Foreign Body

by Robin Cook

  “I can’t imagine anything about this trip being pleasurable, which brings me to the issue of malaria. What do you think I should do?”

  “Ouch,” Neil said, wincing. “I’m sorry to say you should have started something a week ago.”

  “Well, there’s no way I could have anticipated this. I’m okay on everything else, even typhoid, from the scare last year with my patient in internal medicine.”

  Neil grabbed a prescription pad from his drawer and rapidly wrote one out. He handed it to Jennifer, who looked it over.

  “Doxycycline?” Jennifer read out loud.

  “It’s not the number-one choice, but the coverage starts immediately. The best part is you probably don’t need it. It’s the south of India where malaria is a true problem.”

  Jennifer nodded and put the scrip into her shoulder bag.

  “Why did your grandmother go to India for her surgery?”

  “Purely cost, I assume. She didn’t have health insurance. And I’m sure my bastard of a father encouraged it big-time.”

  “I’ve read about medical tourism to India, but I’ve never known someone who actually did it.”

  “I wasn’t even aware of it.”

  “Where are they putting you up?”

  “A hotel called the Amal Palace.”

  “Wow!” Neil said. “That’s supposed to be five-star.” He chuckled, then added, “You’d better be careful; they must be trying to buy you off. Of course I’m kidding. They don’t need to buy you off. One of the negatives about medical tourism is you have no recourse. There’s no such thing as malpractice. Even if they screw up big-time, like taking out the wrong eye or killing someone by mistake or incompetence, there’s not a thing you can do.”

  “It’s my guess they’ve negotiated some kind of deal with the Amal Palace. It’s just where they put people up. I mean, it’s not like I’m getting a special deal. Apparently, they pay airfare and hotel for one relative. That’s why I’m getting the trip. My lazy father claimed he couldn’t go.”

  “Well, I hope something positive comes out of this journey,” Neil said. He gave Jennifer’s wrist one last squeeze. “And keep me informed. Call me anytime: morning, noon, or night. I’m so sorry about your grandmother.” He picked up the pen as a signal he had to get back to work.

  “I have a couple of requests,” Jennifer said, maintaining her seat.

  “Sure. What’s on your mind?”

  “Would you consider coming with me? I think I need you. I mean, I’m going to be completely out of my element. Except for a trip to Colombia when I was nine, I’ve never been out of the country, much less to some exotic place like India. Since you were just there, you already have a visa. I can’t tell you how much more comfortable I’d feel. I know it is asking a lot, but I feel so provincial; even going to New Jersey used to make me anxious. I’m kidding, but I’m not a traveler by any stretch of the imagination. And I know that one of the benefits of emergency-room medicine is that you can take time off, especially since you covered for Clarence a couple of weeks ago, and he owes you.”

  With a sigh, Neil shook his head. The last thing he wanted to do was wing off to India, even if he could get time off. In truth, it had been part of his initial motivation for the specialty, and he’d specifically set up a twenty-four-hours on, twenty-four-hours off schedule for himself so that when his workweek started seven a.m. Monday it was essentially over seven a.m. Thursday, unless he wanted overtime. The four remaining days of the week were available for his true love, surfing. At that very moment he was looking forward to a surfing meet over the weekend in San Diego. It was also true that his friend, colleague, and fellow surfer Clarence Hodges did owe him for a Hawaiian trip he’d made. But all that didn’t matter. Neil did not want to go to India because of a dead grandmother. If it had been Jennifer’s mother who had passed away maybe, but not her grandmother.

  “I can’t,” Neil said, after a pause, as if he’d given the idea true consideration. “I’m sorry, but I can’t go. Not now, anyway. If you can wait a week, maybe, but it’s not a good time.” He spread his hands awkwardly in the air over the schedule he was working on as if it was the problem.

