Review July 2018
The main plot, which attracted this reviewer’s interest, follows the political manoeuvrings around a newly discovered life extension drug Juventel. In the first chapters, the author makes a good effort to dip enough into the science that those with prior knowledge will not reject the premise as flawed. Less believable perhaps for those steeped in the subject matter is the fact that Juventel was developed, apparently entirely in-house, by the third largest pharmaceutical company in the world. This company now faces the dilemma that has often been discussed in LongeCity circles: how to get the drug approved given that its suspected life-extending properties would take decades to establish?
Here life-extension policy nerds may have expected more discussion of classification of ‘aging as a disease’ (which I was content to see omitted entirely) and possible ‘surrogate endpoints’ (which the author obliquely touches on, but does not develop- perhaps because it might lessen the dilemma on which the hinges the plot).
But the further trajectory is realistic: to fast-track market entry the life extension drug is developed for a niche (‘orphan’) indication with a view towards off-label sales. The neat tweak: to circumvent rules against off-label promotion the company introduces a bill relating to the drug, thereby covering the ensuing political discourse under ‘free speech’.
Again, were this a treatise on “how to get an anti-aging drug to market” one might criticise the lack of attention to many aspects: consideration of the Caronia decision, a look at FDA-internal processes, pressures and politics, the strategies to get into ‘off label’ prescribing circles, the difference between the US and the international markets etc.
But if one follows the plot to this point it then develops themes that relate to the professional experience of the author: more by accident, the ‘smokescreen’ bill becomes a political hot potato and now the rest of the story charts manoeuvres of political decision making in congress. A major sub-plot, and one where the author draws on experience and passion, is the re-election campaign of a John McCain-like figure: an elderly distinguished veteran, a Republican Congressman, who faces for the first time in his long political career an electoral challenge which also becomes a challenge to his ‘old-fashioned’ decency. He emerges as the noble hero of the piece, but it is nice to see that protagonists and arguments on both sides get a relatively fair treatment. There are villains: “Big Pharma” gets short shrift and in the process any discussion about potentially legitimate reasons for opposing lower drug prices or how significant the effect of the medicare drug prices negotiation ban might be. There are Russian troll factories and corrupt politicians, but by and large the author manages to uphold to the end (and despite of the foreseeable twist) a mature ambiguity that contrasts refreshingly with the ‘morality tale’ tone of the book. This contrast also gives rise to the terribly awkward title: there are “no popes in heaven” because no-one who wields real power can stay ‘pure’.
In the face of this aspiration the book does not stand out as an exemplar for exploring the dilemma of power - and not for its literary qualities. The narrative voice fails in trying to assume three tasks at once: a teacher-explainer for political and technical circumstances, a rather stilted inner voice reporting directly what the characters are thinking and feeling, and also a third party commentator remarking on “evil laughs”. Most forays into descriptive prose fail but remain mercifully rare.
Yet once the reader manages to set misgivings about these aside, the story nonetheless flows apace: through dialogue which constitutes most of the text and through its structure of quick back-and forth scenes often only 2 pages in length. An ideal ebook for a public transport commute.
Of course the reason that one might pick the book up and then finds it pleasantly easy to persist, are its qualities as treatise: a “Washington insider” sharing insights into a hidden world. Hal Malchow is chairman of MSHC Partners, one of America’s leading “voter contact” firms, he has a law degree and served as campaign manager for Al Gore’s first campaign for the U.S. Senate. The reader might be sceptical about the million-dollar PR shenanigans described in this book, but surely the author knows what he is talking about. This makes one basic tenet of the book particularly interesting: Malchow assumes that –albeit abetted by nefarious internet troll factories– once a life extension drug becomes available, voters will clamour for it. I have always been sceptical about this assumption. Surely voters (Americans especially) encounter claims for ‘miracle’ drugs every day? The backpage presents a quote attributed to Mark Twain “if voting made any difference they wouldn’t let us do it” – but the book actually portrays the opposite: politicians swept aside by the voters desire to live a few extra years in spite of a lack of expert consensus, counter-spin, economic concerns, big-pharma lobbying, tribal politics and ‘fake news’.
In describing these strategies mustered by both sides in a morally ambiguous battle the book hits its strongest notes. There are weaknesses: for all its valiant attempts at even-handedness the ‘other side’ is not always developed. An inside-FDA perspective is presented very late and rather perfunctory; an inside perspective from the Democratic challenger is missing almost entirely. For a ‘realistic’ scenario it seems unlikely that Juventel would face scientific criticisms only from bought stooges, or that the action should be limited to the USA.
Nonetheless, the novel delivers unique, informed and nuanced insight into US lobbying applied to a potential life-extension treatment via an enjoyable read.
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