TOXIN by Robin Cook, MD, Berkley Publishing Group, New York, 1999, 432 Pages, $8 (Paperback); Putnam Berkley Audio Book, 6 Hours, $25; ISBN: 0-425-16661-9

Review by Del Meyer, MD

Robin Cook, MD Columbia, Ophthalmologist, has treated us with another best seller-- his 20th. This time he's raising our consciousness about the increasing problem of contaminated meat. It is more prevalent than the Jack-in-the-Box outbreak of 1992 or the Hudson meat recall in the summer of 1997 would suggest. Up to 500 of our children are dying from contaminated meat each year.

Dr Cook opens with a prologue introducing "Bart" and "Willy" who are in the 4D business of picking up dead, dying, diseased, and disabled farm animals, and then delivering them to a rendering plant. On this day they pick up an ailing cow from a farmer who wants to be of the diseased animal before it infects the rest of his herd. After hosing down the cow which had been lying in its liquid stool, they conclude that it doesn't look half bad. They decide to take her to the Higgins and Hancock slaughterhouse instead of the rendering plant. There they are paid $50 instead of the usual $25 that the rendering plant would have paid. The reader is then given a rather vivid description of how the animals are slaughtered, then put on a track where some portions go in one direction for beef cuts and the head and other parts go to the hamburger vats.

The protagonist, Dr Kim Reggis, former chief of cardiac surgery, has difficulty understanding that he is now just "one of the indians" since his hospital has been purchased by the HMO, Americare. The nurses no longer interrupt their discussions with housekeeping to listen to the demands of a surgeon. Sometimes they remind him that he, like they, work for Americare and answer to the administrators.

The story advances when Reggis, later in the evening than he had promised, picks up his daughter, Becky, from his ex-wife Tracy's home. Because it's late and dining at a restaurant is no longer an option, he takes her to the popular new fast food place, the "Onion Ring," where she orders a hamburger and fries. That evening she develops severe gastroenteritis and is rushed to the emergency room where, because of the new HMO regime, he, Becky, and his ex-wife must wait their turn along with the rest of the crowd. Later in the examining room, he discovers that tests he thinks are required are not approved by Americare protocols. When he confronts a nurse and demands to see the Doctor in charge, she makes a phone call and the hospital administrator appears. After a brief confrontation, Reggis literally punches him out.

Becky has a progressive downhill course, develops arrhythmias, and is placed in the ICU. E. Coli septicemia is diagnosed and cascade multiple organ failure occurs. When she develops cardiac standstill, and efforts by the cardiologist and pediatrician fail, Reggis physically clears the room of those he believes are incompetent, and takes over external massage. When his compressions do not bring a pulse, he grabs a scalpel from the crash cart and with one slice lays his daughter's heart bare, does direct cardiac compression, and to his horror, finds that her heart literally "squishes" between his fingers like hamburger.

Cook skillfully weaves a scenario whereby Reggis obtains a hamburger patty from the Onion Ring, assaults the manager, is arrested, spends the evening in jail, is released the following morning, determines that Mercer Meats supplies the Onion Ring with their hamburger, meets the USDA inspector, and eventually gets back to the hospital to change from his soiled white coat and greens. While he is in the shower, the new chief of surgery and chief of staff come to the surgical dressing room and summarily suspend him. (He's not sure which side of his naked body he should point at the intruders).

With a contract out for his life by the beef industry, he becomes a fugitive which makes the sleuthing all the more dangerous and suspenseful. He determines that Mercer Meats gets their Hamburger from the Higgins and Hancock slaughterhouse. He changes his appearance by cutting and dyeing his hair, and gets hired on at Higgins and Hancock. His purpose is not only to investigate the plant practices, but also discover what has become of the USDA agent who disappeared while trying to help him expose illegal procedures at the slaughterhouse. During a clandestine visit, Reggis is sickened to find, not the body, but the head of the agent floating in a huge hamburger vat.

It's a large order, but Cook fills the plate with problems in the food industry, the resultant spread of E. Coli, O157:H7, the problems physicians face in the HMO era, the resultant lower level of patient care, and the problems which arise in a marriage and family when a parent is forced by a career to spend long hours away from home. The final resolution is another example of Cook's expertise as an author of the modern medical thriller. As before, he lists the reference to the real world where these conditions truly exist. This book is so convincing that ground meat of any kind has been eliminated from our household. Dr Cook's suggestion for solving our contaminated meat problem may surprise many. He thinks it should be privatized. After all, he states, isn't Kosher inspection the world's best?

Del Meyer, MD