Lex Fridman Podcast - #263 - John Abramson: Big Pharma

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 Borla.

And here, please allow me to say a few additional words

about this episode with the Pfizer CEO,

and in general, about why I do these conversations

and how I approach them.

If this is not interesting to you, please skip ahead.

What do I hope to do with this podcast?

I want to understand human nature,

the best and the worst of it.

I want to understand how power, money,

and fame changes people.

I want to understand why atrocities are committed

by crowds that believe they’re doing good.

All this, ultimately, because I want to understand

how we can build a better world together,

to find hope for the future,

and to rediscover each time,

through the exploration of ideas,

just how beautiful this life is.

This, our human civilization,

in all of its full complexity,

the forces of good and evil,

of war and peace, of hate and love.

I don’t think I can do this with a heart and mind

that is not open, fragile, and willing to empathize

with all human beings,

even those in the darkest corners of our world.

To attack is easy.

To understand is hard.

And I choose the hard path.

I have learned over the past few months

that this path involves me getting more and more attacked

from all sides.

I will get attacked when I host people

like Jay Bhattacharya or Francis Collins,

Jamie Merzl or Vincent Ricanello,

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 the 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 Bourla conversation.

The goal was to reveal as much as I could

about the human being before me

and to give him the opportunity to contemplate in long form

the complexities of his role,

including the tension between making money

and helping people, the corruption

that so often permeates human institutions,

the crafting of narratives through advertisements,

and so on.

I only had one hour,

and so this wasn’t the time to address these issues deeply

but to show if Albert struggled with them

in the privacy of his own mind,

and if he would let down the veil of political speak

for a time to let me connect with a man

who decades ago chose to become a veterinarian,

who wanted to help lessen the amount of suffering

in the world.

I had no pressure placed on me.

There were no rules.

The questions I was asking were all mine

and not seen by Pfizer folks.

I had no care whether I ever talked to another CEO again.

None of this was part of the calculation

in my limited brain computer.

I didn’t want to grill him.

The way politicians grill CEOs in Congress,

I thought that this approach is easy,

self serving, dehumanizing, and it reveals nothing.

I wanted to reveal the genuine intellectual struggle,

vision, and motivation of a human being,

and if that fails, I trusted the listener

to draw their own conclusion and insights from the result,

whether it’s the words spoken

or the words left unspoken or simply the silence.

And that’s just it.

I fundamentally trust the intelligence of the listener, you.

In fact, if I criticize the person too hard

or celebrate the person too much,

I feel I fail to give the listener

a picture of the human being that is uncontaminated

by my opinion or the opinion of the crowd.

I trust that you have the fortitude and the courage

to use your own mind, to empathize, and to think.

Two practical lessons I took away.

First, I will more strongly push

for longer conversations of three, four, or more hours

versus just one hour.

60 minutes is too short for the 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 with leaders

can be aided by further conversations

with people who wrote books about those leaders

or their industries.

Those that can steel man each perspective

and attempt to give an objective analysis.

I think of Teddy Roosevelt’s speech

about the man in the arena.

I want to talk to both the men and women in the arena

and the critics and the supporters in the stands.

For the former, I lean toward wanting to understand

one human being’s struggle with the ideas.

For the latter, I lean towards understanding

the ideas themselves.

That’s why I wanted to have this conversation

with John Abramson, who is an outspoken critic

of the pharmaceutical industry.

I hope it helps add context and depth

to the conversation I had with the Pfizer CEO.

In the end, I may do worse than I could have or should have.

Always, I will listen to the criticisms without ego

and I promise I will work hard to improve.

But let me say finally that cynicism is easy.

Optimism, true optimism is hard.

It is the belief that we can and we will

build a better world and that we can only do it together.

This is the fight worth fighting.

So here we go.

Once more into the breach, dear friends.

I love you all.

This is 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, Overdose to 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 it 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, in 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 in other wealthy nations.

So okay, 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 on 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 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.

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 on 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.


And so, and then we look at the outcomes

that you’re describing, and it looks,

and that’s why the narrative takes hold

that Pfizer CEO, Al Bobrola, who I talked to, is malevolent.

The sense is 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.

Paying the fines is just part of the game of science.

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 Berla, and I’d like to raise with you

some of the concerns I raised with him.

