By Chuck Strouse
By Scott Fishman
By Terrence McCoy
By Ryan Yousefi
By Ciara LaVelle, Kat Bein, Carolina Del Busto, and Liz Tracy
By Pepe Billete
By Ryan Yousefi
By Kyle Swenson
There is a certain type of drug trafficker who doesn't fit the popular image. These dealers aren't rich and don't live large. They're underground outlaws who usually look more bedraggled than menacing. They are indigent AIDS patients who sell their sophisticated and costly HIV medications on the street for cash.
It's difficult to accept the notion of sick people selling the very medicine that can make them well, that could even save their lives. But many such traffickers do exist in Miami, though they are nearly invisible, because they live at the periphery of society and few are willing to expose the black-market network they believe provides them the means to survive.
These people, who are almost always addicted to other drugs and who subsist in the most precarious of circumstances, are at the lowest level of an efficient criminal system that is set up to rip off Medicaid, the federal program that finances most medical care for very low-income and disabled citizens.
Last month federal, state, and local law enforcement authorities arrested 75 people in Miami and charged them with cheating Medicaid of ten million dollars via schemes involving the sale of prescription drugs of all kinds, including AIDS medicines. It was Miami-Dade County's second round of mass arrests relating to illegal traffic in prescription drugs in just over a year, by far the largest yet in Florida, and an indication that Medicaid fraud has become a priority for law enforcement. The recent arrests resulted from investigations in and near the Little Havana area, and targeted almost exclusively Hispanic pharmacists, pharmacy employees, and clients.
This story explores only one aspect of Medicaid fraud -- that within the AIDS community -- and it takes place in the heavily African-American neighborhoods northwest of downtown Miami, such as Overtown, Allapattah, and Liberty City; almost all the AIDS patients interviewed are American blacks. It's true that white Hispanics and Caucasians sell their AIDS medicines in other drug-infested inner-city enclaves (Little Havana, for one), but demographics alone suggest that blacks, who suffer disproportionately from both poverty and AIDS, make up the majority of AIDS drug traffickers in Miami.
All AIDS patients in this story use aliases. Those who agreed to share some of their experiences or information are exceptional; simply raising the subject usually provokes denials and silence. Like any form of drug trafficking, this kind is highly profitable (although not so much for the AIDS patients themselves) and thus protected by secrecy. Perhaps by threats of violence, too; one woman, who sold not her AIDS medications but other prescription drugs on the street, said she was threatened with death from an "accidental" overdose of heroin if she continued talking to the press.
Regardless of the seriousness of that threat, selling AIDS drugs is its own death sentence. Even if the sellers are never arrested and jailed, they face consequences more dire, and with unique implications. By neglecting their prescribed drug regimens, they're clearly hastening their own demise. Less obviously, they are contributing to the increasingly ominous development of drug-resistant strains of HIV, a danger to all strata of society.
"Green and white, that's what it's all about. Green and white," intones Wayne, referring to the color of money. He is on the job early today, fortifying himself with a bottle of Bud Dry. At eleven o'clock in the morning he can't keep much else down. In fact beer is about all he can stomach at any given hour, with the help of some marijuana.
Gray clouds have begun to gather in the azure sky in preparation for Miami's usual afternoon downpour. Also collecting in Wayne's vicinity, which is outside the pink façade of the privately owned Metro-Dade Medical Center at 1521 NW 54th St., is a handful of men and women who could be considered his co-workers. They mill around an unshaded pay phone on the sidewalk and along a covered walkway leading to the clinic. Languidly exchanging news and views, they pause to take quick hard puffs on cigarettes, all the while watching with darting eyes to see who will arrive next. These Medicaid clients aren't here for medical treatment, exactly, despite the fact that all are infected with HIV and some have full-blown AIDS. No, they're working. Green and white.