  Jennifer was taken aback and disappointed. She’d given a lot of thought about whether to ask him or not and if she truly needed him. What had tipped the balance was the realistic question in her mind whether she could actually handle the situation once she got to India. What was clear to her was that after the initial shock of learning about Maria’s death, she’d marshaled significant defenses, including all the rushing around, making the plans to take the trip, and what psychiatrists called “blocking.” So far things had worked reasonably well and she was functioning. But as close as her grandmother had been to her, she feared there would be problems when the reality of the loss set in. She truly feared she could get to India and be an emotional train wreck.

  Jennifer stared daggers at Neil. Surprise and disappointment had instantly metamorphosed into anger. Jennifer had been so confident that if she asked him directly and admitted she needed him, which she felt she had done, he would surely acquiesce as a direct spin-off of the confidences they shared. The fact that he was turning her down so promptly and with a flimsy, ridiculous explanation, something she never would have done had the situation been reversed, could mean only that their relationship was not what she thought it was. In short, like men in general, in her mind he was demonstrating he couldn’t be counted on.

  Jennifer stood abruptly and without saying anything walked out of the tiny office and back into the crowded emergency room. She could hear Neil call her name, but she didn’t stop or respond. It tormented her that she knew now that it had been a mistake to confide in him. As for asking to borrow some cash, at this point she wouldn’t even consider it.

  Chapter 6

  OCTOBER 16, 2007

  TUESDAY 6:30 A.M.

  NEW DELHI, INDIA

  Cal Morgan was a deep sleeper and needed a powerful alarm to wake up. What he employed was a clock radio with a CD player, and the CD he used was martial music. At three-quarter volume the player was capable of vibrating the night table enough to move itself and other objects on its crowded surface. Even Petra in the neighboring master suite could hear it as if it were in her room. So when it sounded, Cal made an effort to turn it off the moment he became adequately conscious. Even so, he occasionally fell back into deep sleep.

  But that was not going to happen this morning. He was much too keyed up about the previous night’s activities for more sleep. He stared up at the high ceiling and thought about what had transpired the evening before.

  What bothered him was how close Veena’s suicide attempt had come to bringing his whole project down. If he hadn’t gone in to check on her when he did, she would have died, and there was little doubt that her death would have resulted in an inquest, and an inquest would have been a disaster. It would certainly have closed Nurses International, and in the process, at the very least, slowed his progress toward his ultimate goal of becoming truly wealthy as the CEO of SuperiorCare Hospital Corporation.

  Cal hadn’t been interested in healthcare initially, and he still wasn’t interested in taking care of patients or nurses, for that matter. He just liked the money involved, two trillion per year in the United States alone, and the field’s record of sustained growth. Back when he was in high school, advertising had been his first career choice, and he had gone through UCLA and the Rhode Island School of Design in preparation. But briefly working in the field caused him to recognize its limitations, especially financially. Giving up on advertising, but not its principles of deception, he sailed through Harvard Business School, where he was introduced to the mind-boggling money involved in healthcare. When he finished business school he sought and got an entry-level job at the SuperiorCare Hospital Corporation, which was one of the biggest players in the field. The company owned hospitals, feeder clinics, and healthcare plans in almost every state and major city in the United States.


  To best utilize his creative bent, Cal entered the company via the public relations department, where he saw the best opportunity to make a name for himself and thereby attract the attention of the company’s officers. On his first day he boasted he would lead the company in ten years, and after two it appeared as if his prophecy might have merit. Along with a striking woman five years his senior and an inch taller than his six feet named Petra Danderoff, who’d been part of PR when he joined, he found himself co-running the entire department thanks to a series of extremely successful ad campaigns the two had contrived that had nearly doubled the enrollment in several of the company’s healthcare plans.

  Some people had been surprised at his meteoric rise, but not Cal. He was accustomed to success from an early age, partly as a self-fulfilling prophecy of the confidence and competitiveness that was part of his genetic makeup, and which had been honed to an obsession by his equally competitive father. From early childhood he’d wanted to win at everything, especially in competition with his two older brothers. From board games like Monopoly to school grades, from athletics to the presents he gave his parents at Christmas, Cal insisted on being number one with a kind of single-mindedness few could match. And success only reinforced his appetite for more success, to the extent that over the years he lost all vestiges of the need for moral principles. In his mind cheating, which he didn’t refer to as such, and ignoring ethics, which he considered mere limitations for the faint of heart, were simply tools to advance one’s agenda.

