Are drug prices fair?

Recently in the Huffington Post, Allen Frances wrote a blog asking, “Why are most cancer drugs so expensive and so ineffective?” The link is below for those interested.
(http://www.huffingtonpost.com/allen-frances/why-are-most-cancer-drugs_b_8294392.html?utm_hp_ref=science&ir=Science )
That is most certainly a good question. A summary of his points includes that the pharmaceutical industry is essentially a monopoly, in that only one company will make any given patented product. In the US, it exerts far too much political pressure, and as an example, he claimed Congress denied the Medicare program the right to negotiate drug prices. He claims there is a price monopoly, for even when generic drugs can be made, the pharmaceutical companies buy up the companies. He claims patent lives are extended with phoney variations. But in my mind, even worse, drug companies test their own products, but do not have to release the data for analysis by neutral observers. The companies hype the benefits and minimize disclosure of any risks.

He then cites some data from a Dr Prasad. Some of his findings include, the price of Gleevac rose from $30,000 in 2001 to $70,000 today, despite the fact the cost to make it is $200 (for a year’s course). However, at least Gleevac actually works. According to Dr Prasad, the median improvement in survival for 71 drugs for solid tumours produced in the last decade is 2.1 months. That may well be an overestimate because only 36% of those over 65 yrs old were in the trial, but that age group represents 60% of the patients in the wider community. Another interesting question is, given that many of these drugs have very severe consequences to the patient, is that 2.1 months worth it?

So, how do the companies do? Seemingly, remarkably well, with returns of between 10 – 42%. I saw a recent article that stated one product that had been sold for $20 per prescription had it raised to $1,000. When asked why, a spokesman said they wanted to make more money. Well, yes, I suppose they do. Don’t we all? The products are grossly overpriced, and only too often it appears they don’t really work all that well. There is the argument that research costs a lot. Yes, it does, but despite this, these companies are hugely profitable. In my view, this is simply price gouging, and it shows the ugly side of capitalism. A further interesting question would be, how much tax do they pay on these profits? Given that some large companies pay very little, one suspects the answer is, not much.

Usually, economic theory works on the basis that if there is a bad product, people will not buy it. However, with cancer drugs, that theory goes out the window. The average person has no hope whatsoever of deciding whether the product is any good, and you find out it is not when you die, or come close to it. Earlier this year, my wife died of cancer, so I know the pressure on the relations. Who can tell someone dying that product B is a waste of money, and it will bring penury to the remaining family members? And no, this situation did not arise for me. Claire was diagnosed in November, some simple treatment was provided as a holding measure while various things were done, and proper treatment was to start after Christmas. As it happened, her funeral was on the day scheduled for the start of treatment. Nevertheless, when someone you love is dying, you cannot really think rationally. There is a temptation to grasp at straws, but think what the grasping is like if you hear promising things from the drug companies? The very least we could ask for is a fair and open discussion of the prospects, and the basis for saying that. And we should expect that where there is little to substantiate the claims, at the very least the straw to be grasped should involve only reasonable expenses. Price gouging for performance is, in my view, not justifiable, but price gouging for what may be little better than snake oil is in my view criminal.

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Even more on writing about Caligulae

Previous posts have considered the difficulties faced when I was writing about Caligulae for my novel Athene’s Prophecy, and these difficulties were largely about his relations with the senatorial class. His limited military “adventures” produce far more difficulties. One example was his so-called “invasion of Germany”, which lasted about a week, after which he came back to Gaul. What do you do about that?

My answer is quite straightforward. The reason for going north was to arrest the Legates of two legions (who were almost certainly plotting a coup) but he had to take enough force with him that he would clearly succeed, and he had to have a diversion so the Legionnaires would think something else was going on. Once there, he embarked on a large number of military exercises involving the digging of fortifications, forced marches, and this ended with “the invasion of Germany”. Actually, what he was reported as having done was following the fairly conventional procedures for disciplining and bringing legions up to efficiency, and would have been somewhat milder than such procedures later employed by Corbolo. Invariably, these procedures included a river crossing, and the Rhine was the only available river. The “invasion” would comprise nothing more than crossing the river, followed by the setting up of defensive fortifications and a minor march inland, i.e. a drill for what would happen if there were war, followed by returning to base at the end of the drill.  What many do not recognize is that the Roman army was probably the most disciplined army ever, they drilled incessantly, and any slackness was jumped on mercilessly.

