Doctor consults her teenage patient

Treatment Plan

by Seanan McGuire

This original story from Vital has been made available here in honor of being a finalist for the Walter Dinjos Memorial Award For Disability In Speculative Fiction in the Disabled Writers category (Read more in Locus).

The pandemics of the early twenty-first century, devastating as they were, would have a follow-on death toll so high as to boggle the mind, which would not be fully understood or documented for the better part of a century. By the time anyone realized the poisonous pills they had been forced to swallow, it was far too late for anything to be done; they had been convinced that they were being medicated, after all. And any medicine, however toxic, can be counted upon to have a placebo effect on a certain percentage of the population. Any poison can seem a panacea when there’s nothing else available.

America’s medical system had been imbalanced and severely slanted to prioritize the rich while punishing the impoverished, the disabled, and anyone in need of ongoing care even before the first COVID outbreak. COVID-19, which originated in 2019 in a contested Chinese province, swept around the globe in months despite the best warnings of epidemiologists and doctors on the ground at the site of the first major outbreak in Wuhan, China.  Hundreds of millions were sickened.  Millions died.  Medical facilities were overwhelmed and, as they were unable to supplement costly long-term care with profitable surgical procedures, collapsed under the weight of their own debts.

Most nations, even as they misstepped and struggled with the realities of life during a global pandemic, did not shift the burden of public health onto their citizens.  America was not so discerning.

It began with a modified version of a campaign to report welfare fraud.  The disruptions to the economy were caused, after all, by lockdowns, and the lockdowns were necessary to protect members of the designated “vulnerable population.” The fact that everyone in the country would eventually receive that designation for one reason or another didn’t matter, any more than the fact that the majority of those who sickened and recovered would be immediately recategorized; it was a quick and easy way to divide the population into “us” and “them,” without drawing attention to the fact that the real division was based entirely on dollar signs.

If the world was being brought to a grinding halt to protect the vulnerable, ran the campaign’s logic, why not protect the vulnerable by isolating them completely? Why not make sure they were protected, because they were bubbled so perfectly that they couldn’t be considered anything else? Medical records were unsealed, privacy laws revised, social media streams analyzed and dissected to identify as many people in the “vulnerable” category as possible.

The rest of the population was so relieved when the lockdowns immediately lifted that few of them questioned the genuinely draconian restrictions placed on the “vulnerable.” At first it was house arrest, complete with tracing applications on their phones and fines for any offenders. All groceries had to be provided via delivery service; those who lived in rural areas where such services were unavailable were quietly relocated to “Concern Homes” established in and near major metropolitan areas.  Shortly after, to meet promised occupancy rates for the corporations running them, the Concern Homes were stocked with more vulnerable individuals, ones whose budgets had been exhausted by the cost of infinite delivery or whose landlords had seized upon an opportunity to decrease their own potential liability and increase their rents at the same time.

By the point when the outbreaks began raging through the Concern Homes, fully sixty percent of the “vulnerable” population was internally housed. Their friends, family, and loved ones on the outside screamed for compassionate release, but the response was that if there was that much damage inside, wouldn’t the outside be even worse?  At least the Concern Homes were self-contained. At least they weren’t swamping the hospitals. Good people, people who had taken care of themselves and taken the necessary steps to avoid pre-existing conditions, could still get the treatment they needed when they were injured or suffered a catastrophic event.

The death toll inside the Concern Homes was stratospheric. The death toll outside was substantially lower than it had been in the previous wave. A surprising percentage of the objectors dropped their complaints, slinking home with their ableism and their willingness to compromise the lives and happiness of their loved ones in exchange for the freedom to go about the lives as they always had. Some of them even found the world to be improved by the absence of the elderly and the disabled, two categories which they were almost guaranteed to eventually join.

