HARVARD POLITICAL REVIEW
REVISITING RECOVERY
FROZEN FUTURES
ACCESSING AMERICA
VOLUME XLV NO. 1, SPRING 2018 HARVARDPOLITICS.COM
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HARVARDPOLITICS.COM
SIDE EFFECTS
This issue’s cover topic was originally proposed by Amir Siraj, Jessica Boutchie, and Chimaoge Ibe.
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Is Direct-to-Consumer Advertising Right for You? Minnie Jang
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Marijuana, Rx Alexis Mealey
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Revisiting Recovery Meena Venkataramanan
Revisiting Recovery Meena Venkataramanan
CULTURE
17 Democracy’s Gatekeepers Matthew Rossi
35 Accessing America Campbell Erickson
20 Home Detention Cate Brock
38 Food Gap Siri Ninotchka Diaz-Granados
23 Can Democrats Win the South? Byron Hurlbut
41 On Fame and Fidelity Carter Nakamoto
WORLD
17 Democracy’s Gatekeepers Matthew Rossi
Seeing Through the Smoke Clara Bates
11 Emergent Biotechnology Christopher Li
UNITED STATES
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INTERVIEWS
25 Frozen Futures Joseph Winters
44 Daniel and Jordan Allott Cara Kupferman
27 Nasty Party Raphaelle Soffe
46 Russell Bobbitt Yuri-Grace Ohashi
30 Cleaning Up Vanessa Ruales
CAMPUS
ENDPAPER 48 Udaipur Ali Hakim
33 Imperfect Union Will Imbrie-Moore
35 Accessing America Campbell Erickson Email: president@harvardpolitics.com. ISSN 0090-1032. Harvard Political Review. All rights reserved. Image Credits: Photographer: 1, 35- Redie Mumbili; 10- Meena Venkataramanan; 33- Matthew Rossi; 44Daniel and Jordan Allott; 46- Russell Bobbitt. Flickr: 20- doe-oakridge; 41- PunkToad; 41- sashimomura; 48- Tommy. Pixabay: 12- Qimono; 16- Axonite; 41- Alles. Public Domain Pictures: 1, 3- George Hodan; 11- B.C. Unsplash: Cover- Michael Grosicki; 8- Justin Luebke; 14- Itay Kabalo; 25- Steve Halama; 27- James Giddins. Wikimedia: 5- Laurie Avocado; 17- Re Jean Soo; 22- Jeremy Bentham; 23- wapcaplet; 30- Cayambe; 38lyzadanger; 41- Wellcome Gallery; 43- US National Archives. Design by: Victoria Berzin, Eliot Harrison, Quinn Mulholland, Erica Newman-Corre, Yuri-Grace Ohashi, and Matthew Rossi.
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FROM THE PRESIDENT
HARVARD POLITICAL REVIEW
Side Effects
A Nonpartisan Undergraduate Journal of Politics, Est. 1969—Vol. XLV, No. 1
EDITORIAL BOARD PRESIDENT: Samuel Kessler PUBLISHER: Drew Pendergrass MANAGING EDITOR: Akshaya Annapragada ASSOCIATE MANAGING EDITOR: Jacob Link ASSOCIATE MANAGING EDITOR: Russell Reed STAFF DIRECTOR: Sal DeFrancesco SENIOR COVERS EDITOR: Nicolas Yan ASSOCIATE COVERS EDITOR: Sarah Shamoon SENIOR U.S. EDITOR: Amir Siraj ASSOCIATE U.S. EDITOR: Chimaoge Ibe ASSOCIATE U.S. EDITOR: Jessica Boutchie SENIOR WORLD EDITOR: Alicia Zhang ASSOCIATE WORLD EDITOR: Darwin Peng ASSOCIATE WORLD EDITOR: Perry Arrasmith SENIOR CULTURE EDITOR: Katie Weiner ASSOCIATE CULTURE EDITOR: Savitri Fouda SENIOR CAMPUS EDITOR: Cindy Jung ASSOCIATE CAMPUS EDITOR: Julia Shea INTERVIEWS EDITOR: Martin Berger HUMOR EDITOR: Joseph Minatel BUSINESS MANAGER: Jacob Kern ASSOCIATE BUSINESS MANAGER: Wyatt Hurt SENIOR DESIGN EDITOR: Eliot Harrison ASSOCIATE DESIGN EDITOR: Erica Newman-Corre ASSOCIATE DESIGN EDITOR: Yuri-Grace Ohashi SENIOR MULTIMEDIA EDITOR: James Blanchfield ASSOCIATE MULTIMEDIA EDITOR: Sarah Tisdall SENIOR TECH DIRECTOR: Alisha Ukani ASSOCIATE TECH DIRECTOR: Gerardo Parra ASSOCIATE TECH DIRECTOR: Jason Huang COMMUNITY ENGAGEMENT DIRECTOR: Alexis Mealey
