by Gary Braver
“Originally, yes. My mother was Chinese, my father Canadian, but originally from London.”
That explained his exotic appearance. Maybe even his aristocratic demeanor.
Jordan looked over at her when they approached the restaurant. “You’re very attractive. Just wondering why someone like you is unattached.”
“Thank you, but who says I am?”
“Well, you caught me. I was talking to Nick Mavros.”
Nick was a mentor, perhaps a father figure, and a friend, but there was a strain of village matchmaker in him. “I see. Well, I’m fairly busy. And frankly I’m downsizing.”
“Downsizing. Ahh, a recent parting of ways?”
“Something like that.”
“Clearly bad judgment on his part.”
“Thanks. And what about you?”
“Divorced, two children, and paying dearly because her attorney’s a velociraptor.”
They turned into the restaurant parking lot.
13
THE HOSTESS GREETED DR. CARR BY NAME and led them to a private candlelit table in a far corner.
While Carr read the wine menu, René studied his face. In the soft candlelight he was very handsome, with long-lashed quasi-Asian eyes, smooth fine features, hair that closed over his brow like a leather flap, and an absence of beard shadow. Adding to the effect was the silky voice and manner. And despite his obvious avoidance of the issue at the forefront of René’s mind, Jordan Carr was very charming—another lesson for her that people aren’t what they seem. He ordered a sixty-dollar merlot.
Awkward silence filled the air after the waiter left. René studied the menu just to fill the gap. Then she looked up. “So … ,” she said. “Clara Devine.”
Carr lit up. “Ahh, the wine.” And almost by magic the waiter appeared and filled the glasses. Jordan raised his glass. “To a better future through medicine.”
“Sounds more like a slogan than a toast.”
“Maybe a little of each.” And he took a sip and settled back in his chair. “So, what do you want to know?”
René leaned forward. “Okay. You are not Clara Devine’s primary physician.”
A bemused smile spread like an oil slick across Carr’s face. “Correct.”
“Why have her medical charts not come back to me?”
“I believe the police have impounded them.”
Maybe.
“Next question.”
“There are four more patients on the AD ward than in the census—which is highly irregular.”
He nodded. “They’re under special care with me.”
“Special care?”
“Yes,” but he did not elaborate.
“You know, of course, that I’m supposed to have total access to all patients’ records in order to determine the effect of their meds. If there’s a problem, I need documentation, nurses’ observations, et cetera.”
“Of course. And that’s all been documented. Next question.”
Stonewalling again, and with an irritating glint in his eyes that said he was savoring her annoyance. One call from her could get the state to review the practices at Broadview, but she pushed that to the back of her mind. “And where are they documented?”
“In the home computers.” He took another sip of wine. “Next.”
“Clara Devine is a seventy-six-year-old AD patient who mysteriously eloped from a locked unit and ended up the next morning three miles away in a CVS where she killed a guy. None of that is supposed to happen.”
“Do you know how she got out?”
She could not betray Alice. “Pardon me?”
His gaze hardened. “Do you know how she got out, how she eloped?”
Yes. “No.”
“Then how do you know she eloped and wasn’t let out?”
Shit! “I don’t. That’s probably what the police are wondering.”
“I know you saw the security videos.”
Her chest tightened. “Security videos?”
“It’s okay. In fact, we were eventually going to show them to you.” He leaned forward and lowered his voice. “Tell me exactly what you saw on those videos.”
René wondered if this was a trick to get the nurses in trouble. “I saw an elderly woman with Alzheimer’s tap a security code and let herself out, then emerge in disguise at the front of the building and disappear.”
“Yes. And how do you explain that? What are the possibilities?”
“That she’d been misdiagnosed. Or that somebody had instructed her how to do it. Or that it wasn’t Clara Devine.”
“And what does your gut tell you the most likely explanation is?”
“My gut tells me nothing.”