Most are waiting to see the clinic's sole doctor, Marvin Isaacson, who will write them a few weeks' or a month's worth of prescriptions. These will quickly be filled (all paid for by the government) and the medicine sold (or not filled and the actual prescription sold), either to men waiting outside in cars or to some other prearranged contact. Dr. Isaacson is aware that some AIDS victims sell their medications for cash, but he isn't going to stop writing prescriptions. "This is a problem everywhere," Isaacson acknowledges. "I don't know how you can control it. But all we do is write prescriptions for medicine that's going to help them. After that it's out of our hands. We see people two times a month. What they do with the medication I don't know. I don't know how many doctors they go to. I cannot police 150 people coming in here with a variety of problems. I have a patient [who has improved markedly]. I assume, judging by the results, that she's taking the medication. But even if she's not getting better, that doesn't mean she's not taking it. Sometimes a drug doesn't work."
Wayne, 62 years old and exuding a wry world-weariness, scowls as a red Dodge pickup truck pulls to the curb a half-block to the east along NW 54th Street. Immediately two men approach the cab, one to each window, converse with the driver, and walk back toward the pay phone. For most of the day this truck and other vehicles will come and go, dropping off patients, picking up others. Law enforcement officials refer to these drivers as "unlicensed brokers," the next step up the criminal ladder from the street sellers. AIDS patients generally call them middlemen or runners (although runners more often steer patients to middlemen). The brokers buy the meds and/or the prescriptions, then sell them either to a bigger broker, a pharmacist, or a pharmaceutical wholesaler.
Wayne drains the beer bottle. Beneath the brim of his black cap, his eyes droop almost mournfully, but it's impossible to read any emotion in them, only that bleary look produced by freshly smoked crack and marijuana. "I need tires on my car," he announces more to himself than to any bystander. "And I got $20. I gotta live. I gotta survive." Someone calls to him from the clinic waiting room, and he rushes toward the door, his striped shirttail flying. "I'll be out in ten minutes," he mutters.
He emerges with a month's supply of prescriptions for the newest AIDS medications, called protease inhibitors, that must be taken in conjunction with each other. "They call it a cocktail," Wayne says unhappily, as if trying to deny the permanence of the virus that has defined his existence for what seems like several lifetimes. He won't reveal the names of the medicines he's supposed to take, but he has no problem explaining why he's not going to take them. "Never proven that they work," he insists. "Unless I'm dying in the hospital and they give me something and it saves my life, you can't convince me it works." He sidles over to the darkened driver's-side window of a white sedan parked at the curb. After a quick conversation, Wayne frowns and shakes his head. "His ass don't have enough money," he says a few minutes later, gesturing with his goateed chin toward the white car. Then he notices that the red pickup is back, having driven away and returned to let off a woman and her baby at the clinic. Wayne moves to speak with the pickup driver, a white man sporting a shaved head and gold chains.
He climbs into the cab and they drive to a pharmacy in Allapattah, where Wayne legally fills one of his prescriptions, likely for pain pills such as the popular Percocet, though he won't say. The driver then buys the bottle from him (going rate: $2.25 to $2.40 per pill) and returns him to the clinic.
The routine is not unique to the Metro-Dade Medical Center. Many patients visit as many different doctors at as many different offices as they can. Wayne, for example, is a client here and at Specialty Medical Care Center at 1313 NW 36th St., another clinic catering to indigent patients. Each time he sees a doctor he receives prescriptions, and each time he walks out he can convert his medicine to money in a variety of ways, from a quick sale to a man in a car to the more profitable encounter with a buyer in a pharmacy or even in the comfort of his own home. (Most buyers make house calls and provide transportation to a pharmacy if necessary.)