So one, you already mentioned, I raised the concern

that Pfizer’s 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, I’ve not been an expert in litigation

for a few years, and I don’t know what’s going on currently,

but let’s take him at his word.

It could be true, it might not be, but it could be.

But if that’s true, in his world, in his culture,

that’s ethical business behavior.

From a common sense person’s point of view,

a drug company paying highly skilled media folks

to take the information about the drug

and create the illusion, the emotional impact,

and the takeaway message for viewers of advertisements

that grossly exaggerate the benefit of the drug

and minimize the harms, it’s sociopathic behavior

to have viewers of ads leave the ad

with an unrealistic impression

of the benefits and harms of the drug.

And yet he’s playing by the rules,

he’s doing his job as CEO

to maximize the effect of his advertising,

and if he doesn’t do it, this is a key point,

if he doesn’t do it, he’ll get fired and the next guy will.

So the people that survive in the company,

the people that get raises in the company,

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 can just clearly see that the space of opinions

that they’re willing to engage in,

or a space of ideas they’re willing to play with,

is one that doesn’t include negative,

anything that could possibly be negative about the company.

They just choose not to.

Because, you know, why?

And that’s really sad to me,

that if you give me a hundred 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,

sort of having dinners and shaking hands,

and oh, aren’t we friends?

But the fact that money has that effect

is really sad to me.

On the news media, on the journalists, on scientists,

that’s scary to me.

But of course, the direct advertisement to consumers,

like you said, is a 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 of the doctors?

Which I’m surprised to learn,

I was vaguely looking at,

is more 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.

Trulicity 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.

Trulicity costs, I think, $6,200 a year.

So $48 a year versus $6,200.

Trulicity 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 Trulicity

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 nonfatal 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 Trulicity does.

Now, to be fair to the company, the sponsor,

there’s never been a study that compared Trulicity

to lifestyle changes.

But that’s part of the problem of our advertising.

You would think in a rational society

that was way out on a limb as a 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.

Because 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 know, you can do whatever you want,

you can stand on your head,

you can beg and plead, people won’t change.

So give it up and let’s just move on with the drugs

and not waste any time.

Except this study that was published

in the New England Journal, I think in 2002,

shows that’s wrong.

That the people who were 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?

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 inexpensive 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 espouses 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

and 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.

That science that involves humans, especially.

But it’s just, these studies are very expensive.

They’re difficult.

It’s difficult to find conclusions

and to control all the variables.

And so it’s very easy to dismiss them

unless you really do a huge study that’s very well funded.

And so maybe the doctors just lean

towards the simpler studies over and over,

which is what the drug companies fund.

They can control more variables.

See, but the control there is sometimes

by hiding things too, right?

So sometimes you can just say

that this is a well controlled study

by pretending there’s a bunch of other stuff.

It’s 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 the 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?


Answer either one.

I believe, I’ve been told by lawyers who I trust,

that the freedom of speech in the U.S. Constitution

is such that you can’t ban them,

that you could ban cigarettes and alcohol,

which have no therapeutic use,

but drugs have a therapeutic use,

and 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

want to spend their money advertising,

they should have to have independent analysis

of the message that the viewers are left with

about the drug, so that it’s realistic.

What’s the chance the drug will help them?

Well, in true city, it’s one out of 323.

322 people aren’t gonna benefit

from the cardiovascular reduction, risk reduction.

What’s the true cost?

When drugs advertise that you may be able to get this

for a $25 copay or something,

tens of thousands of dollars a year drug,

for 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 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.

And I’ve just, people should definitely look you up 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 one part of the message that you’re talking about,

but that’s not like, your brilliance actually shines

in the positive, in 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 respected 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 there,

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 that you then publish?

Or is it the worst case,

which is just change some of the numbers?

It happened.

All three happened.

I can’t, I don’t know what the denominator is,

but I spent about 10 years in litigation.

And for example, in Vioxx,

which was withdrawn from the market in 2004

in the biggest drug recall in American history,

the problem was that it got recalled

when a study that Merck sponsored

showed that Vioxx doubled the risk,

more than 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.


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 line.

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 was signed, 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.

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 reviewers should see the data.

That’s one step.

So to even push back on that idea is,

I assume you mean the data remains private

except to the peer reviews, reviewers.

The problem with, 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 the way,

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 to.

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 it 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 like 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 lives, 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 like 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 I, you know, there’s some argument to be made

for a lot of this data to become public,

like deanonymized, 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 micro,

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 blah, 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 Bourla.

