Lost in the Emerald City
I met one patient after a heroin overdose and followed him for a year. He so badly wanted to share his story. I wondered: Could it help him?
Mark Valotta wanted to go to sleep forever in the Emerald City.
Only somebody found him, another addict, under the Emerald Street overpass in Kensington, known by the homeless addicts who live there as The Emerald City.
An ambulance crew with the Philadelphia Fire Department, Medic 45, injected him with Narcan, which counteracted the heroin, and he woke up in the emergency room of Temple University Hospital’s Episcopal Campus, where as many as 80 overdose patients get treated each week.
“Why did you bring me back?” he groaned. “Just let me go. I’m so lost.”
Dr. Naomi Rosenberg has seen so much as an ER physician in North Philadelphia, the gun violence, poverty and addiction, yet such raw pain and suffering still knocked her back on her heels, literally, like an unexpected gust.
“We aren’t ready to let you go,” she said. “We think you still have a chance.”
I told him I was a writer, shadowing the doctor, and I’d like to tell his story.
He sat up. He was wearing an oxygen cannula. His long, straggly goatee made him look like a character out of fiction.
But no fiction could match his reality.
“I would love to tell my story,” he said, “but not today. This took so much out of me.”
Yet he continued to talk, growing more animated.
“If you write about me you gotta tell everything. It’s the saddest, craziest, up-and-down, hair-on-fire story that you’ll ever hear. And it begins with how I came on this earth.”
His eyes were blazing now.
“My father is my mother’s stepfather,” he began. “From birth I’ve been destroyed by this, the knowledge that I have… of my mother being raped at 11 years old. My mother was raped when she was 11 years old! A baby having a baby! And you let him stay in the house knowing what’s going on? You allow this? You turned a blind eye to it! The man was a MONSTER.”
He paused. He was overwhelmed.
The only sound in the dark, dimly lit room was the metronome beat of his heart monitor.
“I don’t talk to psychiatrists. I haven’t talked to anyone about this for 42 years.”
Tattoos covered his arms. “You know the expression, you wear your heart on your sleeve?” he asked. “Well I literally do. I only have words on me because they tell stories. Everything on me tells a story or tells a time in my life.”
He pointed to one of the first tattoos, a quote he put on his forearm as a teenager: “I feel the pain that was created on a sad, sad day when all innocence was lost.”
• • •
After about 20 minutes, I felt I should leave. If Mark was serious about sharing his story, we could meet later. I suggested — where else? — under the Emerald Street bridge on Tuesday. I knew there was a good chance I would never see him again. But he took my card.
• • •
As a journalist, I have been telling stories for 40 years. In many cases, I have felt the simple act of listening had great healing power. The people I was writing about would find enormous validation, dignity, and meaning in sharing their stories with me, a willing listener.
Over two years ago, I came to Temple University’s hospital and medical school to build a narrative medicine program. Simply defined, narrative medicine puts an emphasis on listening to a patient’s story, seeing beyond the symptoms, scans and test results. In listening to and sharing stories, trust develops. The patient feels heard, the doctor finds fulfillment, and in the end the patient often gets better care.
Narrative medicine is also a reaction to the moment. In the last half century, medicine has left little time for stories, and placed less value on them. The humanity that brought so many doctors into the profession too often gets lost, crushed. Burnout and depression result as anyone in medicine knows.
I arrived at Temple with one guiding belief: If I could get the busy people here to love, appreciate and share stories, I knew good things would happen. And they have. Doctors and students have written powerful reflections; we’ve hosted nights of storytelling that fill the auditorium; we’ve run classes and workshops with students and residents eager for the opportunity to process the extraordinary things they experience working here in the poorest part of Philadelphia.
In my role here, I also wanted to write, too, to bring an outsider’s sense of wonder to the hospital, to underscore my belief that everyone has a story to tell, and there is a story in every room. By writing these stories, I wanted to document the compassion of people who work here and honor the dignity of even the weakest, poorest, most overlooked, neglected or dysfunctional among us, the kinds of patients Temple so often treats, patients like Mark Valotta.