A half-hour later, now with a bagged can of Schlitz malt liquor in his hand, Wayne catches a ride to Overtown with three of the people who've been waiting around the Metro-Dade clinic. They stop at Viko Drug Store at 1490 NW Third Ave., where they plan to exchange their prescriptions for green-and-white bills. Not just anyone can do this; it's referral only. Today the pharmacy is busy, so busy Wayne reports that the pharmacist is running short of cash and can offer him only half the $200 he expects for his prescriptions. So he takes $100 with the proviso he'll return the next day for the balance. (Viko's owner and pharmacist, Victor Osagie, says he is unaware that his small store is one of several pharmacies named by AIDS patients as a place to sell prescriptions. "I fill prescriptions," Osagie insists. "I don't buy them. Who was it who told you this?")
Total Medicaid expenditures in Florida are $6.5 billion annually. Miami-Dade County is home to about 24 percent of the state's 1.4 million Medicaid recipients. This year the program will spend $1.1 billion on pharmaceuticals throughout Florida, according to Jerry Wells, pharmacy program manager for the state Agency for Health Care Administration, which administers Medicaid in Florida. Of the total pharmaceutical budget, $130 million will go to HIV medications, a fourteen percent increase over last year.
Wells estimates that an astounding $50 million to $100 million per year in Medicaid reimbursements result from fraudulent claims, though there are no figures for fraud involving AIDS drugs specifically. (Medicaid is separate from Medicare, a federal health program for the elderly and disabled.)
"The general public has no conception of what goes on," declares Rocco De Leo, Miami bureau chief of the state attorney general's Medicaid fraud-control unit. The black-market demand for all kinds of prescription drugs, from sedatives and pain pills to expensive blood-pressure and depression medications, is seemingly insatiable. Cesar Arias, a drug agent supervisor for the state Department of Health, oversaw several of the reverse-sting operations in Little Havana that led to the recent arrests. Arias repeatedly gave a handful of informants money to buy medicine to resell to pharmacists. The informants were either agents posing as brokers or were actual brokers who had been arrested and had agreed to cooperate with the state. Numerous transactions were captured on a hidden camera carried by an informant's associate. "In three months I bought $25,000 worth of pharmaceuticals from brokers," Arias recalls. "We sold them [to pharmacists] for at least three times that. And we could have bought more if we had more money."
The basic routine, as described by investigators and participants, is pretty much the same regardless of the type of medication. Middlemen or brokers buy medicines from patients for about a tenth to a seventh the drugs' retail value. The brokers then sell the medications, this time for 20 to 25 cents on the dollar, to another broker or to a pharmaceutical wholesaler, who will charge a pharmacist 35 to 45 cents on the dollar, still a much cheaper rate than obtaining the drugs through legitimate wholesalers. Whether the pharmacist eventually sells the repackaged medications at retail price or provides them to customers with insurance and then bills the insurance company or Medicaid, he makes a huge profit.
In another scenario a patient or a broker simply sells prescriptions to a pharmacist, who then bills Medicaid at a much higher rate, as if he had actually filled the prescription for a customer. There are many instances of "pharmacies" existing only as post office boxes, while the owners submit legitimate prescriptions to Medicaid for reimbursement but never incur the cost of purchasing medicines. This scheme, though, has become riskier than operating a real pharmacy with real medicine, because state auditors can easily compare Medicaid billings with actual drug purchases. In one segment of last month's Medicaid fraud sweep, 56 people were arrested for involvement in an operation by one pharmacy that billed Medicaid for three million dollars in prescriptions that were never filled.
Some of those involved in prescription fraud are or were traditional illicit drug dealers, investigators say, but most are just enterprising working people. "In some areas we've seen old dope dealers, some really bad guys," De Leo says, "but overall most of the [alleged Medicaid defrauders] went into a business legitimately and found so many ways to make easy money." Among those apprehended in the September roundups were the owners of a barbershop, a fruit stand, and a calling-card enterprise -- all of whom allegedly used those shops as fronts for their more lucrative prescription-brokering businesses. One broker, whose name can't be revealed because it would endanger his life, never even bothered to establish a legitimate front business, yet he owns two cars and a four-bedroom home with a swimming pool. He's never paid tax on his broker income, receives food stamps, and has already put his children through college. That broker was arrested several months ago, after which he agreed to cooperate with investigators.
