John Abramson: Big Pharma | Lex Fridman Podcast #263
the jury found pfizer guilty of fraud and racketeering violations how does big farm affect your mind everyone's allowed their own opinion i don't think everyone's allowed their own scientific facts despiser played by the rules pfizer isn't battling the fda pfizer has joined the fda the following is a conversation with john abramson faculty at harvard medical school a family physician for over two decades and author of the new book sickening about how big pharma broke american healthcare and how we can fix it this conversation with john abramson is a critical exploration of the pharmaceutical industry i wanted to talk to john in order to provide a countervailing perspective to the one expressed in my podcast episode with the ceo of pfizer albert berla and here please allow me to say a few additional words about this episode with the pfizer ceo and in general about why i do these conversations and how i approach them if this is not interesting to you please skip ahead what do i hope to do with this podcast i want to understand human nature the best and the worst of it i want to understand how power money and fame changes people i want to understand why atrocities are committed by crowds that believe they're doing good all this ultimately because i want to understand how we can build a better world together to find hope for the future and to rediscover each time through the exploration of ideas just how beautiful this life is this our human civilization in all of its full complexity the forces of good and evil of war and peace of hate and love i don't think i can do this with a heart and mind that is not open fragile and willing to empathize with all human beings even those in the darkest corners of our world to attack is easy to understand is hard and i choose the hard path i have learned over the past few months that this path involves me getting more and more attacked from all sides i will get attacked when i host people like jay bhattacharya or francis collins jamie mertzel or vincent ruckanyello when i stand for my friend joe rogan when i host tech leaders like mark zuckerberg elon musk and others when i eventually talk to vladimir putin barack obama and other figures that have turned the tides of history i have and i will get called stupid naive weak and i will take these words with respect humility and love and i will get better i will listen think learn and improve one thing i can promise is there's no amount of money or fame they can buy my opinion or make me go against my principles there's no amount of pressure that can break my integrity there's nothing in this world i need that i don't already have life itself is the fundamental gift everything else is just a bonus that is freedom that is happiness if i die today i will die a happy man now a few comments about my approach and lessons learned from the albert berla conversation the goal was to reveal as much as i could about the human being before me and to give him the opportunity to contemplate in long-form the complexities of his role including the tension between making money and helping people the corruption that so often permeates human institutions the crafting of narratives through advertisements and so on i only had one hour and so this wasn't the time to address these issues deeply but to show if albert struggled with them in the privacy of his own mind and if he would let down the veil of political speak for a time to let me connect with a man who decades ago chose to become a veterinarian who wanted to help lessen the amount of suffering in the world i had no pressure placed on me there were no rules the questions i was asking were all mine and not seen by pfizer folks i had no care whether i ever talked to another ceo again none of this was part of the calculation in my limited brain computer i didn't want to grill him the way politicians grill ceos in congress i thought that this approach is easy self-serving dehumanizing and it reveals nothing i wanted to reveal the genuine intellectual struggle vision and motivation of a human being and if that fails i trusted the listener to draw their own conclusion and insights from the result whether it's the words spoken or the words left unspoken or simply the silence and that's just it i fundamentally trust the intelligence of the listener you in fact if i criticize the person too hard or celebrate the person too much i feel i fail to give the listener a picture of the human being that is uncontaminated by my opinion or the opinion of the crowd i trust that you have the fortitude and the courage to use your own mind to empathize and to think two practical lessons i took away first i will more strongly push for longer conversations of three four or more hours versus just one hour 60 minutes is too short for the guests to relax and to think slowly and deeply and for me to ask many follow-up questions or follow interesting tangents ultimately i think it's in the interest of everyone including the guests that we talk in true long form for many hours second these conversations with leaders can be aided by further conversations with people who wrote books about those leaders or their industries those that can steal man each perspective and attempt to give an objective analysis i think of teddy roosevelt's speech about the man in the arena i want to talk to both the men and women in the arena and the critics and the supporters in the stands for the former i lean toward wanting to understand one human being's struggle with the ideas for the latter i lean towards understanding the ideas themselves that's why i wanted to have this conversation with john abramson who is an outspoken critic of the pharmaceutical industry i hope it helps add context and depth to the conversation i had with the pfizer ceo in the end i may do worse than i could have or should have always i will listen to the criticisms without ego and i promise i will work hard to improve but let me say finally that cynicism is easy optimism true optimism is hard it is the belief that we can and we will build a better world and that we can only do it together this is the fight worth fighting so here we go once more into the breach dear friends i love you all this is a lex friedman podcast to support it please check out our sponsors in the description and now here's my conversation with john abramson your faculty at harvard medical school your family physician for over two decades rated one of the best family physicians in massachusetts you wrote the book overdosed america and the new book coming out now called sickening about how big pharma broke american healthcare including science and research and how we can fix it first question what is the biggest problem with big pharma that if fixed would be the most impactful so if you can snap your fingers and fix one thing what would be the most impactful you think the biggest problem is the way they determine the content the accuracy and the completeness of what doctors believe to be the full range of knowledge that they need to best take care of their patients so that with the knowledge having been taken over by the commercial interests primarily the pharmaceutical industry the purpose of that knowledge is to maximize the profits that get returned to investors and shareholders and not to optimize the health of the american people so rebalancing that equation would be the most important thing to do to get our health care back aimed in the right direction okay so there's a tension between helping people and making money so if we look at particularly the task of helping people in medicine in health care is it possible if money is the primary sort of mechanism by which you achieve that as a motivator is it possible to get that right i think it is lex but i think it is not possible without guard rails that maintain the integrity and the balance of the knowledge without those guard rails it's like trying to play a professional basketball game without referees and having players call their own fouls but the players are paid to win and you can't count on them to call their own fouls so we have referees who are in charge we don't have those referees in american health care that's the biggest um way that american health care is distinguished from health care and other wealthy nations so okay so you mentioned milton friedman and you mentioned his book called capitalism and freedom he writes that there are only three legitimate functions of government to preserve law and order to enforce private contracts and to ensure that private markets work you said that uh that was a radical idea at the time but we're failing on all three how are we failing and and uh also maybe the bigger picture is what are the strengths and weaknesses of capitalism when it comes to medicine and healthcare can we separate those out because those are two huge questions so how we're failing in all three and these are the minimal functions that our guru of free market capitalism said the government should perform so this is the absolute baseline on preserving law and order the drug companies routinely violate the law in terms of their marketing and uh in terms of their presentation of the results of their trials i know this because i was an expert in litigation for about 10 years i presented some of what i learned in civil litigation to the fbi and the department of justice and that case led to the biggest criminal fine in u.s history as of 2009 and i testified in a federal trial in 2010 and the jury found pfizer guilty of fraud and racketeering violations in terms of violating the law it's a routine occurrence the drug companies have paid 38 billion dollars worth of fines from i think 1991 to 2017. it's never been enough to stop the uh misrepresentation of their data and rarely are the fines greater than the profits that were made uh see uh executives have not gone to jail for misrepresenting data that have involved even tens of thousands of deaths in the case of vioxx oxycontin as well and when companies plead guilty to felonies which is not an unusual occurrence the government usually allows the companies the parent companies to allow subsidiaries to take the plea so that they are not one step closer to getting disbarred from medicare not being able to participate in medicare um so in that sense there is a mechanism that is appearing to impose law and order on drug company behavior but it's clearly not enough it's not working can you actually speak to human nature here are people corrupt are people malevolent are people ignorant that work at the low level and at the high level advisor for example at big pharma companies how's this possible so i believe just in a small tangent that most people are good and i actually believe if you join big pharma so a company like pfizer your life trajectory often involves dreaming and wanting and enjoying helping people yes and so and then we look at the outcomes that you're describing and uh it looks and that's why the narrative takes hold that like pfizer ceo albert brola who i talked to is malevolent the sense is like these these companies are evil so if the the different parts the people are good and they want to do good how are we getting these outcomes yeah i think it has to do with the cultural milieu that this is unfolding in and we need to look at sociology uh to understand this that when the cultural milieu is set up to maximize the returns on investment for shareholders and other venture capitalists and hedge funds and so forth when that defines the culture and the higher up you are in the corporation the more you're in on the game of uh getting rewarded for maximizing the profits of the investors that's the culture they live in and it becomes normative behavior to do things with science that look normal in that environment and our shared values within that environment by good people whose self-evaluation becomes modified by the goals that are shared by the people around them and within that millior you have one set of standards and then the rest of good american people have the expectation that the drug companies are trying to make money but that they're playing by rules that aren't part of the insider milieu that's fascinating the the game they're playing modifies the culture you know of inside the meetings inside the rooms day to day that there's a bubble that forms like we're all in bubbles of different sizes right and that bubble allows you to drift in terms of what you see as ethical and unethical because you see the game as just you know it's just part of the game so marketing is just part of the game right and paying the fines is just part of the game of science yeah and without guard rails it becomes even more part of the game you keep moving in that direction if you're not bumping up against guardrails and i think that's how we've gotten to the extreme situation we're in now so like i mentioned i spoke with pfizer ceo albert berla and i'd like to raise with you some of the concerns i raised with him so one you already mentioned i raised the concern that pfizer is engaged in aggressive advertising campaigns as you can imagine he said no what do you think i think you're both right i think that the i agree with you that the aggressive advertising campaigns do not add value to society and i agree with him that they're for the most part legal and it's the