John Elias, my patient, has a dilemma. He can't afford to buy his medicines and also pay his rent. I'm sure he won't give up his apartment just to keep his veins filled with my chemical suggestions. But he is willing to take whatever free drug samples I provide. Luckily, drug company representatives visit my office regularly and drop off oversize, brightly colored boxes of pills, one or two pills per box. Sometimes I can fill a plastic bag with enough medicine to supply a patient's needs. Still, my sample closet is not as well stocked as the local pharmacy.
The explosion of samples occurs most often when two drug companies are competing over a similar product. When I have one set of pills, it's Elias's diabetes that's treated; when I have another set, it's the hypertension. He does not die, but his blood pressure goes up and down, and his blood sweetens with rising sugar, which lowers whenever I happen to have the right pills. Elias leaves my office smiling, more comfortable with his predicament than I am.
"See you in a month, Doc. And don't worry. I got enough pills here to last me a good ten days."
I do worry--about the remaining twenty days, about his risk of a heart attack or a stroke--but samples arrive at the drug company's rate, not in response to my urgent requests.
Elias is disabled, the result of a spine operation that didn't go his way. He has Medicare, but like millions of other disabled and elderly Americans, he's unable to afford the secondary insurance that would include a drug plan. He earns too much in his part-time clerical job to qualify for Medicaid, which also covers prescriptions, or to be accepted into a drug company's "Share the Care" program. He does qualify for New York State's EPIC plan, which allows some Medicare patients to fill all their prescriptions for under $100 per month, but he says he can't afford even that. He says he won't consider leaving his job to get Medicaid as others have done; he's proud of the fact that he can still work.
Elias lives in his wheelchair; the levers and locks are extensions of his arms, the wheels his legs. He navigates the street outside my office, leaning back on two wheels to jump the curb. His arching wheelies are another man's sidestep. But he has not managed to navigate his other diseases the way he has his paralysis. When I tell him the dangers of not controlling his diabetes and his high blood pressure, his smile fades. "When you're out, then I'm out," he says simply.
Meanwhile, the same company that makes his diabetes pill offers to fly me, all expenses paid and with a $1,000 stipend, to a frolicking weekend in Naples, Florida, where I would hear lectures for three hours a day on a drug I already prescribe, before adjourning to the surf and a sightseeing sunset booze cruise. The competitor invites me to the corporate box at the ballgame, with a lobster buffet and a live calypso band to entertain us between innings.
The drug salesman infiltrates the somber atmosphere of my medical office, trailed by a huge sample case on tiny wheels. It's uncanny: He knows how much of his drug I prescribe, and he wrongly assumes that I will respond to his enticements. He provides catered lunches to my office staff where the only apparent cost is listening to him harp on about a product that he freely admits I know more about than he does.
Despite the money spent on massive advertising, the manufacturers insist that exorbitant drug prices are the result of research and development. Several of the industry's best researchers are former professors who have been wooed away from the universities for higher salaries and better laboratories, and for every participant in the drug pipeline, from discovery to production, the excitement is almost palpable. New medicines for arthritis, hypertension, high cholesterol and diabetes improve the quality of life with fewer side effects. However, the new drugs are sold in Canada and Europe for a much lower price--a $15 pill in Detroit may cost $5 across the river in Windsor, Ontario--and there are foreign chemists producing these drugs in the laboratory and companies selling them for a fraction of their cost in the United States.
The more expensive the drug, the more difficult it is to determine how it is going to be paid for. Recently, a new wonder drug for arthritis became available in two formulations, one oral, the other intravenous. The choice of which form to use illustrates a basic problem in reimbursement. Since Medicare pays only for the more expensive intravenous, patients are being hospitalized unnecessarily to receive it.
As a doctor, I'm frustrated by the current system's inability to consistently provide for a patient's medicinal needs. Clearly, there is a need for government to intervene, but it's crucial that this intervention include an understanding of inflated costs and a plan for combating this inflation. As Medicare expands to cover pills, will the federal government drive a hard bargain and negotiate a lower price per pill the way HMOs, hospitals and other countries already do? I don't see how taxpayers can avoid being penalized if the government agrees to pay top dollar.