The AIDS patients working the next level down, the ones who supply the brokers, make a lot less money. If they had to purchase their medications, most would have to pay at least $1000 per month; more often the total would be in the $7000 to $10,000 range. Yet an AIDS patient who pockets a mere $500 per month for selling those medications is doing well. For example, a 60-tablet bottle of Combivir, a popular new protease inhibitor patients say they sell on the street for $15 to $25 per bottle (on rare occasions as much as $50), carries a wholesale price of $470 and retails for $565.
Joe, a young, round-faced man wearing a black knit cap and sweating rivulets in the heat of the day, is pacing in front of the Metro-Dade clinic. Glancing back and forth, he begins a monologue on the subject of AIDS medications. "All you gotta do is ask [a doctor] for Combivir and you good to go," he allows. "They're buying all the AIDS drugs now. It's like that now. It's a black market. Some places on the street, they give you like twenty dollars for some Combivir. Ten for Viramune. Some places you bust fifty dollars [for a bottle of Combivir]. Then you outta your medicine for the whole month. What you need it for? You gonna get high." Joe's tongue, visible when he speaks, is chalk-white, and his eyes roll every few minutes as though he's dizzy.
As Troy, a lean man of about 40, leaves the clinic, he stops to converse with Joe. "It's all according to who you know, who's paying how much for what," Troy says, explaining the AIDS-meds pricing system on the street. "These days there are quite a few middlemen. They're all around town; they're everywhere. It didn't used to be like that. There's so much money in it now. You can get about the same for Crixivan as you can for Combivir, but [Crixivan] is not that popular lately. Sustiva is; it's the same [price] as Combivir. The thing is, the middleman, he's getting paid a lot more than you are."
Joe interjects: "[The middlemen] are selling back to the pharmacies. It's fucked up. If I knew the top man I'd go to him. But no, I sure don't...."
Troy, bumming a cigarette from a passing woman, nods slowly. He lights up, takes a deep drag, and stares out at the street with a resigned expression. "Most people don't know where the middleman sells to. He ain't gonna let you know. He's gonna protect himself good. And hey, [here Troy pounds his T-shirted chest with his fist, then lets his arm drop to his side] them boys is living large."
Joe ambles west on 54th Street toward Seventeenth Avenue, where in about a half-hour he'll catch a jitney back home to Tenth Street in Overtown. He passes an abandoned house next door to the clinic where another patient, a tall older man who is so skinny he looks withered, is standing in the yard at the side of the house, smoking crack. "Hey, don't mess with that!" Joe calls jokingly.
Lately there's one drug every AIDS patient wants. It's Neupogen, an injectible medication that boosts the white blood cell count and is currently the gold mine of AIDS meds. The patient for whom it is prescribed can, with the right connection, make $200 to $300 for a box of ampoules that retails for $1700. Here the shrewdness of the sellers comes into play. A doctor can determine from monthly blood tests whether a patient is taking Neupogen. The savvy ones inject their Neupogen for a few days before their next doctor's appointment, having saved the rest to sell. "You have to be smart," advises Aaron, who just turned 40 and has been HIV positive since the Eighties. "I got some in a box right now I'm about to get rid of."
Patients who've been in the sales business a long time have their own brokers who not only transport them to pharmacies to fill prescriptions but make house calls to buy medications, and even pay commissions for bringing in other customers. "I use Mr. Manny," Aaron confides. "That's what everyone call him. He works with his son. Child, that boy owns a big house, and he just bought himself a brand-new pickup truck." Aaron is tall and big boned, and his deep voice has a musical, feminine lilt to it. His naturally fleshy face is worn and scarred from more than fifteen years of rough life on the street, selling his body for crack and knowing AIDS is catching up with him. Every time he becomes sick he tells himself he must stop the crack for good, but once he begins feeling better, he's back on it.
