back to indexJohn Abramson: Big Pharma | Lex Fridman Podcast #263
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The jury found Pfizer guilty of fraud
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and racketeering violations.
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How does Big Pharma affect your mind?
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Everyone's allowed their own opinion.
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I don't think everyone's allowed their own scientific facts.
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Does Pfizer play by the rules?
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Pfizer isn't battling the FDA.
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Pfizer has joined the FDA.
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The following is a conversation with John Abramson,
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faculty at Harvard Medical School,
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a family physician for over two decades,
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and author of the new book, Sickening,
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about how Big Pharma broke American healthcare
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and how we can fix it.
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This conversation with John Abramson
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is a critical exploration of the pharmaceutical industry.
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I wanted to talk to John
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in order to provide a countervailing perspective
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to the one expressed in my podcast episode
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with the CEO of Pfizer, Albert Borla.
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And here, please allow me to say a few additional words
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about this episode with the Pfizer CEO,
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and in general, about why I do these conversations
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and how I approach them.
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If this is not interesting to you, please skip ahead.
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What do I hope to do with this podcast?
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I want to understand human nature,
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the best and the worst of it.
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I want to understand how power, money,
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and fame changes people.
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I want to understand why atrocities are committed
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by crowds that believe they're doing good.
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All this, ultimately, because I want to understand
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how we can build a better world together,
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to find hope for the future,
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and to rediscover each time,
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through the exploration of ideas,
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just how beautiful this life is.
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This, our human civilization,
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in all of its full complexity,
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the forces of good and evil,
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of war and peace, of hate and love.
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I don't think I can do this with a heart and mind
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that is not open, fragile, and willing to empathize
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with all human beings,
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even those in the darkest corners of our world.
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To attack is easy.
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To understand is hard.
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And I choose the hard path.
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I have learned over the past few months
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that this path involves me getting more and more attacked
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I will get attacked when I host people
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like Jay Bhattacharya or Francis Collins,
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Jamie Merzl or Vincent Ricanello,
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when I stand for my friend, Joe Rogan,
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when I host tech leaders like Mark Zuckerberg,
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Elon Musk, and others,
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when I eventually talk to Vladimir Putin, Barack Obama,
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and other figures that have turned the tides of history.
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I have and I will get called stupid, naive, weak,
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and I will take these words
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with respect, humility, and love, and I will get better.
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I will listen, think, learn, and improve.
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One thing I can promise is there's no amount of money
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or fame that can buy my opinion
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or make me go against my principles.
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There's no amount of pressure that can break my integrity.
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There's nothing in this world I need
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that I don't already have.
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Life itself is the fundamental gift.
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Everything else is just the bonus.
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That is happiness.
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If I die today, I will die a happy man.
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Now, a few comments about my approach
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and lessons learned from the Albert Bourla conversation.
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The goal was to reveal as much as I could
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about the human being before me
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and to give him the opportunity to contemplate in long form
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the complexities of his role,
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including the tension between making money
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and helping people, the corruption
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that so often permeates human institutions,
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the crafting of narratives through advertisements,
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I only had one hour,
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and so this wasn't the time to address these issues deeply
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but to show if Albert struggled with them
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in the privacy of his own mind,
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and if he would let down the veil of political speak
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for a time to let me connect with a man
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who decades ago chose to become a veterinarian,
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who wanted to help lessen the amount of suffering
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I had no pressure placed on me.
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There were no rules.
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The questions I was asking were all mine
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and not seen by Pfizer folks.
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I had no care whether I ever talked to another CEO again.
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None of this was part of the calculation
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in my limited brain computer.
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I didn't want to grill him.
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The way politicians grill CEOs in Congress,
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I thought that this approach is easy,
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self serving, dehumanizing, and it reveals nothing.
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I wanted to reveal the genuine intellectual struggle,
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vision, and motivation of a human being,
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and if that fails, I trusted the listener
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to draw their own conclusion and insights from the result,
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whether it's the words spoken
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or the words left unspoken or simply the silence.
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And that's just it.
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I fundamentally trust the intelligence of the listener, you.
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In fact, if I criticize the person too hard
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or celebrate the person too much,
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I feel I fail to give the listener
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a picture of the human being that is uncontaminated
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by my opinion or the opinion of the crowd.
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I trust that you have the fortitude and the courage
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to use your own mind, to empathize, and to think.
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Two practical lessons I took away.
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First, I will more strongly push
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for longer conversations of three, four, or more hours
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versus just one hour.
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60 minutes is too short for the guest to relax
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and to think slowly and deeply,
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and for me to ask many follow up questions
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or follow interesting tangents.
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Ultimately, I think it's in the interest of everyone,
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including the guest, that we talk in true long form
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Second, these conversations with leaders
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can be aided by further conversations
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with people who wrote books about those leaders
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or their industries.
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Those that can steel man each perspective
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and attempt to give an objective analysis.
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I think of Teddy Roosevelt's speech
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about the man in the arena.
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I want to talk to both the men and women in the arena
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and the critics and the supporters in the stands.
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For the former, I lean toward wanting to understand
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one human being's struggle with the ideas.
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For the latter, I lean towards understanding
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the ideas themselves.
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That's why I wanted to have this conversation
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with John Abramson, who is an outspoken critic
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of the pharmaceutical industry.
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I hope it helps add context and depth
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to the conversation I had with the Pfizer CEO.
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In the end, I may do worse than I could have or should have.
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Always, I will listen to the criticisms without ego
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and I promise I will work hard to improve.
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But let me say finally that cynicism is easy.
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Optimism, true optimism is hard.
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It is the belief that we can and we will
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build a better world and that we can only do it together.
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This is the fight worth fighting.
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Once more into the breach, dear friends.
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This is the Lex Friedman podcast.
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To support it, please check out our sponsors
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in the description.
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And now, here's my conversation with John Abramson.
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Your faculty at Harvard Medical School,
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your family physician for over two decades,
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rated one of the best family physicians in Massachusetts,
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you wrote the book, Overdose to America,
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and the new book coming out now called Sickening
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about how Big Pharma broke American healthcare,
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including science and research, and how we can fix it.
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First question, what is the biggest problem with Big Pharma
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that it fixed would be the most impactful?
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So if you can snap your fingers and fix one thing,
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what would be the most impactful, you think?
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The biggest problem is the way they
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determine the content, the accuracy,
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and the completeness of what doctors believe
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to be the full range of knowledge
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that they need to best take care of their patients.
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So that with the knowledge having been taken over
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by the commercial interests, primarily
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the pharmaceutical industry, the purpose of that knowledge
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is to maximize the profits that get returned
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to investors and shareholders, and not to optimize
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the health of the American people.
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So rebalancing that equation would be the most important
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thing to do to get our healthcare back aimed
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in the right direction.
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Okay, so there's a tension between helping people
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and making money, so if we look at particularly
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the task of helping people in medicine, in healthcare,
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is it possible if money is the primary sort of mechanism
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by which you achieve that as a motivator,
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is it possible to get that right?
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I think it is, Lex, but I think it is not possible
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without guardrails that maintain the integrity
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and the balance of the knowledge.
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Without those guardrails, it's like trying to play
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a professional basketball game without referees
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and having players call their own fouls.
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But the players are paid to win, and you can't count
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on them to call their own fouls, so we have referees
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who are in charge.
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We don't have those referees in American healthcare.
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That's the biggest way that American healthcare
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is distinguished from healthcare in other wealthy nations.
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So okay, you mentioned Milton Friedman,
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and you mentioned his book called Capitalism and Freedom.
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He writes that there are only three legitimate functions
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of government to preserve law and order,
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to enforce private contracts, and to ensure
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that private markets work.
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You said that that was a radical idea at the time,
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but we're failing on all three.
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How are we failing?
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And also maybe the bigger picture is what are the strengths
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and weaknesses of capitalism when it comes to medicine
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Can we separate those out?
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Because those are two huge questions.
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So how we're failing on all three,
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and these are the minimal functions that our guru
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of free market capitalism said the government
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should perform, so this is the absolute baseline.
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On preserving law and order, the drug companies
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routinely violate the law in terms of their marketing,
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and in terms of their presentation
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of the results of their trials.
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I know this because I was an expert in litigation
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for about 10 years.
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I presented some of what I learned in civil litigation
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to the FBI and the Department of Justice,
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and that case led to the biggest criminal fine
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in US history as of 2009.
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And I testified in a federal trial in 2010,
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and the jury found Pfizer guilty of fraud
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and racketeering violations.
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In terms of violating the law, it's a routine occurrence.
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The drug companies have paid $38 billion worth of fines
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from I think 1991 to 2017.
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It's never been enough to stop the misrepresentation
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of their data, and rarely are the fines greater
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than the profits that were made.
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Executives have not gone to jail for misrepresenting data
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that have involved even tens of thousands of deaths
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in the case of Vioxx, OxyContin as well.
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And when companies plead guilty to felonies,
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which is not an unusual occurrence,
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the government usually allows the companies,
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the parent companies, to allow subsidiaries to take the plea
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so that they are not one step closer
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to getting disbarred from Medicare,
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not being able to participate in Medicare.
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So in that sense, there is a mechanism
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that is appearing to impose law and order
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on drug company behavior, but it's clearly not enough.
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Can you actually speak to human nature here?
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Are people corrupt?
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Are people malevolent?
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Are people ignorant that work at the low level
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and at the high level at Pfizer, for example,
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at big pharma companies, how is this possible?
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So I believe, just on a small tangent,
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that most people are good.
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And I actually believe if you join big pharma,
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so a company like Pfizer, your life trajectory
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often involves dreaming and wanting
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and enjoying helping people.
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And so, and then we look at the outcomes
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that you're describing, and it looks,
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and that's why the narrative takes hold
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that Pfizer CEO, Al Bobrola, who I talked to, is malevolent.
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The sense is these companies are evil.
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So if the different parts, the people, are good
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and they want to do good, how are we getting these outcomes?
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Yeah, I think it has to do with the cultural milieu
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that this is unfolding in.
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And we need to look at sociology to understand this,
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that when the cultural milieu is set up
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to maximize the returns on investment
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for shareholders and other venture capitalists
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and hedge funds and so forth,
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when that defines the culture
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and the higher up you are in the corporation,
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the more you're in on the game of getting rewarded
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for maximizing the profits of the investors,
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that's the culture they live in.
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And it becomes normative behavior
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to do things with science that look normal
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in that environment and are shared values
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within that environment by good people
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whose self evaluation becomes modified
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by the goals that are shared by the people around them.
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And within that milieu, you have one set of standards,
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and then the rest of good American people
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have the expectation that the drug companies
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are trying to make money, but that they're playing
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by rules that aren't part of the insider milieu.
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That's fascinating, the game they're playing
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modifies the culture of inside the meetings,
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inside the rooms, day to day,
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that there's a bubble that forms.
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Like we're all in bubbles of different sizes.
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And that bubble allows you to drift in terms
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of what you see as ethical and unethical.
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Because you see the game as just part of the game.
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So marketing is just part of the game.
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Paying the fines is just part of the game of science.
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And without guardrails, it becomes
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even more part of the game.
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You keep moving in that direction.
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If you're not bumping up against guardrails.
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And I think that's how we've gotten
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to the extreme situation we're in now.
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So, like I mentioned, I spoke with Pfizer CEO,
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Albert Berla, and I'd like to raise with you
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some of the concerns I raised with him.
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So one, you already mentioned, I raised the concern
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that Pfizer's engaged in aggressive advertising campaigns.
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As you can imagine, he said no.
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What do you think?
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I think you're both right.
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I think that the, I agree with you,
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that the aggressive advertising campaigns
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do not add value to society.
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And I agree with him that they're, for the most part, legal.
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And it's the way the game is played.
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Right, so, sorry to interrupt,
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but oftentimes his responses are,
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especially now, he's been CEO for only like two years,
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three years, he says Pfizer was a different company,
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we've made mistakes, right, in the past.
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We don't make mistakes anymore.
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That there's rules, and we play by the rules.
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So like, with every concern raised,
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there's very, very strict rules, as he says.
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In fact, he says sometimes way too strict.
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And we play by them.
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And so in that sense, advertisement,
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it doesn't seem like it's too aggressive,
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because it's playing by the rules.
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And relative to the other, again, it's the game.
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Relative to the other companies,
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it's actually not that aggressive.
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Relative to the other big pharma companies.
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Yes, yes, I hope we can quickly get back
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to whether or not they're playing by the rules,
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But let's just look at the question
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of advertising specifically.
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I think that's a good example of what it looks like
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from within that culture, and from outside that culture.
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He's saying that we follow the law on our advertising.
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We state the side effects,
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and we state the FDA approved indications,
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and we do what the law says we have to do for advertising.
