John Abramson: Big Pharma - Lex Fridman 知识图谱

Lex Fridman (01:21.840)

I want to understand why atrocities are committed

John Abramson (01:24.620)

by crowds that believe they're doing good.

Lex Fridman (01:27.240)

All this, ultimately, because I want to understand

Lex Fridman (01:30.720)

how we can build a better world together,

Lex Fridman (01:33.240)

to find hope for the future,

Lex Fridman (01:35.400)

and to rediscover each time,

Lex Fridman (01:38.520)

through the exploration of ideas,

John Abramson (01:40.880)

just how beautiful this life is.

Lex Fridman (01:43.340)

This, our human civilization,

John Abramson (01:45.360)

in all of its full complexity,

Lex Fridman (01:47.640)

the forces of good and evil,

John Abramson (01:49.280)

of war and peace, of hate and love.

Lex Fridman (01:53.400)

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

John Abramson (01:55.560)

that is not open, fragile, and willing to empathize

Lex Fridman (01:59.040)

with all human beings,

John Abramson (02:00.920)

even those in the darkest corners of our world.

Lex Fridman (02:04.400)

To attack is easy.

John Abramson (02:06.760)

To understand is hard.

Lex Fridman (02:09.520)

And I choose the hard path.

John Abramson (02:11.800)

I have learned over the past few months

Lex Fridman (02:13.840)

that this path involves me getting more and more attacked

John Abramson (02:17.360)

from all sides.

Lex Fridman (02:19.000)

I will get attacked when I host people

John Abramson (02:21.600)

like Jay Bhattacharya or Francis Collins,

Lex Fridman (02:24.500)

Jamie Merzl or Vincent Ricanello,

John Abramson (02:28.120)

when I stand for my friend, Joe Rogan,

Lex Fridman (02:31.840)

when I host tech leaders like Mark Zuckerberg,

John Abramson (02:34.720)

Elon Musk, and others,

Lex Fridman (02:36.400)

when I eventually talk to Vladimir Putin, Barack Obama,

Lex Fridman (02:40.800)

and other figures that have turned the tides of history.

Lex Fridman (02:44.920)

I have and I will get called stupid, naive, weak,

Lex Fridman (02:50.800)

and I will take these words

Lex Fridman (02:52.520)

with respect, humility, and love, and I will get better.

John Abramson (02:57.200)

I will listen, think, learn, and improve.

Lex Fridman (03:00.680)

One thing I can promise is there's no amount of money

John Abramson (03:04.520)

or fame that can buy my opinion

Lex Fridman (03:06.920)

or make me go against my principles.

John Abramson (03:09.280)

There's no amount of pressure that can break my integrity.

Lex Fridman (03:13.480)

There's nothing in this world I need

John Abramson (03:16.120)

that I don't already have.

Lex Fridman (03:18.540)

Life itself is the fundamental gift.

John Abramson (03:21.440)

Everything else is just the bonus.

Lex Fridman (03:24.520)

That is freedom.

John Abramson (03:26.640)

That is happiness.

Lex Fridman (03:28.680)

If I die today, I will die a happy man.

John Abramson (03:33.040)

Now, a few comments about my approach

Lex Fridman (03:35.960)

and lessons learned from the Albert Bourla conversation.

John Abramson (03:39.560)

The goal was to reveal as much as I could

Lex Fridman (03:41.880)

about the human being before me

Lex Fridman (03:43.920)

and to give him the opportunity to contemplate in long form

Lex Fridman (03:48.120)

the complexities of his role,

John Abramson (03:49.920)

including the tension between making money

Lex Fridman (03:53.200)

and helping people, the corruption

John Abramson (03:55.320)

that so often permeates human institutions,

Lex Fridman (03:58.180)

the crafting of narratives through advertisements,

Lex Fridman (04:00.800)

and so on.

Lex Fridman (04:02.400)

I only had one hour,

Lex Fridman (04:04.040)

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

Lex Fridman (04:07.440)

but to show if Albert struggled with them

John Abramson (04:10.200)

in the privacy of his own mind,

Lex Fridman (04:12.240)

and if he would let down the veil of political speak

John Abramson (04:16.280)

for a time to let me connect with a man

Lex Fridman (04:19.400)

who decades ago chose to become a veterinarian,

John Abramson (04:22.560)

who wanted to help lessen the amount of suffering

Lex Fridman (04:24.840)

in the world.

