In Time of Famine, the Devil Dines on Flies

Lately, I’ve been wanting to write down what happened between me and the crazy lady, but what with graduating, applying, packing and finally traveling to my little town in Ghana, I haven’t had the time or the brain space. And I know it won’t be a good story. There are no plot twists. There is no bear at the door. There is no redemption, at least not yet. There is very little action, none if I’m honest, and also no plot. There is only an old lady who wore a dog muzzle to pick up her insulin, thereby meriting the nickname crazy lady, not even dramatic enough for a catchy nickname in initial capital letters. I looked her up as I was getting her first prescription, and breaking all rules of patient privacy, I will tell you that her name was Ingrid Levitt, that she had a concentration camp tattoo number on her left forearm and that she was older than God. I am hoping I will not be punished for this disclosure, but I doubt the pharmacy police will see what I write here in my poky village in Ghana, which has only one intersection but twelve bars, homicidal donkeys, warm Fanta, and a raging case of the AIDS epidemic and its associated woes.

It is a good place to write about Ingrid, I think, because the same gritty, bitter taste of rage infuses the dust I breathe every day before the rainy season turns the problem to mud. Like expensive green tea, you know? You don’t taste the rage directly, but it crawls onto your tongue and lingers. Although she was only nice to me, the rage came out her pores or something, like those people who eat a lot of garlic and radiate the scent on a hot day, or those men who smoke cheap cigarettes and taste like Clorox during oral sex.

I have watched movies backwards since I was a kid, running the “making of” documentaries first, then watching the movie with the director’s commentary, and only then watching the movie straight up. I mourned when DVDs became irrelevant, and movies were streamed without all the extras and hidden Easter eggs, and I treasure my antiquated collection of DVD movies and cheap my DVD player. I like to know what’s behind the action.

So, the second day of my pharmacy internship, the last rotation before graduation, when all the PharmDs, and pharm techs and students fell back from the customer service windows and found places to hide where they couldn’t be seen from the waiting area, I stepped up to staff the one window that policy required always to be open. My mother told me that once, soon after I learned to walk, I ran toward a coral snake, or maybe it was a cottonmouth. In our family, stories change with the retelling. She scooped me out of the way with one arm and killed the snake with the other, her big hand expertly chopping its head off with the shovel she had grabbed on her way to me. She darted out of the way of the still snapping jaws and beat it quiet, with me now screaming against her neck. I wish she had saved the snake, or at least that one of the other relatives on the lawn had shot the scene, but this was long before making memories was a fashion and phones with cameras had not yet been invented. Ever after, whenever I proposed anything my family deemed outrageous, I was dismissed with, “Yeah, this from the girl who runs towards snakes.” No one at the time thought to ask me why I had run towards the snake; I only remember it was pretty and looked like a good playmate, like a longer, more colorful puppy than the ones in Lady’s recent litter.

When I stepped up to the window that Tuesday to see what had made my colleagues flee, I was confronted by a short frail woman with bright blue eyes and short grey hair, who had obviously seen my co-workers disappear. Black coat, cashmere I thought, a little long on her and a little warm for the early spring day, but nothing odd. What was odd, I immediately realized, was that she was wearing a muzzle. I later learned it was a Funny Muzzle, produced by Cesar Millan, a famous TV celebrity dog trainer, to render a muzzle-wearing dog more friendly looking. There was a video on his web site explaining he had developed the Funny Muzzle (in three styles and three bright colors, sizes from small to X-large) to appeal to humans who were frightened or intimidated by a dog wearing a muzzle. The whole idea was to get everybody to lighten up and create a better, more comfortable human energy around a dog who for one reason or another had to be muzzled. All the muzzles had smiles printed onto their nylon fabric, one close-mouthed, one close-mouthed but with a bright red tongue hanging out, and the third, the one crazy lady was wearing, featured human-looking teeth in a big smile on a bright yellow background. The idea was modestly successful for dogs, not Amazon’s biggest seller in the muzzle category, but not the worst seller either.

On a human, the toothy smiling yellow muzzle looked bizarre and hugely threatening. Crazy lady faced me straight on, which didn’t improve the look. The muzzle covered both her mouth and nose, substituting a generic dog nose on the face-on view of the muzzle. I thought quickly, panicked, that it was nowhere near Halloween. Were there other cultures that had similar holidays on different days? She had no children around her, so it wasn’t to make kids laugh. Had she had oral cancer, and the muzzle was hiding a gaping hole while her prostheses were being made, and she just had a peculiar sense of humor but was harmless? The last thought steadied me, and I fell back on our scripted opening to greet our guests, as pharmacy management insisted patients be called. “Hi, I’m Brittany, and welcome to the City Hospital Outpatient Community Pharmacy. How can I help you?” The ungrammatical robot-like greeting grated on me whenever I used it, but I knew better than to go up against management. I needed a good letter of recommendation from this rotation.