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And I have not, I've not been an expert in litigation
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for a few years, and I don't know what's going on currently,
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but let's take him at his word.
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It could be true, it might not be, but it could be.
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But if that's true, in his world, in his culture,
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that's ethical business behavior.
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From a common sense person's point of view,
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a drug company paying highly skilled media folks
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to take the information about the drug
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and create the illusion, the emotional impact,
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and the takeaway message for viewers of advertisements
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that grossly exaggerate the benefit of the drug
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and minimize the harms, it's sociopathic behavior
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to have viewers of ads leave the ad
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with an unrealistic impression
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of the benefits and harms of the drug.
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And yet he's playing by the rules,
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he's doing his job as CEO
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to maximize the effect of his advertising,
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and if he doesn't do it, this is a key point,
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if he doesn't do it, he'll get fired and the next guy will.
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So the people that survive in the company,
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the people that get raises in the company,
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move up in the company are the ones that play by the rules,
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and that's how the game solidifies itself.
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But the game is within the bounds of the law.
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Sometimes, most of the time, not always.
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We'll return to that question.
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I'm actually more concerned
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about the effect of advertisement
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in a kind of much larger scale
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on the people that are getting funded
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by the advertisement in self censorship,
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just like more subtle, more passive pressure
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to not say anything negative.
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Because I've seen this, and I've been saddened by it,
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that people sacrifice integrity in small ways
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when they're being funded by a particular company.
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They don't see themselves as doing so,
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but you can just clearly see that the space of opinions
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that they're willing to engage in,
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or a space of ideas they're willing to play with,
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is one that doesn't include negative,
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anything that could possibly be negative about the company.
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They just choose not to.
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Because, you know, why?
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And that's really sad to me,
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that if you give me a hundred bucks,
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I'm less likely to say something negative about you.
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That makes me sad.
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Because the reason I wouldn't say something negative
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about you, I prefer, is the pressure of friendship
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and human connection, those kinds of things.
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So I understand that.
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That's also a problem, by the way,
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sort of having dinners and shaking hands,
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and oh, aren't we friends?
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But the fact that money has that effect
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is really sad to me.
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On the news media, on the journalists, on scientists,
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that's scary to me.
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But of course, the direct advertisement to consumers,
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like you said, is a potentially very negative effect.
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I wanted to ask if what you think
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is the most negative impact of advertisement,
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is it that direct to consumer on television?
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Is it advertisement of the doctors?
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Which I'm surprised to learn,
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I was vaguely looking at,
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is more spent on advertising to doctors than to consumers.
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That's really confusing to me.
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It's fascinating, actually.
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And then also, obviously, the law side of things
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is the lobbying dollars,
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which I think is less than all of those.
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But anyway, it's in the ballpark.
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What concerns you most?
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Well, it's the whole nexus of influence.
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There's not one thing, and they don't invest all their,
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they don't put all their eggs in one basket.
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It's a whole surround sound program here.
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But in terms of advertisements,
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let's take the advertisement.
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Trulicity is a diabetes drug,
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for type two diabetes, an injectable drug.
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And it lowers blood sugar just about as well
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as Metformin does.
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Metformin costs about $4 a month.
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Trulicity costs, I think, $6,200 a year.
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So $48 a year versus $6,200.
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Trulicity has distinguished itself
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because the manufacturer did a study
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that showed that it significantly reduces
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the risk of cardiovascular disease in diabetics.
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And they got approval on the basis of that study,
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that very large study being statistically significant.
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So the ads obviously extol the virtues of Trulicity
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because it reduces the risk of heart disease and stroke,
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and that's one of the major morbidities,
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risks of type two diabetes.
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What the ad doesn't say is that you have to treat
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323 people to prevent one nonfatal event
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at a cost of $2.7 million.
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And even more importantly than that,
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what the ad doesn't say is that the evidence shows
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that engaging in an active, healthy lifestyle program
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reduces the risk of heart disease and strokes
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far more than Trulicity does.
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Now, to be fair to the company, the sponsor,
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there's never been a study that compared Trulicity
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to lifestyle changes.
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But that's part of the problem of our advertising.
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You would think in a rational society
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that was way out on a limb as a lone country
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besides New Zealand that allows
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direct to consumer advertising,
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that part of allowing direct to consumer advertising
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would be to mandate that the companies establish
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whether their drug is better than,
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say, healthy lifestyle adoption
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to prevent the problems that they claim to be preventing.
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But we don't require that.
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So the companies can afford to do very large studies
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so that very small differences
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become statistically significant.
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And their studies are asking the question,
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how can we sell more drug?
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They're not asking the question,
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how can we prevent cardiovascular disease
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in people with type 2 diabetes?
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And that's how we get off in this,
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we're now in the extreme arm of this distortion
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of our medical knowledge of studying
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how to sell more drugs than how to make people more healthy.
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That's a really great thing to compare to,
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is lifestyle changes.
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Because that should be the bar.
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If you do some basic diet, exercise,
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all those kinds of things,
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how does this drug compare to that?
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And that study was done, actually, in the 90s.
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It's called the Diabetes Prevention Program.
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It was federally funded by the NIH
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so that there wasn't this drug company imperative
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to just try to prove your drug was better than nothing.
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And it was a very well designed study,
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randomized controlled trial
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in people who were at high risk of diabetes,
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so called pre diabetics.
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And they were randomized to three different groups,
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a placebo group, a group that got treated with metformin,
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and a group that got treated
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with intensive lifestyle counseling.
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So this study really tested
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whether you can get people in a randomized controlled trial
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assigned to intensive lifestyle changes,
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whether that works.
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Now the common wisdom amongst physicians,
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and I think in general,
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is that you can't get people to change.
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You know, you can do whatever you want,
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you can stand on your head,
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you can beg and plead, people won't change.
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So give it up and let's just move on with the drugs
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and not waste any time.
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Except this study that was published
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in the New England Journal, I think in 2002,
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shows that's wrong.
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That the people who were in the intensive lifestyle group
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ended up losing 10 pounds,
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exercising five times a week, maintaining it,
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and reduced their risk of getting diabetes by 58%,
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compared to the metformin group,
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which reduced its risk of getting diabetes by 31%.
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So that exact study was done
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and it showed that lifestyle intervention is the winner.
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Who, as a small tangent, is the leader,
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who is supposed to fight for the side of lifestyle changes?
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Where's the big pharma version of lifestyle changes?
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Who's supposed to have the big bully pulpit,
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the big money behind lifestyle changes?
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In your sense, because that seems to be missing
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in a lot of our discussions about health policy.
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Right, that's exactly right.
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And the answer is that we assume
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that the market has to solve all of these problems.
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And the market can't solve all of these problems.
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There needs to be some way of protecting the public interest
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for things that aren't financially driven.
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So that the overriding question has to be
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how best to improve Americans health,
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not companies funding studies to try and prove
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that their new inexpensive drug is better
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and should be used.
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Well, some of that is also people sort of like yourself.
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I mean, it's funny, you spoke with Joe Rogan.
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He constantly espouses lifestyle changes.
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So some of it is almost like understanding the problems
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that big pharma is creating in society
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and then sort of these influential voices
link |
speaking up against it.
link |
So whether they're scientists or just regular communicators.
link |
Yeah, I think you gotta tip your hat to Joe
link |
for getting that message out.
link |
And he clearly believes it and does his best.
link |
But it's not coming out in the legitimate avenues,
link |
in the legitimate channels that are evidence based medicine
link |
and from the sources that the docs are trained to listen to
link |
and modify their patient care on.
link |
Now, it's not 100%.
link |
I mean, there are articles in the big journals
link |
about the benefits of lifestyle,
link |
but they don't carry the same gravitas
link |
as the randomized controlled trials
link |
that test this drug against placebo
link |
or this drug against another drug.
link |
So the Joe Rogans of the world keep going.
link |
But it's not gonna carry the day for most of the people
link |
until it has the legitimacy of the medical establishment.
link |
Yeah, like something that the doctors
link |
really pay attention to.
link |
Well, there's an entire mechanism established
link |
for testing drugs.
link |
There's not an entire mechanism established
link |
in terms of scientific rigor of testing lifestyle changes.
link |
I mean, it's more difficult.
link |
I mean, everything's difficult in science.
link |
That science that involves humans, especially.
link |
But it's just, these studies are very expensive.
link |
They're difficult.
link |
It's difficult to find conclusions
link |
and to control all the variables.
link |
And so it's very easy to dismiss them
link |
unless you really do a huge study that's very well funded.
link |
And so maybe the doctors just lean
link |
towards the simpler studies over and over,
link |
which is what the drug companies fund.
link |
They can control more variables.
link |
See, but the control there is sometimes
link |
by hiding things too, right?
link |
So sometimes you can just say
link |
that this is a well controlled study
link |
by pretending there's a bunch of other stuff.
link |
It's just ignoring the stuff that could be correlated.
link |
It could be the real cause of the effects you're seeing,
link |
all that kind of stuff.
link |
So money can buy ignorance, I suppose, in science.
link |
It buys the kind of blinders that are on
link |
that don't look outside the reductionist model.
link |
And that's another issue is that we kind of,
link |
nobody says to doctors in training,
link |
only listen to reductionist studies and conclusions
link |
and methods of promoting health.
link |
Nobody says that explicitly.
link |
But the respectable science
link |
has to do with controlling the factors.
link |
And I mean, it just doesn't make sense to me.
link |
I'm gonna pick on trulicity
link |
because it's such an obvious example,
link |
but it's not more egregious than many others.
link |
It doesn't make sense to me to allow a drug
link |
to be advertised as preventing cardiovascular disease
link |
when you haven't included lifestyle changes
link |
as an arm in the study.
link |
It's just so crystal clear that the purpose of that study
link |
is to sell trulicity.
link |
It's not to prevent cardiovascular disease.
link |
If we were in charge, I would try to convince you
link |
that anywhere that study, the results of that study
link |
were presented to physicians,
link |
it would be stamped in big red letters,
link |
this study did not compare trulicity to lifestyle changes.
link |
They need to know that.
link |
And the docs are kind of trained,
link |
these blinders get put on,
link |
and they're trained to kind of forget that that's not there.
link |
Do you think, so first of all,
link |
that's a small or big change to advertisement
link |
that seems obvious to say,
link |
like in force that it should be compared
link |
to lifestyle changes.
link |
Do you think advertisements, period,
link |
in the United States for pharmaceutical drugs
link |
I think they can't be banned.
link |
So it doesn't matter what I think.
link |
Okay, let's say you were a dictator,
link |
and two, why can't they be banned?
link |
Answer either one.
link |
I believe, I've been told by lawyers who I trust,
link |
that the freedom of speech in the U.S. Constitution
link |
is such that you can't ban them,
link |
that you could ban cigarettes and alcohol,
link |
which have no therapeutic use,
link |
but drugs have a therapeutic use,
link |
and advertisements about them can't be banned.
link |
Let's assume that they can't be,
link |
because we know they won't be anyway,
link |
but let's assume they can't be,
link |
and especially our Supreme Court now
link |
would be unlikely to take that seriously.
link |
But that's not the issue.
link |
The issue is that if the drug companies
link |
want to spend their money advertising,
link |
they should have to have independent analysis
link |
of the message that the viewers are left with
link |
about the drug, so that it's realistic.
link |
What's the chance the drug will help them?
link |
Well, in true city, it's one out of 323.
link |
322 people aren't gonna benefit
link |
from the cardiovascular reduction, risk reduction.
link |
What's the true cost?
link |
When drugs advertise that you may be able to get this
link |
for a $25 copay or something,
link |
tens of thousands of dollars a year drug,
link |
for a $25 copay, what an enormous disservice that is
link |
to misrepresent the cost to society.
link |
That should not be allowed.
link |
So you should have to make it clear to the viewers
link |
how many people are gonna benefit,
link |
what's your chance of benefiting?
link |
How does it compare to lifestyle changes
link |
or less expensive therapies?
link |
What do you give up if you use a less expensive therapy
link |
And how much it costs.
link |
How much it costs.
link |
Now, that can go either way,
link |
because if you say Humira costs $72,000
link |
and it's no more effective as a first line drug
link |
than methotrexate, which costs $480,
link |
people might say, I want the expensive drug
link |
because I can get it for a $25 copay.
link |
So you'd have to temper that a little bit.
link |
Oh, you mean people are so, they don't care.
link |
Their insurance is gonna cover it and it's a $25 copay,
link |
but we could figure out how to deal with that.
link |
The main point is that if we assume
link |
that advertisements are gonna keep going, and they are,
link |
we could require that there be outside evaluation
link |
of the message that reasonable, unbiased viewers
link |
take away from the ads,
link |
and the ads would have to tell the truth about the drug.