John Abramson (04:26.300)

I had no pressure placed on me.

Lex Fridman (04:28.400)

There were no rules.

John Abramson (04:29.760)

The questions I was asking were all mine

Lex Fridman (04:32.120)

and not seen by Pfizer folks.

John Abramson (04:34.120)

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

Lex Fridman (04:38.700)

None of this was part of the calculation

John Abramson (04:41.820)

in my limited brain computer.

Lex Fridman (04:44.140)

I didn't want to grill him.

John Abramson (04:45.920)

The way politicians grill CEOs in Congress,

Lex Fridman (04:48.920)

I thought that this approach is easy,

John Abramson (04:51.400)

self serving, dehumanizing, and it reveals nothing.

Lex Fridman (04:56.240)

I wanted to reveal the genuine intellectual struggle,

John Abramson (04:59.000)

vision, and motivation of a human being,

Lex Fridman (05:01.400)

and if that fails, I trusted the listener

John Abramson (05:04.280)

to draw their own conclusion and insights from the result,

Lex Fridman (05:08.080)

whether it's the words spoken

John Abramson (05:10.080)

or the words left unspoken or simply the silence.

Lex Fridman (05:14.480)

And that's just it.

John Abramson (05:15.800)

I fundamentally trust the intelligence of the listener, you.

Lex Fridman (05:21.920)

In fact, if I criticize the person too hard

John Abramson (05:24.880)

or celebrate the person too much,

Lex Fridman (05:26.840)

I feel I fail to give the listener

John Abramson (05:29.320)

a picture of the human being that is uncontaminated

Lex Fridman (05:32.800)

by my opinion or the opinion of the crowd.

John Abramson (05:36.480)

I trust that you have the fortitude and the courage

Lex Fridman (05:39.320)

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

John Abramson (05:43.280)

Two practical lessons I took away.

Lex Fridman (05:46.400)

First, I will more strongly push

John Abramson (05:48.520)

for longer conversations of three, four, or more hours

Lex Fridman (05:52.000)

versus just one hour.

John Abramson (05:53.480)

60 minutes is too short for the guest to relax

Lex Fridman (05:56.000)

and to think slowly and deeply,

Lex Fridman (05:58.280)

and for me to ask many follow up questions

Lex Fridman (06:00.880)

or follow interesting tangents.

John Abramson (06:03.000)

Ultimately, I think it's in the interest of everyone,

Lex Fridman (06:05.920)

including the guest, that we talk in true long form

John Abramson (06:09.640)

for many hours.

Lex Fridman (06:11.600)

Second, these conversations with leaders

John Abramson (06:13.840)

can be aided by further conversations

Lex Fridman (06:16.160)

with people who wrote books about those leaders

John Abramson (06:18.760)

or their industries.

Lex Fridman (06:20.440)

Those that can steel man each perspective

Lex Fridman (06:22.440)

and attempt to give an objective analysis.

Lex Fridman (06:25.160)

I think of Teddy Roosevelt's speech

John Abramson (06:26.840)

about the man in the arena.

Lex Fridman (06:28.520)

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

Lex Fridman (06:32.400)

and the critics and the supporters in the stands.

Lex Fridman (06:36.120)

For the former, I lean toward wanting to understand

John Abramson (06:38.880)

one human being's struggle with the ideas.

Lex Fridman (06:43.360)

For the latter, I lean towards understanding

John Abramson (06:45.960)

the ideas themselves.

Lex Fridman (06:48.400)

That's why I wanted to have this conversation

John Abramson (06:50.320)

with John Abramson, who is an outspoken critic

Lex Fridman (06:53.640)

of the pharmaceutical industry.

John Abramson (06:55.600)

I hope it helps add context and depth

Lex Fridman (06:58.840)

to the conversation I had with the Pfizer CEO.

John Abramson (07:02.320)

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

Lex Fridman (07:06.680)

Always, I will listen to the criticisms without ego

Lex Fridman (07:10.080)

and I promise I will work hard to improve.

Lex Fridman (07:14.640)

But let me say finally that cynicism is easy.

John Abramson (07:20.040)

Optimism, true optimism is hard.

Lex Fridman (07:24.480)

It is the belief that we can and we will

John Abramson (07:28.160)

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

Lex Fridman (07:32.720)

This is the fight worth fighting.

