“Hmm. Of course you know this subject a lot better than me,” Duncan said. What Weinberg was saying seemed implausible, even with all the evidence the document had presented. “But I think it’s pretty well accepted that drugs work better than things like acupuncture, all that.”
“Do you think people believe more in drugs than in acupuncture?” Weinberg said.
“Here, sure, in general. For most things.”
“There you go,” Weinberg said. “This is why pharmaceuticals are so powerful.”
“Drugs work better because people believe in them more?” Duncan said, trying not to show his skepticism. “Shouldn’t it be the other way around?”
Weinberg’s smile was cynical. “Of course, it should. But the evidence indicates otherwise.” He put up a hand. “Now, to be fair, there are some drugs that are different. I’m no anti-vaxxer. Vaccines work. Antibiotics for infections. Those really do work better than placebos. But for a lot of other conditions, no.”
“Well, here’s what puzzled me when I was reading your summary,” Duncan said. The wine had made him more relaxed, and he felt his tongue getting looser. “Isn’t this a huge problem for Cinasat, not to mention any other pharmaceutical company that’s producing the same sorts of drugs? Why would Cinasat be passing around this document?”
Weinberg shook his head. “First of all, they are not passing it around. Most of these studies are unpublished. Occasionally some overzealous journalist trying to demonize the pharmaceutical industry gets hold of this or that and puts out a story, but that blows over pretty quickly.” He wagged his finger at Duncan. “And you, don’t forget, have signed a nondisclosure agreement. I assume you had training sessions before you started. On what you can and can’t disclose to people outside the company.”
Duncan opened his mouth to speak, but Weinberg went on. “Now, it could become a problem for the company in the long run. If these studies start getting out more . . . But Cinasat, instead of taking this lying down, has decided to be proactive and use the data to their advantage. Make lemon soufflé out of lemons, so to speak.” He laughed and pushed his hair back with a gesture that seemed too conceited for a man his age. “Pure genius, I have to say. And that’s where you come in.”
Duncan was just about to speak when the waiter arrived and, with a flourish, set a plate garnished with edible flowers in front of Duncan. The smell rising from it made his mouth water.
“Why don’t we eat first,” Weinberg said, picking up his cutlery and setting upon his own dish with gusto. “Then we can talk.”
By the time Duncan’s plate had been cleared away and he had ordered his dessert, his nervousness had disappeared. He recognized, with surprise, that he’d been much more open about his experiences at St. Casilda than he would usually be in a conversation with a stranger. Weinberg was a sympathetic listener, and the wine had smoothed the conversation further. Duncan had ended up describing the absence of tenure, the limited research budget, the administrative pushback when he wanted time off to write, and the poorly stocked library.
“Well, you are going to have a very different experience at Cinasat,” Weinberg said, refilling Duncan’s wineglass. “Any resources you need, you can be sure to get.”
“But what exactly will I need?” Duncan realized that he still had very little idea about what he was expected to do. “What will I be working on other than this paper with you?”
Weinberg leaned back. “Let me just put it to you straight,” he said. “We—Cinasat, that is—may have made the biggest drug discovery in the history of medicine.” He paused, evidently waiting for Duncan to react.
Duncan raised his eyebrows politely. What hyperbole, he thought.
“We’ve found the basis for the placebo effect,” Weinberg said. He raised his glass triumphantly.
“The basis for the placebo effect,” Duncan said, turning the words over in his mind, trying to make them sound less like gibberish.
“Can you imagine what that means? This is going to revolutionize health care.”
“Revolutionize?” Duncan realized how dim he must sound, repeating Weinberg’s words. “Sorry, I don’t quite get what you mean.”
Weinberg gazed at Duncan. Duncan saw disappointment, and even exasperation, in his face.
“Right,” Weinberg said. “You’re an anthropologist.” The tone, disparaging, made Duncan wince. “What I mean is, we’ve found the biological basis for the placebo effect. We’ve figured out what makes it happen. Or at least we understand it well enough that we’ve been able to come up with a drug that mimics it.”
“A drug that mimics the placebo effect?” Duncan wished he didn’t feel so confused. What the hell was the guy talking about?
Weinberg sighed. “Alright. You know a little about the biological research on the placebo effect. Correct? I gathered that from the paper of yours that Bentley sent me. You know about the hypotheses people have been proposing for years. About neurotransmitters being involved in the placebo effect.” He turned his gaze on Duncan again.
The waiter arrived with two outsize plates, each with a small, artfully arranged dessert portion. Duncan tried to focus on the delicacy before him. There was no need to get defensive, he reminded himself. Weinberg couldn’t expect him to know about research studies in biology. “My knowledge is probably outdated,” he said. “I haven’t been following the biological research, you know. I’m not a scientist.”
“I know, I know. Anthropologists are the furthest thing from scientists.” Weinberg skimmed a fork over his own dessert, a black chocolate concoction adorned with shreds of gold leaf.
