ON THE FRONT LINES:

THE NEW AIDS FIGHT 
BY ROGER WILLIAMS rwilliams@florida-weekly.com
Outfitted in his standard slate-gray suit with white dress shirt, cuff links and striped tie, Dr. Bob Schwartz greets each patient who enters his non-profit AIDS Treatment Center on Central Avenue in Fort Myers like an ambassador from the Land of Hope - sometimes with good results and sometimes not.

Whatever AIDS has become in America, this is the front line, where about half of the county's estimated 1,300 AIDS patients receive long-term treatment. On a mid-day in August, the waiting room is nearly full. The long hallway with small offices situated off it is cool in front and warm in the rear (the air conditioning is broken, the funding has slowed to a trickle). Schwartz is alternately fuming or solicitous, depending on whether he's talking about Lee County health officials, or talking to patients.

For the county health officials, who told him Aug. 1 that he would receive state monies for the new fiscal year but then informed him by e-mail a day later he would not, he has sharp words. (Earlier this year, he learned that county health officials wrongly billed his Treatment Center for $73,000 in tests required of patients seeking drugs through a federal program, when they appeared to be aware of that fact.)

SCHWARTZ "It's chicanery and mendacity," he insists. "It's mendacious to not tell us we don't have to pay for drug tests. And it's the same to say we will pay for your overhead and not do it. It's mendacious to say we are retroactively withdrawing, and then do it (he didn't learn no money would be forthcoming until he'd accumulated a month's worth of bills in the new fiscal year, he says). And to say they don't have a copy of our contract? Come on, it's public record. Or just ask, and we'll send it."

For patients, it's a different story.

"How're you feeling today, Mary?" Schwartz gently inquires of a wheelchairbound woman who just arrived. When she remains silent and stony, Schwartz says, "That good, huh?"

There's a stethoscope around his neck, which he applies quickly, after tape recording notes and talking about on-going treatment. His dog Max, about the size of a meatloaf on legs, is tucked beside him on the chair; both dog and doctor stare intently into the eyes of the patient. He finally sends her into a treatment room so a nurse can draw blood. "She's been with me since before 1990," he comments quietly. "She was told she had 'terminal' AIDS, then - I hate that diagnosis. I hate it. You see her now." Who they are

FLORIDA WEEKLY PHOTO A patient offers his payment for services. Frequently patients claim they have no money, and the reply is usually, "Try to remember to bring it next time." To 650 people with AIDS, many of them poor and uninsured, Schwartz is a champion, a confessor, a friend, a coach, a colleague in the science and art of war (the war on pathogens - or for that matter the war against any who won't help the patient). He's been known to drive patients to the emergency room of a hospital that wouldn't give them X-rays, too.

"They were poor, they had AIDS, and the hospital didn't want them in there," explains Earl Givens, former Executive Director of the Treatment Center. Schwartz demanded care for other immediate problems, until finally hospital officials relented, and provided X-rays as a pro-bono service.

"He cares about us a lot," says Joe Shamulwas, a tattooed 43-year-old wearing a red baseball cap and a sleeveless T-shirt, who's been with Schwartz for years. "Once the insurance company wouldn't pay something, and he got on the phone with them himself, and started arguing. I had my wife down here, and I even brought her in to listen - it was amazing."

He's an antagonist, too, interested in their health, not their whimsies, capable of dressing down a patient like a drill instructor excoriating a Marine with rust on his rifle.

"Dr. Schwartz knows me - for sometimes not doing the right thing," says Palestine Claitt, a 45-year-old patient who was bent double in despair and alone in an empty room, teary-eyed, before she spoke to a reporter. She hadn't been taking her medicines. Schwartz had let her know: that won't work for him, or her.

Out in the front room, her 21-year-old daughter, Carletha Delaford, waited patiently. Along with her own three children, she also cares for her mother, and keeps her in the family's Dunbar apartment, encouraging her to eat and drink enough water. It helps when the good doctor yells at her mother, she says.

