Lex Fridman PodcastJohn Abramson: Big Pharma | Lex Fridman Podcast #263
EVERY SPOKEN WORD
150 min read · 30,008 words- 0:00 – 7:52
Introduction
- JAJohn Abramson
The jury found Pfizer guilty of fraud and racketeering violations.
- LFLex Fridman
How does Big Pharma affect your mind?
- JAJohn Abramson
Everyone's allowed their own opinion. I don't think everyone's allowed their own scientific facts.
- LFLex Fridman
Does Pfizer play by the rules?
- JAJohn Abramson
Pfizer isn't battling the FDA. Pfizer has joined the FDA.
- LFLex Fridman
The following is a conversation with John Abramson, faculty at Harvard Medical School, a family physician for over two decades, and author of the new book, Sickening, about how Big Pharma broke American healthcare, and how we can fix it. This conversation with John Abramson is a critical exploration of the pharmaceutical industry. I wanted to talk to John in order to provide a countervailing perspective to the one expressed in my podcast episode with the CEO of Pfizer, Albert Bourla. And here, please allow me to say a few additional words about this episode with the Pfizer CEO, and in general about why I do these conversations and how I approach them. If this is not interesting to you, please skip ahead. What do I hope to do with this podcast? I want to understand human nature, the best and the worst of it. I want to understand how power, money and fame changes people. I want to understand why atrocities are committed by crowds that believe they're doing good. All this ultimately because I want to understand how we can build a better world together, to find hope for the future, and to rediscover each time through the exploration of ideas just how beautiful this life is, this, our human civilization, in all of its full complexity, the forces of good and evil, of war and peace, of hate and love. I don't think I can do this with a heart and mind that is not open, fragile, and willing to empathize with all human beings, even those in the darkest corners of our world. To attack is easy. To understand is hard. And I choose the hard path. I have learned over the past few months that this path involves me getting more and more attacked from all sides. I will get attacked when I host people like Jay Bhattacharya or Francis Collins, Jamie Metzl or Vincent Racaniello, when I stand for my friend, Joe Rogan, when I host tech leaders like Mark Zuckerberg, Elon Musk, and others, when I eventually talk to Vladimir Putin, Barack Obama, and other figures that have turned the tides of history. I have and I will get called stupid, naive, weak, and I will take these words with respect, humility, and love, and I will get better. I will listen, think, learn, and improve. One thing I can promise is there's no amount of money or fame that can buy my opinion or make me go against my principles. There's no amount of pressure that can break my integrity. There's nothing in this world I need that I don't already have. Life itself is the fundamental gift. Everything else is just a bonus. That is freedom. That is happiness. If I die today, I will die a happy man. Now, a few comments about my approach and lessons learned from the Albert Bourla conversation. The goal was to reveal as much as I could about the human being before me, and to give him the opportunity to contemplate in long form the complexities of his role, including the tension between making money and helping people, the corruption that so often permeates human institutions, the crafting of narratives through advertisements, and so on. I only had one hour, and so this wasn't the time to address these issues deeply, but to show if Albert struggled with them in the privacy of his own mind, and if he would let down the veil of political speak for a time to let me connect with a man who decades ago chose to become a veterinarian, who wanted to help lessen the amount of suffering in the world. I had no pressure placed on me. There were no rules. The questions I was asking were all mine and not seen by Pfizer folks. I had no care whether I ever talked to another CEO again. None of this was part of the calculation in my limited brain computer. I didn't want to grill him the way politicians grill CEOs in Congress. I thought that this approach is easy, self-serving, dehumanizing, and it reveals nothing. I wanted to reveal the genuine intellectual struggle, vision, and motivation of a human being. And if that fails, I trusted the listener to draw their own conclusion and insights from the result, whether it's the words spoken or the words left unspoken, or simply the silence. And that's just it. I fundamentally trust the intelligence of the listener. You. In fact, if I criticize the person too hard or celebrate the person too much, I feel I fail to give the listener a picture of the human being that is uncontaminated by my opinion or the opinion of the crowd. I trust that you have the fortitude and the courage to use your own mind, to empathize, and to think. Two practical lessons I took away. First, I will more strongly push for longer conversations of three, four, or more hours versus just one hour. 60 minutes is too short for the guest to relax and to think slowly and deeply, and for me to ask many follow-up questions or follow interesting tangents. Ultimately, I think it's in the interest of everyone, including the guest, that we talk in true long form for many hours.Second, these conversations with leaders can be aided by further conversations with people who wrote books about those leaders or their industries, those that can steel man each perspective and attempt to give an objective analysis. I think of Teddy Roosevelt's speech about the man in the arena. I want to talk to both the men and women in the arena and the critics and the supporters in the stands. For the former, I lean toward wanting to understand one human being's struggle with the ideas. For the latter, I lean towards understanding the ideas themselves. That's why I wanted to have this conversation with John Abramson, who is an outspoken critic of the pharmaceutical industry. I hope it helps add context and depth to the conversation I had with the Pfizer CEO. In the end, I may do worse than I could have or should have. Always, I will listen to the criticisms without ego, and I promise I will work hard to improve. But let me say finally that cynicism is easy. Optimism, true optimism is hard. It is the belief that we can and we will build a better world, and that we can only do it together. This is the fight worth fighting. So here we go, once more into the breach, dear friends. I love you all. This is the Lex Fridman Podcast. To support it, please check out our sponsors in the description. And now here's my conversation with John Abramson.
- 7:52 – 16:54
Biggest problem with big pharma
- LFLex Fridman
You're faculty at Harvard Medical School. You're a family physician for over two decades, rated one of the best family physicians in Massachusetts. You wrote the book Overdosed America and the new book coming out now called Sickening about how big pharma broke American healthcare, including science and research, and how we can fix it. First question, what is the biggest problem with big pharma that, if fixed, would be the most impactful? So if you can snap your fingers and fix one thing, what would be the most impactful, you think?
- JAJohn Abramson
The biggest problem is the way they determine the content, the accuracy, and the completeness of what doctors believe to be the full range of knowledge that they need to best take care of their patients. So that with the knowledge having been taken over by the commercial interests, primarily the pharmaceutical industry, the purpose of that knowledge is to maximize the profits that get returned to investors and shareholders, and not to optimize the health of the American people. So rebalancing that equation would be the most important thing to do to get our healthcare back aimed in the right direction.
- LFLex Fridman
Okay, so there's a tension between helping people and making money. So if we look at particularly the task of helping people in medicine, in healthcare, is it possible, if money is the primary sort of, uh, mechanism by which you achieve that as a motivator, is it possible to get that right?
- JAJohn Abramson
I think it is, Lex, but I think it is not possible without guardrails that maintain the integrity and the balance of the knowledge.
- LFLex Fridman
Hmm.
- JAJohn Abramson
Without those guardrails, it's like trying to play a professional basketball game without referees and having players call their own fouls. But the players are paid to win, and you can't count on them to call their own fouls, so we have referees who are in charge. We don't have those referees in American healthcare. That's the biggest, um, way that American healthcare is distinguished from healthcare in other wealthy nations.
- LFLex Fridman
So, okay, so you mentioned Milton Friedman, and you mentioned his book called Capitalism and Freedom. He writes that there are only three legitimate functions of government, to preserve law and order, to enforce private contracts, and to ensure that private markets work. You said that, uh, that was a radical idea at the time, but we're failing on all three. How are we failing? And- and, uh, also maybe the bigger picture is what are the strengths and weaknesses of capitalism when it comes to medicine and healthcare?