link |
And the truth should have sub truth guardrails,
link |
meaning like the cost that we talked about,
link |
the effects compared to things that actually,
link |
lifestyle changes, just these details,
link |
very strict guardrails of what actually has to be specified.
link |
And I would make it against the law
link |
to have family picnics or dogs catching Frisbees in the ads.
link |
So, you mean 95% of the ads, yes.
link |
I mean, there's something dark and inauthentic
link |
about those advertisements, but they seem,
link |
I mean, I'm sure they're being done
link |
because they work for the target audience.
link |
And then the doctors too.
link |
Can you really buy a doctor's opinion?
link |
Why does it have such an effect on doctors?
link |
Advertisement to doctors, like you as a physician,
link |
again, like from everything I've seen, people love you.
link |
And I've just, people should definitely look you up from,
link |
there's a bunch of videos of you giving talks on YouTube,
link |
and it's just, it's so refreshing to hear
link |
just the clarity of thought about health policy,
link |
about healthcare, just the way you think
link |
throughout the years.
link |
So like, it's easy to think about like,
link |
maybe you're criticizing Big Pharma,
link |
that's one part of the message that you're talking about,
link |
but that's not like, your brilliance actually shines
link |
in the positive, in the solutions and how to do it.
link |
So as a doctor, what affects your mind?
link |
And how does Big Pharma affect your mind?
link |
Number one, the information that comes through
link |
legitimate sources that doctors have been taught
link |
to rely on, evidence based medicine,
link |
the articles in peer reviewed journals,
link |
the guidelines that are issued.
link |
Now, those are problematic,
link |
because when an article is peer reviewed
link |
and published in a respected journal,
link |
people and doctors obviously assume
link |
that the peer reviewers have had access to the data
link |
and they've independently analyzed the data,
link |
and they corroborate the findings in the manuscript
link |
that was submitted, or they give feedback to the authors
link |
and say, we disagree with you on this point,
link |
and would you please check our analysis
link |
and if you agree with us, make it.
link |
That's what they assume the peer review process is,
link |
The peer reviewers don't have the data.
link |
The peer reviewers have the manuscript
link |
that's been submitted by the,
link |
usually in conjunction with or by the drug company
link |
that manufactures the drug.
link |
So peer reviewers are unable to perform the job
link |
that doctors think they're performing
link |
to vet the data to assure that it's accurate
link |
and reasonably complete.
link |
And then we have the clinical practice guidelines,
link |
which are increasingly more important
link |
as the information, the flow of information
link |
keeps getting brisker and brisker,
link |
and docs need to get to the bottom line quickly.
link |
Clinical practice guidelines become much more important.
link |
And we assume that the authors
link |
of those clinical practice guidelines
link |
have independently analyzed the data
link |
from the clinical trials and make their recommendations
link |
that set the standards of care based on their analysis.
link |
That's not what happens.
link |
The experts who write the clinical trials
link |
rely almost entirely on the publications
link |
presenting the results of the clinical trials,
link |
which are peer reviewed,
link |
but the peer reviewers haven't had access to the data.
link |
So we've got a system of the highest level of evidence
link |
that doctors have been trained over and over again
link |
to rely on to practice evidence based medicine
link |
to be good doctors that has not been verified.
link |
Do you think that data that's coming
link |
from the pharma companies,
link |
do you think there,
link |
what level of manipulation is going on with that data?
link |
Is it at the study design level?
link |
Is it at literally there's some data
link |
that you just keep off, keep out of the charts,
link |
keep out of the aggregate analysis that you then publish?
link |
Or is it the worst case,
link |
which is just change some of the numbers?
link |
All three happened.
link |
I can't, I don't know what the denominator is,
link |
but I spent about 10 years in litigation.
link |
And for example, in Vioxx,
link |
which was withdrawn from the market in 2004
link |
in the biggest drug recall in American history,
link |
the problem was that it got recalled
link |
when a study that Merck sponsored
link |
showed that Vioxx doubled the risk,
link |
more than doubled the risk of heart attacks,
link |
strokes, and blood clots, serious blood clots.
link |
It got pulled then.
link |
But there was a study, a bigger study
link |
that had been published in 2000
link |
in the New England Journal of Medicine
link |
that showed that Vioxx was a better drug
link |
for arthritis and pain,
link |
not because it was more effective.
link |
It's no more effective than Aleve or Advil,
link |
but because it was less likely
link |
to cause serious GI complications,
link |
bleeds and perforations in the gut.
link |
Now, in that study that was published
link |
in the New England Journal that was never corrected,
link |
it was a little bit modified 15 months
link |
after the drug was taken off the market,
link |
but never corrected, Merck left out three heart attacks.
link |
And the FDA knew that Merck left out three heart attacks,
link |
and the FDA's analysis of the data from that study
link |
said that the FDA wasn't gonna do the analysis
link |
without the three heart attacks in it.
link |
And the important part of this story
link |
is that there were 12 authors listed on that study
link |
in the New England Journal.
link |
Two were Merck employees.
link |
They knew about the three heart attacks
link |
that had been omitted.
link |
The other 10 authors, the academic authors,
link |
didn't know about it.
link |
They hadn't seen that data.
link |
So Merck just, they had an excuse.
link |
It's complicated, and the FDA didn't accept it,
link |
so there's no reason to go into it.
link |
But Merck just left out the three heart attacks.
link |
And the three heart attacks,
link |
it may seem three heart attacks in a 10,000 person study
link |
may seem like nothing,
link |
except they completely changed the statistics
link |
so that had the three heart attacks been included,
link |
the only conclusion that Merck could have made
link |
was that Vioxx significantly increased
link |
the risk of heart attack.
link |
And they abbreviated their endpoint
link |
from heart attack, strokes, and blood clots
link |
to just heart attacks.
link |
So those are, maybe in their mind,
link |
they're also playing by the rules
link |
because of some technical excuse that you mentioned
link |
that was rejected.
link |
How can this, because this is crossing the line.
link |
No, no, let me interrupt.
link |
No, that's not true.
link |
The study was completed.
link |
The blind was broken, meaning they looked at the data.
link |
In March of 2000, the article was published
link |
in the New England Journal in November of 2000.
link |
In March of 2000, there was an email by the head scientist
link |
that was published in the Wall Street Journal
link |
that said the day that the data were unblinded,
link |
that it's a shame that the cardiovascular events are there,
link |
but the drug will do well and we will do well.
link |
But removing the three heart attacks,
link |
how does that happen?
link |
Like who has to convince themselves?
link |
Is this pure malevolence?
link |
You have to be the judge of that,
link |
but the person who was in charge of the Data Safety
link |
Monitoring Board issued a letter that said
link |
they'll stop counting cardiovascular events
link |
a month before the trial is over
link |
and they'll continue counting GI events.
link |
And that person got a contract to consult with Merck
link |
for $5,000 a day, I think for 12 days a year,
link |
for one or two years that was signed, that contract
link |
was signed within two weeks of the decision
link |
to stop counting heart attacks.
link |
I wanna understand that man or woman.
link |
I wanna, I want, it's the, I've been reading a lot
link |
about Nazi Germany and thinking a lot
link |
about the good Germans because I want to understand
link |
so that we can each encourage each other
link |
to take the small heroic actions that prevents that.
link |
Because it feels to me, removing malevolence
link |
from the table where it's just a pure psychopathic person,
link |
that there's just a momentum created
link |
by the game like you mentioned.
link |
And so it takes reversing the momentum within the company,
link |
I think requires many small acts of heroism.
link |
Not gigantic, I'm going to leave and become a whistleblower
link |
and publish a book about it.
link |
But small, quiet acts of pressuring against this.
link |
Like, what are we doing here?
link |
We're trying to help people.
link |
Is this the right thing to do?
link |
Looking in the mirror constantly asking,
link |
is this the right thing to do?
link |
I mean, that's how, that's what integrity is.
link |
Acknowledging the pressures you're under
link |
and then still be able to zoom out
link |
and think what is the right thing to do here.
link |
But the data, hiding the data makes it too easy
link |
to live in ignorance.
link |
So like within those, inside those companies.
link |
So your idea is that the reviewers should see the data.
link |
So to even push back on that idea is,
link |
I assume you mean the data remains private
link |
except to the peer reviews, reviewers.
link |
The problem with, of course, as you probably know
link |
is the peer review process is not perfect.
link |
You know, it's individuals.
link |
It feels like there should be a lot more eyes on the data
link |
than just the peer reviewers.
link |
Yes, this is not a hard problem to solve.
link |
When a study is completed,
link |
a clinical study report is made.
link |
And it's usually several thousand pages.
link |
And what it does is it takes the raw patient data
link |
and it tabulates it in the ways it's supposedly and usually
link |
in the ways that the company has pre specified.
link |
So that you then end up with a searchable,
link |
let's say 3000 page document.
link |
As I became more experienced as an expert in litigation,
link |
I could go through those documents pretty quickly.
link |
Quickly may mean 20 hours or 40 hours,
link |
but it doesn't mean three months of my work.
link |
And see if the companies,
link |
if the way the company has analyzed the data
link |
is consistent with the way,
link |
with their statistical analysis plan
link |
and their pre specified outcome measures.
link |
And I think you're right.
link |
Peer reviewers, I don't peer review clinical trials,
link |
but I peer review other kinds of articles.
link |
I have to do one on the airplane on the way home.
link |
I mean, we're just ordinary mortal people volunteering to.
link |
Unpaid, the motivation is not clear.
link |
The motivation is to keep,
link |
to be a good citizen in the medical community
link |
and to be on friendly terms with the journals
link |
so that if you wanna get published,
link |
there's sort of an unspoken incentive.
link |
As somebody who enjoys game theory,
link |
I feel like that motivation is good,
link |
but it could be a lot better.
link |
Yes, you should get more recognition
link |
or in some way academic credit for it.
link |
It should go to your career advancement.
link |
If it's an important paper
link |
and you recognize it's an important paper
link |
as a great peer reviewer,
link |
that this is not in that area
link |
where it's like clearly a piece of crap paper
link |
or clearly an awesome paper
link |
that doesn't have controversial aspects to it
link |
and it's just a beautiful piece of work.
link |
Okay, those are easy.
link |
And then there is like the very difficult gray area,
link |
which may require many, many days of work
link |
on your part as a peer reviewer.
link |
So it's not just a couple hours,
link |
but really seriously reading.
link |
Like some papers can take months to really understand.
link |
So if you really wanna struggle,
link |
there has to be an incentive for that struggle.
link |
Yes, and billions of dollars ride on some of these studies.
link |
And lives, right, not to mention.
link |
Right, but it would be easy to have full time statisticians
link |
hired by the journals or shared by the journals
link |
who were independent of any other financial incentive
link |
to go over these kind of methodological issues
link |
and take responsibility for certifying the analyses
link |
that are done and then pass it on
link |
to the volunteer peer reviewers.
link |
See, I believe even in this,
link |
in the sort of capitalism or even social capital,
link |
after watching Twitter in the time of COVID
link |
and just looking at people that investigate themselves,
link |
I believe in the citizenry.
link |
People, if you give them access to the data,
link |
like these like citizen scientists arise.
link |
A lot of them on the, it's kind of funny,
link |
a lot of people that are just really used
link |
to working with data,
link |
they don't know anything about medicine
link |
and they don't have actually the biases
link |
that a lot of doctors and medical
link |
and a lot of the people that read these papers,
link |
they'll just go raw into the data
link |
and look at it with like they're bored almost
link |
and they do incredible analysis.
link |
So I, you know, there's some argument to be made
link |
for a lot of this data to become public,
link |
like deanonymized, no, sorry, anonymized,
link |
all that kind of stuff, but for a lot of it to be public,
link |
especially when you're talking about things
link |
as impactful as some of these drugs.
link |
I agree 100%, so let's turn the micro,
link |
let's get a little bit more granular.
link |
On the peer review issue,
link |
we're talking about pre publication transparencies
link |
and that is critically important.
link |
Once a paper is published, the horses are out of the barn
link |
and docs are gonna read it,
link |
take it as evidence based medicine.
link |
The economists call what then happens as stickiness
link |
that the docs hold on to their beliefs
link |
and my own voice inside says,
link |
once doctors start doing things to their patients bodies,
link |
they're really not too enthusiastic
link |
about hearing it was wrong.
link |
Yeah, that's the stickiness of human nature.
link |
Wow, so that bar, once it's published,
link |
the doctors, that's when the stickiness emerges, wow.
link |
Yeah, it's hard to put that toothpaste back in the tube.
link |
Now, that's pre publication transparency,
link |
which is essential and you could have,
link |
whoever saw that data pre publication
link |
could sign confidentiality agreements
link |
so that the drug companies couldn't argue
link |
that we're just opening the spigots of our data
link |
and people can copy it and blah, all the excuses they make.