Lex Fridman (07:35.000)

So here we go.

Lex Fridman (07:36.520)

Once more into the breach, dear friends.

John Abramson (07:39.160)

I love you all.

Lex Fridman (07:41.680)

This is the Lex Friedman podcast.

John Abramson (07:43.880)

To support it, please check out our sponsors

Lex Fridman (07:46.000)

in the description.

Lex Fridman (07:47.280)

And now, here's my conversation with John Abramson.

Lex Fridman (07:52.320)

Your faculty at Harvard Medical School,

John Abramson (07:55.200)

your family physician for over two decades,

Lex Fridman (07:57.800)

rated one of the best family physicians in Massachusetts,

John Abramson (08:01.120)

you wrote the book, Overdose to America,

Lex Fridman (08:03.400)

and the new book coming out now called Sickening

John Abramson (08:07.360)

about how Big Pharma broke American healthcare,

Lex Fridman (08:10.080)

including science and research, and how we can fix it.

John Abramson (08:14.720)

First question, what is the biggest problem with Big Pharma

Lex Fridman (08:18.720)

that it fixed would be the most impactful?

Lex Fridman (08:21.800)

So if you can snap your fingers and fix one thing,

Lex Fridman (08:24.920)

what would be the most impactful, you think?

John Abramson (08:26.760)

The biggest problem is the way they

Lex Fridman (08:30.040)

determine the content, the accuracy,

Lex Fridman (08:35.560)

and the completeness of what doctors believe

Lex Fridman (08:39.560)

to be the full range of knowledge

John Abramson (08:42.520)

that they need to best take care of their patients.

Lex Fridman (08:46.000)

So that with the knowledge having been taken over

John Abramson (08:51.440)

by the commercial interests, primarily

Lex Fridman (08:53.840)

the pharmaceutical industry, the purpose of that knowledge

John Abramson (08:57.400)

is to maximize the profits that get returned

Lex Fridman (09:00.720)

to investors and shareholders, and not to optimize

John Abramson (09:04.920)

the health of the American people.

Lex Fridman (09:07.220)

So rebalancing that equation would be the most important

John Abramson (09:11.440)

thing to do to get our healthcare back aimed

Lex Fridman (09:15.120)

in the right direction.

John Abramson (09:16.440)

Okay, so there's a tension between helping people

Lex Fridman (09:20.680)

and making money, so if we look at particularly

John Abramson (09:24.520)

the task of helping people in medicine, in healthcare,

Lex Fridman (09:29.680)

is it possible if money is the primary sort of mechanism

John Abramson (09:35.440)

by which you achieve that as a motivator,

Lex Fridman (09:38.300)

is it possible to get that right?

John Abramson (09:39.840)

I think it is, Lex, but I think it is not possible

Lex Fridman (09:43.120)

without guardrails that maintain the integrity

Lex Fridman (09:46.760)

and the balance of the knowledge.

Lex Fridman (09:48.760)

Without those guardrails, it's like trying to play

John Abramson (09:52.000)

a professional basketball game without referees

Lex Fridman (09:54.840)

and having players call their own fouls.

Lex Fridman (09:57.600)

But the players are paid to win, and you can't count

Lex Fridman (10:01.000)

on them to call their own fouls, so we have referees

John Abramson (10:03.760)

who are in charge.

Lex Fridman (10:05.080)

We don't have those referees in American healthcare.

John Abramson (10:08.180)

That's the biggest way that American healthcare

Lex Fridman (10:13.800)

is distinguished from healthcare in other wealthy nations.

Lex Fridman (10:17.520)

So okay, you mentioned Milton Friedman,

Lex Fridman (10:19.680)

and you mentioned his book called Capitalism and Freedom.

John Abramson (10:24.280)

He writes that there are only three legitimate functions

Lex Fridman (10:27.220)

of government to preserve law and order,

John Abramson (10:30.120)

to enforce private contracts, and to ensure

Lex Fridman (10:33.800)

that private markets work.

John Abramson (10:36.840)

You said that that was a radical idea at the time,

Lex Fridman (10:40.160)

but we're failing on all three.

Lex Fridman (10:41.840)

How are we failing?

Lex Fridman (10:43.720)

And also maybe the bigger picture is what are the strengths

Lex Fridman (10:47.560)

and weaknesses of capitalism when it comes to medicine

Lex Fridman (10:50.880)

and healthcare?