- JAJohn Abramson
Can we separate those out 'cause those are two huge questions?
- LFLex Fridman
Sure.
- JAJohn Abramson
So how we're failing on all three, and these are the minimal functions that our guru of free market capitalism said the government should perform, so this is the absolute baseline. On preserving law and order, the drug companies routinely violate the law in terms of their marketing and, uh, in terms of their presentation of the results of their trials. I know this because I was an expert in litigation for about 10 years. Um, I presented some of what I learned in civil liga- litigation to the FBI and the Department of Justice, and that case led to the biggest criminal fine in US history as of 2009. And I testified in a, uh, federal trial in 2010, and, uh, the jury found Pfizer guilty of fraud and racketeering violations. In terms of violating the law, it's a routine occurrence. The drug companies have paid $38 billion worth of fines from, I think, 1991 to 2017.Um, it's never been enough to stop the, uh, misrepresentation of their data. Um, and rarely are the fines greater than the profits that were made. Uh, see, uh, executives have not gone to jail for misrepresenting data that have involved even tens of thousands of deaths, in the case of Vioxx. OxyContin as well. And when companies plead guilty to felonies, which is not an unusual occurrence, the government usually allows the companies, the parent companies to allow subsidiaries to take the plea so that they are not one step closer to getting disbarred from Medicare, not being able to participate in Medicare. Um, so in that sense, there is (clears throat) a mechanism that is appearing to impose law and order on drug company behavior, but it's clearly not enough. It's not working.
- LFLex Fridman
Can you actually speak to human nature here? Are people corrupt? Are people malevolent? Are people ignorant that, uh, work at the low level and- and at the high level at Pfizer, for example, at big pharma companies? How is this possible? So I believe, just on a small tangent, that most people are good. And I actually believe if you join big pharma, so a company like Pfizer, your life trajectory often involves dreaming, and wanting, and enjoying helping people.
- JAJohn Abramson
Yes.
- LFLex Fridman
And so... And then we look at the outcomes that you're describing, and, uh, it looks... And that's why the narrative takes hold that, like, Pfizer CEO, Albert Bourla, who I talked to, is malevolent. The sense is, like, these- these companies are evil. So if the- the different parts, the people are good, and they want to do good, how are we getting these outcomes?
- JAJohn Abramson
Yeah. I think it has to do with the cultural milieu that this is unfolding in. And we need to look at sociology, uh, to understand this, that when the cultural milieu is set up to maximize the returns on investment for shareholders a- and other venture capitalists, and hedge funds, and so forth, when that defines the culture, and the higher up you are in the corporation, the more you're in on the game of, uh, getting rewarded for maximizing the profits of the investors. That's the culture they live in. And it becomes normative behavior to do things with science that look normal in that environment, and our shared values within that environment by good people whose self-evaluation becomes modified by the goals that are shared by the people around them. Um, and within that milieu, you have one set of standards, and then the rest of good American people have the expectation that the drug companies are trying to make money, but that they're playing by rules that aren't part of the insider milieu.
- LFLex Fridman
That's fascinating. The- the game they're playing modifies the culture, you know, of inside the meetings, inside the rooms, day-to-day, that there's a bubble that forms. Like, we're all in bubbles of different sizes.
- JAJohn Abramson
Right.
- LFLex Fridman
And that bubble allows you to drift in terms of what you see as, um, ethical and unethical. Because you see the game as just, you know, as just part of the game. So marketing is just part of the game.
- JAJohn Abramson
Right, and-
- LFLex Fridman
Uh, paying the fines is just part of the game-
- JAJohn Abramson
Just part of the game.
- LFLex Fridman
...of science.
- JAJohn Abramson
Yep. Yep. And without guardrails, it becomes even more part of the game. You keep moving in that direction, if you're not bumping up against guardrails. And I think that's how we've gotten to the extreme situation we're in now.
- LFLex Fridman
So
- 16:54 – 36:45
Advertising
- LFLex Fridman
like I mentioned, I spoke with Pfizer CEO, Albert Bourla, and I'd like to, uh, raise with you some of the concerns I raised with him. So one, you already mentioned, I raised the concern that Pfizer's engaged in aggressive advertising camp- campaigns. As you can imagine, he said no. What do you think?
- JAJohn Abramson
I think you're both right. Um, I think that the... I agree with you that the aggressive advertising campaigns, uh, do not add value to society. And I agree with him that they're, for the most part, legal, and it's the way the game is played.
- LFLex Fridman
Right, so... Sorry to interrupt, but oftentimes, his responses are, um... Especially now, he's been CEO for only, like, two years, three years, h- he says, "Pfizer was a different company. We've made mistakes," right, "in the past. We don't make mistakes anymore." That "There's rules, and we play by the rules." So, like, uh, with every concern raised, "There's very, very strict rules," as he says. In fact, he says, "Sometimes way too strict, and we play by them." And so in that sense, advertisement, it doesn't seem like it's too aggressive because it's playing by the rules.And relative to the other, again, it's the game, relative to the other companies, it's actually not that aggressive. Re- relative to the other big pharma companies.
- JAJohn Abramson
Yes, yes. I, I hope we can quickly get back to whether or not they're playing by the rules, but-
- LFLex Fridman
Yes.
- JAJohn Abramson
... uh, in general. But let's just look at the question of advertising specifically. I think that's a good example of what it looks like from within that culture and from outside that culture. Um, he's saying that we follow the law on our advertising. We state the side effects and we state the FDA approved indications, and we, we do what the law says we have to do for advertising. And I have not, I've not been an expert in litigation for a few years, and I don't know what's going on currently, but let's take him at his word. It could be true, it might not be, but it could be. But if that's true, in his world, in his culture, that's ethical business behavior. From a common sense person's point of view, a drug company paying highly skilled media folks to take the information about the drug and create the illusion, uh, the emotional impact and the takeaway message for viewers of advertisements that grossly exaggerate the benefit of the drug and minimize the harms, it's sociopathic behavior to have viewers of ads leave the ad with an unrealistic impression of the benefits and harms of the drug. And yet he's playing by the rules. He's doing his job as CEO to maximize the effect of his advertising. And if he doesn't do it, this is a key point, if he doesn't do it, he'll get fired and the next guy will.
- LFLex Fridman
Mm-hmm. So the people that survive in the company, the people that get, uh, raises in the company and move up in the company are the ones that play by the rules. And that's how the game solidifies itself. But the game is within the bounds of the law, so-
- JAJohn Abramson
Sometimes, most of the time, not always. (laughs)
- LFLex Fridman
(laughs) We'll, we'll return to that question. I'm actually more concerned about the effective advertisement in a kind of much larger scale on the people that are getting funded by the advertisement in self-censorship. Just like more subtle, more, uh, more passive pressure to not say anything negative. Because I've seen this and I've been saddened by it, that, uh, people sacrifice integrity in small ways when they're being funded by a particular company. They don't, they don't see themselves as doing so, but you could just clearly see that the space of opinions that they're willing to engage in, or a space of ideas they're willing to play with, is one that doesn't, uh, include negative, anything that could possibly be negative about the company. They just choose not to, 'cause, you know, why? And that, that's really sad to me that, you know, if you give me 100 bucks, I'm less likely to say something negative about you. Um, that makes me sad because, like the, the reason I wouldn't say something negative about you, I prefer, is the pressure of friendship and human connection, th- those kinds of things. So I understand that. Um, that's also a problem, by the way. So we start having dinners and shaking hands and, "Oh, aren't we friends?" But the f- the fact that money has that effect is really sad to me. On the news media, on the journalists, on scientists, that's scary to me. Um, but of course, the direct advertisement to consumers, like you said, has a potentially very negative effect. I, I, I wanted to ask if, um, what you think is the most negative impact of advertisement. Is it that direct to consumer on television? Is it advertisement to doctors? Which I'm surprised to learn, I was vaguely looking at, is more than the advertisement... more spent on advertising to doctors than to consumers. That's really confusing to me. It's fascinating actually. And then also obviously the, the law side of things is the lobbying dollars, which I think is less than all of those. But anyway, it's in, in the ballpark. What concerns you most?
