John Abramson: Big Pharma | Lex Fridman Podcast #263
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John Abramson is faculty at Harvard Medical School and a family physician for over two decades. He's the author of the new book Sickening about how big pharma broke American healthcare and how we can fix it. Please support this podcast by checking out our sponsors:
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EPISODE LINKS:
John's Website: https://hcp.hms.harvard.edu/people/john-david-abramson
Sickening (book): https://amzn.to/3gsVHef
Overdosed America (book): https://amzn.to/3LmrWKn

PODCAST INFO:
Podcast website: https://lexfridman.com/podcast
Apple Podcasts: https://apple.co/2lwqZIr
Spotify: https://spoti.fi/2nEwCF8
RSS: https://lexfridman.com/feed/podcast/
Full episodes playlist: https://www.youtube.com/playlist?list=PLrAXtmErZgOdP_8GztsuKi9nrraNbKKp4
Clips playlist: https://www.youtube.com/playlist?list=PLrAXtmErZgOeciFP3CBCIEElOJeitOr41

OUTLINE:
0:00 - Introduction
7:52 - Biggest problem with big pharma
16:54 - Advertising
36:45 - Corruption
53:01 - Pfizer vaccine data
1:01:53 - Vaccine profits
1:12:48 - Censorship
1:33:34 - FDA
1:42:09 - NIH
1:51:06 - Live longer
1:54:36 - Medications
2:03:00 - Doctors
2:07:07 - Advice for young people
2:08:03 - Big pharma's influence
2:12:47 - Mortality
2:14:38 - Meaning of life

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 The jury found Pfizer guilty of fraud and racketeering violations. How does Big Pharma affect your mind? Everyone's allowed their own opinion. I don't think everyone's allowed their own scientific facts. Does Pfizer play 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 Burla. 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 attack from all sides. I will get attacked when I host people like Jay Bhattacharya or Francis Collins, Jamie Mertzel or Vincent Racinello, 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 that 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, 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 guest 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 guest, that we talk in true long form for many hours. Second, these conversations will lead to a more and more intense conversation with the audience. I think that 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 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 the 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 healthcare 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 and healthcare, 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 guardrails that maintain the integrity and the balance of the knowledge. Without those guardrails, 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 healthcare. That's the biggest way that American healthcare is distinguished from healthcare 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 that was a radical idea at the time, but we're failing on all three. How are we failing? And 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 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 US history as of 2010. US 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 worth of fines from I think 1991 to 2017. It's never been enough to stop the misrepresentation of their data, and rarely are the fines greater than the profits that were made. See, 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. 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 at Pfizer, for example, at big pharma companies? How is 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 then we look at the outcomes that you're describing and it looks, and that's why the narrative takes hold that like Pfizer CEO Albebrola, who I talked to, is malevolent. The sense is like these companies are evil. So if 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 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 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 are 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 milieu, you have one set of standards and then the rest of good American people have the expectation that the drug companies are trying to make money, but that they're playing by rules that aren't part of the insider milieu. That's fascinating. The game they're playing modifies the culture 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. And that bubble allows you to drift in terms of what you see as ethical and unethical. Because you see the game as just part of the game. So marketing is just part of the game. Right. And paying the fines is just part of the game. Just part of the game. Of science. Yep, yep. And without guardrails, it becomes even more part of the game. You keep moving in that direction if you're not bumping up against guardrails. And 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 Berola. 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, 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 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. Relative to the other big pharma companies. Yes, yes. 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 do what the law says we have to do for advertising. And I have 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 true. And I think that's a good example of what it looks like from within that culture. 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, the emotional impact, the consequences 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. But this is a key point. If he doesn't do it, he'll get fired and the next guy will. So the people that survive in the company, the people that get raises in the company and move up in the company are the ones that play by the rules. And that's how the game solidifies itself. But the game is within the bounds 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 passive pressure to not say anything negative. Because I've seen this and I've been saddened by it that people sacrifice integrity in small ways when they're being funded by a particular company. 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 anything that could possibly be negative about the company. They just choose not to because why? And that's really sad to me that if you give me 100 bucks, I'm less likely to say something negative about you. That makes me sad because 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. That's also a problem, by the way, so just having dinners and shaking hands and 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. But of course, the direct advertisement to consumers, like you said, is potentially very negative effect. I wanted to ask if what you think is the most negative impact of advertisement. Is it that direct to consumer on television? Is it advertisement to the doctors? Which I'm surprised to learn I was vaguely looking at is more than the advertisement. More is spent on advertising to doctors than to consumers. That's really confusing to me. It's fascinating, actually. And then also, obviously, 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 they don't invest all their, they don't put all their eggs in one basket. It's a whole surround sound program here. But in terms of advertisements, let's take the advertisement. Truelicity is a diabetes drug, for type two diabetes, an injectable drug. And it lowers blood sugar just about as well as metformin does. Metformin costs about $4 a month. Truelicity costs, I think, $6,200 a year. So $48 a year versus $6,200. Truelicity has distinguished itself because 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. So the ads obviously extol the virtues of truelicity because it reduces the risk of heart disease and stroke. And that's one of the major morbidities, risks of type two 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. 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 truelicity does. Now, to be fair to the company, the sponsor, there's never been a study that compared truelicity 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 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 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. That should be the bar. 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 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 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 groups, a placebo group, a group that got treated with metformin, 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 intensive lifestyle changes, whether that works. Now, the common wisdom amongst physicians, and I think in general, is that you can't get people to change. 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 in the intensive lifestyle group ended up losing 10 pounds, exercising five times a week maintaining it, and reduced their risk of getting diabetes by 58% compared to the metformin group, which reduced its risk of getting diabetes by 31%. So 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 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 of these problems, and the market can't solve all of these problems. There needs to be some way of protecting the public interest for things that aren't financially driven, 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 and expensive drug is better and should be used. Well, some of that is also people sort of like yourself. I mean, it's funny, you spoke with Joe Rogan. He constantly exposes lifestyle changes. So some of it is almost like understanding the problems that big pharma is creating in society, and then sort of these influential voices speaking up against it. So whether they're scientists or just regular communicators. Yeah, I think you gotta 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 from the sources that the docs are trained to listen to and modify their patient care on. Now, it's not 100%. I mean, there are articles 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. I tip my hat. But it's not gonna 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 an entire mechanism established for testing drugs. There's not an entire mechanism established in terms of scientific rigor of testing lifestyle changes. I mean, it's more difficult. I mean, everything's difficult in science. Science involves humans especially. But these studies are very expensive. They're difficult. It's difficult to find conclusions to control all the variables. So it's very easy to dismiss them unless you really do a huge study that's very well-funded. 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 that could be correlated, it could be the real cause of the effects you're seeing, all that kind of stuff. So 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 that's another issue is that we kind of, nobody says to doctors in training only listen to reductionist studies and conclusions and methods of promoting health. Nobody says that explicitly, but the respectable science has to do with controlling the factors. And I mean, it just doesn't make sense to me. I'm gonna pick on trulicity because it's such an obvious example, but it's not more egregious 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's just so crystal clear that the purpose of that study is to sell trulicity. It's not to prevent cardiovascular disease. 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 force that it should be compared to lifestyle changes. Do you think advertisements period in the 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. Answer either one. I believe, I've been told by lawyers who I trust that the freedom of speech in the US 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 advertisements about them can't be banned. Let's assume that they can't be, because we know they won't be anyway, but let's assume they can't be, and especially our Supreme Court now would be unlikely to take that seriously. But that's not the issue. The issue is that if the drug companies wanna 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, in truth, the city, it's one out of 323. 