John Abramson: Big Pharma | Lex Fridman Podcast #263

The jury found Pfizer guilty of fraud and racketeering violations.

How does Big Pharma affect your mind?

Everyone's allowed their own opinion. I don't think everyone's allowed their own scientific facts.

Does Pfizer play by the rules?

Pfizer isn't battling the fda. Pfizer has joined the fda.

The following is a conversation with John Abramson, faculty at Harvard Medical School, a family physician for over two decades and author of the new book Sickening, about how Big Pharma broke American healthcare and how we can fix it. This conversation with John Abramson is a critical exploration of the pharmaceutical industry. I wanted to talk to John in order to provide a countervailing perspective to the one expressed in my podcast episode with the CEO of Pfizer, Albert 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 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 J. Bhattacharya or Francis Collins, Jamie Mertzl 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 Berla conversation. The goal was to reveal as much as I could about the human being before me and to give him the opportunity to contemplate in long form the complexities of his role, including the tension between making money and helping people, the corruption that so often permeates human institutions, the crafting of narratives through advertisements, and so on. I only had one hour, so this wasn't the time to address these issues deeply, but to show if Albert struggled with them in the privacy of his own mind and if he would led 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 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 guests, that we talk in true long form for many hours. Second, these conversations with leaders can be aided by further conversations with people who wrote books about those leaders or their industries, those that can steel man. Each perspective and attempt to give an objective analysis. I think of Teddy Roosevelt's speech about the man in the arena. I want to talk to both the men and women in the arena and the critics and the supporters in the stands. For the former, I lean toward wanting to understand one human being's struggle with the ideas. For the latter, I lean towards understanding the ideas themselves. That's why I wanted to have this conversation with John Abramson, who is an outspoken critic of the pharmaceutical industry. I hope it helps add context and depth to the conversation I had with the Pfizer CEO. In the end, I may do worse than I could have or should have. Always, I will listen to the criticisms without ego, and I promise I will work hard to improve. But let me say finally that cynicism is easy. Optimism, true optimism is hard. It is the belief that we can and we will build a better world and that we can only do it together. This is the fight worth fighting. So here we go, once more into the breach. Dear friends, I love you all. This is the Lex Friedman podcast. To support it, please check out our sponsors in the description. And now here's my conversation with John Abramson.

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 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 health care back aimed in the right direction.

Okay, so there's a tension between helping people and making money. So if we look at particularly the task of helping people in medicine, in healthcare, is it possible? If money is the primary sort of.

Mechanism by which you achieve that as a motivator, is it possible to get that right?

I think it is, Lex, but I think it is not possible without guardrails that maintain the integrity and the balance of the knowledge. Without those guardrails, it's like trying to play a professional basketball game without referees and having players call their own fouls, but the players are paid to win, and you can't count on them to call their own fouls. So we have referees who are in charge of. We don't have those referees in American health care. That's the biggest way that American healthcare is distinguished from healthcare in other wealthy nations.

Okay, so you mentioned Milton Friedman, and you mentioned his book called Capitalism and Freedom. He writes that there are only three legitimate functions of government. To preserve law and order, to enforce private contracts, and to ensure that private markets work.

You said that that was a radical idea at the time, but we're failing on all three.

How are we failing?

And also maybe the bigger picture is what are the strengths and weaknesses of capitalism when it comes to medicine and healthcare?

Can we separate those out? Because those are two huge questions. So how we're failing in all three? And these are the minimal functions that our guru of free market capitalism said the government should perform. So this is the absolute baseline on preserving law and order. The drug companies routinely violate the law in terms of their marketing and in terms of their presentation of the results of their trials. I know this because I was an expert in litigation for about 10 years. I presented some of what I learned in civil litigation to the FBI and the Department of Justice. And that case led to the biggest criminal fine in U.S. history as of 2009. And I testified in a federal trial in 2010, and the jury found Pfizer guilty of fraud and racketeering violations. In terms of violating the law, it's a routine occurrence. The drug companies have paid $38 billion worth of fines from, I think, 1991 to 2017. It's never been enough to stop the misrepresentation of their data. And rarely are the fines greater than the profits that were made. Executives have not gone to jail for misrepresenting data that have involved even tens of thousands of deaths. In the case of Vioxx, oxycontin as well. And when companies plead guilty to felonies, which is not an unusual occurrence, that the government usually allows the companies, the parent companies, to allow subsidiaries to take the plea so that they are not one step closer to getting disbarred from Medicare, not being able to participate in Medicare. So in that sense, there is a mechanism that is appearing to impose law and order on drug company behavior. But it's clearly not enough. It's not working.