- JAJohn Abramson
Well, it's the whole nexus of influence. There, there's not one thing, and, and they don't, uh, invest all their, they don't put all their eggs in one basket. It's a whole-
- LFLex Fridman
Yeah.
- JAJohn Abramson
... surround sound, um-
- LFLex Fridman
(laughs)
- JAJohn Abramson
... (clears throat) program here.
- LFLex Fridman
Yeah.
- JAJohn Abramson
Uh, but in terms of advertisements, let's take a look at the advertisement. Trulicity is a diabetes drug, a tub, uh, for type 2 diabetes, an injectable drug. Um, and it lowers blood sugar just about as well as, um, metformin does. Metformin costs about $4 a month. Uh, Trulicity costs, I think, $6,200 a year. So $48 a year versus 6,200. Trulicity has distinguished itself because it did a, uh, the manufacturer did a study that showed that it significantly reduces the risk of cardiovascular disease in diabetics. And they got approval on the basis of that study, that very large study being statistically significant. What the... so the ad, the ads obviously extol the virtues of Trulicity because it reduces the risk of heart disease and, uh, stroke, and that's one of the major morbidities, uh, risks of type 2 diabetes. What the ad doesn't say is that you have to treat 323 people to prevent one non-fatal event at a cost of $2.7 million. And even more importantly than that, what the ad doesn't say is that the evidence shows that engaging in an active healthy lifestyle program-... reduces the risk of heart disease and strokes far more than Trulicity does. Um, now there's, to be fair to the company, the sponsor, um, there's never been a study that, uh, compared Trulicity to lifestyle changes.
- LFLex Fridman
Mm-hmm.
- JAJohn Abramson
But that's part of the problem of o- of our advertising. You would think in a rational society that was way out on a limb a- as a, a l- a lone country, besides New Zealand, that allows direct to consumer advertising, that part of th- allowing direct to consumer advertising would be to mandate that the companies establish whether their drug is better than, say, healthy lifestyle adoption, to prevent the problems that they claim to be preventing. But we don't require that. So the companies can afford to do very large studies so that very small differences become statistically significant, and their studies are asking the question, "How can we sell more drug?" They're not asking the question, "How can we prevent cardiovascular disease in people with type two diabetes?" And that's how we get off in this, we're now on the, in the extreme arm of this distortion of our medical knowledge of studying how to sell more drugs than how to make people more healthy.
- LFLex Fridman
That's a really great thing to compare it to, is, uh, lifestyle changes, 'cause that should be the bar. If you, if you, uh, if you do some basic diet, exercise, all those kinds of things, how does this drug compare to that?
- JAJohn Abramson
Right. Right, and that study was done actually in the '90s. It's called the Diabetes Prevention Program. It was federally funded, uh, by the NIH so that there wasn't this drug company, um, imperative to just try to prove your drug was better than nothing. Um, and it was, it was a very well designed study, randomized controlled trial in people who were at high risk of diabetes, so-called pre-diabetics, and they were randomized to three different, three different groups, a placebo group, a group that got treated with Metformin, um, and a group that got treated with intensive lifestyle counseling. So this study really tested whether you can get people in a randomized controlled trial assigned to, uh, intensive lifestyle changes, whether that works. Now the, the, uh, common wisdom amongst physicians, and I think in general, is that you can't get people to change. You know, you can do whatever you want, you can stand on your head, you can beg and plead, people won't change, so give it up and let's just move on with the drugs and not waste any time. Except this study that was published in the New England Journal, I think in 2002, shows that's wrong, that the people who were the, in the intensive lifestyle group ended up losing 10 pounds, exercising five ti- times a week, maintaining it, and reduced their risk of dia- getting diabetes by 58% compared to the Metformin group, which reduced its risk of getting diabetes by 31%. So that, that exact study was done and it showed that lifestyle intervention is the winner.
- LFLex Fridman
Who, as a small tangent, is the leader? Who is supposed to fight for the side of lifestyle changes? Where's the big pharma version of lifestyle changes? Who's supposed to have the big bully pulpit, the big money behind lifestyle changes-
- JAJohn Abramson
Right.
- LFLex Fridman
... in, in your sense? Beca- because that seems to be missing in a lot of our discussions about health policy.
- JAJohn Abramson
Right. That's exactly right, and the answer is that we assume that the market has to solve all these problems.
- LFLex Fridman
Yeah.
- JAJohn Abramson
And the market can't solve all of these problems. There needs to be some way of protecting the public interest for things that aren't financially driven so that the overriding question has to be how best to improve Americans' health, not companies funding studies to try and prove that their new inexpensive drug is better and should be used.
- LFLex Fridman
Well, some of that is also people sort of, uh, like yourself. I mean, it, it's funny, y- you spoke with Joe Rogan. He constantly espouses lifestyle changes so s- some of it is almost like understanding the problems that big pharma is creating in society and then, uh, sort of these influential voices speaking up against it, so whether they're scientists or just, uh, regular communicators.
- JAJohn Abramson
Yeah, I think, uh, you gotta tip your hat to Joe for getting that message out, um, and he clearly believes it and does his best.
- LFLex Fridman
Yeah.
- JAJohn Abramson
But it's not coming out in the legitimate avenues, in the legitimate-
- 36:45 – 53:01
Corruption
- LFLex Fridman
Can you really buy a doctor's opinion? Why does it have such an effect on doctors, um, advertisement to doctors? Like, you, you as a physician, again, like from everything I've seen, people love you. (laughs) And I- I've, uh, just, um... People should, uh, uh, definitely look you up from... There's a bunch of videos of you giving talks on, uh, YouTube, and it's just, just the... It's so refreshing to hear just the clarity of thought about health policy, about healthcare. Just the way you think throughout the years.
- JAJohn Abramson
Thank you.
- LFLex Fridman
So like it's easy to think about, like maybe you're criticizing big pharma. That's part of the, one part of the message that you're talking about. But, you know, that's not like... Your brilliance actually shines in, in the positive, in the solutions, and how to do it. So as a doctor, what affects your mind?
- JAJohn Abramson
Yeah.
- LFLex Fridman
And how does big pharma affect your mind?