322 people aren't gonna benefit from the cardiovascular risk reduction. What's the true cost? When drugs advertise that you may be able to get this for a $25 copay or something, a tens of thousands of dollars a year drug for a $25 copay, what an enormous disservice that is to misrepresent the cost to society. That should not be allowed. So you should have to make it clear to the viewers how many people are gonna 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 costs $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 a $25 copay. So you'd have to temper that a little bit. Oh, you mean people are so, they don't care. They don't care. Their insurance is gonna cover it and it's a $25 copay, but we could figure out how to deal with that. The main point is that if we assume that advertisements are gonna keep going, and they are, 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 truth should have like sub-truth guardrails, meaning like the cost that we talked about, the effects compared to things that actually, lifestyle changes, 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. I mean, there's something dark and inauthentic about those advertisements, but they seem, 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. People should definitely look you off from, there's a bunch of videos of you giving talks on YouTube and it's just, it's so refreshing to hear just the clarity of thought about health policy, about healthcare, 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 the, one part of the message that you're talking about, but you know, that's not like your brilliance actually shines in the positive and the solutions and how to do it. So as a doctor, what affects your mind 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 respective journal, people and doctors obviously assume that the peer reviewers 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, make it. 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 what level of manipulation is going on with that data? Is it at the study design level? Is it at literally there's some data that you just keep off, keep out of the charts, keep out of the aggregate analysis and you then publish or is it the worst case which is just change some of the numbers? It happened, all three happened. 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 doubled the risk of heart attacks, strokes and blood clots, serious blood clots. It got pulled then. But there was a study, 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 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 data from that study said that 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 three heart 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 attack 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, because this is crossing the- No, no, no, let me interrupt. No, that's not true. 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 who has to convince themselves? Is this pure malevolence? 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 $5,000 a day, I think for 12 days a year, for one or two years, that contract was signed within two weeks of the decision to stop counting heart attacks. I wanna understand that man or woman. I wanna, I want, it's the, I've been reading a lot about Nazi Germany 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 a 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 one step. So to even push back on that idea is, I assume you mean that data remains private except to the peer review. The peer review reviewers. The problem of course, 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, 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 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 3000 page document. As I became more experienced as an expert in litigation, I could go through those documents pretty quickly. 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 their statistical analysis plan and their 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, to be a good citizen in the medical community and to be on friendly terms with the journals so that if you wanna get published, there's sort of an unspoken incentive. 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. 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 clearly a 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 just a couple hours, but really seriously reading. Like some papers can take months to really understand. So if you really wanna struggle, there has to be an incentive for that struggle. Yes, and billions of dollars ride on some of these studies. And lies, right? Not to mention. Right, but it would be easy to have full-time statisticians hired by the journals or shared by the journals who were independent of any other financial incentive to go over these kind of methodological issues and take responsibility for certifying the analyses that are done and then pass it on to the volunteer peer reviewers. See, I believe 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 citizen scientists arise. A lot of them on the, it's kind of funny. A lot of people that 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 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 as impactful as some of these drugs. I agree 100%. So let's turn the mic, let's get a little bit more granular. 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 gonna 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 my own voice inside says, once doctors start doing things to their patients' bodies, they're really not too enthusiastic about hearing it was wrong. Yeah, that's the stickiness of human nature. Wow, so that bar, once it's published, the doctors, that's when the stickiness emerges, wow. 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 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. 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 Albert Berla. What did he say? There's several things I didn't like about what he said. 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, wait a minute. He wasn't aware of? The how long. So here I'll explain what he. Do you know that since you spoke to him, Pfizer has petitioned the judge to join the suit 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 sure he's aware in some formulation, the exact years he might have not been aware. But the point is that there is, that is the FDA, the relationship with Pfizer 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 wanna talk about the FDA. And that relate, it was clear that there was a relationship there that 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 I don't know how to interpret it if he's actually aware or not, but the deeper truth is that he's deeply uncomfortable, bringing light to this part of the game. Yes, and I'm gonna read between the lines and Albert Borla certainly didn't ask me to speak for him. But I think, when did you speak to him? How long ago? Wow, time flies when you're having fun. Two months ago. Two months ago. So that was just recently it's come out, just in the past week it's come out, that Pfizer isn't battling the FDA. Pfizer has joined the FDA in the opposition to the request to release 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 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, yes, of course, we can only publish some X number of pages a day. 500 pages. 500 pages of data. It's not a day though, it's a week I think. The point is whatever they're able to publish is ridiculous. It's like, my printer can only print three pages a day and we cannot afford a second printer. So it's some kind of bureaucratic language for, there's a process to this. And now you're saying that Pfizer is obviously 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 gonna take them some number of, 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 $3 million. $3 million 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 $3 million either. So bought for $3 million. I mean, maybe the FDA should do a GoFundMe campaign. Well, obviously the money thing, I mean, I'm sure if Elon Musk comes along and says, I'll give you a hundred million, publish it now, I think they'll come up with another. So, I mean, it's clear that there's 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 wanna release the data. They don't wanna release the three or 500,000 pages of documents, and I don't know what's in there. I wanna say one thing very clearly. I am not an anti-vaxxer. I believe the vaccines work. I believe everybody should get vaccinated. 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 wanna be very clear about this. That said, there's something I would give you 10 to one odds on a bet that there's something in that data that is gonna 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. I mean, it's a lot of data that they have a sense there might be something embarrassing in there. And if we release it, surely the world will discover the embarrassing and to do a 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-vax campaign. I think that's all possible. Nonetheless, the data are about the original clinical trial and the emergency youths 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-vax argument here. But I suspect that there's something pretty serious in that data. And the reason why I'm not an anti-vaxxer having not been able to see the data that the FDA and Pfizer seem 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-vax aside 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 side effects that overcome the benefits of vaccine. So 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 world use large scale data 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. 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 because it's not really pro-vaccine versus anti-vaccine because it's pro-vaccine, triple mask, Democrat, liberal, and then anti-mandate, whatever those groups are. I can't quite, cause they're changing, anti-mask, but not really, but kind of. So those two groups that feel political in nature, not scientific in nature, they're bickering. And then it's clear that this data is being interpreted by the different groups differently. And 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 there's real human emotion and fear and also credibility. Scientists don't wanna ruin their reputation if they speak out in whatever, like speak their opinion or 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 don't know what to make of that. And the only happy people here is Pfizer. It's just plowing all ahead. I mean, with every single variant, there's, I would say outside of arguably a very flawed system, there's a lot of incredible scientific and engineering work being done in constantly developing new antiviral drugs, new vaccines to deal with the variants. So they're happily being a capitalist machine. And 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 approved for the treatment of rheumatoid arthritis and eight other indications. And it's sold about $20 billion globally over the past few years. It leveled out, it peaked at that level. Pfizer expects to sell $65 billion of vaccine in the first two years of the pandemic. So this is by far the biggest selling and most profitable drug that's ever 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 flying around, where do you land? So we're gonna 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 vaccines. 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 for the next two years. 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 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 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 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. 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% of the vaccines early on went to the first world. And very, very few vaccinations went to the third world. So what happened is 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, the World Health Organization, the IMF and the World Bank made a plea for $50 billion 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 gonna have a constant supply of variants of COVID that are gonna 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 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 that was requested by the four organizations back in May of 2021, 32 billionaires made $50 billion from the vaccines at that point, took it into their private wealth. So what had been taken, there's 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 kind of allocation of vaccines? Because they can make- More money in the United States. They're gonna distribute their vaccines where they can make the most money. Right, is there a malevolent aspect to this where, boy, 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 damage. And also kind of believe, convince yourself that if we give into 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 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 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, I think that's a belief you can hold. 