by Andrew Smyth
If anything he looked even more annoyed. ‘I made some enquiries but as far as I could find out it all seems to have been a mistake.’
‘A mistake? It cost me my career.’
‘I know but there’s nothing I can do. It was all a bit messy.’
Messy was one way of putting it, I thought, although I could think of several other suitable words.
As I watched him go, I wondered about our friendship. He hadn’t been the same person since our tour in Afghanistan. You could never tell with him; sometimes he would act like a high priest, above all mortal concerns, but at other times he saw things quite differently and appeared to show little regard for rules if he thought they were simply obstacles. Perhaps because of his Asian background he’d always had a different way of looking at things that I had found refreshing, but now I wasn’t so sure.
I went back inside and put in a desultory hour’s working, but it did little to relieve my depression at the way things had changed between us.
7
When she arrived, Greta was wearing her usual trouser suit and waved away my attempt to help her on board. I showed her into the saloon and opened a bottle of wine. This was the first time she had been able to relax with me, but now she seemed surprisingly reticent – even shy. She was obviously still grieving – she told me how close she’d been to her father who certainly wasn’t of an age to die.
‘I’m sorry,’ she said after a while. ‘I’m not normally like this but I’m still finding it hard to deal with. It was a routine operation.’
‘I can understand the shock.’ As I said it I realised how feeble it sounded. ‘I promise I’ll get to the bottom of it.’ Although I felt much less confident than I sounded.
I tried pointing out the various sights along the river but her listless attention wandered so I was glad when Sally finally arrived and Greta immediately perked up. In the same way, and despite our divorce, Sally often managed to lift my spirits.
Unlike Greta, Sally was pint-sized, with close-cropped dark hair, but she made up in personality what she lacked in size and people crossed her at their peril. As her determination to qualify as a doctor had demonstrated, once she’d made up her mind about something that was it.
Recognising that her usual levity would be out of place, she refrained from making any more sarcastic comments about my boat, though I had no doubt that she would be saving them up for a later date. I poured out the wine and brought some chairs up on deck. I thought we might as well make ourselves comfortable while I brought Sally up to date with my various researches, ending with the false label stuck over the insulin cartridges. I took them out of the evidence bag I’d put them in and handed them to her.
‘I looked it up before coming,’ she said, putting them on the table next to her. ‘The insulin is obviously for his diabetes, and insulin is particularly susceptible to degradation. The active ingredients fade very quickly, in a matter of months, so if the original expiration date on this batch was correct, then it would have lost its usefulness long before. I’m not sure if you realise how serious this is – relabelling drugs like this is criminal. Thanks,’ she said, taking the glass from me. ‘I needed this after the day I’ve had.’
‘The start of the slippery slope,’ I said – she’d often had a go at me for my alcohol consumption, so I couldn’t let it pass.
Sally ignored me as she downed a good measure of her wine. ‘Have you heard of the MHRA? The Medicines and Healthcare Regulatory Agency? They’re the government body that oversees all aspects of pharmaceuticals. They licence drugs and manufacturers, they monitor clinic trials and investigate counterfeit medications. I think you should call them in; they’re the experts in this sort of thing.’
I explained my fears about the hospital clamming up and repeated what I’d been told by the professor and Bob Tyler. ‘I’ve arranged to see Tyler again tomorrow, although I’ve no idea whether he’s going to stonewall me, or whether he’s prepared to help. He seemed pretty genuine and didn’t hold back his criticism of some of the hospital’s policies. Apparently, they’re currently advertising for a new head of security without letting him apply, so that hasn’t helped. But tell us about the other medication – what about this Oxaban?’
Sally picked up the second medicine. ‘Oxaban is an anticoagulant, a Factor Xa inhibitor. It’s an alternative to Warfarin which is given to thin the blood and stop it clotting, so there’s less chance of thrombosis – of an artery getting blocked. If patients have CHD, that’s coronary heart disease, then they’re put on anticoagulants to prevent heart attacks. But if the patient needs an operation then the last thing they want is for the blood to be so thin that it doesn’t clot, so they either stop the anticoagulant a few days before the surgical procedure, or replace it with a specialist anticoagulant a couple of weeks beforehand. This Oxaban is one of a number available. They then start the normal anticoagulant shortly afterwards.’
‘And are they subject to degradation like insulin?’
‘Some of them are, yes. The active ingredients of Warfarin, for example, and other vitamin K antagonists, have only a short life so it’s vital that their expiration date is followed exactly.’ She looked more closely at the label, turning it around. ‘Although we can see clearly that the insulin cartridges have been relabelled, there’s no evidence that this has.’
‘No, but it’s possible, isn’t it? Tell us about the heart attack. Could that have been caused by taking medications beyond their expiration date?’
‘The heart attack,’ Sally repeated thoughtfully. ‘I haven’t seen his notes, so I can’t comment in any detail, but if he was taking something like Oxaban, then he must have had a pre-existing CHD – not uncommon in a man of his age.’
‘But what caused the heart attack?’ I repeated.