link |
You could argue that you didn't have to
link |
but let's just let them do it.
link |
Let the peer reviewers sign confidentiality agreements
link |
and they won't leak the data
link |
but then you have to go to post publication transparency,
link |
which is what you were just getting at
link |
to let the data free and let citizens
link |
and citizen scientists and other doctors
link |
who are interested have at it.
link |
Kind of like Wiki, Wikipedia, have at it.
link |
Let it out and let people criticize each other.
link |
Okay, so speaking of the data,
link |
the FDA asked 55 years to release Pfizer vaccine data.
link |
This is also something I raised with Albert Bourla.
link |
There's several things I didn't like about what he said.
link |
So some things are expected
link |
and some of it is just revealing the human being,
link |
which is what I'm interested in doing.
link |
But he said he wasn't aware of the 75 and the 55.
link |
I'm sorry, wait a minute.
link |
He wasn't aware of?
link |
The how long, so here I'll explain what he.
link |
Do you know that since you spoke to him,
link |
Pfizer has petitioned the judge to join the suit
link |
in behalf of the FDA's request
link |
to release that data over 55 or 75 years?
link |
Pfizer's fully aware of what's going on.
link |
I'm sure he's aware in some formulation.
link |
The exact years he might have not been aware.
link |
But the point is that there is,
link |
that is the FDA, the relationship of Pfizer and the FDA
link |
in terms of me being able to read human beings
link |
was the thing he was most uncomfortable with,
link |
that he didn't wanna talk about the FDA.
link |
And that really, it was clear
link |
that there was a relationship there
link |
that if the words you use may do a lot of harm,
link |
potentially because like you're saying,
link |
there might be lawsuits going on, there's litigation,
link |
there's legal stuff, all that kind of stuff.
link |
And then there's a lot of games being played in this space.
link |
So I don't know how to interpret it
link |
if he's actually aware or not,
link |
but the deeper truth is that he's deeply uncomfortable
link |
bringing light to this part of the game.
link |
Yes, and I'm gonna read between the lines
link |
and Albert Borla certainly didn't ask me to speak for him.
link |
But I think, but when did you speak to him?
link |
Wow, time flies when you're having fun.
link |
So that was just recently it's come out,
link |
just in the past week it's come out
link |
that Pfizer isn't battling the FDA.
link |
Pfizer has joined the FDA in the opposition to the request
link |
to release these documents in the same amount of time
link |
that the FDA took to evaluate them.
link |
So Pfizer is offering to help the FDA
link |
to petition the judge to not enforce the timeline
link |
that he seems to be moving towards.
link |
So for people who are not familiar,
link |
we're talking about the Freedom of Information Act request
link |
to release the Pfizer vaccine data, study data
link |
to release as much of the data as possible,
link |
like the raw data, the details,
link |
or actually not even the raw data,
link |
it's data, doesn't matter, there's details to it.
link |
And I think the response from the FDA is that of course,
link |
yes, of course, but we can only publish
link |
we can only publish like some X number of pages a day.
link |
500 pages of data.
link |
It's not a day though, it's a week I think.
link |
The point is whatever they're able to publish is ridiculous.
link |
It's like my printer can only print three pages a day
link |
and we cannot afford a second printer.
link |
So it's some kind of bureaucratic language for,
link |
there's a process to this, and now you're saying
link |
that Pfizer is obviously more engaged
link |
in helping this kind of bureaucratic process prosper
link |
in its full absurdity, Kafkaesque absurdity.
link |
This really bothered people.
link |
This is really troublesome.
link |
And just to put it in just plain English terms,
link |
Pfizer's making the case that it can't,
link |
the FDA and Pfizer together are making the case
link |
that they can't go through the documents.
link |
It's gonna take them some number of hundredfold,
link |
hundreds of folds more time to go through the documents
link |
than the FDA required to go through the documents
link |
to approve the vaccines,
link |
to give the vaccines full FDA approval.
link |
And the FDA's argument, talk about Kafkaesque,
link |
is that to do it more rapidly
link |
would cost them $3 million.
link |
$3 million equals one hour of vaccine sales over two years.
link |
One hour of sales.
link |
And they can't come up with the money.
link |
And now Pfizer has joined the suit
link |
to help the FDA fight off this judge, this mean judge,
link |
who thinks they ought to release the data.
link |
But evidently Pfizer isn't offering
link |
to come up with the $3 million either.
link |
So, but for $3 million, I mean, maybe,
link |
maybe the FDA should do a GoFundMe campaign.
link |
Well, obviously the money thing,
link |
I mean, I'm sure if Elon Musk comes along and says,
link |
I'll give you $100 million, publish it now,
link |
I think they'll come up with another.
link |
So, I mean, it's clear that there's cautiousness.
link |
I don't know the source of it from the FDA.
link |
There's only one explanation that I can think of,
link |
which is that the FDA and Pfizer
link |
don't wanna release the data.
link |
They don't wanna release the three
link |
or 500,000 pages of documents.
link |
And I don't know what's in there.
link |
I wanna say one thing very clearly.
link |
I am not an anti faxer.
link |
I believe the vaccines work.
link |
I believe everybody should get vaccinated.
link |
The evidence is clear that if you're vaccinated,
link |
you reduce your risk of dying of COVID by 20 fold.
link |
And we've got new sub variants coming along.
link |
And I just wanna be very clear about this.
link |
That said, there's something I would give you 10 to one odds
link |
on a bet that there's something in that data
link |
that is gonna be embarrassing to either FDA or Pfizer
link |
So there's two options.
link |
I agree with you 100%.
link |
One is they know of embarrassing things.
link |
That's option one.
link |
And option two, they haven't invested enough
link |
to truly understand the data.
link |
Like, I mean, it's a lot of data
link |
that they have a sense
link |
that might be something embarrassing in there.
link |
And if we release it,
link |
surely the world will discover the embarrassing
link |
and to do a sort of the steel man their argument.
link |
They'll take the small, the press,
link |
the people will take the small embarrassing things
link |
and blow them up into big things.
link |
Yes, and support the anti vax campaign.
link |
I think that's all possible.
link |
Nonetheless, the data are about the original clinical trial.
link |
And the emergency use authorization was based
link |
on the first few months of the data from that trial.
link |
And it was a two year trial.
link |
The rest of that data has not been opened up
link |
and there was not an advisory committee meeting
link |
to look at that data
link |
when the FDA granted full authorization.
link |
Again, I am pro vaccine.
link |
I am not making an anti vax argument here.
link |
But I suspect that there's something pretty serious
link |
And the reason why I'm not an anti vaxxer,
link |
having not been able to see the data
link |
that the FDA and Pfizer seem to willing
link |
not just to put effort into preventing the release of,
link |
but seem to have quite a bit of energy
link |
into preventing, invest quite a bit of energy
link |
in not releasing that data.
link |
The reason why that doesn't tip me over
link |
into the anti vaxxer side
link |
is because that's clinical trial data,
link |
early clinical trial data
link |
that involved several thousand people.
link |
We now have millions of data points
link |
from people who have had the vaccine.
link |
This is real world data,
link |
showing the efficacy of the vaccines.
link |
And so far, knock on wood,
link |
there aren't side effects
link |
that overcome the benefits of vaccine.
link |
I'm now, I guess, three shots of the vaccine.
link |
But there's a lot of people that are kind of saying,
link |
well, even the data on the real world use large scale data
link |
The way it's being reported,
link |
the way it's being interpreted.
link |
Well, one thing is clear to me
link |
that it is being politicized.
link |
I mean, if you just look objectively,
link |
don't have to go to at the shallow surface level.
link |
It seems like there's two groups
link |
that I can't even put a term to it
link |
because it's not really pro vaccine versus anti vaccine
link |
because it's pro vaccine, triple mask, Democrat, liberal,
link |
and then anti mandate, whatever those groups are.
link |
I can't quite, cause they're changing.
link |
Anti mask, but not really, but kind of.
link |
So those two groups that feel political in nature,
link |
not scientific in nature, they're bickering.
link |
And then it's clear that this data is being interpreted
link |
by the different groups differently.
link |
And it's very difficult for me as a human being
link |
to understand where the truth lies,
link |
especially given how much money is flying around
link |
So the anti vaxxers can make a lot of money too.
link |
Let's not forget this.
link |
From the individual perspective,
link |
you can become famous being an anti vaxxer.
link |
And so there's a lot of incentives on all sides here.
link |
And there's real human emotion and fear
link |
and also credibility.
link |
Scientists don't wanna ruin their reputation
link |
if they speak out in whatever, like speak their opinion
link |
or they look at some slice of the data
link |
and begin to interpret it in some kind of way.
link |
They're very, it's clear that fear is dominating
link |
the discourse here, especially in the scientific community.
link |
So I don't know what to make of that.
link |
And the only happy people here is Pfizer.
link |
It's just plowing all ahead.
link |
I mean, with every single variant,
link |
there's very, I would say, outside of arguably
link |
a very flawed system, there's a lot of incredible
link |
scientific and engineering work being done
link |
in constantly developing new, like antiviral drugs,
link |
new vaccines to deal with the variants.
link |
So they're happily being a capitalist machine.
link |
And it's very difficult to know what to do with that.
link |
And let's just put this in perspective for folks.
link |
The best selling drug in the world has been Humira
link |
for a number of years.
link |
It's approved for the treatment of rheumatoid arthritis
link |
and eight other indications.
link |
And it's sold about $20 billion globally
link |
over the past few years.
link |
It peaked at that level.
link |
Pfizer expects to sell $65 billion of vaccine
link |
in the first two years of the pandemic.
link |
So this is by far the biggest selling
link |
and most profitable drug that's ever come along.
link |
I can ask you a difficult question here.
link |
In the fog that we're operating in here,
link |
on the Pfizer BioNTech vaccine,
link |
what was done well and what was done badly
link |
that you can see now, it seems like we'll know
link |
more decades from now.
link |
But now in the fog of today with the $65 billion
link |
flying around, where do you land?
link |
So we're gonna get to what I think is one of the key problems
link |
with the pharmaceutical industry model in the United States
link |
about being profit driven.
link |
So in 2016, the NIH did the key infrastructure work
link |
to make mRNA vaccines.
link |
That gets left out of the discussion a lot.
link |
And Pfizer BioNTech actually paid royalties voluntarily
link |
I don't know how much it was.
link |
I don't think it was a whole lot of money,
link |
but I think they wanted to avoid the litigation
link |
that Moderna got itself into by just taking that 2016
link |
knowledge and having that be the foundation
link |
So Pfizer took that and they did their R&D,
link |
they paid for their R&D having received that technology.
link |
And when they got the genetic code from China
link |
about the virus, they very quickly made a vaccine
link |
and the vaccine works.
link |
And President Trump to his credit launched
link |
Operation Warp Speed and just threw money at the problem.
link |
They just said, we spent five times more per person
link |
than the EU early on, just pay them whatever they want.
link |
Let's just get this going.
link |
And Americans were vaccinated more quickly.
link |
We paid a lot of money.
link |
The one mistake that I think the federal government made
link |
was they were paying these guaranteed fortunes
link |
and they didn't require that the companies participate
link |
in a program to do global vaccinations.
link |
So the companies doing their business model
link |
distributed the vaccines where they would make
link |
And obviously they would make the most money
link |
in the first world.
link |
And almost I think 85% of the vaccines early on
link |
went to the first world and very, very few vaccinations
link |
went to the third world.
link |
So what happened is there was such a low vaccination rate
link |
in May of 2021, there was all hands on deck cry for help
link |
from the World Trade Organization,
link |
the World Health Organization, the IMF and the World Bank
link |
made a plea for $50 billion so that we could get
link |
to 40% vaccination rate in the third world
link |
by the end of 2021.
link |
And it was unrequited, nobody answered.
link |
And now Africa has about a 8.9% vaccination rate.
link |
India is coming up, but it's been very low.
link |
The problem with all this is I believe those mRNA vaccines
link |
are excellent vaccines.
link |
But if we leave the third world unvaccinated,
link |
we're gonna have a constant supply of variants of COVID
link |
that are gonna come back into the United States
link |
and harm Americans exactly like Delta and Omicron have.
link |
So we've made a great drug, it reduces the risk of mortality
link |
in Americans who get it by a lot.
link |
But we're not doing what we need to do
link |
to protect Americans from Omicron.
link |
You don't have to be an idealist
link |
and worry about global vaccine equity.
link |
If you're just ordinary selfish people like most of us are,
link |
and you're worried about the health of Americans,
link |
you would ensure global vaccine distribution.
link |
Let me just make one more point.