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, Ayn Rand's position would get some votes, but not many, and it would be way outvoted by the common people. Let me ask you about this very difficult topic. I'm talking to Mark Zuckerberg of Metta, the topic of censorship. I don't know if you've heard, but there's a guy named Robert Malone and Peter McCullough that were removed from many platforms for speaking about the COVID 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 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 scientific publications? And particularly in the era of COVID, where there are large public health ramifications to this public discourse, 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 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-vax messages. The way to defeat anti-vax messages is by being great communicators, by 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 deep scientific truth. Because I think if you censor, you get worse at doing science and you give the wrong people power. So 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 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 doesn't seem to be sustainable. Especially given a very real observation now that the reason Robert Malone has a large following is there's a deep distrust of institutions, deep distrust of scientists, of science as an institution, of power centers, of companies, of everything, and perhaps rightfully 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 and maybe a lot of them to get fired. And for new minds, for new fresh scientists and for new fresh scientists, ones who are more authentic, more real, better communicators to step up. So I fear censorship because it feels like censorship is an 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 always the incompetent people, and not just the incompetent, but the biggest whiners. So what happens is the people that get the most emotional and the most outrage will drive the censorship. And it doesn't seem like reason drives the censorship. That's just objectively observing how censorship seems to work in this current. So there's so many forms of censorship. You look at the Soviet Union with the propaganda or Nazi Germany, it's a very different level of censorship. People tend to conflate all of these things together. Social media trying desperately to have trillions or hundreds of billions of exchanges a day and try to make sure that their platform has some semblance of quote, healthy conversations. People just don't go insane. They actually like using the platform and they censor based on that. That's a different level of censorship, but even there, you can really run afoul of the people that get the whiny C students controlling too much of the censorship. I believe 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 advocating for any kind of censorship, but Marshall McLuhan was very influential when I was in college and his, that meme, 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 TV's hotter or something, but we now have the medium is the message in a way that we've never seen, we've never imagined before where rage and anger and polarization are what drives the traffic on the internet. 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, 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% of the people in the middle who want to 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 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 is 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 I can mention 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. 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 big center that's actually going to be affected by the results of our pursuit of scientific truth, right? 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, 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 rational as intelligent human beings, can look at both and make up our own minds. And that's where social media can be very good at this collective intelligence. We together listen to all of these voices and make up our own mind. Humble ourselves actually often. 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, all it takes is a few times, you know, looking back 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 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, it's the internet. So financially, in terms of platforms, this cannot be censored, which is why 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 wanna push back a little bit on what you're saying. I have 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-vax argument, but I am saying that it's almost like we were talking about 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. 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-vax 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 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 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, ugh. Like they don't want to interact with this. But 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 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 the little ants interacting at scale. I think that allows us to progress towards truth, at least I hope so. I think you're an optimist. I want to work with you a little bit on this. Let's say a person like Joe Rogan, who by the way, had me on his podcast and let me- It was 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. And he pushed back on Joe a bunch, which is great. And 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- Jamie. Jamie. He had Jamie check it and was very forthright in saying, yeah, you know, John's got a right here. We got to modify this a little bit. In any event, in any event- You got him. Well, I wasn't trying to get him. I was just trying to get him. No, no, no, no, no. Totally, it was, there's a beautiful exchange. There's so much respect in the room, pushing back and forth. That was great. Yeah. So I respect him. And I think when he has somebody on who's a dyed 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 a really interesting idea. By the way, 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. 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. You know, arguments against certain parts. That's very interesting to sort of, as one podcast publish like addendums, publish the peer review together with the publication. That's very interesting. I might actually do that. That's really interesting. Because 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 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-vax, I've been fascinated by listening to arguments from this community of folks that's been quite large called the 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 take it in like listening normally. It's all very logical. Like if you don't think very, well, no. 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 at 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 the whole progress of science and physics of the past, but that's difficult to integrate into your thought process. So it's very true that 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 charismatic arguments. Right. And if we're arguing about whether the earth is flat or not, 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. 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 and school and so forth. 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. There are millions of lives involved. Let me ask you yet another question, issue I raised with Pfizer 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, including 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? Do you think that's a problem? Hoo-ha. And also maybe this is a good time to talk about this Pfizer play by the rules. Let's, one at a time. One at a time. Okay, and this isn't even about Pfizer, but it's an answer to the question. Yes. So there's this drug, Aja-Helm, that was approved by the FDA 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, Aja-Helm, 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% more people in the Aja-Helm group developed symptomatic brain swelling and bleeding than people in the placebo group. There was an advisory committee convened to debate and determine how they felt about the approvability of Aja-Helm, given those facts. And those facts aren't in dispute. They're in Biogen slides as well as FDA documents. The advisory committee voted 10 against approval and one abstain. So that's essentially universal, unanimous vote against approving Aja-Helm. 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 gonna be part, if the FDA is not gonna listen to a unanimous vote against approving this drug, which shows more harm than benefit, undisputed, we're not gonna 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 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 Albert said, there's rules. I mean, you're not allowed to have direct financial conflicts of interest. 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. Wow. 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 side of 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 worked- I don't know. Two separate questions. One is, should the 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 advisory committee people should not have conflicts of interest. I think their only interest ought to be the public interest. And that was true from my understanding of the situation. It's the afterward in my book, I spent some time studying it about Aja Helm. I think it's a slam dunk that there ought to be no conflicts of interest. Now the head of CDER, Center for Drug Evaluation Research, thinks that that's gonna give you a biased result because we don't have company influence. And that I think shows 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. But they have a voice at the table. They've designed the studies. Right, that's their voice. That's the whole point. They analyze the data. I mean, what bigger voice do you deserve? But I do also think on the more challenging question, 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 regulatory agency. Yes. You should not, I mean, that going back and forth, it just, even if it's 30 years later. Yeah, 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 Towson was head of the 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 Towson did not finish out his term in Congress. He went to pharma for a $2 million a year job. 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. 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? So my knowledge of the NIH is not as granular as my knowledge of pharma. That said, in broad brushstrokes, the NIH is doing the infrastructure work for all drug development. I think they've participated in 100% of the drugs that have been approved by 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, when they find a target that is mutable 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 4% 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 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 about basically everything that just leads to drug development, vaccine development, but also speaking about healthy lifestyles and speaking about health, not just sickness. Yes, and investing, investing in health. I mean, it's like one feeds the other. One, you have to communicate to the public the importance 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. That communicates, I mean, everything that Anthony Fauci says or Francis Collins says has an impact on scientists. I mean, it sets the priorities. I don't think they, it's the sad thing about leaders, forgive me for saying the word, but mediocre leaders, is they don't see themselves as part of a game. 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, and bigger, inspiring people in the power and the trustworthiness of science. That's on the shoulders of Anthony Fauci. I'm gonna abstain from that, because I'm not expert enough. Neither am I, but I'm opinionated. I am too, but not on camera. No, but seriously, the problem is pretty simple, that we're investing 96% of our 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. 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 68th. We've gone down. You have this excellent, there's a few changes that I'll overlay that tell this story in really powerful ways. So one is the healthcare spending as 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 growing. Right, we are now spending 7% more of our GDP, 17.7% versus 10.7% on healthcare. 