We should be grateful for institutions and practices mandated by law and enforced to some extent that serve the general welfare of Americans. These are not gifts from generous oligarchs or reprieves from indulgent dictators. They are the fruits of struggles by millions of Americans to improve the lives of anybody and everybody. There always have been and always will be fellow citizens who insist on promoting their self-interests ahead of the general welfare, but few can deny that this country has more opportunity and fairness now than it had a hundred or even fifty years ago.  It has social safety nets in place to help keep people from starving to death or to being denied healthcare. It has systematically shed laws and practices that institutionalized racism, antisemitism, and xenophobia. It has a financial system that has kept us out of cyclical economic booms and busts that were considered inevitable just a century ago.

With all of these achievements, one would think that the general population of our country would be focused on further improvements, rather than on diminishing what has been achieved. Current events and trends indicate that this is not the case. We are at a tipping point when our safety nets may soon lay in tatters and our somewhat democratic system of government may soon be extinguished and replaced with a totalitarian oligarchy. A totalitarian oligarchy is a government in which a few ridiculously wealthy and unscrupulous men call the shots and stay in power by handing out favors and eliminating opposition. To see how this happens and how it works look at Belarus, Venezuela, Nicaragua, Russia, China, Myanmar, Iran, and others.

It takes relatively few greedy and power-hungry people to overthrow a democracy.  Even while some democratic institutions survive, the machinery of government can be undermined or co-opted by special interests. In the nineteenth and early twentieth century, Tammany Hall, an organized crime syndicate controlling most of the political machinery in the Northeastern United States, routinely frustrated the will of voters by rigging elections and funneling unspeakable fortunes to its loyal members. It overcharged state and city treasuries fantastic sums for routine maintenance contracts that it awarded its own members. Plaster repairs to a single room in city or state facilities would routinely cost hundreds of thousands of dollars. Honest citizens risked their lives if they objected or even voiced concern. Since Tammany Hall controlled the legislatures, courts and police, there really was no one to whom you could complain. This is the nature of a totalitarian oligarchy.

In more recent times, we have seen the rise of special interest groups that hold sway over a Congress financed by and indebted to financial firms, the drug industry, the military-industrial complex, the medicine lobby, religious groups and a host of other entities clamoring for special attention and consideration in the drafting of legislation and the promotion of specific projects.  Even when the Constitution was being drafted, the Founders recognized that there would be special interests exerting influence over the Congress. James Madison argued that the number and variety of special interests would effectively cancel each other out, and the Congress would be obliged to follow a course that represented all interests, rather than just a few.  He was wrong.

I worked in the drug industry and observed millions of dollars in “campaign contributions” and other considerations flow into the coffers of legislators who decided whether or not drugs were approved by the Food and Drug Administration (FDA). The notion that the FDA was an autonomous agency unaffected by Congress was most recently undermined by the surprise approval of Aduhelm, a drug developed to treat Alzheimer’s Disease. Aduhelm had no demonstrable benefit in trials conducted using the drug. The committee of experts reviewing the trials for the FDA deemed the trial results inconclusive and voted against the drug’s being approved. The FDA approved the drug anyway.

In a demonstration of unabashed greed, the company selling Aduhelm said that it would charge $56,000 for a one year course of treatment, with treatment courses continuing for years until the affected patient died. When Medicare approves this drug for re-imbursement (as it inevitably will) every American with Part B Medicare insurance will have a major increase in their annual premiums. ‘Big pharma,’ the pharmaceutical lobby, contributes heavily to the health and well-being of our Congress.

Of course, Congress could demand a more competitive pricing of drugs, as is the case in most European countries. Unfortunately, the pharmaceutical lobby insisted that would not happen and guaranteed that Americans paid top dollar for their drugs by having their legislators pass laws that effectively barred Medicare from negotiating drug prices. 

As a physician, I have no way of knowing how the military-industrial complex secures a giant chunk of the national budget. I find it odd that suppliers to the military get paid hundreds of billions of dollars for preparedness when we are not engaged in a major conflict, and yet the Congress needs to borrow trillions more to finance longstanding conflicts, like our 20 year involvement in Afghanistan. We have a Congress that frets about spending a few million dollars on homeless children while providing blank checks to our friends in the aerospace, munitions and related industries.

Frederick Gates was John D. Rockefeller’s chief financial adviser. When Rockefeller had secured control over much of the American economy, Gates told him he needed to start giving it away to avoid a popular uprising that might destroy his empire.  Rockefeller took the advice of this wise man and lived to see his empire survive. Let us hope that we have enough wise men and women in our government to guarantee it will not be destroyed by special interests promoting their own agendas without regard for the general welfare of all Americans.  Let us hope we celebrate future holidays without future history books noting the month and year when our fragile and unfinished American democracy crumbled.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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