Six by nine inches, bound in stiff black boards, it didn’t immediately fall open to reveal the key to its secrets. About half the pages had been used, filled with hurried pen scratches. Each entry was carefully dated and filled with abbreviations.
I flipped to the last page he’d written. Mark had definitely mastered the physician’s scrawl. Decoding it would take more concentration than I could muster sitting here in a busy snack bar. I worked backward, looking for TJ. Those initials were dotted through the book on various dates.
I stopped on the December 5 entry, two months earlier. Referral from Ellin, Jas. Isl.—TJ. Initial prep and consent
Could that be Dr. Lazarus Ellin on James Island? I knew him. I’d cochaired a panel with him at a statewide medical meeting, where doctors earned continuing medical education credits by learning how not to get sued. Maybe he could help me decode the riddle of Mark’s journal. I bent over my cell phone, dialing directory assistance and then Dr. Ellin’s office.
His receptionist, in a thick, smooth, sea-island singsong, at first warded me off with expert parries. I carefully explained and asked her to please check with the doctor. When she returned, her voice sounded a bit exasperated—probably with both me and Dr. Ellin. “He can see you at eleven-thirty this morning. But he really can’t spare more than a few minutes.”
“Yes, ma’am. I do appreciate it. I know how busy you all are.”
A visit to Dr. Ellin wouldn’t be too much of a detour from Jake Baker’s case. Not too much. I tossed my paper cup, checked my watch, and found a quiet comer to call Melvin. He was an early riser. Maybe he could give me something helpful for Jake’s case, something so my obsession about Mark would not seem so disloyal.
“Melvin. Any news?”
“My dear girl. It’s not even been twenty-four hours. How are you?”
“Fine. And you?” Melvin didn’t deserve my abruptness. “Sorry, I’m just—”
“I know. In a hurry. What I have so far is the obvious stuff. Perforce Pharmaceuticals has grown from a small family-owned drag company to a multibillion-dollar research giant. The scientists ran the place and always have. The bean counters take a backseat, but that’s been a good strategy for them over the years. Research scientists want to save the world from horrible diseases and afflictions and, so far, that’s been wildly profitable.”
I heard papers rustle before he continued. “Uplift is their newest star. Like many drags, it was twenty years in the making. But its development revolutionized the way we view brain function. It’s an SSRI, a selective serotonin reuptake inhibitor. You need to get one of your neurosci-entist experts to explain how it works, but Uplift is the new and improved version. SSRIs are, according to the business press, miracle drags for depressed patients. None of the side effects of the old dope-’em-outta-their-gourd treatments. Lots of controversy, though, which has sent stock prices dancing over the years since these things went on the market.”
None of that was really news. “How do your business sources weigh the controversy?”
“One side cites a handful of folks I’m sure you’ve already come across, about how drugs can’t treat head cases, that they need talk therapy. Others say the drags have side effects. Others counter that nothing is worse than consigning someone to the depths of depression. Arguments sound familiar?”
“Yep.”
“Okay, how about this? Perforce desperately needs Uplift, so Perforce desperately needs to win this lawsuit. Uplift accounts for one-third of its total sales, an incredible percentage for a company its size. Thanks to Uplift’s success, Perforce has grown dramatically, so we’re talking one-third of a much larger pie than they had ten years ago. At the same time, several Perforce patents are timing out on them; drags that have been staples for them over the years are going generic.”
“They knew that was coming. Patents have a time limit.”
“Sure, but for whatever reason, Perforce doesn’t have anything else hitting the market that could fill the void. To make things worse, the Nedham Group will hit the market with cheaper generics and huge advertising campaigns as soon as these patents expire. Perforce has already got some competition from that sector on their headache drags. Nedham is aggressive. There’s a rumor they’ll try to get a court to speed up the patent expiration.”
“They can do that?” News to me and I’m supposed to be the lawyer.