Mrs. Levitt, as I found out from her prescriptions, had no insurance, being an illegal alien and unemployed. She paid full price for her insulin, two types, her high blood pressure medications, a cholesterol lowering drug, and a diuretic. Also for needles, test strips, lancets, and the other miscellaneous, high-priced gear that goes along with Type I insulin dependent diabetes. She carefully took off her coat and hung it on a hook in the waiting area. At the window, she passed me a note, obviously pre-written, and got out a fountain pen and a small leather notebook, both good quality but well worn. As I watched her write a second note, I saw that she had a faint tattoo of numbers on her left forearm. The pre-written note said, “I called these prescriptions in two days ago and have been notified via email that they are ready, so I would like to pick them up. The insulin should be in the refrigerator. At prices like this, poor people will die, many of them. My gift to you today is to tell you that nobody uses alcohol wipes any more to clean the injection site. Although they are one of the few things about diabetes that isn’t usuriously expensive, every little bit helps. Of course, this omission leads to skin and other infections, compounded by reusing the so-very-expensive needles ten to twelve times per one-use needle. Thank you for your time. I realize you are just following orders. Guten Tag.”

She watched while I read through the note. I am sure I looked her full in her face and stared, my eyes wide like a cartoon character. She nodded encouragingly and possibly smiled behind the muzzle, or at least crinkled her eyes, waving me toward the prescription filling area.

I brought back her medications and waited while she meticulously checked through them, entering each one into the notebook along with its price, praying that no one had made an error. She carefully counted out $791.28 from a cracked leather coin purse, laying out the biggest bills, a couple of 50s and several 20s, in a line, then piling the rest and waited patiently while I recounted the cash, another management policy. She used the time to write me a short note: “Brittany is a good doggie breed, intelligent yet obedient. I will wear my white muzzle next time in honor of your name. Danke for not being dead inside yet, child, and watch yourself among those who are.  Sincerely, The Crazy Lady.” I gave her change, and took the note, reading it quickly and stuffing it in my smock pocket. I looked back at her, downward because I was much taller than she was, and risked a small smile. She nodded briskly, and having packed her medications for the next twelve days into a cheap tote bag that said “Healthy City, “passed out free by the hospital as advertising, she left, walking stiffly but quickly toward the bus stop.

My colleagues came out after she was safely out of sight to enjoy my crazy lady initiation. I knew what to do, but suddenly the side of me that runs towards snakes came out and I pretended nothing had been unusual.

“Hey, where did you all go?” I asked them. “What if I had questions?”

“No problem, crazy lady gets the same stuff every time, and it’s simple. We always have it ready right away and she always gives us at least a day. The goal is to get her in and out as fast as you can. Don’t make eye contact, and for God’s sake stay on script or there could be trouble.”

I tried to probe for more info, but that was all they would give me except to say that she had a history of becoming agitated in front of patients and had been spoken to sharply by management, who had threatened to cut her off from our services. I don’t think my reaction to this news was entertaining enough, and heard nothing more from them about crazy lady, except that somehow she became my personal guest.

Twelve days later I was ready, both for the disappearance of the other staff and the appearance of Ingrid. I had a note in my pocket, folded small, asking her why she wore the muzzle.

She responded with a pre-written note, also folded small, and gestured for me to put it in my smock pocket and read it later. I smiled and obeyed, and we repeated our previous visit, with her counting out exactly $791.28 for twelve days of medication, and me recounting the cash according to management policy. After she left, I went to the bathroom and read her note. Paraphrasing, it said that she had made the comment about insulin prices being so high that people would die to one of the pharm techs before I had begun my internship, and that this tech had gotten very angry and tried to argue with her, the most salient points being that guests could always go elsewhere if they didn’t like the service here, that no one would die because there were programs to help those who couldn’t afford their medications, just check the Internet, that City Hospital Pharmacy price-matched, so all she had to do was find a lower price and it would lower her price, and that she was just following orders. Then the tech called City Hospital Pharmacy a non-profit pharmacy, and Ingrid wrote that she couldn’t help herself, she fell apart laughing. Ingrid had received a call a few days later from the pharmacy manager, whom I knew to be a stickler for following management’s rules. This woman had threatened to cut Ingrid off from getting her medications for being condescending and rude to the poor pharm tech, whom I had already realized was a brainless idiot.

Following her script for dealing with “difficult patients,” the manager had tried to get Ingrid to agree to be nice and docile. Ingrid, assuming the call was being recorded with the aim of putting her on a denial-of-services trail, politely refused to agree to anything, and came up with the muzzle strategy. She said she enjoyed doing nothing that anyone could possibly criticize her for and watching both the tech and the manager give off shrieking panic vibes. Wanting to do something useful as well as Dada, she wrote, she had decided to pre-write an educational note to give to the person serving her about how poor people who fell through the cracks in the safety net dealt with expensive chronic illnesses. I was the first to read one of her educational notes in front of her, as well as the first to have eye contact with her since muzzling and she thought I might have potential to be a humane human, an unusual condition anywhere but especially in our fascist healthcare system. She thanked me, then gave me the educational tidbit that there were two grades of needles, boxes that had passed quality control and boxes that had not. The boxes that had not passed quality control were much cheaper than those that had, and about one out of 10 of those needles were either bent but could be straightened with your fingers or were insecurely attached to the collars that mated the needle to the syringe or injection pen. These loose needles could usually be spotted when the diabetic inserted the needle into their flesh, and could be managed by being much more gentle than usual pulling the needle out. If that didn’t work or wasn’t possible, the needle would detach from the syringe or pen but could sometimes be pulled out of the patient’s flesh with tweezers like a splinter. If the patient had bad luck, and the tiny needle disappeared into their flesh, they might get an infection and a hard lump would form around the errant needle, which would either work its way back through the skin or stay encapsulated there. Only with very bad luck would the needle travel to a blood vessel and move somewhere important and kill the diabetic. But worth it for the price, since needles were very expensive, and life is risky, is it not? Some pharmacists knew about the two grades of needles and stocked both types, although City Hospital Pharmacy did not.

