Vital Signs dmb-2, page 40part #2 of Dr. Marissa Blumenthal Series
"Most of the rural health clinics have such a table."
Marissa nodded as if she understood. But she didn't. Of all the pieces of modern equipment to be sent to rural clinics, it seemed strange for them to choose an examining table with stirrups. But having read of the bureaucratic mismanagement problems of
Communist governments, she assumed this was just another case in point.
"We use such a table frequently," Tse said.
"Birth control has been gi vena high priority by the government."
"I see," Marissa said. She was about to walk on when she looked back at the table. She was puzzled.
"What type of birth control do you favor?" she asked.
"No," Tse said.
"Diaphragms?" Marissa asked, even though she knew they couldn't use diaphragms since they were too expensive and not effective enough. Yet why a table equipped for internal exams?
"We use sterilization," Tse said.
"After one child the woman is often sterilized. Sometimes we perform sterilization even before the woman has a child if there is a request or if the woman should not have a child."
Tristan called to Marissa from the next room, but Marissa ignored him. Although she had remembered hearing that sterilization was used for birth-control in the PRC, she hated to hear a doctor speaking so coldly about it. She wondered who got to make the decision of who could bear a child and who couldn't.
The issue offended her feminist sensibilities.
"How do you sterilize these women?" she asked.
"We cannulate the fallopian tubes," Tse said matter-of-factly.
"Under anesthesia?" Marissa asked.
"No need for anesthesia," Tse said.
"How can that be?" Marissa asked. She knew that to cannulate the fallopian tubes, the cervix had to be dilated, and dilating the cervix was excruciatingly painful.
"It is easy for us rural doctors," Tse explained.
"We use a very small catheter with a wire guide. It is done by feel. We do not need to see. It is not painful for the patient."
"Marissa!" Tristan called. He had come back to the threshold of the examining room.
"Come out here and see the garden. They grow their own medicines!"
But Marissa waved Tristan away. She stared at Tse, her mind racing.
"Can Chi-Li perform this technique as well?" she asked.
"I'm sure," Tse said.
"All rural doctors are taught it."
"Once you cannulate the fallopian tube," Marissa said, "what do you use to sterilize?"
"Usually a caustic herbal solution," Tse said.
"It is like a kind of pepper."
Tristan left the doorway and approached Marissa.
"What's the matter, luv?" he asked.
"You look like you've just seen a ghost."
Without saying a word, Marissa. hurried back to the procedure room and walked up to the cabinet. She studied the shelf of vaccines.
Tristan followed her, wondering what she was thinking.
"Marissa," he said, as he reached out and grabbed her shoulders, swinging her around to face him.
"Are you okay?"
"I'm fine," Marissa said.
"Tristan, I think I just figured it all out. All of a sudden I think I understand-and if I'm right, the truth is much worse than we imagined."
The health clinic van took the four of them to Shigi and dropped them off at the Shigi bus station. Since there was frequent service to Forshan, they had only a short wait. During the trip, Marissa sat next to Tristan while Bentley sat with Tse.
"I've never seen anybody spit more than these Chinese," Tristan said to make conversation. It was true. At any given moment someone on the bus was either preparing to spit or was in the process of spitting out the window.
"What the hell is wrong with these blokes?"
"It's a national pastime," Bentley said, hearing Tristan's comment.
"You see it all over China."
"It's disgusting," Tristan said.
"It reminds me of that foolish American game of baseball."
Everyone on the bus seemed to be busy talking except Marissa and Tristan. Tristan had finally given up after Marissa persisted in meeting his every question with only one-word replies. She seemed to be deep in thought.
Suddenly she turned to him.
"Do you know the pH indicator phenol red?"
"Vaguely," Tristan said, surprised by er sudden inquiry.
"When does it turn red?" Marissa asked.
"In an acidic or an alkaline solution?"
"I think alkaline," Tristan said.
"In an acid solution it's clear."