Again, the disparaging tone, Duncan thought. “Of course, I know neurotransmitters are supposedly implicated,” he said, trying to keep his tone neutral. He struggled to remember the details of what he’d written in that long-ago paper. The mechanistic explanations in the biological research literature had always irritated him. All biologists wanted to do, it seemed, was to boil everything down to chemicals and molecules. The most interesting aspects of a therapeutic ritual—the symbols, the words, the gestures, the context—were brushed aside as if they were irrelevant. “I get the idea: when people believe they are going to get well, these brain chemicals are released, and they act on the immune system so that people actually get well. But the problem, as I recall, was that no one knew which neurotransmitters, or how they would act on the immune system in such a broad way that practically any condition would be alleviated. Not much of an explanation there.” He allowed disparagement to creep into his own tone.
Weinberg smiled—condescendingly, Duncan thought. “You’ve got the basic idea. Sufficient for a nonscientist. The problem was that people were focusing on individual neurotransmitters—serotonin, dopamine, endorphins. That didn’t go anywhere. What we’ve found out is that it’s the combination of neurotransmitters that matters, not the level of any individual one. And we’ve come up with a drug that mimics the combination of neurotransmitters. This combination affects the immune system in the same broad way as when people believe they’re going to get well. We still have a way to go to work out the exact mechanism, but what matters is that our drug—Symb86—works. We’ve gone all the way through Phase 3 trials, and we’re waiting for final approval to get it to market.”
“Phase 3 trials?” Duncan said, and then cleared his throat, realizing he’d parroted Weinberg again. “You’re referring to the approval process at the Food and Drug Administration? Sorry, I’m really not familiar with the drug industry at all.” He tapped his dessert fork against his plate. “Which is why I was surprised that Cinasat even wanted to hire me.”
Weinberg paused. He took a careful bite of his dessert. He glanced at Duncan, his expression more relaxed. “Of course. All this probably seems very foreign to you. That’s natural. You don’t need to know the ins and the outs of the drug industry to do the job you’ve been hired to do. In fact, it’s better that way, given the proprietary concerns. I can explain whatever it is you need to know.” He had
another bite and wiped his lips with his napkin. “Our people often each have only a small slice of our information pie. It works better that way. Less room for accidental leaks, so to speak.”
He raked his fork across a stream of chocolate. “Let me tell you what you need to know. Phase 3 is just FDA jargon. Basically, we’ve gone through all the testing to demonstrate that Symb86 works. In the last human trials, we tested people with an assortment of conditions that are considered difficult to treat: irritable bowel syndrome, back pain, asthma, psoriasis, arthritis, ulcerative colitis, and so forth. For every condition, we tested three groups of people. One group got the drugs they normally would get for their condition. The second group got a placebo, and the third group got our drug. The group that got our drug improved much more than the other two groups.” He waited, watching Duncan.
Duncan blinked. “But wait, the group that got the drug—what is it, Symb . . . ?”
“Symb86.”
“The Symb86 group did better than the group that got the placebo?”
“Much better. Because you see, our drug is like a highly refined placebo. Regular placebos don’t work for everyone. No one knows why. Maybe the context isn’t good enough to set off the right combination of neurotransmitters, or they don’t believe enough that they’re going to get better. But we’ve figured out what’s behind the placebo effect, so it works for almost everyone.”
“But not everyone?”
Weinberg shrugged. “Real life is messy. Nothing’s perfect. No drug is going to work for everyone. But this is as good as perfect. And we’ve replicated this effect for a number of other conditions, both medical and psychological disorders: depression, anxiety, bulimia, infertility . . .”
“It works for infertility?”
“For several patients, so far,” Weinberg said. He picked up a shred of gold leaf with his fork and conveyed it to his mouth. “And also chronic fatigue syndrome. CFS.”
Duncan stared at him. “CFS?”
Weinberg considered him with a half smile, only nodding in response.
Duncan pretended to be absorbed in savoring his dessert, turning this information over in his mind. His mother had tried so many CFS treatments over the years. His dad had taken her to physicians as far away as Vancouver and Dallas. He had taken her to chiropractors and acupuncturists. She’d tried stimulants and steroids, hormones and vitamins. Nothing had worked for more than two or three weeks; she’d always returned to her bed, clearly exhausted or in pain. Could this drug really make a difference? How much a cure would mean to her, and to his father. He took a deep breath. Not so fast, he reminded himself. No need to get carried away.
“I’m sure you have questions,” Weinberg said.
Duncan dragged his mind away from his mother. “How will my work contribute?”
“Well, this is going to be marketed as a broad-spectrum drug that works for a wide array of conditions. We want people to understand its value. You’ll not only be writing scholarly papers, but also helping to educate the drug reps and figuring out how to demonstrate the value of the drug. Good advertising is the key, not just for physicians who will be prescribing, but also for the consumers. And you know the drug industry has been getting a bad rap these days. Telling people that this drug acts like the placebo effect is not going to work.” Weinberg laughed and shook his head. “The average person understands so little about the placebo effect. Most people think a placebo is something that doesn’t work, when it’s just the opposite.”
“But wait a minute,” Duncan said. “This drug will work whether or not people think it will work, isn’t that right?”
“Not quite right. It is a real drug and it works, but if people believe it won’t work, then it won’t be as effective. Any drug is that way. Your belief can work against you just as it can work for you. The nocebo effect. You know this, I gather, from your mention of black magic rituals in your 2005 paper.”