The “healthy” who contracted COVID-19 often found themselves dealing with vascular and organ damage that extended for years, causing some of them to be relocated to the Concern Homes themselves.  And as there was no one left to fight for them, they lingered there, forgotten by the society that had voted to expel them.  Some of them had voted for the Concern Homes in their former lives.  The irony of their new situation was, on the whole, overlooked in their outrage, and the newly-disabled raised the loudest and most sustained objections they could, which were neither louder nor more sustained than the objections that had already been going on.

Human rights violation, they said.  Unreasonable punishment, they said. A violation of what it meant to be an American citizen, they said. And the Concern Homes stayed open, and the outbreaks stayed open, and the shape of society changed.  Disability protections were dismantled as no longer necessary; privacy laws were not reinstated, as they would only allow individuals who needed the safety and care of the Concern Homes to slip through the cracks. Medicine became less about treating people, and more about rapidly identifying any condition that could be used to shuttle a patient into the Concern Home system. This was spun as a way to reduce risk for the rest of the population: the vulnerable were spun as health risks to everyone around them, unable to avoid triggering an outbreak, as if their very bodies exuded the sickness they had been imprisoned to avoid.

And the outbreaks continued.

It wasn’t until COVID-26 was burning its way around the world that anyone thought to ask whether the Concern Homes had ever truly served a purpose apart from guaranteeing that out of sight would be out of mind by locking up anyone who failed the annual medical exam, and concentrating circulating pools of infection—multiple new disease mutations had arisen from the Homes, each more vicious than the one before it. A vulnerable population whose supposed isolation made them a low priority for vaccination made for a perfect breeding ground, after all.

By then, it was too late, really.

Dr. Christina Paulson looked at the test results in her hands and shuddered.  There was no family history, no reason to suspect this as a possible result; the child was healthy, had always been well within government parameters for height and weight, had been perfectly fine at her previous physical.

No, there was no reason for these results to be correct, no reason at all, save for the fact that genetics were an endless lottery—as the unending pandemics were cheerfully willing to demonstrate—and sometimes, even the most deserving were going to come up on the wrong side of the dice.

Angelica Patton was a sweet, smart, sociable sixteen-year-old girl with a bright future ahead of her. She’d been planning on a career in social work. Her parents were heavily involved in the campaign to abolish the Concern Homes and reintegrate their population with the rest of the world, citing them as both a human rights violation, and a public health hazard.  It was their hope that by combining the two, they could finally convince people that public health was precisely that: public. When fighting an airborne disease, it did no good to protect yourself and allow your neighbor to suffer. It would only guarantee that the disease remained in circulation when your guard inevitably slipped. And it would slip. You had to be perfect every time, meticulous every time. The disease only needed one moment of inattention, and it could get past any barrier.

Angelica Patton was one of Dr. Paulson’s favorite patients. And now she had to walk into the exam room with the results in hand and tell that girl that her life was over, that she had no future outside the menial positions allowed to the occupants of the Comfort Homes, who had no need for money, after all, and were legally classified as disabled,  meaning that in most states they could be paid pennies on the dollar for remote, unskilled labor (which was not unskilled at all, as anyone who had ever attempted to navigate a telephone service treatment without the aid of a trained representative or file remote taxes without a skilled accountant would be happy to attest).  That as soon as her test results reached the state computer, assuming they weren’t there already, a complicated system of status changes would be put into motion.

There was money in the Comfort Homes, in their functionally captive workforce and endless need for support of all kinds, from medical workers and supplies to provisions and the basic necessities of life. Because all Comfort Home residents were functionally captives, the meager paychecks they were able to earn went almost entirely to their room and board, with supplements for the lucky provided by concerned friends and family members on the “outside.”

Not that many of them had those anymore. Thanks to ongoing government campaigns to convince people that all medical conditions were purely due to the immoral actions of the person affected, most people place their unwell or elderly friends and relations into custody and walk away without a second glance.

Most people aren’t Angelica Patton’s parents. Christina knew before she stepped back into the exam room with a patently artificial smile plastered across her face that these were going to be the kind of people who fought. Fought as hard and unrelentingly as they could.