"I thought so," Marissa said. Then she lapsed back into silence.
They rode for another mile. Finally, Tristan could no longer contain his curiosity.
"What's with you, Marissa?" he asked.
"Why won't you tell me what you're thinking?"
"I will," Marissa said.
"But not yet. We have to get out of the PRC. There are a couple of things I have to check to be sure first."
From Forshan they were able to get hard seats on a train to Guangzhou. Bentley and Tse left them at the Forshan bus station.
By the time they got to Guangzhou it was dark. They took a taxi from the train station. On the recommendation of the driver, they went to the White Swan Hotel. During the short trip both Marissa and Tristan remarked that the city looked more Western than they'd expected, although even at night the bicycles far outnumbered the motor vehicles in the streets.
The hotel turned out to be a surprise as well. The lobby was impressive, with a waterfall. The rooms had all the modern conveniences, including TVs, refrigerators and, more importantly, direct-dial telephones. They booked a suite with two bedrooms and a view over the Pearl River.
Marissa was exhausted. She eyed the bed with longing, hoping that she would at last get a good night's rest. But even before bed, what she was interested in most was the telephone. After calculating the time on the East Coast of the United States, she decided to put off her call for a few hours. She knew it wouldn't help to wake Cyrill Dubchek from his sleep.
"They have a Western-style restaurant," Tristan said with excitement, coming into Marissa's bedroom with the hotel directory in his hand.
"What do you say to a nice big steak!"
Marissa wasn't hungry, but she accompanied Tristan, who polished off a sizable slab of meat and a number of beers. Marissa ordered a chicken dish, but she hardly touched it except to move it around her plate. They talked about going to the consulate in the morning with the story that they had hired a junk to take them to Guangzhou but that the captain had taken their money and forced them to jump off the boat.
"It's the best we can do," Tristan said.
"And it's close enough 4 to the truth."
Marissa said that she would try to get some State Department intervention through the CDC.
Several hours later, Marissa made her call. Knowing Cyrill's schedule, she timed the call to catch him before he left for the lab.
Although there was some static as well as a peculiar echo, Marissa could understand him easily. Marissa told Cyrill that she was calling from Guangzhou, in the People's Republic of China.
"With other people, I might be surprised to get an unexpected call from the PRC," Cyrill said.
"But with you, Marissa, nothing surprises me."
"There's a rational explanation."
"I didn't doubt it for a moment."
Marissa quickly explained how she and a colleague had inadvertently entered the PRC without going through proper immigration.
She told him she was afraid she would have trouble getting out. She emphasized that the colleague was the Australian doctor who'd written the paper Cyrill had given her.
"You're with the author?" Cyrill said.
"I'd say that is going directly to the primary source."<
"Back when I was at the CDC, you once told me that you hoped you could make it up to me for what I went through in cracking the Ebola outbreaks. Well, Cyrill, you now have your chance."
"What can I do?" he asked.
"First, I'd like you to use CDC connections to pressure the State Department to get me and Dr. Williams out of the PRC. I was told that there is a U.S. consulate here. We'll go to the consulate in the morning, about ten hours from now."
"I'll be happy to see what I can do," Cyrill said.
"But they may ask why the CDC is intervening."
"There is a very good reason," Marissa said.
"It's extremely important that I get back to the CDC immediately. It can be considered legitimate CDC business. Tell that to the State Department and let them tell it to the PRC."
"What kind of business?" Cyrill asked.
"It concerns the TB salpingitis," Marissa said.
"And that leads me to my next request. I need the CDC to get success rate statistics concerning in-vitro fertilization for all the Women's Clinics around the U.S. I want statistics about efficacy per patient as well as per cycle. And if possible, I would like data on the specific causes of infertility among the women the Women's Clinics treat with VF."
"How many months do I have?" Cyrill asked wryly.
"We need this as soon as possible," Marissa said.
