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Joe Rogan Experience #1756 - John Abramson

John Abramson, MD, is a Harvard Medical School Lecturer, national drug litigation expert, and author. His new book, "Sickening: How Big Pharma Broke American Health Care and How We Can Repair It," will be available on February 8.

John AbramsonguestJoe Roganhost
Jun 27, 20242h 29mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 7:20

    Why the U.S. allows prescription drug ads (and what makes them misleading)

    1. JA

      (drumbeats) Joe Rogan podcast, check it out. The Joe Rogan Experience. Train by day, Joe Rogan podcast by night, all day. (instrumental music plays)

    2. JR

      All right, we're, we're on. Hello, John.

    3. JA

      Joe.

    4. JR

      Thanks for doing this, man.

    5. JA

      Blessed to meet you.

    6. JR

      So, uh, this is obviously a subject, um, that, uh, in this current era is, uh, very intriguing and very important for people, um, Big Pharma. And this is, uh, the subject of your book. How, uh, Big Pharma... What, what is the, uh, the, the, the heading? How Big Pharma Broke America? Is that what it is?

    7. JA

      Uh, uh, it's, uh, I actually have a copy

    8. JR

      Broke, broke our healthcare system. a copy of it before. Oh, good, because it's not available. I tried to get it and they, uh, they sent me copies of the audiobook, but it's in these weird wave files and when the, you have to turn your screen off or it shuts off, the sound. All right.

    9. JA

      There you go.

    10. JR

      Sickening. How Big Pharma Broke American Healthcare and How We Can Repair It. Um, so how did they break American healthcare? What happened? How did it, how did we get so deep in? And how is it that we're one of only two countries on earth that allows pharmaceutical companies to advertise?

    11. JA

      Well, let, let's start with that question first.

    12. JR

      Yeah, let's do that.

    13. JA

      Um, so, uh, so it's, uh, the United States and New Zealand allow drug companies to advertise, but New Zealand has very active oversight of its pharmaceutical program. Active oversight of the, uh, evaluation of the efficacy of the drugs and to, whether the pricing of the drugs is reasonable. So, it turns out that even though we in New Zealand allow drug advertising, New Zealand spends the least per person amongst developed countries, and we spend the most by far.

    14. JR

      Hm. So, uh, uh, so is, ha- has there ever been a conversation, like, whether it's, uh, publicly or privately that you know of where they've tried to stop this? Is this one of those things that once it gets into play, once there is a, a, a law that allows pharmaceutical drug companies to sponsor or, or, or to, uh, advertise, are we doomed then? Because then the amount of money that's involved in advertising and when you see those, "Brought to you by Pfizer," those CNN commercials, and when you see the, um, whether it's for allergy medications or antidepressants, the sheer volume of money that's involved, it seems like extracting that from our system would be very difficult to manage. Because they're gonna fight tooth and claw to keep that ad.

    15. JA

      Absolutely. So, uh, as best I understand it, from, from the lawyers who do understand it, in, in our Constitution, the advertising of, uh, prescription drugs is, falls under the free speech, uh, mandate of our Constitution. And some things, uh, you can control the advertising of. Cigarettes and alcohol. There's no, uh, beneficial use of those. Uh, they're not a, um, they can be recreational, but there's no, uh, absolute benefit to them. But with drugs, there is a, an absolute benefit. And they, because of that, they qualify as protected under the, uh, First Amendment. However, that said, uh, the floodgates were opened, and it's clear that the drug companies are gonna spend as much advertising, however many billions of dollars, uh, they want, uh, to make as much money as they can. Uh, but there's nothing that says the drug ads need to be allowed, uh, that we need to allow them to be misleading. So, you never see in a drug ad that you have to treat, uh, 323 people with Trulicity for a year to prevent one cardiovascular event. They don't tell you that. They tell you, "Trulicity for diabetes prevents cardiovascular events in diabetics." But if they said, "You have to treat 323 people to get one better and the other three- 322 aren't gonna have a cardiovascular benefit," then you'd be delivering information that people can use. And if you said that you can't play, uh, violins or have family picnics while you're, uh, reciting all the side effects, then people would listen to the side effects.

    16. JR

      Hm.

    17. JA

      So, I think the key is that the drug companies know how to use the ads very skillful to manipulate people on an emotional level, and we don't have to settle for that. We can have... You wanna advertise drugs? Okay. Let's decide what facts need to be told about this. Is this better than other therapies? Is this better than lifestyle intervention? How much does it cost? How many people do you need to treat in order for one to get better? I think if that information were included in the ads, they'd be much less, uh, the, the, the, the cost benefit of the ads would be reduced or the benefit-cost ratio would be reduced for the drug companies. And then, they wouldn't advertise so much. But right now, they can make these ads that make anything look great and make people want them and make people go to their doctor and ask for them and they make a ton of money.

    18. JR

      Yeah, it just doesn't seem like it should have a place. Uh, like advertising in terms of the way they're advertising, not just showing something in a print form like we, uh, you know, there is a new medication that stops, you know, the damages of high blood pressure or whatever it is. What they're doing is they have these theatrical representations of the most beautiful and wonderful life where people are dancing in wheat fields and, and, and d- delivering picnic food while everybody laughs and cheers. That should be illegal.

    19. JA

      Right.

