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In Control

by Marc Colten

 

Jeffrey Gold sat in his doctor’s waiting room gently swinging the quart food saver bag with his pill bottles.   Even though this was the same office that had written all of his prescriptions they always asked him questions on dosage or how often he took the pills.  He never remembered them all and, even when he wrote down the information to bring with him, they invariably asked him a question he couldn’t answer.  Now he just brought all of the bottles with him which they could read for themselves.  After a while he looked up and saw how annoyed the other patients were at the rattling of the pills, so he sat back and held the bag in his lap.

He didn’t like the remodeled waiting room.  The new chairs were padded and were more comfortable than the old hard plastic ones and there were now little tables between the rows.  Unfortunately those tables were piled high with boating magazines reviewing the newest in high end yachts and travel magazines touting all the international hot spots he could never afford to see.  Thanks for reminding us where our insurance and co-pay dollars were going, he thought.  Worse yet they had found another way to squeeze money out of the system by installing a large flat screen television that played constant “health” programming.  Over and over they repeated fake shows that started out by telling you how a healthier lifestyle could keep you out of the doctor’s office, but they always ended with pills as the answer to all your problems.  Gold didn’t know the economics of putting in that TV but he knew they wouldn’t have done it if it was losing them money.  Somehow intruding into sick people’s comfort by turning them into a captive audience for Big Pharma added to their yacht and travel budget.   All he could think as he watched the smiling actors pretending to be doctors, nurses and patients was how far ahead of his time George Orwell really was.

He would have preferred to come after work but Doctor Julius’ practice was thriving and he had to take the opening he could get, forcing him to lose a half day’s pay. He had arrived early and now desperately wanted a cold drink from the brand new water fountain on the other side of the room but he was satisfied with his seat, with a seemingly healthy person on his left and a table on his right.  The waiting room was always crowded so whenever a seat became vacant someone would immediately move to get away from a wheezing or coughing patient.  In the time it would take him to walk to the fountain and back he’d lose his seat and would have to choose which sicker person to sit next to.  So he sat, thirsty and bored, refusing to pick up any of the magazines and wallow in the prosperity of his health care providers.

Gold had to marvel at the efficiency of the practice.  Patients were constantly being moved into the examination rooms or out the front door with the office staff (apparently divided into specialities such as bringing patients in, collecting fees and scheduling future appointments) managing the flow so the medical professionals did not waste a minute of their day.  Time was money, even in the healing arts.

Gold had been sick for a long time with no end in sight.  As an asthmatic boy he had suffered the constant ragging of the other kids as he puffed on the inhaler he carried everywhere.  Now he was in his thirties, still “frail” and still living in a cold (and now snowy) suburb of Chicago despite always promising himself he’d live somewhere warm someday.  He remembered even back then his doctor’s office had been filled with little gifts from the drug companies but the constant promotion had only gotten worse.   This waiting room and the examination rooms inside were stocked with every manner of useful item donated by the drug reps who made regular visits to the clinic to drop off samples and push their new products.  There were clocks, calendars, clipboards, pencil cups and posters everywhere, each emblazoned with the name the donator’s product.   Less obvious were the trips and “seminars” available to the doctors.  How many news shows had he seen on “educational” junkets for doctors that consisted mainly of sailing, golf and banquets?

In recent years it seemed that the big drug companies were no longer satisfied with just treating the diseases people already had but were inventing new conditions that mankind had somehow avoided for the last million years and spending billions on advertising suggesting that you ask your doctor if you had them.  And the list of symptoms!  Are you tired after a long day?  Would you rather stay in bed than get up and go to a job you hated?  Are you in your nineties and unable to get an erection?  Tell your doctor to prescribe our new pill for you.  When he began getting, and paying for, his own medicines he started wondering if it wasn’t the doctor’s job to find out what you had and then tell you what medicine you needed.

When he was finally called he couldn’t resist taking a side trip to the water fountain with a quick look back at his former seat.  As he suspected, even before he managed to take a drink, someone had moved away from a sicker patient and taken his place.  The nurse led him to an exam room, stopping at a scale to take his weight even though he had been there only a week earlier.  Then there was another long wait before another nurse came in to take his particulars.  She seemed surprised when he dumped the plastic bag of his medicines on the counter in front of her after she asked what medications he was on, but she shrugged and quickly reviewed the labels, comparing them to the list in front of her.  She followed the drug review by taking his temperature with a digital thermometer and then his blood pressure.  Apparently neither was all that alarming because she gave the usual “someone will be with you soon” speech and left.  It wasn’t “soon”.