- JAJohn Abramson
Yeah. Number one, the information that comes through legitimate sources that doctors have been taught to rely on. Evidence-based medicine, the articles in peer-reviewed journals, the guidelines that are issued. Now, those are problematic because when an article is peer-reviewed and published in a respected journal, people and doctors obviously assume that the peer reviewers have anal- ha- have had access to the data and they've independently analyzed the data and they corroborate the findings in the manuscript that was submitted or they give, give feedback to the authors and say, "We disagree with you on this point. Would you please check our analysis and if you agree with us make it..." That's what they assume the peer review process is, but it's not. The peer reviewers don't have the data. The peer reviewers have the manuscript that's been submitted by the, usually in conjunction with or by the drug company that manufactures the drug. So peer reviewers are unable to perform the job that doctors think they're performing to vet the data to assure that it's accurate and reasonably complete. They, they can't do it. And then we have the clinical practice guidelines which are increasingly more important as, um, the information, the flow of information keeps getting brisker and briskier and docs need to get to the bottom line quickly. Clinical practice guidelines become much more important and we assume that the authors of those clinical practice guidelines have independently analyzed the data from the cli- clinical trials and make their recommendations that set the standards of care based on their analysis. That's not what happens. The experts who write the clinical trials rely almost entirely on the publications presenting the results of the clinical trials, which are peer reviewed, but the peer reviewers haven't had access to the data. So we've got a system of the highest level of evidence that doctors have been trained over and over again to rely on to practice evidenced-based medicine to be good doctors that has not been verified.
- LFLex Fridman
Do you think that data that's coming from the pharma companies, do you think they're, um... What level of manipulation is going on with that data? Is it at the study design level? Is it that literally there's some data that you just keep off, you know, keep out of the charts? Keep out of the, the aggregate analysis then you then publish? Or is it the worst case which is just change some of the numbers?
- JAJohn Abramson
It happened. All three happened. I can't... I don't know what the denominator is.
- LFLex Fridman
Right.
- JAJohn Abramson
But I spent about ten years in litigation and for example, in Vioxx, uh, which was withdrawn from the market in 2004 in the biggest dr- drug recall in American history. Uh, the problem was that, um, it got recalled when a study that Merck sponsored showed that Vioxx doubled the risk, more than doubled the risk of heart attacks, strokes, and blood clots, serious blood clots. It got pulled then. But there was a study, a bigger study, that had been published in 2000 in New England Journal of Medicine that showed that Vioxx was a better drug for, um, arthritis and pain, not because it was more effective. It's no more effective than Aleve or Advil. Um, but because it was less likely to cause, uh, serious GI complications, bleeds and perforations in the gut. Um, now in that study that was published in the New England Journal that was never corrected, it was a little bit modified 15 months after the drug was taken off the market, but never corrected, Merck left out three heart attacks. And the FDA knew that Merck left out three heart attacks and the FDA's analysis of the, of the data from that study said that they weren't gonna, the FDA wasn't gonna do the analysis without the three heart attacks in it. And the important part of this story is that there were 12 authors listed on that study in the New England Journal. Two were Merck employees. They knew about the three heart attacks that had been omitted. The other 10 authors, the academic authors, didn't know about it. They hadn't seen that data.So Merck just, they had an excuse, it's complicated and the FDA didn't accept it, so there's no reason to go into it. Um, but Merck just left out the three heart attacks and the three heart attacks, it may seem three heart attacks in a 10,000 person study may seem like nothing, except they completely changed the statistics, so that had the three heart attacks been included, the only conclusion that Merck could have made was that Vioxx significantly increased the risk of heart attack. And they abbreviated their endpoint from heart attacks, strokes, and blood clots, to just heart attacks.
- LFLex Fridman
Yeah. So those are maybe, in their mind, they're also playing by the rules because of some technical excuse that you mentioned that was rejected. How can this-
- JAJohn Abramson
No.
- LFLex Fridman
... 'cause this is crossing the-
- JAJohn Abramson
No, no. Let me interrupt.
- LFLex Fridman
Y-
- JAJohn Abramson
No. That's not true. Um, the study was completed, the blind was broken, meaning they looked at the data in March of 2000. The article was published in the New England Journal in November of 2000. In March of 2000, there was an email by the head scientist that was published in the Wall Street Journal that said the day that the data were unblinded, that it's a shame that the cardiovascular events are there, but the drug will do well and we will do well.
- LFLex Fridman
But removing the three heart attacks, how does that happen? Like, uh, who has to convince themselves, is this pure malevolence?
- JAJohn Abramson
Um, you have to be the judge of that. But the person who was in charge of the data safety monitoring board issued a letter that said they'll stop counting cardiovascular events a month before the trial is over, and they'll continue counting GI events. And that person got a contract to consult with Merck for $5,000 a day, I think for 12 days a year, for one or two years, that was signed, that l- contract, uh, was signed within two weeks of the decision to stop counting heart attacks.
- LFLex Fridman
I wanna understand that man or woman. I wanna, I want, it's the, uh, I've been reading a lot about Nazi Germany and, and thinking a lot about the good Germans. Because I want to understand so that we can each encourage each other to take the small heroic actions that prevents that. Because it feels to me removing malevolence from the table, where it's just a pure psychopathic person, that there's just a momentum created by the game, like you mentioned.
- JAJohn Abramson
Yes.
- LFLex Fridman
And so it takes reversing the momentum within the company, I think requires many small acts of heroism. Not gigantic, "I'm going to leave and become a whistleblower and publish a book about it." But small, quiet acts of pressuring against this. Like, what are we doing here? We're trying to help people. Is this the right thing to do? Looking in the mirror constantly and asking, "Is this the right thing to do?" I mean, that's how, that's what integrity is. Uh, acknowledging the pressures you're under and then still be able to zoom out and think what is the right thing to do here. But the data, hiding the data makes it too easy to live in ignorance. So like within those, inside those companies... (exhales through lips) . So your idea is that the reviewer should see the data. That's, that's one step. So th- to even push back on that idea is, I assume you mean that data remains private except to the peer reviews, r- reviewers. The problem, of course, as y- as you probably know, is the peer review process is not perfect. You know, it's individuals. It feels like there should be a lot more eyes on the data than just the peer reviewers.
- JAJohn Abramson
Yes. This is not a hard problem to solve. When a study is completed, um, a clinical study report is made, um, and it's usually several thousand pages. And what it does is it takes the raw patient data and it tabulates it in the ways, uh, supposedly and usually, in the ways that the company has pre-specified. So that you then um, end up with a searchable, let's say, 3,000 page document. As I became more experienced as an expert in litigation, I could go through those documents pretty quickly. Uh, quickly may mean 20 hours or 40 hours, but it doesn't mean three months of my work. And see if the company's, if the way the company has analyzed the data is consistent with the way, with their statistical analysis plan and their, uh, pre-specified, uh, outcome measures. Um, it's not hard. And I think you're right. Peer reviewers, I don't peer review clinical trials, but I peer review other kinds of articles. I have to do one on the airplane on the way home. And it's hard. I mean, we're just ordinary mortal people volunteering to-
- LFLex Fridman
Unpaid. The motivation is not clear.
- JAJohn Abramson
The motivation is to keep, um, to be a good citizen, uh, in the medical community, um, and to be on friendly terms with the journals, so that if you wanna get published, there's sort of an unspoken-
- LFLex Fridman
Yeah.
- JAJohn Abramson
... uh, incentive.
- LFLex Fridman
As, uh, as somebody who enjoys game theory, I feel like that motivation is good, but could be a lot better.
