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Patients of a Saint

An estimated 600 detainees at Cook County Jail are HIV positive. Dr. James "Kirby" Cunningham is trying to take care of all of them.

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By Justin Hayford

Deep beneath the sprawling Cook County Jail campus, the largest single-site jail in the nation, lie six miles of concrete tunnels. They connect 11 separate housing divisions spread across 97 acres, through which 100,000 detainees are herded each year. For the most part, the tunnels are painted a drab, institutional gray. No signs indicate where they might lead, and they bend and turn in such a nonsensical manner they seem designed to induce disorientation--ideal for trapping anyone trying to escape. As security personnel will tell you with a laugh, if you get lost down there you'd better just scream.

Dr. James "Kirby" Cunningham walks these tunnels every day. In December of last year, he became the first physician hired at Cook County Jail to coordinate HIV care for inmates. According to a blind study done at the jail a few years back, between five and six percent of detainees have HIV--an exceptionally high proportion considering that most researchers define a "high risk" population as having an infection rate between one and two percent. That means 500 to 600 of the 10,000 individuals housed there on any given day are infected, though many have never been tested, while others who know their status choose not to inform the medical staff. Still, with nearly 200 known patients spread among the 11 divisions, the 67-year-old doctor gets a daily workout--and not just from walking the tunnels.

One typical morning in May, Cunningham is about to step into a tunnel leaving division two, a minimum-security building that resembles a long-unfunded YMCA. He's spent the last 20 minutes with a new patient in a tiny, secured examination room just down the hall. The patient, an emaciated Texan who survived five bullets in the back, was diagnosed HIV positive in 1998 but was never prescribed any antiviral medications; his life was in such chaos from his drug addictions the doctors he saw didn't feel he could handle the complicated, multidrug regimen that has become the standard of HIV therapy over the past few years. Cunningham started him on two new drugs two weeks ago and hoped to add a third today. At this suggestion, the man began laughing and rocking in his chair. "You've got to want to do this," Cunningham said in his quiet, south Texas drawl. "I can't make you want it." In fact, the patient didn't want it; he already took too many pills, he said, "too many pills, too many damn pills."

As Cunningham collects his papers, a half dozen African-American men play a listless game of pool in a gloomy rec room with grime-coated windows. A few wave amiably as he passes. With his full head of gray hair, slight paunch, and boyish grin, he looks a bit like a clean-shaven, underfed Santa Claus in the off-season. He leaves division two with his physician's assistant, Harry Przekop, and heads into the tunnels on his way to division nine, one of the maximum-security buildings. Along the way a dozen men shackled into a line are shepherded by jail personnel who regularly move detainees from division to division in order to prevent gangs from forming. As a result, Cunningham often can't find his patients for days at a time.

After 15 minutes winding through tunnels, Cunningham and Przekop emerge in division nine. Here there are no windows at all, just massive cement walls that make the place feel like a tomb buried under a mountain. After being frisked, they walk through the crowd of men waiting to see a doctor. The air seems charged with hostility. One detainee barks, "Are you doctors? Are you doctors?" It's clear from his tone that he already knows the answer.

The two men pass into an open examination area, where a male nurse in a cowboy hat is struggling to convince a silent patient to offer his arm for a blood pressure test. They head into a private room where they meet a powerfully built man with a menacing scowl. He's here on a drug possession charge, and as with many of the patients Cunningham sees he's not sure which HIV medications he's on--and he hasn't had any since they were confiscated by correctional officers during his booking two days ago. Cunningham knows that if he guesses wrong and prescribes different HIV drugs he can seriously jeopardize his patient's health; switching regimens suddenly can allow HIV to mutate and become resistant to many medications. So he pulls out a color poster with all the current HIV drugs pictured. The patient identifies one--Sustiva--but isn't sure about the others. Cunningham suggests that they call his doctor. The patient agrees but can't recall the name of the clinic where he's been going. He offers three possible names, and Cunningham starts flipping through the phone book. All three turn out to be dead ends. "You're sending us on all kinds of wild-goose chases," he says with a chuckle.

After twenty minutes of calling other leads, Cunningham finally locates the patient's physician and confirms his medications. Then he begins to question the man about his family history and his criminal background. He's been arrested many times for possessing and selling drugs. He's lost numerous jobs after failing to show up for work during heroin binges. The mother of his children won't let him come around because of his addiction. Cunningham rests his chin on his hand and leans in toward his patient as he listens, staring him square in the eyes as though the two are old friends sharing a late-night chat. Then he says in a gentle voice, "Heroin is fucking up your life."