    20. JR

      I mean, it's manipulation. It's clear, they're clearly fucking with people's heads and they're using psychology. They're, they're not doing it in a way where they're trying to objectively, coldly relate, rely facts and have people see these facts and, and recognize that this has benefit to them. No, what they're doing is they're trying to get people excited about the possibility of living a life like they're seeing. When they're relaying these facts of the, they're doing it with music, they're doing it with joyous dancing and-... it's bullshit. It's, it's really wrong because it's... Y- you're not selling a car. You know, if you, if you wanna do that to sell a car, that doesn't bother me at all. But you're doing something that you... People, uh, who have health problems are really thinking that they're gonna wind up like these people in this video. They're, they're really th- they're... You're manipulating them to the point where you're getting them to bring things up to their doctor, things about antidepressants or anti-anxiety medication, or all kinds of stuff that people could just ask for. And it's just... It seems insane that of all the countries on Earth, there's only two that allow it and, as you're saying, one that allows it pretty much unchecked.

    21. JA

      Right. That's, uh, that's exactly right. And, uh, I'm in total agreement with you, Joe, that... I, I don't think we're gonna get rid of drug ads, but I think we could make the drug ads... We... You could ensure that the drug ads leave people with, uh, an accurate, uh, understanding of what the benefit of the drug is gonna be.

  2. 7:20 – 10:19

    Regulating ad truthfulness vs. banning ads: pragmatic constraints

    1. JR

      But don't you think if you have any ads, they're gonna... There's gonna be room for fuckery? And there's gonna be... I mean, if the... You have any ads that say, "Okay, well, no theatrical representations," they're gonna go, "Whoa. Okay." What about music? Can I have music?

    2. JA

      (laughs)

    3. JR

      Like, what about the way people talk? Like, when the... When they reli-... When they say these, uh, side effects at the end, when they list off the side effects, it's, uh, crazy the way they're talking about death and suicide. "You may have-"

    4. JA

      Right.

    5. JR

      "... suicidal thoughts." Like, oh, like, th- what? Why is it like that?

    6. JA

      Yeah. Right.

    7. JR

      Like...

    8. JA

      And why is the dog wagging its tail?

    9. JR

      Yeah.

    10. JA

      (laughs)

    11. JR

      Why are you, why are you saying this-

    12. JA

      Yeah.

    13. JR

      ... while this lady's dancing?

    14. JA

      Yeah.

    15. JR

      Like, you know, what?

    16. JA

      Yeah. I'm totally with you. I, I just think that it's not gonna happen that we get rid of them. But if we made them tell the truth and if we did studies that looked at the messages that people actually take away from these drug ads and made sure that the messages were accurate, that it would be an improvement.

    17. JR

      So, you're just being pragmatic. You're just saying, realistically, we're so far fucked, we're never gonna remove these ads.

    18. JA

      I, I, I, I don't... Uh, it's worse than that. I think they're so baked into our Constitution, the right to advertise is so baked into our Constitution, that it, it's not gonna happen. But, but I do think that if, um, if you made the ads tell the truth about how the drug compares to other therapeutic approaches, how it compares to taking charge of your lifestyle, what the real cost is, not what your co-pay is, if you made the ads communicate an accurate picture of the role of that drug in therapi- in therapeutics and the price, the relative price, that, that it wouldn't be so bad. I, I agree 100% with you. It makes no sense. Doctors know how to read medical journals and they should be deciding what's good for people.

    19. JR

      Right.

    20. JA

      We don't need the TV ad to tell us that. All that said, it ain't going away. So, I think the energy oughta be to figure out how to deliver a constructive message.

    21. JR

      It seems like... But if you did have a constructive message and it was comprehensive, it would take... It would... You'd need like a half-an-hour infomercial. It wouldn't necessarily fit inside of one-minute advertising if you're talking about the benefit of different lifestyle choices, if you're talking about diet and exercise and how it, uh, affects the way these things interact with the body and, you know, how... what's the actual cost, co-pay, all the, all the... If you have all those factors in, how are you gonna squeeze that into a one-minute ad?

    22. JA

      Well, maybe you can't.

    23. JR

      Yeah.

    24. JA

      But, but maybe it needs to be a two-minute ad. Maybe the law-

    25. JR

      (laughs)

    26. JA

      ... needs to be that you need a two-minute-

    27. JR

      That's... Maybe-

    28. JA

      ... or a five...

    29. JR

      Maybe make it as boring as possible-

    30. JA

      (laughs)

  3. 10:19 – 12:07

    Big Pharma’s job is profit: how incentives distort medical knowledge

    1. JR

      So, I think you and I share one common thought that we're not on one side or the other and that pharmaceutical drug, pharmaceutical drugs have some amazing benefits. And they're, they've been incredible for mankind in so many different ways. The problem is unchecked capitalism, like, unchecked profit, unchecked... Where, where you have so much money that you can influence the way things are regulated, you can influence the way things are promoted by health officials, where you just have full rein with your ability to distort information and to cover up the damaging and detrimental effects of these drugs. And that's where I think we, we agree about pharmaceutical companies, what, what they've done in terms of whether, whether it's lying about studies, lying about the addictive properties of these drugs. It's been absolutely horrific. But as well, some pharmaceutical drugs are amazing.

    2. JA

      Correct.

    3. JR

      Both things are true, right?

    4. JA

      Both things are true. And, uh, I think there are two important points to be made. One is the f-... This may sound impolite, but the primary function of the drug companies is to make money for their investors. And we've gotta get over the illusion that they're... Somehow, their purpose is to serve our health. The purpose is to make money. And in our largely unregulated system, uniquely unregulated healthcare system, uh, pharmaceutical system, uh, amongst developed countries, we allow the drug companies to control the information that flows to doctors and patients. And that's what has to change.

  4. 12:07 – 22:07

    Hidden trial data and the Bextra case: why even DOJ outcomes can stay opaque

    1. JR

      That's what has to change. And, um, the amount of accountability that drug companies have... Uh, so like, you know, we've talked before about Pfizer and that... What was the one drug where they had the largest, uh, settlement ever with the, the largest penalty ever? It was like...

