Big Pharma and the Barkeep
Excerpted notes for cocktail recipes
Lobbyist Lemon Drop
Tart. In taste and character.
by all appearances safe and refreshing.
has something slipped into it.
This one will take you
from Kansas to Oz and back.
You just don’t know it.
The Good Journalist
A call drink with your favorite brand
of gin, Diet Coke, lime,
is on the house, every time.
We need Clark Kent more than Superman.
We need reporters who know
the way to save the world
is to inform it.
This one takes a swizzle stick
with a tiny plastic crane.
Use cracked ice
before the grapefruit juice, before
The Federal Trade Commission prevents
deceptive business practices.
Except when they don’t.
Except when they won’t.
This one has a lonnnng, aftertaste.
A daily special,
its price changes any time.
Its availability changes
The barkeep gets a phone call
and goes back
to erasing and hand-lettering
This drink is named
pharmacy benefit managers,
the post-merger Goliaths.
You must repeatedly show ID to prove
the chance to be served.
Serve The Prayer in ceramic steins
by Benedictine monks.
Serve it hot
Spicy, comforting, sharp.
Drink it with your eyes closed
One of my favorite artists is Sally Stewart. Based in Johnstown, Pennsylvania, the wise and skilled former art teacher works in different media, but she is most known for her pieces in wood. When she started exhibiting in the 1970’s she was the only woman in shows with male artists. Those were the years when “boys went to shop class and girls went to home economics classes,” she said. Luckily, that is different today. When visiting the National Museum of Women in the Arts in Washington, D.C. this summer I thought of this surrounded by Ursula von Rydingsvard’s huge cedar sculptures at her exhibit Contour of Feeling.
After 9/11 Stewart began making sculptures of crosses integrating woods from around the world. They have been presented as ecumenical gifts by the Office of the Presiding Bishop of the ELCA in more than 30 countries.
I was intrigued by a recent conversation Stewart and I had about art and healthcare and access to essential medicines. I was describing some of the misconceptions around drug pricing. She saw a correlation. Stewart has done a lot of commissioned pieces. She has been surprised at how frequently someone will be looking at a piece of wood and touch the spot where a flaw begins. The flaw or change in texture often results from a disease, insects, or an injury that disrupts the way a tree would usually grow. They like it. “This,” they insist, should be included.
This is where it gets interesting. This has personality. We trick ourselves into thinking only perfection is desirable. We dismiss damage, and the aging process and how to attend to them.
Today I am also thinking about two lines from “The Hill We Climb,” Amanda Gorman’s 2021 inaugural poem:
our people diverse and beautiful will emerge,
battered and beautiful
Here’s to making that emerging possible. Here’s to what we craft and stop and change and summon on behalf of each other – battered and beautiful people in our battered and beautiful country.
Pictured are some yet-to-be used pieces of wood we looked at during a studio visit. On the far right is a detail from Sally Stewart's “Jonah and the Great Fish” (cherry, obeche, walnut and poplar).
According to STAT’s review of federal disclosures, more than 450 lobbyists worked to help drug makers and their trade group PhRMA oppose lawmakers’ proposals to lower prescription drug prices in 2019.
This spring I had a piece included in the open exhibit for accordion books at the Kalamazoo Book Arts Center. Because the accordion form can be as short or long as you like, it offered a fitting way to illustrate this. The book uses black board covers and pages of metallic paper (the green of U.S. dollars, of course) printed with 450 briefcase icons of different sizes. Each briefcase represents a lobbyist. Sections are joined by bands of red metallic paper. I initially chose red as a color that warns, stops, and alerts. One of the artists in the exhibit said the bands remind her of red tape and the hassle often involved in access to medicines and healthcare in general. Exactly...
Take a look at the range of materials and topics in the May 2020 Illustrated Accordion exhibit.
Today is World Diabetes Day, and the birthday of Sir Frederick Banting, one of the co-discoverers of insulin.
A breadline is an appropriate place to hang out during the ongoing insulin price crisis we find ourselves in. The Franklin Delano Roosevelt Monument in Washington, D.C. includes multiple sculptures. “Depression Breadline” by George Segal was cast in bronze at the Johnson Atelier Technical Institute of Sculpture (now The Seward Johnson Atelier). Banting's own words are on this t-shirt from T1International: “Insulin does not belong to me. It belongs to the world.”
View a full photograph of “Depression Breadline.”
Read about the FDR Monument.
Read about Banting and visit a virtual exhibit "Dear Dr. Banting" curated by Kat MacDonald in London, Ontario.
Even the Kisses Have Changed
The 34 major pharmaceutical corporations that belong to PhRMA together spent more than $120 million lobbying Congress in 2019
In the museum today
policy creeps into everything.
The Brancusi Kiss is
the magical crinkle of limestone hair,
locked arms, unity.
Rodin’s Francesca and Paolo convene
in cool shadows, lighter
than marble has a right to be.
in other times and countries shift
before my eyes.
Art in the days of Big Pharma
is the permanent hug
of lobbyist to lawmaker.
No air between them. No light
just the heavy intimacy of money,
the universal seal
of trust and permission,
an ancient contract
with American proportions and flair.
Real bodies are beholden
to what the market will bear.