“Hello, Angelica,” she said, voice as bright as she could make it. “I have your test results here. I know you’re considering colleges right now. Have you thought about the University of Toronto?”

Angelica’s parents exchanged a look behind her as she began talking enthusiastically about the advantages of the University of California school system over traveling outside the country. Canada would cost more, she said earnestly. They would require special paperwork, and none of their degrees were exciting enough to make up for going through all the extra trouble. And of course there was the matter of their terrible socialized medicine….

Christina paused to think longingly of Canada’s medical system, which was far from perfect—there had been that nasty organ harvesting scandal after it became clear that COVID-19 survivors needed transplants at a higher rate than the general population, but that when they died, their own organs couldn’t be harvested due to vascular damage—but which had been retooled over the years to allow vulnerable citizens to remain active and unrestricted members of society. All Canadians were legally recognized under the law, which was more than she could say of America.

“I swear, the last time I went to give a lecture, it was like returning a library book, it was so fast and easy.  I’m pretty sure I cleared customs in less time than it’s going to take for these tests to finish uploading to the state database,” she said, in the same bright, utterly focused tone of voice. “You wouldn’t have any issues getting into Canada if you did it on a weekday. Of course, I can’t in good conscience recommend taking a campus tour when we need to be discussing your medical results.”

Angelica’s father nodded. Message received. He held up one hand, index finger extended, and Christina nodded back. Yes, Type One Diabetes was the most likely interpretation of Angelica’s test results. Yes, the great wheels of bureaucracy were already grinding into motion, and if Angelica was here when they finished their turn, she would never get away. No, she couldn’t say the words out loud. All physicians’ offices were equipped with recording devices, and if the state could verify the Pattons had been warned about their daughter’s medical status, she would lose her license before they could unpack their bags. She had to hint. She had to imply. And she had to hope that they were as clever as she thought they were; she had to hope they’d understand, and be able to get their daughter to safety.

“You’re a good woman, Dr. Paulson,” said Angelica’s father, reaching for her hands.  She only flinched a little before she let him take them, and she was proud of that.  It was a small thing, but still.

Like most medical professionals who had lived through the early COVID waves, and the drug-resistant infections that followed them, Christina didn’t like to be touched.  Too much of a chance of passing something between her and the patient, even in a supposedly sterile setting. Unlike many of her peers, she could still handle the strain of performing her own physical exams, rather than farming them off on machines and nurse practitioners.

That was already suspicious enough in certain quarters. Angelica Patton was the fifth medical refugee she’d sent to Canada in the last three years, and Christina was fairly sure this was where she had to stop, had to shut down her practice and move to someplace with warm beaches and friendly faces where she could claim to be a retired accountant and no one would ever know she had practiced medicine. She was going to get caught soon if she didn’t stop.

But she couldn’t stop. She couldn’t. Her own future was written in her genes: her family had a tendency toward high blood pressure and rheumatoid arthritis, both conditions that would eventually consign her to a Comfort Home, one more unwilling guest in a hotel where checkout time is halfway after never. Four of her close family members had died in the Comfort Homes when they could have lived long, healthy, productive lives in their own homes, curtailing their daily activities a little, maybe, but surviving.

Or maybe they would have died anyway, and she’s only fooling herself. But she knew the numbers and the statistics, knew how long and brutally the epidemics had raged in the Concern Homes, how once the bugs checked in they, like the residents, never checked out, and she knew at least one of her relations would still be with her today if only she’d been allowed to keep them home.

And if she ran, they would figure out what she’d been doing, and all the patients she’d seen safely to and across the border would be in danger. She could run to Canada herself, of course, but she would be a pariah there, as all former American doctors were. She wouldn’t survive long in the Comfort Homes, but she’s grown accustomed to a certain amount of respect from the people around her, and she’s not sure she could trade that for starting over in a country where she would be reviled as a butcher for the name on her medical degree, never allowed to practice again, barely trusted to go to the pharmacy and pick up over the counter medications. No. Canada is not for her.