STAFF Victor Agbafe, Marie Becker, Devon Black, Evan Bonsall, Beverly Brown, Jiafeng Chen, Pedro Luis Cunha Farias, Justin Curtis, Ashish Dahal, Nick Danby, Sunaina Danziger, Hadley DeBello, Sophie DiCara, Casey Durant, Austin Eder, Steven Espinoza, Adam Friedman, Daniel Friedman, Miro Furtado, Melissa Gayton, Jay Gopalan, David Gutierrez, Olivia Herrington, Thomas Huling, Chimaoge Ibe, Michael Jasper, Cindy Jung, Matthew Keating, Daniel Kenny, Andrew Kim, Kieren Kresevic, Amelia Lamp, Jose Larios, Ashiley Lee, Elton Lossner, Elizabeth Manero, Patrick McClanahan, Olivia McGinnis, Jake McIntyre, Ayush Midha, Andrew Morley, Iriowen Ojo, Nadya Okamoto, Mfundo Radebe, Anna Raheem, Anne Raheem, Alyssa Resar, Chico Payne, Juliet Pesner, Stefan Petrovic, Lily Piao, Allison Piper, Lizzy Schick, Matthew Shaw, Audrey Sheehy, Wright Smith, Nick Stauffer-Mason, Gloria Su, Anirudh Suresh, Richard Tong, Rachel Tropp, Nico Tuccillo, Derek Wang, Joseph Winters, Jenna Wong, Sarah Wu, Catherine Zheng, Anna Zhou, Andrew Zucker SENIOR WRITERS: Perry Abdulkadir, Chad Borgman, Henry Brooks, Ali Hakim, Quinn Mulholland, Derek Paulhus, Samuel Plank, Tess Saperstein, Akash Wasil, Emily Zauzmer
ADVISORY BOARD Jonathan Alter Richard L. Berke Carl Cannon E.J. Dionne, Jr.
Ron Fournier Walter Isaacson Whitney Patton Maralee Schwartz
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here is a strange dichotomy in every drug. Drugs lift people up, and they knock people out. They are used to heal, and they are used to get high. They boost economies and line purses while shrinking workforces and draining bank accounts. The same drugs manufactured to save life can be used to escape it. It is often side effects, the unanticipated—or at the very least, unintended—consequences of drug use, which have the most significant impact. These side effects are as diverse as they are potent. They are medical, economic, environmental, political and often all of the above. These side effects—positive, negative, and in between—permeate every area of society. As the U.S. federal government continues to classify cannabis as a Schedule 1 drug alongside heroin and ecstasy, Colorado has earned over half a billion dollars in tax revenue from recreational marijuana, San Francisco and others have promised to reverse decades of marijuana-related convictions, and Peru has added itself to the list of countries that have legalized medical marijuana. Meanwhile, the opioid epidemic has continued to wreak havoc across the rural United States, and politicians have promised to devote more attention to combating prescription drug abuse while taking donations from the very drug companies who stand to profit from it. In this edition of the HPR, we explore side effects from a variety of different perspectives. In “Is Direct-toConsumer Pharmaceutical Advertising Right for You?” Minnie Jang dives
into the fascinating history of those pesky pharmaceutical ads that flood U.S. airwaves. In “Marijuana, Rx” and “Seeing Through Smoke,” Alexis Mealey and Clara Bates both explore the side effects of marijuana legalization, with the former documenting the lack of progress in medical marijuana research and policy, and the latter discussing the tenuous state of America’s fledgling recreational marijuana industry under Jeff Sessions’ Justice Department. In “Revisiting Recovery,” Meena Venkataramanan discusses developments in youth substance abuse treatment and prevention in Southern Arizona, and in “Emergent Biotechnology,” Christopher Li explains how recent advancements in biotechnology should invite caution as well as excitement. Alongside these articles on side effects are a number of pieces that are no less interesting—on topics ranging from Arctic governance to bigotry in the British Labour Party. As the HPR embarks on its 50th year as a magazine, we look forward to continuing the same tradition of journalistic excellence that has defined it since its inception. This magazine is the first of four to be published by the HPR’s newest masthead, and I am so proud of the amazing work that our team does each day to make the HPR the nation’s preeminent collegiate political publication. Thank you for reading, and we hope you’ll enjoy.