- JAJohn Abramson
Yes, you should get more recognition or in some way, um, academic credit for it. Um, it should go to your career advancement. Uh-
- LFLex Fridman
If it's an important paper and you recognize it's an important paper as a great peer reviewer, that this is not in that area where it's a, a, like clearly piece of crap paper or clearly an awesome paper that doesn't have controversial aspects to it and it's just a beautiful piece of work. Okay, those are easy. And then there is like the very difficult gray area which may require many, many days of work on your part as a peer reviewer. So it's not, you know, it's not just a couple of hours, but really seriously reading. Like some papers can take months to really understand. So if you really wanna struggle, um, there has to be an incentive for that struggle.
- JAJohn Abramson
Yes. And billions of dollars ride on some of these-
- 53:01 – 1:01:53
Pfizer vaccine data
- JAJohn Abramson
- LFLex Fridman
Okay. So speaking of the data, the FDA asked 55 years to release Pfizer vaccine data. This is also something I raised with, uh, Albert Bourla, the Pfizer s-
- JAJohn Abramson
Oh. What did he say?
- LFLex Fridman
There's several things I didn't like about what he said. Uh, so some things are expected and some of it is just revealing the human being, which is what I'm interested in doing. But he said he wasn't aware of the 75 and f- the 55.
- JAJohn Abramson
I, I'm sorry, wait a minute. Uh, he wasn't aware of?
- LFLex Fridman
The how long... So here, I'll explain what-
- JAJohn Abramson
Do you, do you know that since you spoke to him, Pfizer has petitioned the judge to join the suit o- in behalf of the FDA's request to release that data over 55 or 75 years? Pfizer's fully aware of what's going on.
- LFLex Fridman
He's aware. I'm, I'm sure he's aware in some formulation. The exact years, he might have not been aware. But, but the point is that there is... That is the FDA, the relationship with Pfizer and the FDA in terms of me being able to read human beings was the thing he was most uncomfortable with. That he didn't want to talk about the FDA. And that, that rela- it was clear that there was a relationship there that if w- if the words you use may do a lot of harm potentially because, like you're saying, there might be lawsuits going on. There's li- litigation, there's legal stuff, all that kind of stuff, and then there's a lot of games being played in this space. So, um, I don't know how to interpret it, uh, if he's actually aware or not, but the, the deeper truth is that he's deeply uncomfortable, um, bringing light to this part of the game.
- JAJohn Abramson
Yes, and I'm gonna read between the lines, and Albert Bourla certainly didn't ask me to speak for him. But I think the... When did you speak to him? How long ago?
- LFLex Fridman
Wow, time flies when you're having fun. Uh, two months ago.
- JAJohn Abramson
Two months ago. So that was just recently it's come out, uh, just in the past week it's come out, that, um, Pfizer isn't battling the FDA. Pfizer has joined the FDA in the opposition to the request to release these, uh, these documents in the same amount of time that the FDA took to evaluate them.
- LFLex Fridman
Yeah.
- JAJohn Abramson
So Pfizer is offering to help the FDA to petition the judge-
- LFLex Fridman
Right.
- JAJohn Abramson
... to not enforce the timeline that he seems to be moving towards.
- LFLex Fridman
So for people who are not familiar, we're talking about the Freedom of Information Act request to release the Pfizer vaccine data, study data, to release as much of the data as possible, like the raw data, the details. Or s- actually not even the raw data. It's s- well, s- data. Doesn't matter. There's details to it. And, uh, I think the response from the FDA is that a- of qu- yes, of course (laughs) , uh, but, uh, you know, we can only publish, like some X number of pages a day bec-
- JAJohn Abramson
Five- 500 pages.
- LFLex Fridman
500 pages of data.
- JAJohn Abramson
Uh, I- I- it's not a day though. It's, uh-
- LFLex Fridman
Whatever.
- JAJohn Abramson
... a week I think, or-
- LFLex Fridman
The point is, whatever they're able to publish is ridiculous.
- JAJohn Abramson
(laughs)
- LFLex Fridman
It's like, um, (laughs) my printer can only print three pages a day-
- JAJohn Abramson
(laughs)
- LFLex Fridman
... and, uh, we cannot afford a second printer. So it's, it's some kind of bureaucratic language for, you know, there's a process to this. I d- you know, and now you're saying that Pfizer is obviously, um, more engaged in helping this kind of bureaucratic process prosper in it- in- in its full a- uh, absurdity, Kafkaesque absurdity. So what is this? This really bothered people. This really-
- JAJohn Abramson
This, this is really troublesome. And just to put it in just plain English terms, Pfizer is making the case that it can't... Pfizer, the FDA and Pfizer together are making the case that they can't go through the documents. It's gonna take them some number, 100-fold, hundreds of folds more time to go through the documents than the FDA required to go through the documents to approve the vaccines, to give the vaccines full, uh, uh, FDA approval. And the FDA's argument, talk about Kafkaesque, is that to do it more rapidly would cost them three million dollars. Three million dollars equals one hour of vaccine sales over two years. One hour of sales, and they can't come up with the money. And now Pfizer has joined the suit to help the FDA fight off this judge, this mean judge-
- LFLex Fridman
Yeah.
- JAJohn Abramson
... who thinks they oughta release the data, but evidently Pfizer isn't offering to come up with the three million dollars either. So but for three million... I mean, maybe the, uh, may- (laughs) maybe the FDA should do a GoFundMe-
- LFLex Fridman
(laughs)
- 1:01:53 – 1:12:48
Vaccine profits
- LFLex Fridman
But there's a lot of people that are kind of saying, "Well, even the data on the real, the real world use large scale data has, um, has, is messy." The way it's being reported, the way it's being interpreted. Be- well, one thing is clear to me that it is being politicized. That it's... I mean, if you just look objectively, don't have to go to, at the shallow surface level, it seems like there's two groups that... I can't even put a term to it, uh, because it's not really pro-vaccine versus anti-vaccine, 'cause it's, it's, it's pro-vaccine, triple mask, Democrat, Liberal, and then anti-mandate, whatever, whatever those groups are. I can't quite... 'cause they're changing. Anti-mask, but not really, but kind of. So those two groups that feel political in nature, not scientific in nature. It's, they're, they're bickering and then it's clear that this data is being interpreted by the different groups differently. And it's very difficult for me as a human being to understand where the truth lies, especially given how much money is flying around on all sides. So the anti-vaxxers can make a lot of money too. Let's not forget this. From the individual perspective you can become famous being an anti-vaxxer. And so there's a lot of incentives on all sides here. (laughs)
- JAJohn Abramson
Yeah.
- LFLex Fridman
And, and, and there's real human emotion and fear, and also credibility, you know. Um, scientists don't wanna ruin their reputation if they, if they speak out in whatever, like speak their opinion or, um, they look at some slice of the data and begin to interpret it in some kind of way. They're very... it, it's clear that fear is dominating the discourse here, especially in the scientific community. So I, I don't know what to make of that. (laughs) Um, and the only happy people here (laughs) is Pfizer. Just plowing all ahead. I mean, uh, uh, you know, with every single variant there's ex- you know, th- there's very, I would say, outside of arguably a very flawed system, there's a lot of incredible scientific and engineering work being done in constantly developing new, like antiviral drugs, uh, new v- uh, new vaccines to deal with the variants. So they're happily being a, a capitalist machine (laughs) and, uh, it's very difficult to kn- know what to do with that.