    2. JA

      Pfizer. It was Paxtra-

    3. JR

      Yeah.

    4. JA

      ... an arthritis drug.

    5. JR

      And what did they do? Uh, uh, uh, like, what was their...... what was the, uh, the e- not I wanna say error, but what was the lie? Like, what did th- what did, what were they selling versus what was reality?

    6. JA

      So, I can't tell you. I know, but I can't tell you. I, I spent about 10, 10 years, a little more than 10 years, in litigation as an expert in the national drug cases. And when I served as an e- as an expert, I got to see all the documents. So there would be like 20 million documents in a case. And I could see the science, and if I needed a statistician to do a reanalysis of the primary data, I got that. I got to see how the marketing people strategize to exploit the science to the fullest, uh, to, to create the most, uh, profit. I got to see how they marketed it to doctors, how they wrote the articles in the medical journals. And I did that for f- in the case of Pfizer. Uh, plaintiff's attorneys hired me to analyze the situation. So, I wrote a report and submit- it got submitted to the court. And Pfizer's behavior was, in my opinion, so outrageous that I picked up the phone and called the Department of Justice and said, "I know a lot about this drug, but I can't tell you because I've signed a confidentiality agreement as an expert." So, the Department of Justice and the FBI sent me a subpoena and said, "You must come with your computer and tell us what they did wrong." And I did. Um, and that was the end of it. They keep their cards close to their chest. And six months later, I read in the newspaper that the Department of Justice had found, um, the company had committed f- uh, a felony and, uh, they were dealt the largest fine in, um, US history, the largest criminal fine in US history. So, I know what happened, but I can't tell you.

    7. JR

      You can't tell me because of the confidentiality agreement?

    8. JA

      Yep.

    9. JR

      Wow. And this l- well, we, we can read it, right? We can l- well...

    10. JA

      No.

    11. JR

      No?

    12. JA

      You can read what the Department of Justice ... You can read the Department of Justice press release, and I would encourage anyone who thinks this story is too crazy to be true to just search Department of Justice and Bextra, and they'll see the story that I just told.

    13. JR

      But none of the real data is available as far as like what they lied about and nothing?

    14. JA

      Nope.

    15. JR

      Nope? Wow.

    16. JA

      Nada.

    17. JR

      So, how is that possible? Was it some sort of a deal they had? They were gonna pay the amount of the fine, this enorminate- enormous, exorbitant amount, and in the deal it was that the, the actual details of it would not be divulged?

    18. JA

      That's correct. A- a- and it's even more serious because the drug companies own the data from those clinical trials. It's so serious, Joe. When a drug company sponsors a clinical trial and they do the analyses and they write up a manuscript and they say what happened and they send it to a medical journal and it gets peer reviewed, and doctors are trained that they should read and trust peer-reviewed articles that are well conducted and that- that's how the system works, the peer reviewers and the editors of the medical journals don't get to see the data. They have to take the word of the drug companies that they've presented the data accurately and reasonably completely. And you only get to see it in litigation, you know, five years later when, eh, when it doesn't matter because everyone's formed their opinion.

    19. JR

      That seems insane.

    20. JA

      It's insane. And doctors don't know this. They're taught there's this, uh, paradigm of evidence-based medicine where good doctors practice evidence-based medicine, and that's p- based on the peer-reviewed articles published in medical journals and the, and the clinical practice guidelines. And the doctors don't know that the peer reviewers didn't have access to the data and couldn't perform their independent analyses. And the clinical tri- the experts who write the clinical trials, or the, excuse me, the experts who write the clinical practice guidelines don't have access to the data.

    21. JR

      So, the data is only held by the pharmaceutical companies. They release their analysis of the data?

    22. JA

      Correct.

    23. JR

      And then the peer reviewers do everything based on the analysis of the data that was released by the pharmaceutical companies?

    24. JA

      That's correct.

    25. JR

      That's insane.

    26. JA

      That's insane. And docs don't understand it. They don't understand that they're getting manipulated, that the, that the control of the knowledge has been turned over to the drug companies. And the drug companies they pay for, I think, 86% of the clinical trials. They design them. First, they design w- they decide what they're about, and they're about the things that are gonna make money, obviously. They're not about the things that are gonna make people healthy. They're not prioritized that way.

    27. JR

      Right.

    28. JA

      But, uh, they design the studies. They figure out the doses. They figure out the conditions and exclusions of the people who are in the trials, and they do what they can to exercise their fiduciary responsibility to their shareholders, which is to make this thing come out with data that's gonna sell the drug. And then, after they've done all of that, they own the data.

    29. JR

      How did that ever become the way that system is set up? Like, what, what steps were not put into place to protect people from the kind of fraud that's possible when the pharmaceutical drug companies are the, the ones who are relaying the data and their interpretation of the data to the peer reviewers? Like, how, how is that ever acceptable?

    30. JA

      Yeah. I, I think we drifted into this situation. Um, and what made it so important, so destructive to American healthcare, is that we don't put a limit on what the drug companies can charge.... so that our prescription drugs, our brand name prescription drugs cost three and a half more- three and a half times more than prescription brand name pr- the same brand name prescription drugs in the other OECD countries, Organization of epi- economic cooperation and development. So we have a price that is making this, uh, manipulation of data, some people would say BS. Um, the price drive, it- it creates an enormous incentive. And then we don't have what's called health technology assessments. So we have no governmental or quasi-governmental oversight of, that compares the value of new drugs in terms of the therapeutic value and the economic value to old drugs, to older drugs, older- other available therapies that inform coverage decisions and inform physicians about how best to apply the new therapeutics. Um, and we also don't allow... This one is- is cr- it's just mind-boggling. We don't allow government-funded cost-effectiveness studies, and we don't allow cost-effectiveness studies to be used in government-funded health care. So we've created this situation where the prices are sky-high, where the knowledge is not being overseen, and where the cost-effectiveness is not... The- the government is not allowing cost-effectiveness to get into our dialogue in the way it should be. And we're essentially like playing a- a professional basketball game where the players are calling their own fouls.

