Leaning against a wall, hands stuffed into his jean pockets, Dr. Fred Rottnek quietly surveys the lobby of his makeshift medical office at the Harbor Light Center, a shelter for homeless men.
A line of patients snakes past soda machines and cafeteria tables. Mickey Wood, a nurse practitioner, takes a blood pressure. Medical student Haus Larson gingerly removes a shoe from a patient's swollen foot.
Just outside the fray, Rottnek smiles and nods at the homeless men who greet him, but there is an unmistakable sadness in his blue eyes.
For six years, Rottnek and his team of volunteers have doctored these men who fall between the cracks of corporate medicine and HMOs -- and the bottom line that even a nonprofit must revere.
On this night, the clinic will close, with no immediate plans to reopen. Not because the money ran out -- money was always scarce, and Rottnek still made it work. It wasn't because he lost his passion for the work, either. He is propelled by need. It is all he ever sees.
What closed the clinic doors at Harbor Light weren't the usual pitfalls encountered in caring for the poor. It was something more mundane and much more bitter -- bureaucratic infighting between Rottnek and Grace Hill, a prestigious nonprofit known nationally for its work with the poor and disadvantaged.
Because of the kind of politics found more often in corporate boardrooms and the corridors of City Hall, St. Louis' more than 13,000 homeless folks have lost one of only two clinics that snatched health care out of the hospital and brought it directly to the streets and shelters -- straight to the people who need it most.
After all these years, the need is big enough to buckle the knees of even the strongest advocate. He knows it will still be here, immense and heavy, after he is gone. There is no time, even on this last night, to dwell on the reasons. He can't focus on the weight, only the need.
So, on this cold December evening, he does what he has done so many times before. He rolls up his sleeves and gets to work.
And he thinks of Barry.
Rottnek met Barry in the fall of 1999. The homeless man became his private symbol of why medical care should be a right, not a privilege. Volunteering in the rock-bottom world of a homeless shelter taught the young physician the necessity of a solid professional distance cloaked in kindness.
"You have to get a protective shell," he says. "It is the only way to survive doing this."
But Rottnek's defensive crust was no match for the unrelenting grimness of Barry's life.
A house fire left him severely burned and with only one leg at age 15. A life of alcohol and drug use shredded Barry's connection to family. They dropped him off at the shelter and never looked back at the thin man with the bushy gray hair.
"He looked like someone who came out of a concentration camp," said Rottnek.
Barry came to Harbor Light's evening clinic asking for pain killers. He had lung cancer. The disease took a back seat to survival on the streets. Barry never bothered with follow-up visits to ConnectCare, the city's health service for the poor, where his cancer was discovered. The killer cells continued to grow and spread through his body, swelling his arm, invading his only good leg.
Pain marked the steady onslaught of Barry's disease. He had a prescription for a narcotic but couldn't come up with the $7.50 to pay his share of the cost. Without pharmaceutical relief, Barry suffered unalloyed agony.
"This man was breaking my heart," Rottnek says.
The heartache didn't end there. Rottnek prescribed ibuprofen to help ease Barry's pain, but nurses from Grace Hill who ran the shelter's small dispensary would only give the homeless man a lower dosage than what the doctor ordered.
"They said it would damage his liver," Rottnek says. "I ended up going to ConnectCare and picking up his prescription and paying for it myself."
Despite Rottnek's attention, Barry couldn't get his cancer treated or his pain medicated. Rottnek decided the only way he was going to get care for Barry was to bend the rules. He admitted Barry to Forest Park Hospital, where he had practice privileges.
Six weeks after he walked into the clinic at Harbor Light, Barry died. But he did so in the comfort of a nursing home, with a hospice worker by his side.
"We had to push, push, push just to get it all the way through," Rottnek says. "Nobody wants to take care of a homeless guy, not even one with Medicaid."
Barry knew the stony math of the homeless and expected nothing but more zeroes from its equations. That he would be an exception to the cold rules of health care for the poor stunned a man who alienated his family and trashed his already tragic life.
"He would say, 'I don't know why this has happened to me,' and for the first time I could say, 'I don't know either.' He would get tearful, he was so grateful," Rottnek says. "It was outside the norm of what he was used to, and he didn't feel like he deserved it. "
That a dying man would be so thankful for treatment that was simply humane disturbs Rottnek -- but not as much as how in the midst of a system designed to help the poor, dramatic shades of life and death could still get so easily lost in a bureaucratic gray.