way the game is played right so sorry to interrupt but oftentimes his responses are um especially now he's been ceo for only like two years three years he says pfizer was a different company we've made mistakes right in the past we don't make mistakes anymore that there's rules and we play by the rules so like uh with every concern raised there's very very strict rules as he says in fact he says sometimes way too strict and we play by them and so in that sense advertisement it doesn't seem like it's too aggressive because it's playing by the rules and relative to the other again it's the game relative to the other companies it's actually not that aggressive but relative to the other big pharma company yes yes i i hope we can quickly get back to whether or not they're playing by the rules but in general but let's just look at the question of advertising specifically i think that's a good example of what it looks like from within that culture and from outside that culture he's saying that we follow the law on our advertising we state the side effects and we state the fda approved indications and we we do what the law says we have to do for advertising and i have not i've not been an expert in litigation for a few years and i don't know what's going on currently but let's take him at his word it could be true it might not be but it could be but if that's true in his world in his culture that's ethical business behavior from a common sense person's point of view a drug company paying highly skilled media folks to take the information about the drug and create the illusion uh the emotional impact and the take away message for viewers of advertisements that grossly exaggerate the benefit of the drug and minimize the harms it's sociopathic behavior to have viewers of ads leave the ad with an unrealistic impression of the benefits and harms of the drug and yet he's playing by the rules he's doing his job as ceo to maximize the effect of his advertising and if he doesn't do it this is a key point if he doesn't do it he'll get fired and the next guy will so the people that survived the company the people that get uh raises in the company move up and the company are the ones that play by the rules and that's how the game solidifies itself but the game is within the balance of the law sometimes most of the time not always we'll return to that question i'm actually more concerned about the effect of advertisement in a kind of much larger scale on the people that are getting funded by the advertisement in self-censorship just like more subtle more uh more passive pressure to not say anything negative because i've seen this and i've been saddened by it that uh people sacrifice integrity in small ways when they're being funded by a particular company they don't they don't see themselves as doing so but you could just clearly see that the space of opinions that they're willing to engage in or a space of ideas they're willing to play with is one that doesn't include negative anything that could possibly be negative about the company they just choose not to because you know why and that that's really sad to me that you know if you give me a hundred bucks i'm less likely to say something negative about you um that makes me sad because like the reason i wouldn't say something negative about you i prefer is the pressure of friendship and human connection those kinds of things so i understand that um that's also a problem by the way so they started having dinners and shaking hands and oh aren't we friends but the fact that money has that effect is really sad to me on the news media on the journalists on scientists that's scary to me um but of course the direct advertisement to consumers like you said is a potentially very negative effect i i wanted to ask if um what do you think is the most negative impact of advertisement is it that direct to consumer on television is it advertisement of the doctors which i'm surprised to learn i was vaguely looking at is more than the advertisement more spent on advertising to doctors than to consumers that's really confusing to me it's fascinating actually and then also obviously the the law side of things is the lobbying dollars which i think is less than all of those but anyway it's in the ballpark what concerns you most well it's the whole nexus of influence there's not one thing and and they don't uh invest all their they don't put all their eggs in one basket it's a whole surround sound um program here yeah uh but in terms of advertisements let's take an advertisement trulicity is a diabetes drug a tub for type 2 diabetes an injectable drug and it lowers blood sugar just about as well as um metformin does metformin costs about four dollars a month uh true licity costs i think sixty two hundred dollars a year so forty eight dollars a year versus sixty two hundred trulicity has distinguished itself because it did uh the manufacturer did a study that showed that it significantly reduces the risk of cardiovascular disease in diabetics and they got approval on the basis of that study that very large study being statistically significant what the so the ad the ads obviously extol the virtues of trulicity because it reduces the risk of heart disease and uh stroke and that's one of the major morbidities risks of type 2 diabetes what the ad doesn't say is that you have to treat 323 people to prevent one non-fatal event at a cost of 2.7 million dollars and even more importantly than that what the ad doesn't say is that the evidence shows that engaging in an active healthy lifestyle program reduces the risk of heart disease and strokes far more than true licity does now this to be fair to the company the sponsor there's never been a study that uh compared trulicity to lifestyle changes but that's part of the problem of our advertising you would think in a rational society that was way out on a limb as a a lone country besides new zealand that allows direct to consumer advertising that part of allowing direct-to-consumer advertising would be to mandate that the companies establish whether their drug is better than say healthy lifestyle adoption to prevent the problems that they claim to be preventing but we don't require that so the companies can afford to do very large studies so that very small differences become statistically significant and their studies are asking the question how can we sell more drug they're not asking the question how can we prevent cardiovascular disease in people with type 2 diabetes and that's how we get off in this we're now on the in the extreme arm of this distortion of our medical knowledge of studying how to sell more drugs than how to make people more healthy that's a really great thing to compare to is lifestyle changes because that should be the bar if you uh if you do some basic diet exercise all those kinds of things how does this drug compare to that right right and that study was done actually in the 90s it's called the diabetes prevention program it was federally funded uh by the nih so that there wasn't this drug company imperative to just try to prove your drug was better than nothing and it was it was a very well designed study randomized controlled trial in people who were at high risk of diabetes so-called pre-diabetics and they were randomized to three different three different groups a placebo group a group that got treated with metformin um and a group that got treated with intensive lifestyle counseling so this study really tested whether you can get people in a randomized controlled trial assigned to uh intensive lifestyle changes whether that works now the the uh common wisdom amongst physicians and i think in general is that you can't get people to change you know you can do whatever you want you can stand on your head you can beg and plead people won't change so give it up and let's just move on with the drugs and not waste any time except this study that was published in the new england journal i think in 2002 shows that's wrong that the people who were the in the intensive lifestyle group ended up losing 10 pounds exercising five times a week maintaining it and reduced the risk of getting diabetes by 58 compared to the metformin group which reduced its risk of getting diabetes by 31 so that that exact study was done and it showed that lifestyle intervention is the winner who as a small tangent is the leader who is supposed to fight for the side of lifestyle changes where's the big pharma version of lifestyle changes who's supposed to have the big bully pulpit the big money behind lifestyle changes right in your sense because because that seems to be missing in a lot of our discussions about health policy right that's exactly right and the answer is that we assume that the market has to solve all these problems and the market can't solve all these problems there needs to be some way of protecting the public interest for things that aren't financially driven so that the overriding question has to be how best to improve americans health not companies funding studies to try and prove that their new inexpensive drug is better and should be used well some of that is also people sort of uh like yourself i mean it's funny you spoke with joe rogan he constantly espouses lifestyle changes so some of it is almost like understanding the problems that big farmers creating society and then uh sort of these influential voices speaking up against it so whether they're scientists or just regular communicators yeah i think you got to tip your hat to joe for getting that message out and he clearly believes it and does his best but it's not coming out in the legitimate avenues in the legitimate channels that are evidence-based medicine and the from the sources that the docs are trained to uh listen to and and modify their patient care on now it's not a hundred percent i mean there are articles in in uh in the big journals about the benefits of lifestyle but they don't carry the same gravitas as the randomized controlled trials that test this drug against placebo or this drug against another drug so the joe rogans of the world keep going you know i tip my hat but it's not going to carry the day for most of the people until it has the legitimacy of the medical establishment yeah like something that the doctors really pay attention to well there's there's an entire mechanism established for testing drugs there's not an entire mechanism established for in terms of scientific rigor of testing lifestyle changes i mean it's it's it's more difficult i mean everything is difficult in science with that science that involves humans especially uh but it's just it's these studies are very expensive they're difficult it's difficult to find conclusions and to control all the variables and so it's very easy to dismiss them unless you really do a huge study that's very well funded and so maybe the doctors just lean towards the simpler studies over and over which is what the drug companies fund they can control more variables see but the control there is sometimes by hiding things too right so sometimes you can just say that this is a well-controlled study by pretending there's a bunch of other stuff just ignoring the stuff um that could be correlated it could be the real cause of the effects you're seeing all that kind of stuff so uh money can buy ignorance i suppose in science it buys kind of blinders that are on that don't look outside the reductionist model and and that's another issue is that we kind of nobody says to uh doctors in training only listen to reductionist um uh studies and conclusions and methods of promoting health nobody nobody says that explicitly but the respectable science has to do with controlling the factors and um i mean it just doesn't make sense to me i'm going to pick on true literacy because it's such an obvious example but it's not more egregious than the than many others it doesn't make sense to me to allow a drug to be advertised as preventing cardiovascular disease when you haven't included lifestyle changes as an arm in the study it just it's just so crystal clear that the purpose of that study is to sell trulicity it's not to prevent cardiovascular disease you know if if we were in charge i would try to convince you that anywhere that study the results of that study were presented to physicians it would be stamped in big red letters this study did not compare trulicity to lifestyle changes they need to know that and the docs are kind of trained these blinders get put on and they're trained to kind of forget that that's not there do you think so first of all that's a small or big change to advertisement that seems obvious to say like in in enforce that it should be compared to lifestyle changes do you think advertisements period in united states for pharmaceutical drugs should be banned i think they can't be banned so it doesn't matter what i think okay let's say you were a dictator and two why can't they be banned okay uh either answer either one i believe i've been told by lawyers who i trust that the uh freedom of speech in the in the u.s constitution is such that you can't ban them that you could ban cigarettes and alcohol which have no therapeutic use but drugs have a therapeutic use and they uh advertisements about them can't be banned let's assume that they can't be because we know they won't be anyway um but let's assume they can't be that the and especially our supreme court now is unlike would be unlikely to um take that seriously but that's not the issue the issue is that if drugs want us if the drug companies want to spend their money advertising they should have to have independent analysis of the message that the viewers are left with about the drug so that it's realistic what's the chance the drug will help them well with intrulicity it's one out of 323. 