- JAJohn Abramson
Yeah. And let's just put this in perspective for folks. The best-selling drug in the world has been Humira for a number of years. It's, uh, uh, approved for the treatment of rheumatoid arthritis and eight other indications. Uh, and it sold about 20 billion dollars, uh, globally over the past few years. It, it leveled out at, it peaked at that level. Pfizer expects to sell 65 billion dollars of vaccine in the first two years of the, uh, pandemic. So this is by far the biggest selling and most profitable drug that's ever be- come along.
- LFLex Fridman
Can I ask you a difficult question here? In the fog that we're operating in here, on the Pfizer-BioNTech vaccine, what was done well and what was done badly that you can see now? It seems like we'll know more decades from now.
- JAJohn Abramson
Yes.
- LFLex Fridman
But now in the fog of today with the 65 billion dollars flying around, where, where do you land?
- JAJohn Abramson
So w- we're gonna get to what I think is one of the key problems with the pharmaceutical industry model in the United States about being profit driven. So in 2016 the NIH did the key infrastructure work to make mRNA, uh, vaccines. Uh, that gets left out of the discussion a lot. And Pfizer-BioNTech actually paid royalties voluntarily to the NIH. I don't know how much it was. I don't think it was a whole lot of money, but I think they wanted to avoid the litigation that Moderna got itself into by just taking that 2016 knowledge and having that be the foundation of their product. So Pfizer took that and they did, um, their R&D, they paid for their R&D having received, um, that technology, and when they got the, uh, genetic code from, uh, China, uh, about the vaccine, about the, uh, virus, they very quickly made a vaccine and the vaccine works. And President Trump, to his credit, launched Operation Warp Speed and just threw money at the problem.They just said, "We're, the, we, we spent five times more per person than the EU early on. Just pay them whatever they want. Uh, let's just get this going." And Americans were vaccinated, uh, more quickly. We paid a lot of money. The one mistake that I think the federal government made was they were paying these guaranteed fortunes and they didn't require that the companies participate in a program to do global vaccinations. They... So the companies, doing their business model, distributed the vaccines where they would make the most money.
- LFLex Fridman
Mm-hmm.
- JAJohn Abramson
And obviously they would make the most money in the First World. And almost all, I think 85% of the vac- vaccines early on went to the First World.
- LFLex Fridman
Mm-hmm.
- JAJohn Abramson
And very, very few vaccinations went to the Third World. So what happened is the- there was such a low vaccination rate in May of 2021, there was a all hands on deck cry for help from the World Trade Organization, um, the World Health Organization, the IMF, and the World Bank, made a plea for $50 billion so that we could get to 40% vaccination rate in the Third World by the end of 2021. And it was unrequited. Nobody answered. And now Africa has about a 8.9% vaccination rate and India's coming up, but it's been very low. The problem with all this is I believe those mRNA vaccines are excellent vaccines, but if we leave the Third World unvaccinated, we're gonna have a constant supply of variants of COVID that are gonna come back into the United States and harm Americans exactly like Delta and Omicron have. So we've made a great drug. It reduces the risk of mortality in Americans who get it by a lot, but we're not doing what we need to do to protect Americans from Omicron. You don't have to be an idealist and worry about global vaccine equity. If you just... Ordinary selfish people like most of us are and you're worried about the health of Americans, you would ensure global vaccine distribution. Let, let me just make one more point.
- LFLex Fridman
Mm-hmm.
- JAJohn Abramson
That $50 billion that was requested by the four organizations back in May of 2021, 32 billionaires made $50 billion from the vaccines at that point, took it into their private wealth. So what had been take- this enormous amounts of money that had been taken into private wealth was enough to do what those organizations said needed to be done to prevent the subvariants from coming back and doing what they're doing.
- LFLex Fridman
So the money was there, but how does the motivation, the money-driven motivation of big pharma lead to that, um, that, that kind of allocation of vaccines?
- JAJohn Abramson
Because they can make-
- LFLex Fridman
More money in the United States?
- JAJohn Abramson
Yeah, they're gonna distribute their vaccines where they can make the most money.
- LFLex Fridman
Right. Is there a malevolent aspect to this where, boy, I, I don't like saying this, but that they don't see it as a huge problem that variants will come back to the United States?
- JAJohn Abramson
I think it's the issue we were talking about earlier on where they're in a different culture and their culture is that their moral obligation, as Milton Friedman would say, is to maximize the profits that they return to shareholders.
- LFLex Fridman
Yeah, and don't think about the bigger picture.
- JAJohn Abramson
The collateral damage. Don't think about the collateral damage.
- LFLex Fridman
And also kind of believe, convince yourself that if we give into this capitalist machine in this very narrow sense of capitalism, that in the end they'll do the most good. This kind of belief that like if we just maximize profits, we'll do the most good.
- JAJohn Abramson
Yeah, that's an orthodoxy of several decades ago, and I don't think people can really say that in good faith. When you're talking about, uh, vaccinating the Third World so we don't get hurt, it's a little bit hard to make the argument that the world's a better place because the profits of the investors went up.
- LFLex Fridman
Yeah, but at the same time it's (laughs) , I, I, I think that's a belief you can hold.
- JAJohn Abramson
(laughs) .
- LFLex Fridman
I, I mean, I've interacted with a bunch of folks that kinda, it's the, I don't wanna mischaracterize Ayn Rand, okay? I respect a lot of people, but there's, it's a belief that can take hold, "If I just focus on this particular maximization, it will do the most good for the world." The problem is when you choose what to maximize and you put blinders on, it's too easy to start making gigantic mistakes that have a big negative im- impact on society. So it really matters what you're maximizing. (laughs)
- JAJohn Abramson
Right.
- LFLex Fridman
Uh-
- JAJohn Abramson
And if we had a true democracy and everybody had one vote, everybody got decent information and had one vote, Ayn Rand's position would get some votes, but not many.
- 1:12:48 – 1:33:34
Censorship
- JAJohn Abramson
- LFLex Fridman
Let me ask you about this very, um, difficult topic, I'm talking to, uh, Mark Zuckerberg of Meta, the topic of censorship. I don't know if you've, uh, heard, but there's a guy named Robert Malone and Peter McCullough that were removed from many platforms for speaking about the COVID vaccine as being risky. They were both on Joe Rogan's program. What do you think about...... censorship in this space, in this difficult space where so much is controlled by, not controlled but influenced by advertisements from big pharma. And science can even be influenced by big pharma. Where do you lean on this? Should we allow, should we lean towards freedom and just allow all the voices, even those that go against the scientific consensus? Is that one way to fight the- the science that is funded by big pharma or is that do more harm than good, having too many voices that are contending here? Should the ultimate battle be fought in the space of, uh, scientific publications?
- JAJohn Abramson
And particularly in the, uh, era of COVID, where there are large public health ramifications to the, this public discourse, uh, the ante is way up. So I don't have a simple answer to that. Uh, I think everyone's allowed their own opinion. I don't think everyone's allowed their own scientific facts. And how we develop a mechanism that's other than an open internet where whoever is shouting the loudest gets the most clicks and rage creates value on the internet, I think that's not a good mechanism for working this out. And I don't think we have one. I don't have a solution to this. I mean, ideally if we had a philosopher king, we could have a panel of people who were not conflicted by rigid opinions decide on what the boundaries of public discourse might be. I don't think it should be fully open. I don't think people who are making, um, who are committed to an anti-vaccine position and will tailor their interpretation of complex scientific data to support their opinion, I think that can be harmful. Constraining their speech can be harmful as well. So I, I don't have an answer here, but yeah.