This year, after many insufficient attempts to maintain his health with samples, Elias wheels into my office with, if wheels were legs, an almost detectable swagger. All his years in service as a clerk have finally paid off. He is now the recipient of secondary insurance with a drug plan. He is one of the lucky ones. Now all his medications will be covered, at least for the moment.
"I'm ready to be healthy," he says with a grin that reveals his neglected teeth. "Lay those prescriptions on me."
Click here to review some of the more perceptive comments on the Scalia Five's judicial coup d'etat.
New York City; Saturday, June 23, 2001--The Stop Global AIDS March today brought together thousands of AIDS, debt relief, anti-racist and anti-globalization activists from around the world
The concept captures fundamental characteristics of today's world order.
With the Bush Administration, the corruption isn't hidden in the Lincoln Bedroom. It's paraded in your face. On June 18 Treasury Secretary Paul O'Neill lunched with executives of leading financial houses at Windows on the World high atop New York's World Trade Center. His unstated purpose was to help raise $20 million from the companies he regulates, as an initial ante for a private advertising campaign to promote Social Security privatization. When George W. Bush joked during the campaign that the rich were "my base," he wasn't kidding.
The Administration has lurched straight from its tax cut to privatizing Social Security. On June 11 the sixteen members of Bush's Commission to Strengthen Social Security, all handpicked by the White House for their prior support of private accounts, announced that they are unanimously in favor of using part of Social Security taxes to create "individually controlled personal retirement accounts" to be invested in the stock market. Commission co-chairman Richard Parsons, co-chief operating officer of AOL-Time Warner, made the costs clear, saying the panel would consider raising the retirement age and cutting benefits. "For future retirees, you can consider everything on the table," he said.
A coalition of citizen organizations led by the Institute for America's Future and including labor, women's groups, the National Urban League, senior and youth groups, and disability activists immediately denounced the commission members as "astonishingly unrepresentative of the views held by most Americans concerning Social Security's future." A week later two members of the House Ways and Means Committee ran into a Midwestern version of the same citizens' coalition in Missouri when they conducted a "field hearing" to promote privatization. According to the St. Petersburg Times, committee chairman Bill Thomas had envisioned the hearing as an opportunity to foment an "intergenerational clash" between retirees and Generation Xers on Social Security reform. Instead, seniors and young people demonstrated for "intergenerational solidarity" against privatization.
Similarly, O'Neill's airy power lunch was punctuated by a protest rally organized by the AFL-CIO, the Institute for America's Future, the New York Statewide Senior Action Council, the 2030 Center (for young people) and other groups. Joined by Representatives Jerrold Nadler and Jan Schakowsky, the protesters denounced the blatant impropriety of O'Neill's helping solicit private funds to lobby for a plan that will generate billions for financial barons like Morgan Stanley, American International Group, Citigroup and Deutsche Bank, all of whom were expected to be at the lunch.
To repeat what we've said before: Social Security is not in financial trouble now and may never be; just tweak the actuarial assumptions used by the privatizers and any shortfall disappears. But even if more money is needed at some point to pay benefits, sensible solutions are at hand--the simplest being to raise or remove the cap on the amount of earnings on which Social Security taxes are levied. That idea, of course, does not go down well with the high-income crowd that supports Bush.
By the fall, the Bush Administration will hang around the neck of every Republican running for Congress a detailed plan for privatization, and Bush and O'Neill will be publicly identified with the campaign designed to sell this lemon to the American people. In 2002, Americans will have a clear choice to make.
Democrats and Republicans alike are claiming the education bill as a victory. The national testing plan--mandating annual tests in grades three through eight, plus one in high school--is a significant departure from the past. As right-wing pundit Chester Finn once observed, liberals have traditionally hated the word "testing" and conservatives have hated the word "national." But old principles gave way to current political imperatives. Democrats seized on words like "accountability" and Republicans armed themselves with "compassion."
The bill is not, however, a victory for children in public schools, particularly those from disadvantaged backgrounds. The Harvard Civil Rights Project has shown that poor and minority children are hurt the most by an excessive reliance on high-stakes testing--in which performance on standardized tests determines promotion to the next grade, graduation or even the survival of the school. High-stakes tests are associated with high dropout rates, an escalating problem among African-American boys. Exams alone don't motivate struggling students and can even have the opposite effect, according to a Boston College study.