She’ll just send the Pattons there and trust in the lack of an extradition treaty to let them stay.

Canada is far from perfect, and they resent medical refugees on a well-documented and international scale. But if the Pattons could clear border control before Angelica was officially recategorized by the American government, they would be allowed to stay, protected by the refugee laws that had been hastily modified to include America in the list of countries where returning refugees to their point of origin would mean consigning them to an unpleasant and potentially avoidable death. All they had to do was make it.

Angelica’s father squeezed Christina’s hands, snapping her back into the present, and the problem she was facing. “We won’t forget this,” he said, which was treading dangerous close to saying too much. She forced a wan smile.

“I have very much enjoyed being Angelica’s pediatrician, and I know she’s going to do great things with her life,” she said, and forced herself to keep smiling as the Pattons left her office, heading for their car and then, hopefully, for the airport.

If they went home to pack their most precious possessions, they wouldn’t make it.  They could probably—probably—collect birth certificates and other essential paperwork, if their filing system was as organized as she assumed it. They had always approached Angelica’s medical care with such efficiency. Stop the car outside, allow only one of them to run in and grab the folder, and then head straight for the airport.  The clerks handling on-the-spot ticket sales were used to medical refugees, had learned to recognize the desperation in their eyes, and could almost always get them onto the next flight.

If the Pattons had tickets in hand and were through the line at customs, they would be legally on Canadian soil, and they would get clear.  Christina smiled and forced herself to keep smiling as she watched the small family go, hustling toward an uncertain future. Then she straightened, strengthening her smile, and pressed the button for the intercom.

(The government could listen in on her office whenever they wanted to, filtering for key words, listening for proof that one of their doctors was betraying the ideals of the Comfort system. Her office staff didn’t have the same privileges. Thankfully for all of them. Some vestiges of privacy still needed to exist, for her and for the patients alike.)

“You can send my next appointment in, Tracy,” she said, voice calm. “The Pattons have left.”

“Everything all right in there, Doctor Paulson?”

“Everything’s fine, Tracy,” she said, still smiling. “Everything’s just fine.”

And everything was working the way it was supposed to work, and nothing was fine. Nothing was ever going to be fine again.

The rest of the day passed in a blur of appointments and standard physical exams. There were always people who needed to see a doctor, even in this world where the majority of chronic illnesses had  been reclassified as reason for enrollment in the Comfort Homes, where their private doctors were still trained in the techniques necessary for long-term management of hypertension, diabetes, rheumatoid arthritis, and a dozen other conditions that Christina encountered only in passing, if she even saw them at all. Most people who had so much as a distant cousin who had developed one of those conditions found ways to stay out of her office, seeking their medical care on the black market, or just letting themselves slowly sicken and die from wholly preventable conditions.

It was revolting. It was inhumane. It was the inevitable outcome of a system that had transformed doctors into spies, and taken “mandatory reporting” out of the realm of abuse and into the realm of betrayal.  No one trusted their doctor anymore.  What little affection Christina could find for and from her job came from the fact that the majority of her patients were children. They didn’t know to hate her yet.

Once, she could have sustained her practice as a full-time pediatrician, filling her hours with nothing but the children, free from the need to ever lay hands on another adult. Once, she would have had a team of physical nurses handling half the physical work she did, making sure she didn’t forget things or blow blood draws. These days, it was even harder to keep nurses than it was to keep doctors. Most headed up to Canada or down to Mexico to finish their schooling in communities where they could actually lay hands on patients whose conditions call for reliable intervention, and the ones who choose to stay either go to work in the Comfort Homes or have worse bedside manners than she does. Or they go into hospital work, serving in operating rooms, working with patients who need intervention but will be able to make a full recovery.

She’d seen a recent proposal to reclassify all transplant nurses to the Comfort Homes. Apparently, seeing their patients break down upon learning that their anti-rejection meds move them into a higher risk group and will thus be stripped of rights and freedoms and sent to the Homes had been taking a toll on their profession. She wasn’t sure that transferring them into a setting where they would have to watch their patients risk infection and slowly lose their mental stability due to isolation and rigid limitation on their personal choices was going to help, but something had to be done.