7%, and I think GDP is the fairest way to compare healthcare spending. 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, no, 18% of GDP, 18% of GDP spent on healthcare, 7% higher than the comparable country average. Right. 17.7% versus 10.7, 7% higher. Right, and 7% of $23 trillion GDP is more than $1.5 trillion a year in excess. And then you have another chart that shows healthcare system performance compared to spending. And there's a point cloud of different countries, the X axis being healthcare spending as a percentage of GDP, which we just talked about, that US is 7% higher than the average. And then on the Y axis is 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 high performance for what they're spending. And then US 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 healthcare. 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 wanna qualify that and say, it's not all big pharma's fault. They're not responsible for all the problems in our healthcare system. They're not responsible for the administrative costs, for example. But they are the largest component of the rising, our rising healthcare 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, so everything you've seen, we've talked about 80% of the impact on health is lifestyle. How do we live longer? What advice would you give to general people? 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 impacted by socioeconomic status. And we don't wanna blame the victims here, so we gotta understand that when we talk about all of these things, not cigarettes, but exercise and 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 fish bowl analogy, if you're swimming in a fish bowl, 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 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'd like to discuss this because the market isn't gonna 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 intervention 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 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, communicators, like podcasts and so on, but other channels of communication will be the way to fight big pharma. Your book is the way to, 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 the public. Making it exciting to buy books, to make better and better communicators on Twitter, through books, through op-eds, through podcasts, through so on. So basically, because there's a lot of incentive to communicate against the messages of big pharma. There is incentive because people want to understand what's good for their lives and they're willing to listen to charismatic people. They're able to clearly explain what is good for them. And they do. And more than 80% of people think that drugs cost too much and the drug industry is too interested in profits. But they still get influenced. They can't, you can't get the vote through Congress. Yeah. You know, Democrats and Republicans alike are taking money from Congress. And somehow it just doesn't work out that these even small changes. I mean, the pared down part of Medicare, the plan for increasing Medicare negotiation drug costs in Build Back Better, it's literally gonna reduce the number of new drugs that are beneficial, uniquely beneficial, by about one new drug or two new drugs over 30 years. And it will have virtually an indecipherable impact. And yet pharma is talking about the impact on innovation. And if you vote for this, if you let your Congressman vote for this, you're gonna severely slow down drug innovation and that's gonna affect the quality of your life. Let me ask you about 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 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 healthcare 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 overprescribing of antidepressants. Right. So a paper in the New England Times, 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, performing their normal social roles. 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, that concept that serotonin metabolism is the root cause of depression is really a destructive one. We have drugs that change serotonin metabolism but we don't know if that's why antidepressants work on major depression. And they 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 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. Individual therapy, group therapy, maybe lifestyle modification would work. We gotta try that. But let's call it what it is instead of saying, oh, you're 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 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 healthcare providers who acknowledge that you're suffering. So let's take that first step. And then- Big 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, some time with a psychiatrist, some time 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 a marital problem and there's something going on and one of the spouses can't find satisfaction in the life they have to live within their relationship. Maybe there's a past history of trauma or abuse that somebody is projecting onto their current situation. Maybe there's socioeconomic circumstances where they can't find a job that gives them self-respect and enough money to live with. 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 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 your time is worth money. Your, what you prescribe and your efforts after the visit are worth money. And it seems like the task of the doctor is to not think about any of that. Or 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 resources are allocated to serve the whole population's interest best. That's a tension that you have as a physician. Let's take the extreme example. Let's say you had a patient in front of you who if you gave a one $10 billion pill to, you would save their life. I would just be tortured by that as a physician because I know that $10 billion spent properly in an epidemiologically guided way is gonna 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 wouldn't say that. I think it's your responsibility to be tortured by it. That's exactly right. The human condition. That's a tough job, but yeah, to maintain your humanity through it all. 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. And 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 and become more legitimate in 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 drive to try to help the patient, that humanity of dealing with the uncertainty of it all. 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 healthcare at this point. And my answer is if you've got the calling, you should do it. You should do it because nobody's gonna do it better than you. And if you don't have the calling and you're in it for the money, you're not gonna be proud of yourself. How do you prevent yourself from doing, from letting the system change you over years and years, like letting the game of pharmaceutical influence affect you? It's a very hard question because the sociologic norms are to be affected and to trust the sources of information that are largely controlled by the drug industry. And that's why I wrote Sickening, is 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's getting ruined by the money that's getting pulled out of other socially beneficial uses to pay for healthcare that is not helping us. So fundamentally, the thing that is normal, question the normal. Don't, if you conform, conform hesitantly. Well, you have to conform. You can't become a doctor without conforming. I just made it through. But there aren't many and it's hard work, 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 is 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 renewed. And I said, are you having hot flashes or any problem? No, no, no, no. But 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 from my alma mater, medical school, and they said that healthy people should be given hormone replacement. And I said, there's gotta be drug companies involved in this. And she said, no, no, no, it was at my university. 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 Kuhn 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 subject of I don't have data on this. This is just my opinion. 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 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 ideal of medicine, of healthcare. Yeah, in Kuhnian 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? I mean, I'm not, I've faced it. I've been close. Yourself? Yeah, yeah. How do you think about it? What wisdom do you gain from having come close to death and the fact that the whole thing ends? It's liberating. It's very liberating. I mean, I'm serious. I was close and not too long ago. And it was a sense of, you know, this may be the way it ends. And 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, I got pulled out of it, but it didn't look like I was gonna get pulled out of it. Are you ultimately grateful for the ride, even though it ends? Well, it's a little, I think so. If I know, you know, you can't take the ride if you know what the, it's gonna end well. It's not the real ride. It's just a ride. But I, having gone through the whole thing, I definitely freed me of a sense of anxiety about death. And it said to me, do your best every day, because it's gonna end sometime. I apologize for the ridiculously big question, but what do you think is the meaning of life, of our human existence? 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 healthcare, 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, being in that commitment, for me, is the meaning of life. Put your whole heart and soul into the thing. What is it, the Bukowski poem, go all the way. John, you're an incredible human being, incredible educator. Like I said, I recommend people listen to your lectures. 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 amazing. Well, Lex, I wanted back to you. 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. So for anyone who don't know Gilbert 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 to us. This was 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.
 The jury found Pfizer guilty of fraud
 and racketeering violations.
 How does Big Pharma affect your mind?
 Everyone's allowed their own opinion.
 I don't think everyone's allowed
 their own scientific facts.
 Does Pfizer play 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 Burla.
 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 attack
 from all sides.
 I will get attacked when I host people
 like Jay Bhattacharya or Francis Collins,
 Jamie Mertzel or Vincent Racinello,
 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 that 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,
 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 guest 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 guest,
 that we talk in true long form for many hours.
 Second, these conversations will lead to
 a more
 and more intense conversation with the audience.
 I think that 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 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 the 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 healthcare 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 and healthcare, 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 guardrails that maintain the integrity
 and the balance of the knowledge.
 Without those guardrails, 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 healthcare.
 That's the biggest way that American healthcare
 is distinguished from healthcare 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 that was a radical idea at the time,
 but we're failing on all three.
 How are we failing?
 And 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 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 US history as of 2010.
 US 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 worth of fines
 from I think 1991 to 2017.
 It's never been enough to stop the misrepresentation
 of their data, and rarely are the fines greater
 than the profits that were made.
 See, 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.
 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 at Pfizer, for example,
 at big pharma companies?
 How is 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 then we look at the outcomes that you're describing
 and it looks, and that's why the narrative takes hold
 that like Pfizer CEO Albebrola, who I talked to,
 is malevolent.