What students need are tests that truly measure how well schools are teaching basic skills, accompanied by constructive responses to weak points--tutoring, after-school programs that go beyond remediation, summer school (when necessary) that does more than rehash the year's curriculum and, above all, expertly trained, decently paid teachers for all our schools, especially those serving a high concentration of poor students. The education bill emerging from Congress guarantees none of those things. Instead, failing schools receive as little as one year of technical assistance, and students get tutoring and transportation subsidies to attend another school; within five years the failing school could face total "reconstitution," meaning the staff would be fired.
A critical difference between the House and Senate bills is the method of measuring school success. The House would require schools to break out test scores by race, exposing schools where well-off white students are thriving while minority kids are stuck in the low-performing track (the "soft bigotry of low expectations" that Bush is fond of lamenting); the Senate lets schools average their test scores, masking any racial achievement gap. Bush is under intense pressure from the Republican-dominated National Governors Association--conservative governors fear having to pour resources into schools revealed to be neglecting their minority students--to support the Senate's version on this point.
Ted Kennedy and the other Senate liberals hailing the education bill as a triumph focus on the dollar signs. They can claim that the Senate bill authorizes $33 billion--including more money for teacher training, improving school buildings and programs for disabled and immigrant children--versus Bush's $19 billion and the House's $24 billion. But even the Senate figure falls woefully short, and getting the funds appropriated down the road will entail a messy fight, given the promised tax cuts. That inconvenient fact could spoil the bipartisan fun.
When George W. Bush announced from Sweden on June 14 that he planned to pull the US Navy out of the Puerto Rican island of Vieques by 2003, it struck some as odd when he referred to the people of Vieques, all US citizens, as "our friends and neighbors" who "don't want us there." It was as though he was saying Puerto Rico is a foreign country.
In reality, Puerto Rico is a colony of the United States. A consequence of this is the situation in Vieques, where the Navy has reigned over people who at another period in history were simply subjects. But the people of Puerto Rico are also human beings with a right to live and prosper that brute force cannot deny. And the fact that they are US citizens makes them more than just the President's "friends and neighbors," and connects their plight to the United States in a very direct way that the President cannot ignore.
The struggle to force the Navy out of Vieques, which goes back sixty years to when the Navy first took over most of the small island, has gathered steam since the accidental killing of a civilian Navy employee two years ago. Besides the environmental destruction and resulting health problems associated with the Navy's presence, now there was an actual victim to mourn and organize around. The people of Vieques and Puerto Rico were outraged, and the consensus that emerged was dazzling for an island nation long divided about its political status.
The pro-statehood governor at the time, Pedro Rosselló, cut a highly unpopular deal with President Clinton to hold a referendum this November to ask the people of Vieques whether they want the Navy to leave by 2003. The action cost his party the gubernatorial race last year. Buttressed by protests on Vieques in the rest of Puerto Rico and by the stateside Puerto Rican community, the new pro-Commonwealth governor, Sila María Calderón, called for an earlier referendum, to be held at the end of July, and has led the movement to have the Navy leave Vieques immediately.
In addition to such opponents of the Navy bombings as Rubén Berríos Martínez, president of the Puerto Rican Independence Party, the move to oust the Navy has gained unlikely supporters such as singer Ricky Martin, boxer Felix Trinidad, actor Benicio del Toro and the new Miss Universe, Denise Quiñones August. Backing has also come from the African-American leadership, with Jesse Jackson and Al Sharpton joining the protest, and from Republican New York Governor George Pataki, whom Calderón recently endorsed for re-election even though she's a Democrat. Some of these unusual alliances result from politicians' perception of the growing clout of Latino voters and some from Puerto Rico's need for GOP support in Washington for federal funding for the island, which has no votes in Congress (it has a nonvoting resident commissioner in the House).
There were also lawsuits against the Navy by people like high-profile environmentalist Robert Kennedy Jr. and the arrests of more than 180 protesters in Vieques, including Sharpton and three New York Puerto Rican politicos. There was even a virtual protest that tied up the Navy's website for a while. The Vieques issue has gone mainstream.