Can you actually speak to human nature here? Are people corrupt? Are people malevolent? Are people ignorant that work at the low level and at the high level.

At Pfizer, for example, at big pharma.

Companies, how is this possible? So I believe, just on a small tangent, that most people are good. And I actually believe if you join big Pharma. So a company like Pfizer, your life trajectory often involves dreaming and wanting and enjoying helping people.

Yes.

And then we look at the outcomes.

That you're describing and it looks, and that's why the narrative takes hold that.

Like Pfizer CEO Albert Brola, 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?

Yeah, I think it has to do with the cultural milieu that this is unfolding in. And we need to look at sociology to understand this, that when the cultural milieu is set up to maximize the returns on investment for shareholders and other venture capitalists and hedge funds and so forth, when that defines the culture and, and the higher up you are in the corporation, the more you're in on the game of getting rewarded for maximizing the profits of the investors. That's the culture they live in. And it becomes normative behavior to do things with science that look normal in that environment and 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. 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 mileure.

That's fascinating. The game they're playing modifies the culture you know, of inside the meetings, inside the rooms, dayto day, that there's a bubble that forms. Like we're all in bubbles of different sizes.

Right.

And that bubble allows you to drift in terms of what you see as.

Ethical and unethical because you see the.

Game as just, you know, it's just part of the game. So marketing is just part of the game.

Right.

And paying the fines is just part of the game of science.

Yep, yep. And without guardrails, it becomes even more part of the game. You keep moving in that direction if you're not bumping up against guardrails. And I think that's how we've gotten to the extreme situation we're in now.

So, like I mentioned, I spoke with Pfizer CEO Albert Brola and I'd like to raise with you some of the concerns I raised with him. So one you already mentioned, I raised the concern that Pfizer is engaged in aggressive advertising campaigns. As you can imagine, he said no. What do you think?

I think you're both right. I think that the. I agree with you that the aggressive advertising campaigns do not add value to society. And I agree with him that they're for the most part legal and it's the way the game is played.

Right. So sorry to interrupt, but oftentimes his responses are, especially now, he's been CEO for only like two years, three years. He says Pfizer was a different company. We've made mistakes. Right. In the past. We don't make mistakes anymore that there's rules and we play by the rules.

So like with every concern raised, there's.

Very, very strict rules, as he says. In fact, he says sometimes way too strict and we play by them. And so in that sense, advertisement it doesn't seem like it's too aggressive because it's playing by the rules. And relative to the other, again, it's the game relative to the other companies. It's actually not that aggressive relative to the other big pharma companies.

Yes, yes. I hope we can quickly get back to whether or not they're playing by the rules. But in general. But let's just look at the question of advertising specifically. I think that's a good example of what it looks like from within that culture and from outside that culture. He's saying that we follow the law on our advertising. We state the side effects and we state the FDA approved indications, and we, we do what the law says we have to do for advertising. And I have not, I've not been an expert in litigation for a few years and I don't know what's going on currently. But let's take him at his word. It could be true. It might not be, but it could be. But if that's true in his world, in his culture, that's ethical business behavior from a common sense person's point of view, a drug company paying highly skilled media folks to take the information about the drug and create the illusion, the emotional impact and the takeaway message for Viewers of advertisements that grossly exaggerate the benefit of the drug and minimize the harms. It's sociopathic behavior to have viewers of ads leave the ad with an unrealistic impression of the benefits and harms of the drug. And yet he's playing by the rules. He's doing his job as CEO to maximize the effect of his advertising. And if he doesn't do it, this is a key point. If he doesn't do it, he'll get fired and the next guy will.

So the people that survive in the company, the people that get raises in the company, move up in the company, are the ones that play by the rules. And that's how the game solidifies itself. But the game is within the balance.

Of the law sometimes, most of the time, not always.