"And there's more: remember that case you told me about, the young woman with the disseminated tuberculosis in Boston?"
"I do," Cyrill said.
"Find out what happened to her," Marissa said.
"If she died, which I'm afraid she must have by now, get a serum sample and her autopsy report as well as a copy of her chart. Then there is a patient by the name of Rebecca Ziegler-"
"Hold on," Cyrill complained.
"I'm trying to write this down."
Marissa paused for a moment. Once Cyrill gave her the okay, she continued: "Rebecca Ziegler supposedly committed suicide.
She was autopsied at the Memorial. Get a serum sample from her as well."
"My God, Marissa!" Cyrill said.
"What's this all about?"
"You'll know soon enough," Marissa said.
"But there'd still more. Is there an ELISA test for BCG bacillus?"
"Offhand, I don't know," Cyrill said.
"But if there isn't, we can have it made up."
"Do it!" Marissa said.
"And one last thing."
"Jesus, Marissa…" Cyrill sighed.
"We'll need an emergency U.S. visa for Dr. Tristan Williams."
"Why don't I just call President Bush and have him take care of all this?" Cyrill said.
"I'm counting on you," Marissa said.
She knew she was asking a lot of Cyrill, but she was convinced it was vitally important. After exchanging goodbyes, they each hung up.
"Did I hear that a trip to the States is in the offing?" Tristan said as he peeked through the door.
"I hope so," Marissa said.
"The sooner the better."
The following morning both Marissa and Tristan were pleasantly surprised by their reception at the U.S. Consulate. As soon as Marissa gave her name, they were shown into Consul David Krieger's office.
During the night, communications had been received from the State Department and from the U.S. ambassador in Beijing.
"I don't know who you people are," David told them, "but I'm certainly impressed by the behind-the-scenes flurry your being here has stirred up. It's not often I'm given instructions to issue an emergency U.S. visa. But I'm pleased to say I have one for Dr. Williams."
David Krieger himself accompanied Marissa and Tristan to the Public Security Bureau on Jeifong Bei Lu Street in front of Yuexiu Park. Although the police had been advised of the case, they still insisted on interrogating Marissa and Tristan, but did so in David Krieger's presence. They proceeded to check Marissa's and Tristan's story by dispatching several officers by helicopter to the two villages Marissa and Tristan claimed to have passed through.
During the interview, it was apparent to Marissa that the Chinese authorities associated their presence with the cigarette boat incident. Marissa was quick to say that it was at the appearance of the powerboat and the patrol boat that the captain of the junk had made them jump overboard.
When they returned to the consulate, David Krieger was optimistic that the problem would be resolved swiftly. He graciously invited Marissa and Tristan to have lunch with him. After lunch, the consul arranged for Marissa and Tristan to get some Westernstyle clothes. By the time they returned to the consulate, word had already arrived that Marissa and Tristan were free to leave the PRC whenever they cared to.
"If you are in a hurry," the consul said, "we can make arrangements for you to fly to Hong Kong this afternoon."
"No, not Hong Kong," Marissa said quickly.
"Are there other foreign destinations available directly from Guangzhou?" She didn't like the idea of returning to Hong Kong even if only in transit. She didn't want to risk any more run ins with the thugs from the FCA or the Wing Sin.
"There is a daily flight to Bangkok," David Krieger said.
"That would be much better," Marissa said.
"But it's out of your way if you're heading back to the States," David Krieger said.
Marissa smiled innocently.
"Regardless, I think we'd both rather spend a little more time flying than going back through Hong Kong. Do you agree, Tristan?"
"Right you are, luv," Tristan said.
"Here are all the statistics we could get on such short notice," Cyrill Dubchek said, handing computer printout pages to Marissa.
Marissa, Tristan, and Cyrill were sitting in Cyrill's office at the Centers for Disease Control in Atlanta, Georgia. Marissa and Tristan had just arrived that afternoon from their grueling flight across the Pacific, flying from Bangkok to Honolulu to L.A. to Atlanta.