The man folds his hands and stares at the floor. Finally he says, "You're right."

Cunningham has been a fixture in Chicago's AIDS service network since 1993, when he became director of the Uptown and Lakeview public health clinics. For seven years he provided primary care to folks trapped without insurance in the epicenter of the city's worst public health disaster. Like most of the detainees at Cook County Jail, his patients were largely poor, disenfranchised minorities, precisely the people who might have a problem trusting a white, southern doctor, especially one who'd completed his training before anybody heard of the Tuskegee experiments. Yet Cunningham developed a fiercely loyal following among the poorest of the poor.

He's quick to point out that his practice was far from a Peace Corps outpost. "They weren't all destitute," he says. "I saw the kids just out of college who want to be actors, people with professions that just don't provide health insurance."

He also saw a fair number of patients newly discharged from jail. "I would get very upset about what was happening with people coming to me from there," he says. "When they finally found us, they'd been off their medicines for a month or so, because they're not allowed to take medications with them when they leave. And nobody at the jail quite knew what was happening or could tell me much about their health care. It would be two weeks before we could get them an appointment, and they were trying to find a place to live, a place to work--I mean, they had bigger things on their minds than seeing me. So when I realized last year this was a big problem, and a big problem all over the country, I thought, well"--his eyes sparkle--"why not?"

At about the same time, Dr. James McAuley, medical director of Cook County Jail's Cermak Health Services, was having similar thoughts. He'd crossed paths with Cunningham a few years before, when he worked as the Centers for Disease Control and Prevention's tuberculosis officer in Chicago, running periodic clinics out of Cunningham's Uptown facility. McAuley knew HIV care in his jail needed an overhaul.

"We've got 11 housing divisions, each with 500 to 1,000 inmates, and each unit has one doctor," he explains. "And HIV therapy is very complicated, and rapidly changing. So it was difficult to keep all the providers as up to speed as possible on HIV, especially when they have to be up to speed on everything else. And we had all levels of aggressiveness. Some doctors would pursue all the necessary information and try to get the meds started right away. Others would fill out a form, fax it to the appropriate place, and get what they needed two weeks later. So we thought we needed one person on campus who is knowledgeable about HIV, who wouldn't necessarily provide all of the HIV care but could provide the impetus for coordination."

Fortunately for McAuley, people in high places were coming to the same conclusion. In 1999 the Centers for Disease Control and the Health Resources and Services Administration jointly offered money for demonstration projects that would revamp medical care and discharge planning for HIV-positive inmates around the nation. Under the umbrella of the Chicago Department of Public Health, Cermak is receiving part of a three-year million-dollar grant to do just that, teaming up with the AIDS Foundation of Chicago, the CORE Center (the infectious-disease facility jointly run by the Cook County Bureau of Health Services and Rush-Presbyterian-St. Luke's Medical Center), and several community AIDS service organizations. With enough money to hire a physician's assistant, two case managers inside the jail, and six more in the community to help newly released detainees connect with health care, Cunningham was ready to jump from the frying pan into the fire--at an age when many doctors would be jumping to a condo in south Florida.

He reported to Cermak in December, though there wasn't enough room to give him his own office. There still isn't. For a while he was holed up in the office of a doctor away on maternity leave. When she returned, he moved to a corner in the library. One day a week he sets up shop at the CORE Center, hoping to provide easy access to medical care for patients newly discharged from the jail. "When I see them in jail, I tell them where to find me. They can just show up, they don't need an appointment, which sort of rattles the CORE Center people, but it has to be that way."

He spent his first month just trying to understand how the health care system worked in the jail. "Right now I'm so far behind I'm just playing catch-up," he said in January. "I can only see seven or eight people a day. The records are hard to find, or incomplete. Trying to centralize all the HIV records is just impossible. I'm suddenly beginning to realize I'm taking on a shitload of stuff."

And he quickly discovered that the tunnel system was only the first of many mazes he had to navigate. Just trying to find his patients could be a Herculean task. Not only are detainees transferred among divisions without notice but fully half of the people booked at Cook County are gone within 14 days. Many are discharged even quicker. No one knows when inmates might be let out, making even short-range planning nearly impossible. As McAuley explains, "You can't predict when a judge will rule somebody free to go, and the jail has six hours to get someone off campus after the decision. And up until recently there were night courts, so the judge could say at ten o'clock at night, 'You're done.' And if you're on major antipsychotic meds, you're on HIV meds, you have all sorts of important medical issues, those don't get packed when they let you out the door at 3 AM."