And that was the beginning of my relationship, if you can call seeing somebody six times total a relationship, with Ingrid Levitt, our very old, uninsured and not qualified for Medicare or Medicaid, concentration camp survivor. As I am writing this, it is 2017, and her birthday was listed for identification purposes in our records as 1930, making her 87 or thereabouts when we met. I never saw Ingrid again after graduating that June, but the half dozen times I did see her, she always had a pre-written piece of education for me about how poor people handle the cost of diabetes. The most disturbing one said that if money could not be found even for Canadian, Chinese or Mexican insulin, the diabetic person could just not use insulin and stay hydrated but eat very little if at all for two to three weeks, as long as they didn’t have to function at a very high level. Intermediate steps were to use half a dose and double the time between refills. She noted that both of these strategies were dangerous in a well-run health system, since there would be a risk of being labeled “noncompliant” and kicked out of the system, with no access to insulin at all, ever. In our town, there were only two systems, but thankfully both were inefficient and didn’t communicate well with the doctors who could rule a patient noncompliant and cut them off from prescriptions. I wrote a note back on this one asking if there weren’t programs that could help people in this situation, to which she replied at the bottom of my note, “No. Try it and see.”

I did call the number we had been told to give people who stated they couldn’t afford their medications (and they had to use this exact wording), and after a 28 minute wait reached a baffled bureaucrat who said she could only help people who had a large inpatient bill for a hospital stay arrange a payment plan, and she had nothing to do with drugs at all. She did ask me to convey this to whoever gave me her number, but I knew better and did not. I needed a good letter of recommendation, after all.I wondered if poor people could afford to wait on the phone that long, and suspected most just gave up before being told they couldn’t be helped.

The last time I saw Ingrid I had a note written ahead of time, and passed it to her surreptitiously, aware of my colleagues lurking in the back, watching. She took the note and bent down to fumble with her coin purse in her tote bag, reading my note bent over. I had asked her how she paid for her medications and which concentration camp she had been in. As I assembled her order, she quickly wrote a response and tore it out of her notebook. It said, “1.  I steal cash out of hospital staff’s wallets, of course. I’ve hit your colleagues twice now, but never you. No one seems to notice if the amount is small enough. Forty dollars is about right. You have been a humane human to a difficult old crazy lady, and I thank you for this. 2.  Buchenwald. If you will read about it, they will say there were no women there but this is not true. I was a child prostitute in the brothel there for the SS. Thank you for noticing my tattoo and not remarking on it. Your mother raised you with good manners, you should tell her I said this, a mother likes to hear good feedback.3.  I understand you are graduating and will soon be a pharmacist. Congratulations! I wish for you that you are able sometimes not to follow orders and that you may sometimes do some good. Always remember, ‘In time of famine, the devil dines on flies.’ It has been a pleasure working with you, Doggie Girl.  Sincerely, Crazy Lady.”

She smiled at me behind her muzzle, bright yellow with human teeth that day, and left. I waited a week after graduation, accumulating several job offers, since my letters of recommendation were very good and I interview well. The salaries were impressive and would have gotten rid of my student loan debt very quickly. Then I applied to Doctors Without Borders, which had a standing request for pharmacists, and I am here in Ghana now, finishing my not very good story about Ingrid. I wasn’t sure what to do with it, although I have been writing stories seriously all the way through school, and have published several. Later, when we had our sporadic Internet access, I found Ingrid’s address and emailed it to her. I hope she enjoys it. We runs-toward-the-snake people have to stick together.

 

 

Anne Vinsel spent 16 years at the University of Utah Hospital doing medical writing and surgical photography. She holds a MS in psychology and an MFA in painting. She loves reading and writing fiction and playing with her friends, including her adorable and wiggly pit bull/great Dane/basset rescue dog, Dr. Miranda Bailey.

Rubor Participation:
2019: Poems, "Waiting: 10 Poems Begun at a Bus Stop," web edition
2019 Prose, "In Time of Famine, the Devil Dines on Fries," web edition
2019 Poem, "Lemon Drops," web edition
2019 Poem, "Triplets"
2015 Essay, "Pas Seul"
2014 Photograph, "Irrigation"
2014 Photograph, "Ghost Surgeon"
2014 Essay, "Listen, meine Kinder"
2014 Oil Painting, "Chemo Pond"