322 people aren't going to benefit from the cardiovascular reduction risk reduction um what's the true cost when when drugs advertise that you may be able to get this for a 25 copay or something tens of thousands of dollars a year drug for 25 copay what an enormous disservice that is to misrepresent the costs of society that should not be allowed so you should have to make it clear to the viewers how many people are going to benefit what's your chance of benefiting how does it compare to lifestyle changes or less expensive therapies what do you give up if you use a less expensive therapy or gain perhaps and how much it costs how much it costs now that can go either way because if you say humira cost 72 000 and it's no more effective as a first-line drug than methotrexate which costs 480 people might say i want the expensive drug because i can get it for 25 copay um so you'd have to uh temper that a little bit oh you mean people are so they don't care they don't care their insurance is going to cover it and it's a 25 copay but we could figure out how to deal with that the the main point is that if we assume that advertisements are going to keep going and they are um we could require that there be outside evaluation of the message that reasonable unbiased viewers take away from the ads and the ads would have to tell the truth about the drug and the the truth should have like sub truth guard rails meaning like the cost that we talked about the effects compared to things that actually you know lifestyle changes um just these details very strict guardrails of what actually has to be specified and i would make it against the law to have family picnics or dogs catching frisbees in the ads so you mean 95 of the ads yes um i mean there's something dark and authentic about those advertisements but they see i mean i'm sure they're being done because they work for the target audience and then the doctors too can you really buy a doctor's opinion why does it have such an effect on doctors advertisement to doctors like you as a physician again like from everything i've seen people love you and i of uh just um people should uh definitely look you up from there's a bunch of videos of you giving talks on youtube and it's just just the it's so refreshing to hear just a clarity of thought about health policy about health care just the way you think throughout the years thank you so like it's easy to think about like maybe you're criticizing big pharma that's part of one part of the message that you're talking about but you know that's not like your brilliance actually shines in in the positive in the solutions and how to do it so as a doctor what affects your mind yeah and how does big pharma affect your mind number one the information that comes through legitimate sources that doctors have been taught to rely on evidence-based medicine the articles in peer-reviewed journals the guidelines that are issued now those are problematic because when an article is peer-reviewed and published in a respected journal people and doctors obviously assume that the peer reviewers have anal have had access to the data and they've independently analyzed the data and they corroborate the findings in the manuscript that was submitted or they give feedback to the authors and say we disagree with you on this point and would you please check our analysis and if you agree with us making that's what they assume the peer review process is but it's not the peer reviewers don't have the data the peer reviewers have the manuscript that's been submitted by the usually in conjunction with or by the drug company that manufactures the drug so peer reviewers are unable to perform the job that doctors think they're performing to vet the data to assure that it's accurate and reasonably complete they can't do it and then we have the clinical practice guidelines which are increasingly more important as the information the flow of information keeps getting brisker and brisker and docs need to get to the bottom line quickly clinical practice guidelines become much more important and we assume that the authors of those clinical practice guidelines have independently analyzed the data from the clinical trials and make their recommendations that set the standards of care based on their analysis that's not what happens the experts who write the clinical trials rely almost entirely on the publications presenting the results of the clinical trials which are peer reviewed but the peer reviewers haven't had access to the data so we've got a system of the highest level of evidence that doctors have been trained over and over again to rely on to practice evidence-based medicine to be good doctors that has not been verified do you think that data that's coming from the pharma companies do you think they're uh what level of manipulation is going on with that data is it the at the study design level is it that literally there's some data that you just keep off you know keep out of the charts keep out of the the aggregate analysis then you then publish or is it the worst case which is just change some of the numbers it happened all three happen i can't i don't know what the denominator is but i spent about 10 years in litigation and for example in vioxx which was withdrawn from the market in 2004 in the biggest drug recall in american history the problem was that it got recalled when a study that merck sponsored showed that vioxx doubled the risk more than double the risk of heart attacks strokes and blood clots serious blood clots it got pulled then but there was a study that a bigger study that had been published in 2000 in the new england journal of medicine that showed that vioxx was a better drug for um arthritis and pain not because it was more effective it's no more effective than aleve or advil but because it was less likely to cause serious gi complications bleeds and perforations in the gut now in that study that was published in the new england journal that was never corrected it was a little bit modified 15 months after the drug was taken off the market but never corrected merck left out three heart attacks and the fda knew that merck left out three heart attacks and the fda's analysis of the of the data from that study said that they weren't gonna the fda wasn't gonna do the analysis without the three heart attacks in it and the important part of this story is that there were 12 authors listed on that study in the new england journal two were merck employees they knew about the three heart attacks that had been omitted the other 10 authors the academic authors didn't know about it they hadn't seen that data so merck just they had an excuse it's complicated and the fda didn't accept it so there's no reason to go into it but merck just left out the three heart attacks and the three heart attacks it may seem 300 attacks in a 10 000 person study may seem like nothing except they completely changed the statistics so that had the three heart attacks been included the only conclusion that merck could have made was that vioxx significantly increased the risk of heart attack and they abbreviated their endpoint from heart attacks strokes and blood clots to just heart attacks yeah so those are maybe in their mind they're also playing by the rules because of some technical excuse that you mentioned that was rejected how can this no because this is not let me interrupt no that's not true um the study was completed the blind was broken meaning they looked at the data in march of 2000 the article was published in the new england journal in november of 2000. in march of 2000 there was an email by the head scientist that was published in the wall street journal that said the day that the data were unblinded that it's a shame that the cardiovascular events are there but the drug will do well and we will do well but removing the three heart attacks how does that happen like uh who has to convince themselves is this pure malevolence um you have to be the judge of that but the person who was in charge of the data safety monitoring board issued a letter that said they'll stop counting cardiovascular events a month before the trial is over and they'll continue counting gi events and that person got a contract to consult with merck for five thousand dollars a day i think for 12 days a year for one or two years that was signed that contract was signed within two weeks of the decision to stop counting heart attacks i won't understand that man or woman i wanna i want it's the uh i've been reading a lot about nazi germany and and thinking a lot about the good germans because i want to understand so that we can each encourage each other to take the small heroic actions that prevents that because it feels to me removing malevolence from the table where it's just a pure psychopathic person that there's just no momentum created by the game like you mentioned yes and so it takes reversing the momentum within the company i think requires many small acts of heroism not gigantic i'm going to leave and become a whistleblower and publish a book about it but small quiet acts of pressuring against this like what are we doing here we're trying to help people is this the right thing to do looking in the mirror constantly asking is this the right thing to do i mean that's how that's what integrity is acknowledging the pressures you're under and then still be able to zoom out and think what is the right thing to do here but the data hiding the data makes it too easy to live in ignorance so like within those inside those companies so your idea is that the reviewer should see the data that's that's one step so to even push back on that idea is i assume you mean that data remains private except to the peer reviews reviewers the problem of course is as you probably know is the peer review process is not perfect you know it's individuals it feels like there should be a lot more eyes on the data than just the peer reviewers yes this is not a hard problem to solve when a study is completed um a clinical study report is made and it's usually several thousand pages and what it does is it takes the raw patient data and it tabulates it in the ways uh it's supposedly and usually in the ways that the company has pre-specified so that you then end up with a searchable let's say 3 000 page document as i became more experienced as an expert in litigation i could go through those documents pretty quickly uh quickly may mean 20 hours or 40 hours but it doesn't mean three months of my work and see if the companies if the way the company has analyzed the data is consistent with the way with their statistical analysis plan and their uh pre-specified outcome measures it's not hard and i think you're right peer reviewers i don't peer review clinical trials but i peer review other kinds of articles i have to do one on the airplane on the way home and it's hard i mean we're just ordinary mortal people volunteering unpaid the motivation is not clear the motivation is to keep um to be a good citizen uh in the medical community um and to be on friendly terms with the journals so that if you want to get published this sort of an unspoken yeah uh incentive as a as somebody who enjoys game theory i feel like that motivation is good but could be a lot better yes you should get more recognition or in some way academic credit for it um it should go to your career advancement if it's an important paper and you recognize it's an important paper as a great peer reviewer that this is not in that area where it's uh uh like clearly piece of crap paper or clearly an awesome paper that doesn't have controversial aspects to it and it's just a beautiful piece of work okay those are easy and then there is like the very difficult gray area which may require many many days of work on your part as a peer reviewer so it's not you know it's not just a couple hours but really seriously reading like some papers can take months to really understand so if you really want to struggle um there has to be an incentive for that struggle yes and billions of dollars right on some of these studies and lies yeah right right not to mention right but it would be easy to have full-time statisticians hired by the journals or shared by the journals um who were independent of any other financial incentive to go over these kind of methodological issues and take responsibility for the for certifying the analyses that are done and then pass it on to the volunteer uh peer reviewers see i believe in even in this in the sort of capitalism or even social capital after watching twitter in the time of covid and just looking at people that investigate themselves i believe in the citizenry people if you give them access to the data like these like citizen scientists arise a lot of them on the it's kind of funny a lot of people are just really used to working with data they don't know anything about medicine and they don't have actually the biases that a lot of doctors and medical and a lot of the people