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Source: The Texas Observer, February 11, 1994
A history of the Smith County Public healthcare clinics

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Bubba’s Got AIDS
An East Texas County in Denial
BY CAROL COUNTRYMAN

THEY’RE AN ULIKELY bunch of rabble rousers: Jerry Jamieson, slickly tailored corporate lawyer and Waco Baptist. His world never had come into contact with the poor. Reverend Tom Jackson, liberal Episcopal priest and seasoned activist; his long ponytail contrasts with his clerical collar, his Northern accent so different from Jamieson’s Southern drawl. Mike Murphy, atheist and scholar, professor by vocation, agitator by avocation. And Kerfoot Walker, M.D. – a curmudgeon who barks orders like a drill sergeant, sometimes reducing his patients to tears. He also purchases and clandestinely takes medicines into Mexico — a sort of oddity in the drug trade these days – crossing the Rio Grande to attend the poor in shanty towns clustered around U.S.-owned plants and factories. “It’s just my contribution to NAFTA.” he observes.

For the past year, this unlikely congregation has led a crusade to draw attention to the neglected state of public health in East Texas. They have formed a committee to agitate for a new health facility for the medically underserved in Smith County. They have stormed the Commissioners’ Court, insisting that the county meet its obligation to the poor. And under Jamieson’s direction, they began publishing Ad Vivendum Bene, a newspaper designed to educate East Texans about the facts and myths of HIV/AIDS – and to provide support and encouragement for the growing number of people in East Texas who have AIDS or have tested positive for the HIV virus.

“No one in East Texas wants to admit this disease is here. The schools won’t talk about it. Churches won’t respond to anything having to do with HIV. The county commissioners don’t want media exposure because they don’t want to be known as the AIDS focus for East Texas” – Walker waves his hand to dispel the obvious thought. “And in the meantime, Bubba’s got AIDS. And spreading it.”

In 1989, Dr Walker, director of the Tyler-Smith County Public Health District, collaborated with seven volunteer physicians in a bit of sleight of hand. Together, they opened an AIDS clinic in an eight-by eight room in an already overcrowded fire station-turned-clinic, and began treating AIDS patients from Paris to Nacogdoches.

“All the doctors were seeing these patients in their offices, and their other patients didn’t like it, so they called me and we set up a time to see them there,” Walker explained. “The commissioners didn’t exactly know everything that was happening at the time it happened.”

“These doctors are unbelievable,” said HIV case manager Cheryl Cooper, described by the patients as the heart of the AIDS clinic. “They all volunteer, and they haven’t missed a scheduled appointment.” Cooper tells of one physician whose patient could not pay the high cost of the proscription drug AZT — until the doctor’s office staff took up a collection. “We ended up being able to get the prescription for the patient, but it shows the lengths these doctors go to for their patients.”

For HIV/AIDS patients, the new clinic often is the only safe haven for them — free from the hostility and fear they encounter in their everyday lives. Several participate in a “Writing as Therapy” class that Murphy teaches. Conceived by Cooper, who holds degrees in nursing and anthropology, the course helps some patients to deal with their disease, and others, their impending death.

The need for such a clinic in East Texas has become more evident each year. In 1983 the city-county public health clinic tested 260 people for the HIV virus. Thirteen tested positive. The next year, the same number were tested and the positives increased to 26. In 1987, 260 were again tested and again the number doubled, reaching 52 positive. Currently, over 250 HIV/AIDS patients receive treatment at the clinic, which provides AIDS services to several East Texas counties. According to the Texas Department of Health, between the years 1986 and 1990, rural Texas saw a 146-percent increase in the number of diagnosed AIDS cases, compared to a 95-percent increase in urban areas. Much of the increase in AIDS in rural Texas is a result of the return of those afflicted with the disease to their families.

“That’s how Jamieson came to Tyler – to be closer to his brother. A classic Type A personality, aggressive and driven, Jamieson was a success by 40. “I practiced law for 22 years in Waco, counsel for a mortgage company. My wife was a Junior Leaguer. We were members of the Country Club. Toured Europe. Hired drivers and touring cars. We spent,” Jerry said in a raspy voice. “Then the industry collapsed. I lost my job, my money, my wife.” Jerry paused and looked away from the coffee he was stirring. A transfusion of tainted blood in 1982, one of four he received for bleeding ulcers, Jamieson believes, was the event that altered the course of his life.

“I woke up dying. And then it hit me that, other than making money, I’d not done much with my life.” For Jamieson, his first visit to the clinic in Tyler was like Alice falling down the rabbit hole.

No clean, antiseptic smell associated with a hospital or doctor’s office. Instead, a packed waiting room, with the line snaking out the door. A child with chicken pox toddling at the feet of a woman with tuberculosis and a man with AIDS. Hispanic women and their children stood or sat in Iine inside while their husbands waited outside. A street woman in colorful getup shrugged against the wall, while a preoccupied young white man in western garb tapped his booted heel and cracked his knuckles, anxiously awaiting the result of his AIDS test. Two older men, one asleep, slumped in chairs.

