Pharma, Matrix and the Studentloanization of Health Care in America
NOTES for a Presentation to Pharma Reps about Minority Inclusivity and Sensitivity Within Bigger Pictures of Cohort Targeting, Profiteering, Indenturement and Slavery
by Lawrence D. Mass, M.D.
“If Millennials Think College Debt Was Bad, Wait ’Til They See Their 65x Larger Healthcare Bill. “ — David Chase, Forbes, 2016
In the spring of 2024, I was contacted by representatives from a leading pharmaceutical company, asking if I would speak to them during a planned junket to New York City. In advance of our meeting, the motivation and purpose for which weren’t clear but were presumably in the interests of community outreach, they wanted me to sign a non-disclosure agreement, which I did not complete or submit.
At the hotel event gathering of some 40 reps, I joined the esteemed partner I chose, a leading figure in LGBTQ+ and HIV/AIDS community relations, to give very brief (as designated by the coordinators) presentations followed by a similarly very brief Q&A at an event that was a lot more festive than reflective. Our session ended with a donation from the pharma company sponsoring the event to our organization of AIDS services.
Dinner followed. I sat next to and chatted amiably with the group’s chief salesman, an Irish Catholic married father who began our brief introductions onstage earlier by asking me if I knew “who won the game.” Without knowing me, he had presumed I had no idea. Gay men, or so the stereotype persists, don’t follow sports. As my deceased life partner Arnie Kantrowitz observes in his novel, Song of Myself, being published posthumously, “sports is the standard medium of discussion between men who don’t know each other.”
Hmmm, I wondered. Was such a jaunty moment of macho humor supposed to be disarming? And how did it jibe with the event’s putative overall theme of minority sensitivity and inclusivity?
The concerns I expressed in my statement to the group were culled from my observations and experience with pharma over decades. My narrative follows.
In sync with my work — my mission, really, since it has been mostly unpaid — in calling attention to the emerging epidemic of AIDS, I advocated for those with hepatitis C. In the wake of AIDS, hep C had become pandemic. Early on in “the stealth epidemic,” as hep C came to be called because of its slow, hidden progression from infection to cirrhosis and liver failure, something unprecedented and monumental happened. A pharmaceutical cure became available.
In fact, hep C became the first known major viral illness to be fully curable (as opposed to treatable with medication or preventable with a vaccine). As such, it was a landmark development in the history of medicine and science.
It was also a watershed moment for pharma (the term in common use for the pharmaceutical industry) in demarcating an era of expansion with new and repurposed medications and vaccines for a broad spectrum of illnesses and conditions. As such, it surpassed even pharma’s earlier pinnacle scientific success in developing antiviral treatment for HIV/AIDS. Apart from diseases like polio for which preventable vaccines were developed, never before had there been such success in medical treatment for a major deadly viral pandemic disease.
In the case of the new cure for hep C, as with the new HIV antivirals, however, there was a catch. The medications were staggeringly expensive. The cost of $120,000 for the 8 to 12 week treatment per person for hep C was prohibitive, especially for those who most needed it — injection drug users. Over the ensuing years, I watched as scores of my patients on Methadone Maintenance began dying of a completely curable illness because they didn’t have access to the cure and couldn’t afford it, even when they had insurance. Since not every case of hep C was certain to advance to an extent and in a time frame that could be characterized unequivocally as “life-threatening,” their insurers wanted “proof” that the patients had already entered later stages of cirrhosis to be considered for coverage.
According to the World Health Organization (WHO), an estimated fifty million people have chronic hep C (HCV) infection worldwide now, increasing at a rate of one million per year. In 2022, WHO estimated that 242,000 people died from hepatitis C, mainly from cirrhosis and hepatocellular carcinoma (primary liver cancer), a frequent, high-risk complication of CHC (chronic active hepatitis C). In the United States, the Centers for Disease Control (CDC) estimates that over 2 million adults have HCV infection, but only one in three people nationally have been treated.
Because hep C is completely curable, preventable deaths in such numbers are perforce mass casualty occurrences.
In the bigger picture of my work with substance abusers, most of them poor, not only was hep C treatment widely unavailable because of its high cost, but so, suddently, were other common, formerly inexpensive, essential life-saving medications for diabetes, epilepsy, asthma and hypertension. As the years passed, I bore witness to growing numbers of preventable deaths among those without access or means for their otherwise easily treatable health care.
Though there were protests of Gilead’s price-gouging for hep C as well as for HIV antiviral medications from a ragtag assortment of health care activists, including me and notably from the ranks of ACT UP, not much changed. In fact, the price-gouging rapidly metastasized to encompass a much wider spectrum of medications. If you needed life-sustaining treatments, in some cases there were loan and debt deferment or repayment options in an economic system where “creative financing” could often be found. Providers, insurers and pharma promotions might appear to commiserate about costs and gesture to help, at least initially. In the end, payment was the patient’s responsibility, not theirs.
Pharmaceutical Marketing: The Positives
As price-gouging continues its high-speed chase, repeatedly veering out of control to the extent of wrecking lives and engendering headlines, protest and litigation, it can seem paradoxically wonderful the way pharma has embraced diversity, inclusivity and sensitivity in its outreach. It’s gratifying to see advertisements for antiviral HIV and other treatments that show little vignettes of minority and subcultural life that are humanizing and upbeat.
On mainstream television today you can see identifiably LGBTQ+ persons of all colors, ages, and sizes holding hands, dancing, hugging, kissing, cruising at subway stops and sharing a sunset meal on a terrace overlooking Manhattan. One spot glimpses the huge yellow Black Lives Matter logo that covered city blocks in D.C. during BLM protests. However primarily motivated by marketing for expensive, profitable medications, these visuals also do serve to combat anti-gay bigotry and racism. As the far right, which otherwise politically facilitates the deregulation that fuels pharma’s Wild-West profiteering, advances hundreds of Draconian anti-LGBTQ+ bills across the country, and as politically fomented anti-gay and especially anti-trans hatred, scapegoating and incomparably high murder rates metastasize globally, some of America’s and the world’s biggest corporate entities are presenting normalizing and affirming images of LGBTQ+, ethnic, and minority life. As times darken, pharma, it can appear, has become our ally.
That pharma is helping many with medications and inventing important new ones can’t be doubted and commands appreciation. Such drugs, especially the antivirals, but others such as blood thinners with lower bleeding risks and the GLP-1 agonists for diabetes with a range of benefits, are often remarkable and in some cases indeed wondrous.
Effective vaccines for Tb and HIV are now on the horizon of realistic expectation, even as pharma’s history of prioritizing less effective but more profitable treatments accumulate. In “How a Drugmaker Profited by Slow-Walking a Promising H.I.V. Therapy” the New York Times (7/22/23) reported on how “Gilead delayed a new version of a drug, allowing it to extend the patent life of a blockbuster line of medications.”
On the plus side, it can also be argued that pharma advertising is educating the broader public with inspiring messages about common diseases. Thanks to catchy jingles in advertisements for the newer long-acting injectables, many diabetics and pre-diabetics are inescapably more aware of the importance of testing for AIC, more committed to self-care and more realistically hopeful about minimizing risk for debilitating complications of diabetes such as ESKD (End Stage Kidney Disease).
So much pharmaceutical advertising also puts pressure on insurance companies and other resources to cover costs. The IRA (Inflation Reduction Act) is currently being negotiated with pharma execs to lower prices for those with Medicare for a number of medications that are raking in billions annually.
Pharma’s blue-chip growth indirectly promotes other developments in health care that are widely appreciated as salutary by patients and health care practitioners. Foremost for pharma among these is the funding of research for product innovation, which in turn stimulates the greater economy and social welfare, and with that an increase in life expectancy. Claims for the positive impact of pharma are great and to a real extent, certainly for a number of products, valid.
Being more sensitive to minorities, to women, to the elderly, and to other underserved cohorts is exemplary of the social welfare benefits of pharma success and is indeed welcome. True, the cost of the latest PrEP medications such as the new bimonthly and biannual injectables run upwards of $40,000 yearly with insurance coverage for those on Medicaid “still in development.” And, yes, many who are living at poverty levels can qualify for financial assistance, leaving those who are living near but above subsistence levels scrambling to find the means to pay for these medications. But, yes, Thank You, Pharma, for your enterprise and outreach, for your cohort sensitivity and inclusivity, for your contributions to social welfare and to a future evermore bright with possibility and promise.
Meanwhile, there is fundamental work to be done to improve the pharmaceutical industry’s image of cutthroat profiteering and ruthless ineffectiveness at getting their medications to those who most need them. While innovation will always be in its own class of importance, sensitivity, inclusivity, and innovation are no longer what primarily needs to happen in the shortfall of the growing divide between health care and its constituents. Today, it’s surpassingly about access and affordability.
The Unaffordability of Life-Sustaining Medications
“The current trajectory will have millennials spend an unbelievable two-thirds of their income on a healthcare system designed as a perfect polar opposite to what millennials want and value. If that isn’t the definition of indentured servitude, I don’t know what is.” — Forbes, 2016
If Pharma really wants to persuasively reach underserved communities and individuals and the rest of us, outreach needs to become far more up front about the hard realities of cost, starting with a lot less pretense otherwise. By most estimates, nearly 40 percent of Americans are struggling to pay for their essential medications. According to CDC (5/18/24), 9 million Americans are not taking medications due to their high cost.