link |
That $50 billion that was requested
link |
by the four organizations back in May of 2021,
link |
32 billionaires made $50 billion
link |
from the vaccines at that point,
link |
took it into their private wealth.
link |
So what had been taken,
link |
this enormous amounts of money that had been taken
link |
into private wealth was enough to do
link |
what those organizations said needed to be done
link |
to prevent the sub variants from coming back
link |
and doing what they're doing.
link |
So the money was there, but how does the motivation,
link |
the money driven motivation of Big Pharma lead to that,
link |
that kind of allocation of vaccines?
link |
Because they can make more money in the United States.
link |
They're gonna distribute their vaccines
link |
where they can make the most money.
link |
Right, is there a malevolent aspect to this
link |
where, boy, I don't like saying this,
link |
but that they don't see it as a huge problem
link |
that variants will come back to the United States.
link |
I think it's the issue we were talking about earlier on
link |
where they're in a different culture
link |
and their culture is that their moral obligation,
link |
as Milton Friedman would say,
link |
is to maximize the profits
link |
that they return to shareholders.
link |
And don't think about the bigger picture.
link |
The collateral damage, don't think about the collateral.
link |
And also kind of believe, convince yourself
link |
that if we give into this capitalist machine
link |
in this very narrow sense of capitalism,
link |
that in the end, they'll do the most good.
link |
This kind of belief that like,
link |
if we just maximize profits, we'll do the most good.
link |
Yeah, that's an orthodoxy of several decades ago.
link |
And I don't think people can really say that in good faith.
link |
When you're talking about vaccinating the third world
link |
so we don't get hurt,
link |
it's a little bit hard to make the argument
link |
that the world's a better place
link |
because the profits of the investors went up.
link |
Yeah, but at the same time,
link |
I think that's a belief you can hold.
link |
I mean, I've interacted with a bunch of folks that kinda,
link |
it's the, I don't wanna mischaracterize Ayn Rand, okay?
link |
I respect a lot of people,
link |
but there's a belief that can take hold.
link |
If I just focus on this particular maximization,
link |
it will do the most good for the world.
link |
The problem is when you choose what to maximize
link |
and you put blinders on,
link |
it's too easy to start making gigantic mistakes
link |
that have a big negative impact on society.
link |
So it's really matters what you're maximizing.
link |
Right, and if we had a true democracy
link |
and everybody had one vote,
link |
everybody got decent information and had one vote,
link |
Ayn Rand's position would get some votes, but not many,
link |
and it would be way outvoted by the common people.
link |
Let me ask you about this very difficult topic.
link |
I'm talking to Mark Zuckerberg of Metta,
link |
the topic of censorship.
link |
I don't know if you've heard,
link |
but there's a guy named Robert Malone and Peter McCullough
link |
that were removed from many platforms
link |
for speaking about the COVID vaccine as being risky.
link |
They were both on Joe Rogan's program.
link |
What do you think about censorship in this space?
link |
In this difficult space where so much is controlled by,
link |
not controlled, but influenced by advertisements
link |
and science can even be influenced by Big Pharma.
link |
Where do you lean on this?
link |
Should we lean towards freedom
link |
and just allow all the voices,
link |
even those that go against the scientific consensus?
link |
Is that one way to fight the science
link |
that is funded by Big Pharma,
link |
or is that do more harm than good,
link |
having too many voices that are contending here?
link |
Should the ultimate battle be fought
link |
in the space of scientific publications?
link |
And particularly in the era of COVID,
link |
where there are large public health ramifications
link |
to this public discourse, the ante is way up.
link |
So I don't have a simple answer to that.
link |
I think everyone's allowed their own opinion.
link |
I don't think everyone's allowed their own scientific facts.
link |
And how we develop a mechanism
link |
that's other than an open internet
link |
where whoever is shouting the loudest gets the most clicks
link |
and rage creates value on the internet,
link |
I think that's not a good mechanism for working this out.
link |
And I don't think we have one.
link |
I don't have a solution to this.
link |
I mean, ideally, if we had a philosopher king,
link |
we could have a panel of people
link |
who were not conflicted by rigid opinions
link |
decide on what the boundaries of public discourse might be.
link |
I don't think it should be fully open.
link |
I don't think people who are making,
link |
who are committed to an anti vaccine position
link |
and will tailor their interpretation
link |
of complex scientific data to support their opinion,
link |
I think that can be harmful.
link |
Constraining their speech can be harmful as well.
link |
So I don't have an answer here.
link |
I tend to believe that it's more dangerous
link |
to censor anti vax messages.
link |
The way to defeat anti vax messages
link |
is by being great communicators,
link |
by being great scientific communicators.
link |
So it's not that we need to censor
link |
the things we don't like.
link |
We need to be better at communicating
link |
the things we do like,
link |
or the things that we do believe represent
link |
the deep scientific truth.
link |
Because I think if you censor,
link |
you get worse at doing science
link |
and you give the wrong people power.
link |
So I tend to believe that you should give power
link |
to the individual scientists
link |
and also give them the responsibility
link |
of being better educators, communicators,
link |
expressers of scientific ideas,
link |
put pressure on them to release data,
link |
to release that data in a way that's easily consumable,
link |
not just like very difficult to understand,
link |
but in a way that can be understood
link |
by a large number of people.
link |
So the battle should be fought
link |
in the open space of ideas
link |
versus in the quiet space of journals.
link |
I think we no longer have that comfort,
link |
especially at the highest of stakes.
link |
So this kind of idea that a couple of peer reviewers
link |
decide the fate of billions
link |
doesn't seem to be sustainable,
link |
especially given a very real observation now
link |
that the reason Robert Malone has a large following
link |
is there's a deep distrust of institutions,
link |
deep distrust of scientists,
link |
of science as an institution,
link |
of power centers, of companies, of everything,
link |
and perhaps rightfully so.
link |
But the way to defend against that
link |
is not for the powerful to build a bigger wall.
link |
It's for the powerful to be authentic
link |
and maybe a lot of them to get fired,
link |
and for new minds, for new fresh scientists,
link |
ones who are more authentic, more real,
link |
better communicators to step up.
link |
So I fear censorship
link |
because it feels like censorship
link |
is an even harder job to do it well
link |
than being good communicators.
link |
And it seems like it's always the C students
link |
that end up doing the censorship.
link |
It's always the incompetent people,
link |
and not just the incompetent, but the biggest whiners.
link |
So what happens is the people
link |
that get the most emotional and the most outraged
link |
will drive the censorship.
link |
And it doesn't seem like reason drives the censorship.
link |
That's just objectively observing
link |
how censorship seems to work in this current.
link |
So there's so many forms of censorship.
link |
You look at the Soviet Union
link |
or the propaganda or Nazi Germany,
link |
it's a very different level of censorship.
link |
People tend to conflate all of these things together.
link |
Social media trying desperately to have trillions
link |
or hundreds of billions of exchanges a day,
link |
and try to make sure that their platform
link |
has some semblance of, quote, healthy conversations.
link |
People just don't go insane.
link |
They actually like using the platform,
link |
and they censor based on that.
link |
That's a different level of censorship.
link |
But even there, you can really run afoul
link |
of the people that get the whiny C students
link |
controlling too much of the censorship.
link |
I believe you should actually put the responsibility
link |
on the self proclaimed holders of truth,
link |
AKA scientists, at being better communicators.
link |
I agree with that.
link |
I'm not advocating for any kind of censorship.
link |
But Marshall McLuhan was very influential
link |
when I was in college.
link |
And his, that meme, the medium is the message.
link |
It's a little bit hard to understand
link |
when you're comparing radio to TV
link |
and saying radio's hotter or TV's hotter or something.
link |
But we now have the medium as the message
link |
in a way that we've never seen,
link |
we've never imagined before,
link |
where rage and anger and polarization
link |
are what drives the traffic on the internet.
link |
And we don't, it's a question of building the commons.
link |
Ideally, I don't know how to get there,
link |
so I'm not pretending to have a solution.
link |
But the commons of discourse about this particular issue,
link |
about vaccines, has been largely destroyed by the edges,
link |
by the drug companies and the advocates on the one side
link |
and the people who just criticize and think
link |
that even though the data are flawed
link |
that there's no way vaccines can be beneficial.
link |
And to have those people screaming at each other
link |
does nothing to improve the health
link |
of the 95% of the people in the middle
link |
who want to know what the rational way to go forward is
link |
and protect their families from COVID
link |
and live a good life
link |
and be able to participate in the economy.
link |
And that's the problem.
link |
I don't have a solution.
link |
Well, there's a difficult problem for Spotify and YouTube.
link |
I don't know if you heard,
link |
this is a thing that Joe Rogan is currently going through.
link |
As a platform, whether to censor the conversation
link |
that, for example, Joe's having.
link |
So I don't know if you heard,
link |
but Neil Young and other musicians have kind of spoke out
link |
and saying they're going to leave the platform
link |
because Joe Rogan is allowed to be on this platform
link |
having these kinds of conversations
link |
with the likes of Robert Malone.
link |
And it's clear to me that Spotify and YouTube
link |
are being significantly influenced
link |
by these extreme voices, like you mentioned, on each side.
link |
And it's also clear to me that Facebook is the same
link |
and it was going back and forth.
link |
In fact, that's why Facebook has been oscillating
link |
on the censorship is like one group gets louder
link |
than the other, depending on whether it's an election year.
link |
There's several things to say here.
link |
So one, it does seem, I think you put it really well,
link |
it would be amazing if these platforms
link |
could find mechanisms to listen to the center,
link |
to the big center that's actually going to be affected
link |
by the results of our pursuit of scientific truth.
link |
And listen to those voices.
link |
I also believe that most people are intelligent enough
link |
to process information and to make up their own minds.
link |
Like they're not, in terms of,
link |
it's complicated, of course,
link |
because we've just been talking about advertisement
link |
and how people can be influenced.
link |
But I feel like if you have raw, long form podcasts
link |
or programs where people express their mind
link |
and express their argument in full,
link |
I think people can hear it to make up their own mind.
link |
And if those arguments have a platform on which
link |
they can live, then other people could provide
link |
better arguments if they disagree with it.
link |
And now we as human beings, as rational,
link |
as intelligent human beings, can look at both
link |
and make up our own minds.
link |
And that's where social media can be very good
link |
at this collective intelligence.
link |
We together listen to all of these voices
link |
and make up our own mind.
link |
Humble ourselves, actually, often.
link |
You think, you know, like you're an expert,
link |
say you have a PhD in a certain thing,
link |
so there's this confidence that comes with that.
link |
And the collective intelligence, uncensored,
link |
allows you to humble yourself eventually.
link |
Like as you discover, all it takes is a few times,
link |
you know, looking back five years later,
link |
realizing I was wrong.
link |
And that's really healthy for a scientist.
link |
That's really healthy for anybody to go through.
link |
And only through having that open discourse
link |
can you really have that.
link |
That said, Spotify also, just like Pfizer is a company,
link |
which is why this podcast,
link |
I don't know if you know what RSS feeds are,
link |
but podcasts can't be censored.
link |
So Joe's in the unfortunate position
link |
he only lives on Spotify.
link |
So Spotify has been actually very good
link |
at saying we're staying out of it for now.
link |
But RSS, this is pirate radio.
link |
Nobody can censor it, it's the internet.
link |
So financially, in terms of platforms,
link |
this cannot be censored,
link |
which is why podcasts are really beautiful.
link |
And so if Spotify or YouTube wants to be
link |
the host of podcasts,
link |
I think where they flourish is free expression,
link |
no matter how crazy.
link |
Yes, but I do wanna push back a little bit on what you're saying.
link |
I have anti fax friends who I love.
link |
They're dear, cherished friends.
link |
And they'll send me stuff.
link |
And it'll take me an hour to go through what they sent
link |
to see if it is credible.
link |
And usually it's not.
link |
It's not a random sample of the anti fax argument.
link |
I'm not saying I can disprove the anti fax argument.
link |
But I am saying that it's almost like we were talking about
link |
how medical science clinical trials,
link |
the presentation of clinical trials to physicians
link |
could be improved.
link |
And the first thing we came up with
link |
is to have pre publication transparency
link |
in the peer review process.
link |
So bad information, biased information doesn't get out
link |
as if it's legitimate, and you can't put it back,
link |
recapture it once it gets out.
link |
I think there's an element of that
link |
in the arguments that are going on about vaccines.
link |
And they're on both sides.
link |
But I think the anti fax side puts out more units
link |
of information claiming to show that the vaccines don't work.
link |
And I guess in an ideal situation,
link |
there would be real time fact checking by independent people,
link |
not to censor it, but to just say that study was set up
link |
to do this, and this is what the conclusions were.
link |
So the way it was stated is on one side of this argument.