Something had to happen.

America wasn’t the only country on the Comfort Home model: the United Kingdom had something very similar, as did Sweden and Germany. Most of the rest of Europe had taken a more proactive approach to the ongoing issue of viral infection, and South America had collectively declared that every one of their citizens was entitled to the full protection of the state. There was very little medical news out of Asia anymore; after the continent had borne so much of the blame for COVID-19 and successive waves of infection, they had stopped sharing their research breakthroughs and treatment protocols.

In a world made once more small by fear of infection and enclosed spaces, the United States was very much alone, and Dr. Paulson had no real idea whether this new reality was ever going to change again.

It seemed arrogant to assume it wouldn’t: after all, human history, and indeed, the history of the universe, was one long story of change and turmoil.  Stasis was not the natural state of anything alive, not even the simple virus, which was how they had gotten into their current global predicament.

Christina finished entering the last of her notes about the day’s patients and turned toward the door, nodding to the intercom. “Good night, Tracy,” she said.

“Good night, Dr. Paulson.”

Even after all this time, she wasn’t entirely sure whether Tracy was a real person or a computer subroutine. She hoped it was the former. Tracy had responded to some deeply odd requests over the years…but she was also always there, no matter how early Christina arrived or how late she stayed. She remembered the doctors of her youth, and their office managers, who had always seemed so efficient and unapproachable, like the goddesses of the administrative world. She’d occasionally fantasized about her own office manager.

Not in an inappropriate way, just picturing the sweet, grandmotherly woman who would keep her staff in line and bring in cookies for the break room. Not possible now, naturally, since most of the grandmothers were locked up in the Comfort Homes, and eating too many cookies could invite weight gain and all its attendant consequences.  Develop diabetes or hypertension and see your world change in a single medical exam.

She shivered and locked the door behind herself, walking across the lobby of the shared medical practice to the door to the parking garage. It was equipped with a temperature scanner, to protect everyone who used the garage, and a fingerprint scanner for her personal protection—some people were so desperate to avoid the Comfort Homes that they had been reduced to abducting medical personnel when they needed urgent care, and doctors were sadly often easier to grab than nurses. No amount of segregation and filtering the “genetically unfit” from the population could stop the circulation of new and emergent pathogens.  Any elevation in her temperature would signal the building’s security system to stop her before she could exit the garage.

The door beeped and let her through, and she walked, wearily, out to her car. No one stopped or questioned her. No one even passed her. She sighed and unlocked the door, sliding behind the wheel and relaxing into the pre-warmed leather of her seat.  Now, home, and a small, healthy dinner before bed.

At least her cat would be happy to see her. Pets were recommended for people in her profession, small, fuzzy pets that could be stroked to bring down blood pressure as necessary. Not that her blood pressure was ever supposed to reach a point where it needed to be lowered; that could be a sign of underlying conditions, and the Comfort Homes were always hungry for doctors. If she was a resident, they wouldn’t even have to pay her, not really, not compared to the rates a consulting doctor could bill. So she lived on carrots and quinoa, and kept a cat who seemed to care about her mostly as a source of food—which was reasonable, since all cats seemed to care about their people primarily as a source of food.

Still, it was good to know that if she ever disappeared, Mr. Biscuits wouldn’t be heartbroken. He wouldn’t pine, not the way dogs did. Dogs always worried her a bit.  They were too invested in their people, too unequipped to live independent lives. Cats were better.

Christina adjusted her rearview mirror before pulling carefully out of her assigned parking space, pausing only to unclip her ID badge from her lapel and drop it onto the seat next to her. The garage doors slid automatically upward as she approached, allowing her to exit, and she was free, gliding out into the night, one more car amidst a sea of thousands.

