Summary

Dr. R. K. Smile, MD, founder of Smile Pharmaceuticals, Inc. (SPI), enjoys a sudden lurch into fortune and celebrity. Dubbed the ‘Little King’ by his Atlanta-based Indian community, Dr. Smile is a towering medical authority, philanderer and philanthropist, known to be both generous and avaricious. His pinnacle pharmaceutical coup, the patent that has earned him billionaire status, is InSmile™, a sublingual fentanyl spray designed for terminally ill cancer patients. Dr. Smile’s entrepreneurial vim, however, hardly stems from benevolent medical research, but rather an ‘excellent business model’ that he observed on a visit to India during which a Bombay ‘urchin’ handed him a business card that read, ‘Are you alcoholic? We can help. Call this number for liquor home delivery.’ The blunt practicality of building a market around sating addiction strikes the doctor as entirely sensible. Often wistful about India’s ‘old days,’ Dr. Smile fondly recounts the insouciance of neighborhood dispensary hawkers, their willingness to ‘hand out drugs without a doctor’s chit.’ Though admitting that ‘it was bad for [their] customers’ health but good for the health of the business,’ Dr. Smile yearns to replicate a similar culture of delinquent pharmacology, an unregulated market capable of profiting from supply-and-demand forces but indifferent to the wellbeing of its patrons. 

In the meantime, Dr. Smile’s wife, Mrs. Happy Smile, a simpering and daft socialite, envisions grand branding prospects that will globalize the Smile name through ostentatious publicity—inscribed name placards at the ‘Opera, art gallery, university, hospital […] your name will be so, so big.’ She refers to the worldwide reputation of the OxyContin family, the proliferation of the family’s name and esteemed place among prestigious cultural institutions: ‘So, so many wings they have,’ she says, ‘Metropolitan Museum wing named after them, Louvre wing also, London Royal Academy wing also. A bird with so, so many wings can fly so, so high.’ 

InSmile™ sales drive Dr. Smile’s burgeoning drug trade, as his prescription becomes preferred to conventional OxyContin highs due to its ‘instant gratification’ in the form of an oral spray. While SPI fulfills special house-calls for American celebrities and customers in ‘gated communities from Minneapolis to Beverly Hills,’ it also ships millions of opioid products to places such as Kermit and Mount Gay, West Virginia—communities, outside fictional contexts, that bear real-world vestiges of the opioid epidemic (West Virginia has the highest rate of drug overdose in the United States). Through a lecture series scheme, Dr. Smile bribes respected doctors to publicize and prescribe the medication, further entrenching the dangerous drug in medical circles.

As the SPI empire collapses following a SWAT-led arrest of his wife, Dr. Smile muses indignantly on his reputation and the ingratitude of his clients. Tugged again by nostalgia for the old country, he justifies his drug trafficking by likening it to quotidian misdemeanors, instances when one could circumvent the inconveniences of India’s law by knowing how to pull the venal strings of corrupt systems—like cutting a long ticket queue at the rail station, he says, by paying a little extra at a backyard office; or bribing government officers to stamp customs papers required to ship restricted antiques abroad—‘We know what is the oil that greases the wheels.’ With this deleterious mindset, combining nostalgia and entrepreneurial greed, Dr. Smile’s future is uncertain, but he is resolved to return—after all, he says, ‘I have lawyers.’

Commentary

In an interview with The New Yorker, Rushdie remarks that the fictional Dr. Smile is based on the divisive Indian-American pharmaceutical entrepreneur, John Kapoor, the former CEO of Insys Therapeutics. Kapoor conceptualized an FDA-approved fentanyl spray technology (SUBSYS) as a highly potent palliative drug for cancer patients. When sales peaked over $330M in 2015, however, Kapoor’s critics voiced concerns that Insys’ revenues were derived from prescribing SUBSYS to patients who did not have cancer. Isolated cases of bribery emerged, providing evidence that Kapoor’s machinations involved using racketeering and mail/wire fraud to sell the drug to ineligible patients. One reported instance involved a Connecticut-based nurse practitioner who pleaded guilty to prescribing SUBSYS to non-cancer Medicare patients after accepting a kickback from Insys. One Insys sales representative also pleaded guilty to bribing doctors to prescribe the drug. A Michigan doctor testified that he received thousands of dollars from Insys as he prescribed SUBSYS to patients he knew were addicted and did not require the drug. Like the bogus speaker series described in Dr. Smile’s story, Kapoor used funded lectures to conceal kickbacks allotted to physicians selling the drug.

The poignancy of Rushdie’s narrative lies in obfuscating the line dividing the old country and the modern-day American medical establishment—that is, is the Bombay urchin who sells liquor to alcoholics different from American physicians who receive kickbacks for prescribing a highly addictive drug to ineligible patients? Indeed, Dr. Smile is not unlike the old-world dispensary vendor, the Bombay liquor distributor, the railway ticket clerk, the customs official with the government stamp—he, like them, as a practical and phlegmatic provider of goods, executes a transaction without asking questions or scrutinizing consequences. Like the old country, with its bureaucracies and graft, American medicine may be just as susceptible to corruption.

Primary Source

The New Yorker

Publisher

Condé Nast

Publisher

Condé Nast

Publisher

Condé Nast

Place Published

New York

Place Published

New York

Place Published

New York

Edition

August 24 & 31, 1998

Edition

May 20, 2019 (Print Issue)

Page Count

68-75

Page Count

52-60