 The sense is like these companies are evil.
 So if 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 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 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 are 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 milieu, you have one set of standards
 and then the rest of good American people
 have the expectation that the drug companies
 are trying to make money, but that they're playing by rules
 that aren't part of the insider milieu.
 That's fascinating.
 The game they're playing modifies the culture
 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.
 And that bubble allows you to drift
 in terms of what you see as ethical and unethical.
 Because you see the game as just part of the game.
 So marketing is just part of the game.
 Right.
 And paying the fines is just part of the game.
 Just part of the game. Of science.
 Yep, yep.
 And without guardrails, it becomes even more part
 of the game.
 You keep moving in that direction
 if you're not bumping up against guardrails.
 And 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 Berola.
 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,
 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 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.
 Relative to the other big pharma companies.
 Yes, yes.
 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 do what the law says we have to do for advertising.
 And I have 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 true.
 And I think that's a good example of what it looks like
 from within that culture.
 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, the emotional impact,
 the consequences 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.
 But this is a key point.
 If he doesn't do it, he'll get fired and the next guy will.
 So the people that survive in the company,
 the people that get raises in the company
 and move up in the company
 are the ones that play by the rules.
 And that's how the game solidifies itself.
 But the game is within the bounds 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 passive pressure to not say anything negative.
 Because I've seen this and I've been saddened by it
 that people sacrifice integrity in small ways
 when they're being funded by a particular company.
 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 anything
 that could possibly be negative about the company.
 They just choose not to because why?
 And that's really sad to me that
 if you give me 100 bucks,
 I'm less likely to say something negative about you.
 That makes me sad because 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.
 That's also a problem, by the way,
 so just having dinners and shaking hands
 and 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.
 But of course, the direct advertisement to consumers,
 like you said, is potentially very negative effect.
 I wanted to ask if what you think
 is the most negative impact of advertisement.
 Is it that direct to consumer on television?
 Is it advertisement to the doctors?
 Which I'm surprised to learn I was vaguely looking at
 is more than the advertisement.
 More is spent on advertising to doctors than to consumers.
 That's really confusing to me.
 It's fascinating, actually.
 And then also, obviously, 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 they don't invest all their,
 they don't put all their eggs in one basket.
 It's a whole surround sound program here.
 But in terms of advertisements,
 let's take the advertisement.
 Truelicity is a diabetes drug,
 for type two diabetes, an injectable drug.
 And it lowers blood sugar just about as well
 as metformin does.
 Metformin costs about $4 a month.
 Truelicity costs, I think, $6,200 a year.
 So $48 a year versus $6,200.
 Truelicity has distinguished itself
 because 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.
 So the ads obviously extol the virtues of truelicity
 because it reduces the risk of heart disease and stroke.
 And that's one of the major morbidities,
 risks of type two 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.
 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 truelicity does.
 Now, to be fair to the company, the sponsor,
 there's never been a study that compared truelicity
 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 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 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.
 That should be the bar.
 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 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 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 groups,
 a placebo group, a group that got treated with metformin,
 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 intensive lifestyle changes,
 whether that works.
 Now, the common wisdom amongst physicians,
 and I think in general,
 is that you can't get people to change.
 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 in the intensive lifestyle group
 ended up losing 10 pounds,
 exercising five times a week maintaining it,
 and reduced their risk of getting diabetes by 58%
 compared to the metformin group,
 which reduced its risk of getting diabetes by 31%.
 So 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 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 of these problems,
 and the market can't solve all of these problems.
 There needs to be some way of protecting the public interest
 for things that aren't financially driven,
 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 and expensive drug is better
 and should be used.
 Well, some of that is also people sort of like yourself.
 I mean, it's funny, you spoke with Joe Rogan.
 He constantly exposes lifestyle changes.
 So some of it is almost like understanding the problems
 that big pharma is creating in society,
 and then sort of these influential voices
 speaking up against it.
 So whether they're scientists or just regular communicators.
 Yeah, I think you gotta 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
 from the sources that the docs are trained to listen to
 and modify their patient care on.
 Now, it's not 100%.
 I mean, there are articles 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.
 I tip my hat.
 But it's not gonna 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 an entire mechanism established
 for testing drugs.
 There's not an entire mechanism established
 in terms of scientific rigor of testing lifestyle changes.
 I mean, it's more difficult.
 I mean, everything's difficult in science.
 Science involves humans especially.
 But these studies are very expensive.
 They're difficult.
 It's difficult to find conclusions
 to control all the variables.
 So it's very easy to dismiss them
 unless you really do a huge study that's very well-funded.
 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 that could be correlated,
 it could be the real cause of the effects you're seeing,
 all that kind of stuff.
 So 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 that's another issue is that we kind of,
 nobody says to doctors in training
 only listen to reductionist studies and conclusions
 and methods of promoting health.
 Nobody says that explicitly,
 but the respectable science
 has to do with controlling the factors.
 And I mean, it just doesn't make sense to me.
 I'm gonna pick on trulicity
 because it's such an obvious example,
 but it's not more egregious 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's just so crystal clear
 that the purpose of that study is to sell trulicity.
 It's not to prevent cardiovascular disease.
 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 force that it should be compared
 to lifestyle changes.
 Do you think advertisements period
 in the 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.
 Answer either one.
 I believe, I've been told by lawyers who I trust
 that the freedom of speech in the US 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 advertisements about them can't be banned.
 Let's assume that they can't be,
 because we know they won't be anyway,
 but let's assume they can't be,
 and especially our Supreme Court now
 would be unlikely to take that seriously.
 But that's not the issue.
 The issue is that if the drug companies
 wanna 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, in truth, the city, it's one out of 323.
 322 people aren't gonna benefit
 from the cardiovascular risk reduction.
 What's the true cost?
 When drugs advertise that you may be able to get this
 for a $25 copay or something,
 a tens of thousands of dollars a year drug for a $25 copay,
 what an enormous disservice that is
 to misrepresent the cost to society.
 That should not be allowed.
 So you should have to make it clear to the viewers
 how many people are gonna 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 costs $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 a $25 copay.
 So you'd have to temper that a little bit.
 Oh, you mean people are so, they don't care.
 They don't care.
 Their insurance is gonna cover it and it's a $25 copay,
 but we could figure out how to deal with that.
 The main point is that if we assume
 that advertisements are gonna keep going, and they are,
 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 truth should have like sub-truth guardrails,
 meaning like the cost that we talked about,
 the effects compared to things that actually,
 lifestyle changes, 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.
 I mean, there's something dark and inauthentic
 about those advertisements, but they seem,
 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.
 People should definitely look you off from,
 there's a bunch of videos of you giving talks on YouTube
 and it's just, it's so refreshing to hear
 just the clarity of thought about health policy,
 about healthcare, 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 the, one part of the message
 that you're talking about, but you know,
 that's not like your brilliance actually shines
 in the positive and the solutions and how to do it.
 So as a doctor, what affects your mind
 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 respective journal,
 people and doctors obviously assume that
 the peer reviewers 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, make it.
 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 what level of manipulation
 is going on with that data?
 Is it at the study design level?
 Is it at literally there's some data
 that you just keep off, keep out of the charts,
 keep out of the aggregate analysis
 and you then publish or is it the worst case
 which is just change some of the numbers?
 It happened, all three happened.
 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 doubled the risk of heart attacks,
 strokes and blood clots, serious blood clots.
 It got pulled then.
 But there was a study, 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 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 data from that study
 said that 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 three heart 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 attack 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, because this is crossing the-
 No, no, no, let me interrupt.