From time to time Aaron will take some of his AIDS medicine, but because he (like many other Medicaid recipients) regularly visits different doctors at different clinics, he winds up every month with more medication than he'd need even if he were following a strict regimen and not selling everything he gets his hands on. Such doctor- and clinic-hopping is common and legal, even though it's basically just a way to convince as many doctors as possible to write as many prescriptions as possible. Unless the doctors are in contact with one another, they don't know what their patient has or hasn't been taking. And physicians at privately owned clinics normally are not in touch with one another.
Aaron says he usually goes once a month to the Metro-Dade clinic and to the Specialty Medical Care Center on NW 36th Street. So he receives double the number of prescriptions. Since Medicaid doesn't pay for unlimited prescription drugs per month, one way Aaron gets around possible problems is by paying cash for some of his cheaper prescriptions, such as like Percocet, a narcotic painkiller that isn't an HIV medication but is prescribed to AIDS patients. "I [fill] two Percocet [prescriptions]," he explains. "One I pay for and the other I don't, and both I sell."
When he thinks back a few years ago, before many of the really expensive drugs were in wide circulation, drugs such as Atovaquone, Crixivan, Combivir, Sustiva (each costing from $400 to almost $700 per month), and before the advent of Neupogen and Epogen (another injectible medication, modestly priced at about $250 for a month's supply), Aaron remembers how much time and work it took just to earn a few hundred dollars.
That was before he had a regular broker and sometimes had to shop around bottles of medicine to different buyers. He'd spend hours near pay phones at shopping centers, waiting for a runner he'd beeped to return the call. Then if he were lucky, the man would feel safe enough to meet him at a pharmacy to complete the transaction of exchanging a prescription or bottles of pills for cash. Today, Aaron says, he can make $1000 in a good month selling AIDS meds. The market is booming. "They got it going on more than ever because there are more AIDS drugs now," he says cheerily. "I call my man, first of the month, tell him to meet me at the pharmacy, he meets me at the pharmacy."
In an attempt to cut down on doctor-hopping and the accompanying prescription proliferation, the state Agency for Health Care Administration has requested permission from federal officials in Washington, D.C., to restrict Medicaid patients to only one doctor and one pharmacy. That request is expected to be granted and to take effect in about a year. Meanwhile most clinics have already tried, to some degree, to keep closer tabs on their patients and to run off the hustlers who wait outside.
"They would post up outside," recounts Albena Sumner, director of social services for the Specialty Medical Care Center. "One guy with a van. You get in and they give you money. You have runners who will approach patients and hustle patients. It took us a long time to clean this up. We got rid of 200 patients who we knew were just running scams." Yet as happens after most crackdowns, the vigilance has simply forced participants to move elsewhere or to vary their routines.
"There's so much 'game' out there I can't keep up with it," huffs one young woman waiting at the Floral Park Healthcare Center, just across 54th Street from the Metro-Dade clinic. Floral Park, however, is not game-friendly. It's not a place where patients run in for ten minutes and leave with a pocketful of prescriptions. Off-duty City of Miami police officers keep watch during working hours and have instructions to banish from the clinic anyone they spot selling or soliciting or otherwise making trouble.
Floral Park, like other medical offices with virtually all of their patients on Medicaid and other forms of public assistance, is where the most difficult AIDS patients end up -- difficult to treat because, owing to poverty and ignorance, they've never received decent care and their illness is now far advanced, or because years of drug addiction combined with HIV have rendered them physical and mental invalids. They're easy prey for the lurking hustlers who are paid to steer patients to certain brokers who will buy their prescriptions or medications. Even at Floral Park a buyer is never far outside the front door. "When you come out of a clinic," says an AIDS patient who sells his meds, "there's always someone there to ask you what you got."