The media are flooded with advertisements for sky-high priced drugs. This is sales, just like the automobile industry that is pharma’s closest analogue in prime-time advertising volume. Without our quite realizing it — like the proverbial frog in the pot of water slowly heating up—pharma has overtaken all competitors in television advertising bombardment. In “the boiling frog syndrome,” the frog jumps out of the pot quickly if the water is already hot. But if it warms gradually, the frog is more likely to stay until it’s too late.
People are being enticed to buy products that promise lifestyle improvement. In television promotions, people with debilitating arthritis look wistfully at professional dancers, as if the medication holds the key to a gig on Dancing with the Stars. People with psoriasis and Crohn’s Disease are shown cavorting on yachts and having sexy fun in bathing suits. People with memory challenges are shown pursuing hobbies and walking along nature trails and pristine beaches, living the good life in retirement. People are enticed and intimidated into getting vaccinated against dangerous (especially for the elderly) and painful diseases like RSV and shingles. Television today is a nonstop cavalcade of exhortations to better living by drugs. Remember Dupont’s “Better Living Through Chemistry”? Remember napalm manufacturer Dow Chemical Company?
While hope, optimism and proactivity can be positive values for health care outcomes, many advertised drugs are being hyped to appear more effective and hopeful than they actually are. Some are being repackaged in repurposing schemes (drugs doing double duty as enhancements for more than one disease or condition). As I’ve recently advised friends about very expensive new drugs being promoted by top stars in glossy prime-time advertisements, their claimed rates of symptom improvement for migraine headaches and arthritic pain relief need to be carefully evaluated. The same is true of psychedelics, anesthetics and other medications for treating depression, anxiety, and PTSD. What’s being repackaged as frontier advancement is often just new schemes for older medications or next-generation derivatives backed by internet studies puffed up with anecdotal evidence and slippery phraseology rather than persuasive, scientifically demonstrated effectiveness.
Over time pharma has become evermore adept at marshaling phraseology and expertise, including using ranking experts and agencies, that imply rather than ascertain efficacy. Even when the present-day opioid crisis, one of the worst catastrophes in the history of addiction and health care malfeasance, exploded and oxycontin was finally required to carry a black-box label warning, this most successfully and aggressively marketed and dangerous opiate before fentanyl managed to retain FDA approval.
More on the opioid crisis anon. Meanwhile, it’s challenging not to ponder that Dr. Gal Mayer, the brilliant and accomplished former medical director of Callen-Lorde— the LGBTQ+ health center in New York City— who became a premiere researcher on anal cancer, left Callen-Lorde to become a senior medical advisor to Gilead Sciences. While a growing and concerning number of important leaders in health care and gay health care like Dr Mayer hold advisory positions with leading pharmaceutical companies, and Mayer can still be an articulate spokesperson and advisor for marginalized peoples in health crises such as COVID, and though he also serves on the advisory board of GLMA (the Gay and Lesbian Medical Association), he has not been known to be a vocal critic of the high pharma pricing he’s ineluctably in bed with and that has as much impact on patients as any other consideration. Hopefully, his involvement with Gilead is not more than coincidental with the bigger picture of pharma’s ever-expanding cooptation of leading physicians for its own credibility.
Dr. Mayer’s impressive credentials as a leading authority and researcher on LGBTQ+ health are listed in his faculty-advisory board bio on the LGBTQIA+ website. Not included in that bio, however, is his having left Callen-Lorde to become a senior medical advisor to Gilead. An interview with Dr. Mayer for TheBodyPro on his work with marginalized communities during the COVID epidemic, for which Gilead marketed the antiviral rx remdesivir with predictable controversy over its pricing, includes the following statement:
“[Editor’s note: Gilead Sciences is an ad sponsor on TheBodyPro. However, the decision to interview Gal Mayer for this article was based entirely on his many years of experience as a highly respected HIV clinician and health care administrator. We maintain a strict separation between advertising and editorial.]”
Full disclosure: After a caesura of more than a decade, including the period of ACT UP’s protests of Gilead, but having had my own earlier very positive interactions with Dr. Mayer as his patient, colleague and friend, my outreach to him for comment — after his briefly noting that he had been targeted by activists to such an extent that he had to change his email address — was not engaged.
When Dr. Mayer became a senior advisor to Gilead, did he have to sign nondisclosure agreements? Almost certainly. Is Gilead still the profiteering villain it was outed for being early on in the hep C pandemic? Is that still the right perspective to have? While its price-gouging continues here in America, and its profits remain inestimably huge, Gilead has been leveraging its real-life miracle-cure for hep C, Harvoni, elsewhere with impressive selectivity, sagacity and much better PR. Working with the Egyptian government, Gilead spearheaded a country-wide campaign to eliminate the disease. In 2014, Egypt had the highest rates of hep C of any country in the world due to its use of unsterile needles. Less than 10 years later, the disease has been virtually eliminated there, thanks largely to Gilead’s innovative and cost-saving approach for the specific circumstances of Egypt.
Progress may not be perfection, but it can be a resounding riposte to accusatory health-care-is-a-right activists and “do-gooders,” as folks like me are privately referred to in the world of corporate. The New York Times, which did such a notably poor job early on in calling attention to both HIV and hep C (“We’re not an advocacy journal,” Lawrence Altman explained to me at the first international AIDS conference in Atlanta in 1985) called the Egypt campaign “one of the greatest accomplishments ever in public health,” while also noting that most hep C in Africa and elsewhere remains untreated.
The Pre-authorization Barrier
While pharma has become more creative and inclusive in soliciting customers for its products, jaw-droppingly high pricing has remained its top priority. How are these drugs to be paid for? For many or most consumers and in the face of fees that are more like ransoms, the most logical option would be insurance. One’s health insurance should pay for life-sustaining treatment, right? Since insurance is likewise for profit, however, it too, per corporate modeling, is more primarily invested in denying claims.
Regarding the weight-loss medication market, I myself have begun taking the GLP1 agonist inhibitor semaglutide. Coverage of Wegovy, a drug that is identical to Ozempic, which is prescribed for type 2 diabetes, is being denied to people like me who are not diabetic but who would benefit from the medication’s ability to “lower cardiovascular risk,” just as its prime-time tv advertisements proclaim. The reasoning for this distinction is entirely financial and corporate. The only difference between the two medications is pharma ownership and promotion for selective insurance and payment compartmentalization.
Admittedly, I’m vexed about Wegovy’s high cost — $1500 monthly without insurance (or cheaper via a compounding pharmacy or internet mail order option of variable verifiability and safety) and wonder about future long term, currently unknown or downplayed side effects, even as I too am enticed by advertisements showing us overweight types being upbeat about ourselves. Is it my imagination or were several of those good-looking guys in the latest Wegovy advertisements gay?
Say good bye to fat shaming, right? That’s the messaging of the new advertisements that rely on fat-shaming to appeal to customers, although images of the new Wegovy slimmed-down Oprah doubtless did more to promote these medications (there are several other brand versions) than anything else. It’s an obvious principal tool of advertising to utilize celebrities. For years, Oprah was a poster girl for Weight Watchers. For those with moderate to severe plaque psoriasis and debilitating migraine headaches, endorsements by the likes of Cyndi Lauper and Lady Gaga soften the blow of stratospheric costs.
Paying the exorbitant fees for these medications, far higher here than in any other country, is not going to derail me, at least not in the short term, even as it coincides with the $12,000 + I must pay annually out of pocket for my husband’s Obamacare. (He’s a laborer in Florida whose few work benefits do not include health insurance.) But for others — especially as treatment must be continued indefinitely and if combined with other costly medications and health services only partly covered or denied by insurance — it will be like student loan debt, a great, extended financial burden that, when figured across a broader spectrum and time frame, is for all practical purposes indenturement.
Most pharma advertisements conclude with small-print, fast-talking statements that help with payment “may be available.” If you can “prove” financial hardship and are willing to go through a laborious process of appeals, you “might” qualify for some level of support, at least initially. Most likely, “proof” would have to be re-petitioned annually. It’s like entering a contest where the odds are against you but where there’s a small chance of winning.
In my own ongoing personal drama of trying to get partial insurance coverage for semaglutide, I’m told I can appeal the rejections I keep receiving. As with patients needing to “prove” their need for hep C treatment, however, my insurer, Aetna Medicare Advantage, wants “proof” that my being overweight presents a significant cardiovascular health risk. At 78, I’m overweight, have hypertension, some COPD, sleep apnea and had a cardiac rhythm disturbance during a recent sleep study, which concluded that I should seek cardiac consultation. They’re asking me to do a mountain of work to “prove” something with no guarantee that whatever “proof” is provided will meet the insurance company’s standards for coverage, which even if approved would be likely only partial.
So far as I can determine, I would need to be hospitalized with a heart attack or stroke for my risk to be more unequivocally established. The next step will be to get that recommended cardiac consult. But will the cardiologist be willing to do the crushingly time-consuming work of pre-authorization?