that read these papers they'll just go raw into the data and look at it with like they're bored almost and they do incredible analysis so i i you know there's some argument to be made for a lot of this data to become public like de-anonymized no sorry anonymized all that kind of stuff but for a lot of it to be public especially when you're talking about things um as impactful as some of these drugs i agree 100 so let's turn the micro let's get a little bit more granular sure on the peer review issue we're talking about pre-publication transparencies and that is critically important once a paper is published the horses are out of the barn and docs are going to read it take it as evidence-based medicine the economists call what then happens as stickiness that the docs hold on to their beliefs and i my own my own voice inside says once doctors start doing things to their patients bodies they're really not too enthusiastic about hearing or was wrong yeah that's the stickiness of human nature wow so that that bar once it's published in the doctors that's when the stickiness emerges well yeah yeah it's hard to put that toothpaste back in the tube now that's pre-publication transparency which is essential and you could have whoever saw that data pre-publication could sign confidentiality agreements so that the drug companies couldn't argue that we're just opening the spigots of our data and people can copy it and blo all the excuses they make you could argue that you didn't have to but let's just let them do it let the peer reviewers sign confidentiality agreements and they won't leak the data but then you have to go to post publication transparency which is what you were just getting at to let the data free and let citizens and citizen scientists and other doctors who are interested have at it kind of like wiki wikipedia have at it and let it out and let people criticize each other okay so speaking of the data the fda asked 55 years to release pfizer vaccine data this is also something i raised with uh albert barola there's several things i didn't like about what he said uh so some things are expected and some of it is just revealing the human being which is what i'm interested in doing but he said he wasn't aware of the 75 and the 55. i'm sorry women he wasn't aware of the how long so here i'll explain what do you do you know that since you spoke to him pfizer has petitioned the judge to join the suit on in behalf of the fda's request to release that data over 55 or 75 years pfizer's fully aware of what's going on he's aware i'm i'm sure he's aware in some formulation the exact years he might have not been aware but but the point is that there is that is the fda the relationship with faiza and the fda in terms of me being able to read human beings was the thing he was most uncomfortable with that he didn't want to talk about the fda and that that relate it was clear that there was a relationship there that if if the words you use may do a lot of harm potentially because like you're saying there might be lawsuits going on there's litigation there's legal stuff all that kind of stuff and then there's a lot of games being played in this space so um i don't know how to interpret it uh if he's actually aware or not but the the deeper truth is that he's deeply uncomfortable um bringing light to this part of the game yes and i'm going to read between the lines and albert borla certainly didn't ask me to speak for him but i think but when did you speak to him how long ago wow time flies when you're having fun uh two months ago two months ago so that was just recently it's come out uh just in the past week it's come out that um pfizer isn't battling the fda pfizer has joined the fda in the opposition to the request to release these uh these documents in the same amount of time that the fda took to evaluate them yeah so pfizer is offering to help the fda to petition the judge to not enforce the timeline that he seems to be moving towards so for people who are not familiar we're talking about the freedom of information act request to release the pfizer vaccine data study data to release as much of the data as possible like the raw data the details or so actually not even the raw data it's data doesn't matter there's details to it and i think the response from the fda is that of course yes of course uh but uh you know we can only publish like some x number of pages a day 500 pages 500 pages of data it's not a day though it's uh whatever a week i think the point is whatever they're able to publish is ridiculous it's like um my printer can only print three pages a day and we cannot afford a second printer so it's it's some kind of bureaucratic language for you know there's a process to this i you know and now you're saying that pfizer is obviously um more engaged in helping this kind of bureaucratic process prosper in its full absurdity kafka-esque absurdity so what is this this really bothered people this really this is really troublesome and just to put it in just plain english terms pfizer's making the case that it can't the fda and pfizer together are making the case that they can't go through the documents it's going to take them some number 100 fold hundreds of folds more time to go through the documents than the fda required to go through the documents to approve the vaccines to give the vaccines full fda approval and the fda's argument talk about kafka-esque is that to do it more rapidly would cost them three million dollars three million dollars equals one hour of vaccine sales over two years one hour of sales and they can't come up with the money and now pfizer has joined the suit to help the fda fight off this judge this mean judge who thinks they ought to release the data but evidently pfizer isn't offering to come up with the three million dollars either so bought for three million i mean maybe the maybe the fda should do a gofundme thing well obviously the money thing [Music] i mean i'm sure if elon musk comes along and says i'll give you 100 million publish it now i think they'll come up with another so i mean that there it's clear that there is um cautiousness i don't know the source of it from the fda there's only one explanation that i can think of which is that the fda and pfizer don't want to release the data they don't want to release the three or five hundred thousand pages of of uh documents and i don't know what's in there i'm i want to say one thing very clearly i am not an anti-faxer i believe the vaccines work i believe everybody should get vaccinated uh the evidence is clear that if you're vaccinated you reduce your risk of dying of covid by 20-fold and we've got new sub-variants coming along and i just want to be very clear about this that said there's something i would give you ten to one odds on a bet that there's something in that data that um is going to be embarrassing to either fda or pfizer or both so there's two options i agree with you 100 one is they know of embarrassing things that's option one and option two they haven't invested enough to truly understand the data like to i mean it's a lot of data that they they have a sense there might be something embarrassing in there and if we release it surely the world will discover the embarrassing end uh to do uh sort of the steel man their argument they'll take the small the press the people will take the small embarrassing things and blow them up into big things yes and support the anti-vaxx yes campaign yes i think that's all possible nonetheless the data are about the original clinical trial and the emergency youth's authorization was based on the first few months of the data from that trial and it was a two-year trial the rest of that data has not been opened up and there was not an advisory committee meeting to look at that data when the fda granted full authorization again i am pro-vaccine i am not making an anti-facts argument here but i suspect that there's something pretty serious in that data and the reason why i'm not an anti-faxer having not been able to see the data that the fda and pfizer seemed to willing not just to put effort into preventing the release of but seem to have quite a bit of energy into preventing invest quite a bit of energy in not releasing that data the reason why that doesn't tip me over into the anti-vaxxer side is because that's clinical trial data early clinical trial data that involved several thousand people we now have millions of data points from people who have had the vaccine this is real world data showing the efficacy of the vaccines and so far knock on wood there aren't um side effects that overcome the benefits of vaccine so i'm i'm with you i'm now i guess three shots of the vaccine but there's a lot of people that are kind of saying well even the data on the real the real world use large-scale data has um has is messy the way it's being reported the way it's being interpreted well one thing is clear to me that it is being politicized it's i mean if you just look objectively don't have to go to at the shallow surface level it seems like there's two groups that i can't even put a term to it uh because it's not really pro-vaccine versus anti-vaccine because it's it's it's pro vaccine triple mask democrat liberal and then anti-mandate whatever whatever those groups are i can't quite cause they're changing but not really but kind of so those two groups that feel political and nature not scientific in nature it's they're bickering and then it's clear that this data is being interpreted by the different groups differently it's very difficult for me as a human being to understand where the truth lies especially given how much money is flying around on all sides so the anti-vaxxers can make a lot of money too let's not forget this from the individual perspective you can become famous being an anti-vaxxer and so there's a lot of incentives on all sides here and and there's real human emotion and fear and also credibility you know um scientists don't want to ruin their reputation if they if they speak out in whatever like speak their opinion or um they look at some slice of the data and begin to interpret it in some kind of way they're very it's clear that fear is dominating the discourse here especially in the scientific community so i i don't know what to make of that um and the only happy people here is pfizer he's just plowing all ahead i mean uh you know with every single variant there's x you know there's very i would say outside of arguably a very flawed system there's a lot of incredible scientific and engineering work being done and constantly developing new like antiviral drugs new of new vaccines to deal with the variants so they're happily being a capitalist machine and uh it's very difficult to know what to do with that and let's just put this in perspective for folks the best-selling drug in the world has been humira for a number of years it's uh uh approved for the treatment of rheumatoid arthritis and eight other indications uh and it sold about 20 billion dollars uh globally over the past few years it it leveled out it peaked at that level pfizer expects to sell 65 billion dollars of vaccine in the first two years of the uh pandemic so this is by far the biggest selling and most profitable drug that's ever been come along can i ask you a difficult question here in the fog that we're operating in here on the pfizer biontech vaccine what was done well and what was done badly that you can see now it seems like we'll know more decades from now yes but now in the fog of today with the 65 billion dollars flying around where where do you land so we're going to get to what i think is one of the key problems with the pharmaceutical industry model in the united states about being profit driven so in 2016 the nih did the key infrastructure work to make mrna uh vaccines uh that gets left out of the discussion a lot and pfizer biontech actually paid royalties voluntarily to the nih i don't know how much it was i don't think it was a whole lot of money but i think they wanted to avoid the litigation that moderna got itself into by just taking that 2016 knowledge and having that be the foundation of their product so pfizer took that and they did their r d they paid for their r d having received that technology and when they got the genetic code from china about the vaccine about the virus they very quickly made a vaccine and the vaccine works and president trump to his credit launched operation warp speed and just threw money at the problem they just said we we spent five times more per person than the eu early on just pay them whatever they want let's just get this going and americans were vaccinated uh more quickly we paid a lot of money the one mistake that i think the federal government made was they were paying these guaranteed fortunes and they didn't require that the companies participate in a program to do global vaccinations they so the companies doing their business model distributed the vaccines where they would make the most money and obviously they would make the most money in the first world and almost all i think 85 percent of the vac vaccines early on went to the first world and very very few vaccinations went to the third world so what happened is the there was such a low vaccination rate in may of 2021 there was all hands on deck cry for help from the world trade organization um the world health organization