link |
But that's what I'm arguing.
link |
What I'm arguing is that this big network of humans
link |
that we have, that is the collective intelligence,
link |
can't do that real time if you allow it to,
link |
if you encourage people to do it.
link |
And the scientists, as opposed to, listen,
link |
I interact with a lot of colleagues,
link |
a lot of friends that are scientists,
link |
they roll their eyes.
link |
Their response is like, ugh.
link |
Like they don't want to interact with this.
link |
But that's just not the right response.
link |
When a huge number of people believe this,
link |
it is your job as communicators to defend your ideas.
link |
It is no longer the case that you go to a conference
link |
and defend your ideas to two other nerds
link |
that have been working on the same problem forever.
link |
I mean, sure, you can do that,
link |
but then you're rejecting the responsibility
link |
you have explicitly or implicitly accepted
link |
when you go into this field,
link |
that you will defend the ideas of truth.
link |
And the way to defend them is in the open battlefield
link |
of ideas, and become a better communicator.
link |
And I believe that when you have a lot,
link |
you said you invested one or two hours
link |
in this particular, but that's little ants interacting
link |
at scale, I think that allows us to progress towards truth.
link |
At least, you know, at least I hope so.
link |
I think you're an optimist.
link |
I want to work with you a little bit on this.
link |
Let's say a person like Joe Rogan,
link |
who, by the way, had me on his podcast and let me.
link |
It's an amazing conversation, I really enjoyed it.
link |
And I didn't know Joe.
link |
I didn't know much about his podcast.
link |
He pushed back on Joe a bunch, which is great.
link |
And he was a gentleman, and we had it out.
link |
In fact, he put one clip, at one point,
link |
he said something that was a little bit wrong,
link |
and I corrected him.
link |
And he had the guy who.
link |
Jamie, he had Jamie check it,
link |
and was very forthright in saying,
link |
yeah, you know, John's got a right here.
link |
We gotta modify this.
link |
In any event, in any event.
link |
Well, I wasn't trying to get him,
link |
I was just trying to. No, no, no, no.
link |
Totally, it was a beautiful exchange.
link |
There was so much respect in the room,
link |
pushing back and forth, it was great.
link |
Yeah, so I respect him.
link |
And I think when he has somebody on
link |
who's a dyed in the wool anti faxer,
link |
the question is, how can you balance,
link |
if it needs balance, in real time?
link |
I'm not talking about afterwards.
link |
I'm talking in real time.
link |
Maybe you record, well, he does record it, obviously.
link |
But maybe when there's a statement made
link |
that is made as if it's fact based,
link |
maybe that statement should be checked by
link |
imaginary folks who are trustworthy.
link |
And in real time, as that discussion
link |
is being played on the podcast,
link |
to show what independent experts say about that claim.
link |
That's a really interesting idea.
link |
By the way, for some reason,
link |
this idea popped into my head now.
link |
I think real time is very difficult,
link |
and it's not difficult,
link |
but it kind of ruins the conversation
link |
because you want the idea to breathe.
link |
I think what's very possible is before it's published,
link |
it's the pre publication, before it's published,
link |
you let a bunch of people review it,
link |
and they can add their voices in post.
link |
Before it's published, they can add arguments,
link |
arguments against certain parts.
link |
That's very interesting to sort of,
link |
as one podcast, publish addendums.
link |
Publish the peer review together with the publication.
link |
That's very interesting.
link |
I might actually do that.
link |
That's really interesting.
link |
Because I've been doing more debates
link |
where at the same time have multiple people,
link |
which has a different dynamic
link |
because both people, I mean,
link |
it's really nice to have the time to pause
link |
just by yourself to fact check,
link |
to look at the study that was mentioned,
link |
to understand what's going on.
link |
So the peer review process, to have a little bit of time.
link |
That's really interesting.
link |
I actually would, I'd like to try that.
link |
To agree with you on some point in terms of anti vax,
link |
I've been fascinated by listening to arguments
link |
from this community of folks that's been quite large
link |
called the flat earthers,
link |
the people that believe the earth is flat.
link |
And I don't know if you've ever listened to them
link |
or read their arguments,
link |
but it's fascinating how consistent
link |
and convincing it all sounds
link |
when you just kind of take it in.
link |
Just like, just take it in like listening normally.
link |
It's all very logical.
link |
Like if you don't think very,
link |
well, no, so the thing is,
link |
the reality is at the very basic human level
link |
with our limited cognitive capabilities,
link |
the earth is pretty flat when you go outside
link |
and you look at flat.
link |
So like when you use common sense reasoning,
link |
it's very easy to play to that,
link |
to convince you that the earth is flat.
link |
Plus there's powerful organizations
link |
that want to manipulate you and so on.
link |
But then there's the whole progress of science
link |
and physics of the past,
link |
but that's difficult to integrate into your thought process.
link |
So it's very true that the people
link |
should listen to flat earthers
link |
because it was very revealing to me
link |
how easy it is to be convinced of basically anything
link |
by charismatic arguments.
link |
And if we're arguing about whether the earth is flat or not,
link |
as long as we're not navigating airplanes
link |
and doing other kinds of things,
link |
trying to get satellites to do transmission,
link |
it's not that important what I believe.
link |
But if we're arguing about how we approach
link |
the worst public health crisis in,
link |
I don't know how long,
link |
I think we're getting worse than the Spanish flu now.
link |
I don't know what the total global deaths
link |
with Spanish flu were, but in the United States,
link |
we certainly have more deaths than we had from Spanish flu.
link |
Plus the economic pain and suffering.
link |
Yes, yes, and the damage to the kids in school and so forth.
link |
We got a problem and it's not going away, unfortunately.
link |
So when we get a problem like that,
link |
it's not just an interesting bar room conversation
link |
about whether the earth is flat.
link |
There are millions of lives involved.
link |
Let me ask you yet another question,
link |
an issue I raised with Pfizer CO, Albert Burla.
link |
It's the question of revolving doors.
link |
That there seems to be a revolving door
link |
between Pfizer, FDA, and CDC.
link |
People that have worked at the FDA,
link |
now work at Pfizer, and vice versa,
link |
including the CDC and so on.
link |
What do you think about that?
link |
So first of all, his response, once again,
link |
is there's rules, there's very strict rules,
link |
and we follow them.
link |
Do you think that's a problem?
link |
And also, maybe this is a good time to talk about
link |
this Pfizer play by the rules.
link |
Okay, and this isn't even about Pfizer,
link |
but it's an answer to the question.
link |
So there's this drug, Ajihelm,
link |
that was approved by the FDA maybe six months ago.
link |
It's a drug to prevent the progression
link |
of low grade Alzheimer's disease.
link |
The target for drug development for Alzheimer's disease
link |
has been reducing the amyloid plaques in the brain,
link |
which correlate with the progression of Alzheimer's.
link |
And Biogen showed that its drug, Ajihelm,
link |
reduces amyloid plaques in the brain.
link |
They did two clinical trials
link |
to determine the clinical efficacy,
link |
and they found that neither trial showed a meaningful benefit.
link |
And in those two trials,
link |
33% more people in the Ajihelm group
link |
developed symptomatic brain swelling and bleeding
link |
than people in the placebo group.
link |
There was an advisory committee convened
link |
to debate and determine how they felt
link |
about the approvability of Ajihelm, given those facts.
link |
And those facts aren't in dispute.
link |
They're in Biogen slides, as well as FDA documents.
link |
The advisory committee voted 10 against approval
link |
So that's essentially universal,
link |
unanimous vote against approving Ajihelm.
link |
Now, the advisory committees have been pretty much cleansed
link |
of financial conflicts of interest.
link |
So this advisory committee votes 10 no, one abstention,
link |
and the FDA overrules the unanimous opinion
link |
of its advisory committee and approves the drug.
link |
Three of the members of the advisory committee resign.
link |
They say, we're not gonna be part,
link |
if the FDA is not gonna listen to a unanimous vote
link |
against approving this drug,
link |
which shows more harm than benefit, undisputed,
link |
we're not gonna participate in this.
link |
And the argument against approval
link |
is that the surrogate endpoint,
link |
the reduction of amyloid, the progression of amyloid plaques
link |
is known by the FDA not to be a valid clinical indicator.
link |
It doesn't correlate, 27 studies have shown,
link |
it doesn't correlate with clinical progression,
link |
interrupting the amyloid plaques
link |
doesn't mean that your Alzheimer's doesn't get worse.
link |
So it seems like it's a slam dunk
link |
and the FDA made a mistake and they should do whatever
link |
they do to protect their bureaucratic reputation.
link |
So the head of the Bureau of the FDA,
link |
the Center for Drug Evaluation and Research
link |
that approves new drugs, who had spent 16 years
link |
as an executive in the pharmaceutical industry,
link |
issued a statement and said,
link |
"'What we should do in this situation
link |
"'is to loosen the prohibition of financial ties of interest
link |
"'with the drug companies,
link |
"'so we get less emotional responses.'"
link |
Said this, it's in print.
link |
People are just too emotional about this.
link |
People were just too emotional.
link |
The 10 people who voted against it
link |
and the no people who voted for it,
link |
it's all too emotional.
link |
So this gets back,
link |
this is a long answer to your short question.
link |
I think this is a wonderful window
link |
into the thinking of the FDA
link |
that financial conflicts of interest don't matter
link |
in a situation when I think it's obvious
link |
that they would matter.
link |
But there's not a direct financial conflict of interest.
link |
It's kinda, like it's not, like Albert said, there's rules.
link |
I mean, you're not allowed
link |
to have direct financial conflicts of interest.
link |
Right, but what I'm saying is,
link |
I'm not denying what he said is true,
link |
but the FDA, a high official in the FDA,
link |
is saying that we need to allow conflicts of interest
link |
in our advisory committee meetings.
link |
And that, she wants to change the rules.
link |
So Albert Borla would still be playing by the rules,
link |
but it just shows how one side of the thinking here is.
link |
But you think that's influenced by the fact
link |
that there were pharmaceutical executives
link |
working at the FDA and vice versa?
link |
And they think that's a great idea.
link |
Who gets to fix this?
link |
Do you think it should be just banned?
link |
Like if you worked.
link |
I don't know, two separate questions.
link |
One is should the officials at the FDA come from pharma
link |
That's one question.
link |
And the other question is should advisory committee members
link |
be allowed to have financial conflicts of interest?
link |
I think, in my opinion, and people might say I'm biased,
link |
I think advisory committee people
link |
should not have conflicts of interest.
link |
I think their only interest ought to be the public interest.
link |
And that was true from my understanding of the situation.
link |
It's the afterword in my book.
link |
I spent some time studying it about Ajihelm.
link |
I think it's a slam dunk that there ought to be
link |
no conflicts of interest.
link |
Now the head of CDER, Center for Drug Evaluation Research,
link |
thinks that that's gonna give you a biased result
link |
because we don't have company influence.
link |
And that, I think, shows how biased their thinking is.
link |
That not having company influence is a bias.
link |
Let me try to load that in.
link |
I'm trying to empathize with the belief
link |
that companies should have a voice at the table.
link |
I mean, yeah, it's part of the game.
link |
They've convinced themselves
link |
that this is how it should be played.
link |
But they have a voice at the table.
link |
They've designed the studies.
link |
That's their voice.
link |
That's the whole point.
link |
They analyze the data.
link |
I mean, what bigger voice do you deserve?
link |
But I do also think, on the more challenging question,
link |
I do think that there should be a ban.
link |
If you work at a pharmaceutical company,
link |
you should not be allowed to work
link |
at any regulatory agency.
link |
I mean, that, going back and forth,
link |
it just, even if it's 30 years later.
link |
And I have another nomination for a ban.
link |
We're in this crazy situation
link |
where Medicare is not allowed to negotiate
link |
the price of drugs with the drug companies.
link |
So the drug companies get a patent on a new drug.
link |
Unlike every other developed country,
link |
they can charge whatever they want
link |
so they have a monopoly on a utility
link |
because no one else can make the drug.
link |
Charge whatever they want and Medicare has to pay for it.
link |
And you say, how did we get in this crazy situation?
link |
So how we got here is that in 2003,
link |
when Medicare Part D was passed,
link |
Billy Towson was head of the Ways and Means Committee
link |
in the House, played a key role in ushering this through
link |
with the nonnegotiation clause of it.
link |
And after it was passed,
link |
Billy Towson did not finish out his term in Congress.
link |
He went to pharma for a $2 million a year job.
link |
This is incredible.
link |
You might think that a ban on that would be a good idea.
link |
I spoke with Francis Collins, head of the NIH,
link |
He and NIH have a lot of power over funding in science.
link |
What are they doing right, what are they doing wrong
link |
in this interplay with big pharma?