“Exactly.” Then he ticked them off on his fingers. “One, you know she was not misdiagnosed since you saw her admission profile: a seventyish woman with moderate AD. Two, she was too far gone to be trained to escape or recall the code. And, three, it was Clara Devine because that was her face on camera, correct?”
René’s heart kicked up a beat. Then out of some half-glimpsed premonition she heard him say, “What you witnessed was a medical miracle.”
“A medical miracle,” she said, as if taking an oath.
“Yes. For the last six months Clara Devine and other dementia patients have been part of a large clinical trial of a new compound for the treatment of Alzheimer’s disease. As I am sure you’re aware, the brains of patients with Alzheimer’s on autopsy and on MRI have been observed to have deposits of beta-amyloid protein, or plaques, which do not form on the brains of people without Alzheimer’s. So we know that these plaques are a major cause of dementia, though we’re learning there are other factors as well—a loss of key brain neurotransmitters such as acetylcholine, which is important in learning and memory functions.
“This new compound has been shown not only to dissolve the plaques but also to stimulate neuronal growth, all but reversing the degenerative effects of the disease. In short, patients are getting their memory and functionality back. And what you saw in that video is the result of that reversal.”
It was as if the speech centers of René’s brain had tilted out.
“The woman’s elopement was an unfortunate consequence of a recovered ability to function. My guess is that she overheard a staffer tell someone else the code, which she memorized. Then she escaped, put on a disguise, and walked out of the building. What you witnessed was a woman in the process of being cured of Alzheimer’s disease.” His face was beaming.
For a long moment René tried to process his words, running through her head the crude black-and-white video, trying to find cracks in his explanation against those images of the woman purposefully making good her elopement.
“Like I said, a miracle.”
René felt a fist grip her organs and it had nothing to do with protocol. “I’m having difficulty digesting all this. A cure for Alzheimer’s disease?”
“Exactly. And keep in mind that until a few years ago nobody thought it was possible for nerve cells to reproduce. Now we’ve learned that they divide even in adults, that we’re not born with all the brain cells we’ll ever have. And that’s what this stuff does—stimulates new cell growth in the hippocampus and with it memory functions.”
“But that’s impossible.”
“Only because you’re thinking of meds currently on the market—Aricept, Exelon, Reminyl—which, at best, only slow the progress of the disease. I am sure you know the pharmacology of those as well as I do, right? Why they only slow the progress of the dementia without curing the disease?”
René tried to concentrate on his question around the fist tightening on her internal organs. He was testing her, she told herself. Suddenly this was classroom. So she decided to humor him. “Aricept and the others are cholinesterase inhibitors. Cholinesterase is an enzyme that destroys the neurotransmitter acetylcholine, which, as you said, is crucial in learning and forming memory. By inhibiting the action of cholinesterase, acetylcholine is not destroyed as q
uickly. Yet the amount of new acetylcholine produced in the brain continues to decline. And these drugs keep the acetylcholine that’s produced around longer, but they don’t stop the continuing decline of acetylcholine production. So the dementia continues, but at a slower rate than without these medications.”
Carr’s eyes lit up. “Very good!”
Yeah, because I researched the pharmacology of every damn drug on the market to save my father.
“And, of course,” Carr continued, “the other reason is that the loss of acetylcholine isn’t the only cause of dementia. The big problem is the plaque deposits that spread throughout the brain, causing changes in the levels of other important neurotransmitters. And that may explain the different rates of disease progression seen in different patients—or why some dementia patients slowly become mute, docile, and isolative, while others become very agitated, combative, and aggressive. We don’t understand all the reasons for this, but so far we only have the cholinesterase inhibitors to help deal with the disease.”
She took a deep breath against the conflicting sensations. “So you’re saying you’ve developed a new approach.”
“More than that, a cure.”
And at the core of her body the fist tightened.