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 of 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 really, 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, but when did you speak to him?

How long ago?

Wow, time flies when you’re having fun.

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.


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 of course,

yes, of course, but we can only publish

we can only publish like some X number of pages a day.

500 pages.

500 pages of data.

It’s not a day though, it’s 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, Kafkaesque 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 hundredfold,

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 Kafkaesque,

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, but for $3 million, I mean, maybe,

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 $100 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 faxer.

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.

Like, I mean, it’s a lot of data

that they have a sense

that 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 use 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 vaxxer side

is because that’s clinical trial data,

early clinical trial data

that involved several thousand people.

We now have millions of data points

from people who have had the vaccine.

This is real world data,

showing the efficacy of the vaccines.

And so far, knock on wood,

there aren’t 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

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 very, 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, like 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 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.

I can 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.


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

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 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’re just ordinary selfish people like most of us are,

and you’re worried about the health of Americans,

you would ensure global vaccine distribution.

Let me just make one more point.

That $50 billion 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,

this 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,

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.

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 like,

if we just maximize profits, we’ll do the most good.

Yeah, that’s an orthodoxy of several decades ago.

And I don’t think people can really say that in good faith.

When you’re talking about 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 kinda,

it’s the, I don’t wanna mischaracterize Ayn Rand, okay?

I respect a lot of people,

but there’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’s 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 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 at 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,

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.

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 outraged

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

or 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 as 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.

And we don’t, it’s a question of building the commons.

Ideally, I don’t know how to get there,

so I’m not pretending to have a solution.

But the commons of discourse about this particular issue,

about vaccines, 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’s having.

So I don’t know if you heard,

but Neil Young and other musicians have kind of spoke out

and saying they’re going to leave the platform

because Joe Rogan is allowed to be on this platform

having these kinds of conversations

with the likes of Robert Malone.

And it’s clear to me that Spotify and YouTube

are being significantly influenced

by these extreme voices, like you mentioned, on each side.

And it’s also clear to me that Facebook is the same

and it was going back and forth.

In fact, that’s why Facebook has been oscillating

on the censorship is like one group gets louder

than the other, depending on whether it’s an election year.

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.

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 fax 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 fax argument.

I’m not saying I can disprove the anti fax 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 fax side puts out more units

of information claiming to show that the vaccines don’t work.

And I guess in an ideal situation,

there would be real time fact checking by independent people,

not to censor it, but to just say that study was set up

to do this, and this is what the conclusions were.

So the way it was stated is on one side of this argument.

But that’s what I’m arguing.

I agree with you.

What I’m arguing is that this big network of humans

that we have, that is the collective intelligence,

can’t do that real time if you allow it to,

if you encourage people to do it.

And the scientists, as opposed to, listen,

I interact with a lot of colleagues,

a lot of friends that are scientists,

they roll their eyes.

Their response is like, 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 lot,

you said you invested one or two hours

in this particular, but that’s little ants interacting

at scale, I think that allows us to progress towards truth.

At least, you know, 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’s an amazing conversation, I really enjoyed it.

Well, thank you.

I did too.

And I didn’t know Joe.

I didn’t know much about his podcast.

He pushed back on Joe a bunch, which is great.

And he was a gentleman, and we had it out.

In fact, he put one clip, at one point,

he said something that was a little bit wrong,

and I corrected him.

And he had the guy who.


Jamie, he had Jamie check it,

and was very forthright in saying,

yeah, you know, John’s got a right here.

We gotta modify this.

In any event, in any event.

You got him.

Well, I wasn’t trying to get him,

I was just trying to. No, no, no, no.

Totally, it was a beautiful exchange.

There was so much respect in the room,

pushing back and forth, it 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.

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,

arguments against certain parts.

That’s very interesting to sort of,

as one podcast, publish 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 the people

should listen to flat earthers

because it was very revealing to me

how easy it is to be convinced of basically anything

by charismatic arguments.

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 I 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 in 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,

an issue I raised with Pfizer CO, Albert Burla.

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?

Hoo ha.

And also, maybe this is a good time to talk about

this Pfizer play by the rules.

One at a time?

One at a time.

Okay, and this isn’t even about Pfizer,

but it’s an answer to the question.