  5. 22:07 – 1:30:38

    Vioxx as a case study in fraud, harm at scale, and weak punishment

    1. JA

      the drug companies were influencing what was in the journals. And then the drug... Do you remember the drug Vioxx?

    2. JR

      Yes.

    3. JA

      It was an arthritis drug.

    4. JR

      I have a friend who had a stroke after taking Vioxx.

    5. JA

      Yeah. So it... Yeah. I- I got a letter fr- from a mother whose child died, 14- 17-year-old child died from taking Vioxx, eight samples of Vioxx. Um, but Vioxx came along and there was an article in the New England Journal that Merck had sponsored and it said it was safe and w- uh, was advantageous, not because it was any more effective, but because it reduced the risk of serious GI problems. And then there was another article in the New England Journal of Medicine that fessed up to cardiovascular problems, but the review article said this may be due to the play of chance because there were only 70 events, and such a small number of events is, uh, subject to statistical variation. And I knew that that was crazy because there were only 53 serious GI events, which was the whole reason for selling this $2 billion a year drug, was that it was safer on the GI tract and there were only 53 events.

    6. JR

      It was an anti-inflammatory, right? It was like-

    7. JA

      Mm-hmm. Yeah, exactly.

    8. JR

      So the- the idea was that that was better than non-steroidal anti-inflammatories?

    9. JA

      Exactly. Because it- because it didn't, uh, upset the stomach the same way. And this... The science was elegant and it might have worked, but it didn't. Um, and in changing that balance, it made the blood more likely to form clots.

    10. JR

      Hmm.

    11. JA

      Um, the physiology was a little more complicated than just stomach or no stomach.

    12. JR

      And is something like this, the- the issue is the size of the trial because you could have 10 people and none of them can have a problem, but you could have 10,000 people and you can have quite a few problems. So you have to make this- this study as large as possible so you get all this biological variation between human beings where different things affect different people in different ways?

    13. JA

      That's part of it. And you can have a study of 8,000 people where you leave out three heart attacks and you flip the statistics and claim that there's not a cardiovascular risk.

    14. JR

      Okay, so they just... It was fraud.

    15. JA

      It was fraud. And you couldn't tell the fraud from the article in the New England Journal. They, Merck had submitted this data to the New England Journal and they did what peer reviewers do, which is not have the data, but make sure that the article makes internal sense. They published the article, and then this review article came along.... and they gave a little bit more insight into the cardiovascular problems, but they blew it off as the play of chance because there were only 70 events, and that was crazy. And at that point, I was sitting in my office at lunchtime reading, taking a break between sessions reading this article, and I said, "That's it. I gotta find out what, uh ... I, I gotta figure this out. There's something so wrong going on here that it's beyond my comprehension." So, um, an article was published in JAMA two weeks later that had a footnote that led to FDA, uh, an FDA website that had, um, enough data to see that Merck had been fraudulent about the heart attacks. And when I saw that, I said, "I'm gonna leave practice, and I'm gonna figure this out." And I worked for two years on a book called Overdosed America. It was published in 2004, and it had the Vioxx story in it. And, uh, a week after that book was published, Vioxx was pulled from the market. It wasn't my doing. Another study had co- Merck's, uh, Merck had done a second study that showed the same thing, that the risk of strokes and heart attacks and blood clots was doubled, and at that point, they had to pull it because they were hiding the data on this first study. Now, the second study came along, and it was clear that the jig was up for them.

    16. JR

      And how long had they been prescribing and distributing Vioxx at that point?

    17. JA

      Uh, it came out in May of '99, and that was September of 2004.

    18. JR

      Wow.

    19. JA

      So 25 mil- twen- between 20 and 25 million Americans had taken Vioxx, and between 40 and 60,000 Americans had died, died from the cardiovascular consequences of Vioxx. As, uh, in the same ballpark as the number of Americans who died in Vietnam, died from taking this drug that was no more effective at treating arthritis or aches and pains than non-steroidal anti-inflammatories and caused 40 to 60,000 deaths.

    20. JR

      And what was the punishment for Merck?

    21. JA

      Merck, um, there were 27,000 plaintiffs in the litigation, and they were awarded 4.7 billion. M- Merck sold $12 billion worth of Vioxx in the four and a half years it was on the market. Um, so they paid the plaintiffs 4.7 billion, and the, uh, Department of Justice fined them a little bit under a billion dollars, but nobody went to jail.

    22. JR

      Well, not only that, they're still making profit. That's a profit.

    23. JA

      The, they, Merck, uh, excuse me, um, Vioxx, they probably made a small profit. They probab- they took in 12 billion. They had research and development costs, um, and marketing costs and all, manufacturing costs.

    24. JR

      So a small profit of what, a billion dollars?

    25. JA

      Maybe they made a billion.

    26. JR

      Isn't that wild? Like, you can make a billion dollars from lying-

    27. JA

      Joe, it's cr-

    28. JR

      ... even after being punished.