Samuel Kessler President
Is Direct-to-Consumer Pharmaceutical Advertising Right for You? Minnie Jang
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alk to your doctor to see if [insert drug name] is right for you.” One glance at the television screen tells the story: a shot of the outdoors hints at allergy medications like Claritin, a laughing couple winks for Viagra, and a wind-up toy symbolizes the depressive symptoms treated by antidepressants like Pristiq. With familiar voice-over scripts and images of smiling (read: hired) actors, advertisements for prescription drugs flood our daily consumption of media. One Kantar analysis revealed that 72 percent of commercial breaks during CBS Evening News and 62 percent of commercial breaks during the television show General Hospital include at least one advertisement for pharmaceutical products. Vowing to treat a host of common conditions ranging from arthritis to diabetes to erectile dysfunction, pharmaceutical advertisements have become an established norm in our cultural landscape. However, their seemingly ubiquitous nature belies the fact that direct-to-consumer pharmaceutical advertising is banned in virtually every country except the United States and New Zealand. This form of advertising refers to the marketing of pharmaceutical drugs to patients, rather than healthcare providers, through a wide variety of multimedia channels, from television to social media to print publications. A closer look at the history of DTCPA reveals that consumer-targeted advertising wasn’t always an embedded norm of pharmaceutical promotion. Rather, a balanced set of risks and benefits has complicated this debate for decades, folding into long-term questions over consumer-oriented care and freedom of commercial speech. Meanwhile, spending on pharmaceutical advertisements has swelled by 62 percent since 2012, alongside skyrocketing costs of prescription drugs, which are projected to reach as high as $610 billion by 2021. With increasing pressure from the American public to manage growing healthcare costs, the role of DTCPA in the U.S. economic and cultural landscape warrants further investigation.
A DRUG (AD) OF CHOICE In 1983, Boots Pharmaceuticals aired the first televised prescription drug advertisement for their product, Rufen, a painkiller marketed as less expensive than its competitor, Motrin. Just two years earlier, Merck Pharmaceuticals ran the first print
pharmaceutical advertisement in Reader’s Digest for a pneumococcal vaccine, called PneumoVax. During these early years of direct-to-consumer advertising, companies like Boots and Merck enjoyed a lack of regulatory precedent, expanding their marketing opportunities beyond the healthcare professional sphere for the first time. Around the same period, a nationwide movement championing patients’ rights began to gain traction, leading to the institution of consent forms for medical procedures and privacy acts for health records. Dual pressures from these patients’ rights groups, who demanded more consumer autonomy in medical decision-making, and from pharmaceutical companies, who strove to increase their advertising efforts, helped propel DTCPA to mainstream media. In response to the growing industry of direct-to-consumer pharmaceutical advertising, the U.S. Food and Drug Administration issued a set of guidelines in 1985 that required consumertargeted advertisements to meet the same requirements as those targeted at physicians. The list of criteria included the name of the drug, its purpose, and a “major statement” of potential side effects that effectively precluded the use of short broadcast spots to promote any pharmaceutical products. Persuaded by companies to loosen these restrictions, the FDA released a 1997 guidance outlining standards for “adequate provision” of information regarding drug-related side effects, as long as the advertisement also listed other resources for patients to access more information, such as a toll-free phone number. In the wake of relaxed regulations, budgets for DTCPA more than tripled between 1997 and 1998, launching a period of rapid and sustained growth. In the two decades since, the FDA has maintained its favorable stance towards the advertising practice. Stephanie Caccomo, a press officer for the federal agency, told the HPR that “[the] FDA believes our enforcement of prescription drug promotion strikes an appropriate balance of executing our public health mission and respecting First Amendment rights” with regard to pharmaceutical companies’ commercial speech. These rights have created a legal safety net for companies to market their drugs freely, in the absence of an official process of FDA “approval” for marketing materials, except in rare cases. Today, nine out of the 10 largest revenue-generating pharmaceutical companies, including Johnson & Johnson, Pfizer, and