"If he hadn't come to the clinic that evening, he would have died at Harbor Light, probably very much alone and in a great deal of pain," says Rottnek.
He shakes his head and adds this pensive lament: "It just shouldn't be that hard."
But as he learned in the six months before he closed the clinic, hard that shouldn't be can always get harder.
With his long hair and preference for blue jeans and boots instead of lab coats or scrubs, Rottnek looks like a cleaned-up version of his patients. Most of those he sees have a healthy distrust of doctors.
But they know this doc is different. After an examination and a couple of kind pats on the back, they know the reason why. They may forget his name, but they always remember the "nice doc with the ponytail."
For the 37-year-old physician, providing health care to the poor is a spiritual mission etched into the core of who he is.
"I think health care is a basic human right," he says. "I think it is something people are entitled to because they are people. I am not someone who always wanted to be a doctor. I don't necessarily love medicine. I just love what I can do with medicine."
Rottnek manages to do a lot with very limited funds. Armed with a black duffel bag stuffed with medical instruments, bandages and athlete's-foot cream purchased from the local Kmart and a milk crate filled with medications snagged from pharmaceutical reps, Rottnek can see 50 patients on a given night at the shelter.
Two or three medical student volunteers help him tote the load. Rottnek calls his work "seat-of-the-pants health care."
"The key is to provide quality health care with a minimum number of roadblocks," he says.
And for four years, through fits and starts, he and his volunteers did just that, until March of last year. That's when Rottnek ran into roadblocks of a different kind -- barriers of paper and politics as solid as stone.
The first hard hit came in a letter from Villie Appoo, associate executive director of Grace Hill Neighborhood Health Centers Inc., informing him that their pharmacy would no longer fill his prescriptions -- something they had done readily in the past.
Rottnek was shocked. He shouldn't have been.
Appoo's letter followed Rottnek's abrupt resignation as president of one of Grace Hill's advisory boards. The missive had all the hallmarks of a retaliatory slap, delivered in the aftermath of a boardroom brawl. It was a paper symbol of the widening rift between the doctor with a passion for the homeless and Grace Hill, the golden, century-old charitable organization agency that last year reported serving 10,499 homeless. This powerhouse organization has an $11 million annual budget, including $1.4 million for homeless health care.
Appoo pleads legalities instead of politics. She says Grace Hill stopped filling Rottnek's prescriptions because he refused to sign on as an official Grace Hill volunteer. In the absence of that act, the agency decided, prescriptions and lab work ordered by Rottnek would have to be co-signed by one of their physicians.
"Our pharmacy is not a commercial pharmacy," Appoo says. "If we fill prescriptions for anyone who is not one of our physicians, we will be in violation and lose our funding. Dr. Rottnek was trying to establish a foothold at Harbor Light and made it clear that it was his program. We wanted to be cooperative and wanted to rise above the backstabbing. Our relationship is with our patients."
Maybe so, but Grace Hill's decision meant the homeless would have to navigate another layer of bureaucracy to get the medicine and doctoring they needed. Instead of the one-stop medical shopping offered by Rottnek -- during evening hours, right at the shelter -- his patients had to take off from work and find transportation to a Grace Hill clinic.
"For years, I used to be able to write scripts using Grace Hill's pharmacy for these guys, and the nurses would bring the medications back to the shelter," Rottnek says. "If I make a diagnosis of blood-pressure problems and can get medication delivered to them, that is a whole lot easier than writing a referral for them to get evaluated for hypertension, having them go to a Grace Hill clinic to be evaluated by a Grace Hill doctor and then have a script written for them."
It was a clear duplication of services and an indication that the doctor and agency who had once been on the same pathway, sharing the same vision of easily accessible health care for the homeless, were suddenly moving in very different directions.
The quiet middle child of Fred and Marie Rottnek always seemed out of step with his peers, preferring books over sports and spiritual discussions over a buzzing social scene. His working-class roots separated him from his classmates at Chaminade College Preparatory School, a prestigious Catholic school known for its strong academic environment.