We'll return to that question. I'm actually more concerned about the effect of advertisement in a kind of much larger scale on the people that are.

Getting funded by the advertisement in self censorship.

Just like more subtle, more passive pressure to not say anything negative. Because I've seen this, and I've been saddened by it, that people sacrifice integrity in small ways when they're being funded by a particular company. They don't see themselves as doing so. But you could just clearly see that the space of opinions that they're willing to engage in or a space of ideas they're willing to play with is one that doesn't include negative. Anything that could possibly be negative about the company. They just choose not to because you know why. And that's really sad to me that, you know, if you give me 100 bucks, I'm less likely to say something negative about you. That makes me sad because, like, the reason I wouldn't say something negative about you, I prefer, is the pressure of friendship and human connection, those kinds of things. So I understand that that's also a problem, by the way. So I started having dinners and shaking hands and oh, aren't we friends? But the fact that money has that effect is really sad to me on the news media, on the journalists, on scientists. That's scary to me. But of course, the direct advertisement to consumers, like you said, is potentially very negative effect. I wanted to ask if what do you think is the most negative impact of advertisement? Is it that direct to consumer on television, is it advertisement of doctors, which I'm surprised to learn I was vaguely looking at, is more than the advertisement, more is spent on advertising to doctors than to consumers? That's really confusing to me. It's fascinating, actually. And then also obviously the law side of things is the lobbying dollars, which I think is less than all of those. But anyway, it's in the ballpark. What concerns you most?

Well, it's the whole nexus of influence. There's not one thing and they don't invest all their, they don't put all their eggs in one basket. It's a whole surround sound program here. But in terms of advertisements, let's take the advertisement. Trulicity is a diabetes drug, a type of, for type 2 diabetes, an injectable drug. And it lowers blood sugar just about as well as metformin does. Metformin costs about $4 a month. Trulicity costs, I think $6,200 a year. So $48 a year versus 6,200. Trulicity has distinguished itself because it did. The manufacturer did a study that show that it significantly reduces the risk of cardiovascular disease in diabetics. And they got approval on the basis of that study, that very large study being statistically significant. So the ads obviously extol the virtues of trulicity because it reduces the risk of heart disease and stroke. And that's one of the major morbidities risks of type 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. Now, to be fair to the company, the sponsor, there's never been a study that compared trulicity to lifestyle changes. But that's part of the problem of our advertising. You would think in a rational society that was way out on a limb as a lone country besides New Zealand, that allows direct to consumer advertising. That part of allowing direct to consumer advertising would be to mandate that the companies establish whether their drug is better than say, healthy lifestyle adoption to prevent the problems that they claim to be preventing. But we don't require that. So the companies can afford to do very large studies so that very small differences become statistically significant. And their studies are asking the question, how can we sell more drug? They're not asking the question how can we prevent cardiovascular disease in, in people with type 2 diabetes? And that's how we get off in this. We're now in the extreme arm of this distortion of our medical knowledge of studying how to sell more drugs than how to make people more healthy.

That's A really great thing to compare it to is lifestyle changes, because that should be the bar. If you do some basic diet, exercise, all those kinds of things, how does this drug compare to that?

Right, right. And that study was done actually in the 90s. It's called the Diabetes Prevention Program. It was federally funded by the nih, so that there wasn't this drug company imperative to just try to prove your drug was better than nothing. And it was a very well designed study, randomized controlled trial in people who were at high risk of diabetes, so called pre diabetics. And, and they were randomized to three different groups. A placebo group, a group that got treated with metformin, and a group that got treated with intensive lifestyle counseling. So this study really tested whether you can get people in a randomized controlled trial assigned to intensive lifestyle changes, whether that works. Now the common wisdom amongst physicians and I think in general is that you can't get people to change. You know, you can do whatever you want, you can stand on your head, you can beg and plead. People won't change. So give it up and let's just move on with the drugs and not waste any time. Except this study that was published in the New England Journal, I think in 2002 shows that's wrong. That the people who were the in the intensive lifestyle group ended up losing 10 pounds, exercising five times a week, maintaining it, and reduced their risk of di getting diabetes by 58% compared to the metformin group which reduced its risk of getting diabetes by 31%. So that exact study was done and it showed that lifestyle intervention is the winner.

