Fever and a nagging cough that had gone on for three days had brought him to the hospital. His chest x-ray had been suspicious for pneumonia in the base of the left lung. His arterial blood gases showed his blood oxygen to be quite normal, a finding against his having Pneumocystis carinii. He had noted lymph node enlargement all over his body for a year now, for which he was being followed at Bellevue. “Before I came to Boston, I was fine,” he said, as if this illness was yet more evidence of the city’s shortcomings.
He told me he had contracted rectal gonorrhea twice before, as well as venereal warts and syphilis. He knew people who had died of AIDS.
I examined him carefully. There were white patches of thrush in his mouth and moderate enlargement of the lymph nodes in his armpits and groin. I could detect a few crackles in the base of his left lung. His genitalia were circumcised and normal. He had a small venereal wart around his anus that he was unaware of. I searched his skin carefully, looking for the purple, violaceous lesions of Kaposi’s sarcoma. I found none. I asked him if anyone had ever told him what the two coin-shaped corrugated skin lesions were on his abdomen, exactly six inches below his nipples on either side. They were brown and barely noticeable.
“These?” he asked, scrunching his head down to peek, looking worried. “I’ve had them forever.”
“They’re accessory nipples.”
“What? You’re kidding!”
“They’re very common. This line from your nipples down to your pelvis is the mammary line. Embryologically, mammary glands develop in mammals along this line. Almost any skin blemish you see along this line is an accessory nipple. In your case there isn’t any doubt about it because they are quite symmetrical, and look: they have the shape of an areola with a tiny nipple in the center.”
“Damn! Do you suppose they are sensitive?” I said I had no idea.
I took a specimen of his sputum to stain and look at under the microscope, leaving him to continue his study of his accessory nipples. The sputum showed many white blood cells in it and a predominance of purple, lancet-shaped bacteria. His pneumonia was being caused by a bacterium—the pneumococcus. The pneumococcus is the commonest cause of pneumonia in people without AIDS. Osler had spoken of it as “the captain of the men of death, the old man’s friend.”
I telephoned my attending physician, discussed my findings, and we agreed on what we would recommend to the house staff.
I came back to Tony’s room to answer his, Do I have AIDS? question.
As I write this, it is difficult to imagine that unreal time, 1983, in the history of AIDS. Not only did we not know what caused AIDS, there was no test to say who did and who did not have the mysterious disease.
The best that doctors across the country could do was to agree on a “definition” to ensure that everyone was talking about the same entity: If one was previously healthy and, for no obvious reason, developed an infection with an organism like Pneumocystis or else developed Kaposi’s sarcoma, one had acquired immune deficiency syndrome. AIDS.
(After HIV was discovered to be the cause of AIDS, it made sense to discard the cumbersome appellation “AIDS.” We could simply say “mild,” “moderate” or “severe” HIV infection. But the metaphor of AIDS is so powerful, it appears impossible to eradicate the term. Eligibility for Medicaid and Supplemental Security Income revolve around the definition.)
I was able to tell Tony that he did not have AIDS. On the chart I wrote that he did not “fulfill” the definition. His pneumonia did not look like Pneumocystis carinii pneumonia. He was very pleased to hear this and shook my hand vigorously.
What I didn’t tell Tony was that his lymph node enlargement and the thrush in his mouth suggested that he might be infected with the agent—whatever it was—that caused AIDS. There was mounting evidence that young men like Tony who had the risk factors—in his case, unprotected anal intercourse—and who had lymph node enlargement, often evolved into full-blown AIDS. I had a feeling he knew this already.
I never saw Tony again. As I write this, I have little doubt that Tony was infected with HIV. And that he is dead now.