He sat for another fifteen minutes on the massive exam table that practically filled the tiny room, periodically considering moving to the uncomfortable plastic chair in the corner where he had dumped his jacket but it didn’t seem worth the effort.  So he waited.  There wasn’t much in the room to focus on.  There were various instruments for taking readings or looking in patient’s ears, a rack holding boxes of latex gloves in several sizes, a special container for used syringes and the usual wipes and swabs.   The only non-medical items were more of the magazines that he had seen out in the waiting room, left there for the long wait between exams.  It was all too familiar.  He could see this  room and the others like it with his eyes closed.

When the nurse practitioner finally came in there was the usual routine as she checked the clipboard to see his latest readings.  This practice had one doctor at the top of the heap but several nurse practitioners to carry the load and he almost always saw the same one.  She was neat and professional and he had come to trust her as much as you could trust anyone in the health field.

“Well,” Nurse Jacobson said, “you’re back very soon after your last appointment.  Are you feeling worse?”

“No,” Gold told her.  “My symptoms are no worse, but no better.  When you prescribed the … the red pill which I can’t pronounce for the itching I asked you how long it would take to notice a difference.  There hasn’t been one.”

“Well,” she said, “it often takes longer with some patients.  I’m sure I told you that, too.”

“You said one to two weeks and it’s been almost a month.”

“Medicine isn’t always an exact science.”

No one knew that more than Gold.  How often had a doctor said to him that they were going to try something different and “see what happens”?   He wouldn’t let a mechanic treat his car that way.  We’ll replace the pistons and see if that helps.  Yet, he could not count the number of medicines that doctors had decided to “try” on him.

“Then what brings you here today?”  She actually sounded as if she cared and was not annoyed at his constant demands to feel better.

“I have a question I hope you’ll answer for me,” he said.  “It’s something I’ve been thinking about for a while.”

“Of course, you can ask me anything.”

Gold had been thinking about this question for a long time but had never dared ask anyone either at the clinic or at the drug store where he got his pills.  “What I wanted to ask is this.  Are those real medicines?”

The NP seemed stunned.  She took a moment to pick up the bag and look at the  bottles inside.   “What are you suggesting?”

Was that her way of avoiding the question?

“I’ve been taking some of those medicines for years and the others for just a short time, but I never feel different.  I don’t get better and I don’t get worse.  I’ve never even had any side-effects.”

“Well you don’t want those.”

“No one wants them,” Gold said, “but people get them.  The paperwork that comes with the pill warn you about fatigue, rashes, headaches, diarrhea or constipation.  You’d think that just once I’d get one of them, but I never do.  I also never seem to get any better.”

“Mr. Gold, you certainly can’t complain about a lack of side-effects.  Those people who get them are the unlucky ones.  As for feeling better, well, some things take time.”

He jumped down off the table and fished two of the bottles out of the bag he had brought.  “I’m very careful about reading the instructions before I start taking any new medication, but a few months ago I began to wonder if someone was playing with me.”

“I don’t understand.”

Gold handed her one of the bottles.   “I’ve been taking this medicine for the dry mouth for several months.  Read this warning.  Aloud, please”

The NP studied the label before speaking.  “‘Do not lie down for ten minutes after taking this medication.’  Hmm.”

“What does that mean?”

The NP seemed puzzled.   “Well, I’m sure it’s for a good reason.”

“You’re a health professional,” he said.  “Explain that to me.”

She put the bottle back down on the counter.  “I’ll confess that I don’t quite understand the logic behind that.”

She seemed to be about to say more but Gold pounced on that admission.  “Right?  Right?  I mean does a tiny pill know which way is down in my stomach?  And for just ten minutes?”

“I’m not sure.  Maybe it causes drowsiness or dizziness.”

“In which case shouldn’t they instruct you to be sure to lie down for ten minutes?”

“I could look it up,” she said, “but it might take a while.  These newer drugs aren’t in the usual books.  I’d probably have to go onto the Internet.”

“Before you do that, read the warning on this other bottle.  This is the one Doctor Julius prescribed last week for my vertigo.  I picked it up yesterday.”

She read the label but could not seem to force herself to say it out loud.