Dr. Shelley Wolland, Floral Park's chief physician, scoots around on a wheeled stool in the clinic's infusion room. Patient charts are balanced on her lap. Her strawberry-blond hair is braided and beaded, and multiple earrings adorn her pierced lobes. About five clients, resting on black-vinyl recliners, are hooked up to intravenous blood compounds. Others wait to be seen in a lavender-painted examining room. On busy days the large infusion room is clogged with nurses filling out charts and hooking up IVs; patients trying to maneuver around tables, recliners, chairs, and wheelchairs while grabbing sandwiches and drinks from a refrigerator; everyone arguing, napping, gossiping. On the walls Wolland has tacked snapshots of many of her patients when they first came to her. Most are grimly skeletal, black blotches marring their skin. They have visibly improved, some in just a few months, and they all praise Wolland for saving their lives.
"When I first come here I had the attitude, 'Just give me some medicine so I can sell it,'" says one man, speaking slow and thick, his eyes moist. "I ain't with that anymore. Dr. Wolland here, she made me see I have some hope."
But when the man leaves, an acquaintance quietly asserts that he's still selling his meds. That may or may not be true, since the acquaintance might simply be expert at spinning yarns, or may himself have gone back to smoking crack. One new patient, Ray, a young, fine-featured man who has been leaning back in a recliner, nods and lifts his upper back from the sticky vinyl of the chair. "I need the money [from selling meds] because my [disability] check isn't but $565," Ray announces. He seems vigorous and healthy, though the pants and shirt he's wearing look old and threadbare in places. "But if I do that, I'll get sicker. That's what I keep telling [my roommate]. I knew he was selling his [AIDS] drugs but I just found out there's this whole network they've got. I come home one night and there's this guy sitting in the living room -- Doctor K. He the man. You beep him, he'll come to your house and buy what you got."
Recently, after the boyfriend of a clinic patient was observed trying to find a buyer for some Epogen he was carrying in a paper bag, Dr. Wolland told her nurses and the police officers to banish the man from the clinic. "I can tell what's going on," Wolland says, "when somebody asks me for [a certain medicine] that he never had before. It's got to be a street thing. They come in and say, 'I need my Neupogen and Epogen.' I look in their file and see their blood work and I know they haven't been taking it and aren't [suffering from a condition those medicines can help], and I know someone's been offering them money for it."
Besides the hard data in their medical charts, not much is certain or reliable about many of these patients who drift from apartment to boarding house and in and out of drug rehab. But there's no doubt the indigent people of color who flood clinics like Floral Park are increasingly the future of AIDS in Miami-Dade County. The Miami metropolitan area now ranks second only to New York in per-capita AIDS cases in the nation. Of the almost 23,000 people with AIDS in Miami-Dade, blacks account for 49 percent, despite being just 19 percent of the population. (Hispanics, 49 percent of the population, represent 32 percent of AIDS cases, while whites, 30 percent of the population, account for 18 percent of AIDS cases.) Almost twice as many black men as white men have AIDS. And black women now account for 78 percent of all AIDS cases among women in the county. Even more dramatic, of 464 babies recently born with HIV, 400 were black.
"It's not an epidemic within our community, it's a pandemic, and the only way to stop it is with education," asserts Tomasa Del Toro, supervising pharmacist at the Winn-Dixie pharmacy on NW 35th Street at Seventeenth Avenue in Allapattah. Del Toro's pharmacy fills most of the prescriptions written at the nearby Specialty Medical Care Center, and she says she and her staff have learned from experience to be suspicious of many customers. "People only see the tip of what's going on out in the [AIDS] community," she claims. "I've heard everything from patients. We filled some prescriptions for a man, all [costing] more than $5000. Within two hours he came back saying somebody had stolen them. People think you're making this stuff up and you're not."
It's not surprising that few mainstream AIDS activists -- mostly gay white men who have devoted much of their lives to working in the AIDS arena -- are familiar with the world of street-level traffic in AIDS meds. "I both make my living [in AIDS-related businesses] and play around people with HIV, and I don't see it," says Luigi Ferrer, a long-time community activist serving on the board of several national and local AIDS advocacy organizations. "I've seen a lot of abuses, but not with medications like this."