When Cunningham does find a patient, he can't stop by the cell any time he chooses. "I can't really go to see my patients, like I can in a hospital," he says. "They have to be brought to sick hall. And that involves...movement." He adds the final word shaded with dread. For Cunningham to see a patient, someone has to order that patient brought up. Usually that someone is a Cermak health educator like Leah Fisher Snow, who's worked in the jail for 11 years. "We're visitors here, so we don't have a lot of say-so about how our patients get to us," she says. "We have to ask the correctional officers to bring them up. Some divisions bring patients right away. Some delay so long the doctor has to leave." It might be several days before Cunningham can set up another appointment for that patient, if the patient hasn't already been let out of jail.

One of the most difficult chores Cunningham faces is simply identifying which inmates have HIV. Cermak doesn't screen everyone for it, though they do screen for syphilis, gonorrhea, and chlamydia, diagnosing one-quarter of the city's sexually transmitted diseases. Many inmates report their HIV status to the Cermak health care workers, but many do not, or decline an HIV test. According to McAuley, Cermak identified roughly 500 individuals with HIV in 1999. But of the 70,000 individuals who passed through the jail that same year, about 3,500 were probably infected.

McAuley appreciates the difficulty many detainees have in talking about HIV with his staff. "We don't get a lot of accurate health information at intake, which is to be expected," he says. "Imagine, we've got 300 people every day lining up to go through this six-to-eight-hour process, history and physical, fingerprints, snapshot, X rays, all this stuff. And we do the interviews in cubicles which offer some privacy, but it's in a big open area with a bus station level of activity. So it's my impression that a lot of people just say, 'No, I don't have any health problems, thank you very much.' Maybe it's because they've just been arrested, they're getting booked, they haven't seen a judge yet, all of this stuff is happening to them, and maybe they think the last thing they want to do is complicate the process by talking about a chronic illness. I think it's true not only for HIV but for a whole host of illnesses which carry some sort of stigma.

"And it's hard for people to trust us. We try to emphasize that we're not part of the penal system, because we aren't. But it's hard to believe that, because we're standing 20 feet from the guys in the uniforms.

"If I'm arrested for something like possession, I don't have to go to jail if I've got money. I can make bail right away. So who ends up in jail? It's the poorest people, those who have no resources to start with, and in their eyes we're just another part of a system that hasn't been particularly fair to them throughout their lives."

It may be especially difficult for incoming detainees with HIV to trust a medical staff that confiscates their medications when they're booked, with no guarantee of getting them back for a few days. "The idea is, I could have anything in a pill bottle," McAuley explains, "speed, PCP, you name it. So the corrections people are nervous about just letting you bring in your meds. But we have a pharmacy here and doctors here 24 hours a day who can write prescriptions. So if somebody says, 'I'm on Combivir and Nelfinavir' [two common HIV drugs], we're not going to question that, we'll write that scrip. But if someone says he's on Tylenol 3 for his back, that we're going to question, because that's a drug of abuse."

Still, it's often the case that inmates don't start back on their HIV medications until they've been seen by one of the Cermak doctors, and that process can take several days. It's a kink in the system that makes McAuley wince. "Studies do show that stopping all drugs simultaneously for a brief period is better than being on a partial or incorrect regimen," he says. "I wouldn't use that as an excuse for complacency. But it does make me feel a little less panicked when the person tells me he hasn't had meds for two days."

Understanding the difficulty of generating trust between patient and physician inside the jail, McAuley knew he needed to hire Cunningham when the grant came through. "The bottom line in health care is the physician-patient relationship," McAuley says. "That may sound arrogant on my part, but medicine is all about liking your doctor. If you like your doctor, you take your medicines. If you don't like your doctor, you don't take your medicines. It's not about great systems, it's not about nice buildings. And it's not common for someone with Dr. Cunningham's level of understanding and interpersonal skills to be doing low-paying, low-prestige, inner-city public health primary care."

Alexander Pitts, a health educator who's just completed his eighth year at the jail, has seen the way the detainees have warmed to Cunningham's presence. "If there was ever an illustration of power with compassion, Dr. Cunningham is it," he says. "However resistant they are, however combative they are, he never seems to tire. I think that man is mechanical."

Cunningham says he wasn't born to be a doctor--he fell into medicine before he knew what hit him.