Meanwhile, I hit another pre-authorization snag with my Aetna Medicare Advantage insurance. An unusual set of symptoms prompted my ENT specialist to order a CT scan of my neck. Hopefully, there would be no tumor. Though the procedure was swiftly scheduled, the pre-authorization of it, though completed and submitted, lagged behind in being approved. So the appointment had to be cancelled and rescheduled. Because of my now higher deductable of $1,000 (twice what it was perviously), however, I will still have to pay out of pocket for much of the cost of this procedure. The good news is that the scan was negative, a result that’s well worth whatever it is I’ll have to pay, right?
In the bigger picture of medication access for those who need it is the major barrier posed by insurers of prior authorization. As captured in a New York Times report on doctors “in constant battle with insurers“: “If you want to see a physician go apoplectic at a cocktail party, mention prior authorizations,” said Dr. Robert Wachter, the chair of the medicine department at the University of California, San Francisco. “Doctors and their staff spend an average of 12 hours a week submitting prior-authorization requests, a process widely considered burdensome and detrimental to patient health among physicians surveyed by the American Medical Association.”
Meanwhile, the real-life stories of financial hardship that now besets a rapidly growing majority of Americans are not ones you will see portrayed in the television advertisements for the plethora of medications currently flooding media venues. Nor are we hearing levels of discussion of this crisis that are commensurate with its seriousness from politicians or news headlines.
Today, the hep C situation can give the appearance of being less extreme, especially for those on Medicaid, mostly because insurance companies don’t want to have to pay the much higher cost of a liver transplant that would be the only other life-saving option once the disease advances to late stages. But the targeting of television advertising for hep C treatment is still primarily to those more mainstream folks who can, however stressfully, somehow find the means to pay for their still very expensive treatments, even with insurance.
Drug Addicts, LGBTQ+ persons, Prisoners, Prostitutes, Immigrants and Slaves
Lost in the shuffle are those in greatest need of these treatments: prior or currently active injection drug users. They are not being courted in advertisements or otherwise acknowledged. As with all other products and for-profit businesses, advertising is too sophisticated and expensive to be spent on non-remunerative markets and strategies, though that too could change, with greater commitment, as it has with LGBTQ+ outreach.
For the public and its politicos, and with tacit collusion throughout health care, active drug addicts have tended to be regarded as marginal at best. Like immigrants and the homeless, they are easy and recurrent scapegoats and pawns. Just as in the Hitlerian rhetoric of Donald Trump, all immigrants are defamed with stereotypes of being rapists, terrorists, and drug cartel criminals, so drug addicts are routinely smeared as being subhuman.
Enter former NYC Mayor Rudolph Giuliani, who in 1998 tried to dismantle Methadone Maintenance treatment in New York City — a gross move (to close down all Methadone and opiate treatment centers in the New York City area in 6 months) to appear getting tough on drug use and associated crime, even as Methadone Maintenance treatment has been repeatedly and decisively demonstrated to be premiere among options to reduce opiate and drug-associated crime (“The Mayor’s Crusade Against Methadone,” the New York Times, 8/18/98).
With his gatheringly impressive track record of blunderbuss problem-solving and self-advancement, Rudy ended up throwing kerosine on the wildfires of the later opioid crisis by joining with Purdue Pharmaceuticals to pursue the influence and advocacy that allowed Purdue to continue its FDA-approved, slippery-phrased promotions of oxycontin —as “believed” to be “less addictive”— and the raging drug addiction and abuse crisis that went with it.
“Delayed absorption as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug” is the phrase that allowed Purdue to prevail. While similar reasoning has been used for Methadone Maintenance treatment — that its delayed absorption thwarts the craving to get high — the potential for abuse turned out to be vastly different. Prior to fentanyl, oxycontin was the most widely and dramatically abused prescription opiate though by no means the only one. Methadone, by contrast, his never ranked high in opiate abuse and overdose statistics.
Not surprisingly, navigating this hurdle to retain FDA approval for oxycontin required more collusion than Rudy. A more key figure in shepherding the misleading phrasing needed to allow Purdue to continue its marketing of oxycontin was Curtis Wright IV, a leading researcher with the FDA who went from being oxycontin’s policeman to becoming its enabler when Wright left the FDA to assume full-time work as a senior medical advisor to Purdue. Thus Wright became an exemplar of pharma’s cooptation of leading and trusted authorities to sign off on their dirty work. Dr. Wright’s key role in the enabling of Purdue’s malfeasance is well documented in multiple accounts of the oxycontin-opioid crisis. Suffice it to observe that the Sackler-Purdue railroading of oxycontin for profit is now widely regarded as a landmark in the history of corporate evil.
Not only are addicts stereotyped as recidivist for high-risk behaviors and therein exploited by politicians, they are pre-judged to be incapable of being responsible with medication regimens, a bias that proved false for persons with HIV. With prisoners, prostitutes, sexually active LGBTQ+ persons, immigrants, communities of color and the poor, injection drug users have been among the most disenfranchised of subpopulations.
Without public presence or voice, they are widely shunned and abandoned by society. They are our untouchables. Like slaves and convicted criminals (addicts often have histories of criminal convictions), they tend to be marginalized to the extent of silence until the eruption of something like the opioid crisis and its waves of crime and preventable death. Organizing and protest by drug addicts, like those of immigrants, prisoners, prostitutes and historically rare, easily crushed slave rebellions, have never gotten off the ground. There was no real game changer for slaves until the American Civil War.
Apart from individual advocacy for more humane laws and support, addicts have never sparked a major rebellion, notwithstanding fitful attempts to organize. Nor is it easy to conceptualize what the mechanics and precepts of any such initiative might consist of. If the analogy with slavery holds, they would have to await an equivalent of the American Civil War, a movement of great social and economic upheaval, to find themselves more compassionately and hopefully situated.
In the case of HIV/AIDS, however, a revolution in grass-roots health care was sparked. Thanks to the unprecedented and epochal activism and achievements of ACT UP, not only were wonder-drug antivirals developed and spectacularly effective needle exchanges established, they became a lot more accessible to those at highest risk — sexually active LGBTQ+ persons, injection drug users and their sexual partners.
For the current target population by pharma for hep C treatment — those who made it past their experimental injection drug-using years to more mainstream life, it’s implicit in today’s upbeat advertisements that a life-saving treatment is a good and also doable investment for those with hep C who became, after decades of silent progression, at peak risk of developing cirrhosis. It’s an investment that would make even more sense to those who want their lives to look like those of the self-assured, positive-attitude and more economically-upscale folks being shown in the advertisements. Advertisements for hep C, in other words, can be thought of as an inroad to cohorts of addiction, cohorts with previously unrealized market potential. Indirectly, pharma can now claim that such outreach can be salutary for the otherwise universally stigmatized and shunned world of injection drug users.
When viewed more broadly and certainly in the present, however, it’s difficult not to see most such outreach as, at its core, exploitive, cynical and predatory. What pharma was looking for in asking me to speak to them was not to hear what I had to say, but to hone their skills in utilizing trusted community advocates to access, fortify and expand consumer markets. If you’re selling a product, it’s good business to be on good terms with your customers and their community representatives, to optimize your understanding of and sensitivity to their matrix.
Have you seen the Spectrum commercial with the handsome guys who are shown to be regular community people, their kids going to the same schools, shopping at the same grocery stores and living on the same streets as you and me? Meanwhile, is there something askew in the bigger picture of paying upwards of $4000 annually for cable television, a sizable majority of the programming of which is increasingly for pharma and other advertising?
Marketing and Studentloanization
Marketing outreach to the economically challenged is in league with another version of what we might call studentloanization — the student loan industry for graduate degrees and their advertising promises — whose siren-call of a better life tends to be geared to the young, to people of color and minority ethnicity, and the economically insecure.
Remember Trump University? That pharma, like university education, is among America’s most profitable and profiteering industries is no longer a secret. As with the student loan industry promotions of higher education for optimum living, arguments favoring the high cost of pharmaceuticals for sustained health are plentiful and seductive, but to the extent of being suffocating, as they ring evermore loudly hollow in the face of payment hardship.
Within pharma’s signature appeal to better, more hopeful and upscale living in fulfilling the promise of health enhancement are more overt heartstrings tugs. Take these medications and not only can you too be healthy, happy, and prosperous. You’ll be able to be there for the most precious things life has to offer — playing with your grandchildren or attending their graduations and marriages, or your own. Or just being able to see your loved ones, as advertisements for high-risk treatments for wet and dry MD (macular degeneration) can seem sadistically to propose. Even if you’re not at the top of your game now, you could be, is the tacit message, even for grossly bogus medications like so-called jellyfish derivatives that scientifically are really nothing more than the old snake oils, miracle cures and cure-alls of traditional hucksterism.
On my kitchen shelves is my collection of old medicine bottles, keepsakes of the old America that blustering pols talk about making great again, the America of Trump’s proposed injected bleach or veterinary medicinal Invermectin to treat COVID. Most of these mementos were found by me in rural and small-town garages, old and abandoned warehouses and train yards. Most, like proper, upper crust-sounding Bostonian Lydia Pinkham’s tonic for “female ailments,” were worthless alcohol-based concoctions (as so many of these products were and still are), cynically marketed to the gullible and vulnerable. A Lydia Pinkham tonic is still on sale today as an “Herbal Liquid Supplement” — “with vitamins C and E” — for “Nutritional support to help you feel better during menstruation and menopause.”