Tony, my first gay patient, had been quite pleasant after he got past his initial hostility and annoyance. In the ensuing two years in Boston, I saw a steady increase in the number of AIDS cases presenting to the Boston University hospitals. Not the vast numbers that were being seen in New York or San Francisco or even at the New England Deaconess Hospital where many of the gay men in Boston seemed to go. Still, we were seeing enough patients to accumulate experience with AIDS and to develop some confidence in predicting what certain symptoms meant. At Boston City Hospital, we saw mostly Haitians and intravenous drug users. At the Boston VA we saw intravenous drug users and gay men in equal proportions. At University Hospital we saw predominantly gay men but not in any significant numbers; University Hospital seemed anxious not to develop a reputation like the Deaconess that would attract droves of persons with AIDS to it.
NEAR THE END OF MY training in Boston, Steve Berk, who was now Chief of Medicine at the Mountain Home VA in Tennessee, offered me a staff position at the VA and an appointment as assistant professor at East Tennessee State University School of Medicine. About the same time I was made an offer of a junior faculty position at Boston University. The two jobs could not have been more different.
If I stayed in Boston, the pay would be no better than my fellowship stipend, and within a year I would be expected to generate most of my salary by writing and receiving grants. Basic or bench research and National Institutes of Health funding were the currency of success in Boston. Therefore I would spend ten or eleven months of the year in the labs—“protected time”—and just one or two months on the wards. Most academic departments in Boston were top-heavy with researchers. In Tennessee it would be the reverse: I would spend most of my time on the clinical wards with a small amount of protected time for research; the pay would be much better and not as tenuous.
Rajani, who had completed her M.B.A. in Tennessee, was now working with a commercial real-estate company in Boston. She enjoyed her work and I was proud of what she had accomplished in her short time in America. But she was pregnant now and was planning to quit the work force for an extended period so that she could have and enjoy our first child. We wrestled with the choices: Stay in Boston? Return to Tennessee and raise our baby in a safe, rural, pastoral setting?
Going from India to Johnson City, Tennessee, had been a bit of a culture shock for both of us: the Appalachian accents were twangier, more singsong than we could possibly have imagined. Not even reruns of The Beverly Hillbillies that we had watched in India prepared us for this. But that culture shock was a mere tremor compared with the shock of going from Tennessee to Boston. On a fellow’s stipend in Boston, a roach-infested, third-floor walk-up in Brighton off Commonwealth Avenue was the best we could do. Break-ins were so common that every time I returned to the apartment, my gaze went quickly to the TV and stereo to see if they were still there.
Three years in Tennessee had gotten us used to making eye contact with people anywhere and automatically exchanging a “How you all doing?” or at least a nod. But in Boston, neighbors discouraged this sort of familiarity. The only time we spoke with ours was when a burglar in broad daylight knocked a hole in the neighbors’ wall, reached through it to open the front door and then robbed them. The neighbors came to ask if we had seen or heard anything. We hadn’t.
My academic ambitions had become less lofty. I had worked hard for two years developing an animal model of pneumonia. I had learned how to anesthetize a hamster and then slide a tiny hollow tube past the epiglottis, between the vocal cords and into the trachea—much like the intubation of a patient during a Code Blue. I would then shoot a dose of bacteria into the hamster’s lung. At the end of a morning, thirty-two hamsters would be lined up flat on their backs, their paws in front of them, snoring, looking like a bunch of drunken soccer fans sleeping off a hangover. I sacrificed four hamsters a day, ground up their lun
gs, painstakingly counted the number of bacteria surviving and plotted a “clearance” curve for staphylococci. Each clearance experiment took one week. I did many clearance experiments. Later in my fellowship I began to work with macrophages, the lung scavenger cells, testing their ability to ingest bacteria in the test tube.
But my experimental results were slow in coming and it was a long time before I had enough data to publish a paper. And despite all my effort, I was merely scratching the surface of a biological system. Basic research had become so complex: No one cared if in a certain disease you discovered that some protein in the blood was either high or low. The question being asked was what gene was controlling this protein? And how quickly could you clone it? Science had gone molecular. An investment of a couple of years after fellowship training was necessary just to learn the methodology of molecular biology.
I accepted Steve’s offer to return to Tennessee. Sorting out the real-time, real-world puzzles of living people seemed to be what I wanted. Steve would generously provide me with a lab and a technician so I could continue my hamster research. But I was returning to Tennessee to be a teacher and a clinician, not a researcher.