The differences were all around him. His classmates drove fancy cars to school. They shopped for Izod shirts at Plaza Frontenac. He commuted from his Affton home on a Bi-State bus. When he wasn't studying, he was sweeping out his family's hardware store.
Rottnek was different in other ways. He grappled with chronic depression, not fully understanding what was wrong or how to cope.
"I always felt like I was walking around with a wet army blanket around my shoulders," he says. "I didn't know what it was or that I could feel different, because I always felt that way."
Despite his working-class roots, there was never any doubt the carpenter's son would be the first person in his family to attend college. The daily routine of college classes was enough to keep a major depressive episode in check. He graduated with an honors chemistry degree from South Carolina's Furman University and was one of 30 students in the nation to receive a full graduate-school scholarship from the National Institutes of Health.
Rottnek applied to four top universities -- Massachusetts Institute of Technology, Harvard, Cornell, Columbia -- and was accepted by all. Only 21, he was on the fast track. But two weeks into his graduate program at Harvard, depression hit and his life unraveled.
"It was probably more fear than anything else," he says. "It didn't feel like the right thing to do and, on the other hand, it felt wrong not doing it. I mean, who flushes a chance to go to Harvard and make lots of money down the toilet? It was like the screen going fuzzy on a television. I felt like I had got on this conveyor belt because it was the only thing to do."
Rottnek dropped out of the program and started teaching high school. He then decided he wanted to be a Jesuit priest.
"Going into the Jesuits was a socially acceptable way of killing myself," he says. "It was a way of allowing somebody else to make all the decisions I couldn't."
After first being rejected for the seminary, Rottnek was accepted on his second try. Once again, depression hit, and two weeks into his training he came back home. The valedictorian of Chaminade's class of 1982 found himself living in an efficiency apartment, cleaning houses just to pay the rent.
When Rottnek was finally given the diagnosis of chronic depression, all those wet-blanket years started to make sense. With his depression under control, the 25-year-old stopped floating aimlessly and took time to think about what he wanted to do.
"I knew it had to be something I could feel was important enough to spend my life doing and had to involve some type of community service," he says. "Because of my own experience, I thought maybe psychiatry. I wanted something where I could incorporate my values and teach, where I would have the latitude to do a lot of different things. I wanted to be my own boss. That is how I ended up in medicine. It wasn't a light-bulb moment -- it was more like a Chinese-lantern moment. It wasn't until my third year in medical school before I really felt sure."
In the past, Rottnek had found solace in the rugged discipline of academics. It was a safe shelter from his internal storms. But inner calm wasn't what convinced him of the righteousness of his decision.
These moments did:
Holding a woman's leg while she pushed out a baby. Watching a doctor brush the hair from an elderly woman's forehead. Seeing a homeless man's eyes light up when he realized he was talking to a doc who really listened.
"I think there is a sacred component to health care," he says. "You are touching people in a personal and intimate way. That is something special and should be cherished."
Rottnek was in his second year at the St. Louis University School of Medicine the first time he volunteered at Harbor Light, in a clinic that was relatively unique because it was one of two in the city that were located in the shelters where the homeless stayed. Other clinics serve this needy clientele, but the homeless must come to them. For those who work, taking time off for medical care is a luxury they can't afford.
Work in the shelter resonated with the man who had always struggled to find his place. At the time, the Harbor Light clinic was only open once a month and was sponsored by Health Care for the Homeless, a small nonprofit agency started in the mid-1980s to catch some of the homeless who were falling through the cracks of the public health system.
HCH was formed by a coalition of three charitable organizations -- Grace Hill, St. Patrick's Center and the Salvation Army -- with a goal of securing one of 14 Robert Wood Johnson Foundation grants.
The coalition failed to win a Johnson grant but decided to fish for other funding. After receiving $100,000 from an anonymous donor and additional money from Comic Relief, a fund for the homeless created by comedians across the country, the new group hired an executive director and became a separate agency. It contracted with Grace Hill to provide transportation to its four health clinics and prescriptions for the homeless.
In 1995, HCH's largest source of money, the National Health Care for the Homeless Council, yanked its financial support, citing poor management practices. The coalition scrambled to pick up the slack. Comic Relief funds were awarded to Grace Hill, which was already receiving a $1 million federal homeless-health-care grant. Grace Hill used some of the funds to provide four full-time nurses to work at 32 homeless shelters in the metro area. At this time, Grace Hill also decided to bring the HCH advisory board under its wing.
