Here are some snippets from a Lex Fridman interview with John Abramson, outspoken critic of Big Pharma.

Lex: Are people corrupt? Are people malevolent? Are people ignorant that work at the low level and at the high level, at Pfizer for example? How is this possible? I believe that most people are good, and I actually believe if you join Big Pharma your life trajectory often involves dreaming, wanting, and enjoying helping people. And then we look at the outcomes that you’re describing and that’s why the narrative takes hold that Pfizer CEO Albert Bourla is malevolent. The sense is that these companies are evil. So if the different parts are people that are good and they want to do good, how are we getting these outcomes?

John: I think it has to do with the cultural milieu that this is unfolding in. We need to look at sociology to understand this. When the cultural milieu is set up to maximize the returns on investment for shareholders, … when that defines the culture—and the higher up you are in the corporation the more you’re in on the game of getting rewarded for maximizing the profits of the investors; that’s the culture they live in—it becomes normative behavior to do things with science that look normal in that environment and are shares values within that environment—by good people whose self-evaluation becomes modified by the goals that are shared by the people that are around them—within that milieu 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.

Lex: The game they’re playing modifies the culture inside the meetings, inside the rooms, day-to-day. There’s a bubble that forms. We’re all in bubbles of different sizes, and that bubble allows you to drift in terms of what you see as ethical and unethical. Because you see the game as just part of the game. Marketing is just part of the game; paying the fines is just part of the game of science.This is exactly how it felt working in high-frequency trading. As long as the fines were payed, there is this sense that the rules are just rules of the game. It gave trading groups permission to do things that one might consider unethical outside of the bubble.

John: And without guardrails, it becomes even more part of the game. You keep moving in that direction if you’re not bumping up against guardrails, and that’s how I think we’ve gotten to the extreme situation we’re in now.

They discuss the example of Trulicity, which is a drug by Eli Lilly that improves blood sugar control in diabetics just as well as metformin but also reduces the risk of heart attack and stroke. Metformin costs $48/year, while Trulicity costs $6200/year. The company performed a very large study that demonstrated statistical significance of the reduced risk of cardiovascular events, and so now the advertisements for Trulicity talk about that as a major selling point. What they don’t tell you is that the reduction in risk is very small: only one in 323 people who take Trulicity avoids a cardiovascular event when they would otherwise have one. An active lifestyle program reduces that risk far more. The companies can afford these massive studies to discover these very small differences in order to sell more drugs, not to prevent cardiovascular disease.

“The common wisdom among physicians and people in general is that you can’t get people to change,” but a study by the NIH in the 90s found otherwise. They divided participants into three groups: a placebo group, a metformin group, and a group that received intensive lifestyle counseling. The latter group ended up 58% less likely to develop diabetes, vs. 31% in the metformin group.

John: We assume that the market has to solve all these problems, and the market can’t solve all of these problems. There needs to be some way of protecting the public interest for things that aren’t financially driven. The overriding question has to be how best to improve Americans’ health, not companies funding studies to try and prove that their new and expensive drug is better and should be used.