Lex Fridman (10:51.840)

Can we separate those out?

Lex Fridman (10:53.120)

Because those are two huge questions.

Lex Fridman (10:55.200)

So how we're failing on all three,

Lex Fridman (10:58.080)

and these are the minimal functions that our guru

John Abramson (11:03.320)

of free market capitalism said the government

Lex Fridman (11:06.740)

should perform, so this is the absolute baseline.

John Abramson (11:11.240)

On preserving law and order, the drug companies

Lex Fridman (11:14.800)

routinely violate the law in terms of their marketing,

Lex Fridman (11:20.160)

and in terms of their presentation

Lex Fridman (11:26.360)

of the results of their trials.

John Abramson (11:29.160)

I know this because I was an expert in litigation

Lex Fridman (11:32.920)

for about 10 years.

John Abramson (11:35.860)

I presented some of what I learned in civil litigation

Lex Fridman (11:40.000)

to the FBI and the Department of Justice,

Lex Fridman (11:42.440)

and that case led to the biggest criminal fine

Lex Fridman (11:46.360)

in US history as of 2009.

Lex Fridman (11:49.880)

And I testified in a federal trial in 2010,

Lex Fridman (11:56.120)

and the jury found Pfizer guilty of fraud

Lex Fridman (12:00.020)

and racketeering violations.

Lex Fridman (12:02.360)

In terms of violating the law, it's a routine occurrence.

John Abramson (12:07.480)

The drug companies have paid $38 billion worth of fines

Lex Fridman (12:10.800)

from I think 1991 to 2017.

John Abramson (12:15.760)

It's never been enough to stop the misrepresentation

Lex Fridman (12:21.360)

of their data, and rarely are the fines greater

John Abramson (12:25.640)

than the profits that were made.

Lex Fridman (12:29.520)

Executives have not gone to jail for misrepresenting data

John Abramson (12:34.160)

that have involved even tens of thousands of deaths

Lex Fridman (12:38.460)

in the case of Vioxx, OxyContin as well.

Lex Fridman (12:42.120)

And when companies plead guilty to felonies,

Lex Fridman (12:45.520)

which is not an unusual occurrence,

John Abramson (12:48.360)

the government usually allows the companies,

Lex Fridman (12:51.240)

the parent companies, to allow subsidiaries to take the plea

Lex Fridman (12:56.000)

so that they are not one step closer

Lex Fridman (12:58.880)

to getting disbarred from Medicare,

John Abramson (13:01.260)

not being able to participate in Medicare.

Lex Fridman (13:03.360)

So in that sense, there is a mechanism

John Abramson (13:11.000)

that is appearing to impose law and order

Lex Fridman (13:15.020)

on drug company behavior, but it's clearly not enough.

John Abramson (13:18.140)

It's not working.

Lex Fridman (13:19.480)

Can you actually speak to human nature here?

Lex Fridman (13:24.580)

Are people corrupt?

Lex Fridman (13:26.320)

Are people malevolent?

John Abramson (13:28.400)

Are people ignorant that work at the low level

Lex Fridman (13:32.880)

and at the high level at Pfizer, for example,

Lex Fridman (13:36.480)

at big pharma companies, how is this possible?

Lex Fridman (13:40.440)

So I believe, just on a small tangent,

John Abramson (13:43.280)

that most people are good.

Lex Fridman (13:45.240)

And I actually believe if you join big pharma,

Lex Fridman (13:48.920)

so a company like Pfizer, your life trajectory

Lex Fridman (13:52.600)

often involves dreaming and wanting

Lex Fridman (13:56.320)

and enjoying helping people.

Lex Fridman (13:58.920)

Yes.

Lex Fridman (13:59.760)

And so, and then we look at the outcomes

Lex Fridman (14:03.440)

that you're describing, and it looks,

Lex Fridman (14:07.040)

and that's why the narrative takes hold

Lex Fridman (14:09.400)

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

John Abramson (14:15.440)

The sense is these companies are evil.

Lex Fridman (14:19.520)

So if the different parts, the people, are good

Lex Fridman (14:24.520)

and they want to do good, how are we getting these outcomes?

Lex Fridman (14:27.380)

Yeah, I think it has to do with the cultural milieu

John Abramson (14:33.140)

that this is unfolding in.