 No, that's not true.
 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 who has to convince themselves?
 Is this pure malevolence?
 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 $5,000 a day, I think for 12 days a year,
 for one or two years,
 that contract was signed within two weeks
 of the decision to stop counting heart attacks.
 I wanna understand that man or woman.
 I wanna, I want, it's the,
 I've been reading a lot about Nazi Germany
 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 a 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 one step.
 So to even push back on that idea is,
 I assume you mean that data remains private
 except to the peer review.
 The peer review reviewers.
 The problem of course, 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,
 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 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 3000 page document.
 As I became more experienced as an expert in litigation,
 I could go through those documents pretty quickly.
 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 their statistical analysis plan
 and their 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,
 to be a good citizen in the medical community
 and to be on friendly terms with the journals
 so that if you wanna get published,
 there's sort of an unspoken incentive.
 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.
 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 clearly a 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 just a couple hours,
 but really seriously reading.
 Like some papers can take months to really understand.
 So if you really wanna struggle,
 there has to be an incentive for that struggle.
 Yes, and billions of dollars
 ride on some of these studies.
 And lies, right?
 Not to mention.
 Right, but it would be easy to have full-time statisticians
 hired by the journals or shared by the journals
 who were independent of any other financial incentive
 to go over these kind of methodological issues
 and take responsibility for certifying the analyses
 that are done and then pass it on
 to the volunteer peer reviewers.
 See, I believe 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 citizen scientists arise.
 A lot of them on the, it's kind of funny.
 A lot of people that 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 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
 as impactful as some of these drugs.
 I agree 100%.
 So let's turn the mic,
 let's get a little bit more granular.
 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 gonna 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 my own voice inside says,
 once doctors start doing things to their patients' bodies,
 they're really not too enthusiastic
 about hearing it was wrong.
 Yeah, that's the stickiness of human nature.
 Wow, so that bar, once it's published,
 the doctors, that's when the stickiness emerges, wow.
 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 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.
 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 Albert Berla.
 What did he say?
 There's several things I didn't like about what he said.
 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, wait a minute.
 He wasn't aware of?
 The how long.
 So here I'll explain what he.
 Do you know that since you spoke to him,
 Pfizer has petitioned the judge to join the suit
 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 sure he's aware in some formulation,
 the exact years he might have not been aware.
 But the point is that there is,
 that is the FDA, the relationship with Pfizer 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 wanna talk about the FDA.
 And that relate, it was clear
 that there was a relationship there
 that 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 I don't know how to interpret it
 if he's actually aware or not,
 but the deeper truth is that he's deeply uncomfortable,
 bringing light to this part of the game.
 Yes, and I'm gonna read between the lines
 and Albert Borla certainly didn't ask me to speak for him.
 But I think, when did you speak to him?
 How long ago?
 Wow, time flies when you're having fun.
 Two months ago.
 Two months ago.
 So that was just recently it's come out,
 just in the past week it's come out,
 that Pfizer isn't battling the FDA.
 Pfizer has joined the FDA in the opposition to the request
 to release 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 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,
 yes, of course,
 we can only publish some X number of pages a day.
 500 pages.
 500 pages of data.
 It's not a day though, it's a week I think.
 The point is whatever they're able to publish is ridiculous.
 It's like, my printer can only print three pages a day
 and we cannot afford a second printer.
 So it's some kind of bureaucratic language for,
 there's a process to this.
 And now you're saying that Pfizer is obviously
 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 gonna take them some number of,
 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 $3 million.
 $3 million 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 $3 million either.
 So bought for $3 million.
 I mean, maybe the FDA should do a GoFundMe campaign.
 Well, obviously the money thing,
 I mean, I'm sure if Elon Musk comes along and says,
 I'll give you a hundred million, publish it now,
 I think they'll come up with another.
 So, I mean, it's clear that there's 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 wanna release the data.
 They don't wanna release the three or 500,000 pages
 of documents, and I don't know what's in there.
 I wanna say one thing very clearly.
 I am not an anti-vaxxer.
 I believe the vaccines work.
 I believe everybody should get vaccinated.
 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 wanna be very clear about this.
 That said, there's something I would give you 10 to one odds
 on a bet that there's something in that data
 that is gonna 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.
 I mean, it's a lot of data that they have a sense
 there might be something embarrassing in there.
 And if we release it, surely the world will discover
 the embarrassing and to do a 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-vax campaign.
 I think that's all possible.
 Nonetheless, the data are about the original clinical trial
 and the emergency youths 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-vax argument here.
 But I suspect that there's something pretty serious
 in that data.
 And the reason why I'm not an anti-vaxxer
 having not been able to see the data
 that the FDA and Pfizer seem 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-vax aside 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 side effects that overcome
 the benefits of vaccine.
 So 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 world use large scale data
 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.
 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
 because it's not really pro-vaccine versus anti-vaccine
 because it's pro-vaccine, triple mask,
 Democrat, liberal, and then anti-mandate,
 whatever those groups are.
 I can't quite, cause they're changing,
 anti-mask, but not really, but kind of.
 So those two groups that feel political in nature,
 not scientific in nature, they're bickering.
 And then it's clear that this data is being interpreted
 by the different groups differently.
 And 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 there's real human emotion and fear
 and also credibility.
 Scientists don't wanna ruin their reputation
 if they speak out in whatever, like speak their opinion
 or 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 don't know what to make of that.
 And the only happy people here is Pfizer.
 It's just plowing all ahead.
 I mean, with every single variant,
 there's, I would say outside of arguably a very flawed system,
 there's a lot of incredible scientific
 and engineering work being done
 in constantly developing new antiviral drugs,
 new vaccines to deal with the variants.
 So they're happily being a capitalist machine.
 And 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 approved for the treatment of rheumatoid arthritis
 and eight other indications.
 And it's sold about $20 billion globally
 over the past few years.
 It leveled out, it peaked at that level.
 Pfizer expects to sell $65 billion of vaccine
 in the first two years of the pandemic.
 So this is by far the biggest selling
 and most profitable drug that's ever 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 flying around,
 where do you land?
 So we're gonna 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 vaccines.
 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
 for the next two years.
 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 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 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 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.
 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% of the vaccines early on
 went to the first world.
 And very, very few vaccinations went to the third world.
 So what happened is 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,
 the World Health Organization, the IMF and the World Bank
 made a plea for $50 billion
 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 gonna have a constant supply of variants of COVID
 that are gonna 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 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 that was requested
 by the four organizations back in May of 2021,
 32 billionaires made $50 billion
 from the vaccines at that point,
 took it into their private wealth.
 So what had been taken,
 there's 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 kind of allocation of vaccines?
 Because they can make-
 More money in the United States.
 They're gonna distribute their vaccines
 where they can make the most money.
 Right, is there a malevolent aspect to this
 where, boy, 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 damage.
 And also kind of believe, convince yourself
 that if we give into 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 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 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,
 I think that's a belief you can hold.
 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,
 Ayn Rand's position would get some votes, but not many,
 and it would be way outvoted by the common people.
 Let me ask you about this very difficult topic.
 I'm talking to Mark Zuckerberg of Metta,
 the topic of censorship.
 I don't know if you've heard,
 but there's a guy named Robert Malone and Peter McCullough
 that were removed from many platforms
 for speaking about the COVID 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 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 scientific publications?
 And particularly in the era of COVID,
 where there are large public health ramifications
 to this public discourse, 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 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-vax messages.