“How do you explain that one?   ‘Do not sleep while taking this medication.’   That’s the warning on a medicine that I’m supposed to take three times a day.  Am I supposed to stay awake twenty four hours a day for as long as I’m taking the pills?”

The NP seemed particularly flustered at that question.   “That’s absurd.  It couldn’t possibly mean that.”

“Someone,” he said, sticking his index finger right up to her face for emphasis,  “is playing with me.   Someone is laughing at me, and I don’t like it.”

She backed slightly away and didn’t speak until his offending hand had dropped.  “Mr. Gold …”

“Yeah, I know, paranoia, but something is going on here.  Something that has been going on for a long time.  I never get better.  I never suffer a side-effect.  That’s why I asked you if those are really medicines at all.”

“Why would you be given fake medicines?”

Gold paced, as much as he could in the space left to him between the walls and the exam table.  “I remember when they came out with the first AIDS drugs the patients found out that half of them were getting the real medicine while the other half were getting placebos.   Real people with a real disease were getting fake medicines.”

“Those were drug trials with a control group,” she said.

“Leaving half of the people to just get worse.”

“It’s unfortunate but it’s really the only way to test new drugs.”

And what about Tuskeegee?”

“That I can’t justify,” she said, “but you know that was decades ago and … well, things were different back them.”

“Yeah, different.  In our modern, non-racist world only half of the black men at Tuskeegee would have gone on to die untreated.”

The NP closed up the file and put the medicines back in the plastic bag.  “Mr. Gold, I understand your frustration, but I can assure you that we are prescribing real drugs and your pharmacy is dispensing them.”

“Can you?”

“Can I what?”

“Assure me.   Can you assure me?”

The NP’s smile seemed sincere but there was a hint of nervousness in it.  “I took an oath and yes, I know the people at Tuskeegee and the people who ran the AIDS trials also took the same oath, but I’ve devoted my professional life to helping others.  The real question is why would anyone do this to you?”

“Maybe it’s not just me.  Maybe a thousand people are prescribed one of those medicines and only five hundred get the real thing.  We all go to our doctors and someone back at the drug company gets to see how many of us improve or have side effects.”

“All of your drugs?”

“If I get eight medicines and some are real and some are not then how would they know which was doing what?   That would also explain why I get so many medicines.  After all, if there are no active ingredients in any of them, why not boost your numbers by having me take more of them?”

She shook her head in what might have been sympathy, or pity.  “You’ve spent a lot of time thinking about this, haven’t you?”

“I’ve got a lot of time to think about things.  It’s my life, right?  You can’t explain away my concerns.  You can’t even explain the increasingly weird instructions.  I tell you that something is going on and it’s been going on for so long that the people behind it are getting goofy.  Somewhere between the people who decide who gets the placebos and the people who hand them out someone is having their own brand of fun.  It’s like people working a night shift at newspapers or TV stations who get so tired that they start fooling with the obituaries.”

The NP seemed genuinely flustered.  “I can’t speak for anyone else, but I assure you … I promise you that I have been honest with you.  I report on your condition to the doctor who prescribes the medicine.  I don’t know anything about fake medicines.”

“Then maybe I should talk to the doctor.”

Gold went back to waiting.  He had finally said it.  After years of vague suspicion that something was wrong he had come up with this theory, as insane as it sounded, even to himself.  When he had asked his pharmacist if he could have his pills analyzed (claiming he was worried about additives and preservatives) he had been warned that it was unlikely that any testing lab would accept the job.  Something about being accused of “back engineering” patented medicines.  He had no way of knowing whether that was true or not.  Beyond that, he had been warned, the cost would likely be prohibitive.  Were they in on it, or did they want to avoid getting involved in something that was wiser to stay away from?  He had no real choice, of course.  He either took the medicines or he didn’t.  He could ignore his medical condition or at least try to get better.

Doctor Julius joined him more quickly than he had anticipated.  Did that mean something?  Was the doctor alarmed by his questions?  Or had Gold gotten so used to waiting for the doctors and nurses who saw him when they had the time in their busy careers that any shorter wait seemed significant?  He had been seeing Dr. Julius for the last eight years, averaging a visit every two to three months, but had only seen him in person a few times.  He was a tall, athletic man who seemed to get more healthy every time Gold saw him.  At least, he thought bitterly, at least the health care system works for someone.

“So, Mr. Gold,” the doctor said, “Nurse Jacobson tells me you have some concerns about your medicines.”

“So, what’s your answer?”