You load 16 tons, what do you get?
Another day older and deeper in debt
St. Peter, don’t you call me ’cause I can’t go
I owe my soul to the company store
— refrain from the song made famous by Tennessee Ernie Ford
Meanwhile, on the “new” frontiers of pharma and health-care enterprise, payment support options such as discount coupons and loan deferment options that are gestural than genuinely or reliably mitigating merit perfunctory mention at the conclusion of auctioneer-like fast-talking disclaimers. That you may have to sell your home, give up your retirement savings, sell your life insurance or otherwise go into credit-card and other debt to pay for your medicines isn’t explored or even mentioned. Such eventuation may be unfortunate, but it cannot be blamed on the system. Or so the reasoning goes. Inevitably, it’s your problem, not theirs.
In sum, and as it demands ever-stronger spelling out, confrontation and repetition, that its forefront motive remains financial profit isn’t nearly as closeted or secondary to bigger pictures of health in society and democracy as pharma reps are so incentivized to have everybody believe it is. As everywhere else in sales, the greater the profit, the higher the cut for the salesperson. It remains just that simple. How this operates in pharma is vividly demonstrated in multiple documentaries and docudramatizations on Purdue Pharma, oxycontin and the opioid crisis that remains like a world war or global pandemic in its fallout, and with no end in sight.
Larry Kramer
When preventable deaths in real numbers developed during the early period of AIDS, Larry Kramer, the founder of GMHC and ACT UP, became famous and infamous for describing the crassly manipulative, exploitive and neglectful behavior of pharmaceutical and corporate health care as “mass murder” and “genocide.” I came to agree.
Included in those indictments was the FDA. Larry Kramer may have seemed unreasonable to many, especially in the adversariness of his “love-hate” relations with Anthony Fauci. The NIH that Fauci headed is conjoined with the FDA in the U.S. Department of Health and Human Services. In his heart, gut and oratory, and like no one else, Larry Kramer understood the passive and collusive roles that the NIH, FDA and pharma were playing on multiple fronts in undermining public health. But his periodic indictment of Fauci as a “mass murderer” — a weapon Kramer could seem to wield indiscriminately, calling him “Dr. Omicidio” in The American People after calling him “Dr. Della Vida” in The Destiny of Me— was not as hyperbolic as it might have seemed to many, including me, in those peak years of AIDS activism.
Full disclosure: Admittedly relegated in this discussion is a history of the fraught relationships and complex negotiations that went down over time between AIDS activists and pharma, and that have been decisive in the triumphant, however bumpy, trajectory of HIVAIDS management and containment. Most notable in this heroic history is the constituent Treatment Action Group headed by Peter Staley of ACT UP.
Notable as well was the later advent and progress of the AIDS Health Foundation (AHF) under the directorship of Michael Weinstein. As examined in a New York Times feature on AHF and Weinstein, “The C.E.O. of HIV” (The New York Times Magazine, by Christopher Glazek, 4/26/17), Staley, whose account of his own experience and perspectives are the substance of his memoir, Never Silent: ACT UP and My Life in Activism (Chicago Review Press, 2021) and otherwise well-known and acclaimed in AIDS histories and documentaries such as David France’s How To Survive a Plague, is quoted by Glazek as being skeptical of aspects of Weinstein’s vision: “It is an empire worth building,” Staley concedes. But “A.H.F.’s problem is that once it created the largest AIDS empire on the planet, it started using that power for nefarious purposes: Michael Weinstein’s twisted political views.” Among those views, Glazek’s feature notes, is Weinstein’s belief that “Drug companies are ripping off the American people in a big way…These are bad-news people and they need to be taken on.”
[For a fuller panorama of the blazing achievements of ACT UP, see Sarah Schulman’s Let The Record Show: A Political History of ACT UP New York: 1987–1993, and the film Schulman produced, directed by Jim Hubbard, United in Anger: A History of ACT UP. See also David France’s documentary film and book on ACT UP, How To Survive a Plague.]
Is it valid to compare our relationship to pharma with that of student loan debt and the transhistorical, global industry of slavery?
In my own writing, I’ve previously described pharma as similar to slavery in its disregard for basic human needs and services for the disenfranchised, dispossessed and otherwise marginal.
As a model for business, the cotton, sugar cane, and tobacco industries that catapulted the American economy to global supremacy were primarily about selling products harvested by slave labor and were indifferent to the price paid in workplace enforcement, neglect, misery, suffering, and loss of life.
If you just glanced, you wouldn’t necessarily see the blood on the hands of the industrialists. Rather, you would see a morass of legalese about property, business and insurance.
These transgressions of profiteering — this apathy to the degradation and loss of life in for-profit enterprise — have not gone unnoticed by the public at large in the past or more recently. Artists tell these stories in a wide range of historical novels, plays, films and paintings that highlight inhumanity and injustice with anecdotally illuminating portrayals of the moral failures, sins and crimes of industrialist profiteers.
In the novel and film Belle, based on the true story of a mixed-race legal case that became a cornerstone of the unraveling of slavery in Britain and elsewhere, the court proceedings dealt with the legality of insurance claims for “lost cargo” at sea, which in this case was a cohort of slaves in transit to the Americas. The case was about insurance claims, not about human life or suffering. The points presented in court were entirely about property, business, and the financial and legal rights of the owners versus the insurers— so much so that the status of slaves as slaves virtually never arose as a consideration. There’s little discernible difference between this case and many of those in the lead-up to the American Civil War, or for that matter those in courts today about the rights of patients versus those of drug manufacturers in the opioid crisis and elsewhere.
In Matthew Lopez’s play, The Inheritance, a wealthy gay industrialist discusses pharma’s involvement in AIDS research and drug development. A younger gay man accuses the industrialist of profiteering at the expense of patients’ lives. Without missing a beat, the industrialist notes that a successful treatment was developed for HIV/AIDS in a relatively short time span of just over a decade. So while high cost, sluggish availability and relegation of human rights in research priorities (“war crimes,” Larry Kramer considers them in The American People) were aggressively indicted by gay and AIDS activists throughout the course of the AIDS pandemic, pharma higher-ups could still congratulate themselves about the bigger picture of developing successful treatments in record time.
The same upbeat perspective could be proffered about slavery, a horrifying and dehumanizing system of industrial efficiency and profitability. Maltreatment of slaves may have been a byproduct that was, in more upbeat capitalist perspective, in some measures regrettable. But not only did slavery catapult America to the top of the world’s financial markets, it arguably also situated many Africans to have hopes for better future lives, however still dogged by poverty and discrimination, than would have been the case had they remained in Africa.
In such specious reasoning, while justified dissatisfaction with racism in America might remain for Black lives in history and for today, there’s no great movement among American Blacks to return to Africa. Whatever the past and its costs, such thinking would suggest, American Blacks have it much better now than they could ever have dreamed of having it back in Africa.
As with slavery in ancient Rome and as well in pre-Civil War America, and as in the story of Belle, slavery was not always black-and-white. In some cases, a mixed racial background could matter legally. In others, freedom could be earned. In some locales, qualified freedom might be recognized and legal, but not in others. Once you begin to perceive how labyrinthine and endlessly loopholy the worlds of business, property, insurance, law and finance are, you understand that there is no circumstance, including overt slavery (today more commonly known as “human trafficking” and “forced labor”), that cannot find loopholes for rationalization, litigation and re-litigation.
“America’s Hitler,” “Our Heroin” and Charismatic Evil
Donald Trump has said he believes that the carnage of the American Civil War could have been prevented had there been better leadership, negotiators and negotiations. In the hands of Donald Trump, or so we are to believe, the art of the deal would have prevailed. What Trump doesn’t say with such posturing is what concessions would have had to be made and by whom. Presumably, the same “statesmanship” would be implemented by Trump in “solving” Russia’s invasive, illegal barbaric border land-grab war against Ukraine “in 24 hours.” (How many autocratic empires and their wars begin with border grabs? Answer: Most of them.) Likewise the Middle East Crisis. In each case, the solution is simply to favor the aggressors and perpetrators, the strongmen, with much more leverage to prevail at the expense of all other considerations and affected peoples, especially those without the power to resist or prevail.
Presumably, the Trump solution to the problems of slavery and secession would have been to allow slavery to continue, wrist-tapped and nicked and tucked here and there. It’s a pipedream, smokescreen scenario that makes pie-in-the-sky false promises of a prosperously thriving, happy and stable future in which everyone settles down and gets along, to the benefit of all. Sound familiar? Though it might actually achieve a cessation of strife in the short run in one front or other, it’s the same upbeat hokum, with the same patently deceptive smiley corporate assurance, with which pharma and health insurance keep turning up the heat on our economic lives.
Nowhere is art-of-the-deal Trumpism more on display in theory and discourse than among MAGA Republicans. Whatever their best-face allegations of getting the job done in a way that ultimately serves everyone best, their philosophy and tactics are principally those of arrogance, bullying and perseverance. Never back down. Never give up. Salesmanship and statesmanship, American style. The same people. The same tactics. Wherever there’s the will, there will always be negotiable ways and means via sheer, dogged persistence.