 The way to defeat anti-vax messages
 is by being great communicators,
 by 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 deep scientific truth.
 Because I think if you censor,
 you get worse at doing science
 and you give the wrong people power.
 So 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 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
 doesn't seem to be sustainable.
 Especially given a very real observation now
 that the reason Robert Malone has a large following
 is there's a deep distrust of institutions,
 deep distrust of scientists, of science as an institution,
 of power centers, of companies, of everything,
 and perhaps rightfully 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
 and maybe a lot of them to get fired.
 And for new minds, for new fresh scientists
 and for new fresh scientists,
 ones who are more authentic,
 more real, better communicators to step up.
 So I fear censorship because it feels like
 censorship is an 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 always the incompetent people,
 and not just the incompetent, but the biggest whiners.
 So what happens is the people that get the most emotional
 and the most outrage will drive the censorship.
 And it doesn't seem like reason drives the censorship.
 That's just objectively observing
 how censorship seems to work in this current.
 So there's so many forms of censorship.
 You look at the Soviet Union with the propaganda
 or Nazi Germany, it's a very different level of censorship.
 People tend to conflate all of these things together.
 Social media trying desperately to have trillions
 or hundreds of billions of exchanges a day
 and try to make sure that their platform
 has some semblance of quote, healthy conversations.
 People just don't go insane.
 They actually like using the platform
 and they censor based on that.
 That's a different level of censorship, but even there,
 you can really run afoul of the people that get
 the whiny C students controlling too much of the censorship.
 I believe 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 advocating for any kind of censorship,
 but Marshall McLuhan was very influential
 when I was in college and his, that meme,
 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 TV's hotter or something,
 but we now have the medium is the message
 in a way that we've never seen, we've never imagined before
 where rage and anger and polarization
 are what drives the traffic on the internet.
 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, 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%
 of the people in the middle who want to 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 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 is 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 I can mention 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.
 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 big center that's actually going to be affected
 by the results of our pursuit of scientific truth, right?
 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,
 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 rational as intelligent human beings,
 can look at both and make up our own minds.
 And that's where social media can be very good
 at this collective intelligence.
 We together listen to all of these voices
 and make up our own mind.
 Humble ourselves actually often.
 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, all it takes is a few times,
 you know, looking back 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 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, it's the internet.
 So financially, in terms of platforms,
 this cannot be censored,
 which is why 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 wanna push back a little bit
 on what you're saying.
 I have 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-vax argument,
 but I am saying that it's almost like
 we were talking about 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.
 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-vax 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 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 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, ugh.
 Like they don't want to interact with this.
 But 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 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 the little ants interacting at scale.
 I think that allows us to progress towards truth,
 at least I hope so.
 I think you're an optimist.
 I want to work with you a little bit on this.
 Let's say a person like Joe Rogan,
 who by the way, had me on his podcast and let me-
 It was 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.
 And he pushed back on Joe a bunch, which is great.
 And 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-
 Jamie. Jamie.
 He had Jamie check it and was very forthright in saying,
 yeah, you know, John's got a right here.
 We got to modify this a little bit.
 In any event, in any event-
 You got him.
 Well, I wasn't trying to get him.
 I was just trying to get him.
 No, no, no, no, no.
 Totally, it was, there's a beautiful exchange.
 There's so much respect in the room,
 pushing back and forth.
 That was great.
 Yeah. So I respect him.
 And I think when he has somebody on
 who's a dyed 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 a really interesting idea.
 By the way, 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.
 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.
 You know, arguments against certain parts.
 That's very interesting to sort of,
 as one podcast publish like addendums,
 publish the peer review together with the publication.
 That's very interesting.
 I might actually do that.
 That's really interesting.
 Because 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 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-vax,
 I've been fascinated by listening to arguments
 from this community of folks that's been quite large
 called the 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 take it in like listening normally.
 It's all very logical.
 Like if you don't think very, well, no.
 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 at 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 the whole progress of science
 and physics of the past,
 but that's difficult to integrate into your thought process.
 So it's very true that 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 charismatic arguments.
 Right.
 And if we're arguing about whether the earth is flat or not,
 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.
 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 and school and so forth.
 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.
 There are millions of lives involved.
 Let me ask you yet another question,
 issue I raised with Pfizer 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,
 including 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?
 Do you think that's a problem?
 Hoo-ha.
 And also maybe this is a good time to talk about
 this Pfizer play by the rules.
 Let's, one at a time.
 One at a time.
 Okay, and this isn't even about Pfizer,
 but it's an answer to the question.
 Yes.
 So there's this drug, Aja-Helm,
 that was approved by the FDA 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, Aja-Helm,
 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% more people in the Aja-Helm group
 developed symptomatic brain swelling and bleeding
 than people in the placebo group.
 There was an advisory committee convened
 to debate and determine how they felt
 about the approvability of Aja-Helm, given those facts.
 And those facts aren't in dispute.
 They're in Biogen slides as well as FDA documents.
 The advisory committee voted 10 against approval
 and one abstain.
 So that's essentially universal,
 unanimous vote against approving Aja-Helm.
 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 gonna be part,
 if the FDA is not gonna listen to a unanimous vote
 against approving this drug,
 which shows more harm than benefit, undisputed,
 we're not gonna 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 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 Albert said,
 there's rules.
 I mean, you're not allowed to have direct financial
 conflicts of interest.
 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.
 Wow.
 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 side of 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 worked- I don't know.
 Two separate questions.
 One is, should the 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 advisory committee people
 should not have conflicts of interest.
 I think their only interest ought to be the public interest.
 And that was true from my understanding of the situation.
 It's the afterward in my book,
 I spent some time studying it about Aja Helm.
 I think it's a slam dunk
 that there ought to be no conflicts of interest.
 Now the head of CDER,
 Center for Drug Evaluation Research,
 thinks that that's gonna give you a biased result
 because we don't have company influence.
 And that I think shows 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.
 But they have a voice at the table.
 They've designed the studies.
 Right, that's their voice.
 That's the whole point.
 They analyze the data.
 I mean, what bigger voice do you deserve?
 But I do also think on the more challenging question,
 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
 regulatory agency.
 Yes.
 You should not, I mean, that going back and forth,
 it just, even if it's 30 years later.
 Yeah, 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 Towson was head of the 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 Towson did not finish out
 his term in Congress.
 He went to pharma for a $2 million a year job.
 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.
 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?
 So my knowledge of the NIH is not as granular
 as my knowledge of pharma.
 That said, in broad brushstrokes,
 the NIH is doing the infrastructure work
 for all drug development.
 I think they've participated in 100% of the drugs
 that have been approved by 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, when they find a target
 that is mutable 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 4% 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 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 about basically everything
 that just leads to drug development, vaccine development,
 but also speaking about healthy lifestyles
 and speaking about health, not just sickness.
 Yes, and investing, investing in health.
 I mean, it's like one feeds the other.
 One, you have to communicate to the public
 the importance 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.
 That communicates, I mean, everything that Anthony Fauci says
 or Francis Collins says has an impact on scientists.
 I mean, it sets the priorities.
 I don't think they, it's the sad thing about leaders,
 forgive me for saying the word, but mediocre leaders,
 is they don't see themselves as part of a game.
 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, and bigger,
 inspiring people in the power
 and the trustworthiness of science.
 That's on the shoulders of Anthony Fauci.
 I'm gonna abstain from that,
 because I'm not expert enough.
 Neither am I, but I'm opinionated.
 I am too, but not on camera.
 No, but seriously, the problem is pretty simple,
 that we're investing 96% of our 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.