“To what question?”

Gold started to feel angry.  It was unlikely that the doctor was unaware of what was going on.  If he had prescribed the medicines in good faith he could not be expected to ignore their lack of effect.   For the scheme to work those patients in the control group had to keep taking the medications even if, especially if, they had no effect. If the control group was “blinded” the doctor might suspect something and take the patient off the placebo, thus ruining the entire plan.  He had to be warned to keep the patient going on the medications assigned to him.  How innocent could he ultimately be?

“Doctor, you must know what I’ve been saying.”

“All I know is that you have some concerns as to whether you’re on the right medications.”

“The ‘right’ medications?”  Gold paused and took a deep breath to control his anger.  “I’m not sure I’m getting any medicines at all.  I think I’m in some kind of special control group and all my pills are nothing but placebos.”

The doctor smiled.  “You should have them tested.”

Bastard, Gold thought.  He knew.  Somewhere in the doctor’s private files (which he would never get to see) was a note warning him about Gold’s conversation with the pharmacist.  Was everyone in on this conspiracy?  Certainly enough people that he would have a hard time escaping from it.  He could choose a new doctor at random, and go to a pharmacy picked out of a hat and there still might not be any escape.  Only so many people made medicines and you couldn’t buy a television in this country anymore without two forms of ID.  Even if the doctor and pharmacist were innocent dupes he would still get the medicine picked for him and him alone.

“Mr. Gold,” the doctor continued, “you’ve been coming here for quite a few years now and I assure you that our only concern is your health.”

As long as it pays.  Gold looked past the doctor to a travel magazine on the table behind him.  Ski Zermat!, the cover said. The arrogance of the man. How many of his working class and pensioner patients were planning to ski the Alps?  Maybe he hadn’t always been corrupt.  Maybe, as a medical student, or during his internship, he really believed the crap he had learned to shovel out, but no one less than a saint could stand up to the years of temptations heaped on them.  The only ones who were still honest were the ones who weren’t worth paying off.

“Doctor,” Gold said, “I think there’s no point in taking my medications any more.  Especially as I’m more and more convinced that they’re not real and were never supposed to make me better.”

“Mr. Gold,” the doctor said, “I appreciate your anxiety.  It’s not uncommon for a long term patient to become frustrated with his, let’s say perceived, lack of progress.”

“So it’s just my perceptions that are off?”

“I think so.  Your records show a steady, if slow, improvement in your condition, but it’s only natural for you to concentrate on when you feel bad rather than when you feel good.  Some people tend to ignore the sunny days and think about the weather only when it rains.  I think I have something that might help, at least in the short term.”

The doctor just happened to have a clear plastic bottle in his pocket.  He handed it to Gold who shook it, rattling the two capsules inside.

“More medicines?  Are they real this time?”

“All your medicines are real.  There’s no such thing as this super control group you imagine yourself a part of.  Your problem, your real problem, is this anxiety.  You’re not sleeping well, are you?  You worry and you lose sleep and the fatigue makes you even more anxious.”

“There’s no label,” Gold observed.

“This isn’t a prescription, just a couple of samples.  Take them tonight before you go to bed and I guarantee you will feel much better.”

It took some time, but eventually Gold did feel better.  The warmth and dryness of rural New Mexico seemed to agree with him.  He missed certain things, like the Internet and home mail delivery but he wasn’t completely off the grid.  A few friends knew where he was and could be periodically roused to send him an actual letter which he could pick up at the post office twenty miles away.  Sometimes it had been sitting there for nearly a week by the time he picked it up but the local pace was slower and he didn’t mind the delay.   He even got the occasional pill in the mail.  Not medicines, since that was illegal, but vitamin supplements which were apparently legal to send to people who had not ordered them.  He did not take them, of course, or even throw them out.  He went directly from the post office to the bank where he had rented a safety deposit box to be opened (according to the letter he sent to a trusted friend) in the event of his death.   He didn’t even wrap them in bits of hamburger and put them out for the strays as he had with the two capsules Dr. Julius had given him.  The doctor said they would relax him and, to be honest, he had never seen two more relaxed cats in his life.  Until rigor mortis had set in.  He had left the city not more than one week later.  His phone rang several times as he packed his essentials, the Caller ID displaying the doctor’s office number the first few times and then “Unknown Caller” after that.  He waited until he was in another state, halfway to his destination, before calling to cancel all of his services.

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