Besides bringing environmental and health problems to Vieques, the Navy's presence has been an assault on democracy. The Navy has reneged on a succession of agreements it made with Puerto Rico to respect the environment and economy of Vieques and reinvest in its development. The treatment of the many protesters by Navy personnel has also brought criticism about the abuse of their rights, especially after prominent Puerto Rican officials and members of Congress were physically intimidated by the Navy, with unnecessary body searches and manhandling.
Another issue is the strong nexus between the US military and the federal judiciary in Puerto Rico, a politically unhealthy alliance that is probably more responsible than anything else for the inappropriate sentences given to many of those who practiced civil disobedience on Vieques. The federal judge meting out these harsh sentences, who is presiding over one of the major environmental and civil rights suits on Vieques, is Chief Justice Hector Laffitte, who represented the police officers who murdered Puerto Rican independentistas in the notorious Cerro Maravilla case in 1980. There has been widespread speculation about possible ties between him and the Navy, especially after his overriding of the established federal lottery system for assigning cases so that he could personally dispose of the ones concerning Vieques.
Bush's decision to stop the bombing by 2003 was an obvious concession to the fact that the people of Vieques would choose to do this anyway in the referendum. By eliminating the embarrassment of losing in a popular vote among the more than 9,000 residents of Vieques, Bush could save face and have the bonus of looking as though he was being responsive to the growing "Latino vote." The hard right in Congress and the media criticized him, however, for compromising US military readiness, while everyone else, including the odd duo of Senator Hillary Rodham Clinton and Governor Pataki, felt it was too little, too late, and called for the Navy's immediate withdrawal.
Meanwhile, the President's political expediency on this issue resulted in his undermining of the Navy's complaints about the lack of alternative training sites, which was the only compelling basis it had for arguing that it needed to remain in Vieques. Now that the Navy has resumed its bombing of the island, leading to further protests, we will soon see whether the contradictions of colonial administration in a postcolonial world will come home to roost. But whatever the outcome, it is clear that Vieques has become yet another symbol that the costs of empire may be too high even for the powerful in this new century.
The Kerrey revelations raise anew issues of morality and military power.
On a late June day that will surely have been picked by the political astrologers around him, Kofi Annan of Ghana will likely be coronated for a second five-year term as Secretary General of the United Nations. The 63-year-old Annan's first term doesn't end until December, but since there's no opposition to him, the Security Council--which decides on such things--seems inclined to formally name him in June.
The timing, of course, couldn't be better, both for Annan and the beleaguered UN system, which is hurting financially because the United States, its biggest donor, owes it more than $1.2 billion in arrears and continues to refuse to pay. A freshly crowned Annan will clearly wield re-energized clout as the General Assembly opens a special session on HIV/AIDS on June 25, a three-day conference that is expected to draw even leaders known to harbor antipathy toward the UN--such as George W. Bush.
Annan has made AIDS his special cause this year. He has established a global fund; the initial target was $7-10 billion. Bush has pledged $200 million, a sum that most AIDS activists consider inadequate. It's quite likely that Annan will coax another $300 million out of the Western Europeans. It's not at all certain that the AIDS session will end up as an exercise in effective fundraising, but its value may well lie in drawing unprecedented attention to the subject.
It's probably uncharitable to suggest that Annan's engagement with the AIDS issue flows from concern about the incipient actions of the Oslo-based Nobel Peace Prize Committee. But if Annan is honored by this body, it may well be because of the extraordinary steps he's been taking to advance public support for helping victims of HIV/AIDS. Until recently the UN's approach had been to let the issue be handled by a small, quiet unit in Geneva called UNAIDS. It is headed by a Belgian physician named Peter Piot, who has traveled the world articulating fearful statistics associated with the AIDS pandemic and gaining the reluctant cooperation of various feuding UN agencies. But Dr. Piot lacks Annan's stature and does not enjoy the benefit of his bully pulpit. Moreover, there are many competing issues within the UN system.