 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 68th.
 We've gone down.
 You have this excellent, there's a few changes
 that I'll overlay that tell this story
 in really powerful ways.
 So one is the healthcare spending as 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 growing.
 Right, we are now spending 7% more of our GDP,
 17.7% versus 10.7% on healthcare.
 7%, and I think GDP is the fairest way
 to compare healthcare spending.
 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, no, 18% of GDP, 18% of GDP spent on healthcare,
 7% higher than the comparable country average.
 Right.
 17.7% versus 10.7, 7% higher.
 Right, and 7% of $23 trillion GDP
 is more than $1.5 trillion a year in excess.
 And then you have another chart
 that shows healthcare system performance
 compared to spending.
 And there's a point cloud of different countries,
 the X axis being healthcare spending as a percentage of GDP,
 which we just talked about,
 that US is 7% higher than the average.
 And then on the Y axis is 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 high performance
 for what they're spending.
 And then US 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 healthcare.
 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 wanna qualify that and say,
 it's not all big pharma's fault.
 They're not responsible for all the problems
 in our healthcare system.
 They're not responsible for the administrative costs,
 for example.
 But they are the largest component of the rising,
 our rising healthcare 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,
 so everything you've seen,
 we've talked about 80% of the impact on health is lifestyle.
 How do we live longer?
 What advice would you give to general people?
 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 impacted by socioeconomic status.
 And we don't wanna blame the victims
 here, so we gotta understand
 that when we talk about all of these things,
 not cigarettes, but exercise and 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 fish bowl analogy,
 if you're swimming in a fish bowl,
 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 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'd like to discuss this
 because the market isn't gonna 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 intervention
 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 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,
 communicators, like podcasts and so on,
 but other channels of communication
 will be the way to fight big pharma.
 Your book is the way to, 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 the public.
 Making it exciting to buy books,
 to make better and better communicators on Twitter,
 through books, through op-eds,
 through podcasts, through so on.
 So basically, because there's a lot of incentive
 to communicate against the messages of big pharma.
 There is incentive because people want to understand
 what's good for their lives
 and they're willing to listen to charismatic people.
 They're able to clearly explain
 what is good for them.
 And they do.
 And more than 80% of people think that drugs cost too much
 and the drug industry is too interested in profits.
 But they still get influenced.
 They can't, you can't get the vote through Congress.
 Yeah.
 You know, Democrats and Republicans alike
 are taking money from Congress.
 And somehow it just doesn't work out
 that these even small changes.
 I mean, the pared down part of Medicare,
 the plan for increasing Medicare negotiation drug costs
 in Build Back Better,
 it's literally gonna reduce the number of new drugs
 that are beneficial, uniquely beneficial,
 by about one new drug or two new drugs over 30 years.
 And it will have virtually an indecipherable impact.
 And yet pharma is talking about the impact on innovation.
 And if you vote for this,
 if you let your Congressman vote for this,
 you're gonna severely slow down drug innovation
 and that's gonna affect the quality of your life.
 Let me ask you about 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 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 healthcare 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 overprescribing of antidepressants.
 Right.
 So a paper in the New England Times,
 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,
 performing their normal social roles.
 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, that concept that serotonin metabolism
 is the root cause of depression
 is really a destructive one.
 We have drugs that change serotonin metabolism
 but we don't know if that's why antidepressants
 work on major depression.
 And they 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 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.
 Individual therapy, group therapy,
 maybe lifestyle modification would work.
 We gotta try that.
 But let's call it what it is instead of saying,
 oh, you're 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 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 healthcare providers
 who acknowledge that you're suffering.
 So let's take that first step.
 And then- Big 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,
 some time with a psychiatrist,
 some time 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 a marital problem
 and there's something going on
 and one of the spouses can't find satisfaction
 in the life they have to live within their relationship.
 Maybe there's a past history of trauma or abuse
 that somebody is projecting onto their current situation.
 Maybe there's socioeconomic circumstances
 where they can't find a job that gives them self-respect
 and enough money to live with.
 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 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 your time is worth money.
 Your, what you prescribe and your efforts
 after the visit are worth money.
 And it seems like the task of the doctor
 is to not think about any of that.
 Or 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 resources are allocated
 to serve the whole population's interest best.
 That's a tension that you have as a physician.
 Let's take the extreme example.
 Let's say you had a patient in front of you
 who if you gave a one $10 billion pill to,
 you would save their life.
 I would just be tortured by that as a physician
 because I know that $10 billion spent properly
 in an epidemiologically guided way
 is gonna 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 wouldn't say that.
 I think it's your responsibility to be tortured by it.
 That's exactly right.
 The human condition.
 That's a tough job, but yeah,
 to maintain your humanity through it all.
 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.
 And 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
 and become more legitimate in 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 drive
 to try to help the patient,
 that humanity of dealing with the uncertainty of it all.
 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 healthcare at this point.
 And my answer is if you've got the calling,
 you should do it.
 You should do it because nobody's gonna do it
 better than you.
 And if you don't have the calling
 and you're in it for the money,
 you're not gonna be proud of yourself.
 How do you prevent yourself from doing,
 from letting the system change you over years and years,
 like letting the game of pharmaceutical influence
 affect you?
 It's a very hard question
 because the sociologic norms are to be affected
 and to trust the sources of information
 that are largely controlled by the drug industry.
 And that's why I wrote Sickening,
 is 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's getting ruined by the money
 that's getting pulled out of other socially beneficial uses
 to pay for healthcare that is not helping us.
 So fundamentally, the thing that is normal,
 question the normal.
 Don't, if you conform, conform hesitantly.
 Well, you have to conform.
 You can't become a doctor without conforming.
 I just made it through.
 But there aren't many and it's hard work,
 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 is 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 renewed.
 And I said, are you having hot flashes or any problem?
 No, no, no, no.
 But 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 from my alma mater,
 medical school, and they said that healthy people
 should be given hormone replacement.
 And I said, there's gotta be drug companies involved in this.
 And she said, no, no, no, it was at my university.
 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 Kuhn 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 subject
 of I don't have data on this.
 This is just my opinion.
 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 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 ideal of medicine, of healthcare.
 Yeah, in Kuhnian 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?
 I mean, I'm not, I've faced it.
 I've been close.
 Yourself?
 Yeah, yeah.
 How do you think about it?
 What wisdom do you gain from having come close to death
 and the fact that the whole thing ends?
 It's liberating.
 It's very liberating.
 I mean, I'm serious.
 I was close and not too long ago.
 And it was a sense of, you know,
 this may be the way it ends.
 And 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, I got pulled out of it,
 but it didn't look like I was gonna get pulled out of it.
 Are you ultimately grateful for the ride,
 even though it ends?
 Well, it's a little, I think so.
 If I know, you know, you can't take the ride
 if you know what the, it's gonna end well.
 It's not the real ride.
 It's just a ride.
 But I, having gone through the whole thing,
 I definitely freed me of a sense of anxiety about death.
 And it said to me, do your best every day,
 because it's gonna end sometime.
 I apologize for the ridiculously big question,
 but what do you think is the meaning of life,
 of our human existence?
 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 healthcare,
 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, being in that commitment,
 for me, is the meaning of life.
 Put your whole heart and soul into the thing.
 What is it, the Bukowski poem, go all the way.
 John, you're an incredible human being,
 incredible educator.
 Like I said, I recommend people listen to your lectures.
 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 amazing.
 Well, Lex, I wanted back to you.
 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.
 So for anyone who don't know Gilbert 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 to us.
 This was 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.