the imf and the world bank made a plea for 50 billion dollars so that we could get to 40 vaccination rate in the third world by the end of 2021 and it was unrequited nobody answered and now africa has about a 8.9 vaccination rate india is coming up but it's been very low the problem with all this is i believe those mrna vaccines are excellent vaccines but if we leave the third world unvaccinated we're going to have a constant supply of variants of kovid that are going to come back into the united states and harm americans exactly like delta and omicron have so we've made a great drug it reduces the risk of mortality in americans who get it by a lot but we're not doing what we need to do to protect americans from omicron you don't have to be an idealist and worry about global vaccine equity if you're just ordinary selfish people like most of us are and you're worried about the health of americans you would ensure global vaccine distribution let me just make one more point that 50 billion dollars that was requested by the four organizations back in may of 2021 32 billionaires made 50 billion dollars from the vaccines at that point took it into their private wealth so what had been taken these enormous amounts of money that had been taken into private wealth was enough to do what those organizations said needed to be done to prevent the sub-variants from coming back and doing what they're doing so the money was there but how does the motivation the money-driven motivation of big pharma lead to that um that that kind of allocation of vaccines because they can make more money in the united states they're going to distribute their vaccines where they can make the most money all right is there a malevolent aspect to this where boy i i don't like saying this but that they don't see it as a huge problem that variants will come back to the united states i think it's the issue we were talking about earlier on where they're in a different culture and their culture is that their moral obligation as milton friedman would say is to maximize the profits that they return to shareholders and don't think about the bigger picture the collateral damage don't think about the collateral and also kind of believe convince yourself that if we give in to this capitalist machine in this very narrow sense of capitalism that in the end they'll do the most good this kind of belief that like if we just maximize profits we'll do the most good yeah that's an orthodoxy of several decades ago and i don't think people can really say that in good faith when you're talking about uh vaccinating the third world so we don't get hurt it's a little bit hard to make the argument that the world's a better place because the profits of the investors went up yeah but at the same time it's i i think that's a belief you can hold i i mean i've interacted with a bunch of folks that kind of it's the i don't want to mischaracterize ayn rand okay i respect a lot of people but there's it's a belief that can take hold if i just focus on this particular maximization it will do the most good for the world the problem is when you choose what to maximize and you put blinders on it's too easy to start making gigantic mistakes that have a big negative impact on society so it really matters what you're maximizing right and if we had a true democracy and everybody had one vote everybody got decent information and had one vote and rand's position would get some votes but not many and it would be way out voted by the common people let me ask you about this very um difficult topic i'm talking to uh mark zuckerberg of meta the topic of censorship i don't know if you've uh heard but there's a guy named robert malone and peter mccalla that were removed from many platforms for speaking about the covet vaccine as being risky they were both on joe rogan's program what do you think about censorship in this space in this difficult space where so much is controlled by not controlled but influenced by advertisements from big pharma and science can even be influenced by big pharma where do you lean on this should we allow should we lean towards freedom and just allow all the voices even those that go against the scientific consensus is that one way to fight the the science that is funded by big pharma or is that do more harm than good having too many voices that are contending here should the ultimate battle be fought in the space of uh scientific publications and particularly in the uh era of kovid where there are large public health ramifications to the this public discourse uh the ante is way up so i don't have a simple answer to that i think everyone's allowed their own opinion i don't think everyone's allowed their own scientific facts and how we develop a mechanism that's other than an open internet where whoever is shouting the loudest gets the most clicks and the uh rage creates value on the internet i think that's not a good mechanism for working this out and i don't think we have one i don't have a solution to this i mean ideally if we had a philosopher king we could have a panel of people who were not conflicted by rigid opinions decide on what the boundaries of public discourse might be i don't think it should be fully open i don't think people who are making who are committed to an anti-vaccine position and will tailor their interpretation of complex scientific data to support their opinion i think that can be harmful constraining their speech can be harmful as well so i don't have an answer here but yeah i tend to believe that it's more dangerous to censor anti-vaxx messages the way to defeat anti-vaxx messages is by being great communicators being great scientific communicators so it's not that we need to censor the things we don't like we need to be better communicating the things we do like or the things that we do believe represent the a deep scientific truth because um i think if you censor you get worse at doing science and you give the wrong people power so i i tend to believe that you should give power to the individual scientists and also give them the responsibility of being better educators communicators expressers of scientific ideas put pressure on them to release data to release that data in a way that's easily consumable not just like very difficult to understand but in a way that can be understood by a large number of people so the battle should be fought in the open space of ideas versus in in the quiet space of journals i think we no longer have that comfort especially at the highest of stakes so this kind of idea that a couple of peer reviewers decide the fate of billions is is doesn't seem to be sustainable especially given a a very real observation now that um that the reason robert malone has a large following is there's a deep distrust of institutions deep distressed the scientists of science as an institution of uh power centers of companies of of everything and perhaps rightly so but the way to defend against that is not for the powerful to build a bigger wall it's for the powerful to be authentic um and maybe do a lot of them to get fired and for new minds for new fresh scientists uh ones who are more authentic more real better communicators to step up so i i fear i fear censorship because it feels like censorship is a even harder job to do it well than being good communicators and it seems like it's always the c students that end up doing the censorship that it's like it's always the incompetent people and not just the incompetent but the biggest whiners so like what happens is the people that get the most emotional and the most outraged will drive the censorship and it doesn't seem like reason drives a censorship that's just objectively observing how censorship seems to work in this current so there's so many forms of censorship you know you look at the soviet union with the propaganda or nazi germany is a very different level censorship people people tend to conflate all these things together you know social media trying desperately to have trillions or uh hundreds of billions of exchanges a day and like try to make sure that their platform is has some uh semblance of like quote healthy conversations like people just don't go insane they actually like using the platform and they they censor based on that that's a different level of censorship but even there you can really run afoul of the people they get the the the whiny c students controlling too much of the censorship i i believe that you should you should actually put the responsibility on the self-proclaimed holders of truth aka scientists at being better communicators i agree with that i'm not uh advocating for any kind of censorship but uh marshall mcluhan was very influential when i was in college and his uh that meme uh the medium is the message it's a little bit hard to understand when you're comparing radio to tv and saying radio's hotter or tvs hotter or something but we now have the medium as the message in a way that we've never seen we've never imagined before where rage and anger and polarization uh are what drives the um traffic on the internet and we don't it's a question of building the commons ideally i don't know how to get there so i'm not pretending to have a solution but the commons of discourse about this particular issue about vaccines is has been largely destroyed by the edges by the drug companies and the advocates on the one side and the people who just criticize and think that even though the data are flawed that there's no way vaccines can be beneficial and to have those people screaming at each other does nothing to improve the health of the 95 percent of the people in the middle who want to un know what the rational way to go forward is and protect their families from covid and live a good life and be able to participate in the economy and that's the problem i don't have a solution well there's a difficult problem for uh spotify and youtube i don't know if you heard this is a thing that joe rogan is currently going through as a platform whether to censor the conversation that for example joe's having so i don't know if you heard but neil young and other musicians have kind of spoke out and saying they're going to leave the platform because joe rogan is allowed to be on this platform having these kinds of conversations with the likes of robert malone and it's clear to me that spotify and youtube are being significantly influenced by these extreme voices like you mentioned on each side and it's also clear to me that facebook is the same and it was going back and forth in fact that's why facebook has been oscillating on the censorship is like one group gets louder than the other depending on whether it's an election year it's uh there's several things to say here so one it does seem i think you put it really well it would be amazing if these platforms could find mechanisms to listen to the center to the um to the big center that's actually going to be affected by the results of the our pursuit of scientific truth right um and listen to those voices i also believe that most people are intelligent enough to process information and to make up their own minds like they're not in terms of um this it's complicated of course because we've just been talking about advertisement and how people can be influenced but i feel like if you have raw long-form podcasts or programs where people express their mind and express their argument in full i think people can hear it to make up their own mind and if those arguments have a platform on which they can live then other people could provide better arguments if they disagree with it and now we as human beings as rationals intelligent human beings can look at both and make up our own minds that's where social media can be very good at like this collective intelligence we together listen to all these voices and make up our own mind humble ourselves actually often you know you think you know like you're an expert say you have a phd in a certain thing so there's this confidence that comes with that and the collective intelligence uncensored allows you to humble yourself eventually like as you discover you know all it takes is a few times you know looking back uh five years later realizing i was wrong and that's really healthy for a scientist that's really healthy for anybody to go through and only through having that open discourse can can can you really have that that said spotify also just like pfizer is a company which is why this podcast i don't know if you know what rss feeds are but podcasts can't be censored so joe's in the unfortunate position he only lives on spotify so spotify has been actually very good at saying we're staying out of it for now but rss this is pirate radio nobody can censor it's the internet so um financially in terms of platforms this cannot be censored which is why uh podcasts are really beautiful and so if spotify or youtube wants to be the host of podcasts i think where they flourish is free expression no matter how crazy yes but i do want to push back a little bit on what you're saying because i have um anti-facts friends who i love they're dear cherished friends and they'll send me stuff and it'll take me an hour to go through what they sent to see if it is credible and usually it's not it's not a random sample of the anti-vax argument i'm not saying i can disprove the anti-vaxx argument but i am saying that it's almost like