link |
How connected are they?
link |
Again, returning to the question,
link |
what are they doing right,
link |
what are they doing wrong in your view?
link |
So my knowledge of the NIH is not as granular
link |
as my knowledge of pharma.
link |
That said, in broad brushstrokes,
link |
the NIH is doing the infrastructure work
link |
for all drug development.
link |
I think they've participated in 100% of the drugs
link |
that have been approved by the FDA
link |
over the past 10 years or so.
link |
They've done infrastructure work.
link |
And what they do is not work on particular drugs,
link |
but they develop work on drug targets,
link |
on targets in the human body that can be affected by drugs
link |
and might be beneficial to turn on or off.
link |
And then the drug companies, when they find a target
link |
that is mutable and potentially beneficial,
link |
then the drug companies can take the research
link |
and choose to invest in the development of the drugs,
link |
Now, 96% of the research that's done in clinical trials
link |
in the United States is about drugs and devices.
link |
And only a fraction of the 4% that's left over
link |
is about preventive medicine
link |
and how to make Americans healthier.
link |
I think, again, from the satellite view,
link |
the NIH is investing more in science
link |
that can lead to commercial development
link |
rather than, as you said at the beginning of the podcast,
link |
there's no big fitness and lifestyle industry
link |
that can counter pharma.
link |
So I think at the NIH level, that countering can be done.
link |
And the diabetes prevention program study
link |
that we talked about before where lifestyle
link |
was part of a randomized trial
link |
and was shown to be more effective than metformin
link |
at preventing the development of diabetes,
link |
that is absolute proof positive
link |
that investing in that kind of science
link |
can produce good results.
link |
So I think that we're aimed at drug development
link |
and what we ought to be aimed at
link |
is an epidemiological approach
link |
to improving the health of all Americans.
link |
We rank 68th in the world in healthy life expectancy
link |
despite spending an extra trillion and a half dollars a year.
link |
And I believe strongly
link |
that the reason why we've gotten in this crazy position
link |
is because the knowledge that we're producing
link |
is about new drugs and devices
link |
and it's not about improving population health.
link |
In this problem, the NIH is the perfect institution
link |
to play a role in rebalancing our research agenda.
link |
And some of that is on the leadership side
link |
with Francis Collins and Anthony Fauci,
link |
not just speaking about basically everything
link |
that just leads to drug development, vaccine development,
link |
but also speaking about healthy lifestyles
link |
and speaking about health, not just sickness.
link |
Yes, and investing, investing in health.
link |
I mean, it's like one feeds the other.
link |
One, you have to communicate to the public
link |
the importance of investing in health
link |
and that leads to you getting props for investing in health
link |
and then you can invest in health more and more
link |
and that communicates, I mean,
link |
everything that Anthony Fauci says or Francis Collins says
link |
has an impact on scientists.
link |
I mean, it sets the priorities.
link |
I don't think they, it's the sad thing about leaders,
link |
forgive me for saying the word, but mediocre leaders
link |
is they don't see themselves as part of a game.
link |
They don't see the momentum.
link |
It's like a fish in the water.
link |
They don't see the water.
link |
Great leaders stand up and reverse the direction
link |
of how things are going.
link |
And I actually put a lot of responsibility,
link |
some people say too much, but whatever.
link |
I think leaders carry the responsibility.
link |
I put a lot of responsibility on Anthony Fauci
link |
and Francis Collins for not actually speaking
link |
a lot more about health, not, and bigger,
link |
inspiring people in the power
link |
and the trustworthiness of science.
link |
You know, that's on the shoulders of Anthony Fauci.
link |
I'm gonna abstain from that
link |
because I'm not expert enough, but.
link |
Neither am I, but I'm opinionated.
link |
I am too, but not on camera.
link |
No, but seriously, the problem is pretty simple,
link |
that we're investing 96% of our funding
link |
of clinical research in drugs and devices
link |
and 80% of our health is determined
link |
by how we live our lives.
link |
And this is ridiculous.
link |
The United States is going further and further
link |
behind the other wealthy countries in terms of our health.
link |
We ranked 38th in healthy life expectancy in 2000
link |
and now we're spending a trillion and a half dollars extra
link |
You have this excellent, there's a few charts
link |
that I'll overlay that tell this story
link |
in really powerful ways.
link |
So one is the healthcare spending is percentage of GDP
link |
that on the X axis is years and the Y axis is percentage
link |
and the United States as compared to other countries
link |
on average has been much larger and growing.
link |
Right, we are now spending 7% more of our GDP,
link |
17.7% versus 10.7% on healthcare.
link |
7% and I think GDP is the fairest way
link |
to compare healthcare spending.
link |
Where per person in dollars we're spending even,
link |
the difference is even greater
link |
but other costs vary with GDP.
link |
So let's stick with the conservative way to do it.
link |
17.7 or 18% of GDP, 18% of GDP spent on healthcare,
link |
7% higher than the comparable country average.
link |
17.7% versus 10.7, 7% higher.
link |
Right and 7% of $23 trillion GDP
link |
is more than $1.5 trillion a year in excess.
link |
And then you have another chart that shows
link |
healthcare system performance compared to spending.
link |
And there's a cloud, a point cloud of different countries.
link |
The X axis being healthcare spending
link |
is a percentage of GDP which we just talked about.
link |
That US is 7% higher than everyone, the average.
link |
And then on the Y axis is performance.
link |
So X axis spending, Y axis performance.
link |
And there's a point cloud, we'll overlay this
link |
if you're watching on YouTube,
link |
of a bunch of countries that have high performance
link |
for what they're spending and then US
link |
is all alone on the right bottom side of the chart
link |
where it's low performance and high spending.
link |
So this is a system that is abiding by spending
link |
that is directed by the most profitable ways
link |
to deliver healthcare.
link |
So you put that in the hands of big pharma.
link |
As you maximize for profit, you're going to decrease
link |
performance and increase spending.
link |
Yes, but I wanna qualify that and say
link |
it's not all big pharma's fault.
link |
They're not responsible for all the problems
link |
in our healthcare system.
link |
They're not responsible for the administrative costs
link |
But they are the largest component of the rising,
link |
our rising healthcare costs.
link |
And it has to do with this knowledge issue.
link |
Controlling the knowledge that doctors have
link |
makes it so that doctors can live with this situation
link |
believing that it's optimal when it's a wreck.
link |
Let me ask you the big, so as a physician,
link |
so everything you've seen, we've talked about 80%
link |
of the impact on health is lifestyle.
link |
How do we live longer?
link |
What advice would you give to general people?
link |
What space of ideas result in living longer
link |
and higher quality lives?
link |
Right, this is a very simple question to answer.
link |
Exercise for at least a half hour
link |
at least five times a week.
link |
Number two, don't smoke.
link |
Number three, maintain a reasonably healthy body weight.
link |
Some people argue that being lower than a BMI of 25
link |
I think that may be true,
link |
but I think getting above 30 is unhealthy
link |
and that ought to be.
link |
Now that's largely impacted by socioeconomic status
link |
and we don't wanna blame the victims here.
link |
So we gotta understand that when we talk about
link |
all of these things, not cigarettes,
link |
but exercise and a good diet
link |
and maintaining a healthy body weight,
link |
we have to include in doing those things
link |
the impediments to people of lower socioeconomic status
link |
being able to make those changes.
link |
We've got to understand that personal responsibility
link |
accounts for some of this,
link |
but also social circumstances accounts for some of it.
link |
And back to your fish bowl analogy,
link |
if you're swimming in a fish bowl,
link |
if you live in a fish tank
link |
that's not being properly maintained,
link |
the approach wouldn't be to treat individual sick fish,
link |
it would be to fix your fish tank
link |
to get the bacteria out of it
link |
and whatever bad stuff is in there
link |
and make your fish tank healthier.
link |
Well, we invest far less than the other wealthy countries do.
link |
We're flipped, we have the mirror image
link |
in the spending on social determinants of health
link |
and medical determinants of health.
link |
We have exactly the wrong order.
link |
And not only does that choke off
link |
social determinants of health, which are very important,
link |
but actually just the ratio,
link |
even if you were spending,
link |
if we raise the social spending
link |
and raise our medical spending in proportion,
link |
it's the ratio of social spending to medical spending
link |
that's the problem.
link |
So, and why do we do that?
link |
Well, the answer is perfectly obvious
link |
that the way to transfer money
link |
from working Americans to investors
link |
is through the biomedical model,
link |
not through the social health model.
link |
And that's the problem for,
link |
and I'd like to discuss this
link |
because the market isn't gonna get us
link |
to a reasonable allocation.
link |
All the other wealthy countries
link |
that are so much healthier than we are
link |
and spending so much less than we are
link |
have some form of government intervention
link |
in the quality of the health data that's available,
link |
in the budgeting of health and social factors.
link |
And we don't, we're kind of the Wild West
link |
and we let the market determine those allocations.
link |
And it's an awful failure.
link |
It's a horrendous failure.
link |
So one argument against government,
link |
or sorry, an alternative to the government intervention
link |
is the market can work better
link |
if the citizenry has better information.
link |
So one argument is that
link |
communicators like podcasts and so on,
link |
but other channels of communication
link |
will be the way to fight big pharma.
link |
Your book is the way to,
link |
by providing information.
link |
The alternative to the government intervention
link |
on every aspect of this,
link |
including communication with the doctors
link |
is to provide them other information
link |
and not allow the market to provide that information
link |
by basically making it exciting
link |
to buy books, to make better and better communicators
link |
on Twitter, through books, through op eds,
link |
through podcasts, through so on.
link |
So basically, cause there's a lot of incentive
link |
to communicate against the messages of big pharma.
link |
There's incentive because people want to understand
link |
what's good for their lives
link |
and they're willing to listen to charismatic people
link |
that are able to clearly explain what is good for them.
link |
And they do, and more than 80% of people
link |
think that drugs cost too much
link |
and the drug industry is too interested in profits.
link |
But they still get influenced.
link |
They can't, you can't get the vote through Congress.
link |
You know, Democrats and Republicans alike
link |
are taking money from Congress
link |
and somehow it just doesn't work out
link |
that these even small changes.
link |
I mean, the pared down part of Medicare,
link |
the plan for increasing Medicare negotiation drug costs
link |
in Build Back Better,
link |
it's literally gonna reduce the number of new drugs
link |
that are beneficial, uniquely beneficial
link |
by about one new drug or two new drugs over 30 years.
link |
It will have virtually an indecipherable impact.
link |
And yet pharma is talking about the impact on innovation.
link |
And if you vote for this,
link |
if you let your Congressman vote for this,
link |
you're gonna severely slow down drug innovation
link |
and that's gonna affect the quality of your life.
link |
Let me ask you about over medication
link |
that we've been talking about from different angles.
link |
But one difficult question for me,
link |
I'll just, I'll pick one of the difficult topics,
link |
So depression is a serious, painful condition
link |
that leads to a lot of people suffering in the world.
link |
And yet it is likely they were over prescribing
link |
So as a doctor, as a patient, as a healthcare system,
link |
as a society, what do we do with that fact
link |
that people suffer?
link |
There's a lot of people suffering from depression
link |
and there's also people suffering
link |
from over prescribing of antidepressants.
link |
So a paper in the New England Journal by Eric Turner
link |
showed that the data,
link |
if you put all the data together from antidepressants,
link |
you find out that antidepressants are not effective
link |
for people who are depressed
link |
but don't have a major depression.
link |
Major depression is a serious problem.
link |
People can't function normally.
link |
They have a hard time getting out,
link |
performing their normal social roles.
link |
But what's happened is that the publicity,
link |
I mean, Prozac Nation was a good example
link |
of making the argument that why should people
link |
settle for normal happiness
link |
when they can have better than normal happiness?
link |
And if you're not having normal happiness,
link |
you should take a drug.
link |
Well, that concept that serotonin metabolism
link |
is the root cause of depression
link |
is really a destructive one.
link |
We have drugs that change serotonin metabolism
link |
but we don't know if that's why antidepressants
link |
work on major depression.
link |
And they certainly don't work on everybody
link |
with major depression.
link |
I forget what the number needed a treat is.
link |
I think it's around four,
link |
one out of four people have significant improvement.
link |
But the people without major depression don't get better.
link |
And the vast majority of these drugs
link |
are used for people without major depression.
link |
So what's happened is that the feelings
link |
of life satisfaction of happiness and not sadness
link |
have been medicalized.
link |
The normal range of feelings have been medicalized.
link |
And that's not to say that they shouldn't be attended to.
link |
But the evidence shows that attending to them
link |
by giving somebody a medicine doesn't help
link |
except that they feel like somebody cares about them
link |
and believes that they're suffering.