Who as a small tangent, is the leader who is supposed to fight for the side of lifestyle changes? Where's the big pharma version of lifestyle changes? Who's supposed to have the big bully pulpit, the big money behind lifestyle changes in your sense? Because that seems to be missing in a lot of our discussions about health policy.

Right? That's exactly right. And the answer is that we assume that the market has to solve all of these problems and the market can't solve all of these problems. There needs to be some way of protecting the public interest for things that aren't financially driven. So that the overriding question has to be how best to improve Americans health, not companies funding studies to try and prove that their new inexpensive drug is better and should be used.

Well, some of that is also people sort of like yourself. I mean, it's funny you spoke with Joe Rogan, he constantly espouses lifestyle changes. So some of it is Almost like.

Understanding the problems that Big Pharma is.

Creating society and then sort of these.

Influential voices speaking up against it.

So whether they're scientists or just regular communicators.

Yeah, I think you got to tip your hat to Joe for getting that message out. And he clearly believes it and does his best, but it's not coming out in the legitimate avenues, in the legitimate channels that are evidence based medicine and the, from the sources that the docs are trained to listen to and, and modify their patient care on. Now it's not 100%. I mean there are articles in, in, in the big journals about the benefits of lifestyle, but they don't carry the same gravitas as the randomized controlled trials that test this drug against placebo or this drug against another drug. So the Joe Rogans of the world keep going. You know, I tip my hat, but it's not going to carry the day for most of the people until it has the legitimacy of the medical establishment.

Yeah, like something that the doctors really pay attention to. Well, there's, there's an entire mechanism established for testing drugs. There's not an entire mechanism established in terms of scientific rigor of testing lifestyle changes. I mean it's more difficult. I mean everything is difficult in science, with science that involves humans especially. But it's just these studies are very expensive, they're difficult. It's difficult to find conclusions and to control all the variables. And so it's very easy to dismiss them unless you really do a huge study that's very well funded. And so maybe the doctors just lean towards the simpler studies over and over, which is what the drug companies fund. They can control more variables. See, but the control there is sometimes by hiding things too.

Right.

So sometimes you can just say that this is a well controlled study by pretending there's a bunch of other stuff, just ignoring the stuff that could be correlated, it could be the real cause of the effects. You're seeing all that kind of stuff. So money can buy ignorance. I suppose in science it buys kind.

Of blinders that are on that don't look outside the reductionist model. And that's another issue is that we kind of. Nobody says to doctors in training only listen to reductionists studies and conclusions and methods of promoting health. Nobody says that explicitly but the respectable science has to do with controlling the factors. And I mean it just doesn't make sense to me. I'm going to pick on trulicity because it's such an obvious example, but it's not more egregious. Than many others. It doesn't make sense to me to allow a drug to be advertised as preventing cardiovascular disease when you haven't included lifestyle changes as an arm in the study. It's just so crystal clear that the purpose of that study is to sell trulicity. It's not to prevent cardiovascular disease. If we were in charge, I would try to convince you that anywhere that study, the results of that study were presented to physicians, it would be stamped in big red letters. This study did not compare trulicity to lifestyle changes. They need to know that. And the docs are kind of trained. These blinders get put on and they're trained to kind of forget that that's not there.

Do you think so? First of all, that's a small or big change to advertisement that seems obvious to say, like in force that it should be compared to lifestyle changes. Do you think advertisements, period in the.

United States for pharmaceutical drugs should be banned?

I think they can't be banned, so it doesn't matter what I think.

Okay, let's say you were a dictator. And two, why can't they be banned? Okay, answer either.