“And it’s a completely new drug entity. A proteolytic compound that actually degrades the beta-amyloid protein plaques that cause the dementia. I’m telling you it’s amazing: We’ve seen the plaques recede on MRI in these trials while patients regain functioning and memory. The stuff actually reverses previous damage, not simply slowing the progression. There’s also a mysterious secondary effect—the regeneration of nerve cells. Whatever, the compound’s been in the GEM Tech pipeline for years. And its trade name is Memorine.”
“Memorine.” All those fancy people under the tent yesterday. “GEM Tech.”
A cure.
“Yes, GEM Neurobiological Technologies. As in Gavin Edward Moy.”
The waiter arrived for their orders. René’s appetite had suddenly died, so she ordered an appetizer.
“That’s all you’re going to eat?”
“I’m not very hungry.”
Carr ordered a steak. “You don’t seem very impressed,” he said when the waiter left.
“I’m still trying to process it all.”
“Of course,” he smiled. “It is mind-boggling. But maybe this will help.” From his coat pocket he removed a Palm Pilot. He hit a few buttons, then turned the device for her to see. “You recognize Clara there in the blue sweatshirt.”
“Yes.” On the small screen was an interior shot of patients at a table.
“That was taken seven months ago.” The camera zoomed in on the Manchester Union Leader to confirm the date. Clara was at a table doing a picture puzzle of a puppy. She randomly picked up pieces and tried to fit them together, clearly having difficulty.
“Hi, Clara, how you doing today?” The feathery voice of Jordan Carr off camera.
“Fine,” Clara said, not looking up at the camera.
“Clara, look what I have here.”
Clara lowered her eyes into a shoebox. “See, a button, a hairbrush, and a lollypop.” She inspects them. “You can touch them. Go ahead.” She picks up each item, awkwardly running the brush through her hair. She inspects the button and puts it back, then picks up the lollypop and sniffs it. Carr puts the items back into the box and asks her about the puzzle she’s doing. For maybe a minute she picks up pieces and begins to try to find mates. She’s unsuccessful. Then the lidded shoebox appears. “Clara, remember this? This box?”
Clara looks at it blankly.
“Remember what’s inside?”
She continues to look at it blankly.
“What’s inside?”
“I don’t know,” she says and turns back to the puzzle.
“Remember the lollypop?”
“No,” she says, fingering the puzzle piece.
Carr pokes a few keys with a stylus. “Now this is Clara six months later.”
Clara is sitting at the same table. A wall clock behind her. Dr. Carr’s disembodied voice: “Good morning, Clara.”
“Good morning.” She smiles at the man beside the camera.
A shoebox slides into view. “I’m going to show you what’s inside, okay?”
“Okay.”
A hand opens the box and removes a spoon, a small Mr. Goodbar, and a pencil. Carr identifies each out loud, then puts them in the box and puts the lid back. “Now, do you remember what’s in the box, Clara?”
“Yes. A spoon, a Mr. Goodbar, a pencil.”
“Very good.” And Carr opens the box and removes each and replaces them. With the clock in constant view, he has her put together a child’s puzzle over the next fifteen minutes. She moves very slowly but manages to fit several pieces together. When time is up, the shoebox reappears. “Now, do you remember this shoebox?”
“Yes.”
“Do you remember what’s inside the box?”
Clara blinks at the box for a few seconds. She looks uncertain for a moment, then says, “Yes. Mr. Goodbar, a spoon, and a pencil.”
“Very good,” Carr says, and behind them the nursing staff cheers.
Carr laid the Palm Pilot on the table, the freeze frame of Clara smiling proudly.
The waiter delivered the food while René stared dumbly at the image of the woman smiling back at her. All she could think was, That could have been my father.
“SO WHAT DO YOU THINK?” Carr said, digging into his steak.
“Well, that’s incredible.” And for a second René wondered almost hopefully whether it had all been staged—that she wasn’t actually looking at Clara Devine but some imposter partaking in an elaborate conspiracy for whatever reasons—perhaps some security test gone awry.