“Can—and have, in other cases. Nedham looks for loopholes in the patent. They spent ten million to break another company’s patent last year.”
I leaned against the wall. “Why doesn’t Perforce have anything else on the market to replace the patents they’re about to lose?”
“Good question, but the answers are only speculation. Maybe they got complacent. Maybe they saw their wonder drag skyrocketing. Six million people a year take Uplift now, so maybe they didn’t feel any urgency. Or maybe their scientists just haven’t hit any lucky breaks. Sometimes you just hit dry holes in that business. Without the phenomenal growth of Uplift, this wouldn’t look like such a dry period. Stock analysts always want more, bigger, better, but it’s hard to top a miracle drag. Despite the predictable critics, the market sees Uplift as a bona fide miracle. Unfortunately for its stock prices, Perforce doesn’t have a follow-up miracle in the making.”
I scrunched against the wall, out of the way of the breakfast cart that a girl in a tight pink cotton outfit was pushing toward the patient rooms. Jake Baker had probably already hit the courtroom, ready to study the jury pool during voir dire questioning, to find twelve who would decide the case. He didn’t need an update from me right now. Not this news, anyway.
“I’ll make some more calls.” Melvin’s voice brought me back.
“Thanks. This has been a big help.” Demoralizing. Sobering. But helpful.
“When will you be back, Avery?” Something in Melvin’s tone changed. Not so crisp and businesslike.
“Don’t know. With no hope for a settlement offer, these things can take weeks. But Judge Bream isn’t known for dillydallying around.”
“Folks have been asking about you, wondering if you’ve decided to set up your office here.”
“Maybe word of our impending defeat won’t spread that far, so I can still come home after this. Now there’s a bright spot.” Levity wasn’t lightening my mood. “Thanks, Melvin. I owe you.” I didn’t press Melvin about his own plans. No time for that now.
Damn. I’d lost cases before, but very few—and none this big. Jake Baker probably knew everything I’d just learned. But, for me, having it spelled out hit me right in the gut. God, I hate losing. More than that, I hate not putting up a good fight. I felt like Alice in Wonderland, with things popping up as they shouldn’t and the landscape changing under my feet. Standing still, paralyzed, wasn’t going to improve things, though.
I turned back toward Blaine Demarcos’s office. I was going to be late after all.
9
MIDDAY FRIDAY
Doctors’ offices have a look all their own. Lawyers and executives favor dark wood, books, leather upholstery, brass lamps, though a few buck the traditional with sleek art glass, chrome, and miniature spotlights. The goal, though, is to impress, to provide weight and substance and sangfroid.
Most doctors’ offices don’t impress anybody, and the doctors don’t give a flying fiddle. The drag company giveaways—plastic clocks, ball caps, candy jars, and patient teaching aids—are usually spotlighted by institutional fluorescents glaring overhead. Doctors seldom have receptionists or assistants nearby, though nurses and technicians dog their every step with “Yes, doctor.”
Blaine Demarcos nullified at least part of the stereotype. His office was small and lacked sophisticated artwork, but the furniture and lighting had come out of his own wallet. His mahogany desk, shaded desk lamp, and model Lamborghini paperweight said, I’m not standard issue.
His office opened directly off the bright hospital hallway, the door ajar into his subdued, carpeted sanctum. I didn’t wait long
before a tall, graceful man in a lab coat strode into the hall from the elevators, looking directly at me—the doctor any television medical-drama fan hoped would be at her bedside should she awake from a coma.
“Ms. Andrews? I’m Blaine Demarcos.”
He offered a firm handshake. “I hope I haven’t kept you waiting.”
“Not at all.”
“Wonderful. Can I get you some coffee? It’s not hospital coffee, so you’ve no need to fear.” He cocked his head, inviting me to take him up on his offer.
“I just came from the snack bar. Thanks. Your time is valuable, and I don’t want to waste it.”
He indicated the chair in front of his desk for me and settled into his desk chair.