He grew up in tiny Stinton, Texas. "What went on in Stinton? Nothing," he says. His father was a farmer who owned a feed-and-seed store, and his mother was a housewife. "I didn't know what I wanted to do with my life. I thought I wanted to be a writer, actually. Probably fiction, I guess. But when I was in college I read an article about anesthesiology, which was a pretty new field then. I was sort of interested, and I thought, 'Maybe I'll become premed.' I didn't think much of it." He finished his undergraduate degree at the University of Texas in Austin. "Then suddenly I had to make a decision about medical school, and the next thing I knew I was a doctor. I hardly knew what was happening, just trying to keep my head above water."

He studied medicine at Baylor Medical School in Houston, struggling to find not only a specialty but a sense of confidence. "You're in medical school and then doing an internship and a residency while most of your contemporaries are out making money, good money, getting well ahead of you. And you're at age 30, still training. You don't get out on your own until you're well into your early 30s, if you have any specialization at all. In some ways I think it leads to almost an immaturity among doctors. We're under somebody's thumb for so long."

As he finished medical school, one thing was certain: he was dying to get out of Texas. He'd visited a high school friend who had moved to New York City and fell in love with the place. "I was determined to move there," he says. "I first went there in 1959, and I'll always remember The Caretaker with Donald Pleasence, Alan Bates, and Robert Shaw, and you could sit in the second balcony for a dollar."

He got an internship at New York's Bellevue Hospital, then did his residency at Columbia Presbyterian Hospital. No matter how long the hours, he was running downtown any chance he got. "Everybody else from work would be so tired, and they'd say, 'God, Kirby, you must be worn out, are you going home now?' And I'd say, 'No, I'm going into town.' They called me 'Rural.' 'I'm going to town, see what's going on.'"

He indulged his passion for theater and began to fall in love with opera. "I got a subscription at the Met, every Monday night for $1.75 a seat, the next-to-the-top row. That was the golden age, with Callas, Sutherland, Nilsson."

He spent seven years training in New York, interrupted by a two-year stint in the air force, and at last started to practice on his own in 1966, doing general internal medicine with a subspecialty in oncology and hematology. He loved life in the big city, but after eight years in practice decided he didn't want to live in New York forever.

"When you live there, you go to a really interesting play one night. And the next night you go see another interesting play. And you hardly have time to reflect on what you've done. You just get on a treadmill of going."

So he looked around at less active cities--Charleston, Albuquerque, Santa Fe--and decided on Denver, primarily because he liked to ski. "I was one of only a couple oncologists in southeast Denver," he says. "I was overwhelmed with cancer. I burned out real fast."

After four years he moved to Chicago, taking a low-stress job with Standard Oil as an in-house doctor. "It bored me to death, doing four or five physicals a day," he says. Then he moved into a private partnership with another doctor, doing more corporate physicals. "It gave me time to live my life. I worked eight to five, and we didn't have to deal with insurance. But it wasn't inspiring. After a while I started coming home and thinking, 'What am I doing?' I began to sense that I should be giving a little something back."

Then one day he happened upon a help-wanted ad in a magazine called Chicago Medicine. "They needed somebody to run something to do with HIV and TB with the city," he recalls. "I went out and met with them, and they said, 'Well, you're hired.'"

So in 1993 he became director of the Uptown clinic. "But when I got there, there wasn't too much to do," he says. "There were only about 75 patients split between Uptown and Lakeview. So I suggested taking over both clinics. I can't stand being not busy. I'd already done that at Standard Oil. You can only work so many crossword puzzles."

For the next seven years he directed both clinics, and by the time he left in December the clinics were handling about 500 patients. "I entered the whole thing thinking I was going to be Mother Teresa, just holding people's hands while they faded away into that good night. But I found out a lot of people were doing OK, even before protease inhibitors. They were hanging in there, the deaths were not overwhelming. I found that I loved what I did, for the first time in a long time."

He spent a lot of his time networking with the myriad HIV service agencies in Uptown and Lakeview, as well as getting to know doctors who specialized in HIV in their private practices. "When their patients lost insurance, they would send them over to me," he says. "At that time, a lot of people were losing their coverage as soon as the insurance company found out they were HIV positive. And I tried to work it out so that those physicians would agree to admit their former patients into their hospitals if they got really sick.

"And the more I did the work, I saw that I couldn't just treat people medically. I had to get involved in the social aspects, the legal aspects. I would be beside myself to find out that somebody lost their job because they had HIV through some manipulations of their company. So I got more involved in trying to get people jobs. I would sit down with the Reader every Thursday and circle the job announcements that said, 'Full benefits.' And I'd tell my patients, 'Go apply.'"