“Even more remarkable, her cognitive test scores were double what she got before she was institutionalized and two to three times that of the placebo group—not to mention a five times response rate and enhanced ability to perform her activities of daily living. Six months before she took the drug, she could not dress herself or go to the bathroom alone. Now she’s undergone a clinical regeneration in twenty-four weeks at two ten-milligram dosages daily.”
“I’d very much like to see those results.”
“Of course.” Carr’s eyes beamed like a child sharing a secret.
“She was forgetting things from one moment to the next. It was like watching her being peeled away like an onion.” Cassandra Gould’s words buzzed in René’s brain.
And cutting across those her father’s plea: “Promise me … I don’t want to end up just some gaga thing attached to a diaper.”
Maybe Clara Devine was just some extraordinary anomaly. “Are there other test subjects?”
“Of course.”
“So why all the secrecy if it’s such a miracle drug?”
“It’s a blinded study to keep people unbiased.”
Clinical trials were blinded so that the people responsible for patients wouldn’t attribute any and every change to the drug being tested. And while in such studies the caregivers may not know which patients receive the active drug and which patients receive a placebo, they are made aware that patients are enrolled in a clinical study. “But why wasn’t I or my pharmacy informed?”
“Because technically the trial compound is not among the active meds supplied by CommCare, your pharmacy. The Memorine tablets came from GEM.”
“But these patients were on other meds that CommCare supplies.”
“Look, their medical charts were meticulously kept by the nursing staff.”
“You mean a separate and hidden set.”
“Yes, but the trial data wasn’t kept from those who need to know at the FDA.”
“That still doesn’t explain why there are no nurses’ reports of the trials in my records or the alleged improvement of patients’ behavior and functionality. Or why I wasn’t told.” Because her job centered mostly on paperwork, she had only minimal contact with nurs
ing home residents—something she hoped to change as time passed. Therefore, she could not personally have witnessed any actual improvements in the behavior of these trial subjects. Nonetheless, nurses and other staffers at her homes often talked about patients’ health, behavior, affect, the funny things they may have said. Yet, remarkably, nobody had uttered a word about the extraordinary changes in Clara Devine or any other patients in these trials.
“Well, I’m telling you now.”
“But only because Clara Devine eloped and murdered someone.”
His face darkened. “That was unfortunate.”
“Doctor Carr, this isn’t a blinded study, it’s a concealed one.”
He stared at her for a moment, then shrugged. “If you wish.”
He was trying to disarm her with a concession because he knew that she could report him. As an employee of CommCare, she was an outsider to the nursing home and bound by state and FDA regulations. And they both knew that she could lose her job were she not to report a secret clinical trial. “Doctor, you’re not answering my question: Why was I kept in the dark?”
“It was nothing personal. Even the nursing staff didn’t know what the subjects were on, though they were aware they’d been enrolled in trial of a dementia drug.”
“That still doesn’t answer my question.”
He drained his wineglass. “Because GEM Tech did not want to risk the competition getting wind of what we have. Period.”
The we floated like a lazy feather in the air. “They’re really worried some other drug company’s going to whip up a me-too compound?”
“In a word, yes. They don’t want somebody else beating them to the market. You know what a rat race the pharmaceutical industry is. Somebody invents a Ford, and a Chevy is right on its bumper.” He lowered his voice to a conspiratorial whisper. “René, we’re talking about a supreme blockbuster drug here—a fifty-billion-dollar pill.”
The waiter arrived to clear their dishes. When he left, Carr said, “I know it’s premature, but the FDA is very excited about this, very. And I won’t be surprised if they fast-track its approval.”
That still didn’t justify burying data. But the more he talked about the miraculous results, the more she became self-conscious about raising niggling issues of policy regulations. Here was a celebrated senior neurologist sharing with her what might be the greatest breakthrough in medicine since penicillin, and two months on the job and little Polly Protocol was souring the air with fumes. “I can imagine.”