After his residency, Rottnek wasted no time putting distance between himself and the world of corporate medicine. Putting profits before patients chafed his belief that medicine was a sacred mission. With his new physician's shingle, he stepped in to help rescue Harbor Light and turn it into a weekly clinic. To pay the bills, he worked at Family Medicine Institute, a nonprofit that provides general-medicine care to the poor of St. Louis County.
Spare time was slim and slight. Rottnek gave what little there was to volunteer work at places such as Harbor Light. Still, this healer and activist was not content.
"Any time you are working within a system, that is not going to be ideal, because we are not an ideal world and we are not a perfect people," he says. "But I don't think settling for the status quo is any way to do a job, especially when you are dealing with people's lives and when you are not providing the best possible care, for whatever reason."
And Rottnek didn't think his patients at Harbor Light were getting the best care possible from Grace Hill. The nonprofit operated a small dispensary at the shelter and provided some clinical support on the Tuesday evenings the Harbor Light clinic was open.
He sent his patients to Grace Hill for lab tests but didn't get back the results. He wrote prescriptions for homeless patients that Grace Hill didn't fill. Grace Hill told Rottnek the homeless-health-care grant was drained by unexpected costs. As a result, the agency couldn't help with basic supplies for the clinic -- such as a rinseless antiseptic hand soap Rottnek had to buy with his own money because Harbor Light had no sinks.
Rottnek suspected the homeless were taking a back seat to other obligations, other bureaucratic imperatives.
"Grace Hill has some very good programs that they run out of the neighborhood health centers." he says. "The problem is that the people have to get to those health centers, which can be difficult. They do a good work in the community. I am not disputing that at all. I just thought they could do better in regard to the homeless."
When Rottnek was voted in as president of the Health Care for the Homeless Coalition, the advisory board Grace Hill had brought into its fold, he saw an opportunity to voice his concerns.
But he never anticipated how prickly things would get. Or how fast they would get that way.
For several years, the HCH advisory board hummed along nicely.
"We had a lot of good people on board," Appoo says. "The meetings were nice, and we did a lot of sharing."
Ideas and nice meetings weren't the only thing shared by board members.
Grace Hill held the strings on federal funds for homeless-health-care programs, deciding who would get the money and who wouldn't. Most members of the HCH board worked for agencies getting money from Grace Hill.
"Too many providers were on the board," says Laura Drake, a former board member. "It was somewhat of a conflict of interest."
By Appoo's own admission, the board was passive. But when Barbara Weakley, director of mental-health programs at St. Patrick's Center, a homeless shelter, stepped down as board president and Rottnek was voted in, those nice meetings became contentious affairs.
And the sharing centered on hard words and mistrust.
Rottnek brought Sandra Duvic onto the board. Duvic, a seasoned, no-nonsense administrator at the Institute for Research and Education in Family Medicine, where Rottnek still works, became board treasurer. Another ally with ties to the institute was Drake, who was elected vice president of the board.
"When those three came on board, the meetings, which used to be so good, turned contentious," Appoo says. "Three people from one organization were creating a very negative atmosphere, and all of them were from Family Institute."
Duvic says she was simply asking questions about how money was being spent. She demanded clear answers on the number of homeless patients served by Harbor Light and other agencies.
"I couldn't understand that if the clinic at Harbor Light was carrying the lion's share of providing care to the homeless, how come the funding didn't reflect that," Duvic says. "It only makes sense that if one site had an increase in patients, the funds should be shifted to better meet that need.... The numbers never added up. We kept asking for the same things, and they would always bring something in but never what we asked for."
Appoo cringes when Duvic's name is mentioned.
"I was so glad not to have anything more to do with her," she says with a roll of her eyes.
She also presents a far different slant on the boardroom infighting.
"We did provide them with all the information," Appoo says. "At every meeting, we were providing lists of things. My goodness, it starting getting to us: Why, when we are spending so much money on total health care, are they wanting these pieces of information?"
Rottnek only cared about the homeless he was trying to serve.