Whether Annan will be able to mobilize additional resources for AIDS is an open question. The world's thirty richest countries--members of the Organization for Economic Cooperation and Development--currently give less than $40 billion annually to the poorest 135 nations. The trend has been downward for several years now, since the record foreign-aid high of $75 billion some fifteen years ago. Some suggest that the $7-10 billion target for Annan's new global fund is a conservative figure, considering that the number of AIDS-affected people worldwide may well double in the next decade from the present 33 million. Most of the victims are in poor countries--especially in Africa--where economic and social development is already faltering.
Annan's strategy has been to link AIDS to the broader issues of jump-starting economic growth and insuring environmental security. The AIDS session in New York is only one of several international meetings that Annan is convening in the next eighteen months. The idea is that these conferences will serve as a sort of continuum and fashion a body of work on development issues. The idea is also to get leaders of rich and poor countries to commit at least modest new amounts of money to tackle the widening problems of poverty. And last, the idea is to project a recharged image of the UN.
Thus, a General Assembly special session on the plight of cities was held in early June; after the AIDS conference, there will be another assembly session, on the wide misuse of small arms and light weapons, especially in poor countries, where children are often employed as soldiers and vigilantes. During the summer, there will be a climate conference in Bonn, where the Bush Administration's stance against full recognition of the harmful effects of global warming--and renunciation of the 1997 Kyoto Protocol--will surely be a major item on the agenda. Then the UN will convene in Durban, South Africa, to mobilize world support against racism and other forms of discrimination. There's a summit on issues relating to children's rights and a world food summit in Rome, both in the fall; a conference on financing for development next spring in Mexico; and a conference on the problems of aging, also in the spring, in Madrid.
All these conferences will lead up to a World Summit on Sustainable Development in Johannesburg, in September 2002. Annan wants every head of state or government to attend, and he wants to review what's happened in the fields of environmental protection and poverty alleviation since the June 1992 Earth Summit in Rio de Janeiro. World leaders, including Bush the Elder, promised to act on the Earth Summit's Agenda 21, a sort of blueprint for global economic development, and said that the world's thirty richest nations should commit $125 billion each year in development assistance to the 135 poorest countries. Of course, no one's kept the promise.
Annan and India's Nitin Desai, his Under Secretary General for Economic and Social Affairs, aver that the decline in development assistance is unacceptable, especially at a time when globalization is leaving more and more people further behind. They cite the fact that despite worldwide improvements in such matters as infant mortality and literacy rates, some 2 billion people out of a global population of 6 billion live in poverty.
But Annan knows it's unlikely the rich nations will pony up more cash for development, particularly when public support for foreign aid is steadily losing ground in many wealthy countries. So he's trying to rally big business behind his plans. On the eve of the UN meeting on AIDS, former US ambassador to the UN Richard Holbrooke said that with Annan's encouragement, he has agreed to head the Global Business Council on HIV and AIDS, a UN initiative. Annan also recently persuaded outgoing Shell chairman and CEO Sir Mark Moody-Stuart to chair a new "business action council" for the Johannesburg 2002 summit. Moody-Stuart, a soft-spoken man who acknowledges that the energy industry's environmental record has been less than commendable, wants to devise ways whereby the business community can generate culturally and socially sensitive economic development in the poor countries; he says more economically healthy and socially stable societies are in everyone's self-interest: "Less confrontation, more cooperation--let's give it a try," he said in a London interview.
Nice sentiment. But already some nongovernmental organizations are alarmed that big business may unduly influence the UN at a time when the world body has never been more vulnerable financially. While it's unlikely that various UN organizations would rescind carefully negotiated protocols on subjects like the environment, it's not at all clear that the UN would be able to resist some sort of reciprocity for business largesse. What might such reciprocity consist of--co-branding, such as combining corporate logos with that of the UN? Or perhaps something more troublesome, such as designating UN personnel to serve as de facto commercial representatives?
No one is insinuating, however, that Kofi Annan can be bought. Indeed, the prevailing consensus in the donor community and in the corridors of the UN is that a cozier UN/big business relationship can bring another source of strength to the world body, not to mention burnish Annan's own reputation as a dynamic secretary general.
Third term, anyone?
An early US AIDS group employs direct action to oppose injustice everywhere.