White Ghost (10 page)

A
ny change from last time?” Dr. Louisa Stern asked Gage after she entered the examining room in the cancer center.

Her words echoed in the sparse room. Cabinets. Pneumatic exam table. Sink. Chairs. The click of hard heels and the squish of soft soles on the linoleum-floored hallway beyond the closed door.

“Not as bad.”

“Nausea?”

“A little.”

“Dizziness?”

“Occasionally.”

“Unbutton your shirt. Let me check for any changes in the lumps.”

Stern felt along the inside of Gage's collarbone, under his chin, and pressed hard into his armpits.

“Where's Faith today?”

“She had a class to teach. I told her I'd bring her back a sucker.”

Stern laughed. “Sorry, I'm fresh out.” Then she tilted her head toward two bone marrow biopsy syringes laying on the counter. “You ready?”

“Have you been working out?”

“Every day.”

“Then I guess I'm ready.”

“I can give you a muscle relaxer. That may make it easier.”

Gage shook his head. “I'll pass. I need to be alert later. I'm working on something.”

Stern pointed toward the end of the exam table.

“Take off your belt and unbutton your pants, then lean over and slide yourself up. I need good access to your lower back and hip.”

Gage did as instructed.

Stern pulled down Gage's slacks just far enough to expose his hips, then rubbed alcohol over his right hipbone and injected a local anesthetic.

“I'm going after some of the liquid, then after the bone marrow itself.”

Stern poked at Gage's anesthetized skin with the needle and asked, “Can you feel that?”

“Only pressure, no pain.”

Gage then felt all of Stern's hundred and thirty pounds lean into his hip and the corkscrew motion of the needle. He caught his breath as the hollow needle broke through the outer shell of the hipbone and drove into the marrow. She aspirated some of the liquid marrow, detached the plunger from the syringe, and set it on the counter. He then heard her attach another one.

“Now comes the hard part. Try to stay relaxed.”

Stern began rotating the needle, driving it harder, forcing a sliver of bone and marrow up into the needle.

“Hang in there, I've almost got it.”

Then she released the pressure.

Gage breathed out and pain iced through him as she extracted the needle.

“Jeez . . . I didn't expect that.”

“That's the one you're supposed to get the sucker for. Too bad I'm—”

“Fresh out.”

Gage belted his pants, then took a few steps around the examining room, testing his right leg.

“I don't think you're the squeamish type. You want to see what I took out?”

Stern held up a liquid-filled glass vial in which there stood an inch-and-a-half sliver of bone and marrow about the thickness of a small nail.

“Don't worry, it'll grow back.”

“I'm not worried.” Gage flashed a smile. “I didn't figure you'd break something you couldn't fix.”

“I'll have the results the day after tomorrow. Then I'd like to bring in a few youngsters and put together a treatment plan.”

“A little show-and-tell?”

“We're a research and teaching hospital after all and we need the Graham Gages to keep the kids entertained.”

Gage eased down onto a chair next to Stern's. “I've been doing a little research myself. No one seems to know why normal cells mutate into cancer cells. It seems like an evolutionary misfire.”

“All evolution, good and bad, is fundamentally a matter of mutation. It's just that this mutation makes a particular individual less able to survive in the environment.”

“I think that's what Charles Darwin called extinction.”

“It would be, except he didn't know about chemotherapy.”

“But why lymphoma? I can't find anyone who claims to have found what causes it.”

“There is no known cause. Not pollution, smoking, diet. It's nothing you did to yourself.”

Gage smiled again. “So it's like a guilt-free cancer?”

“No one has ever described it that way before, but you're right. A guilt-free cancer.”

“Lucky me.”

Stern smiled back. “No one has ever said that, either.”

G
age picked up Faith at the Montgomery Street BART Station in San Francisco to drive to the closing dinner of the annual meeting of the International Fraud Investigators Association.

“How was class?”

“Like pulling teeth, but at least no one was drilling into my bones.”

“Intro?”

“Yeah. And I finally figured out why all those football players registered for it. They signed up when they thought Alistair was still going to teach it. Looks like he's been giving free honey to the Golden Bears for the last ten years. By the time he got suspended for that ménage à trois in the library, it was too late for the team to drop the class.” Faith laughed. “One of them is a smart aleck with a neck and face like a walrus. He asked me if he could do a term paper on what he called the function of voluntary associations in generating team loyalty in major college athletics.”