we were talking about uh how medical science clinical trials the presentation of clinical trials to physicians could be improved and the first thing we came up with is to have pre-publication transparency in the peer review process yes so bad information biased information doesn't get out as if it's legitimate and you can't put it back recapture it once it gets out i think there's an element of that in the arguments that are going on about vaccines and they're on both sides but i think the anti-fax side puts out more units of information claiming to show that the vaccines don't work and i guess in an ideal situation there would be real time fact checking by independent people not to censor it but to just say that study was set up to do this and this is what the conclusions were so the way it was stated uh is on one side of this argument but that's what i'm arguing yeah i agree with you what i'm arguing is that this big network of humans that we have that is the collective intelligence can't do that real time if you allow it to if you encourage people to do it and the scientists as opposed to listen i interact with a lot of colleagues a lot of friends that are scientists they roll their eyes their response is like like they don't want to interact with this but it that that's just not the right response when a huge number of people believe this it is your job as communicators to defend your ideas it is no longer the case that you go to a conference and defend your ideas to two other uh nerds that have been working on the same problem forever i mean sure you can do that but then you're rejecting the responsibility you have explicitly or implicitly accepted when you go into this field that you will defend the ideas of truth and the way to defend them is in the open battlefield of ideas and become a better communicator and i believe that when you have a large you said you invested one or two hours in this particular but that's little ants interacting at scale i think that uh allows us to progress towards truth at least you know at least i hope so i think you're an optimist i i want to work with you a little bit on this let's say um a person like joe rogan who by the way had me on his podcast and left an amazing conversation i really enjoyed it well thank you i did too and i didn't know joe i didn't know much about his podcast he pushed back on joe a bunch which is great and he was love it he was a gentleman and we had it out in fact he put one clip at one point he said something that was a little bit wrong and i corrected him and he had the guy who jamie jamie he had jamie check it and was very forthright in saying yeah you know john's got a right here you know we got to modify this in well i did i wasn't trying to get them no just trying on yeah you totally it was there's a beautiful exchange there's so much respect in the room pushing back and forth that's great yeah so i respect him and i think when he has somebody on who's a died in the wool anti-faxer the question is how can you balance if it needs balance in real time i'm not talking about afterwards i'm talking in real time maybe you record well he does record it obviously but maybe when there's a statement made that is made as if it's fact-based maybe that statement should be checked by some folks who imaginary folks who are trustworthy and in real time as that discussion is being played on the podcast to show what independent experts say about that claim that's really interesting idea by the way this for some reason this idea popped into my head now is i think real time is very difficult and it's not difficult but it kind of ruins the conversation because you want the idea to breathe yeah i think what's very possible is before it's published it's the pre-publication before it's published you let a bunch of people review it and they can add their voices in post before it's published they can add arguments um you know what they you know arguments against certain parts that's very interesting it's a sort of as one podcast publish uh like addendums publish the peer review together with the publication yes that's very interesting um i might actually do that that's really interesting because uh i've been doing more debates where at the same time have multiple people which has a different dynamic because both people i mean it's really nice to have the time to pause just on you by yourself to fact check to look at the study that was mentioned to understand what's going on so the peer review process to have a little bit of time that's really interesting i actually would i'd like to try that to agree with you on some point in terms of anti-vaxx i've been fascinated by listening to arguments from uh this community of folks that's been quite large called flat earthers the people that believe the earth is flat and i don't know if you've ever listened to them or read their arguments but it's fascinating how consistent and convincing it all sounds when you just kind of take it in just like just to take it in like listening normally it's all very logical like if you don't think very well no i um so the thing is the reality is at the very basic human level with our limited cognitive capabilities the earth is pretty flat when you go outside and you look it's flat so like when you use common sense reasoning it's very easy to play to that to convince you that the earth is flat plus there's powerful organizations that want to manipulate you and so on but then there's you know the whole progress of science and physics of the past but that's difficult to integrate into your thought process so it's it's very true that the people should listen to flat earthers because it was very revealing to me how easily it is how easy it is to be convinced of basically anything by uh uh charismatic uh arguments right and if we're arguing about whether the fla earth is flat or not uh as long as we're not navigating airplanes and doing other kinds of things trying to get satellites to do transmission it's not that important what we believe but if we're arguing about how we approach the worst public health crisis in i don't know how long i think we're getting worse than the spanish flu now um i don't know what the total global deaths with spanish flu were but in the united states we certainly have more deaths than we had from spanish flu plus the economic pain and suffering yes yes and the damage to the kids in school and stuff we got a problem and it's not going away unfortunately so when we get a problem like that it's not just an interesting bar room conversation about whether the earth is flat it there are millions of lives involved let me ask you yet another question that issue i raised with faisal ceo albert berla it's the question of revolving doors that there seems to be a revolving door between pfizer fda and cdc people that have worked at the fda now work at pfizer and vice versa include in the cdc and so on what do you think about that so first of all his response once again is there's rules there's very strict rules and we follow them do you think that's a problem and also maybe this is a good time to talk about this pfizer played by the rules let's one at a time one time okay and this isn't even about pfizer but it's an answer to the question yes so there's this drug agia helm that was approved by the fda uh maybe six months ago it's a drug to prevent the progression of low-grade alzheimer's disease the target for drug development for alzheimer's disease has been the amyloid reducing the amyloid plaques in the brain which correlate with the progression of alzheimer's and biogen showed that its drug agilem reduces amyloid plaques in the brain they did two clinical trials to determine the clinical efficacy and they found that neither trial showed a meaningful benefit and in those two trials 33 percent more people in the agi-helm group develop symptomatic brain swelling and bleeding than people in the placebo group there was an advisory committee convened to debate the and determine how they felt about the approvability of agile helm given those facts and those facts aren't in dispute they're in biogen slides uh as well as fda documents the advisory committee voted 10 against approval and one abstain so that's essentially universal unanimous vote against approving agile now the advisory committees have been pretty much cleansed of financial conflicts of interest so this advisory committee votes 10 no one abstention and the fda overrules the unanimous opinion of its advisory committee and approves the drug three of the members of the advisory committee resign they say we're not going to depart if the fda is not going to listen to a unanimous vote against approving this drug which shows more harm than benefit undisputed we're not going to participate in this and the argument against approval is that the surrogate endpoint the reduction of amyloid the progression of amyloid plaques is known by the fda not to be a valid clinical indicator it doesn't correlate 27 studies have shown it doesn't correlate with clinical progression interrupting the amyloid plaques doesn't mean that you're that your alzheimer's doesn't get worse so it seems like it's a slam dunk and the fda made a mistake and they should do whatever they do to protect their bureaucratic reputation so the head of the bureau of the fda the center for drug evaluation and research that approves new drugs who had spent 16 years as an executive in the pharmaceutical industry issued a statement and said what we should do in this situation is to loosen the prohibition of financial ties of interest with the drug companies so we get less emotional responses said this it's in print people are just too emotional about this people were just too emotional the 10 people who voted against it and the no people who voted for it it's all too emotional so this gets back this is a long answer to your short question i think this is a wonderful window into the thinking of the fda that financial conflicts of interest don't matter in a situation when i think it's obvious that they would matter but there's not a direct financial conflict of interest it's kind of like it's not like like like uh albert said there's rules i mean you're not allowed to have direct financial conflicts of interest it's it's indirect right but what i'm saying is i'm not denying what he said is true but the fda a high official in the fda is saying that we need to allow conflicts of interest in our advisory committee meetings uh and that she wants to change the rules right so albert borla would still be playing by the rules but it just shows how one-sided the thinking here is but you think that's influenced by the fact that there were pharmaceutical executives working at the fda and vice versa and they think that's a great idea who gets to fix this do you think it should be just banned like if you work two separate questions one is should the uh officials at the fda come from pharma and vice versa yes that's one question and the other question is should advisory committee members be allowed to have financial conflicts of interest yes i think in my opinion and people might say i'm biased i think fina advisory committee people should not have conflicts of interest i think their only interest ought to be the public interest and that's was true from my understanding of this situation it's the afterward in my book i spent some time studying it about agile i think it's a slam dunk that there ought to be no conflicts of interest now the head of cedar center for drug evaluation research thinks that that's going to give you a biased result because we don't have company influence and that i think shows how how biased their thinking is that not having company influence is a bias let me try to load that in i'm trying to empathize with the belief that companies should have a voice at the table i mean yeah it's part of the game they've convinced themselves that this is how it should be played and but they have a voice at the table they've designed the studies right that's their voice i mean what bigger voice do you deserve but i i do also think on the on the more challenging question i i do think that there should be a ban if you work at a pharmaceutical company you should not be allowed to work at any um regulatory agency yes you should not i mean that going back and forth is just even if it's 30 years later i agree and i have another nomination for a ban we're in this crazy situation where medicare is not allowed to negotiate the price of drugs with the drug companies so the drug companies get a patent on a new drug unlike every other developed country they can charge whatever they want so they have a monopoly on a utility because no one else can make the drug charge whatever they want and medicare has to pay for it and you say how did we get in this crazy situation so how we got here is that in 2003 when medicare part d was passed billy thousand was head of the ways and means ways and means committee in the house played a key role in ushering this through with the non-negotiation clause of it and after it was passed billy thousand did not finish out his term in congress he went to pharma for two million dollar a year job this is this is incredible you might think that a ban on that would be a good idea i spoke with francis collins head of the nih on this podcast he and nih have a lot of power over funding in