Kind of a bus-station-waiting-room look, where the trip is medicine. And the way in is the way out. So, there is always a cluster at the door. Only one bathroom to accommodate all these people, Jamieson thought. My God, all that opportunistic infection in such a confined space.

“I was so sick and tired at first that I didn’t really notice how awful conditions were there. Plus, I was a good Republican. I thought indigents were the scourge of society…. Then I met this guy who was out of work and it wasn’t his fault. But he had to bring his wife and children over there, they didn’t want to be using the clinic. I looked at his eyes and saw such despair in there. I started talking to Kerfoot and started thinking about stuff. It became a big deal. I looked around at the other people and I realized what this place robs you of – your human dignity.”

“It’s very difficult to be indigent in Smith County,” Dr. Walker explains. “Getting access to indigent healthcare in Smith County is itself a challenge. Not just because the county has defined indigency for one person at an income not exceeding $75 per month — far below the federal poverty guidelines. Not because there is no city bus service to the clinic. Not even that few physicians in Tyler accept Medicaid, often the only form of payment the poor can offer. What really makes health care inaccessible in Smith County, especially if you are, say, sick or disabled, is the building itself. The sick and infirm had better be in pretty good shape if they want to get into it.

No handicapped parking at the clinic. No parking, period. With luck, you might find a space on a side street, behind the Youth Correction Center, or across the road near one of Tyler’s well-maintained parks. Tyler has always taken pride in its parks. Two ways to enter the clinic – a steep dirt trail littered with tree stumps, loose rock, and hanging branches, or even a steeper, partially paved private drive, littered with chunks of asphalt and loose rock. And deep potholes.

And though there are no warning signs, you need be aware of falling rocks from the building, which periodically crash onto the porch below.

At the clinic, the obstacle course continues. A wedge of plywood serves as a wheelchair ramp — the county’s attempt to comply with the Americans with Disabilities Act. The space inside is divided by a makeshift partition, which makes the small place seem even smaller. Buckets line the floor to catch the water leaking through the roof when it rains and the cement floor has no covering, so women in heels often trip on rotting expansion joints.

One dollar. That’s how much Smith County pays to lease this old fire station, abandoned by the city of Tyler years ago, to house the Tyler-Smith County Public Health District Clinic. Last year 25,000 people made their way through this clinic for adult health care, treatment for sexually transmitted diseases, and clinical care in neurology, HIV, tuberculosis, podiatry, general dermatology, diabetes and, until the unit was moved to St. Paul’s Methodist Church, pediatrics.

Anyone is eligible for services at the clinic, with the amount of payment determined by income. “If a person is 100-prcent poverty or less, they pay a buck or nothing, depending on what they have in their pocket,” Dr. Walker explained. “If over 200 percent, it’s four bucks, if 300 percent, it’s 15; if they’re over that, it’s 25, and that includes the doctor, the nurse, the lab, and medicine. Of course I’ve run into all kinds of problems with the state of our pay scale. And some local pediatricians have written complaints about our prices, telling us to raise the rates on our immunizations because they were losing their patients to us.”

Those who work and volunteer at the clinic see the health district as the bastard stepchild of the county, which reluctantly provides only minimum funding, like court-ordered child support. Other money from the clinic comes through state and federal grants, and what Dr. Walker calls “scrounging.” Walker, the only full-time physician on the clinic staff, spends afternoons in his office, which also serves as the clinic break room, on the telephone, locating physicians who will donate time and medicine. He also fields calls from area schools reporting outbreaks of infectious diseases, from reporters wanting interviews and on this particular afternoon from physicians volunteering for a medical-aid trip to Belize. He relies heavily, he said, on People Attempting to Help (PATH), a non-profit, inter-denominational outreach program, which helps with patient care, counseling, and housing and food for the poor.

“Paying for pharmaceuticals for the poor, by far is the single most expensive program we have,” said local PATH director Lorraine Grant. In 1992, PATH spent over $42,000 on prescriptions for the poor. The figure increased to almost $60,000 in 1993. In only the first quarter of 1993, PATH spent more than $17,000 to provide 443 persons with prescriptions, while feeding more than 4,000 families during the same time period cost the organization $9,000 – a bargain compared to providing medication. “We have to figure out a way to take advantage of sample medicines. The physicians in Tyler are willing to donate their samples, but Dr. Walker has to have a place to dispense them, and a part-time volunteer pharmacist,” Grant said.

For more than a decade, Walker had called for the county to find a larger, more suitable building to house the clinic. It hardly seemed like an outrageous demand; after all, the medical industry is the largest employer in Smith County, with three constantly expanding hospitals in Tyler alone. But County Judge Larry Craig, a pharmacist, and other county commissioners have shown little interest.

“You know, a government agency gives the least money to whatever bothers it the least, and for the county, health bothers them the least,” said Walker. “But the fact that goes over everybody’s heads is if you have a healthy child, you will develop a healthy student; if you have a healthy student, he will become an educated adult; if you have an educated adult, you have a taxpayer in your county. But nobody sees that far.”