"My mom will listen to him if he yells at her, before she'll listen to me," Delaford explains with a smile. "I didn't know about this disease when she got it (in 1999). I was a teenager. And now she has good days and bad days."

She opens her purse and reveals four or five bottles of medicines that her mother must take. "This is only some of what my mom has to take - there's about that many more at home, but you know, you can't do nothing but live."

That multitude of drugs is standard now in a nation where 40,000 people are newly diagnosed with the virus that causes AIDS (H.I.V.) each year - where they live much longer, requiring much more expensive treatment over a lifetime, and where the profile of patients is increasingly indigent and minority. Many of them, and the organizations that treat them, rely on the Ryan White Care Act, which provides federal money - frozen at about $2.1 billion annually in the last few years of Bush administration policy, in spite of increasing need.

Delaford distinguishes carefully between her own life, and her mother's. "When she was 21, she was married. Her at 21: it was probably drugs and stuff. Me at 21: I have three kids. And I don't want to go down that same road she did."

Schwartz's manner suggests no apology for his own elevated circumstance in life, a position categorically unlike those of his mostly poor and uninsured patients. Nevertheless, the non-profit ATC is literally a non-profit, for him; for the last two years, he's taken no salary, instead devoting it to the clinic, and he's taken only partial salaries in years before that. His wife, Dr. Eileen Schwartz, a neurologist, supports the family economically.

The Schwartz uniform - a formal suit and tie - and perhaps his manner both seem to say to patients, "I give you respect because you are important. Now act like it, and take care of yourself." On his wall, distinct from the various medical school and honorary acknowledgements he waves off like so much formal confetti, hangs a Churchillian thought, framed in black: "Don't Give Up."

The patients are dressed in uniforms, too. They wear shorts, sleeveless shirts, tattoos, ball caps, age, youth, hope, despair, too much weight, too little weight, black skins, white skins, brown skins. They bring children with them. They also bring the shadows of children now without them. Their eyes are sunken, their cheeks are swollen, they shed tears or they don big cheery smiles as certain and solid as melting snow, or the wind. Some of them appear angry. Many appear sober. Most of them appear subdued.

It's a pretty sure bet that few or none of them know a thing about Winston Churchill, and his philosophy of never-give-up. But most of them don't give up anyway, especially with Dr. Schwartz on their side. The changing disease

"When I started (in 1990), we used to lose six to eight patients a month," says Norma Dansby, who sits on the board of directors and works in the Treatment Center. "Now if you lose one, you're pissed - they're not taking their medicines."

The biggest problem in Dansby's mind is the rancor between county officials, two or three former employees who quit the Aids Treatment Center under shadowy circumstances or were fired, and Dr. Schwartz, she says.

Her view of the non-funding from the county Health Department is this: "I think they were told to cut funding, and we're usually the first organization to be cut."

The director of Lee County's Health Department, Dr. Judith Hartner, has called Schwartz "difficult to work with" - their relationship is unarguably one of animosity. But she offers a different explanation for the cut to the ATC, and says "politics" or personality has nothing to do with it.

"Due to the downturn in the building industry," she says, "we have no supplemental funds. The governor has asked us to prepare a budget cut of 10 percent, and we've submitted that to his office. We get $200,000 in categorical money for AIDS patient care, and we've been supplementing that from our own (budget). We can't now."

Most of the AIDS money from the state - which Hartner distributes as she sees fit - has gone to the other AIDS clinic in town, the McGregor Clinic, also a non-profit organization that treats a similar number of patients, about 650. That clinic is facing funding cuts, too, Hartner says.

Asked if her office would repay the $73,000 wrongly billed to the AIDS Treatment Center, she replied, "No."

Then she questioned the amount, suggesting it might be nearer $20,000 to $36,000.

Hartner describes both funding for AIDS treatment here, and the relationships of caregivers or "patient advocates," as "complicated."