Never ever back down. No value is higher in Trump world, the world of American and corporate financial enterprise and business. No value, except, perhaps, for loyalty, notwithstanding its virtually SNL-comical track record for Trump and his world. Nor is any value higher for them than loyalty’s playbook reflex partner in temperament —pushing back with the identical accusations being leveled by your accuser (fake, crooked, corrupt, rigged, lying, cheating, stealing, swindling) only with twice the ferocity of punch, “doubling down” with gasseous ranting and tantrums of vehemence, rage, and disinformational conspiracism.
Humility, fairness, honesty, truth, justice, equality, inequality, authenticity, sincerity, ethicality, vulnerability, disadvantage, balance, tolerance and compassion are values and terms that never seem to be heard in the intoxicated ravings of Donald Trump or that ever emerge from the militarily obedient, increasingly militaristic minions that seem finally, at least for this pre-election moment, to have few renegades.
There are only three unmitigatably dirty, forbidden words in Trump world parlance: weakness, defeat and — hold on for the third. These are the tenets of a universal guide to autocracy and fascism. Unconditional power. It’s the openly acknowledged ambition and game plan — the Project 2025 — of all autocrats, from Caligula to Genghis Kahn, from Julius Caesar to Attila the Hun, from Hitler and Stalin to Ceaucescu and Pol Pot, from Franco to Castro, from Mussolini to Putin, from Mao to Kim Jong Un and Xi Jinping, from Fernand Marcos and Sadam Hussein to Ahmed Erdogan, Viktor Orban, Nicolas Maduro, Syria’s Assad, Egypt’s el-Sisi, Saudi Arabia’s Mohammed bin Salmen, Iran’s Supreme Leader, the Ayatollah Khameni and on and on, past, present, and ad infinitum. And now to “America’s Hitler,” “our cultural heroin,” as Trump’s VP pick JD Vance earlier described his current running mate.
Whether the autocrat was “left” or “right” pales in significance alongside their being autocrats. Clearly, Trump’s admitted affinity is with fellow autocrats such as his still leading present bromance partners Vladimir Putin and Viktor Orban. It’s not with standard-bearers for democracy.
As one after another government gives way to autocracy, a trend that’s captured and interpreted by Anne Applebaum in her new book, Autocracy, Inc, it’s hard to nurture hope.
Especially for me. “Larry, you’re a pessimist,” concluded my late life partner, Arnie Kantrowitz, who studied the worst atrocities of the Holocaust with eyes wide open and yet somehow remained hopeful — like Anne Frank, whose “Arnie Kantrowitz”-inscribed Diary so inspired him growing up and which is next to me as I write these notes.
At the 2024 DNC, Bill Clinton spoke eloquently, mostly, while quietly petitioning us to not resort to tactics of demeaning our enemies. In a New York Times opinion piece subsequently (“Here’s Why We Shouldn’t Demean Trump Voters”), Nicholas Kristof echoed this warning, noting the importance of swing, young and undecided voters. Were these warnings in tacit, cautionary reference to Hillary’s dismissal of Trump’s base as “deplorables,” for which she has been hounded ever-since and which some still say is key to her having lost the election in 2016? Kristof thought so.
Should Vice President Harris take up her rival J.D. Vance’s invitation to visit him in his current digs — “She can go to Hell” — she will encounter enablers like Bill Clinton and Kristof along the way who believe heaven would likely have been more in sight for all had we libs watched our tongues and not disrespected our adversaries. So don’t blame the majority of German citizenry that went whole hog for Hitler. No. Hitler was the fault of the liberals, Jews and Communists, and the humiliation of Germany by the allied victors of World War 1, all of whom had bad-mouthed the German volk as deplorables, right? So, just as the election loss of 2016 was the fault of Hillary Clinton, if Trump gets re-elected and his police state dictatorship of Project 2025 is implemented, we will have only ourselves to blame. Have I still got that right?
While such a message — of go high, stay there and never say “deplorables” — could give pause for some, it now seems as off-point and ill-timed as Bill Clinton’s notorious, cowardly capitulation to conservatives in endorsing the Defense of Marriage Act the minute he took office. Talk about flip-floppers! Fortunately, Bill Clinton’s DNC admonition is also one that other leading Dems, the ones currently generating the most enthusiasm, are now out to upend.
Arnie Kantrowitz, by the way, was the first person in my experience to verbalize the forbidden analogy that had likewise occurred to me from prior to Trump’s first campaign for presidency — that between Trump and Hitler. As I later put it, if I had a dime for every time I’ve thought of this analogy over the ensuing years, we’d be millionaires. And that’s notwithstanding my qualified admiration for Trump’s standing up to China and Iran and my dread that stability for the shortfall in the middle east — in the aftermath of what I’ve consistently called, since its inception Oct 7, “the Hamas-Israel War” but still seem to be singular in doing so — is more likely under Trump in his buddyships with fellow-autocrats MBS and el-Sisi, Erdogan and Putin, and in league with Netanyahu’s autocrat buddyships with all of them, including with Soros-villaininzing, antisemitic, anti-LGBTQ, anti-immigrant, Islamophobic Orban.
Meanwhile, given Trump’s obsession with vindictiveness and his proclivity for disinformational defamation and scapegoating, the Trump-Hitler analogy is like the emperor’s nakedness under the clothes we have to keep pretending to see. Only in this case it’s the royal raimants we have to keep pretending not to see and which we must never, for some unstated reason of decorum, bespeak, leaving Trump to do his ever more frenzied dirty work every time he opens his mouth. We’re supposed to keep whitewashing and soft-talking what even Trump’s allies are thinking.
Trump-Hitler is an analogy the media has remained reluctant to use along the lines of the now corrected admonition made famous by Michele Obama with echoes in Bill Clinton’s address and Kristof’s opinion piece — “when they go low, we go high.” Finally, that approach is now more widely appreciated, included by Michele herself, to be evaded at the peril of the present and future for all minorities. And certainly for Jews, with antisemitism no longer being denied by anybody as it heads back to its time-honored place as the most explosively potent, recurrent, malignant and genocidal of all minority scapegoating.
But we must never stoop to Trump’s level, went the earlier logic, especially for many conservative Jews, notwithstanding Trump’s Charlottesville, Jan 6 and other flagrant courtings of neo-Nazis, his denunciations of American Jews as far left, communist, liberal, self-hating and anti-Israel (even as there is dismaying truth to allegations of internalized self-hatred and antisemitism, to this stigma among Jews, especially those of us who are left-leaning and liberal), and his Mar-al-Lago dinners with the likes of proto-Nazi Nick Fuentes and Kanye West, courtings that have dotted the landscapes of his oratory, real-estate career and presidency. Anyone who ever knew Donald Trump from business will tell you that he was always antisemitic.
But we must play nice with Trump, fellow Jews say, because of his daughter’s marriage to Jewish Jared Kushner and his half-Jewish grandkids and pro-Israel track record so far, seen as a kind of insurance policy that Trump will remain pro-Jewish and pro-Israel. Notwithstanding his current Jewish connections, not so unlike those of Mussolini with wealthy Italian Jews (all of whom ended up dead), the analogy between Trump and Hitler is one that is evaded at their peril not only by all Jews, including the “good” ones (even as that definition constantly morphs) but by America and the greater world.
Simple question: If you handed any autocrat, say Machiavelli’s generic “Il Principe,” the keys to the kingdom when he most craved and needed those keys and that kingdom to prevail against the odds of his going to prison or being rat-in-the-gutter hunted down like Saddam Hussein and Muammar Gaddafi by enemies, do you think that autocrat would decline to take those keys and the kingdom because of moral scruples such as those that would seem to protect against Never-Again genocidal antisemitism?
Was Ivana Trump’s Death “Accidental”?
How many dozen Greek and Roman and Elizabethan tragedies can you name where family members murder each other for power? Hamlet, Macbeth, the Oresteia…. Why has no one wondered aloud about this most common of political moves by the ruthless, villainous and evil in the case of Ivana Trump, who had the nerve, moral authority and potential to derail her ex-husband’s future, even with the signed nondisclosure agreements that got her one of the biggest settlements in divorce history? It’s Ivana whose divorce proceedings were initiated with the claim that she was raped by her husband. And it was Ivana in court who spilled the beans on Trump keeping a book of Hitler’s speeches for his bedside reading, an allegation Trump himself has verified.
So we Jews are to believe that in the future, Donald Trump can be expected never to abuse the trust of Israel or the Jewish people? And with certainty because he has several half-Jewish grandkids?
“Get That Monster Out of The White House!”
Looking back at the Hitler era, a simple question can be asked: Would it have been a good thing if Hitler had been whacked early on? The answer is inevitably, unequivocally and unanimously yes. Who but an overt Nazi could possibly say otherwise? The reason it’s incontestable is simply that no other oppositional figure was comparable in seducing such large swaths of the public with charismatic evil (forget the small potatoes of criminality) culminating in the ultimate atrocities of transnational genocide of unprecedented scale, and therefore no other figure presented a comparable danger to the public and to humanity.
That such things were matters explicitly of good and evil is what Larry Kramer believed. As he inevitably and always was, yet again Larry Kramer was right on target with Trump in calling for a consortium of former presidents to “Get that monster out of the White House!”