‘That’s assuming that it was a heart attack and I have no reason to think it wasn’t, so there could have been a number of causes. He was diabetic, which meant he was more at risk…’
‘But could the wrongly-labelled medicines have caused it?’ I interrupted impatiently.
Sally gave me a look as if to say “calm down”. ‘I was coming to that. All we know from Professor West is that the operation on your father’s liver went well and that following a few hours observation in ICU – intensive care – his recovery was considered satisfactory and he was moved back to his room. And then it was some hours later – about ten hours, I think – that his monitor was showing irregular heart function and the nursing staff called in the duty doctor. From what you say, they didn’t have time to carry out an ECG or take a blood sample but it was clearly a heart attack so they paged their cardiologist while they prepared him for the operating theatre. When the cardiologist arrived, they started an emergency bypass operation, but it was too late.’ Sally looked across at Greta who was sobbing quietly at this cold recitation of the facts. ‘I’m sorry, Greta,’ Sally said. ‘Perhaps Philip and I should talk this over between us?’
‘No.’ Greta took a deep breath and managed to compose herself a little. ‘I have to hear this. Carry on, please.’
I sensed that we were moving away from the main points. ‘So what do you think caused the heart attack?’ I repeated. ‘Could it have been the out-of-date insulin or the anticoagulants?’
‘It could have been either, or both together, but whether they caused it is another matter. If his insulin was ineffective then he could have suffered hypoglycaemia – a form of shock reaction which can lead to a coma. In turn this could have produced heart palpitations. If the anticoagulants weren’t effective then there might have been internal bleeding following the operation that could eventually have led to a heart attack.’
‘Will there be an autopsy?’ asked Greta.
‘That’s up to the coroner,’ Sally said. ‘It’s quite likely, given that the death was unexpected, but I don’t think it’s likely to show very much. They’ll do blood tests, but we already know that the insulin must have been ineffective.’
‘But ther
e’s something suspect about this Oxaban,’ I said. ‘Could we get it analysed – find out what it really is?’
‘We could and I think we should, but it might not lead us anywhere. We’d still need to go back and find out where it came from. At least someone should and I still think we need to bring in the MHRA. Even if Greta’s father wasn’t killed by these medications, other people might be.’ Sally paused for a moment and put the bottle down. ‘Do you know anything about counterfeit pharmaceuticals?’
‘It wasn’t really my field,’ I replied. ‘I was more concerned with who had how many tanks and who had the anti-tank missiles to fight them. A bit different from this sort of thing. But anyone who has email is bombarded with offers for Internet medications – Viagra mostly. I’ve always wondered how anyone buying them could know whether they were fake or not.’
‘Much of what is sold online is,’ Sally said. ‘The websites are virtually untraceable and who’s going to complain anyway? And who are they going to complain to? It must be the easiest money ever made – set up a website, take the money and send them a variant of lactose powder in return. I’ve only read the occasional article in the BMJ – the British Medical Journal. Given the cost of some pharmaceuticals today, there’s a lot of money to be made by faking them. Take Oxaban: there was another blood thinner, Heparin, made in China but sold in the USA. It turned out to be contaminated and nearly a hundred people died before they found the cause and withdrew it. That’s one of the problems, you have to identify a common cause before you can isolate what’s causing it and that often involves a lot of luck to find it.
‘The trouble is that everyone knows about the so-called lifestyle drugs like Viagra, so even if they find out they’re fakes, they don’t think it’s very serious. It’s a bit like buying a fake Rolex. If you know you’re paying less than they’re worth then it’s obvious there’s something funny about it. And with fake Viagra it can often work by a psychosomatic placebo effect: it’s effective because you think it is.’ Sally picked up the insulin cartridges again. ‘I think we could be looking at something that goes much deeper.’
We were all silent for a moment, taking sips of our wine. ‘That was the plot of The Third Man,’ I said, as the memory slowly dawned on me. ‘The Orson Welles character, Harry Lime, was stealing penicillin and watering it down. It was set immediately after the end of the war and it probably went on in real life. Penicillin was very expensive back then.’
‘Adulterated antibiotics can present some of the worst cases,’ Sally said. ‘My agency does a lot of work in Africa helping some of the immunisation programmes and these drugs are causing major problems. There’s already growing resistance to them, and if antibiotics are being manufactured with reduced active ingredients, then that only increases the problem.
‘Some agencies estimate that tens of thousands of lives are lost because of watered-down antimalarials. Malaria is one of the biggest killers in Africa and there are numerous charities working on self-immunisation, where they don’t have so much control over the supply of the drugs. It makes it almost impossible to ascertain whether some of these programmes are effective or not.’
‘How do these drugs get distributed?’ I asked. ‘It’s funny, I’ve never really thought about it before, they’re just sort of there. You take a prescription to the chemist and they hand it over. I suppose because there’s no competition. We don’t ask what they are, we follow the doctor’s prescription, pay the standard NHS rate and take them away. I suppose if we had to pay the real price then we might start looking at what was the best.’