science yes what are they doing right what are they doing wrong in this interplay with big pharma how connected are they again returning to the question what are they doing right what are they doing wrong in your view yeah so my knowledge of the nih is not as granular as my knowledge of pharma that said in broad brush strokes the nih is doing the infrastructure work for all drug development i think they've participated in a hundred percent of the drugs that have been approved by the united the fda over the past 10 years or so they've done infrastructure work and what they do is not work on particular drugs but they develop work on drug targets on targets in the human body that can be affected by drugs and might be beneficial to turn on or off and then the drug companies can when they find a target that is mutable um and potentially beneficial then the drug companies can take the research and choose to invest in the development of the drugs specific drug that's our model now 96 of the research that's done in clinical trials in the united states is about drugs and devices and only a fraction of the four percent that's left over is about preventive medicine and how to make americans healthier i think again from the satellite view the nih is investing more in science that can lead to commercial development rather than as you said at the beginning of the podcast there's no big fitness and lifestyle industry that can counter pharma so i think at the nih level that countering can be done and the diabetes prevention program study that we talked about before where lifestyle was part of a randomized trial and was shown to be more effective than metformin at preventing the development of diabetes that is absolute proof positive that investing in that kind of science can produce good results so i think that we're aimed at drug development and what we ought to be aimed at is an epidemiological approach to improving the health of all americans we rank 68th in the world in healthy life expectancy despite spending an extra trillion and a half dollars a year and i believe strongly that the reason why we've gotten in this crazy position is because our the knowledge that we're producing is about new drugs and devices and it's not about improving population health in this problem the nih is the perfect institution to play a role in rebalancing our research agenda and some of that is on the leadership side with francis collins and anthony fauci not just speaking uh about basically everything that just leads to drug development vaccine development but also speaking about healthy lifestyles and uh speaking about health not just sickness yes and investing and investing in i mean it's it's like uh it fee one fee is the other one you have to communicate to the public the importance of of investing in health and that leads to you getting props for investing in health and then you can invest in health more and more and then that communicates i mean everything that anthony fauci says that francis collins says has an impact on scientists i mean the you know it it sets the priorities i i don't think they it's the sad thing about leaders um forgive me for saying the word but mediocre leaders is they don't see themselves as part of a game they uh they don't see the momentum it's like a fish in the water they don't see the water great leaders stand up and reverse the direction of how things are going and i actually put a lot of responsibility some people say too much but whatever i think leaders carry the responsibility i put a lot of responsibility on anthony fauci and francis collins for not actually speaking a lot more about health not not and bigger inspiring people in the power and the trustworthiness of science you know that that's on the shoulders of um anthony fauci uh i'm gonna abstain from that because i'm not expert enough but neither am i but i'm opinionated i am too but not on camera yes no but seriously the problem is pretty simple that we're investing 96 of our clinical funding of clinical research in drugs and devices and 80 of our health is determined by how we live our lives yes and this is ridiculous we're the united states is going further and further behind the other wealthy countries in terms of our health we ranked 38th in healthy life expectancy in 2000 and now we're spending a trillion and a half dollars extra and we rank 68. we've gone down you have this excellent there's a few uh charts that i'll overlay that tell the story in in really powerful ways so so one is the healthcare spending is percentage of gdp that on the x-axis is years and the y-axis is percentage and the united states as compared to other countries on average has been much larger and and growing right we are now spending seven percent more of our point gdp percent versus ten point seven percent on health care seven percent and i think gdp is the fairest way to compare health care spending was per person in dollars we're spending even the difference is even greater but other costs vary with gdp so let's stick with the conservative way to do it 17.7 or you know 18 of gdp 18 of gdp spent on healthcare seven percent higher than the comparable country average right 17.7 versus 10.7 7 higher right and 7 of 23 trillion dollar gdp is more than 1.5 trillion dollars a year in excess and then you have another chart that shows healthcare system performance compared to spending and there's a cloud a point cloud of different countries the x-axis being healthcare spending is a percentage of gdp which we just talked about that uh us is you know seven percent higher than everyone the average and then on the y-axis is uh performance so x-axis spending y-axis performance and there's a point cloud we'll overlay this if you're watching on youtube of a bunch of countries that have uh performance uh for what they're spending and then us is is all alone on the right bottom side of the chart where it's low performance and high spending correct so this is a system that is abiding by spending that is directed by the most profitable ways to deliver health care so you put that in the hands of big pharma is you maximize for profit you're going to decrease performance and increase spending yes but i want to qualify that and say it's not all big pharma's fault uh they're not responsible for all the problems in our health care system the administ they're not responsible for the administrative costs for example but they are the largest component of the rising our rising health care costs and it has to do with this knowledge issue controlling the knowledge that doctors have makes it so that doctors can live with this situation believing that it's optimal when it's a wreck yeah let me ask you the big so as a physician the so everything you've seen we've talked about 80 percent of the impact on health is lifestyle how do we live longer what advice would you give to general people what what space of ideas result in living longer and higher quality lives right this is a very simple question to answer exercise for at least a half hour at least five times a week number one number two don't smoke number three maintain a reasonably healthy body weight some people argue that being lower than a bmi of 25 is healthy i think that may be true but i think getting above 30 is unhealthy and that ought to be now that's largely uh largely impacted by socioeconomic status and we don't want to blame the victims here so we got to understand that when we talk about all of these things not cigarettes but exercise in a good diet and maintaining a healthy body weight we have to include in doing those things the impediments to people of lower socioeconomic status being able to make those changes we've got to understand that personal responsibility accounts for some of this but also social circumstances accounts for some of it and back to your fishbowl analogy if you're swimming in a fishbowl if you live in a fish tank that's not being properly maintained the approach wouldn't be to treat individual sick fish it would be to fix your fish tank to get the bacteria out of it and whatever bad stuff is in there and make your fish tank healthier well we invest far less than the other wealthy countries do we're flipped we have the mirror image in the spending on social determinants of health and medical determinants of health we have exactly the wrong order and not only does that choke off social determinants of health which are very important but actually just the ratio even if you were spending if we raise the social spending and raise the our medical spending in proportion it's the ratio of social spending to medical spending that's the problem so and why do we do that well the answer is perfectly obvious that the way to transfer money from working americans to investors is through the biomedical model not through the social health model and that's the problem for and i i'd like to discuss this because the market isn't going to get us to a reasonable allocation all the other wealthy countries that are so much healthier than we are and spending so much less than we are have some form of government inter intervention in in the quality of the health data that's available in the budgeting of health and social factors and we don't we're kind of the wild west and we let the market determine those allocations and it's it's an awful failure it's a horrendous failure so one argument against government or sorry an alternative to the government intervention is the market can work better if the citizenry has better information so one argument is that you know um you know communicators like podcasts and so on but you know other channels of communication will uh will be the way to fight big pharma your book is the way to so by providing information the alternative to the government intervention on every aspect of this including communication with the doctors is to provide them other information and not allow the market to provide that information by basically making it exciting to to buy books to be to get make better and better communicators on on twitter through books through op-eds through podcasts through so on so basically because there's a lot of incentive to um communicate against the messages of big pharma there's there's incentive because people want to understand what's good for their lives and they're willing to listen to charismatic people that are able to clearly explain uh what what is good for them and they do and more than 80 percent of people think that drugs cost too much and the drug industry is too interested in profits um and but they still get influenced they can't you can't get the vote through congress yeah you know uh democrats and republicans alike are taking money from congress and somehow uh it just doesn't work out that these even small changes i mean the the the pared-down part of medicare the recommend the plan for uh increasing medicare negotiation drug costs and build back better it's literally going to reduce the number of new drugs that are beneficial uniquely beneficial by about one new drug or two new drugs over 30 years it it it will have virtually an indecipherable impact and yet pharma is talking about um the impact on innovation and if you vote for this if you let your congressman vote for this you're going to severely slow down drug innovation and that's going to affect the quality of your life let me ask you um about um over medication that we've been talking about from different angles but one difficult question for me i'll just i'll pick one of the difficult topics depression so depression is is a serious painful condition that leads to a lot of people suffering in the world and yet it is likely they were over prescribing antidepressants so as a doctor as a patient as a health care system as a society what do we do with that fact that people suffer there's a lot of people suffering from depression and there's also people suffering from over prescribing of antidepressants right so a paper in the new england journal by eric turner showed that the data if you put all the data together from antidepressants you find out that antidepressants are not effective for people who are depressed but don't have a major depression major depression is a serious problem people can't function normally they have a hard time getting out doing performing their normal social roles um but what's happened is that the publicity i mean prozac nation was a good example of making the argument that why should people settle for normal happiness when they can have better than normal happiness and if you're not having normal happiness you should take a drug well they that concept that serotonin metabolism is the root cause of depression is really a destructive one we don't we have drugs that change serotonin metabolism but we don't know if that's why uh antidepressants work on major depression and they don't certainly don't work on everybody with major depression i forget what the number needed to treat is i think it's around four one out of four people have significant improvement but the people without major depression don't get better and the vast majority of these drugs are used for people without major depression so what's happened is that the feelings of life satisfaction of happiness and not sadness have been medicalized the normal range of feelings have been medicalized and that's not to say that they shouldn't be attended to but