“You mean he wants to study cheerleaders?”

“You betcha.”

“Will you let him?”

“Why not? I might learn something. I've never understood that whole pom-pom thing.”

A few minutes later, Gage pulled into the driveway of the Mark Hopkins, a Spanish renaissance hotel on the crest of Nob Hill overlooking the city. He retrieved a file folder from the backseat, then handed his ignition key to the valet.

Jacques Matteau, the association president and director of the French
Brigade Centrale de Répression des Fraudes Communautaires,
spotted them as they entered the lobby.

“Why the limp?” Jacques said after kissing Faith on each cheek and shaking Gage's hand. “I hope you haven't gone back to fighting crime with your body instead of your mind.”

“It just got a little rough on the basketball court yesterday. A pick-and-roll that didn't work out right.”

The Peacock Court room was nearly full with the thousand conference attendees seated at the round banquet tables or milling about in the spaces in between, glasses of wine in their hands. As Jacques guided Gage and Faith toward the head table, members waved at Gage or came forward to greet him.

Jacques seated Gage and Faith to the right of the podium on the elevated, flower-adorned table, then walked to the microphone and banged a gavel. The gunshot-like cracks of mahogany on oak shut mouths and turned heads toward the front.

“I'd like to welcome all the members and guests to this closing dinner and thank everyone who made this conference such a success. Represented here tonight are the premier fraud investigators in the world, representing hundreds of law enforcement agencies and investigative and security firms from over sixty countries. The most representative group ever. I know you're anxious to hear from our keynote speaker, but first things first.”

Jacques signaled the waiters poised at the doorways, then seated himself to the right of Faith. Gage overheard them talk
ing as he ate his salad and reviewed his speech, writing in some changes. He sensed Faith peeking at him, then set down his pen, reached under the table, and rested his hand on her thigh.

It's okay.

Later, when his dinner plate had been removed, Gage's eyes fell on the evening's agenda.

Opening remarks

Dinner

Awards

In Memoriam: Juan Cortez-Sanchez

In Memoriam. Gage had forgotten about that part of the annual program. With a couple of thousand members worldwide, some die every year. Usually they retire and leave the organization before they do, so nothing is said. But Juan, Spain's most skilled terrorist financing investigator, was still a member and way too young to die.

Keynote Speaker: Graham Gage

Gage suffered a morbid dyslexia. The text morphed, appearing to read “Keynote Speaker: Juan Cortez-Sanchez. In Memoriam: Graham Gage.” He forced himself to look away, trying to focus on the chandeliers hanging bright and heavy from the ceiling. But he could just as well have been looking up at a rain cloud, and for a moment he wished it was and that he and Faith were back in Costa Rica.

As Jacques resumed his role as master of ceremonies, Gage felt his mind wandering off, abandoning his body.

“Juan was a twenty-year member . . . a friend to many in this room . . . selfless . . . brilliant . . . too young . . . long bout with cancer . . . his wife is here to accept . . .”

“Graham Gage . . . our keynote speaker . . . youngest recipient ever of the Lifetime Achievement Award . . . received last year at the Paris meeting . . . I present to you the man I like to call the diagnostician of deception and the philosopher of fraud.”

Jacques moved back from the podium and gestured Gage to approach. No one in the room could have failed to notice Gage's smile transform into a grimace as pain attacked his hip when he straightened up. After he stepped up to the podium, he steadied himself by gripping the raised edges of the top until he felt his leg hold firm.

Jacques leaned over and pulled the microphone toward him.

“If Graham is going to insist on continuing to play basketball, perhaps we can add another training session to next year's schedule: The proper execution of the pick-and-roll.”

Gage felt his face redden in response to the crowd's laughter. He wondered which was worse: being rightly known to be undergoing a painful search for the extent of his cancer or being viewed as physically incompetent. He shook off the thought, then held up his hand, acknowledging the laughter.

Gage adjusted the mic, then looked about the room at the many familiar faces. An image of Juan slid into his consciousness. Blanket covered, hunched over in a wheelchair at a Spanish hospice, gray, shriveled, hollow eyed, waiting to die. He felt a restlessness in the crowd, opened his file folder, and began.