The impending arrival of our first child had changed our view of life. We wanted now to settle in one place for a while. We looked forward to returning to Appalachia; we were ready for a less frenetic existence in a corner of rural America that we loved.
TOWARD THE END OF my fellowship came the exciting news that Gallo and Montagnier (or Montagnier and Gallo depending on whom you believed—this too was part of the excitement: the personalities and the rivalries) had discovered that AIDS was caused by a virus: HIV.
A test to screen blood for HIV was rapidly developed, and it was confirmed that all those who had AIDS carried the virus in their bodies.
As more people were tested there came the sad confirmation that the Tony Cappelluccis of the world—people with minor symptoms of oral thrush or lymph node enlargement—were also infected with the virus. And even worse, many persons with no symptoms who appeared to be in perfect health but were either gay or intravenous drug users showed evidence that the virus was sitting silently in their immune system, biding its time. Safe sex maxims and warnings about not sharing needles had come too late for many. The virus seemed to have saturated the population of urban gay men even as they became aware of its very existence.
Still, the mystery of causation had been solved.
Surely, the cure was just around the corner.
3
THE MAJOR jet service to Tri-Cities Airport, serving Johnson City, Kingsport and Bristol, was Piedmont (now USAir) coming in from either Pittsburgh or Charlotte. The flight path from Pittsburgh goes over the Blue Ridge chain of the Appalachian Mountains which run parallel to the eastern seaboard. As the plane descends, the densely forested mountains give way to hills and sloped pastures.
At five thousand feet, no geographical basis for a boundary between upper-east Tennessee and southwest Virginia is visible. Here and there a gaping gray basin, like the bite of some giant creature, serves as a memento of a stripmining operation. Through the window one sees finger lakes protruding into valleys then suddenly broadening into expanses of water in which sit spindle-shaped islands crowded with spruce and pine. In September, when the leaves turn color, these islands will appear as old-time four-riggers, their prows pointed downstream, their sails on fire.
Rajani and our baby boy, Steven, now two weeks old, were with my parents. I had come ahead to meet the movers, and once the house was ready, Rajani and Steven would join me.
Allen was at the airport to meet me.
“I sure hope you’re back for good,” he said as he hugged me. Allen is a short, stocky man in his fifties with powerful shoulders, straight blond hair parted neatly on the side, and long sideburns. Years of outdoor work have given the back of his hands a leathery look and his face a perpetual tan. A Vantage cigarette was, as always, afire in his hand, and the outline of the pack showed through the pocket of his spotless blue shirt. Above the pocket, a white patch had his name spelled out in sewing machine script.
Allen owned South Roan Shell: three bays, nine pumps, one wrecker and one flatbed truck. When I was an intern and resident, Rajani and I had lived in an apartment building just up the hill from the station.
Allen’s wife, Claudia, who was part Cherokee, had jet black hair, high cheekbones, dark features and green eyes. I used to think that except for her eyes, she looked like Rajani’s sister. She had gone out of her way to be friendly and helpful to us.
Allen was unfailingly polite but a man of very few words; his usual facial expression was deadly serious. He could mull over his reply to something for so long—“turn it over and tickle it first,” as Claudia would say—that she would often pipe in for him. Allen said Claudia got around so much that she kept running into herself.
Sometimes when I stopped at the station, Allen would ask me in his deadpan fashion, “Hey, Doc, you got any horny pills you can give old Claude?”
The station had a tiny room behind the cash register where boxes of fuel filters and oil filters were stacked to the ceiling. At a small table, Allen and Claudia made phone calls and gobbled down lunch. The wall in front of the table was plastered with business cards of auto parts dealers, body shops, insurers and others.
If I came by near closing time when the stream of customers was dying down and Claudia was totaling the receipts, Allen would beckon for me to come to the back room and offer me bourbon or moonshine. The moonshine came in picnic jugs and had a smooth, refined taste that was quite unexpected.
Someone once asked Allen how he and I had become such close friends.