  SuperiorCare Hospital Corporation officers were not aware of these details of Cal’s background and personality. But they were very aware of his contributions to the company and were eager to reward him, particularly the CEO, Raymond Housman. By coincidence this recognition had materialized more or less at the same time a mounting financial problem had been brought to the CEO’s attention by his CFO, Clyde English. To their collective horror, accounting had determined that the company had lost, in 2006, about twenty-seven million dollars from its bottom line because India’s growing medical tourism industry had caused a disturbing number of American patients to shun SuperiorCare hospitals and wing off to the Asian subcontinent for their surgeries.

  Linking the two issues, Raymond Housman had invited Cal to a secret meeting in his office. He’d explained the medical tourism issue and the need to somehow turn it around. He’d then offered Cal an unparalleled opportunity. He said SuperiorCare was looking to lavishly fund through a secretive bank in Lugano, Switzerland, a company with the express purpose of seriously diminishing demand for patients to go to India for surgery, if he would agree to form it. Raymond was very clear that SuperiorCare Hospital Corporation wanted no ostensible connection with such a company and would strenuously deny there was a connection if asked, nor did they want to know how the company accomplished its goal. What Raymond didn’t say but what Cal definitely heard was that his termination at SuperiorCare Hospital Corporation was temporary and that his success in the current venture would be a cause for him to be welcomed back into the corporate fold with open arms at an extremely high level, essentially leapfrogging the corporate ladder.

  Despite having no idea how he was going to engineer the new company’s objective, Cal had accepted immediately with the proviso that Petra Danderoff, then his co-director of the public relations department, would be included in the deal. At first Housman had balked with no one to run SuperiorCare’s PR, but after being reminded of the seriousness of the medical tourism problem, he relented.

  Two weeks later, Cal and Petra were back in Cal’s hometown of Los Angeles, brainstorming their company-to-be’s modus operandi. To help, each had hired a gifted friend: Cal had chosen Durell Williams, an African-American whom he had befriended at UCLA and who had gone on to specialize in computer security; and Petra had asked Santana Ramos, a Ph.D. in psychology who had joined CNN after she’d worked in private practice for a half-dozen years.

  Most important, all four people were equally competitive, equally dismissive of ethics as a limiting weakness, and equally convinced that their current challenge of curtailing medical tourism for a Fortune 500 company was an opportunity of a lifetime, and each vowed that they would do whatever it took to denigrate medical tourism. Quite expeditiously, the group had settled on a company plan of promoting patients’ fears as the best way to lower demand. Until patients were subjected to propaganda to the contrary, everyone facing surgery had strong reflex reservations about going to India or another developing country for an easily understandable complex of reasons. First was the concern of the country’s general lack of cleanliness, raising the specter of wound infection and catching any one of a number of dreaded infectious diseases. Next there was an obvious question of the skill of the surgeons and the other personnel, including nurses. In addition, there was the question of the quality of the hospitals and whether the necessary high-tech equipment was available. And finally there was the question of whether the operations that were performed were generally successful.

  When the group looked into the propaganda the India Tourist Office was actively putting out, they discovered the office was clearly addressing these specific issues. Consequently, it was decided that Cal’s new company would create ad campaigns to do the opposite and take advantage of people’s fears. Everyone was certain this plan would be successful, since ad campaigns are always easier when the goal is the support of people’s existing beliefs and prejudices.

  Unfortunately, no sooner had they settled on a strategy and begun trading ideas when they ran into a serious problem. They had realized that with India spending serious money and effort promoting their medical tourism, the Indian government would surely investigate if someone started doing the opposite, and an investigation of any sort would invariably cause significant problems if ad campaign claims could not be substantiated.