A
S
G
AGE CAME TO THE END
of his prepared speech he realized he couldn't remember much of what he'd said. He recalled moments of applause and laughter and, more than anything, two thousand eyes peering up at him and him wondering what they were seeing, or maybe who they were seeing, for he knew that he wasn't exactly the same man they had seen in Paris.

Jacques approached the podium clapping. He put his left arm on Gage's shoulder and said, “How about a few questions?”

Without waiting for a response, Jacques pointed at a young woman at the nearest table, whose words were lost in the mumbling crowd.

Voices from the back yelled out, “We can't hear . . . speak up.”

“Let me repeat the question,” Gage said. “It was about my references to the evolution in fraud and the methods used by crooks. And did I have something deeper in mind.” Gage paused, the thought still unfinished in his mind. “The short answer is, yes. The slightly longer answer goes something like this: We typically catch crooks because most frauds, in fact most crimes, are cookie-cutter jobs. They're based on paradigms, so to speak. The crooks who are a little smarter than the rest combine these paradigms, sometimes in unusual ways.”

An image of Ah Ming flickered in his mind.

“The smartest crooks, the most dangerous ones, adapt these paradigms to a changing environment. That is, crime evolves. That's not news. However, my evolution reference points toward something else. It's this: Every adaptation is also a liability. Let me say that again: Every adaptation is a liability. Why? Because it creates a new dependence on the environment.”

Gage looked down at the questioner. She reminded him of Sylvia Washington as a young San Francisco detective. Intent. Earnest. Serious.

“And when the environment changes, the adaptation fails and . . . sorry, I don't know your name . . .”

“Cynthia Fairbourne, National Criminal Intelligence Service, London.”

“Cynthia, you can complete the sentence, the adaptation fails because . . .”

“We're part of the environment.”

“Exactly. We're part of what the crooks adapt to and once we figure out the adaptation, we can make it a liability.”

“But what if we can't adapt,” Fairbourne said. “Like now,
criminals are using encrypted e-mails and text messages. Since we don't have the computing power to break in, we don't know what they're saying. What then?”

“We just have to work smarter. And we don't necessarily need to know what's in them in order to focus our investigations.”

Gage looked away from Fairbourne and let his eyes sweep the crowd.

“How many of you worked narcotics in the 1980s?”

A hundred hands went up.

“That was before cell phones were common. All the dealers used pagers and pay phones, too many to intercept. We didn't know what they were saying. Every crime seemed to be a black box. But we learned the paradigms and became experts in surveillance. When Crook A did X we learned that Crook B would do Y.”

He paused and punched the air with his forefinger for emphasis.

“Remember, once they commit themselves to e-mail, even encrypted ones, they're dependent on the environment they have adapted to. Just like a letter or text message, every e-mail has to start somewhere and end somewhere. We got lazy in the '90s and the early 2000s when the crooks got addicted to cell phones. All we needed were wiretaps and they kept snitching themselves off. But those days are over. So . . .”

Gage raised his eyebrows and nodded at Fairbourne, and she completed the sentence:

“Learn the paradigms and work smart.”

I
nstead of taking the bayside freeway through San Francisco south past the airport and the industrial flank of the peninsula toward Palo Alto, Gage cut inland across the commuter traffic and mall-ridden flatlands and broke out into the coastal mountains. He and Faith let their minds drift as they watched the deer grazing on the hillsides and hawks circling against the blue sky and the light shimmering on the distant reservoir. A twenty-five-minute vacation from worry—

That ended when he turned east and they spotted the sign for the Stanford Linear Accelerator Center.

They both made the same association: accelerator-nuclear-radiation-cancer.

The vacation was over.

A half hour after Gage had blood drawn, a nurse escorted them into a conference room in which Dr. Stern was waiting, along with a male oncology resident and a female research fellow.

After Stern introduced them, the resident shook Faith's hand and smiled at her.

“I'm sure you don't remember me, Professor.”

“I'm sorry?”

“I took one of your classes, about ten years ago. It was wonderful. I spent the whole quarter lost in fantasies of traveling the world, going to remote places like you. I almost changed majors.”

“Thanks, but right now I'm truly grateful you didn't.” She reached out and touched the young man's shoulder. “We'll be needing your help.”

Stern directed Gage and Faith to one side of the conference table, the doctors to the other.

“Before we start,” Stern said, “let me say that we've discussed these results with the tumor board. I called a multidisciplinary case conference at the radiation oncology department this morning.”