So there’s this drug, Ajihelm,

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 reducing the amyloid plaques in the brain,

which correlate with the progression of Alzheimer’s.

And Biogen showed that its drug, Ajihelm,

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 Ajihelm 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 Ajihelm, 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 Ajihelm.

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 kinda, 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.


And that, she wants to change the rules.


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?


That’s one question.

And the other question is should advisory committee members

be allowed to have financial conflicts of interest?


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 afterword in my book.

I spent some time studying it about Ajihelm.

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.


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.


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 nonnegotiation 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

and 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.

You know, that’s on the shoulders of Anthony Fauci.

I’m gonna abstain from that

because I’m not expert enough, but.

Neither am I, but I’m opinionated.

I am too, but not on camera.


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.


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 charts

that I’ll overlay that tell this story

in really powerful ways.

So one is the healthcare spending is percentage of GDP

that on the X axis is years and the Y axis is percentage

and the United States as compared to other countries

on average has been much larger and 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.

Where per person in dollars we’re spending even,

the difference is even greater

but other costs vary with GDP.

So let’s stick with the conservative way to do it.

17.7 or 18% of GDP, 18% of GDP spent on healthcare,

7% higher than the comparable country average.


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 cloud, a point cloud of different countries.

The X axis being healthcare spending

is a percentage of GDP which we just talked about.

That US is 7% higher than everyone, 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.


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.

As 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.


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

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 buy books, to make better and better communicators

on Twitter, through books, through op eds,

through podcasts, through so on.

So basically, cause there’s a lot of incentive

to communicate against the messages of big pharma.

There’s incentive because people want to understand

what’s good for their lives

and they’re willing to listen to charismatic people

that are able to clearly explain 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.

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.

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,


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


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 over prescribing of antidepressants.


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 a 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

in visual 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 nonmajor 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.

All, you know, an infinite range of things.

But let’s figure out, make a diagnosis first.

The diagnosis isn’t that the person feels sadder

than they feel, than they want to feel.

The diagnosis is why does the person feel sadder

than they want to feel?

You mentioned this is what made you want

to get into family medicine.

As a doctor, what do you think about the saying,

save one life, save the world?

This was always moving to me about doctors

because you have like this human in front of you

and 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 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, yeah.

To maintain your humanity through it all.

Yeah, but you’ve been asking at different points

in this conversation, why are doctors so complacent

about the tremendous amount of money we’re spending?

Why do they accept knowledge from different sources

that may not pan out when they really know the truth?

And the answer is that they’re trying to do their best

for their patients.

And there’s this, it’s the same kind of torture

to figure out what the hell is going on with the data.

And that’s a sort of future project.

And maybe people will read my book

and maybe they’ll get a little more excited about it,

become more legitimate 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.

Like what is the best thing to do?

Big pharma can step in and use money

to manipulate that humanity.

Yeah, I would state it quite differently.

It’s sort of an opt out rather than an opt in.

Big pharma will do that.

And you need to opt out of it.

What advice would you give to a young person today

in high school or college

stepping into this complicated world

full of advertisements, of big powerful institutions,

of big rich companies,

how to have a positive impact in the world,

how to live a life they can be proud of?

I would say should that person

who has only good motives go into medicine.

They have an inclination to go into medicine

and they’ve asked me what I think about that

given what I know about the undermining

of American 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 health care that is not helping us.

So fundamentally, the thing that is normal,

now 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 got to be a way to get rid of it.

And I said, there’s got to be drug companies involved in this.

And she said, no, no, no, it was at my university.

It was 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.

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 subjective.

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 normals,

expanding the normals, shifting the normal,

just like with Kuhn.

You’re basically looking to shift

the way medicine is done to the original,

to the intent that it represents the ideal of medicine,

of health care.

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’m not.

I’ve faced it, been close.


Yeah, yeah.

How do you think about it?

What wisdom do you gain from having come close to death,

the fact that the whole thing ends?

It’s liberating.

It’s very liberating.

I’m serious.

I was close, and not too long ago.

And it was a sense of, 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 going to get pulled out of it.

Are you ultimately grateful for the ride, even though it ends?

Well, it’s a little odd.

I think so.

If I know you can’t take the ride if you know it’s going to end well.

It’s not the real ride.

It’s just a ride.

But 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 going to 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 health care.

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 you 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 rockstar of mathematics.

John, thank you so much for talking to us, it 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.

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