I wanted to write about Mark for a few reasons. More than 72,000 people in America died last year from opioid overdose, including more than 1200 in Philadelphia. So many of them, like Mark, had suffered some form of childhood trauma. Research on Adverse Childhood Experiences shows how much more likely those who endure childhood trauma will suffer as adults from addiction, poor health, or violence. I also wanted to tell Mark’s story because he was so excited at the idea of sharing it. And finally, I wondered if sharing his story would help him in any way or was this merely hubris on my part.
• • •
AFTER I LEFT, Mark went up to the Crisis Response Center on the third floor for an evaluation. About 13,000 psychiatric emergencies come through the Episcopal CRC annually, and about one-third of those patients also have substance abuse problems. Many are homeless.
Mark was pumped after our conversation, excited by the opportunity to tell his story. He was evaluated, and according to the medical record, found to be in “no apparent distress.”
He was released to a shelter. Two hours later, however, he was back in the ED, having overdosed again, revived again, with Narcan. After another psychiatric evaluation, doctors sent him to KeyStone Center in Chester, PA for 30 days, to get treatment for his heroin addiction and counseling for his suicide attempt.
Mark said he was allowed to make one phone call that Monday from his case manager’s office at the Keystone Center. He called me. “I really want to tell my story.”
He explained where he was, why he had overdosed again.
“The despair took over, the helplessness,” he said. “There was black again. I was alone with my own thoughts and my own feelings.”
He was glad he was in treatment, he said. He wanted to tell his story. He said he would call in a month when he got out.
• • •
After 30 days in treatment, Mark moved into a recovery house in South Philadelphia. He called me his first day out, and I went to visit a few days later, on June 26, 2017.
“I wasted my whole life getting high and committing crimes,” he said. “That’s what I did. Now I’m having a hard time getting a job or knowing where to start.”
He had been to prison four times totaling nearly 20 years. He’d tried to commit suicide a dozen times. He has been diagnosed with depression, bipolar disorder, and PTSD from the sexual trauma leading to his birth, he said. He was taking Zyprexa, an antipsychotic drug, and Buspar, an anti-anxiety medication.
He had vestiges of a life — a daughter, a new grandbaby, a mother, siblings, aunts, an ex-girlfriend he loved, he told me. But he had alienated virtually all of them. At age 42, he needed not to rebuild a life so much as start one _ with no skills, no home, little to no family support.
For two hours, he told his story.
His grandmother had five children by her first husband, including his mother, the youngest of the five. Then his grandmother remarried, had three more children by the Monster.
When his grandmother was living with the Monster, having those three children, the Monster was also abusing the children by her first marriage, including Mark’s mother.
“And nobody talked about it, ever.” Mark said.
“From the time I was a little kid I felt shame, embarrassment, because of my birth, the way I was born. Nobody had to tell me. I knew.”
The Monster lived with the family for a few more years before he finally moved out.
Mark’s uncle — his mother’s brother — was also abused by the Monster and is long dead from an overdose. His mother, whom I later met, confirmed she was raped and tortured by her stepfather since age 7. She shared a photo of herself at age 11 in her confirmation dress — pregnant. She didn’t realize it or understand.
Mark’s grandmother wanted his mother to put him up for adoption, but his mother fought to keep the baby, raise the baby. She did. Eventually Mark’s mother married, had other children, went back to school, got a GED, then college, and is now teaching in a parochial school in the city.
She never self-destructed.
Her son did.
• • •
“I always felt out of place. I always felt lonely. The class clown, a village idiot,” Mark continued. “I always wanted to get a response from people.”
By age 14, he had fallen out with his mother, stayed with his uncle or grandmother or on the streets.