The McGregor Clinic receives the lion's share of state money distributed by Hartner's office "because it's an offshoot of what was the health department clinic," she says. "No, they don't do anything differently (than the AIDS Treatment Center)."

In fact, though, the ATC is a different sort of animal - a throwback to a previous model for AIDS treatment, in which the doctor is in the house most of the time. The contemporary model relies heavily on nurses or physician's assistants or other medical personnel for much of the care, and visiting doctors who appear only periodically, or consult by telephone.

That's partly because of economics and partly because of the changing nature of the disease and its consequences for patients, officials and caregivers say.

But Schwartz devotes himself to his center, body, heart and soul, it seems. An infectious disease specialist who has spent two decades concentrating on AIDS, he explains what's happened in typically blunt fashion: "There ain't no (expletive) terminal AIDS. It's a disease that no longer kills; things associated with it kill. It sets you up, but certainly cocaine, heart disease, all the rest - add AIDS to that, and less treatment, and then you get mortality."

Which doesn't mean it's not an immense problem in every life, and one that affects not only patients, but families, friends, even staff - about 10 right now at the ATC, supplemented by volunteers (a sign in the front lobby above a television announces, "Volunteers are needed.")

"I work here," explains Mishti Thomas, the head medical assistant, "because it makes me feel like I'm dealing with my own family. I LOVE working here." Political backstory

Some have not, apparently. Two former employees, Sean McIntosh and Dillard Larson, wrote to Florida Weekly last week strongly criticizing Schwartz and citing 2005 reviews by officials of his business plan and his methodology.

They also insisted that many besides Hartner, the county health director, have found him abrasive.

"Dr. Bob Schwartz is spending too much time looking in the rear view mirror...remembering how important he used to be," the letter says. (See Guest Opinions, on page 5, for the full letter.)

That rear-view mirror includes a history that continues to influence events at the ATC, however. During the Christmas season of 2004, recalls Earl Givens, two members of Schwartz's senior staff quit, including the executive director and the chief financial officer. A third was fired, says Givens. McIntosh, the chief financial officer, and Robert Bobo, then executive director, were the ones who resigned.

Givens, a former Navy SEAL and nurse who is now facilities coordinator at Lee Mental Health, the Ruth Cooper Center, had to step in behind them, says Schwartz, volunteering to straighten the books as executive director.

And he did, for the next 18 months. Although Givens will speak ill of no one, and insists he likes and even admires both Schwartz and Judith Hartner, he recalls a sense of embarrassment.

"We were a little embarrassed because they'd spent $286,000 of the $300,000 (in government grants) in the first six months of the fiscal year. Nobody knew. The Feds who were supposed to track that money didn't know, either, and we didn't learn where all of it went. And it sure wasn't Dr. Schwartz's job to know that - he's the medical director, not an accountant."

The next year, 2005, began a few days later. Schwartz's clinic was soon audited and criticized by federal Health Resource Service Administration officials who administer Ryan White monies, and put on probation. But the probation was lifted shortly after that, explains Givens.

Schwartz doesn't care about that, he says - it's water under the bridge. But in typically feisty fashion, he won't let up on Dr. Hartner, or public health officials.

"To constantly do the backroom, nickeland dime politics - that's wrong. And it's not just H.I.V. but across the board. Where is Dr. Hartner saying to restaurants, 'Get rid of trans fat!' Where is she trying to stop smoking in front of buildings? Where is she shouting from the rooftops, 'Get your kids vaccinated for human papilloma virus (HPV, often seen as sexually transmitted genital warts)? Where is she promoting testing for H.I.V. at driver's license bureaus?

"The population 50 and over should be vaccinated for chicken pox so they don't get shingles. That's $200, and nobody's paying for it - the insurance companies aren't paying for it. But if you get shingles you'll wish they were paying for it.

"None of that - to demand those things - costs the Health Department money, but where is the leadership? We're not getting it."

Meantime, Dr. Schwartz is getting more patients. ¦