    29. JA

      It's crazy. And the, M- Merck's chief scientist saw the data from that first study where the three heart attacks were omitted, and there's a, there's a, um, an email that the Wall Street Journal published, uh, from March 9th, 2000 when they opened up the data on that. And the email, I'm paraphrasing, but the email said something like, "It's a shame, but the cardiovascular effect is there, but the drug will do well, and we will do well."

    30. JR

      Oh, God. And that's written down?

  6. 34:09 – 39:04

    Neurontin and off-label marketing: ‘rejiggering’ trial outcomes to sell efficacy

    1. JA

      Kaiser Health Plan, the biggest HMO, sued Pfizer for fraudulently marketing Neurontin when Neurontin, gabapentin, uh, was still on patent.

    2. JR

      And what is, uh, Neurontin?

    3. JA

      Neurontin had been approved for two uses. One was as a second-line seizure drug, and one was for, uh, post-ho- uh, her- herpes zoster pain. Those were the two indications for which Neurontin was approved. And let me preface this by saying Neurontin is still the sixth most... Or gabapentin is still the sixth most frequently prescribed drug in the United States.

    4. JR

      Hmm.

    5. JA

      So, a, a lot of insurance companies sued Pfizer for misrepresenting and marketing, uh, Neurontin for off-label use, for general pain mostly, some migraines, some bipolar disorder. But there were... The... But Kaiser was the only plaintiff that the judge who was overseeing this litigation allowed because Kaiser is... Creates like a bottleneck through which information comes to doctors. So in the other insurers where doctors are getting information from all over the place, the attorneys couldn't prove that Pfizer's marketing had misled the doctors. But they had the opportunity to prove that it had misled the doctors in the Kaiser health system to prescribe this drug. The short of it is that there was a six-week trial, I, uh, testified in it and would love to talk about that, but that Pfizer... The jury found that Pfizer had committed fraud and racketeering. It was the first RICO charge against a drug company. It's in civil litigation, so they're not going to RICO jail. The, the, the damages were tripled. But when the jury heard the story, and I got to explain it to them. I got to explain it to them sitting... Uh, standing at an easel next to the jury box as close as I am to you and explained one of the tricks that Pfizer used to mislead doctors. So occasionally it comes out, but, uh, again, nobody went to jail. They were-

    6. JR

      What, uh, what was the trick that Pfizer used to mislead doctors?

    7. JA

      So what they did, um... This actually is something that I wanted to talk to you about because it has to do with the... With how you feel about hydroxychloroquine not being approved or not being embraced as a... As a therapy for, um, for COVID. What F- what Pfizer did to mislead doctors was they did... There was a randomized controlled trial and it was Neurontin against placebo for the treatment of diabetic painful neuropathy.... and the guy who did the trial faxed them the results and said, "It doesn't look like Neurontin works." And Pfizer rejiggered the results, so they... instead of looking at the comparison between the change in pain level between Neurontin and the placebo group, which wasn't significant, they just looked at the pain level of the people who took the Neurontin, and the pain level went down from the beginning of the study to the end. But it went down in the placebo group almost as much. But when they just showed the Neurontin arm of the randomized control trial, which is no longer a randomized control trial, they misled doctors and-

    8. JR

      Hmm.

    9. JA

      ... claimed that it was effective. So, in hydroxychloroquine for COVID, to change the subject a little bit, people get better, and that's good when people get better. But we don't... it's like one arm of a randomized control trial, and there's... I firmly believe that people who want to take hydroxychloroquine, if they get COVID, should be allowed to take it, and they should talk to their doctor, and there should not be this propaganda against it.

    10. JR

      Y- I, um... my issue was with ivermectin.

    11. JA

      Oh, I'm sorry.

    12. JR

      Yeah.

    13. JA

      I, I apologize.

    14. JR

      But, uh, no. I'm... something, not-

    15. JA

      S- similar issue.

    16. JR

      Is it... uh, is it similar?

    17. JA

      Yeah, similar issue. So people are gonna get better, and whether there's a causal relationship or not is the question.

    18. JR

      Right.

    19. JA

      So if you do... if, if you take, um, 20 people and put them on Ivermectin and 19 of them get better, you can't conclude that the Ivermectin played a causal relationship. I think you can surmise that the Ivermectin didn't hurt them if they get better. And on the situation that you've talked about... I... is it okay to talk about this?

    20. JR

      Sure, yeah.

    21. JA

      Yeah. On the situation, the situation you've talked about where you were derided for taking Ivermectin, I think that's out of bounds. That, that's not fair.

  7. 39:04 – 58:28

    COVID therapeutics controversy: ivermectin, monoclonals, and what ‘not enough data’ means

    1. JR

      Well, the issue that r- was really bizarre was that I listed a laundry list of things that I took, and they only focused on Ivermectin. I talked about all sorts of things that are, like, generally accepted to be effective, like, uh, monoclonal antibodies, which, um, I'm now hearing... now, I need to find out if this is true, but someone posted that, um... here, I'll try to find it, because, uh, it was so weird that I, I couldn't believe it was true, but that someone in the Biden administration, that they're trying to actively block the distribution of monoclonal antibodies, and that someone from Florida is, uh, accusing that, accusing the Biden administration of doing that, which to me sounds insane.

    2. JA

      Well, we- we've got a, um-

    3. JR

      Here. The Florida surgeon general says the Biden administration is actively go- preventing monoclonal antibody treatments, but they're saying that they're not effective with Omicron, but they're very effective with Delta, and a lot of people still have Delta. It's not like Delta went away, but they're blocking the use of monoclonal antibodies. The suspicion is that the re-... Florida surgeon general sends terse letter to Health and Human Services concerning monoclonal antibodies. Dr. Joseph Ladapo says that state facing life-threatening shortage of treatment options. The, uh, the idea is... the primary concern, is the reason why they're doing this is to encourage vaccination only, as, uh, uh... the only way to treat COVID is to get vaccinated. If you don't get vaccinated, you have no other options. If you do get COVID and you take monoclonal antibodies, they're extremely effective. What was bizarre to me was that y-... th- I listed off Z-Pak, uh, prednisone, monoclonal antibodies, uh, I talked about I- vitamin IV drips that I took. All these different things that I took, and I got better really quickly, but they focused only on Ivermectin.