Gage felt himself launched by the phrases “Tumor board and a multidisciplinary case conference” into a world structured by people and facts and titles and organizations and events that were as alien to him as a physics lab. And he knew he'd better find his bearings or risk losing himself to what he didn't understand. He'd done it before, in the early days of his career when he'd learned to operate in the dope world or how to investigate homicides. But that was all about other people's bodies, not his own—except the time he was shot. That was simply a race against death. Rough emergency room medicine. Stop the bleeding and wait. There was nothing for him to learn, it was just a struggle against the darkness.

“At this point, we have a very clear picture of the disease and its progression. The bad news is that you're already at stage three. The good news is that the bone marrow biopsy was negative.”

Faith slipped her hand inside Gage's under the table and squeezed it.

“The extent of the disease accounts for some of the symptoms, the nausea for example.”

“And the dizziness?” Faith asked, and then held her breath.

“The MRI showed that the cancer hasn't spread into his brain.”

Faith exhaled.

“We suspect, however, that one or more of the enlarged lymph nodes are putting pressure on one of his arteries, which in turn reduces oxygen supply, causing the dizziness.”

“Then why isn't it constant?” Graham asked. “It's happening less lately.”

“In the short term, moving about repositions the point of contact and may reduce the pressure. In the long term, lymphoma can wax and wane. That is, shrink enough to stop interfering with blood flow.”

Stern slid over two blood test summaries, one based on blood drawn earlier that day and one taken at the time of his biopsy.

“I've highlighted the tumor markers, ones that tell us about the course of the disease. The changes confirm that the lymphoma has mutated very recently, maybe just in the last month or so, and has become aggressive.”

“Which means?” Gage asked.

“That we should begin treatment before it turns into a wildfire.”

Gage caught the motion of the resident nodding.

“During the first few weeks you'll be able to carry on normally, but after that you'll start to experience some of what appear to be worsening symptoms, nausea for example, and you'll be at increased risk of infection as the chemotherapy depresses your immune system. You'll need to take some time off and you'll need to make sure you are no more than twenty minutes from an emergency room. It's a good idea to plan for it now. It will be a rough regimen, but we need to match the aggressiveness of the treatment to the aggressiveness of the disease.”

Gage noticed he was facing a wall of medical books and jour
nals behind Stern. He scanned the alphabet:
American Journal of Clinical Oncology. British Journal of Cancer. Bulletin du Cancer. Leukemia and Lymphoma
.

What's it come down to?

“Are you ready to give us the bottom line?” Gage asked.

The resident stirred in her chair. The researcher stared ahead.

Stern's eyes remained fixed on Gage, and then said, “We know that, at least, we can shrink the tumors.”

“But the cancer will still be there,” Gage said. It wasn't a question.

“Unless there's a revolution in the treatment of your type of lymphoma, it won't go away.”

“And the tumors will start growing again.”

“Yes.”

“How many times can you stop it?”

“Maybe twice. Maybe three times.”

“For how long?”

“I don't know. As little as one month. As long as eighteen months, maybe even longer.”

“So basically what you're saying is that one way or another, later or sooner, it's going to kill me.”

Gage winced as he said the words. He knew he was pushing too hard and Faith wasn't ready. He held her hand under the table in apology.

“You're healthy in every other way, so yes, in the end.”

“What about clinical trials?” Faith cut in. “I've been reading where . . .”

“Right now we're trying two variations on the best available treatments to see which is most successful in extending the time to recurrence.”

“So I'll play guinea pig?”

“Sort of.”

Gage scanned further down the alphabet:
Medical Oncology
.
Pathology and Oncology Research
.
Radiotherapy and Oncology
.

His eyes drifted back to
Pathology
.

Gage pushed it to the end. They both needed to know.

“Assuming I don't get run over crossing the street, what exactly will I die of?”

“Pneumonia. Your immune system will eventually fail.”

Gage heard Faith take in a breath. He remembered her father dying, suffocated by fluid collecting in his lungs. He reached his arm around her as tears formed in her eyes.

Stern, Faith, and the others stood up to leave. Gage remained seated. He looked up at Stern. There was a question left.

“You said there's such a thing as a complete response,” Gage said.

Stern nodded.

“What are my chances?”

“I can't answer that with any precision. It's one of the things we're trying to find out by doing this comparison. But whatever response you have will be time limited since we can't eliminate the cancer at the DNA level.”