According to County Commissioner Andrew McIontree, whose precinct includes many who use the clinic, the city and county both share responsibility for the clinic. He admits the line is not clear. The county is responsible for maintenance and operation of the building, the city is responsible for the building itself. “The county judge and the commissioners are well aware of the dilapidated facilities over there,” said McIontree. “Dr. Walker has not been hesitant in informing us of the conditions.” McIontree added that conditions at the health clinic illustrate how the poor are treated in Tyler.

In September a group of patients and concerned citizens, led by Jamieson, asked the commissioners’ court to shift taxpayer dollars set aside for a proposed $90,000 pay raise for commissioners and top county officials to the clinic’s operation. The court refused the request and the commissioners responded that they needed the pay raise, which increased each of their annual salaries by almost $10,000.

To Jamieson, the commissioners had drawn a line in the sand and he realized that the only way to change the way the court disposed of the public’s money was a court order. “They kept saying they needed that pay raise,” Jamiesion said. “They kept comparing their salaries to those in Plano. But if they want to see need, they should walk into that clinic.”

The commissioners voted themselves the pay raise and Jamieson informed Judge Craig of his intentions to file a federal class-action lawsuit if the county didn’t provide a reasonable solution to the problems at the clinic. “We’ve got The Judge here in the Eastern District,” Jamieson said, referring to Senior Federal Judge William Wayne Justice, who has a history of ruling on behalf of the disenfranchised. “And it just might get into his court.”

Three months earlier, Jamieson had presented Commissioner McIontree a petition signed by almost 200 persons who use the clinic. The petition stated that conditions at the clinic are “deplorable” and do not comply with state and federal standards, that there is no access to the clinic for sick and handicapped people, and that, among other things, the deficiencies that violate state and federal laws violated the petitioners’ civil rights.

Jamieson also recognized that federal law provides a powerful lever to move the commissioners’ court. The Americans with Disabilities Act (ADA), which Congress enacted in 1990, deals specifically with discrimination that architectural barriers impose upon the people with physical disabilities.
Advocacy Inc., a non-profit federally funded organization that uses litigation and advocacy to advance the rights of the disabled, agreed to take the lawsuit. In the fall, Helen Ferguson, of Advocacy, visited the firehouse clinic.

“I’ve been evaluating facilities for eight years now all over the state of Texas and this is the worst I’ve seen….” Ferguson said. “They couldn’t even get a wheelchair through the door.” According to Ferguson the clinic in Tyler is the first public health facility brought to the attention of Advocacy Inc. “And bear in mind that public entities that have been drawing federal monies for 20 years have had ample time to come into compliance. Whether they had a transition plan or not, they’ve had time,” she said.

The Americans with Disabilities Act, enacted by Congress in 1990, requires all public facilities to submit a self-evaluation and transition plan, then come into compliance with the barrier-free provisions of the act.

Infuriated county officials countered by threatening to shut the clinic down altogether, until Jamieson pointed out to them that they don’t have that option. State law requires a county to spend 10 percent of its receipts on indigent health care and burial.

In the end, the threats made by Smith County’s elected officials proved to be bluster. Confronted with constituent activists who refuse to go away and litigation conducted by an organization whose lawyers understand the applications of the ADA, in December, Smith County purchased, through auction, a new facility to house the clinic. The new building will provide space for separate waiting and treatment rooms for HIV/AIDS, tuberculosis and pediatric patients. One county official stated that the new building was purchased “in spite of Jerry Jamieson.” The building was purchased one day before Advocacy Inc.’s locally publicized visit to the firehouse clinic.

“I don’t care if it is done ‘in spite’ of me or not,” Jamieson said. “I only wanted a clinic.” He is continuing his class-action lawsuit against Smith County. “Advocacy Inc.’s lawyers are talking it over – just in case I should die before it’s heard – and make sure they do right by the clinic. And Kerfoot, and the patients. And that the new clinic is ADA-compatible.”

Father Tom Jackson and Mike Murphy say they intend to ask the county to name the new clinic after Jamieson. “I think it threw the county judge for a loop when he found out Jerry was a lawyer,” Jackson said. “Ant that he meant business.”

At his home in the heart of Tyler’s Azalea District, Jamieson glances at the letter he recently received from President Clinton, in which the President commended Jamieson for his efforts to educate the public about AIDS, and the support he has provided HIV-positive persons, through Ad Vivendum Bene,

“If anyone would have told me a year ago that I would be fighting for the poor, I would have told them they are crazy,” Jamieson said. “If anyone would have told me I would be publishing a newspaper, I would have told them they were crazy. But maybe I’ve done it because I’m poor now. Maybe because I can’t stand the thought of these poor women, with their little children, having to use that one dingy, dirty little bathroom that everybody else uses.

“Or maybe I’ve done it so when people attend my memorial service they can say: “He did something.”

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Available in the tridd library:
http://www.tridd.com/docs/answers/BubbasGotAIDS.pdf