Lex Fridman (14:35.320)

And we need to look at sociology to understand this,

John Abramson (14:41.440)

that when the cultural milieu is set up

Lex Fridman (14:49.340)

to maximize the returns on investment

John Abramson (14:52.560)

for shareholders and other venture capitalists

Lex Fridman (14:55.440)

and hedge funds and so forth,

John Abramson (14:57.520)

when that defines the culture

Lex Fridman (15:00.640)

and the higher up you are in the corporation,

John Abramson (15:04.240)

the more you're in on the game of getting rewarded

Lex Fridman (15:10.080)

for maximizing the profits of the investors,

John Abramson (15:13.040)

that's the culture they live in.

Lex Fridman (15:15.760)

And it becomes normative behavior

John Abramson (15:19.700)

to do things with science that look normal

Lex Fridman (15:25.640)

in that environment and are shared values

John Abramson (15:28.520)

within that environment by good people

Lex Fridman (15:31.240)

whose self evaluation becomes modified

John Abramson (15:34.920)

by the goals that are shared by the people around them.

Lex Fridman (15:39.080)

And within that milieu, you have one set of standards,

Lex Fridman (15:44.760)

and then the rest of good American people

Lex Fridman (15:48.680)

have the expectation that the drug companies

John Abramson (15:50.720)

are trying to make money, but that they're playing

Lex Fridman (15:53.480)

by rules that aren't part of the insider milieu.

John Abramson (15:59.560)

That's fascinating, the game they're playing

Lex Fridman (16:02.920)

modifies the culture of inside the meetings,

John Abramson (16:07.480)

inside the rooms, day to day,

Lex Fridman (16:10.620)

that there's a bubble that forms.

John Abramson (16:12.440)

Like we're all in bubbles of different sizes.

Lex Fridman (16:15.660)

And that bubble allows you to drift in terms

John Abramson (16:18.840)

of what you see as ethical and unethical.

Lex Fridman (16:24.200)

Because you see the game as just part of the game.

Lex Fridman (16:28.520)

So marketing is just part of the game.

Lex Fridman (16:32.040)

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

Lex Fridman (16:36.520)

And without guardrails, it becomes

Lex Fridman (16:40.880)

even more part of the game.

John Abramson (16:42.200)

You keep moving in that direction.

Lex Fridman (16:44.660)

If you're not bumping up against guardrails.

Lex Fridman (16:48.160)

And I think that's how we've gotten

Lex Fridman (16:49.900)

to the extreme situation we're in now.

John Abramson (16:53.400)

So, like I mentioned, I spoke with Pfizer CEO,

Lex Fridman (16:57.200)

Albert Berla, and I'd like to raise with you

John Abramson (17:00.960)

some of the concerns I raised with him.

Lex Fridman (17:03.840)

So one, you already mentioned, I raised the concern

John Abramson (17:07.120)

that Pfizer's engaged in aggressive advertising campaigns.

Lex Fridman (17:11.220)

As you can imagine, he said no.

Lex Fridman (17:15.520)

What do you think?

Lex Fridman (17:18.440)

I think you're both right.

John Abramson (17:21.360)

I think that the, I agree with you,

Lex Fridman (17:23.720)

that the aggressive advertising campaigns

John Abramson (17:27.780)

do not add value to society.

Lex Fridman (17:30.540)

And I agree with him that they're, for the most part, legal.

Lex Fridman (17:34.980)

And it's the way the game is played.

Lex Fridman (17:37.000)

Right, so, sorry to interrupt,

Lex Fridman (17:38.640)

but oftentimes his responses are,

Lex Fridman (17:44.880)

especially now, he's been CEO for only like two years,

John Abramson (17:47.640)

three years, he says Pfizer was a different company,

Lex Fridman (17:50.560)

we've made mistakes, right, in the past.

John Abramson (17:53.880)

We don't make mistakes anymore.

Lex Fridman (17:56.380)

That there's rules, and we play by the rules.

Lex Fridman (18:00.380)

So like, with every concern raised,

Lex Fridman (18:02.800)

there's very, very strict rules, as he says.

John Abramson (18:06.060)

In fact, he says sometimes way too strict.

Lex Fridman (18:08.520)

And we play by them.

Lex Fridman (18:10.200)

And so in that sense, advertisement,

Lex Fridman (18:12.180)

it doesn't seem like it's too aggressive,

John Abramson (18:14.320)

because it's playing by the rules.

