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