One, I believe I've been told by lawyers who I trust that the freedom of speech in the US Constitution is such that you can't ban them, that you could ban cigarettes and alcohol, which have no therapeutic use, but drugs have a therapeutic use and advertisements about them can't be banned. Let's assume that they can't be because we know they won't be anyway. But let's assume they can't be and especially our Supreme Court now would be unlikely to take that seriously. But that's not the issue. The issue is that if drugs want to, if the drug companies want to spend their money advertising, they should have to have independent analysis of the message that the viewers are left with about the drug so that it's realistic. What's the chance the drug will help them? Well, In Trulicity, it's 1 out of 323, 322 people aren't going to benefit from the cardiovascular risk reduction. What's the true cost when drugs advertise that you may be able to get this for a $25 co pay or something, tens of thousands of dollars a year drug for $25 copay. What an enormous disservice that is to misrepresent the cost to society. That should not be allowed. So you should have to make it clear to the viewers how many people are going to benefit. What's your chance of benefiting? How does it compare to lifestyle changes or less expensive therapies. What do you give up if you use a less expensive therapy or gain.

Perhaps and how much it costs, how much it costs.

Now that can go either way because if you say Humira costs $72,000 and it's no more effective as a first line drug than methotrexate which costs $480, people might say I want the expensive drug because I can get it for a $25 copay. So you'd have to temper that a little bit.

Oh, you mean people are so they don't care.

They don't care. Their insurance is going to cover it and then. And it's a 25 copay. But we could figure out how to deal with that. The, the main point is that if we assume that advertisements are going to keep going and they are, we could require that there be outside evaluation of the message that reasonable unbiased viewers take away from the ads. And the ads would have to tell the truth about the drug.

And the truth should have like sub truth guardrails, meaning like the cost that we talked about, the effects compared to things that actually, you know, lifestyle changes, just these details, very strict guardrails of what actually has to be specified.

And I would make it against the law to have family picnics or dogs catching frisbees in the ads.

So you mean 95% of the ads. Yes. I mean there's something dark and inauthentic about those advertisements, but they seem, I mean I'm sure they're being done because they work for the target audience.

And then the doctors too.

Can you really buy a doctor's opinion? Why does it have such an effect on doctors? Advertisement to doctors like you as a physician, again, like from everything I've seen, people love you and I've just. People should definitely look you up from. There's a bunch of videos of you giving talks on YouTube and it's just, it's so refreshing to hear just a clarity of thought about health policy, about healthcare, just the way you think throughout the years.

Thank you.

So it's easy to think about. Maybe you're criticizing big Pharma. That's one part of the message that you're talking about. But that's not like your brilliance actually shines in, in the positive, in the solutions and how to do it. So as a doctor, what affects your mind? Yeah. And how does big pharma affect your mind?

Number one, the information that comes through legitimate sources that doctors have been taught to rely on evidence based medicine the articles in peer reviewed journals, the guidelines that are issued now, those are problematic because when an article is peer reviewed and published in a respected journal, people and doctors obviously assume that the peer reviewers have anal, have had access to the data and they've independently analyzed the data and they corroborate the findings in the manuscript that was submitted, or they give feedback to the authors and say, we disagree with you on this point and would you please check our analysis and if you agree with us, make it. That's what they assume the peer review process is. But it's not. The peer reviewers don't have the data. The peer reviewers have the manuscript that's been submitted by the, usually in conjunction with or by the drug company that manufactures the drug. So peer reviewers are unable to perform the job that doctors think they're performing to vet the data to assure that it's accurate and reasonably complete. They can't do it. And then we have the clinical practice guidelines, which are increasingly more important as the information, the flow of information keeps getting brisker and brisker and docs need to get to the bottom line quickly. Clinical practice guidelines become much more important. And we assume that the authors of those clinical practice guidelines have independently analyzed the data from the clinical trials and make their recommendations that set the standards of care based on their analysis. That's not what happens. The experts who write the clinical trials rely almost entirely on the publications presenting the results of the clinical trials, which are peer reviewed. But the peer reviewers haven't had access to the data. So we've got a system of the highest level of evidence that doctors have been trained over and over again to rely on, to practice evidence based medicine, to be good doctors. That has not been verified.

Do you think that data that's coming from the pharma companies, do you think they're. What level of manipulation is going on with that data? Is it at the study design level?

Is it at.

Literally there's some data that you just keep off, you know, keep out of the charts, keep out of the aggregate analysis, then you then publish. Or is it the worst case, which is just change some of the numbers?

It happened, all three happen. I can't. I don't know what the denominator is, but I spent about 10 years in litigation and for example, in Vioxx, which was withdrawn from the market in 2004 in the biggest drug recall in American history, the problem was that it got recalled.