- LFLex Fridman
I tend to believe that it's more dangerous to censor anti-vax messages. The way to defeat anti-vax messages is by being great communicators, by being great scientific communicators. So it's not that we need to censor the things we don't like, we need to be better at communicating the things we do like or the things that we do believe represent the, a deep scientific truth. Because, um, I think if you censor, you get worse at doing science and you give the wrong people power. So I- I- I tend to believe that you should give power to the individual scientists and also give them the responsibility of being better educators, communicators, expressers of scientific ideas, put pressure on them to release data, to release that data in a way that's easily consumable, not just like, uh, very difficult to understand but in a way that it can be understood by a large number of people. So the battle should be fought in the open space of ideas versus in, um, in the quiet space of journals. I think we no longer have that comfort, especially at the highest of stakes. So this kind of idea that a couple of peer reviewers decide the fate of billions is- is, doesn't seem to be sustainable. Especially given a- a very real observation now that, um, that the reason Robert Malone has a large following is there's a deep distrust of institutions, deep distrust of scientists, of science as an institution, of, uh, power centers, of companies, of- of everything, and perhaps rightfully so. But the way to defend against that is not for the powerful to build a bigger wall. It's for the powerful to be authentic, um, and maybe do, a lot of them to get fired, and for new minds, for new fresh scientists, uh, ones who are more authentic, more real, better communicators to step up. So I- I- I fear, I fear censorship because it feels like censorship is a even harder job to do it well than being good communicators. And it seems like it's always the C students that end up doing the censorship.
- JAJohn Abramson
(laughs)
- LFLex Fridman
That it's like, it's always the incompetent people, and not just the incompetent but the biggest whiners. So like what happens is the people that get the most emotional and the most outraged will drive the censorship, and it doesn't seem like reason drives the censorship. That just ob- objectively observing how censorship seems to work in this current... So there are so many forms of censorship. You know, you look at the Soviet Union with the propaganda or Nazi Germany, it's a very different level of censorship. People- people tend to conflate all of these things together. You know, social media trying desperately to have trillions, uh, or, uh, hundreds of billions of exchanges a day and, like, try to make sure that their platform is, has some, uh, semblance of, like, "healthy conversations," like people just don't go insane, they actually like using the platform.... and they, they censor based on that, that's a different level of censorship. But even there, you can really run afoul of the people they get, the, the, the whiny C students controlling too much of the censorship. I, I believe the, you should, you should actually put the responsibility on the self-proclaimed holders of truth, AKA scientists, at being better communicators.
- JAJohn Abramson
I agree with that. I'm not, uh, advocating for any kind of censorship. But, uh, Marshall McLuhan was very influential when I was in college, and his, uh, that meme, uh, the medium is the message-
- LFLex Fridman
Mm-hmm.
- JAJohn Abramson
... it's a little bit hard to understand when you're comparing radio to TV and saying radio is hotter or TV is hotter or something, but we now have the medium is the message in a way that we've never seen, we've never imagined before, where rage and anger and polarization, uh, are what drives the, um, traffic on the internet. And we don't n- it's a question of building the commons. Ideally, I don't know how to get there, so I'm, I'm not pretending to have a solution, but the commons of discourse about this particular issue about vaccines is, has been largely destroyed by the edges, by the drug companies and the advocates on the one side, and the, um, people who just criticize and, um, think that even though the data are flawed, that, um, there's no way vaccines can be beneficial. And to have those people screaming at each other does nothing to improve the health of the 95% of the people in the middle who want to un- know what the rational way to go forward is and protect their families from COVID and live a good life and be able to participate in the economy, and that's the problem. I don't have a solution.
- LFLex Fridman
Well, there's a difficult problem for, uh, Spotify and YouTube. I don't know if you heard, this is a thing that Joe Rogan is currently going through, as a platform whether to censor the conversations that, for example, Joe is having. So I don't know if you heard, but Neil Young and other musicians have kind of s- spoke out and saying they're going to leave the platform because, uh, J- uh, Joe Rogan is allowed to be on this platform having these kinds of conversations with the likes of Robert Malone. And it's clear to me that Spotify and YouTube are being significantly influenced by these extreme voices, like you mentioned, on each side. And it's also clear to me that Facebook is the same, and that was going back and forth. In fact, that's why Facebook has been oscillating on the censorship, is like one group gets louder than the other depending on, uh, whether it's an election year. (sighs) It, um... There's several things to say here. So one, it does seem, I think you put it really well, it would be amazing if these platforms could find mechanisms to listen to the center, to the, um, to the big center that's actually going to be affected by the results of the, uh, our pursuit of tr- scientific truth, right? Um, and listen to those voices. I also believe that most people are intelligent enough to process information and to make up their own minds. Like they're not, in terms of, um, this... It's complicated, of course, 'cause we've just been talking about advertisement and how people can be influenced, but I feel like if you have raw long form podcasts or programs where people express their mind and express their argument in full, I think people can hear it and make up their own mind. And if those arguments have a platform on which they can live, then other people could provide better arguments if they disagree with it, and now we as human beings, as rational, as intelligent human beings can look at both and make up our own minds. And that's where social media can be very good at, like this collective intelligence. We together listen to all of these voices and, and make up our own mind. Humble ourselves actually often. You know, you think you know, like you're an expert, say you have a PhD in a certain thing, so there's this confidence that comes with that, and the collective intelligence uncensored allows you to humble yourself eventually. Like, uh, as you discovery... And it, all it takes is a, a few times, you know, looking back, uh, five years later realizing, "I was wrong." And that's really healthy for a scientist. That's really healthy for anybody to go through, and only through having that open discourse can, can you- can you really have that. That said, Spotify also, just like Pfizer, is a company, which is why this podcast, I don't know if you know what RSS feeds are, but podcasts can't be censored. So Joe is in the unfortunate position he only lives on Spotify. So Spotify has been actually very good at saying, "We're staying out of it for now." Um, but RSS, this is pirate radio. Nobody can censor. It's the internet. So, um, financially, in terms of platforms, this cannot be censored, which is why, uh, podcasts are really beautiful. And so w- if Spotify or YouTube wants to be the host of podcasts, I think where they flourish is, um, free expression no matter how crazy.
- JAJohn Abramson
Yes, but I do wanna push back a little bit on what you're saying because I have, um, anti-vax friends who I love. Um, they're dear cherished friends and they'll send me stuff.And it'll take me an hour to go through what they sent to see if it is credible. And, uh, usually it's not. It's not a random sample of the anti-vax argument, I'm not-
- LFLex Fridman
Mm-hmm.
- JAJohn Abramson
... saying I can disprove the anti-vax argument. But I am saying that it's almost like we were talking about, uh, how medical science, clinical trials, the presentation of clinical trials to physicians could be improved, and the first thing we came up with is to have pre-publication transparency in the peer review process.
- LFLex Fridman
Yes.
- JAJohn Abramson
So bad information, biased information doesn't get out as if it's legitimate, and you can't put it back, recapture it once it gets out. I think there's an element of that in the arguments that are going on about vaccines. And they're on both sides, but I think the anti-vax side puts out more, uh, units of information, um, claiming to show that the vaccines don't work. And I guess in an ideal situation there would be real time fact checking by independent people. Not to censor it, but to just say, "That study was set up to do this, and this is what the conclusions were, so the way it was stated, uh, is on one side of this argument."
