Harm was there on the horizon — to himself, Munin, career, prospects — but he told her no, it was a business matter. Not much time. He wanted Dr. Munin to present a case at a meeting in May.
“Then there’s still time,” the assistant said. Her calm was maddening.
“You don’t understand.” They were talking about months of prep work. Before the submissions and approvals there had to be talk among investigators, a pre-market push. Enough buzz to stir up some out-of-indication sales — nothing grand, expectations still European in their modesty, but they had to show something on the books. He’d worked the numbers. The major depression indication was worth a fortune, but there was no more room for growth. After a couple of billion dollars a year, it gets tough, market leader always pushing to expand the market, but there’s never enough illness.
Oh, there was talk about doing a few deals with their competitors, promote comorbidity; if there were no more patients, the ones they had would have to take more meds. No one wanted to go that route. A better strategy was to use more drug, double, triple, the dose. A higher dose wouldn’t provide any benefit in depression. A few early adopters had tried it, but it didn’t look good. Medical had already copied the case reports for Legal, just a matter of time before someone — FDA, Scientologists, chat-room crybabies — raised hell as if it were the coming of the Antichrist.
So the per-patient spend was a non-starter for depression, which was where OCD came in. The problem, what Soren’s boss called the challenge, was the limited market potential. OCD wasn’t common enough. Yes, there were dark nights imagining that the epidemiologists had it all wrong, our various obsessions — for pristine armpits, sterile countertops, pangyreic awareness — were so common now, so man-in-the-street pedestrian that they escaped notice. There under the radar, a plague of obsessions and compulsions waiting for a smart marketer to declare a pandemic. Just wishful thinking; Soren was forecasting a couple-three percent of the population as candidates for the drug. The only way to compensate was to use higher amounts, maybe four times the dose they were using for depression. But they needed to show proof of principle, feasibility. They needed the pilot study. They needed Munin to show it could be done.
Soren drafted a memo to Medical Affairs — May be a problem at the Montreal site. Recommend we consider someone else as principal investigator — but was overruled by the higher-ups. Munin was their first choice as PI. They wanted him to do the preliminary work. Munin had the reputation. He could attract other researchers to the project.
But not now. Not with an N-of-one study. It’s a disaster.
Affect calm. Smile. Probe gently. “Who, may I ask, is the patient?” Soren asks Munin.
“P.N. You understand I can’t give you her name.” Munin sees Soren struggling for an expression of infinite patience. “Call her Penelope.”
“This Penelope — she completed what, four months, six months?”
“Eighteen weeks. On the full dose.”
“And she responded? The drug works?” Soren sees Munin hesitate; doctors never like to commit themselves to anything definite. Tries to dial down the marketing angle. “It appears to provide some benefit, yes?”
Munin hesitates but has to agree there is some benefit. They achieved the primary endpoint: a fifty percent reduction in symptoms according to the questionnaires Munin has been filling out every week. Do you avoid public restrooms? Do you wash your hands over and over? Are you tense when you throw things away? Five questions on obsessions, five on compulsions. Yes or no, yes or no.
Are you afraid you will harm someone?
Do you think things should be arranged in a particular configu ration?
Do you have blasphemous thoughts?
Sexual thoughts?
“The treatment cut the severity of her symptoms in half,”
Soren says. “That’s an important gain.”
More of Munin’s famous caution. “A fifty percent reduction appears significant, but her scores were five times higher than normal when we started. She’s still very ill.”
“But the criterion was fifty percent. That’s how we defined response. It was decided. You agreed to it.”
Munin had agreed. His patient was objectively better. But what was the benefit, and what unintended harm had been done?
Soren doesn’t ask about Cynthia — that damn Swedish discretion. Munin figures he’s heard the story, but there are other stories. How cold it was that winter in Montreal, the wind tunnel of McGill College, the chill rolling down the mountain to the river. They took shelter in a half-deserted maison de torréfaction, the inviting damp of the overheated room, the cough and sputter of the machines. The afternoon passing in conversation, ordering coffees, maybe sharing something sweet. He and Cynthia and everything was new. She was animated then, talking about love or destiny, half-wired on caffeine, and Munin was thinking of the corona of light that was her hair. There was a draft from the door that chilled his kidneys, and he tried to ignore his need to urinate. He wanted to master the urge. Oh, he was young. The romantic impulse, he didn’t want any interruption, nothing to disturb this moment, for it would mean the moment had ended, and it was too soon to think of endings.
When he couldn’t hold off any longer, he excused himself. He half wondered if she would still be there when he returned. He wanted to ask but knew how foolish that would sound.
When he returned, she was still life: coffee untouched, the same wisp of hair outlining her cheek. In his absence she had sketched him from memory on a small artist’s pad she carried with her in those days. “Do you like it?”
“Of course I do.” His face was lean and tense, but the eyes were soft. Harder now. “Is that how you see me?”
“I tried to capture your expression, the look in your eyes.”
“They look sad. Sort of watery.”
She apologized. She had imagined tears. She had thought she had said something to upset him — that was why he had left the table so abruptly.
He explained that he had to go to the men’s room. Their first misunderstanding, one they could laugh about. He told her a story about a friend, another med student, who had a phobia about having a car accident with a full bladder — she was afraid it would burst on impact and she’d die of peritonitis.
“She?”
They walked through the grey desert of downtown on that cold afternoon, to a dim bistro for lunch, to Chinatown and the Old Port, a winter sea sharpness under a leaden sky, and then it was night and it snowed and they had to get back. Returning along the rise of St-Laurent, the parade of skin parlours and steamie joints and army surplus stores, all the forlorn places that become a theatre backdrop in the first act of love. They crossed downtown, the follow spot of lit windows on snow, the slow goodbye as they trudged along to her walk-up in the student ghetto.
Cynthia was about to kiss him when she saw he was shivering and invited him in. She opened a bottle of wine, a heavy Amarone to warm them, but he was still chilled, and she told him he didn’t look well. She wrapped him in a blanket and drew a bath, adding eucalyptus to clear his