“Well,” he said, after pondering this forever. “Well, see, Doc used to come down to the station all’a’time to trade. And sometimes he’d ask me where do you get this, and I’d tell him. Or how do you do that, and I’d tell him. Or how do I get somewheres and I’d tell him how to git there. Pretty soon we got to be friends—shit, that’s all I can say. Just one of those things I reckon.”
I considered Allen my closest friend in Tennessee.
As we drove back from the airport, Allen talked about Claudia. They had parted ways while I was away in Boston. “I go bowling some nights. I’ll see her there. Son, I just turn around and walk out. If I’m there before her and she sees me, the sonofabitch just walks out.”
I was fond of Claudia and torn by this state of affairs. Allen said she was now driving a truck long-distance with her new boyfriend. In the divorce settlement, Allen had kept the station and the house but parted with the Cadillac and a large sum in cash.
The airport road wandered past Boone Dam and then over a stretch of Boone Lake, dipping down into a valley before rising to the crossroad three miles from the airport where the signs pointed east to Bristol, north to Kingsport (site of the Eastman-Kodak plant and the Holston ammunition depot), and south to Johnson City.
At the crossroads was a used-car dealer who had been there for years and who specialized in cars that could be hot-rodded or already were: ’78 Camaros, ’55 Chevys, ’55 Fords, ’67 Chevy trucks, old Packards, Mustangs of assorted years. Allen slowed down and we eyed the offerings. The Packard was a beauty, I said.
“It’s nice,” Allen said, “but looky here at the fender over the back tire. Shit, Doc, that’s all bondo. He done just bondoed it and slapped paint over it.”
(I had tried and given up on making Allen call me Abraham. He enjoyed saying, “What’s up, Doc?” when I walked into the station and a bunch of people were milling around the cash register.)
I asked Allen whether he still had the ’55 Chevy that had sat on blocks in the field behind his house for as long as I knew him. He had bought it wrecked years ago with the intention of restoring it.
“I sure do. Still have it. Soon as I finish building the garage in the back, I’m going to fix that Chevy right up.”
If Claudia had been with us, she would have rolled her eyes at this point. Allen was t
enacious and eventually would get the garage built and the Chevy restored. Two years ago he had shown me where the garage would go. Then, when I next visited, he showed me the foundation that he’d poured. “I bought me the brick and cement—got the cement real cheap. I got to get me the walls and roof put up next.” His sense of time had been much too slow for Claudia; that had been part of their problem.
“But I got a car at home for you to drive. I got an ’82 Monte Carlo and I put a ’72 Oldsmobile 455 big block V8 in it. Son, that sonafabitch will fly!”
Route 36, the road to Johnson City, wound past fenced-in farmland with late summer tobacco already standing high in its corner allotment.
A mile down Route 36, a boxlike roadside sign always caught the eye. It sat on a low dolly, its arrow pointing to a hidden driveway. The periphery of the sign had Christmas-tree lights that whipped around like a dog chasing its tail. The lettering was black vinyl, upper case, back-lit in yellow. The words LIVE BAIT NIGHT were visible on the top line; the letters on the next line had been removed leaving only a ghost of CRAWLERS. At night, the sign would stand out; now, in the midday sun, the fluorescent light in the box may or may not have been on.
Further on, after a white-on-green Boat Ramp sign, another flashing box advertised SANDY’S MODELLING STUDIO—a furrowed gravel driveway ran up to a trailer with green paneling and no skirting and too small it would seem to hold the tanning booth, the private rooms and the hot tubs advertised.
“Check it out, Doc.”
“You check it out!”
“Hell, I just might, I tell you what. I just might.”
The number of massage parlors in and around the town seemed to wax and wane with the mood of the sheriff and the proximity of elections.
Closer in to town, subdivision signs carved out of wood and standing high off the ground began to appear: Boone Trail, Tamassee, Sequoyah Heights, Inglewood. Behind the traditional brick houses were newer houses with angled roofs and skylights and solar panels framed in dark and light wood.