I got right to business. “As I told you when I called, I’m working with Jake Baker on the Perforce Pharmaceuticals case. The trial is starting at the courthouse this morning. A friend of mine—Mark Tilman—suggested I talk to you, said you were the expert on human subject testing and new drag development.”
“Mark. What a tragic loss,” he murmured.
“I’m sorry...” I wasn’t sure how well he knew Mark. “I apologize if coming so close after his death is awkward.”
“Mark and I were colleagues. We’re all devastated at his death.” His tone sounded clinical, but he leaned forward, his expression showing real concern. “Of course, we were professional colleagues. I’m sure, as his friend, you must truly feel his loss.”
I gave a quick nod. I didn’t want to trade falsely on a relationship, but I didn’t want to say, Oh, we weren’t really that close and trivialize whatever relationship he had had with Mark. “I spoke with Mark’s father yesterday. His family is truly devastated.”
Demarcos nodded, his lips pursed in sympathy.
I wanted to move past the awkwardly personal. “Mark said you were the best one to explain drag testing, what’s the norm, maybe even give me some insights into how Perforce tested Uplift before bringing it to market.”
“Glad to. Uplift is a textbook case, one of the most tested and proven drag launches in recent memory.”
Great. It dawned on me Demarcos knew me as a medical defense attorney and might not know which side of this lawsuit I was on. I just needed background, so I didn’t interrupt the conversation to explain.
“What makes it textbook?”
He gestured expansively. “It provides the cure or the relief patients need without undue side effects. That’s what every physician, everyone in health care, wants—to cure people’s problems.”
His accent had the sharp, choppy edges of New Jersey or New York. My ear wasn’t particularly good at pinpointing someone’s hometown from the sound of his voice, but South Carolina hosts enough emigres from that part of the world that we learn to spot them. His passion for his subject likely sped up his delivery another notch.
“It’s not easy, though, finding those cures, getting them approved. Some researcher tucked away in a lab somewhere may have a certain disease he wants to attack. Or maybe he’s found a compound in some exotic plant or soil or mold, and he wants to see what it might do. They spend years hunkered over microscopes, searching for solutions.”
“That’s what your research department does here?”
“No, no. The initial discovery phase is usually conducted within pharmaceutical company R&D departments or universities with major Ph.D. research facilities. Pharmaceutical companies and the federal government provide much of the funding. Here, we’re strictly patient care. We’re not the pioneers, the Lee Standers of the world. He’s the one credited with finding the link between manipulating brain levels of certain neurotransmitters and treating depression—the basis for Uplift.”
“How exactly does Uplift work? I’ve read about it, but I must confess, I don’t know that I understand it.”
“Well,” he leaned forward, almost conspiratorial, “frankly, I’m not sure any of us really understands how it works. But neurotransmitters—the mechanism in the brain that carries messages—are affected by levels of certain substances that affect mood. In particular, low levels of serotonin are associated with depression; raising the level of serotonin alleviates depression.”
“As I understand it, though, Uplift doesn’t add serotonin to the brain. It just keeps the brain from losing what it already has.”
“Exactly. It’s not like taking vitamins to supply nutrients your body requires. Instead, Uplift helps prevent the body from reabsorbing the neurotransmitters it already has. Hence, the awkward name selective serotonin reup-take inhibitors or SSRI.”
“So what made Uplift such a wild success?”
“It works. It’s a completely new mechanism for attacking a devastating disease. Too often we use ‘depression’ as slang for ‘I’m blue today’ or ‘It’s raining outside.’ But for those who are clinically depressed, it can be a death sentence. In addition, some people are depressed only for short periods of time—maybe through a tough place in their lives. The conventional treatments were often too strong or had side effects that outweighed the benefit. Not so with Uplift.
“Perforce wasn’t content with a mere breakthrough discovery. It launched one of the largest, most intensive clinical studies ever done on a new drag. Even the FDA commended them for their thoroughness. That’s a major winner in anybody’s book.”