    4. JA

      Yup.

    5. JR

      And it became this thing that seemed to be a concentrated effort to demonize and, um, and mock this one type of treatment by connecting it to veterinary medicine.

    6. JA

      Yes. I'm, I'm completely with you, and-

    7. JR

      It was bizarre.

    8. JA

      Yeah. The, the tr-

    9. JR

      And motivated clearly, also... you've got to think it had to be motivated by money, because that drug, Ivermectin, is a generic drug. It's very cheap. You can get it for, like, 30 cents a dose.

    10. JA

      Yeah. Yeah. Yup. Uh, uh, um, I can't deny that money played a role. I think that the, um, control over the situation, wanting to be in control over the situation also plays a role. So the truth is that the NIH has not ruled one way or the other. They looked at the data and they said there's not enough... there's not enough data to rule on whether Ivermectin's helpful or not. If it were a brand name drug, at this point, the drug company would do a study that was big enough to show that it's helpful or not, and the question would be over, but-

    11. JR

      And they are doing that with, uh... Pfizer has a new antiviral drug, uh, they're gonna release that sim- uh, similar to what people say Ivermectin does.

    12. JA

      Mm-hmm.

    13. JR

      Whether that does or not, I don't know.

    14. JA

      Yeah. But that's, uh, getting back to our original discussion. When there's money involved, you can do the studies, and you can make them big enough to make small differences statistically significant.

    15. JR

      And you do that by manipulation, and occasionally, you go to court. (laughs)

    16. JA

      (laughs) Uh, you, you do that by... uh, 96% of the research that's done in the United States, clinical research, is about drugs and devices, and most of that is paid for by the manufacturers.

    17. JR

      Drugs and devices?

    18. JA

      Medical devices.

    19. JR

      Okay.

    20. JA

      Artificial hips and pacemakers-

    21. JR

      Mm-hmm.

    22. JA

      ... and the like. Um, but the, the point that I'm making is that it, it's like the drunk looking for his keys under the, under the streetlight and he keeps looking, looking, looking, and someone comes along and says, "Why do you keep looking there?" And then he says, "That's 'cause it's... that's where the light is."

    23. JR

      Hmm.

    24. JA

      You know, the keys aren't there, but that's where the light is. That's where the money is.... the, the money is in new therapeutics, so-called innovation. New therapeutics. It's not in looking about which drugs make you healthier.

    25. JR

      Right. It's not in generic, repurposed medicine.

    26. JA

      No. Nobody's funding that.

    27. JR

      Right.

    28. JA

      So, you're not getting an answer to the question that you have a right to have an answer to.

    29. JR

      Well, it's strange to me that monoclonal antibodies do have an emergency use authorization. The, the emergency use authorization, it, it seems to be that, for whatever reason, that drug, these monoclonal antibodies, is being dismissed. It's make, it makes it more difficult to get. There, f- whatever shenanigans are going on, it seems to be there's, there's some sort of conspiring against the distribution of monoclonal antibodies. And I, I think it's gotta be because of its effectiveness.

    30. JA

      Uh, uh, it may be because we can't test fast enough to make a decision, and it, um, it, it, it exposes our deficiency on the testing side.

  8. 58:28 – 1:23:43

    America’s poor health outcomes and massive overspending: the bigger scoreboard

    1. JA

      There's a lot of noise. And, and a lot of the noise is distracting us from the real issues. We, we got real trouble in the United States. For the past two years, about 1,300 people a day have died of COVID. That's bad. Uh, we can talk about things we could do or should do, whatever. That's bad. For the four years before the COVID pandemic, that many people were dying in the United States because our health and healthcare are so inferior to the other wealthy countries. Thirteen hundred people a day dying because our, our, our age-adjusted mortality rate, which allows you to compare different countries of different ages, is so much worse than the average of 10 wealthy countries. And in order to... Uh, uh, uh, and our healthy life expectancy has gone down from 38th in the country... in the world in 2000 to 68th in the world in s-... 2019. We rank 68th in the world in healthy life expectancy. Our health, the health of Americans is just abominable compared to the other wealthy countries. And for this, for this health, uh, you know, devastating health situation, we're spending an extra $1.5 trillion a year. We're spending 7% more of our GDP on healthcare than the other wealthy countries are. And 7% times a GDP of $22 trillion is a h-... $1.5 trillion a year. So, whatever you think of President Biden's Build Back Better plan, and, and... I'm not getting into politics here, but it's $1.5 trillion, $1.7 trillion that... over 10 years that he's arguing for, and this is 10 times that much money that we're pissing away each year while Americans health rank 68th in the world. This is a disaster. It's ruining our country. We can't go on like this.

    2. JR

      Now, what is the best country when it, uh, comes to healthcare?

    3. JA

      Um, France is good. It, uh... The best changes a little bit. But, uh, there's France. The UK is good. Um, Japan does well. Switzerland does well.

    4. JR

      And what do they do different than what we do, other than, uh, the... some of them have socialized medicine?

    5. JA

      (clears throat) Well, l- l- m- let's take that apart a little bit.

    6. JR

      Okay.