For years AIDS organizations locally and throughout the nation have collected medications to distribute to those who couldn't obtain or afford the drugs they needed -- working people, for example, who didn't qualify for Medicaid but didn't have insurance. The groups solicit donations of medicines, mainly from the estates of deceased AIDS victims and medical offices (pharmaceutical companies apparently never contribute), and some even conduct AIDS medication "drives." People involved in local AIDS service organizations say this so-called recycling has declined in Miami, but there are growing efforts in other parts of the United States and internationally to develop recycling networks on behalf of AIDS victims. Humanitarian recycling, however, is worlds apart from the subsistence trade in AIDS medications.
Florida is a stingy state when it comes to public assistance, so a single mother who may receive $40 worth of free food and food stamps each month might justify selling her AIDS drugs to feed her family. That pitiful story, however, is just another mental trap that people with substance-abuse problems fall into, social service workers say. "They may not own up to it," says Karen Gilbert, supervisor of case management for MOVERS, a nonprofit AIDS service agency in Liberty City, "but there's only one thing responsible for them selling their medication, and that is drugs. Most of them live in the moment, and it's the choice they make at the moment. It's a real problem because clients don't understand that if they do sell their medication, it's going to throw their whole immune system off track."
It's also a dilemma for doctors, who have recently been reminded by several published studies of the dangers of haphazard administration of AIDS drugs. If the medications aren't taken according to a strict regimen, not only are the drugs' effects minimized or canceled, but resistant strains of HIV that don't respond to any drug are increasingly likely to develop. "HIV medications have to be taken every day, on a consistent program, and there's not much room for error, to be honest," says Dr. Ernesto Scerpella, a physician who treats AIDS patients at Jackson Memorial Hospital's Special Immunology Clinic and works at the University of Miami's respected AIDS research program. "But there's another problem for society. You could even have a doomsday point of view on this." When the mutant viruses keep multiplying, Scerpella explains, they attack not just new and defenseless victims but render defenseless those already infected with other strains who may be doing well on existing medicine.
Thus it could be disastrous to keep placing AIDS drugs in the hands of people who are going to take them only occasionally and sell them the rest of the time. "I do believe treatment should be offered to every patient," Scerpella reasons. "Obviously the key thing for me is whether he is going to be able to make all the changes in his lifestyle necessary to adhere [to the proper regimen]. If I can't convince him to take the medicine seriously, if he'll end up selling it or whatever, sometimes we decide to withhold therapy and continue educating him. You have to understand it's a difficult decision. When I have patients who openly admit to using crack, I usually prefer not to start therapy until the drug problem is solved, because at this point his priority is crack. When you have a very advanced condition and they're approaching the end, but they're using drugs, you'll usually just [prescribe AIDS medications] because you don't have six months. But when a patient goes on a drug or alcohol binge, he will forgo his HIV medication, and that brings a resistance problem for the patient and also eventually for the public."
Wayne is feeling fine, other than being tired and thirsty and annoyed that he still hasn't got the tires for his car. He's back at the Metro-Dade Medical Center the afternoon after visiting the Viko pharmacy in Overtown, and he's anxious to return to collect his $100. He smokes a little weed and it mellows him out. A vague feeling of goodwill steals over him and he looks around, almost affectionately, at the assortment of feet-dragging, heat-numbed men and women hanging out, just like him, looking to make a buck.
"Hey, man, I need a ride to Overtown," he urges the driver of a rattletrap black Buick that's just pulled into the clinic parking lot. The driver agrees to take him, and they're off, down sun-dappled residential streets Wayne has known all his life. He says his four sons grew up around here too, and continued a family tradition of survival on the criminal edges, dealing in the usual drugs and stolen goods. A few of the sons, Wayne hints, are in prison. "I'm a gangster," he says flatly, not posturing. "Retired gangster. I been around too long to bullshit. I don't stick a gun in your face, but I will do what's necessary for me to live."