Soon he discovered his position required him to become something of an ethnographer as well. "It's meeting all these different crises with different ethnic groups, and seeing how differently Puerto Ricans deal with things compared to Mexicans compared to Central Americans compared to South Americans. And when you get people who have come directly from Africa, you may not have a clue about what drives them. The Ethiopians I've seen, for example, are proud and beautiful but they don't want anybody to know. There are no support groups for them. So they can't find anybody to talk to except you. And they're used to being prosperous in their country, and they're taxi drivers here.

"And then the city gives us lectures on how to deal with different ethnic populations." He laughs. "If they only knew."

Cunningham knows he's not universally loved. "There are a lot of patients who hate me," he says. "Sometimes I question their honesty. And there are people who feel like once they have HIV they're entitled to all sorts of things, public benefits, Social Security, disability. And so they hate me when I tell them, no, you're not entitled to that, and I will not fill out this piece of paper saying you are.

"Still, people used to always ask me, 'What do you think of your practice?' And I would say, 'I think it's fun.'"

A viral load test measures the amount of HIV in a person's blood. Since the goal of current multidrug therapy is to suppress viral levels as much as possible, federal treatment guidelines suggest that patients be given viral load tests every few months to determine the effectiveness of their medications. The month before Cunningham started working at Cermak, the jail ordered seven viral load tests. In his first month on the job, he ordered 34. The next month he ordered nearly 50. And by August he had identified nearly 600 detainees with HIV, more than had been identified at Cermak during all of 1999.

"Everyone thinks I'm trying to do too much," Cunningham says with a grin. "It's not in the grant to improve the health care system within the state penitentiaries, but we have to do it." So he met with the medical director in the Joliet Correctional Facility, where all convicted detainees are held temporarily before being transferred to the state prison where they'll serve out their sentences. He arranged for inmates' medical records to be shipped to Joliet a day in advance of their transfer. "We'd originally planned to send the patient with a week's worth of medications. But they've got a pharmacy there, so if we can get the information in by nine in the morning they can get everything in motion and be ready."

He's also trying to work with the Illinois Department of Corrections to encourage state prison medical directors to refer their patients from Chicago to him when they're released. "Right now a doctor in Dixon, or wherever, probably has a list of referrals. But he doesn't necessarily know what are the best facilities in Chicago, what's near where the patient lives. I can get the person hooked up at the CORE Center and with case management."

He's been seeing a steady stream of former jail detainees during his CORE Center hours every Wednesday morning. "There are about five guys who say they want to come every week. And I tell them, 'I don't need to see you every week.' And they say, 'But we just want to.' So I tell them we'll probably just sit and talk for five minutes. I think I'm kind of a touchstone for them. Now, I can't get 50 guys doing that."

By the spring, his patient load at the CORE Center had grown substantially. One of the regular doctors told him patient traffic had doubled since he arrived. But as part of the CORE Center's regular Wednesday morning HIV clinic, he was sharing space with other doctors, and more often than not disrupting the center's protocol. "A lot of my guys are on home monitor, so we have to rush them in and get them back home by a certain time. And because people never know when they're going to get out of jail, we had a ton of walk-ins. So if they showed up at 10:50 and the clinic staff told them, 'Sorry, the clinic closes at 11,' well, I would say, 'No it doesn't, not for him.'"

So in early August the CORE Center gave him his own clinic hours every Wednesday afternoon, when he can run the whole show as he sees fit. Now he's seeing patients referred not only from Cook County Jail but from the federal Metropolitan Correctional Center in the Loop and several state prisons.

In addition to overhauling HIV care for jail detainees, he's set himself the tidy task of overhauling the government's war on drugs. "I talked to some judges because I'm hoping to make a program--I know this is pie in the sky--where we could identify first-time offenders who really have done nothing horrendous, maybe just possession, or were into the crime scene because of drugs, and get them out of jail as soon as possible and into a rehab facility. I mean, you can tell, as the weeks wear on: for the first days they're scared shitless, and in two or three weeks they're getting tough. So if we can just get to them before they get too tough, get them out of there and into rehab while they're still afraid. How we're going to do that, I don't know. Everyone shakes their heads and says, 'This is impossible.' But I say, 'Well, you never know.'"

When Cunningham's grant ends he'll be turning 70. He's already contemplating his next move. "I was talking to a doctor friend of mine who was thinking about going to work for the World Health Organization," he says. "And I said, 'I have always been interested in that.' And he said, 'Well, Kirby, you really don't have the type of experience they need in Geneva.' And I thought, 'Geneva? I don't want to go to Geneva. I want to go to Africa!'"

Art accompanying story in printed newspaper (not available in this archive): photos/Lloyd DeGrane.

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