Foreword

In the early days of HIV, that in this current pandemic of COVID-19 feels like a lifetime ago, my clinic population in rural Tennessee consisted largely of gay men facing an incurable and fatal illness. The patients were roughly my age then—mid-thirties or younger—and the experience of caring for them felt intensely personal and poignant. Each visit hammered home the notion that time was precious for us all, but especially so for them.

At that point in time, 1985, one did not expect to see HIV in a small Appalachian town; AIDS was viewed as an urban phenomenon. Yet in a few years I was seeing far more patients with HIV than predicted for the town’s small population. These were hometown boys for the most part, and I sensed that their experience and mine might not be unique; that I had stumbled onto a story that held true in every small town in America. The scientific paper I wrote with my colleagues described this paradigm, a quiet yet epic journey of migration: gay men had left their rural homes for the big cities as part of the general exodus for jobs, education, opportunity, but also because they were gay and didn’t want to live that lifestyle under the scrutiny of friends and relatives. In the big cities, they found themselves, came out. Now years later they were coming back home, typically because their partners whom they had nursed through illness had died, and now they themselves were ill; or else they returned hoping to escape the plague that had decimated gay communities in urban areas in America. And there I was at the tail-end of the migration, caring for them as a physician.

What I remember all these years later is not the particular infections or tumors that blossomed when their immune defenses were ravaged; instead, I remember only the emotions that our paper never quite captured: the tragic nature of this voyage, the brave escape, the search for meaning, the defeat, the return, the burden and taint that came with the disease and with their sexual preference, and the heartache of the families who for the most part cared for them with such dignity and love. The paper did not capture my own grief at witnessing this again and again, or the powerful lessons my patients taught me about manhood and courage. The emotions still live in my memory and that of their survivors.¹

“Only connect,” E.M. Forster the novelist says in Howards End. The experience of caring for a patient who is ill, who recovers or does not, or who has a chronic condition, is an emotional one for the patient and the doctor too. Emotions help or impede the ability to connect, they affect diagnosis, color the treatment; emotions must be recognized, must be navigated around or leveraged and their cultural roots grasped. As a young physician I doubt I understood this as clearly as I do looking back. Emotions are the substrate of our clinical encounters.

That’s why this volume you hold in your hands is precious. It astonishes me that I haven’t seen anything like it before, despite the importance of the topic. In short, it is overdue. I hope you will find it to be a welcome and valuable addition to the canon of books you keep on your shelf.