He hung with the worst kids, smoked crack, he said, because he wanted to be accepted. He did robberies because he needed money for crack. Then heroin.
He has done prison stints of 8 and 5 and 3 and 2 ½ years. His court records confirm convictions for robbery, forgery, assault, theft, drugs. As a young man, he said, he would rob small markets and stores, and carry a wrench in his hand, or a hammer, and put a paper bag over it. If the person behind the counter wouldn’t believe it was a gun, or would laugh, Mark would smash them on the side the head with it. Then he’d get the money.
In prison, he said, he earned the nickname Frog, because at the slightest prevarication — real or imagined _ he would pounce and attack. “I was swinging or stabbing right away. `We’ll talk later.’ I would leap right on your ass. So they started calling me Frog.” Many know him only by this name.
He loves his mother. He says there is nobody in the world he admires more, respects more. He knows what unbelievable strength it took for her to endure and surmount the horror in her life. He just can’t stand to be around her. They always seem to start fighting right away.
Through it all, Mark said, he had a true love. He met her in his teens. And she stayed with him for decades — until a few weeks before I met him. Mark was released from prison on April 13, 2017, about five weeks before I met him. It was after his release from prison that she told him it was irrevocably over. This is what made him want to overdose under the Emerald Street bridge.
“I beat myself up every day because of the woman that I lost because of my own mistakes,” he said. “This person loved me unconditionally, and would have never left me if not for my own actions.
As we finished the interview, Mark told me, “I feel like a weight is lifted.”
He wanted to see it published.
“I won’t be hiding anything anymore,” he said. “I think the truth will feel good.”
• • •
I called Mark’s lifelong girlfriend, who chose not to be named. She is a Philadelphia public school teacher.
“He started at a young age using drugs and alcohol as a coping mechanism, to self medicate,” she said.
“I almost wonder if he would have been put up for adoption,” she added, “if he would have been spared all that.
“He has just like a shame,” she said, “or a feeling of not being wanted. Because of the way he came in to this world.”
For the ex-girlfriend, there is no going back.
“I don’t want the emotional torture of it all,” she said.
• • •
I followed Mark for the next year. I wanted to see what would happen. Would his life change? We met every few weeks, talked on the phone.
Weeks after his release from treatment in the summer of 2017, he was back living on Kensington Avenue, only blocks from the Emerald City, staying at Prevention Point, a well known recovery center that provided temporary housing. Mark had been many times over the years. He could get shelter, counseling, support.
Mark’s return to Prevention Point confused me. Why would Mark move back to Kensington Avenue, where temptation is everywhere? Mark said he had to pay rent in South Philly at the halfway house, and at Prevention Point he could stay for free. But only days after moving there, Mark called 911 in the middle of the night with a horrible pain in his back, and was taken to Temple Hospital. He had an abscess on his spinal column. Infection in his blood had seeped into his bones.
This was almost certainly the result of using dirty needles. At Temple, Mark’s urine tested positive for opioids.
After six days at Temple, Mark spent another month in rehab at the lower acuity Kensington Hospital, where he could get infusions of IV antibiotics.
There, in August of 2017, he met a woman, Amanda, a recovering addict on methadone, working as a dancer at a gentlemen’s club. She was also getting antibiotic infusions.
“During smoke breaks,” Amanda said, “he started flirting with me. I thought he was very funny and very charming.”
“I’m a sucker for the bad boys,” she said. But she also wanted somebody who would protect her. And Mark needed somebody to protect.
• • •
Mark left Kensington Hospital around Labor Day, and was given a bed back at Prevention Point.
Mark said he was staying clean, but I had my doubts. Heroin is everywhere and out in the open. We sat on the steps of Prevention Point one evening. Down the street, a woman shot up in plain sight on the sidewalk. A man openly urinated across the street. A stranger came up to Mark and bummed the last puff of his cigarette.