Pharma, Predatory Capitalism and the Trump Era
No industry has been more of a poster child for Trump era profligacy than Big Pharma (a term I’ve effortfully tried not to use), except perhaps, those presently under the ownership of Elon Musk. Dangling the carrot of enterprise and innovation in developing new and better products, its bottom-line strategy is always to seek lucrative markets, to seek new and better ways to entice population cohorts into purchases, in many cases to the extent of indenturement, to pay for glistening new products such as EV’s that happen to be eco-friendlier and money-saving as well as money-making.
For those cohorts who begin leaning in the direction of self-awareness around real vs fabricated need, there’s the stepping up of tactics of predation — the overbearing obnoxiousness of domination, putting you in the position of being the child with the angry, demanding, punishing parent: the doubling up of the volume during advertisements, the screaming and horrible, blasting music that torture us for extended segments every time we turn on the television (e.g., the Mayhem Allstate commercials). Advertising that is often Donald Trump and MAGA incarnate (Jim Jordan). Watching television advertisements these days, even some that are “progressive,” can make you feel like you’re at a Trump rally.
As with slavery, pharma can argue as it does reflexively that its unabashed profiteering is ultimately in the best interests of all — i.e. for research and development of new pharmaceuticals, some of which will be lifesaving (as with HIV and Hep C). And that its trickle-down economics will eventually work for all. Just look at Musk, at all the remarkable innovations that bear his name — space travel and satellite innovation, AI, communications, electronic vehicles. As has always been the case, debating the semantics and rationalizations of advertising and profits and benefits versus humane concerns is a bottomless black-hole vortex of morality, ethics, economics, legality, politics, and penny-pinching. If there are catastrophic losses and casualties with slaves or addicts or women or queers or trans people or immigrants or the poor in the march of progress, so autocratic thinking goes — if you have break a few eggs to make an omelette — so be it. In this, thinking, the “tankies”— the far-leftists who applauded the Soviet tank invasions of major Soviet slave state capitals and who reflexively excuse the worst atrocities of communist extremism under the banner of working for “a new world order” — are indistinguishable from and can even seem to surpass (e.g., Pol Pot) the worst of their far-right extremist counterparts, Hitler.
As in most capitalist-corporate systems, expenses are endlessly whittled down in the same hawk-eye, nickle-and-diming micromanaging developed by American bankers with which employees are given 3.4712531 hours of annual “personal time.” Or which uses tools like arbitrarily increasing “deductables” and surcharges to amass ever greater profits, which seem never to be subject to plausible scrutiny, containment or redress. Exactly the kind of micro-management that corporate deplores when applied to them by governing agencies.
Which is why there is a prize-winner among those three dirtiest words for MAGA Republicans for the most forbidden and hated word in all the lexicons of capitalism and defamation: REGULATION. In Trump-MAGA world, invoking regulation — for fossil fuels, pharma, voting, civil rights, or anything else — is like the moment in Dracula films when the decent, cross-wielding, God-fearing Christians throw open the curtains to let in the blazing sunlight that is a last-recourse weapon against blood-sucking vampires; a weapon that must suffice in the absence of a more decisive finale of driving stakes through their hearts. In this image, in case you missed it, the regulators are the vampires.
Regulation is the cardinal sin of the high church of American business and enterprise that Supreme Court Justice Neal Gorsuch has been leading the charge against with claims that his far right Court is primarily concerned about the burdens so much regulation places on everyday working folks, especially those with small businesses. Gorsuch wants us to believe that his far right agenda is really and primarily about helping the little guy. With this portrait of the little guy up against big-brother government bureaucracy, deregulation comes across as something ethical, something we should all be on board with.
It’s like pharma’s claims that its profiteering is primarily in the interests of innovation, of cohort sensitivity and inclusivity, which is in turn primarily in the interests of the greater public good, even though, in the bigger picture, the unprecedented profits being siphoned off by corporate are the result of broader deregulation at the expense of everyday working people. The little guy, the so-called working stiff, with the small business may not have government bureaucrats hounding him as much in a Trump-Gorsuch-America, but he’ll also be a lot less able to pay his medical bills and feed his family, the costs of which will be higher than ever but, in the absence of regulation, with a lot less hope for recourse.
“When Your Opponent Calls You communist, Maybe You Don’t Propose Price Controls,” headlines a Washington Post opinion piece from 8/16/24 by Catherine Rampell, a panicky response, like those of Bill Clinton and Nicholas Kristof, to Harris’s agenda rollout. So when Donald Trump goes rabid with extremist epithets and lobbing lunatic conspiracist accusations at you like the firings of the automatic machine guns he’s so invested in protecting unregulated access to, doubtless for militias to be called on in the future instigations of insurrection he will doubtless foment— and as he does reflexively, routinely and relentlessly, to the extent that it can seem the only thing he does — our response should be to surrender immediately and change course? Go high? No matter what Harris and Democrats say or do, all non-Trumpers are already tarred and feathered with the stigma of being “far left,” “communist,” or — just as bad in MAGA estimation, albeit with the exceptions of Trump’s favored bromance-buddy dictators of the moment — “socialist.” As the DNC made impressively clear, however belatedly, this is a fight that needs to be engaged, not genuflexively capitulated to.
In the interests of full disclosure, but not in apology, let me say that I don’t consider myself a Marxist, communist or even much of a socialist. I am, not unlike Harris, Walz, Hillary and most Democrats, still in so many ways your garden-variety centrist liberal. That’s how Arnie and I both identified. The reason we weren’t self-identified as persons of the left, as Marxist or communist, is simple and is apart from an admitted emotional and reflex reactivity to what can seem a uniquely insufferable arrogance and hypocrisy in leftist rhetoric, priorities and evasions. The surpassing reason Arnie and I were/are outspokenly not communist is that there has never been a communist revolution or government that has not become, usually from its inception, a police state dictatorship, an autocracy identical in being authoritarian to the far right that often got overthrown in a communist revolution (Cuba, Venezuela); identical and often worse in intolerance; a system of policing where freedoms of assembly, speech, and the press are harshly limited, state-controlled, oppressive, and enslaving, as they were in the USSR (“Union of Soviet Slave Republics,” as I called it).
“Tankies,” who got their name from the cheering of leftist idealogues and disinformation aparatchiks and apologists, discernibly continue to dominate today’s campus protests. From the Russian tank invasions of Hungary, Czechoslovakia and other Soviet slave states to the later so-called peoples’ and cultural revolutions of Iran, Cuba, China, North Korea and Venezuela, their theoretics, motives and methods are inevitably indistinguishable from those of the far right. I was never a great admirer of Susan Sontag, except when she seized a peak moment of her own renown to say something to the world that needed to be said by a leading intellectual and cultural standard-bearer: that communism is fascism.
After such impassioned discourse ostensibly to the contrary, do I not believe that health care — and high quality health care such as they have in Cuba for all, along with housing and work for all— would be a worthy exchange for accepting autocracy? No. Not even in the face of my arguing that pharma and health care profiteering in America is a bloody train wreck of ethical and moral malfeasance, bottom-feeding and, yes, mass murder? No.
Can it really be that simple? Do I not believe pharma, along with the American enterprise it is emblematic of, to be capable of regulating itself? Alas, as is inevitably the case with free-market capitalism, the answer is likewise and resoundingly No. The result is always catastrophic, such as the industrial slavery that led to the American Civil War, the financial collapse of 2008 and the right wing extremism and unhinged billionare profiteering (Go, Bernie!) of the current period.
That said, and being against autocracy and having no easy quick solutions to the messes of health care and for that matter democracy, what I can say for now is that I do believe medicine and health care do indeed need to be far more regulated, far more socialized, as they are in virtually all other developed countries. I do still believe in the benefits of capitalism but with a lot more effective regulation and requisite higher taxation, for all and especially for the super-rich and their corporations.
Socialism light-to-moderate, you might call it. But not punitively. I’d want to work with the likes of Warren Buffet and Bill Gates to come up with solutions. With people who are discernibly honest, caring and well-meaning, I’d be more inspired to seek compromise, to work for a socialism such as there is in much of Europe. What I want for pharma and all other big corporations is what Donald Trump says he wants for NATO — for its partners to be much more accountable and to pay much more into the system, for the benefit of everyday working people, their families and everybody else.
That high cost is needed to fund the research to make new wonder drugs has become the jack-in-the-box default of justification for an industry that has run amok with antebellum cold-bloodedness, lawlessness and loopholiness in having virtually no regulation — an industry that not coincidentally rates among the biggest and most profitable in the world. The time for stepped-up socialization and regulation is past due.
Art of the Steal, Corporate Greed, Mass Murder and Genocide
Earlier this year, the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP), released its big report on pharma, concluding that its business model was “corporate greed.” The profits being made by pharma here in the US far exceed those they make in the rest of the world combined. Statistics reveal how these companies are charging exponentially higher prices for drugs than they did 20 years ago. Why? Simply because they can get away with it.
A report in the Journal of the American Medical Association (JAMA, 3/3/20) on “Profitability of Large Pharmaceutical Companies Compared With Other Large Public Companies” found that “from 2000 to 2018, the profitability of large pharmaceutical companies was significantly greater than other large, public companies, but the difference was less pronounced when considering company size, year, or research and development expense.” In the absence of regulation, that “but” for research costs is the loophole pharma always leverages in making its legally armed-to-the teeth case to the public and in court.