Case in point: Grace Hill continually reported cost overruns on prescriptions for the homeless that were tapping out the grant and preventing some patients from getting any medication. Rottnek pressed for a price list of prescriptions so he could suggest cheaper alternatives but kept running into a stone wall. He kept asking. When the board finally got a printout of prescription costs, some members were shocked at what they found.
Grace Hill was charging a $9.75 dispensing fee on every prescription the agency filled. The fee, tacked onto every prescription, meant that a $5 bottle of Motrin ended up costing the grant $14.75.
"I was appalled," Duvic says. "On one hand, they are saying they can't fill some prescriptions because they are over budget, but it is because they are charging this huge fee. Basically they were charging $9.75 for a bottle and label. I found places that would do it for $3, but Grace Hill said they couldn't do that because they would lose their funding."
The dispensing fee is a fairly standard budget gambit; however, the federal Department of Health and Human Services, which oversees the homeless grant, says dispensing fees shouldn't be higher than those for Medicaid patients. In Missouri, commercial pharmacies can't charge more than $5 to fill a Medicaid prescription.
Those rules don't apply to Grace Hill, Appoo says. As a federally approved health clinic, Grace Hill is allowed to have higher fees.
"When we fill a prescription, it includes others things we provide, like transportation," she says. "The important thing is that whatever we do is audited and approved. Our fees are right in line with other clinics' throughout the country."
Besides, she says: "No homeless person ever had to pay that fee."
Maybe not, Rottnek and his allies say, but money for these overhead costs did come out of the grant. And fewer homeless patients were served as a result.
"Instead of three people getting medicine, only one person is getting it," Duvic says, "all because Grace Hill is charging a $9.75 dispensing fee on a bottle of aspirin. Someone is paying for it -- and it's the ones who need it the most."
Appoo bristles at the notion that Grace Hill was doing anything wrong. She accuses Rottnek, Duvic and Drake of having a hidden agenda.
"Our record speaks for itself. What was their agenda? Now, that is really the question that needs to be asked," she says.
The central problem of the advisory board was its lack of real bureaucratic clout, says Drake.
"We were just interested in people getting the services they needed most," she said. "I think some people were threatened by the questions being asked. If Grace Hill is controlling all funds, then what funds are we really responsible for? Were we just expected to rubber-stamp everything? It wasn't being antagonistic; it was just being honest."
Duvic wonders whether Grace Hill has lost touch with the people it claims it wants to serve.
"At one point, they got a grant to provide diabetes education to the homeless, and one of the suggestions was refrigerator magnets about healthy eating," Duvic says with a snort. "Refrigerator magnets? How many homeless people do you know that even have a refrigerator? And, I'm sorry -- if given the choice between a cream pie and going hungry, I'm sure a homeless person will choose the cream pie, diabetes or not."
For Rottnek, the discovery of the dispensing fee was the last straw. He resigned from the board in December of 1999. The advisory board disbanded one month later -- because its services were no longer needed, says Appoo. Nevertheless, Grace Hill recently formed a new advisory board -- minus Duvic and Rottnek.
Bureaucratic warfare left an aftertaste that reminded Rottnek of the corporate medicine he left so long ago -- only much more bitter because it was served up by an organization created to serve the poor and the homeless.
"I don't know who is making decisions," he says. "I don't think it is malicious. Sometimes I think it would make me feel better if it was. It would make it easier to stomach. I think there is a void in leadership. There are not a lot of leaders in health care today that have a fire in their belly on pursuing what they should, especially when it comes to taking care of a bunch of homeless people."
Despite the rift with Grace Hill, Rottnek was still committed to the clinic at Harbor Light. He continued to operate for a year-and-a-half without any financial support or prescription privileges from the charity giant.
Other volunteer doctors also continued to serve, despite their disillusions. Bic Stafford, a podiatrist, dipped into her own pocket to buy medication.
"It is just not fair," she says. "Grace Hill has money to do this. I was just a volunteer. I shouldn't have to treat the patient and buy the medication."
Stafford tried to apply for prescription privileges, but Grace Hill bureaucrats never gave her access.
"I told them, 'I will fill out the paperwork; tell me what I need to do,' " she says. "I never got a clear response. It just got to be too much."