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Merck, spend more on sales and marketing than on research Merck, spend more on sales and marketing than on research and development. Within this expanded arena of marketing, an estimated $6.4 billion was funneled towards consumer-targeted advertising in 2016 alone. At the same time, recent market trends have also showed stagnant growth rates within the pharmaceutical industry, in terms of lower drug sales and declining research and development productivity, meaning fewer drug approvals each year. Against this discouraging backdrop, the cost of prescription drugs has skyrocketed into one of the largest areas of spending within the U.S. healthcare system, currently making up 10 percent of national health expenditure. Nearly 80 percent of American consumers have called the rising cost of pharmaceuticals as “unreasonable,” adding urgency to current policy debates over healthcare spending and reform. In this context of national outrage, direct-to-consumer advertising presents a potential area for spending reduction and reform. However, with conflicting calls upon the government to simultaneously regulate and deregulate the FDA, the heated debate over DTCPA rages on, nearly 40 years after Rufen and Boots Pharmaceuticals first took to U.S. television screens.
A BITTERSWEET PILL TO SWALLOW Each year, the average American television viewer watches nearly 16 hours of pharmaceutical advertisements, more time than is usually spent with a primary care provider annually. It is estimated that around one-third of patients actually discuss a drug advertisement with their healthcare provider, with the majority eventually requesting a prescription. Proponents of DTCPA cite this idea of consumer empowerment as the major benefit of advertisements that help cultivate patient-clinician dialogue by educating patients about their potential therapeutic options. A trade group representing a number of large pharmaceutical companies,the Pharmaceutical Research and Manufacturers of America, states in its guiding principles, “[Direct to consumer] communications about prescription medicines serve the public health,” noting the power of advertisements to increase awareness about certain diseases. Indeed, DTCPA is often heralded as a de-stigmatizing force for conditions like erectile dysfunction or depression that lack a public media platform. On the other hand, pharmaceutical advertisements may also raise barriers to access through their frequent promotion of higher priced drugs, often of marginal benefit. In response to the growth of DTCPA, the American Medical Association released a statement in 2015 condemning these pharmaceutical advertising practices for “inflat[ing] demand for new and more expensive drugs, even when these drugs may not be appropriate.” Contributing to unnecessary healthcare costs, these advertisements are criticized for spreading misinformation about side effects, ultimately straining relationships between patient and provider. A noteworthy example of this dangerous potential dates back to the boom of pharmaceutical advertising just before the turn of the century. In 1999, Merck Pharmaceuticals released a minute-long commercial for an anti-inflammatory drug called Vioxx, featuring Olympic figure skater Dorothy Hamill testifying to the drug’s benefits for her osteoarthritis. Five years after the drug’s launch, Merck was forced to pull its product from shelves,
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due to new studies that linked Vioxx to increased risk of stroke or heart disease. By then, approximately 20 million Americans had already used the drug, and the company had enjoyed annual profits of $2.5 billion in drug sales. Later research estimates that 88,000 heart attacks resulted from the use of Vioxx, leading to 38,000 deaths. While Merck has since agreed to pay large settlements for lawsuits filed against them, the story of Vioxx remains a cautionary tale.