Remember Martin Shkreli, the hedge fund cum pharmaceutical CEO who gained notoriety as “the most hated man in America” for his increasing the price of life-saving drugs like asthma inhalers for children, so cold-bloodedly, extremely (from pennies to hundreds of dollars) and peremptorily that even in today’s world of no rules or regulations he ended up in jail? As it turns out, Shkreli wasn’t an anomaly or outlier so much as an exemplar of American-based pharma today.
That there is the occasional mega-hit, like antiviral treatment for HIV with the likelihood of a cure, and an actual cure for hep C, does not justify the brutal Martin Shkreli business model for leveraging cohort markets. Nor are “sincere,” “genuine” and “humane” corporate politeness, “sensitivity” and “inclusivity” compensating.
It was always a mystery why rampant profiteering, including that in league with far-right religious morality extremism (in turn allied with conservative political values favorable to capitalist enterprise), waited so long to tap into the cohort market of LGBTQ+ peoples. It always seemed an example of cutting off their nose to spite their face. In terms of money-making, it made little capitalism sense to ignore what had heretofore been decried as immoral and unethical, such as the LGBTQ+ and, later, medical cannabis markets. In the past, it was always more important to have scapegoats on which to build autocracies than to have “no-rules” regulations that don’t discriminate against minorities. Even today, it’s that past that antigay extremists like Florida Governonr Ron Desantis would still have us prioritize above the profiteering that is otherwise sacrosanct.
When all is said and done, how persuasive is this case I’m apparently alone in making for the analogy of pharma with slavery? Along with “mass murder” and “genocide,” do such comparisons seem too strong as terms of indictment? Too emotional, vehement, hysterical, ranting, over the top?
If you think the answer to those questions is yes, it’s time to revisit the public health catastrophe of the opioid crisis and the Sacklers, and the COVID catastrophe of the Trump presidency. In both cases, preventable casualties approaching those of the American Civil War were the result.
The present-day opioid crisis saga has been chronicled and dramatized in multiple books, documentaries and series, including the streaming series Painkiller and Dopesick, Alex Gibney’s The Crime of the Century, and Laura Poitras’s All The Beauty and the Bloodshed with its central figure of the downtown club scene photography artist Nan Goldin and the protests she led against the Sacklers and their endowments at leading cultural citadels such as the Metropolitan Museum of Art.
The protest demonstrations which Goldin led with other PAIN (Prescription Addiction Intervention Now) activists and which began with a demonstration at the Guggenheim Museum, was in the mode of those by ACT UP against the FDA for its foot-dragging on HIV/AIDS drug development, which in turn was inspired by the nonviolent protest activism of the Civil Rights movement.
Was there any difference between the Sacklers and slavers in terms of their indifference to costs in human life, misery, decency, ethics and morality? Were they not committing comparable crimes of conscience and against humanity? Were they not identically motivated by rampant profiteering at the expense of humane and ethical concerns and countless lives?
Addicts and Culpability
How can I have such surpassing compassion for the injection drug users and addicts who might seem at least coequally complicit in the opioid crisis? Indeed, questions of culpability do need to be confronted by addicts themselves, especially around their willingness to avail themselves of available treatment and do the difficult work of getting honest and responsible, of prioritizing recovery, even as the Sacklers did everything they could to shift all the blame for everything that went wrong to drug addicts and thereby stigmatize them as never before.
The reason they’re not more forefront in my indictments in our crises of addiction is the same reason I wouldn’t blame the poor for being less educated and self-sufficient or for having higher unemployment and crime rates. The reason is that society has to advance much further in doing what it can to offer support and bring people into treatment, recovery and socialization, to educate society and work to mitigate stigma, and to do a much better job of monitoring, policing and containing drug trafficking and associated crime. Building walls, literal and political, to bolster isolation isn’t going to cut it. Building bridges to future possibility is a much better and more likely winning strategy for everybody.
In sum, just as it needed to do far more to help LGBTQ+ persons and injection drug users with HIV/AIDS, from the ground up of advancing civil liberties protections to fast-tracking experimental treatments and setting up needle exchanges, society needs to show far more willingness to work with high risk and marginalized communities and cohorts such as immigrants and addicts, to offer genuine rather than gestural understanding, compassion, resources and services.
In the case of my own early advocacy for those with HIV/AIDS, I made it a precept of my medical recommendations that civil liberties protections for LGBTQ+ persons become an essential consideration in the long-range preventive medicine of HIV and other STI’s. In the case of the needle exchanges ACT UP worked so hard to promote, which former Vice-President Mike Pence initially forbad when he was Governor of Indiana with the immediate consequence of skyrocketing rates of HIV and hep C , the quickly developing result was the greatest achievement in harm reduction (the containment of negative consequences) in the history of HIV/AIDS, hep C and addiction.
For a more detailed and personal account of my experience with addiction, I refer the reader to my book, On The Future of Wagnerism: Art, Intoxication, Addiction, Codependence and Recovery.
As dramatized in Dopesick and The Crime of the Century, the Sacklers hoped, with the figurehead influence of former 9/11 hero Mayor Rudolph Giuliani on board as an advisor to principal perpetrator Purdue, to use the stigma of addiction and stereotypes of addicts to shift blame from the Sacklers’ recklessness, predation and profiteering to the addicts themselves, just as HIV/AIDS was likewise blamed on drug addicts and promiscuous (a word I used to place in quotes), “fast-lane” lifestyle gay men as “self-inflicted.”
The defense from pharma for oxycontin was that the completely out-of-control drug trafficking, criminality (robbing pharmacies and local businesses, muggings, murders) and overdose mass casualties that quickly overwhelmed municipalities and took over daily headlines were the fallout of craven drug abuse by addicts and associated criminality of drug traffickers and had nothing to do with pharma or its wholesale invasive cartel-like sales practices. Not surprisingly, those practices were thus wrist-tap indicted but never “proven” to be more than circumstantial partners in responsibility.
Eventually, Purdue pharma and its owners the Sacklers were found responsible for more than half a million opioid deaths in this country since 2000. It bears repeating that that’s approaching the number who died in the American Civil War. Purdue has now declared bankruptcy, issued apologies and paid out billions in damages. But just as Lydia Pinkham is still in legal business, Purdue is still marketing oxycontin. The Sackler family is still worth billions. Currently, they remain in determined legal proceedings to place blocks on any further litigation against them.
The opioid crisis, meanwhile, subsequently advanced from its principal villains, the Sacklers, and their golden-goose jackpot of oxycontin, to a newer product, fentanyl, and its original owner, John Kapoor, CEO of Insys Pharmaceuticals. Following Kapoor’s indictment and prosecution, eyes are now on China and the Mexican drug cartels for the ongoing and endless explosions of opioid crisis. Hey, if a market is there, everything else is just details to be worked out, right?
The portrayals of sales reps and practices in these histories of the opioid crisis are not flattering. How did sales reps end up being such fall guys in the Sackler and greater pharma webs? Answer: They pursued the income and bonuses that seemed easy passes to the good life, and they did so sometimes passively and thoughtlessly but more often with an initiated and trained indifference to conscience and ethics. With the narcotically incentivized fervor they thought they could always count on — that of financial gain — you’d probably have to go back to slavers, pirates and out of control drug addicts to appreciate the boundless expansiveness of their motivation and enthusiasm.
As masterminded by Richard Sackler and Purdue, all the blame would be and was placed on the addicts. It would be as if automobile recalls for faulty parts were being blamed on the drivers for not being more proactive about vehicle maintenance and safe driving priorities. If your airbag doesn’t work or explodes prematurely, why are you in situations that might prompt these malfunctions? If gay men and drug addicts are getting deadly new diseases and overdosing, why are they in situations and venues and with lifestyles and habits that place them at high risk? Blame, in this thinking, should not be on the brutal silence and indifference and overt collusion of pharma masterminds and societal indifference about the circumstances of target population vulnerability they’re enabling and preying upon. Rather, these dire circumstances should be seen as the just-deserts fault of the victims, the consequences of their sins, personal failures and crimes of misbehavior and lifestyle choices.
Did slaves “deserve” their fate for being vulnerable to capture and their fate as slaves? In the real world of for-profit business, being “dumb” — not knowing better, being naive, being unaware, trusting in those offering “gifts” (bribes), being weak, trusting that one would be helped rather than just cynically exploited, on top of being poor, Black or Hispanic— is not likely to win much sympathy, neither from slavers nor their courts of law.
Lost in all the dishonesty, blaming and shaming was the reality that oxycontin, however false its stated risks of addiction, however deviously marketed to suppress that information for greater profit at the known and deliberate cost of widespread human suffering and lives lost, was, as originally claimed, a significant development, however flawed, in the treatment of advanced cancer pain and other major, debilitating and chronic pain. It was a product that was needed, especially for cancer patients, as they survive longer with higher quality of life. No prior pain treatment was comparably effective. The importance and value of oxycontin for this significant cohort of patients got lost in all the addiction mayhem, professional irresponsibility and priority profiteering surrounding the drug.