link |
But there are problems in living
link |
that give rise to much of this symptomatology
link |
of less than major depression.
link |
And let's call it what it is
link |
and figure out a way to help people
link |
in visual therapy, group therapy.
link |
Maybe lifestyle modification would work.
link |
We gotta try that.
link |
But let's call it what it is instead of saying,
link |
oh, you're in this vast basket of people who are depressed
link |
so we'll give you an antidepressant
link |
even though the evidence shows
link |
that people who are suffering from your level of depression
link |
And that's a consequence of not focusing
link |
on preventative medicine, the lifestyle changes,
link |
all that kind of stuff.
link |
Well, yes, but it's really a consequence
link |
of the drug companies creating the impression
link |
that if you're sad, take a pill.
link |
If you're nonmajor depression,
link |
how do you overcome depression?
link |
Well, you have to talk about what the problem is.
link |
So talk therapy, lifestyle changes.
link |
Well, no, I'm not jumping to that.
link |
I'm saying that you ought to,
link |
A, the way you feel must be respected.
link |
Yeah, acknowledge that you're suffering.
link |
Acknowledge that you're suffering
link |
and deal with healthcare providers
link |
who acknowledge that you're suffering.
link |
So let's take that first step.
link |
And then. Big first step also.
link |
Big first step, yeah.
link |
Family docs are pretty good at that.
link |
That's kind of the arena
link |
that caused me to go into family medicine.
link |
The subjective experience of the patient.
link |
Okay, so you're a person
link |
who is not getting the enjoyment out of their life
link |
that they feel they ought to be getting.
link |
Now let's figure out why
link |
and whether that means some time with a social worker,
link |
some time with a psychiatrist,
link |
some time with a psychiatric nurse.
link |
I'm not sure how you'd best do that
link |
most effectively and efficiently,
link |
but that's what you need to do.
link |
And it may be that there's a marital problem
link |
and there's something going on
link |
and one of the spouses can't find satisfaction
link |
in the life they have to live within their relationship.
link |
Maybe there's a past history of trauma or abuse
link |
that somebody is projecting onto their current situation.
link |
Maybe there's socioeconomic circumstances
link |
where they can't find a job
link |
that gives them self respect and enough money to live.
link |
All, you know, an infinite range of things.
link |
But let's figure out, make a diagnosis first.
link |
The diagnosis isn't that the person feels sadder
link |
than they feel, than they want to feel.
link |
The diagnosis is why does the person feel sadder
link |
than they want to feel?
link |
You mentioned this is what made you want
link |
to get into family medicine.
link |
As a doctor, what do you think about the saying,
link |
save one life, save the world?
link |
This was always moving to me about doctors
link |
because you have like this human in front of you
link |
and your time is worth money.
link |
Your, what you prescribe and your efforts
link |
after the visit are worth money.
link |
And it seems like the task of the doctor
link |
is to not think about any of that.
link |
Or not the task, but it seems like a great doctor,
link |
despite all that, just forgets it all
link |
and just cares about the one human.
link |
And somehow that feels like the love and effort
link |
you put into helping one person
link |
is the thing that will save the world.
link |
It's not like some economic argument
link |
or some political argument or financial argument.
link |
It's a very human drive that ultimately
link |
is behind all of this that will do good for the world.
link |
Yes, I think that's true.
link |
And at the same time, I think it's equally true
link |
that all physicians need to have a sense of responsibility
link |
about how the common resources are allocated
link |
to serve the whole population's interest best.
link |
That's a tension that you have as a physician.
link |
Let's take the extreme example.
link |
Let's say you had a patient in front of you
link |
who if you gave one $10 billion pill to,
link |
you would save their life.
link |
I would just be tortured by that as a physician
link |
because I know that $10 billion spent properly
link |
in an epidemiologically guided way
link |
is gonna save a whole lot more lives than one life.
link |
So it's also your responsibility as a physician
link |
to walk away from that patient.
link |
I wouldn't say that.
link |
I think it's your responsibility
link |
to be tortured by it.
link |
That's exactly right.
link |
The human condition.
link |
That's a tough job, but yeah, yeah.
link |
To maintain your humanity through it all.
link |
Yeah, but you've been asking at different points
link |
in this conversation, why are doctors so complacent
link |
about the tremendous amount of money we're spending?
link |
Why do they accept knowledge from different sources
link |
that may not pan out when they really know the truth?
link |
And the answer is that they're trying to do their best
link |
for their patients.
link |
And there's this, it's the same kind of torture
link |
to figure out what the hell is going on with the data.
link |
And that's a sort of future project.
link |
And maybe people will read my book
link |
and maybe they'll get a little more excited about it,
link |
become more legitimate in practice.
link |
I would feel like my life was worthwhile if that happened.
link |
But at the same time, they've got to do something
link |
with the patient in front of them.
link |
They've got to make a decision.
link |
And they probably, there are not many weirdos like me
link |
who invest their life in figuring out
link |
what's behind the data.
link |
They're trying to get through the day
link |
and do the right thing for their patient.
link |
So they're tortured by that decision too.
link |
And so if you're not careful,
link |
big pharma can manipulate that drive
link |
to try to help the patient,
link |
that humanity of dealing with the uncertainty of it all.
link |
Like what is the best thing to do?
link |
Big pharma can step in and use money
link |
to manipulate that humanity.
link |
Yeah, I would state it quite differently.
link |
It's sort of an opt out rather than an opt in.
link |
Big pharma will do that.
link |
And you need to opt out of it.
link |
What advice would you give to a young person today
link |
in high school or college
link |
stepping into this complicated world
link |
full of advertisements, of big powerful institutions,
link |
of big rich companies,
link |
how to have a positive impact in the world,
link |
how to live a life they can be proud of?
link |
I would say should that person
link |
who has only good motives go into medicine.
link |
They have an inclination to go into medicine
link |
and they've asked me what I think about that
link |
given what I know about the undermining
link |
of American healthcare at this point.
link |
And my answer is if you've got the calling,
link |
You should do it because nobody's gonna do it
link |
And if you don't have the calling
link |
and you're in it for the money,
link |
you're not gonna be proud of yourself.
link |
How do you prevent yourself from doing,
link |
from letting the system change you over years and years,
link |
like letting the game of pharmaceutical influence affect you?
link |
It's a very hard question
link |
because the sociologic norms are to be affected
link |
and to trust the sources of information
link |
that are largely controlled by the drug industry.
link |
And that's why I wrote Sickening,
link |
is to try and help those people in the medical profession
link |
to understand that what's going on right now looks normal
link |
The health of Americans is going downhill.
link |
Our society's getting ruined by the money
link |
that's getting pulled out of other socially beneficial uses
link |
to pay for health care that is not helping us.
link |
So fundamentally, the thing that is normal,
link |
now question the normal, don't.
link |
If you conform, conform hesitantly.
link |
Well, you have to conform.
link |
You can't become a doctor without conforming.
link |
I just made it through.
link |
But there aren't many and it's hard work.
link |
But you have to conform.
link |
And even with my colleagues in my own practice,
link |
I couldn't convince them that some of the beliefs they had
link |
about how best to practice weren't accurate.
link |
There's one scene, a younger physician
link |
had prescribed hormone replacement therapy.
link |
This is back in 2000, 2001.
link |
Had prescribed hormone replacement therapy for one of my patients
link |
who happened to be a really good personal friend.
link |
And I saw that patient covering for my colleague at one point
link |
and I saw that her hormone replacement therapy had been renewed.
link |
And I said, are you having hot flashes or any problem?
link |
But Dr. So and So said it's better for my health.
link |
And I said, no, it's not.
link |
The research is showing that it's not, it's harmful for your health
link |
and I think you should stop it.
link |
So my colleague approached me when she saw the chart and said,
link |
wait a minute, that's my patient.
link |
Maybe your friend, but it's my patient.
link |
And I went to a conference from my alma mater, medical school,
link |
and they said that healthy people should be given hormone replacement.
link |
And I said, there's got to be a way to get rid of it.
link |
And I said, there's got to be drug companies involved in this.
link |
And she said, no, no, no, it was at my university.
link |
It was not a drug company thing.
link |
We didn't go to a Caribbean island.
link |
I said, do you have the syllabus?
link |
And she went and got the syllabus and sure enough,
link |
it was sponsored by a drug company.
link |
They're everywhere.
link |
They're everywhere.
link |
And it's back to Kuhn that groups of experts
link |
share unspoken assumptions, and in order to be included
link |
in that group of experts, you have
link |
to share those unspoken assumptions.
link |
And what I'm hoping to do with my book, Sickening,
link |
and being here having this wonderful conversation with you
link |
is to create an alternative to this normal
link |
that people can pursue and practice better medicine
link |
and also prevent burnout.
link |
I mean, about half the doctors complain that they're burned
link |
out and they've had it.
link |
And I think that this is subjective.
link |
I don't have data on this.
link |
This is just my opinion.
link |
But I think that a lot of that burnout
link |
is so called moral injury from practicing in a way
link |
that the docs know isn't working.
link |
It's not actually providing an alternative to the normals,
link |
expanding the normals, shifting the normal,
link |
just like with Kuhn.
link |
You're basically looking to shift
link |
the way medicine is done to the original,
link |
to the intent that it represents the ideal of medicine,
link |
Yeah, in Kuhnian terms, to have a revolution.
link |
And that revolution would be to practice medicine
link |
in a way that will be epidemiologically most
link |
effective, not most profitable for the people
link |
who are providing you with what's called knowledge.
link |
You helped a lot of people, as a doctor, as an educator,
link |
live better lives, live longer.
link |
But you yourself are a mortal being.
link |
Do you think about your own mortality?
link |
Do you think about your death?
link |
Are you afraid of death?
link |
I've faced it, been close.
link |
How do you think about it?
link |
What wisdom do you gain from having come close to death,
link |
the fact that the whole thing ends?
link |
It's very liberating.
link |
I was close, and not too long ago.
link |
And it was a sense of, this may be the way it ends.
link |
And I've done my best.
link |
It's not been perfect.
link |
And if it ends here, it ends here.
link |
The people around me are trying to do their best.
link |
And in fact, I got pulled out of it.
link |
But it didn't look like I was going to get pulled out of it.
link |
Are you ultimately grateful for the ride, even though it ends?
link |
Well, it's a little odd.
link |
If I know you can't take the ride if you know it's going to end well.
link |
It's not the real ride.
link |
But having gone through the whole thing,
link |
I definitely freed me of a sense of anxiety about death.
link |
And it said to me, do your best every day,
link |
because it's going to end sometime.
link |
I apologize for the ridiculously big question.
link |
But what do you think is the meaning of life,
link |
of our human existence?
link |
I think it's to care about something and do your best with it.
link |
Whether it's being a doctor and trying
link |
to make sure that the greatest number of people
link |
get the best health care.
link |
Or it's a gardener who wants to have the most beautiful plants.
link |
Or it's a grandparent who wants to have a good relationship
link |
with their grandchildren.
link |
But whatever it is that gives you a sense of meaning,
link |
as long as it doesn't hurt other people,
link |
to really commit yourself to it.
link |
That commitment, being in that commitment for me
link |
is the meaning of life.
link |
Put your whole heart and soul into the thing.
link |
What is it, the Bukowski poem, go all the way.
link |
John, you're an incredible human being, incredible educator.
link |
Like I said, I recommend people listen to your lectures.
link |
It's so refreshing to see that clarity
link |
of thought and brilliance.
link |
And obviously, your criticism of Big Pharma
link |
or your illumination of the mechanisms of Big Pharma
link |
is really important at this time.
link |
So I really hope people read your book, Sickening,
link |
that's out today, or depending on when this comes out.
link |
Thank you so much for spending your extremely valuable time
link |
Well, Lex, I wanted back to you.
link |
Thanks for engaging in this conversation,
link |
for creating the space to have it,
link |
and creating a listenership that is
link |
interested in understanding serious ideas.
link |
And I really appreciate the conversation.
link |
And I should mention that offline,
link |
you told me you listened to the Gilbert Strang episode.
link |
So for anyone who don't know Gilbert Strang,
link |
another epic human being that you should check out.
link |
If you don't know anything about mathematics
link |
or linear algebra, go look him up.
link |
He's one of the great mathematics educators of all time.
link |
So of all the people you mentioned to me,
link |
I appreciate that you mentioned him,
link |
because he is a rockstar of mathematics.
link |
John, thank you so much for talking to us, it was awesome.
link |
Thanks for listening to this conversation with John Abramson.
link |
To support this podcast,
link |
please check out our sponsors in the description.
link |
And now, let me leave you some words from Marcus Aurelius.
link |
"'Waste no time arguing about what a good man should be.
link |
Thank you for listening and hope to see you next time.