DON’T SUGARCOAT IT—THE FUTURE OF DTCPA Nearly 20 years after the FDA lifted its moratorium on DTCPA, opinions on either side of the debate have hardly shifted. The FDA continues to struggle with enforcing its “fair balance” requirement for promotional materials, a stipulation that seeks to balance the provided risk and benefit information. While some groups, like the AMA, have called for a complete ban of the practice, certain safeguards of drug companies’ First Amendment rights, as mentioned earlier, are likely to present obstacles. Health policy researcher Dr. Aaron Kesselheim reinforced this likelihood to the HPR, stating that “[DTCPA] isn’t going anywhere anytime soon,” while pointing to the legal precedents set in favor of commercial speech by court cases that have upheld protections for off-label drug promotion. Nevertheless, policy experts have suggested other solutions to improving DTCPA practices, rather than completely dismantling them. These include mandating pre-clearance of advertisements by the FDA, delaying advertising until providers have been fully educated on products in the market, and promoting disease-specific ads, thus removing their commercial aspect while retaining an educational component. In fact, new research has shown that the latter helps achieve the informative purpose of consumertargeted advertisements more effectively than product-specific ads. Harvard University health economist David Cutler also suggested that policy experts are moving in the direction of “academic advertising,” which could manifest in government-run funds in charge of creating brand-less advertisements or dollarfor-dollar advertising that matches product-specific ads with disease-specific ones. However, Professor Cutler notes that changes to advertising practices might not directly translate to reduced pharmaceutical costs. Instead, he believes that regulation of marketing and sales “gives you leeway to enact other changes that would affect drug prices.” For example, if the government mandated all pharmaceutical companies to lower their prices by a certain margin, a ban or restrictions on DTCPA could provide an avenue through which to comply with those measures. While President Trump’s administration has generally opposed efforts to further regulate government bodies like the FDA, the spiraling state of national health expenditure should justify calls for pharmaceutical advertising reform. With sales and marketing budgets for large drug companies only continuing to grow, driving the costs of prescription drugs ever higher, it might be time for Congress to re-assess the risks and benefits of DTCPA, and whether or not consumer-targeted pharmaceutical advertising is right for the American public.
Investigating Barriers to Medical Marijuana Legalization Alexis Mealey
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lex Beck was in his early twenties when he was diagnosed with Stage III lymphoma. After he experienced debilitating side effects from the chemotherapy drug Rituximab and made no progress in treating his cancer, Beck turned to holistic medicine through a Facebook group called The Medicine TrWibe. The organization raised three thousand dollars to send Beck cross country to Colorado where he stopped chemotherapy entirely and used only cannabis in an attempt to cure his cancer. Two years later, Beck continues to baffle doctors at Stanford University, “The doctors said that there is absolutely no reason, with the little amount of chemotherapy I received, that I should still be in remission ... I should have malignant tumors, but my PET scan showed no signs of disease.” Beck’s story is just one of many cases of individuals being cured of numerous ailments by using cannabis, and anecdotal evidence has been bolstered by academic research. Cannabis has been shown to assist in the treatment of childhood seizure disorders, some cancers, muscle spasms, nausea, eating disorders, arthritis, and multiple sclerosis. This research, however, has been limited and obstructed by marijuana’s status as a federally illegal substance. Beck told the HPR that cannabis’ federal status has created tense, even dangerous conditions for researchers, explaining that, “If you release any information on the research you’re doing, you can get arrested.” Regardless of the potential legal repercussions, researchers appear to have made a convincing case, with 76 percent of doctors now favoring the use of medical cannabis. Support for the healing capabilities of cannabis extends beyond the medical community. According to a 2017 Quinnipiac
poll, the American public recognizes the benefits of marijuana, and 94 percent of voters favor medical marijuana legalization. Furthermore, 29 states legalized medical marijuana before the start of 2018. Public support has not, however, been sufficient to garner legal approval, with medical marijuana remaining illegal at the federal level. The Drug Enforcement Agency’s interference and the Food and Drug Administration’s complicated approval system have contributed to the problem.
BUREAUCRATIC BARRIERS Medical cannabis’ path to federal approval has been obstructed by bureaucratic opposition to research, stemming from the FDA’s failure to approve marijuana as medication. The FDA claims to have no issues with approving medical marijuana, so long as it is done using proper clinical research. The obstacles to marijuana legalization arise not from FDA attitudes towards the drug, but rather from the approval process itself. FDA approval begins with companies submitting Investigational New Drug Reports for clinical trials of new medications. The FDA then has 60 days to review and approve the trial. The Center for Drug Evaluation and Research, a research center controlled by the FDA, reviews the work done by outside agents, then makes recommendations on labelling and dosages to the FDA, with the FDA itself conducting no actual studies. Because the FDA relies on outside research firms, cannabis research is at the mercy of state laws. Marijuana’s status as a federally illegal substance makes clinical trials extremely difficult, if not impossible to conduct, hence barring any possible FDA review and approval.
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