  What had been quickly recognized was that real data were needed involving private Indian hospitals, particularly in relation to outcomes, mortality, and complications, which included such statistics as infection rates. Yet the data were not available. The group had checked the Internet, medical journals, and even the Indian health ministry, which they soon discovered was dead set against releasing any such information, even refusing to admit if it existed. In their own ads they used no data whatsoever, merely claiming their outcomes were as good as or better than outcomes in the West.

  Stymied for a time, the group had suddenly realized they needed a fifth column inside the private Indian hospitals participating in the highly profitable and growing medical tourism industry. What would have been best were accountants, but the efficacy of that idea seemed questionable at best. Instead, they had hit on the idea of using nurses, mainly because Santana knew something the others didn’t—namely, that there existed a worldwide business in nurses. In the West there was a shortage. In the East, particularly in the Philippines and India, there was a surplus, with many young nurses desperately wanting to emigrate to the United States for economic and cultural reasons but facing significant, almost insurmountable, hurdles.

  After extensive research and much discussion, Cal et al. had decided to go into the nurse business by founding a company called Nurses International. Their plan, as was accomplished, was to hire a dozen young and vulnerable, attractive, impressionable, newly graduated Indian nurses, pay them U.S. nurses’ wages, and bring them to the States on tourist visas, specifically to California, for a monthlong training session with the idea of turning them into a team of beholden and therefore easily manipulated spies. In California they had been purposefully spoiled to maximize their manipulability and to take advantage of their wish to emigrate. At the same time, they had been trained in computers during the morning hours, particularly in regard to computer-hacking techniques. In the afternoons they had worked for a few hours as nurses in a SuperiorCare hospital to improve their American English as well as acquaint them with American patient expectations, both of which, it had been assumed, would make it easier to hire them out to private
Indian hospitals.

  Everything had gone miraculously according to plan, with teams of two nurses currently in six private Indian medical tourism hospitals. For housing, all had been required to live together in a mansion rented by Nurses International in the diplomatic area of New Delhi, to the initial chagrin of the nurses’ families. Since the money the nurses were providing continued, however, family complaints vanished.

  After they had been working for a week, with all of them complaining they wanted to go back to California sooner than the six months they were required to remain in India, they had been instructed to begin extracting patient-outcome data from the computers in their respective hospitals. The goal was to be able to begin to calculate infection rates, adverse outcome rates, and death rates for their future ad campaigns. To Cal and the others’ surprise, none of the nurses questioned this activity, and they were wonderfully successful. But then disaster had struck. Something had happened that no one had anticipated. The stats had turned out to be quite good, even strikingly excellent in several of the institutions.

  For a few days Cal and Petra had been depressed and unsure of what to do. After all the money they’d gone through to set up the elaborate spy system, they had begun to feel pressure for results. Raymond Housman had even sent a secret representative a week earlier for an update on when they could expect something to happen. It seemed that the bottom-line losses from medical tourism were continuing, and ticking upward at an alarming rate. Cal had promised results would soon be forthcoming, since at the time of the envoy’s visit, the outcome data were just beginning to flow in.

  But then, by tapping into his creativity and urge to win, Cal had come up with a second idea. If there were no bad statistics to be found for the basis of a negative ad campaign, why not create their own bad-outcome, hard-luck stories with the help of their installed fifth column and feed the stories to the media in real time. With the unsuspecting help of an anesthesiologist and pathologist whom he’d gotten to know in Charlotte, North Carolina, while he’d worked at SuperiorCare’s corporate office, Cal had settled on succinylcholine as his drug of choice to cause sudden death. The idea was to find patients who’d had a history of some sort of heart disease and who’d had succinylcholine as part of their anesthesia, and inject them with an additional bolus of the muscle-paralyzing drug the evening following their operations. Cal had been assured the drug would be undetectable, and if it was detected, it would be assumed to be from the patient’s anesthesia. Best of all, there’d be an immediate diagnosis of a fatal heart attack because of the cardiac history.