"Even the Kisses Have Changed" first appeared in The Healing Muse, vol. 20, no 1
The Healing Muse is the annual journal of literary and visual art published by SUNY Upstate Medical University's Center for Bioethics & Humanities.
See "The Kiss" by Constantin Brancusi.
See "The Kiss" by Auguste Rodin.
This post first appeared on the BMJ Medical Humanities Blog
On this side of the pond access to medicines is called “complicated” and that’s no accident. As Fran Quigley points out in his introduction to Prescription for the People: An Activist’s Guide to Making Medicine Affordable, calls for reform get bogged down in technical terms and acronyms. Furthermore, he writes, “[T]his thicket of complexity provides cover for corporations that rely on the for-profit medicine model and are determined to protect the status quo.”
And the status quo is alarming.
The practice of drug formulary exclusions is just one of our bountiful barriers to access in the U.S. There is surprisingly little resistance to it, but tons of exasperation. Impeding access is about more than outright denial. Drug formulary exclusions serve to increase shareholder profits. The motivation behind these decisions is not complicated at all.
What can we do? The Welsh poet R.S. Thomas called a metaphor “a shortcut.” I love that. A good metaphor is efficient. A good metaphor gets the job done. We could use such shortcuts to start real conversations in the face of jargon and intimidation surrounding access to medicines, and to this one practice in the midst of the pharmaceutical industry’s intentional complications.
So, here’s a visual metaphor. In this illustration strips of printed formulary exclusions from one of the largest pharmacy benefit managers (PBMs) in the country are made into chain links. You can hardly get more accessible than the act of making handcrafted paper chains. Just give a child a glue stick.
Paper is powerful, even in this digital age. A valid passport, an expired passport, a divorce subpoena, test results, lottery tickets, university degrees, protest signs, currency, love letters, employment contracts… paper can change your life.
When a drug flies off the formulary the preauthorization process arguing for its importance to the patient takes time from clinicians and their staff and can be denied despite everyone’s best efforts. The process also undermines clinician authority. While most changes go into effect at the beginning of a calendar year, they can occur at any time. Patients are “free” to continue taking a medication that is effective for them, or that comes in cartridges that fit their delivery device if they wish to pay cash, as if they had no insurance at all.
It’s a curious blind spot in a country that is usually so wild about choice. Have you walked down the breakfast cereal aisle in an American supermarket? We specify the milkfat percentage and flavourings in coffee shops with nuanced precision. How many channels do you watch on how many devices? But what if we were informed that we could only purchase a Ford this January, if that were declared the preferred automobile brand of 2021? We could technically go to other dealerships but suddenly the cost of a Subaru or a Volkswagen would leap exponentially. What if we could only purchase cell phones from a single company? Think of the outcry. And yet, there is a meekness surrounding the medicines we put into our bodies, which are arguably more important than other consumer choices. That is what a drug formulary exclusion does.
In addition to data, research articles, and patient stories we need more clarity. We need more urgency, because the chain metaphor rings true. Formulary exclusions hold us down and hold us back. None of us knows when our lives, or the quality of our lives will depend on a medication. It should not be a partisan issue. It should not be a patient issue. All clinicians are patients, after all. It is doubly in the interest of clinicians to push back against the practice.
PBMs are middlemen. Like pharmaceutical companies, competition-killing patent laws and PhRMA lobbyists they use complexity to serve their needs. Any way to see their barriers more clearly can help us to improve access, including, perhaps, a few lengths of paper chains.
 Quigley, Fran. Prescription for the People: An Activist’s Guide to Making Medicine Affordable, Ithaca and London: Cornell University Press, 2017, p. 3.
Before this pandemic I had been thinking about a virtual bar, and about the characteristics of a great barkeep. There is just something about the making and the receiving of a handcrafted drink. The right experience can be had in an international airport, a pub in the basement of a quiet neighborhood, a chandeliered icon of a lounge, or a porch in the mountains at the end of a lonnnng dirt road. Hospitality and aesthetics. A good barkeep is slow to judge, quick to observe. A good barkeep also has a radar for danger, and will not let things get out of hand.
What does a bar have to do with essential medicine access?
Well, things have gotten out of hand. When describing American health care costs per capita to other nations in a recent review of the new book by by Ezekiel J. Emanuel in The New York Review of Books David Oshinsky puts it well: “For head-spinning price disparities, however, nothing compares to pharmaceuticals. Americans account for almost half the $1 trillion spent annually for prescription drugs worldwide, while comprising less than 5 percent of the world’s population. It is probably no coincidence that the pharmaceutical industry spent almost twice as much on political lobbying between 1998 and 2020 as its nearest competitor, the insurance industry.”
Access to medicines is one part of the vast topic of access to healthcare. It generally isn’t being tackled by artists. It is not restricted to a single disease or place or group of people, but the issue will catch up to most of us, directly or indirectly, at some point. “Big Pharma and the Barkeep” is the title of a poem forthcoming from The Examined Life Journal from the Carver College of Medicine at University of Iowa. I’ll include it when it comes out, and I will continue to explore visual and verbal metaphors to help make clear that this problem is not insurmountable. We can do better.
I look forward to discovering and including work by artists who do approach the topic. In the meantime, stop by weary advocates who could use a rest and inspiration. Stop by if you're not convinced of the out-of-proportion costs of access to medicines. Stop by to grasp the urgency. Stop by to take a load off.