it the evidence shows that attending to them by giving somebody a medicine doesn't help except that they feel like somebody cares about them and believes that they're suffering but there are problems in living that give rise to much of this symptomatology of less than major depression and let's call it what it is and figure out a way to help people in visual therapy group therapy um maybe lifestyle modification would work we got to try that um but let's call it what it is instead of saying oh you're uh in this vast basket of people who are depressed so we'll give you an antidepressant even though the evidence shows that people who are suffering from your level of depression don't get better and that's a consequence of not um focusing on preventative medicine the lifestyle changes all that kind of stuff well yes but it's really a consequence of the drug companies creating the impression that if you're sad take a pill if you're non-major depression how do you overcome depression well you have to talk about what the problem is so talk therapy lifestyle changes well no i'm not jumping to that i'm saying that you ought to a the way you feel must be respected yeah acknowledge that you're suffering acknowledge that you're suffering and deal with health care providers who acknowledge that you're suffering so let's take that first step and first step also big first step yeah family docs are pretty good at that that's kind of the arena that caused me to go into family medicine the subjective experience of the patient okay so you're a person who is not getting the enjoyment out of their life that they feel they ought to be getting now let's figure out why and whether that means some time with a social worker sometime with a psychiatrist sometime with a psychiatric nurse i'm not sure how you'd best do that most effectively and efficiently but that's what you need to do and it may be that there's um a marital problem and there's something going on and uh one of the spouses can't find satisfaction in the life they have to live in within the relationship maybe there's a past history of trauma or abuse that somebody is projecting onto their current situation uh maybe the socioeconomic circumstances where they can't find a job that gives them self-respect and enough money to live all you know an infinite range of things but let's figure out make a diagnosis first the diagnosis isn't that the person feels sadder than they feel than they want to feel the diagnosis is why does the person feel sadder than they want to feel you mentioned this is what made you want to get into family medicine as a doctor what do you think about the saying save one life save the world this was always moving to me about doctors because you have like this human in front of you and um your time is worth money your what you prescribe and your efforts after the visit or worth money and uh it seems like the task of the doctors to not think about any of that uh or not not the task but it seems like a great doctor despite all that just forgets it all and just cares about the one human and somehow that feels like the love and effort you put into helping one person is the thing that will save the world it's not like some economic argument or some political argument or financial argument it's a very human drive that ultimately is behind all of this that will do good for the world yes i think that's true and at the same time i think it's equally true that all physicians need to have a sense of responsibility about how the common uh resources are allocated to serve all the whole population's interests best that's a tension that you have as a physician let's take uh the extreme example let's say you had a patient in front of you who uh if you gave a 10 1 10 billion dollar pill to you would save their life i i would just be tortured by that as a physician because i know that 10 billion dollars spent properly in an epidemiologically guided way is going to save a whole lot more lives than one life so it's also your responsibility as a physician to walk away from that patient i i wouldn't say that i think it's your responsibility torture that's exactly right the human condition that's a tough job but yeah yeah to maintain your humanity through it all yeah but you've been asking at different points in this conversation why are doctors so complacent about the tremendous amount of money we're spending why do they accept knowledge from different sources that may not pan out when they really know the truth and the answer is that they're trying to do their best for their patients yeah and um there's this it's the same kind of torture to figure out what the hell is going on with the data and that's a sort of future project and maybe people will read my book and maybe they'll get a little more excited about it become more legitimate and practice i would feel like my life was worthwhile if that happened but at the same time they've got to do something with the patient in front of them they've got to make a decision and they probably there are not many weirdos like me who invest their life in figuring out what's behind the data they're trying to get through the day and do the right thing for their patient so they're tortured by that decision too and so if you're not careful big pharma can manipulate that that drive to try to help the patient that um that humanity of dealing with the uncertainty of it all like what is the best thing to do big pharma can step in and use money to manipulate that humanity yeah i would state it quite differently it's sort of an opt out rather than an opt-in big pharma will do that and you need to opt out of it what advice would you give to a young person today in high school or college stepping into this complicated world full of advertisements of big powerful institutions of big rich companies how to have a positive impact in the world how to live a life they can be proud of i would say should that person who has only good motives go into medicine they have an inclination to go into medicine and they've asked me what i think about that given what i know about the undermining of american health care at this point and my answer is if you got the calling you should do it you should do it because nobody's going to do it better than you and if you don't have the calling and you're in it for the money you're not going to be proud of yourself how do you prevent yourself from doing from letting the system change you over a year over years and years like letting letting the game [Music] of pharmaceutical influence affect you it's a very hard question because the sociologic norms are to be affected and to um trust the sources of information that are largely controlled by the drug industry and that's why i wrote sickening is to um to try and help those people in the medical profession to understand that what's going on right now looks normal but it's not the health of americans is going downhill our society is getting ruined by the money that's getting pulled out of that pulled out of other social socially beneficial uses to pay for health care that is not helping us so fundamentally the thing that is normal not question the normal don't uh if you conform conform hesitantly well you have to conform you can't become a doctor without conforming um i i i just made it through but there aren't many and it's uh hard work um but you have to conform and even with my colleagues in my own practice i couldn't convince them that some of the beliefs they had about how best to practice weren't accurate there's one scene a younger physician had prescribed hormone replacement therapy this back in 2000 2001 had prescribed hormone replacement therapy for one of my patients who happened to be a really good personal friend and i saw that patient covering for my colleague at one point and i saw that her hormone replacement therapy had been uh renewed and i said are you having hot flashes or any problem no no no no but uh dr so and so said it's better for my health and i said no it's not the research is showing that it's not it's harmful for your health and i think you should stop it so my colleague approached me when she saw the chart and said wait a minute that's my patient maybe your friend but it's my patient and i went to a conference at my from my alma mater medical school and they said that healthy people should be given hormone replacement and i said there's got to be drug companies involved in this and she said no no no it was at my university it was it was not a drug company thing we didn't go to a caribbean island i said do you have the syllabus she said yeah and she went and got the syllabus and sure enough it was sponsored by a drug company they're everywhere they're everywhere and it's back to that groups of experts share unspoken assumptions and in order to be included in that group of experts you have to share those unspoken assumptions and what i'm hoping to do with my book sickening and being here having this wonderful conversation with you is to create an alternative to this normal that people can pursue and practice better medicine and also prevent burnout i mean about half the doctors complain that they're burned out and they've had it and i think that this is a subjective i don't have data on this this is just my opinion um but i think that a lot of that burnout is so-called moral injury from practicing in a way that the docs know isn't working it's not actually providing an uh alternative to the normal it's expanding the normal it's shifting the normal just like with kuhn i mean you're basically looking for to shift the way medicine is done to the original i mean to the intent that it represents that the the the ideal of medicine of health care yeah in cuny in terms to have a revolution and that revolution would be to practice medicine in a way that will be epidemiologically most effective not most profitable for the people who are providing you with what's called knowledge you helped a lot of people as a doctor as an educator live better lives live longer but you yourself are a mortal being do you think about your own mortality do you think about your death are you afraid of death oh yeah um i'm not i've faced it been close yourself yeah yeah how do you think about it what wisdom do you gain from having come close to death oh the fact that the whole thing ends it's liberating it's very liberating i mean i'm serious i i was close and not too long ago um and uh it was a sense of you know this may be the way it ends and um i've done my best it's not been perfect and if it ends here it ends here the people around me are trying to do their best and in fact uh i got pulled out of it but it didn't look like i was going to get pulled out of it are you ultimately grateful for the ride even though it ends well it's a little hot i think so if i know you know you can't take the ride if you know what the it's going to end well it's not the real ride it's just a ride um but i haven't gone through the whole thing i definitely freed me of a sense of anxiety about death and it said to me do you best every day because it's going to end sometime i apologize for the ridiculously big question but what do you think is the uh the meaning of life of our human existence i i think it's to care about something and do your best with it whether it's being a doctor and trying to make sure that the greatest number of people get the best health care um or it's a gardener who wants to have the most beautiful plants or it's a grandparent who wants to have a good relationship with their grandchildren but whatever it is that gives you a sense of meaning as long as it doesn't hurt other people to really commit yourself to it that commitment that being in that commitment for me is the meaning of life put your whole heart and soul into the thing yep what is it the bukowski poem go all the way john um you're an incredible human being incredible educator like i said i recommend people listen to your lectures it's it's so refreshing to see that clarity of thought and brilliance and obviously your criticism of big pharma or your illumination of the mechanisms of big pharma is really important at this time so i really hope people read your book sickening that's out today or depending on when this comes out thank you so much for spending your extremely valuable time with me today it was it was amazing well lex i wanted back to you uh thanks for engaging in this conversation for creating the space to have it and creating a listenership that is interested in understanding serious ideas and i really appreciate the conversation and i should mention that offline you told me you listened to the gilbert strang episode uh so for anyone who don't know goodwill strang another epic human being that should check out if you don't know anything about mathematics or linear algebra go look him up he's one of the great mathematics educators of all time so of all the people you mentioned to me i appreciate that you mentioned him because he is a rock star of mathematics john thank you so much for talking this is awesome great thank you thanks for listening to this conversation with john abramson to support this podcast please check out our sponsors in the description and now let me leave you some words from marcus aurelius waste no time arguing about what a good man should be be one thank you for listening and hope to see you next time you