Lex Fridman (18:17.600)

And relative to the other, again, it's the game.

John Abramson (18:19.800)

Relative to the other companies,

Lex Fridman (18:22.160)

it's actually not that aggressive.

John Abramson (18:24.920)

Relative to the other big pharma companies.

Lex Fridman (18:26.480)

Yes, yes, I hope we can quickly get back

John Abramson (18:29.560)

to whether or not they're playing by the rules,

Lex Fridman (18:31.280)

but in general.

Lex Fridman (18:32.760)

But let's just look at the question

Lex Fridman (18:34.360)

of advertising specifically.

John Abramson (18:36.640)

I think that's a good example of what it looks like

Lex Fridman (18:39.620)

from within that culture, and from outside that culture.

John Abramson (18:44.880)

He's saying that we follow the law on our advertising.

Lex Fridman (18:49.800)

We state the side effects,

Lex Fridman (18:51.520)

and we state the FDA approved indications,

Lex Fridman (18:53.960)

and we do what the law says we have to do for advertising.

Lex Fridman (18:57.720)

And I have not, I've not been an expert in litigation

Lex Fridman (19:01.780)

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

Lex Fridman (19:04.960)

but let's take him at his word.

Lex Fridman (19:07.080)

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

Lex Fridman (19:09.920)

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

Lex Fridman (19:15.480)

that's ethical business behavior.

John Abramson (19:18.160)

From a common sense person's point of view,

Lex Fridman (19:22.560)

a drug company paying highly skilled media folks

John Abramson (19:27.200)

to take the information about the drug

Lex Fridman (19:30.440)

and create the illusion, the emotional impact,

Lex Fridman (19:34.400)

and the takeaway message for viewers of advertisements

Lex Fridman (19:38.000)

that grossly exaggerate the benefit of the drug

Lex Fridman (19:41.200)

and minimize the harms, it's sociopathic behavior

Lex Fridman (19:45.400)

to have viewers of ads leave the ad

John Abramson (19:49.960)

with an unrealistic impression

Lex Fridman (19:52.960)

of the benefits and harms of the drug.

Lex Fridman (19:56.200)

And yet he's playing by the rules,

Lex Fridman (19:58.880)

he's doing his job as CEO

Lex Fridman (1:00:00.020)

And if we release it,

Lex Fridman (1:00:02.100)

surely the world will discover the embarrassing

Lex Fridman (1:00:04.380)

and to do a sort of the steel man their argument.

Lex Fridman (1:00:08.860)

They'll take the small, the press,

John Abramson (1:00:11.660)

the people will take the small embarrassing things

Lex Fridman (1:00:14.420)

and blow them up into big things.

John Abramson (1:00:16.380)

Yes, and support the anti vax campaign.

Lex Fridman (1:00:20.260)

I think that's all possible.

John Abramson (1:00:22.660)

Nonetheless, the data are about the original clinical trial.

Lex Fridman (1:00:27.860)

And the emergency use authorization was based

John Abramson (1:00:33.340)

on the first few months of the data from that trial.

Lex Fridman (1:00:36.140)

And it was a two year trial.

John Abramson (1:00:37.780)

The rest of that data has not been opened up

Lex Fridman (1:00:40.140)

and there was not an advisory committee meeting

John Abramson (1:00:43.460)

to look at that data

Lex Fridman (1:00:44.940)

when the FDA granted full authorization.

John Abramson (1:00:47.340)

Again, I am pro vaccine.

Lex Fridman (1:00:49.220)

I am not making an anti vax argument here.

Lex Fridman (1:00:52.540)

But I suspect that there's something pretty serious

Lex Fridman (1:00:56.060)

in that data.

Lex Fridman (1:00:57.380)

And the reason why I'm not an anti vaxxer,

Lex Fridman (1:01:00.980)

having not been able to see the data

John Abramson (1:01:03.380)

that the FDA and Pfizer seem to willing

Lex Fridman (1:01:06.020)

not just to put effort into preventing the release of,

Lex Fridman (1:01:09.940)

but seem to have quite a bit of energy

Lex Fridman (1:01:12.100)

into preventing, invest quite a bit of energy

John Abramson (1:01:15.140)

in not releasing that data.

