 1950s and 1960s films, and throughout my early years, I’d caught glimpses of Hudson starring opposite Elizabeth Taylor and Doris Day. My mother was shocked to learn that the movie idol she adored was gay. It was my first exposure to the idea of someone leading a closeted sexual life.

  Not long after this, a family friend in his thirties, one long rumored to be gay by people in our family, took ill and died within a few months. To my knowledge, his parents never confirmed that he had AIDS, but given the circumstances, this was the conclusion that everyone reached. These two deaths formed my initial impression of AIDS as a gay disease, even though I didn’t understand at the time how being gay increased one’s risk of contracting HIV.

  When I was in middle school in the mid-1980s, AIDS took on new dimensions with the case of Ryan White. A thirteen-year-old Indiana boy with hemophilia who contracted AIDS through a blood transfusion, White, along with his mother, became a cause célèbre while facing virulent ostracism in his fight to attend public school. A year after White’s death in 1990, basketball legend Magic Johnson revealed, in a now-famous 1991 press conference, that he had HIV and was retiring from the Los Angeles Lakers. I was a high school senior at the time, getting ready to start the basketball season as our team’s captain and top returning player. Given his fame and incredible talents, Magic’s announcement resonated throughout the country, but it carried added meaning in the black community, where, until then, many people had viewed HIV as a disease of urban, gay white men. No one had considered that a world-class athlete such as Johnson could contract the disease.

  A few months earlier, I had attended a basketball camp filled with Division I basketball coaches who were scouting our games. One day during a break between games, an ex-player who’d had a brief stint in the NBA spoke to us about the pitfalls of life in major college and professional basketball. He started off talking about drugs. Then he turned to sex:

  “If you’re having sex, you need to use condoms each time. First off, you don’t want any babies before you can afford to take care of them. But there’s also AIDS, man. It will kill you.”

  That evening, I sat in the campus dining hall with a small group of other campers. The conversation eventually got around to our guest speaker. Cedric, a six-foot-four guard from Delaware who had his sights set on playing in the Big East or ACC, offered his opinion about safe sex: “Man, he was bullshitting us. You can’t get AIDS from a girl. That’s a fag disease.”

  We all giggled in ignorance. In the macho culture of competitive sports back then, being gay was like having leprosy. Never mind the statistical odds that in a camp of two hundred teenage boys, at least a few were probably gay or would come out as adults. No one believed that reality.

  One of the camp counselors, a burly guy with a shaved head and thick goatee who’d played at a small college, had overheard our conversation. “Who told you that?” he asked. We sat up straight, self-conscious like a group of kids caught looking at a porn video. Cedric was tongue-tied. “That’s stupid,” the counselor said. “Whoever told you that is the same idiot who says you can’t get a girl pregnant the first time you bang her. Stupidity can ruin your life.”

  However accurate the counselor’s statements, they had little meaning to me personally. As I finished high school and began college, I hadn’t come close to having sex, and given my awkwardness around women, it didn’t seem to be something on my horizon. My interest in HIV took a scientific turn in college, where I became a biology major. I learned how the virus infected the body and, over time, progressively destroyed it. My education coincided with rapid changes in the field, most notably the introduction of protease inhibitor medication, the first of which came out during my senior year. Two more protease inhibitors hit the market during my first year of medical school, where my various coursework covered the latest updates in the field.

  Starting my clinical rotations as a second-year student, I’d hoped to see this scientific knowledge in medical practice. But in a succession of multiweek stints through surgery, general medicine, pediatrics, and obstetrics-gynecology, I didn’t see a single patient with HIV. Some of this was mere chance, as each medical team saw only a sampling of patients admitted to the hospital, and medical students interacted with fewer still. My experience might have been different had I gone to medical school in New York, Washington, D.C., or San Francisco, where HIV was more prevalent. Yet the adoption of protease inhibitors a
s treatment for HIV infection spoke to a broader trend. Thanks to their introduction, the illness that brought people to emergency rooms, general medicine floors, and intensive care units a decade earlier had become a chronic disease largely managed in outpatient clinics.

  I decided during my third year to spend several weeks shadowing doctors in their outpatient HIV/AIDS clinic. I didn’t want medical school to pass by without getting to see up close the clinical view of an illness that had such wide-ranging societal implications. The few dozen patients I saw in the HIV/AIDS clinic fit the profile of AIDS that I’d grown up with: They were all openly gay men; most of them white.

  During the first eight months of my medical internship, I’d come across only a handful of people with HIV or full-blown AIDS, and even then only in passing. Once, I’d been called to draw blood overnight from a HIV-positive patient who developed a fever, and on two occasions, I’d rushed to the bedside with other doctors to try and revive men with end-stage AIDS who’d gone into cardiac arrest. George was the first patient whose case allowed me to slowly digest the social impact of the disease from its diagnosis. If the social worker’s theory was correct about George’s sexual orientation, then he fit the profile of gay black men living in secret. A few weeks later, I would see a similar case, but from a different perspective.

  * * *

  Monica was a twenty-eight-year-old woman from a small town about an hour north of Durham. She’d grown up the way far too many black kids do, raised by a single mom after her dad abandoned the family when she was a toddler. For as long as Monica could recall, her mom spent her days on the cleaning crew at a local hospital. With no support from her ex-husband, she also took on part-time evening and weekend jobs whenever she could. Many of the families in their neighborhood had similar stories.

  Monica exceeded the expectations most people had for someone with her background. While her brother dropped out of high school and did a short stint in prison, Monica graduated with honors and never got into trouble. She avoided the teenage pregnancy trap that had befallen her mother and aunts. She went to community college and found a job doing billing at a local medical practice. A few years later, while working full-time, she went back to school at nights and on weekends and completed a bachelor’s degree. She wanted to become the office manager of a medical practice, or maybe a hospital administrator. She’d set her sights on helping her mother move out of a small two-bedroom apartment into a comfortable two-story house.