    7. JA

      But what they do differently is what I'm writing about in, in Sickening.What they do is they oversee the integrity of the medical knowledge that reaches doctors. They can't control the journals, they can't control that problem with peer reviewers not having the data, but they can do, uh, governmental or quasi-governmental, it's called health technology assessment, where they determine the medical value of new drugs and the e- economic value of new drugs and make recommendations about covering new drugs. Um, and they also control the price of drugs because w- with our allowing drugs to be three and a half... brand name drugs to be three and a half times more expensive, uh, than in the other, uh, developed countries, we're creating such an incentive to distort the medical knowledge. So we've got a Wild West situation where the drug companies pay PR people and the lobbyists to create this illusion that their innovation is our only hope for a long and healthy life when that's rarely true. One out of, um... in terms of new drugs, new molecular entities that are approved, about one out of four is actually an improvement over a previous drug. But in the United States, we don't know that because there's no oversight. In the other countries, they're evaluating it. So when, for example, insulin analogs come along and replace human recombinant insulin and they start to jack up the price and there's no evidence that it's better for type two diabetics who use 80% of the insulin in the United States, there's no evidence that it's better, doctors are bombarded with marketing materials that say, "You gotta give your type two diabetics insulin analogs because it's more physiologic and it reproduces, uh, natural insulin function." And in the other countries that have health technology assessment, they're saying there's no evidence that it's superior to recombinant human insulin, so use that first. If your patient fails on recombinant hum- human insulin, if they have idiosyncratic problems with low blood sugar or anything else, you can use it as a second-line drug, but not a first-line drug. But we're essentially playing this game without... it's like professional athletes not having umpires.

    8. JR

      Now, when you said... y- you said 68th, United States ranked 68th?

    9. JA

      Sixty-eighth.

    10. JR

      And that is for overall health?

    11. JA

      Yeah, yeah, healthy life expectancy is probably the best single, uh, measure of the overall health. It's how many years you live in good health. So if you live to be 86 and you had kidney disease for the last six years that compromised the quality of your life for 50%, then your healthy life expectancy would be 83. So it integrates longevity with, uh, the time you spend in good health.

    12. JR

      And do they calculate the factors involved in that? Like how- how many... how much of the factors is... how many of the factors are calculated? Is it obesity? Is it, uh, drugs, like recreational drugs, nicotine, alcohol? Like what- what are the factors that lead us to be so poorly represented there?

    13. JA

      Right. So, um, one of the issues that I'm sure you've heard of is the diseases of despair that, um, uh, Professors Deaton and Case... Professor Angus Deaton is a Nobel Prize winner, and his wife is a professor at Princeton as well, they wrote a book about diseases of despair and how non-college-educated, non-college-educated white Americans are having, um, an epidemic of drug overdoses and suicides and liver disease. Um, and it... that it has to do with the economic context that, um, that the, um, wages and quality of life are not as high, that people's expectations about how their lives are going to unfold and having families and living independently and owning a house have gone down. And that all that adds up to these diseases of despair causing, uh, 100 deaths out of 100,000 white Americans, and they chose ages between 50 and 54, but you could take any age group. (clears throat) But the important fact here, that's true and that's awful, but the increased death rate in that group is not 100 per 100,000, but 400 per 100,000, and the other 300 deaths have to do with cardiovascular disease and diabetes and all the things they die of. But those folks are exposed to the social pressures that are compromising their health. This is a long answer to your short question.

    14. JR

      No worries.

    15. JA

      Um, but, um, so my opinion, um, what I tell you as a medical fact, I stand by. My opinion on this is that since 1980, the United States has had a radical growth in economic inequality. That, um, essentially, the share of the, um, income pie has been so distorted to the wealthy that it's like the average family living at the median income level of $55,000 with 2.6 people in their household, i- if they were getting the same share of the income pie that they got in 1980 as they are now, they would have $20,000 more a year. But as it stands now, that $20,000 is transferred from people who are working hard and trying to keep their kids in clothes and pay their bills to the top 1%. So it's like the working people in America are donating $20,000 per family to the top 1%, and that's having a disastrous effect.

    16. JR

      How... Y- This is kind of an interesting, uh, d- side track, right? Because now we're talking about economics, but, uh, d- is there a way that that could be switched? Is there a way that that could be somehow or another rediverted?

    17. JA

      Absolutely.

    18. JR

      What would, what would that-

    19. JA

      A-

    20. JR

      ... way be?

    21. JA

      Absolutely. Um, if the economy is such that companies on their own are suppressing the wages of working people and they wel- uh, and transferring that money to the wealthy people, you simply do it with tax policy. If you can't do it pre-tax, you can do it with tax policy.

    22. JR

      And how would you do that? You would give them a tax break, or you would tax the rich more? What would you do?

    23. JA

      You'd pull some of that money back. And you could do it with tax credits. You could do it with tax rates. You could do it with, um, inheritance taxes. Uh-

    24. JR

      The, the problem people have with taxes, whether this is, uh, accurate or not, is that no one trusts the government to do well with that money. No one trusts the, the bureaucracy and the, the, the nonsense and red tape that's involved in our over-bloated government to the point where they're like, "Yeah, I'd be more than happy to give them extra money, because I know they're gonna do with it very good things."

    25. JA

      I agree. And what we got, we got because we don't trust the government. And how we get to some middle ground on this, uh, I hope you're smart enough to figure it out, 'cause I'm not.

    26. JR

      No.

    27. JA

      But-

    28. JR

      Definitely not.

