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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. "