- LFLex Fridman
But that's what I'm arguing. Yeah, I agree with you. What I'm arguing is that this big network of humans that we have, that is the collective intelligence, can do that real time if you allow it to, if you encourage people to do it. And the scientists, as opposed to... Listen, I interact with a lot of colleagues, a lot of friends that are scientists, they roll their eyes. Their response is like, "Ugh." Like they don't want to interact with this. But it, th- that, that's just not the right response. When a huge-
- JAJohn Abramson
Right.
- LFLex Fridman
... number of people-
- JAJohn Abramson
Right.
- LFLex Fridman
... believe this, it is your job as communicators to defend your ideas. It is no longer the case that you go to a conference and defend your ideas to two other, uh, nerds that have been working on the same problem forever. I mean, sure, you can do that, but then you're re- rejecting the responsibility you have explicitly or implicitly accepted when you go into this field, that you will defend the ideas of truth, and the way to defend them is in the open battlefield of ideas, and become a better communicator. And, and I believe that when you have a large... You said you invested one or two hours in this particular... But that's little ants interacting at scale, I think, that, uh, allows us to progress towards truth. At least, you know, at least I hope so.
- JAJohn Abramson
I, I think you're an optimist. I, I want to work with you a little bit on this.
- LFLex Fridman
(laughs)
- JAJohn Abramson
Let's say, um, a person like Joe Rogan, who, by the way, had me on his podcast, and let me-
- LFLex Fridman
It's an amazing conversation. I really enjoyed it.
- JAJohn Abramson
Well, thank you. I did too. And I didn't know Joe, I didn't know much about his podcast.
- LFLex Fridman
And you pushed back on Joe a bunch, which is great. (laughs)
- JAJohn Abramson
(laughs) And he was-
- LFLex Fridman
I love it.
- JAJohn Abramson
He was a gentleman. And we had it out, in fact, he put one clip th- at one point he said something that was a little bit wrong and I corrected him. And he had the guy, uh-
- LFLex Fridman
Jamie.
- 1:33:34 – 1:42:09
FDA
- LFLex Fridman
Let me ask you yet another question I, issue I raised with Pfizer CEO Albert Bourla. It's the question of revolving doors, that there seems to be a revolving door between Pfizer, FDA and CDC. People that have worked at the FDA now work at Pfizer and vice versa, inclu- and the CDC and so on. Um, what do you think about that? So first of all, his response once again is, "There's rules. There's very strict rules and we follow them." Do you think that's a problem?
- JAJohn Abramson
Hoo-ha. (laughs)
- LFLex Fridman
And also maybe this is a good time to talk about, does Pfizer play by the rules?
- JAJohn Abramson
Let's... One at a time.
- LFLex Fridman
One at a time.
- JAJohn Abramson
Okay. And this isn't even about Pfizer, but it's an answer to the question.
- LFLex Fridman
Yes.
- JAJohn Abramson
So there's this drug Aduhelm that was approved by the FDA, uh, maybe six months ago. It's a drug, uh, to prevent the progression of low-grade Alzheimer's disease. Um, the target for, uh, drug development for Alzheimer's disease has been the amyloid, reducing the amyloid plaques in the brain, which correlate with the progression of Alzheimer's. And Biogen showed that its drug Aduhelm reduces amyloid plaques in the brain. They did two clinical trials to determine the clinical efficacy, and they found that neither trial showed a meaningful benefit. And in those two trials, 33% more people in the Aduhelm group developed symptomatic brain swelling and bleeding than people in the placebo group. There was an advisory committee convened, uh, to debate the, and determine how they felt about the approvability of Aduhelm given those facts. And those facts aren't in dispute. They're in Biogen slides, uh, as well as FDA documents. The advisory committee voted, 10 against approval and one abstain. So that's essentially universal, uh, unanimous vote against approving Aduhelm. Now, the advisory committees have been pretty much cleansed of financial conflicts of interest. So this advisory committee votes 10, no, one abstention, and the FDA overrules the unanimous opinion of its advisory committee and approves the drug. Three of the members of the advisory committee resign. They say, "We're not gonna be part... If the FDA's not gonna listen to a unanimous vote against approving this drug, which shows more harm than benefit, undisputed, we're not gonna participate in this." And the argument a- against approval is that the surrogate endpoint, the reduction of amyloid, the progression of amyl- amyloid plaques, is known by the FDA not to be a valid clinical indicator. It doesn't correlate. 27 studies have shown it doesn't correlate with clinical progression. Interrupting the amyloid plaques doesn't mean that your, um, that, that your Alzheimer's doesn't get worse. So it seems like it's a slam dunk and the FDA made a mistake, and they should do whatever they do to protect their bureaucratic reputation. So the head of the bureau of the FDA, the Center for Drug Evaluation and Research that approves new drugs, who had spent 16 years as an executive in the pharmaceutical industry, issued a statement and said, "What we should do in this situation is to loosen the prohibition of financial ties of interest with the drug companies so we get less emotional responses." (laughs) Said this, it's in print. (laughs)
- LFLex Fridman
(laughs) People are just too emotional about this.
- JAJohn Abramson
People were just too emotional, the 10 people who voted against it and the no people who voted for it, it's all too emotional. So this gets back... This is a long answer to your short question. I think this is a wonderful window into the thinking of the FDA that financial conflicts of interest don't matter in a situation when I think it's obvious that they would matter.
- LFLex Fridman
But there's not a direct financial conflict of interest. It's kinda... Like, it's not... Li- like, like, uh, Albert said, th- there's rules. I mean, you're not allowed to have direct financial conflicts of interest. It's, it's indirect.
- JAJohn Abramson
Right, but what I'm saying is-
- LFLex Fridman
Yes.
- JAJohn Abramson
... I'm not denying what he said is true, but the FDA, a high official in the FDA is saying that we need to allow conflicts of interest in our advisory committee meetings.
- LFLex Fridman
Ah.
- JAJohn Abramson
And that, she wants to change the rules.
- LFLex Fridman
Right.
- JAJohn Abramson
So Albert Bourla would still be playing by the rules, but it just shows how one-sided the thinking here is.
- LFLex Fridman
But you think that's influenced by the fact that, that there were pharmaceutical executives working at the FDA and vice versa?
- JAJohn Abramson
And they think that's a great idea.
- LFLex Fridman
Who gets to fix this? Do you think it should be just banned, like if you worked-
- JAJohn Abramson
I, I don't know. Two separate questions.
- LFLex Fridman
Yeah.
- JAJohn Abramson
One is, should the, uh, officials at the FDA come from pharma-
- LFLex Fridman
Yeah.
- JAJohn Abramson
... and vice versa?
- LFLex Fridman
Yes.
- JAJohn Abramson
That's one question, and the other question is should advisory committee members be allowed to have financial conflicts of interest?
- LFLex Fridman
Yes.
- JAJohn Abramson
I think, in my opinion, and people might say I'm biased, I think fini- advisory committee people should not have conflicts of interest. I think their only interest ought to be the public interest, and that's was true from my understanding of the situation. It's the afterword in my book, I spent some time studying it, about Aduhelm. I think it's a slam dunk that there ought to be no conflicts of interest. Now, the head of CDER, Center for Drug Evaluation Research, thinks that that's gonna give you a biased result because we don't have company influence. And that, I think, shows how, how biased their thinking is, that not having company influence is a bias.
Episode duration: 2:17:28
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