More difficult to understand was the so-called invasion of Britain. Caligulae took a legion to the Brittany coast, and when the men refused to board some fairly rotten ships, he gave them the alternative of declaring war on the sea and collecting seashells, which is apparently what they did. The way I interpreted this is not a sign of madness, but the deliberate humiliation of a potentially rebellious legion. One legion would be quite inadequate for the invasion. However, there are problems with this interpretation, and one was particularly troublesome. Towards the end of my novel, Scaevola (my protagonist) was appointed temporary Legatus of Legio III, Cyrenaica, temporarily at Bostra. As I was finishing, I found that anyone doing a deep historical search would be able to jump on me. Apparently, when Caligulae went north, he was accompanied by troops from the Cyrenaica, including the logistics experts. That means he planned the invasion of Britain. So, what actually happened? My guess is that when he saw the effects of his drills, he realized what would happen when he took troops to the coast. 

That does not mean he was a good man. He was definitely cruel and he had a superiority complex, but then consider his upbringing. All his family had been killed, one way or another, by Tiberius. Then he was brought to Capri, and watched Tiberius behave. If Tiberius did not like you, you were thrown off the cliff to your death. There is no doubt Gaius Julius Caesar was erratic, and he liked to put senators in their place. Perhaps the most obvious example was when he made his horse a Consul and tried to deify it. He made the senators worship his horse. Not exactly overly wise, but bearing in mind his objective, not exactly mad. Then there was the way he managed to get the streets of Rome clean. For that, you will have to read the book, or do some research.

What that meant for the novel was that my protagonist, who was of senatorial class, would have something to worry about. A particular problem was that the book concluded with the crisis of the Temple of Jerusalem. Caligulae wanted a statue of himself put there, to make up for the fact that Jews had defaced his statue somewhere else. That would have led to a revolt, and real bloodshed. In the end, Caligulae backed down, and I had to end my story about that back down. However, the way that ended did not signify madness, and this is one of the few incidents for which a real record remains, from the journal of Philo of Alexandria. What Caligulae did was to let everyone present thoroughly embarrass themselves, then he did the rational thing. Not exactly mad.

 If nothing else, while writing this I learned some classical history, or at least a version of what might have happened because I feel exactly what happened under Caligulae will never be known.

More on Writing about Caligulae

In my previous post, I mentioned some of the problems as to why we know so little that is clear about Caligulae, and why we have so many reports indicating he was mad. The question then was, how should I write about him? One of the first things that becomes apparent is that while many situations can have multiple interpretations, in general the author must settle on one for each incident, and overall, they must be self-consistent. I have tried to follow the interpretation of Anthony Barrett in his book, “Caligula, The Corruption of Power”, but I have also added some of my own personal interpretations. That actually brought me a further problem but also a solution. Caligulae does not appear personally in the novel other than in the very beginning, while Tiberius was still Princeps, and for most of the novel the information is delivered by letters from Claudius. Now Claudius is also on record of accusing Caligulae of being a very bad Princeps, but this was largely after Caligulae’s death, and Claudius had a very good reason to argue that the assassination was caused by some who had had enough of Caligulae’s bad behaviour. That raises the problem of what would be Claudius’ attitude prior to the assassination. As far as we know, the two got on quite well together, and Caesar did make Claudius a Consul, so I had Claudius making neutral or slightly favourable reports.