Another night, as I walked out of Prevention Point with Mark, a woman approached him. He walked with her down the street, I think to get away from me. He pulled something out of his backpack and gave it to the woman, and took a dollar. I asked him about it. He was selling her a clean needle. This is how he made money, he said. He went around the drug areas and collected dirty needles. It was really easy to do. He could get 70 in half an hour, he said. The needle exchange at Prevention Point would give him 150 new needles in exchange for 150 dirty needles. They didn’t actually count, he said, so he’d be fine with 70 or so. Then he’d sell the new needles for $1 a piece to people desperate for a clean needle.
The federal Drug Enforcement Agency calls this area the largest open-air drug market on the East Coast. The problems are so immense that city leaders are trying to open the nation’s first supervised injection site — a place where substance abusers can inject heroin safely, with doctors or nurses present, to cut down on overdoses. Proponents say it would also be a great place for outreach, for offering help and counseling. But there is fierce opposition, including from the U.S. Attorney. Heroin is an illegal and deadly drug.
By late October, at Prevention Point, Mark began a treatment program on Suboxone, a medication assisted treatment for substance abuse. This form of treatment is gaining tremendous support around the nation from doctors and public health officials. Daily Suboxone pills will suppress both the craving for heroin and the onset of withdrawal.
“This is my new heroin,” Mark told me. “This is what keeps me out of trouble and out of jail.”
Mark was also waiting to get an apartment through Pathways to Housing, a local non-profit focusing on homeless people with mental health issues. The City of Philadelphia asked Pathways to expand to include people living in Emerald City.
• • •
The night before he was supposed to get his new apartment, Nov. 16, Mark and Amanda got arrested on the 2800 block of North Boudinot Street, just off Kensington Avenue, around 6 p.m., according to police. He was charged with possession of drugs and purchasing or receiving drugs. Mark insisted he was just walking Amanda back after meeting her at the Market El train, that he wasn’t buying, selling or carrying drugs.
“They sweep everybody up,” he explained. “That’s just what they do. I got caught in the net.”
Again, I found Mark’s explanation hard to believe. He was released from jail the next morning, but had no intention of showing up on his court date. He knew he’d never convince a judge he was innocent.
He believed he’d be sent back upstate to finish out his prison sentence. He’d never get his apartment. He’d lose Amanda.
He decided he would just avoid the law as long as he could.
• • •
A few days later, Mark moved into his new apartment, provided by Pathways, in the Frankford section of the city.
It was a weary apartment in a weary building. But it was his. Amanda moved in.
Pathways provided used furniture. He got a TV and cable with Amanda’s dancing income. He arranged his shoes neatly on the floor, filled the freezer with frozen pizzas.
He took in two stray cats and walked around the city with one peeking out of his backpack.
On Christmas Eve, he trash-picked up a giant wreath with lights and hung it in the apartment. He bought Amanda a teddy bear on Kensington Avenue for $3 that said, “I love you.”
“I’m happy as shit” he said in January. “I didn’t’ think I could ever love a female again. I didn’t think I would be happy again after what happened to me.”
After the Philadelphia Eagles won the Super Bowl, Mark went to the parade.
But Mark was still spending time on Kensington Avenue. This is where his friends are, he said. Mark told me to stop expecting him to get a job, to change, to live as I think he should live. He had lived on the streets too long to change his ways. He was going to hustle, to scam, to get by with his wits, to get rough if he had to. “You’ve got your way of doing things,” he said, “and I’ve got mine.”
• • •
In February, Mark’s food stamps were canceled because of the bench warrant for his arrest. He knew the world was closing in.
His worst fear, he said, is that he’d gotten this far, and he could lose it all.
“I’m in cuffs and I’m gone for four years,” he said.
“And I end up homeless,” added Amanda.
I went with Mark to his March checkup at Prevention Point.