Even though they were exhausted, Marissa insisted on going directly to the CDC.
Marissa studied the pages carefully. Tristan looked at Cyrill and shrugged. Tristan was still in the dark as to Marissa's suspicions.
"Just as I thought," Marissa said, raising her eyes from the computer paper.
"These statistics mirror those that I found in Australia with the FCA data. They show that the Women's Clinics around the country have a high rate of pregnancy per patient in their in-vitro fertilization program but a low success rate per cycle. In other words, most IVF patients at Women's Clinics get pregnant but it takes multiple cycles before they're met with success. Look how the success rate shoots up after the fifth lVF attempt."
Marissa pointed to the statistics spelled out on the computer printout she was holdin in her hands.
"That's not so surprising," Tristan said.
"In every clinic, most patients have to go through several attempts before they conceive.
What are you getting at?"
A knock on Cyrill's door interrupted them before Manissa could reply. It was one of the technicians from the lab.
"We have the results on those ELISA tests," she said.
"That was fast," Cyrill commented.
"They were very positive," she said.
"Evenat high dilutions."
"All of them?" Cyrill asked incredulously.
"All of them," the technician repeated.
"That's the proof I wanted," Marissa said. When she'd first arrived at the CDC, she'd gone directly to the lab to have some blood drawn. Then she'd made arrangements for her serum to be tested with the ELISA test for BCG along with Rebecca Ziegler's and Evelyn Welles' serums.
"I don't understand," Cyrill said.
"How can that be?"
"I think it is rather clear," Marissa said.
"Evelyn Welles didn't have tuberculosis. She had disseminated BCG bacillus." Marissa reached for Welles' hospital chart and opened it to her autopsy page.
"Look," she said, pointing to a description of the microscopic appea
"It says there was an intense, overwhelming infection in her oviducts. I'll tell you why that was the case: the fallopian tubes were the port of entry of the BCG. The fact that it disseminated was because of her immunological problem. And look here at the description of her cervix.
It describes a recent punched-out lesion. That had to be a biopsy site." Marissa flipped through the chart until she came to the woman's last Pap smear report.
"Now look at this. The Pap smear was normal four weeks before. Does that make any sense to you men?"
"I think I'm beginning to get the picture," Tristan said.
"You're suggesting that the twenty-three cases of TB salpingitis that I reported were actually BCG, not TB."
"That's exactly what I'm suggesting," Marissa said.
"I didn't have TB salpingitis either. I had a deliberate inoculation with BCG vaccine. I think the basis of this whole mystery is nothing but business interest. A few years ago, Female Care Australia realized that they were sitting on a potential gold mine with their IVF technology. The only trouble was that their increased success was denying them income by lowering revenue. So they decided on two courses of action to ensure increased revenues.
One was to create more demand. The only absolute indication for IVF is hopelessly blocked fallopian tubes. Someone found out that the rural Chinese doctors had been clever enough to develop a way of cannula ting the fallopian tubes without the need for anesthesia. So they began bringing these doctors out of China to do just what they had been doing in China: sterilizing women.
The trick was to sterilize without leaving evidence of it, or leaving evidence that could be misinterpreted. Someone must have come up with the BCG vaccine. It causes an intense immunologic reaction that seals the tubes totally and destroys the organisms in the process. That's how BCG works. On biopsy, it looks like tuberculosis. There just aren't any organisms. Obviously, they only tried this ploy on certain candidates. They chose only young, recently married, middle-class females. All they had to do was schedule these women for a minor procedure of some sort, like a cervical biopsy. I know that one ruse was to tell the patient that her Pap smear was CIN Grade #1. That's how they got me and Wendy. Neither Wendy nor I had told the clinic we were physicians. If they had known, they probably wouldn't have risked including us in the scheme. And they certainly didn't know about Evelyn Welles'immunological problem. And Rebecca Ziegler.