To illustrate one of the problems, Seneca reports at one time Caligulae offered his foot to be kissed. That would represent the ultimate of arrogance to Romans, and would be seen as an abominable practice; so much for gravitas and dignitas. However, Seneca also added that there was an alternative interpretation, and some had reported this incident as Caligulae showing off his new slippers. There is a difference! As for the excessive and sadistic killing, there are only twelve people who are unambiguously executed by him, and some of these executions were actually ordered by the senate without reference to Caligulae. There were another twelve examples that involved suicide or some other similar ending. So, approximately 24 deaths in four years, and recall there were at least four attempts at assassinating him. That is hardly the record of a mad tyrant.

Caligulae is often accused of having depleted the Treasury to an unacceptable level. This is almost certainly untrue, because after his assassination, Claudius gave out lavish donations from the Treasury to buy the loyalty of certain sections of the Roman community. He could not have done that without there being adequate cash on hand. So why would this accusation be made? My guess is, taxation. Prior to Caligulae, Rome itself was exempt from taxation. Caligulae argued that all Roman citizens should be equal, and hence all should pay tax. This was extremely unpopular with the Senatorial class. As an aside, the Roman flat tax rate at the time was about 1%. They should be so lucky! Interestingly, another complaint was that he taxed clients at brothels, which also seems to have upset the Senatorial class. Again, a 1% tax to all is hardly a sign of an extreme tyrant.

 I should also add that I am not trying to rehabilitate Gaius as a benign Princeps. He was not; all I am saying is that he was nowhere nearly as bad as certain Senatorial accounts, and certain lurid Hollywood outputs, would have us believe. More next post.

What do you think of Caligulae?

Let me start my first post of 2014 by wishing you all a happy, healthy and prosperous new year. In my last post of 2013, I mentioned my latest ebook, Athene’s Prophecy, and that the main protagonist had to dodge the erratic imperium of the other Gaius Julius Caesar (Caligulae – note he had two feet!). That makes this ebook at least partially a historical novel, and the question then is, how do you portray Caligulae? Before I address that, stop and ask yourself, how would you describe the man?

I think the average response would be to describe him as a mad tyrant who delighted in killing at random and ruling through terror, I have seen him listed amongst the most despicable rulers. Now, pause, and try to describe what you think.

Now, let us be fair. If he were a terrible tyrant, then surely there would be great cheering when he died. That more or less happened when Tiberius died, and Gaius was cheered vigorously when he publicly destroyed the information Tiberius had on various other Romans. They may have cheered a little less vigorously had they known he had made copies and kept those. Nevertheless, when Gaius was assassinated, the crowds became very angry and they demanded the guilty be caught and punished. All evidence is that the general public were angered by Caesar’s assassination. To understand this, it is necessary to recognize that those of senatorial class tended to want a return to the ideals of the Republic, whereas the masses could not care less for the Republic. The Republic was of no value to the masses, and when, in the Republic, people of adequate means and property volunteered for the legions, when they came back they tended to find themselves dispossessed of their property, and the senators the new owners.

The various privileges the senators had in the old Republic allowed them to amass huge wealth, at the expense of the ordinary Roman. These privileges had been taken in part by the first Gaius Julius Caesar, then further by Augustus and Tiberius, because they knew that you could not run a professional army unless the soldiers could look forward to something in retirement. The first Caesar appealed to the masses, and tried to make their life better, and, at the same time, give himself the masses as defence to being isolated by the senators. Caligulae tried to follow the principle of the first Caesar, except that he did not have quite the same ability. The problem for us is that most of our information comes from people of senatorial class, and they were clearly against Caligulae. One popular source of material is Seneca. Now, he would hardly enthuse about Gaius after Gaius’ death, given the Gaius had exiled Seneca for being involved with plotters who were trying to assassinate him. As an aside, is that what a brutal tyrant would do? Not execute those plotting to kill him? Accordingly, Seneca’s complaints cannot be relied on at all. A secondary problem is that the relevant sections of Tacitus’ Annals are missing, and while Tacitus was of senatorial class and probably did not have any love for Caligulae, Tacitus appears to at least attempt to provide a true picture of what happened, even if he does add some personal comments.

So, what to do? Next post I shall explain my solution.