Although Grace Hill didn't provide the Harbor Light clinic any financial support, the agency was anxious to keep track of how many homeless patients were served by Rottnek. They hired a receptionist for the Tuesday-night clinic to count each patient.
"It just makes you look good," Appoo says. "It is always nice to say, 'Here this is what we do.' It doesn't count for our grant or helps us get more funds."
Not directly. But these homeless patients could help Grace Hill in its grant-chasing games if they were referred from the Harbor Light clinic to the charity's own physicians and nurses. Those visits would win the agency more federal money, so keeping score at Harbor Light was an important priority even if providing enough money for medication and supplies didn't seem to be.
For Rottnek, providing quality medical care to the homeless was not about counting bodies or looking good. It was a spiritual mission, as essential as breathing or eating. But slamming past all the political roadblocks was wearing him down.
This wasn't clear to him until he started a new job at the St. Louis County Jail and found the support he was missing at Harbor Light. Surrounded by inmates and iron bars, he began to understand the need for strong allies. In the midst of what he expected to be a stifling atmosphere of top-down oppression, he found people who would lend a hand and not worry about what the suits might say.
"I have wonderful, bossy floor nurses who are true patient advocates," he says. "It makes it so much easier to provide quality care when everyone is on the same page."
Barry still prowls Fred Rottnek's memory.
But these days, a new patient also tugs at Rottnek's soul: Willie, an inmate who, like Barry, has lung cancer. When chemotherapy stopped working, Willie wanted to kill himself. He didn't have the nerve, so he robbed a Walgreens, pointed a gun at a cop and hoped the officer would blow him away -- suicide by police.
Instead, the cop wrestled the frail man to the floor and arrested him for armed robbery. Willie pleaded guilty and went to the county lockup. At one point, close to dying, he was given the option of going home.
Willie decided jail was a better place to die.
Rottnek pulls a chair close to the side of Willie's bed. His blue eyes glow with compassion. He takes Willie's thin hand.
"How are you doing today?" he asks softly.
Willie mumbles incoherently.
He is in the final stages of dying. His body is shutting down. He is starting to hallucinate. But Rottnek knows that somewhere, somehow, his words are understood. He patiently explains the medicine he is prescribing for the painful lesions under Willie's arms.
Sarah Lenhart, Willie's hospice worker, says her patient's hallucinations are becoming more terrifying for him with each passing day. Willie thinks he sees rats and wants the door closed. But that's against jailhouse rules.
She pats Willie's hand: "I told him that the door had to stay open and promised I would keep him safe."
"Sarah will take good care of you," Rottnek says. "I promise, too."
One of those bossy floor nurses, Rose Rafferty, watches this exchange unfolding in the tiny cell with the metal toilet and small jail bed.
"He is getting the best care here," Rafferty says. "He knows that. That is why he wanted to stay."
She looks at Rottnek with a mixture of pleasure and respect.
"It doesn't matter who they are or what they did, just that they are here and they are sick," she says, "He cares about all of them -- body, mind and spirit."
Rottnek walks out of Willie's cell and stops at the door. He grins as he whispers: "We've been accused of keeping him alive longer and costing the county more money. We thought he was going to die in July, but he wasn't ready. There were things he had to make peace with. Now, I think, he is ready to let himself go."
He is still stunned at the at the slim choice of Willie's rapidly ebbing life -- dying in jail or dying alone.
"He is getting better care in here than if he was out there," he says. "I am happy about that, but it just shouldn't be that hard."
Inevitably these moments at the jail lead him back to reminders of Harbor Light. He often meets men he treated at the shelter -- but this time they're behind bars.
"We give new meaning to the term 'continuity of care,'" he says wryly.
In his quip is the hope that somehow others will see what he sees -- how poverty, crime, homelessness and other social woes are tightly interconnected. To work in this world requires an ability to put yourself in the same place as the patients you serve, he says.
"When you work with the poor," he says, "you have to really side with them and understand what is going on with them to do a good job. If you really understand that, then what we do is never going to be enough."
On this final December night at Harbor Light, Rottnek sees his last homeless patient. He slings his black duffel bag over his shoulder and walks across the shelter's parking lot one last time.
It is a faceless voice in the dark.
Instead of his customary "See you later," Rottnek answers with something that sounds more final, something harder and more fatal.