Duncan nodded.
“We need to educate people about the placebo effect. Show them that it works. Give them all the data about alternative therapies—you know the National Institutes of Health has been investing in that research for a while—on acupuncture, Reiki, chiropractic. And traditional healing practices like your devil dancing ceremonies. The masses love all that mumbo jumbo. Here’s the key: we get people to understand that they all work through the placebo effect. And then we explain how they can get that same effect with this drug. We have people writing papers on all these therapies, connecting them to the placebo effect. A whole woo-woo team. You will be the one writing about devil dancing ceremonies. You persuade people that ceremonies that have been used for centuries, maybe millennia, are working through the placebo effect.”
“Woo-woo,” Duncan said.
“No need to take offense,” Weinberg said. “You can help people see that it’s not woo-woo. There is no magic. Context and expectancy release chemicals in your body, and the chemicals are what cure you. And we can give you those chemicals in a nice pill form. You can take the pills in the comfort of your own home. No need to go through these nonsense rituals. Everyone free of woo-woo.” He laughed, raising his glass in a salute. “You see, everyone wins. And Cinasat makes a killing.”
10
GRACE
Tuesday
Grace tried to return Dr. Chung’s smile, to soften the irritation she was feeling. “I have to think about the risks. And the feasibility of the treatment. Such a big commitment of time and effort, isn’t it?”
Dr. Chung nodded. Her cheeks were dimpled, even when her smile was only slight. “Reducing your workload might be good anyway. There’s nothing like a relaxed lifestyle for promoting a healthy pregnancy.”
Grace felt her irritation surge. Dr. Chung had to be barely thirty. Her ideas about working and producing had to be completely different from her own. She wouldn’t understand the urgency Grace felt.
“My job isn’t always compatible with a relaxed lifestyle,” she said. “But honestly, I don’t think that’s what’s preventing me from having a baby. If it were just stress, why would I miscarry at the same point in the pregnancy every time? That suggests there’s some biological process going awry, doesn’t it? It’s like clockwork. Every miscarriage at nine weeks.”
Dr. Chung shrugged, the smile now pasted on her lips. “As I said, everything looks normal, and nothing in the exam results suggests you couldn’t carry a pregnancy to term. All I can tell you is what the research tells us. High stress is linked to lower rates of conception and higher rates of miscarriage.”
“Well,” Grace said. “I’ll talk it over with my husband. I just don’t know if it would be worthwhile, given the risks.” There could be a biological problem, even if the tests didn’t show it. What if she took these risks and then had another nine-week miscarriage?
Leaning forward to retrieve her purse, she saw a small framed photo on the desk of Dr. Chung by the ocean, arm in arm with a young man. It reminded Grace of a long-ago midsummer picnic at the lake beach in Chicago. She and Duncan had eaten hunks of cheese and French bread, their hands oily from canned smoked oysters and the olives they’d fished from a jar. Two children in Cub Scout uniforms had been throwing sticks for a boisterous dalmatian. Duncan had talked about having children. But fate decided those things. She was not to blame. Life had seemed so relaxing back then, before the fateful breakup that had preceded their engagement. She shook herself mentally. There was no way she could have known the breakup was temporary, she reminded herself for the thousandth time.
11
DUNCAN
Tuesday
Grace edged the dishes aside to make room for the grocery bags and sniffed the roasted garlic and tomato sauce in the air. “Smells good,” she said.
She was wearing a patterned blue blouse she’d had for years. Duncan appreciated her thrift. In graduate school, they had survived on a meager budget, buying household items and clothing from garage sales and thrift stores. More than a decade later, they still had most of tha
t old clothing and furniture, and even some of the crockery. They had only recently managed to pay off their graduate school loans and still owed a lot on their mortgage. But he knew that Grace’s refusal to spend money on new clothes for herself had less to do with thrift and more to do with her guilt about how meager his St. Casilda salary had been relative to her own. Now they could afford to spend, he thought. They should go shopping, buy her some nice clothes. New briefcases for them both. Start looking for a new car for her. He could manage with his Volkswagen, but her old Honda wouldn’t last much longer.
“What made you bring those out?” Grace said.
Duncan gathered the jumble of photographs together and pushed them back into the biscuit tin, a square old one he’d had since childhood, printed with a winter scene. It had been years since he’d taken the tin off the shelf in their bedroom closet.
Grace picked up a photo that had fallen to the floor. It showed Duncan at the age of eight or nine, his arms stretched to catch an orange Frisbee. His mother, in jeans and a bright-pink tartan shirt, had thrown the Frisbee, her mouth open with glee. How vigorous she looks, Duncan thought. Not the way she had looked the last time he’d seen her, when he had visited his parents in January. Now his mother’s face was lined not only with age, but also her continuing pain and exhaustion. Her sedentary life had thickened her body and sucked the joy out of her eyes.
“Just thinking about what she used to be like,” Duncan said. He handed Grace another photo: his mother leaning out of the window of a baby-blue boat of a Chevy, waving, a mischievous grin on her face. “Did I tell you she used to drag race when we were kids?”
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