    29. JA

      But, but we've got to get to a middle ground. The working people in the United States are getting a raw deal. S-

    30. JR

      So do we achieve, like, some sort of a, a, a better state with unions? Is it-

  9. 1:23:43 – 1:51:28

    Repair agenda: coalitions, cost-effectiveness, and treating lifestyle as the main lever (80%)

    1. JA

      How we can repair it is by the constituencies that are affected becoming knowledgeable and politically active. If the consumers who wanna be healthy, and instead of putting their hope in Aduhelm to, uh, reverse Alzheimer's disease when there's no evidence that it does that, um, if the consumers would understand that 80% of their health comes from how they live their lives and-

    2. JR

      80%?

    3. JA

      80%. 80%. And now some of that has to do with social context that, uh, people who are disa- live in disadvantaged circumstances can't just turn around. They can't just decide to go jogging, uh, five times a week. So it has, it also has to do with inequality. Um, we've got to address that. But consumers say, "Look, we're not getting a fair deal. We're paying a fortune for our healthcare. Our wages aren't going up because so much money's going to healthcare. And our out-of-pocket costs are out of sight. Um, we're not gonna take it anymore." And that doesn't mean settling for a government program that says the co-pay for insulin will all be $35, because that's just shifting. That's just having the government pick up the money. Um, that doesn't help to contain the costs. It makes it better for somebody who needs insulin, uh, but it doesn't help to contain the costs or rationalize the use of insulin, insulin analogs and human recombinant insulin. So the consumers need to represent their interests, and their interests are to live the longest, healthiest lives they can. It's not to get the most expensive medicines. It's not to invest so much money in, you know, medical innovation that we can't invest in social services. It's to live the longest, healthiest lives that we can. Business, fair business people who wanna run an honest business, pay their employees a decent wage and make a, make uh, uh, uh, an honorable product, um, they're getting ripped off.... and they need to get into this as, as, as some kind of buyer's trust to, uh, control the price of the new drugs. Say, "We're not just... We're, we're big enough now so we're just, we're just not gonna buy your new drug at that price."

    4. JR

      So how are, how are drug prices regulated currently? Like, say if, if, uh, Pfizer comes out with this new medication that's an antiviral medication for COVID, how do they decide how much each pill costs?

    5. JA

      Right. So the way they decide that (clears throat) is they get together and they decide how can they maximize the amount of money they make. And that's a price, the equation is price times volume. If, if you charge, you know, um, a billion dollars per pill, you're not gonna sell many and you're not gonna make much money. But they will price their drug to determine how much money they're gonna make, to, to maximize the money they're gonna make.

    6. JR

      And so, they have to realize that if you make it too expensive, everyone can afford it, so you have to make it just expensive enough so that they can maximize their profit and the most amount of people can afford it?

    7. JA

      No, that's too kind. Because it's not a, a real market like that, because most of the drug is paid for by insurance. So people, um, it's not Adam Smith's economy where you go and, uh, buy the bread or the beer, uh, from the one who's selling it, quality products for a fair price. Um, the consumer is only worried about the co-pay, or most consumers are only worried about the co-pay. So what you do is you get a, a, a pharmaceutical benefits manager, a middleman, and you say to them, um, "We'll give you a rebate," which really means kickback, "We'll give you a sizeable rebate if you place this drug that doesn't have therapeutic advantage over less effective drugs higher in the formulary so it has a lower co-pay. We'll give you, the PBM manager, a rebate." So it's this whole other level of chicanery that's going on. So, um, so the drug company is thinking about how are they gonna get their drug? It, it, i- i- it's not, "How do we price this so consumers can afford it so we sell a high volume?" It's, "How do we get this drug marketed to PBMs, pharmaceutical benefits managers, so that they'll let us give them a rebate and have an advanta- advantageous tiering?" The, the thing that's missing in this equation is nobody's saying, "Wait a minute. There's a ceiling on this. This drug is not worth this." So that the end result is that between two thirds and three quarters of global pharmaceutical profits come from the United States.

    8. JR

      Wow.

    9. JA

      Two thirds to three quarters.

    10. JR

      (laughs) Wow.

    11. JA

      (clears throat)

    12. JR

      Oh my God.

    13. JA

      And, and, (clears throat) and...

    14. JR

      That's crazy.

    15. JA

      It's crazy and it gets crazier because when the Democrats passed, uh, it was H.R.3, and the Democrats in the House passed the, uh, drug Medicare negotiation bill in 2019, that they would, uh, negotiate the price of 25 to 50, uh, of the most revenue-consuming drugs. Uh, and the, um, CBO said that that would cost $456 billion in pharmaceutical profits over the next 10 years. And the pharmaceutical company (clears throat) went into this spasm of saying that this is gonna be a nuclear winter for drug innovation and you're not gonna get the drugs that you need to be healthy. Meanwhile, the drug companies instead of 456 billion in 10 years had just spent 577 billion in cash buying back their own stock to jack up those stock prices between 2016 and 2020. So they're out there saying, "If you don't, if you control our drug prices, you won't have any more innovative drugs," and they're buying back their stock. And since 2020, they have another $500 billion in cash that they're gonna use to buy, uh, startup companies and inflate the price of the new drugs that are coming online.

    16. JR

      There's so many layers of fuckery that you have to pay attention to with all this stuff.

    17. JA

      There is. I've, I've laid it out.

    18. JR

      (laughs)

    19. JA

      You wanna know how much fuckery there is? I know how much fuckery there is and it's in that book. And you need, you don't need to know all these facts, 577 billion and 456 billion, you don't need to know those. But what you do need to know is that the drug company is in the business of making money. And they do it very well, and they will continue to do it ever better, until they're stopped. And we might as well stop them sooner rather than later. And we need the drug companies. We need them to commercialize medical science. I'm not for socializing this.

Episode duration: 2:29:34

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