Manuel Cabrera, a third year student at the Lewis Katz School of Medicine at Temple, was on his family medicine rotation at Prevention Point. He stood behind Mark in the bathroom and watched him give a urine sample. It looked and sounded like an honest sample, and Cabrera believed Mark’s urine that day was clean, although experts will tell you heroin addicts find all kinds of ways to cheat on a urine test.
• • •
On June 1, Mark was arrested on Kensington Avenue. Charged with possession of controlled substance and simple assault. He was in possession of 14 packets of heroin, police said.
“I was at work,” Amanda explained. “Mark was on Kensington Avenue hanging out with friends. Some guy he is friends with named Billy is kind of disabled and on crutches all the time. This other guy was (picking on him) chasing him around a car. And when Mark saw this, he walked up and punched the guy in the face. And he punched the guy so hard he split the face open and the guy needed 8 stitches. I’ve been told Mark’s fists are like cement, luckily I don’t know this first hand. He did this right in front of the cops. And once they arrested him, you know he wasn’t getting out.”
• • •
On July 19, in court, Judge Robert P. Coleman waved a handful of death certificates at Mark, one after another, reading off the names. “And these are all just from the last week,” said the judge. Increasingly, the judge said, dealers were lacing the heroin with fentanyl, a synthetic opioid cheaper to produce and more powerful. And the number of overdoses was soaring.
Mark pleaded guilty to assault and to possession, and the judge sentenced him to 9 to 23 months in prison, and four years probation. But then he paroled Mark immediately to a treatment facility when one becomes available. Mark would remain in jail until then.
One more wrong step, the judge said, “I’m sending you upstate.”
He also told Mark the treatment and Suboxone programs work but he’s got to take responsibility. “Man up,” the judge told him.
“I’m doing everything I can to keep you alive,” the judge added. “I’m the only one who seems to care. You don’t.”
• • •
Amanda said she would wait for Mark, at least this time.
I visited Mark twice in jail.
Suddenly freedom seemed incredibly precious.
Mark wore an orange jumpsuit. The second visit he was despondent and in handcuffs. Amanda had been caught trying to smuggle in tobacco for him. He’d asked her to do it, he said, because he thought it would be valuable as barter, and now he was “in the hole for 60 days.”
He said he’d been taking the Suboxone faithfully until May. “At the end I couldn’t keep up the race no more,” he said. “I had to put heroin in my veins.”
I honestly don’t know if he’d been lying to me for months, using heroin the whole time, or telling me the truth. I suppose it didn’t matter. He ended up in the same place.
Police arrested him with 14 packets of heroin. But half, he said, were powdered sugar that he was hoping to sell. He was running a scam to the end.
He acknowledged the system in so many ways has tried to help him, — housing, Suboxone program, counseling, medical care — but “I keep screwing it up.”
Even still, he said, he was in a much better place then when I met him in the emergency room over a year earlier, when he’d overdosed on purpose. He now had Amanda, an apartment he hoped would still be available when he got out of jail, a reason to live.
He insisted talking to me had helped him, especially early on. “It gave me something,” he said. “You made me believe I was capable of more than I was doing.”
I have no idea of any that is true. I do know this: Tears welled in his eyes in jail as he read this story.
But what can compete with heroin? With a tortured past? Mark will be out of jail soon, and sent to another rehab facility. Will he be able to stay on Suboxone, stay off Kensington Avenue? The odds may be as long as his goatee, but I hope so.
What I do know is that inside this troubled man is a tender heart, and inside every hospital room is a story.
11/7/18 Update: Mark called the other day from Rehab. His head was clear and his voice was so hopeful. Pathways had kept his apartment for him, and Amanda was waiting. So in another 30 or 60 days, after completing Rehab, he’d be starting out in a good position. He was hoping this time would be different.
• • •
Michael Vitez, winner of the 1997 Pulitzer Prize for Explanatory Journalism at The Philadelphia Inquirer, is the director of narrative medicine at the Lewis Katz School of Medicine at Temple University. Michael.email@example.com