‘Many of the drugs are generic,’ Sally said. ‘That is they’re out of patent, or were never in patent in the first place. Anyone can make them and they’re much cheaper. As for competition, you should see the number of drug company reps we get calling at the surgery. It’s been a bit better since they introduced a new code of practice a couple of years ago, but I can tell you the competition is fierce out there. Unless you’re a monopoly supplier of a drug in-patent, you’ve got to fight it out on the open market and the worldwide market is huge.’
‘So who organises the vaccination programmes?’ I asked. ‘Is it the UN?’
‘It can be one of a number of aid agencies but they’re usually overseen by the WHO – the World Health Organization, usually in association with UNICEF, because it affects principally the children. There’s a really big programme being planned now for East Africa. Instead of relying on people to come to a few vaccination centres, they’re trying to set up units in most of the villages with the vaccinations being delivered directly to them.’
‘But doesn’t that increase the risk of counterfeits getting into the supply chain?’ I asked. ‘There wouldn’t be any centralised control.’
‘It’s a trade-off,’ Sally said. ‘Previous centralised programmes often failed because they didn’t have the reach and missed out swathes of the rural population. And also localised corruption doesn’t help. We’ll see.’
I thought about this. ‘Perhaps I should admit that I have a sort of personal interest.’
Sally looked surprised. ‘What kind of personal interest?’
‘I told you about my mother?’
‘How could I forget? It must be something you have to live with every day. But you said you didn’t know anything about what exactly happened.’
I turned to Greta. ‘My mother committed suicide when I was eight – nearly nine. You understand things differently at that age. They told me about my mother’s death but it wasn’t until some years later that I learnt what had happened. They hid it from me at the time, but when I was old enough I went back to find out what happened. I discovered that she’d committed suicide.’ I’d told Sally about the suicide, but not the reasons behind it, but now I wanted Greta to know the details – to show that I had at least some idea of what she was going through.
Greta was staring at me in shock. ‘That must have been devastating.’
‘She was suffering from depression and she did kill herself, but it wasn’t really her fault.’
‘Fault?’ Greta said. ‘That’s a strange word to use. How could it have been her fault?’
‘She was on a mixture of antidepressants but I’ve since discovered that in some cases they can actually increase the risk of suicide, rather than reduce it.’
‘That’s why we’re told to be careful when prescribing them,’ Sally said. ‘It seems that some psychotropic drugs can have that effect. Especially in larger doses.’
I nodded. ‘It seems they didn’t know that at the time. The pharmaceutical companies were peddling their antidepressants in ever increasing quantities without proper trials on the effects. I managed to get a transcript of the inquest and from the reports I read, it seemed that her doctor prescribed these antidepressants without realising that she sort of got sucked into a vicious cycle. From what I could tell, it seems she was taking drugs hoping they would help, but instead they led her to kill herself.’
‘Philip, I’m so sorry,’ Greta said and I wasn’t sure I could handle the pity in her eyes.
‘Why didn’t you tell me this before?’ Sally asked. ‘When did you find this out?’
‘Just before we got married, but I didn’t want to say anything in case… you know, in case…’
‘You mean in case it changed the way I thought about you?’
‘I always thought you were judging me. Looking out for signs of the effect my upbringing might have had on me. It was bad enough you knowing that my mother had killed herself without adding to your anxiety by telling you that it was avoidable.’
‘Philip, that’s not true. I wasn’t judging you, but with your childhood it would have been surprising if it had left you unscathed.’
‘People always assume that because I was brought up in institutions that it was difficult and I suppose it was in many ways. But I tried not to bear a grudge although many of the kids did. We had talks from various worthy people who came and told us that we were in control of our
future and that background wasn’t important. Complete nonsense, of course, and I still get angry at what happened to my parents – angry at the life together that was taken away from us. It’s caused a few problems over the years – it sort of builds up, raising the pressure until I explode. Most of the time I manage to control it, but not always. When I discovered the truth about my mother, about what had really killed her, I nearly went off the rails.’
I said nothing, remembering my stunned reaction when I learnt about my mother’s prescriptions and wondering what she must have been going through right at the end. My memories of her were of a sort of hazy, undefined warmth – a warmth that was never really replaced. Finding out about the effect of her medication had at least given me the consolation of knowing that she hadn’t intended her own death. She hadn’t meant to leave me alone. ‘I still can’t understand why it happened the way it did, but thinking about it makes it worse so the only way I can live with myself is if I put it behind me.’
‘As long as you could do what you wanted.’ Sally said. ‘I often wondered why you went into the army. It didn’t strike me as a place for an individualist but then I realised it gave you a structure and a platform and you made the best of it.’
‘It didn’t make me easy to live with, did it?’
Sally smiled. ‘I wasn’t easy to live with either. We were both looking for someone who would complement us; instead we got someone who competed with us. We were both too preoccupied with our work – we would have made good colleagues, but we made lousy spouses.’
She held up her glass and I got up and poured out some more wine and eventually the conversation moved on. It was the first time that Greta had seen Sally since her father’s death and they swapped reminiscences about him, but when this moved onto their school days, I thought it was time to intervene. ‘You’ve both hung up your hockey sticks long since. Leave them where they belong, gathering dust in an attic.’