To look at the streets around her, you’d never know how much of the population had been siphoned away into the Comfort Homes, how many people had quietly disappeared into a community that had no exit, quietly forgotten, their places papered over and filled in with new bodies before their beds had even had the time to cool. They couldn’t have brought those people back now if they’d wanted to. There wasn’t room.

So instead, the most vulnerable were stacked one atop the other in small, crowded rooms where a sniffle could mean death, and the world sprawled selfishly on looking for new things to devour and too busy to ever be contained.

She was almost home when the light above her mirror blinked, signaling an incoming call. “Accept,” she said. Then, after a short pause: “Dr. Paulson speaking.  How may I help you?”

It was a struggle to keep the frustration from her voice. Night calls were the worst. They were almost always emergencies, and the last thing she wanted to do right now was turn around and go back to the office. That, at least, hadn’t changed since the pandemics. Everything she’d ever been able to read or learn about older medicine said that on-call evenings had always been like this.

“Are you alone in the car, Dr. Paulson?” asked Tracy, voice bland and professional as always.

Christina blinked. “Yes, Tracy, I am. What can I do for you?”

The light blinked again, going from green to red. The next time Tracy spoke, her voice was low and urgent, the voice of a woman on a mission. “You need to head for the airport, Dr. Paulson. Now. Do you have your passport with you?”

“Yes, in my purse—Tracy, what is this about—?”

“ICE is here in the office. They’re going through your files. They said immigration irregularities associated with some of your patients had triggered a series of red flags in their system.” Tracy’s voice dipped, if possible, even lower, becoming grim. “They know, Dr. Paulson. They know.”

Christina’s stomach dropped toward her heels, a sickening descent that left her fighting not to dry-heave as she rolled down her residential street, glad only that she was no longer on the highway.  They know what, Tracy?”

It was possible no one knew anything, and Tracy was fishing, possibly with a law enforcement officer standing behind her. If the Pattons had managed to set off some kind of alarm on their way out of the country, if they had tripped a warning system none of them realized was there, it could have triggered an investigation. This could still be early enough for her to get out of it.

“They know you’ve been flagging patients who suddenly developed health conditions that would land them in the Comfort Homes and redirecting them to Canada.”  There was a beat before Tracy added, with wry amusement, “I know you thought I might be a computer program. Sorry to tell you I’m not. You’ve seen me in the cafeteria. I’m the little blonde one with the glasses and the cane.”

“The cane, yes.”  She had always wondered about that, a little.

“Broke my hip in a skiing accident when I was sixteen. It didn’t come with any increased medical risks, and so I’ve managed to avoid the Comfort Homes, for now.”  Tracy must be alone in her office while agents rip apart the files, or she wouldn’t be speaking so freely. “All my girls are out, I’m the only one in the office, and they can’t find anything on me. But you have to go to the airport. You might still get stopped before you can board. It’s the only chance you have.”

Christina hesitated. There was her cat to be considered, and more, there was her time within the system.

So she’d saved a few people. So what? She’d consigned so many more to a living death, followed by the inevitable literal death when another wave of infection came along and ripped through their community, finding them packed into insufficient space with no proper PPE and no way of either distancing or acquiring better gear.  She’d handed countless victims over to the Comfort Homes, and once they were there, they’d become someone else’s patients, someone else’s problems.

So she got a few of them out of harm’s way. Could she really say that was enough to earn her an escape? Christina swallowed, hard, and turned onto her street.

The lights were on in her house. She knew she’d turned them off before she went to work. They were already here.

“How long have you been working with me, Tracy?”

“Five years.”

“And how many times have I been late for an appointment?”

Tracy paused for a long moment. When she spoke again, it was with creeping dread in her voice. “None.”

“Thank you for calling me, but I didn’t need the warning.” Christina sighed and smiled. She had done some good. She had saved a few people. Not enough. It never could have been enough. “If you’ll excuse me, I have an appointment to keep.”

She pressed the button to disconnect the call and drove on, into the unpleasant and all-too-certain future.