Great. A freaking FDA commendation. Jake would be so happy to hear that. My dream case, showing Perforce took shortcuts or covered up information about patient agitation, went flying out the window.
“So Uplift doesn’t have side effects?”
His TV-soap-star mouth made a mild grimace. “I didn’t say no side effects. Everything has side effects. Drinking too much water has side effects—it can kill you. But Uplift doesn’t suppress all emotion and response to save the patient. If the research is right—and clinical use indicates it is—then SSRIs help target the organic cause of depression. At least for many people. It doesn’t work on everyone, so we haven’t fully unlocked the secret. Depression seems to develop along at least two major pathways, so, with older treatments, if one type of antidepressant didn’t work, we just switched to the other. Now, even with the success of Uplift and its cousins, we still have those two older tracks to fall back on, in more intractable cases.”
“How do you recognize what’s more ‘intractable’?” I made little quotation marks with my fingers.
He shrugged. “I’m no psychiatrist, understand. I can only comment from a general-medicine standpoint, but the more extreme cases often have more complex psychoses operating. The patients have issues they need to work through that are not solely organic and therefore can’t be treated with drags. Those patients require intensive counseling in addition to drag therapies.”
“At what point does your research department here get involved?”
“The pharmaceutical companies often use teaching hospitals to conduct the Phase I, II, and III clinical studies. But that’s only after animal and other testing has passed excruciating scrutiny by the FDA and within the company itself. After all, they’ve invested a lot and want to make sure it’s a good bet before they sink any more time and money into it.”
I knew the FDA’s three phases all involved human test subjects. Phase I tests for safety, on twenty or so healthy subjects, often college students. Phases II and HI are increasingly broad, often using thousands of test patients, to see if the drag actually works on the disease.
Demarcos continued his lecture. “People complain all the time about the high cost of drags. What they don’t understand—and what the politicians choose to ignore at campaign time—is the high cost of developing those drags. It may take twenty years to get from the laboratory to the patient, with an average cost of $800 million. Maybe one in fifty drags moves past the FDA’s preclini-cal IND—Investigational New Drag—stage to human testing. Maybe one in four or five of those are ultimately approved for use. Think about all the ideas that don’t pan out. Think about all the scientists—and all the microscopes and la
b equipment and testing—that may come up with zero instead of a zinger.”
“But they make a lot of money when they do hit a zinger.”
“Like playing the slots in Atlantic City. Sometimes it’s lemons, sometimes it’s bells.”
It reminded me of dropping a fishhook in Luna Lake instead of a quarter in a slot. Different cultural frames for different folks.
“Who pays for the testing you do here?”
“The pharmaceutical companies, sometimes with federal grants. Occasionally there may be private investors.”
“They pay your salary?”
He shifted in his chair.
“Barnard Medical pays my salary, though I may, depending on the terms of a grant, receive additional funds to use for patient recruiting or overhead.”
Asking Do you make a lot of money doing that? would be rude, so I changed the subject.
“So the research you do here is always on something newly discovered and you provide a sort of patient laboratory for them to carry their work to the next level.” Guinea pigs popped to mind. Human lab rats. But, for a made-for-TV doctor like Demarcos, they probably lined up to help advance medical science.
“No, no, that’s not all we do. I didn’t mean to create that impression. We don’t have researchers bringing new molecules out of the lab to develop; we’re not set up for that. But we do generate our own original research here. Frankly, that’s what attracted me to Barnard. A facility like this must promote an active research agenda, to attract the best physicians and the funding needed to support cutting-edge work.
“The FDA approves drags for a particular use, but once those drags are used by the mass of humanity, with all its quirks, sometimes other benefits are discovered. For instance, an acne cream might help diminish wrinkles, or a diuretic for heart patients might treat androgen-sensitive acne in adult women.”
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