What eventually and inevitably became clear in the bigger picture of its options and choices is that it was surpassingly not in the Sacklers’ interest to have more effective controls on oxycontin and thereby limit its sales. Greater regulation might have resulted in a lot less crime, misery and loss of life. But it would also have resulted in a lot less profit. If street crime and casualties happened in the wake of increasing drug profits, that’s not the Sacklers’ responsibility, right? Meanwhile, what the Sacklers did understand to be the bottom-line of their professional responsibility in promoting and protecting oxycontin, and from the inception of its death march, was its genuine medicinal value in treating moderate to severe pain. However whitewashed the drug’s dangers, it’s this responsibility for the treatment of advanced pain that the Sacklers realized needed to remain sacrosanct. And so it has, however beseiged.
In the wake of the acceptance speech by Donald Trump that closed the RNC (Republican National Convention) 7/18/24 was a new feature article in Propublica about the role of Mexico’s drug cartels in financing the campaign of Mexico’s President Lopez Obrador. The beat goes on.
Already, semaglutide is being secondarily repurposed and promoted for what seems, at least anecdotally and on the basis of scattershot circumstantial evidence, to be reduced craving for alcohol and drugs. Could it be a new wonder drug treatment for addiction, for pharma scouts always on the lookout for multi-purposing, repurposing and repackaging of drugs for ever-greater profit?
The development of a drug that can genuinely suppress craving, the way semaglutide appears to do with suppressing appetite and thereby craving for food, is the ultimate ambition, the mother lode of all pharma enterprise pursuits. To find a medication that would somehow suppress all craving — e.g., for compulsive gambling, sexual compulsivity, bulimia and anorexia as well as for alcohol, opiates, cocaine, amphetamines, tranquailizers and nicotine — would be even bigger than the discovery of penicillin, insulin, gold in California, diamonds in Africa or uranium for bomb-making. Such a drug would be the philosopher’s stone that was central to the symbolism of alchemy, in pursuit of perfection. It would be the spice of the Frank Herbert science fiction series, Dune. Efforts to discover the philosopher’s stone were known as the Magnum Opus (“Great Work”). It would be the supreme pharmaceutical of all time.
Back on earth, virtually every time there is a new drug with some success, it quickly becomes a candidate for repurposing for other conditions, often enough addiction, that might seem to go along with treatment improvement — such as a sense of well-being, easily interpreted with fast-talk as craving-reducing.
Meanwhile, that those taking semaglutide may be eliciting tolerance, which can lead to dependence, an often early manifestation of addiction, isn’t much pondered. Could it be that eventually, those like me taking semaglutide long-term will need to take progressively higher doses, as we must do initially and like those on opiates, with progressively higher costs? In my own case, increasing my compounding pharmacy semaglutide rx from a starting dose of .25 mg to 1 mg (with an eventual suggested maintenance dose of 2.4 mg) demonstrates that I am developing tolerance, for which I am already being charged twice as much as when I began.
Pharma, meanwhile, and otherwise so intent on preventing any and all regulation, is suddenly very concerned about the safety of compounding pharmacies offering semaglutide, coincidentally at less ransomly inflated prices. So much so that they are aggressively pursuing litigation to stop any and all production of this drug outside their own jurisdiction of ownership. Pharma, like the runaway America First enterprise it has become so emblematic of, ever putting the American people, the customer and safety first!
Remember the tobacco industry coverup — the long, winding, endless road of suppressed and corrupt studies, of lies, of corporate lobbyists and political influencers, of mass casualty cancer and emphysema and cardiovascular deaths, of what it took to get boundaries on advertisements for cigarettes, especially those targeted to minors, and the relentless failure of accountability? That’s what happened with the Sacklers and the opioid crisis that peaked under their influence.
The US government secured criminal convictions against Purdue Pharma in the mid-2000s but failed to prevent sales of the drug after Giuliani, representing Purdue, reached a deal to avoid a bar on Purdue doing business altogether, even as they were forced to declare bankruptcy, which turned out to be another evasion ploy. Though still far from a happy ending, the multifaceted ever-changing playout of the Purdue-Sackler saga was against the backdrop of a vaster matrix of ancient and never-ending opioid crises bound up with industrial profiteering. It’s a playout that remains global, transhistorical and likely headed to a spice-wars, Dune like future of infinite ramification and repetition.
In our own time, let’s not forget the COVID crisis that veered so wildly out of medical and scientific control during the Trump presidency. After demonstrating rare genuine leadership in endorsing the strategy of Operation Warp Speed for rapid vaccine development, the Trumper in Chief could not brook any criticism for the collective failure of supplies preparations. Then, and in short order, notably as criticsm became more widespread and outspoken, he couldn’t resist defiant stances on mask-wearing in grandstanding public appearances. The clashes with Fauci, who he had initially and wisely enlisted to head his team, and the later silencing, naysaying of and MAGA base threats to Fauci and his family are vivid reminders of who and what we are dealing with.
As reported in the New York Times (“Deborah Birx Says Trump White House Asked Her to Weaken Covid Guidance,” 6/23/22), Trump’s own chosen White House COVID coordinator and spokesperson — in another example of Trumpworld loyalty — said that disinformation, political pressure and underestimation of casualties and risk became the new rules of the game, as dictated by Trump. According to her estimates, 30 to 40 percent of deaths from COVID were preventable. That’s hundreds of thousands of unnecessary, preventable deaths, numbers comparable, as with the opioid crisis, to those of the American Civil War.
Nor is this fallout of the Trump administration’s anti-science, defiant, blame-gaming, MAGA collapse of principle, ethics and strategy around COVID over with. The Long COVID we keep hearing about is now widely reported as a not uncommon, long-term complication of COVID. In fact, there is growing concern that upwards of 30 percent of these cases, in which cardiovascular consequences are notable, will eventually develop CHF (Congestive Heart Failure). Yet another looming catastrophe for the future of American health care MAGA Republicans want us to trust them to “manage” with circuses of profiteering “enterprise.” Perhaps Lydia Pinkham’s tonic can be promoted, like Christian My Pillows, as the new snake oils and curealls to swear by.
Comparable as well to the losses of the American Civil War is the biggest single catastsrophe in the history of AIDS, the preventable deaths of a third of a million people in South Africa because of the HIV/AIDS denialism currently embraced by supreme conspiracist RFK Jr., now a high-ranking member of Team Trump.
Back to the Future
In sum, at least as I see it, the current era of intoxicated, unregulated, virtually lawless profiteering by pharma, in league with soullessly incentivized for-profit health insurance, disinformation and criminality is likely to look in retrospect something like, at best, that of studentloanism and other forms of profiteering indenturement, and at worst like the global, transhistorical phenomena of slavery— with America and its politicians once again assuming the lead roles of exemplars in the relegation of the price being paid in human exploitation, deception, deprivation and misery. When all is said and done, history is repeating itself, and often doing so as malevolently as ever.
For all our progress, it’s still, as Jean-Baptiste Alphonse Karr put it in 1848, plus ca change, ce’st plus la meme chose (French accents omitted). The more things change, the more they stay the same.
Hope for the future? As the saying and Bachman-Turner Overdrive song go, “You Ain’t Seen Nothin’ Yet.”
Resources:
“If Millennials Think College Debt Was Bad, Wait ’Til They See Their 65x Larger Healthcare Bill,” David Chase, Forbes, 6/28/2016
“Egypt Wiped Out Hepatitis C. Now It Is Trying to Help the Rest of Africa,” The New York Times, by Stephanie Nolan, 11/28/2023
“HELP Majority Staff Releases Report Revealing Big Pharma’s Business Model: Corporate Greed,” US Senate Committee on Health, Education, Labor and Pensions, 2/6/24
“Senate Report Exposes Big Pharma’s Profiteering at Americans’ Expense,” PharmaNews Intelligence, 2/14/24
“How Big Pharma Reaps Profits by Hurting Everyday Americans,” CAP 20 Branding Guide, Center for American Progress, Aug 30, 2019
“In Constant Battle With Insurers, Doctors Reach for a Cudgel: AI,” Teddy Rosenbluth, The New York Times, 7/1024
Trump University: A Look at an Enduring Education Scandal,” CAP 20, 3/30/2017
“The Middle Men: The Opaque Industry Secretly Inflating Prices for Prescription Drugs,” Rebecca Robbins and Reed Abelson, The New York Times, 6/21/24
Autocracy, Inc.: The Dictators Who Want to Run the World, Anne Applebaum, Penguin Random House, 7/23/24
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Lawrence D. Mass, M.D., is a co-founder of Gay Men’s Health Crisis and was the first to write about AIDS in the press. In 2019 he was awarded GMHC’s Founders Activism Award. He is the author of Homosexuality and Sexuality: Dialogues of the Sexual Revolution, Volume 1, and Homosexuality as Behavior and Identity: Dialogues of The Sexual Revolution, Volume 2. He is the author/editor of an anthology, We Must Love One Another Or Die: The Life and Legacies of Larry Kramer. He is the author of a memoir, Confessions of a Jewish Wagnerite: Being Gay and Jewish in America; of the sequel to that memoir, On the Future of Wagnerism: Art, Intoxication, Addiction, Codependence and Recovery; and the forthcoming Wayfaring With Ned Rorem: A Nonfiction Novella. They form a trilogy Mass has designated as his Jewish Wagnerism Series. Mass has written widely on medicine, health and culture for mainstream and specialist publications. A recently retired physician specializing in addiction medicine, he resides in New York City and South Florida. Lawrencedmass.com, Sentinelvoices.com