Lex Fridman (1:01:16.460)

The reason why that doesn't tip me over

John Abramson (1:01:18.380)

into the anti vaxxer side

Lex Fridman (1:01:20.180)

is because that's clinical trial data,

John Abramson (1:01:22.380)

early clinical trial data

Lex Fridman (1:01:23.660)

that involved several thousand people.

John Abramson (1:01:25.780)

We now have millions of data points

Lex Fridman (1:01:28.900)

from people who have had the vaccine.

John Abramson (1:01:31.060)

This is real world data,

Lex Fridman (1:01:32.900)

showing the efficacy of the vaccines.

Lex Fridman (1:01:35.700)

And so far, knock on wood,

Lex Fridman (1:01:38.100)

there aren't side effects

John Abramson (1:01:41.220)

that overcome the benefits of vaccine.

Lex Fridman (1:01:45.100)

So I'm with you.

John Abramson (1:01:46.500)

I'm now, I guess, three shots of the vaccine.

Lex Fridman (1:01:53.180)

But there's a lot of people that are kind of saying,

John Abramson (1:01:55.740)

well, even the data on the real world use large scale data

Lex Fridman (1:02:03.980)

is messy.

John Abramson (1:02:05.660)

The way it's being reported,

Lex Fridman (1:02:06.820)

the way it's being interpreted.

John Abramson (1:02:08.780)

Well, one thing is clear to me

Lex Fridman (1:02:11.500)

that it is being politicized.

John Abramson (1:02:13.820)

I mean, if you just look objectively,

Lex Fridman (1:02:17.120)

don't have to go to at the shallow surface level.

John Abramson (1:02:21.740)

It seems like there's two groups

Lex Fridman (1:02:25.180)

that I can't even put a term to it

John Abramson (1:02:29.020)

because it's not really pro vaccine versus anti vaccine

Lex Fridman (1:02:32.140)

because it's pro vaccine, triple mask, Democrat, liberal,

Lex Fridman (1:02:41.140)

and then anti mandate, whatever those groups are.

Lex Fridman (1:02:44.700)

I can't quite, cause they're changing.

John Abramson (1:02:46.540)

Anti mask, but not really, but kind of.

Lex Fridman (1:02:50.380)

So those two groups that feel political in nature,

John Abramson (1:02:53.260)

not scientific in nature, they're bickering.

Lex Fridman (1:02:56.700)

And then it's clear that this data is being interpreted

John Abramson (1:03:01.200)

by the different groups differently.

Lex Fridman (1:03:04.020)

And it's very difficult for me as a human being

John Abramson (1:03:07.460)

to understand where the truth lies,

Lex Fridman (1:03:11.180)

especially given how much money is flying around

John Abramson (1:03:14.060)

on all sides.

Lex Fridman (1:03:15.380)

So the anti vaxxers can make a lot of money too.

John Abramson (1:03:19.380)

Let's not forget this.

Lex Fridman (1:03:20.220)

From the individual perspective,

John Abramson (1:03:22.500)

you can become famous being an anti vaxxer.

Lex Fridman (1:03:25.260)

And so there's a lot of incentives on all sides here.

Lex Fridman (1:03:28.060)

And there's real human emotion and fear

Lex Fridman (1:03:33.300)

and also credibility.

John Abramson (1:03:37.620)

Scientists don't wanna ruin their reputation

Lex Fridman (1:03:41.100)

if they speak out in whatever, like speak their opinion

John Abramson (1:03:45.340)

or they look at some slice of the data

Lex Fridman (1:03:49.540)

and begin to interpret it in some kind of way.

John Abramson (1:03:51.300)

They're very, it's clear that fear is dominating

Lex Fridman (1:03:53.740)

the discourse here, especially in the scientific community.

Lex Fridman (1:03:57.020)

So I don't know what to make of that.

Lex Fridman (1:04:01.860)

And the only happy people here is Pfizer.

John Abramson (1:04:06.780)

It's just plowing all ahead.

Lex Fridman (1:04:08.660)

I mean, with every single variant,

John Abramson (1:04:13.240)

there's very, I would say, outside of arguably

Lex Fridman (1:04:20.300)

a very flawed system, there's a lot of incredible

John Abramson (1:04:23.260)

scientific and engineering work being done

Lex Fridman (1:04:25.760)

in constantly developing new, like antiviral drugs,

John Abramson (1:04:29.820)

new vaccines to deal with the variants.

Lex Fridman (1:04:33.380)

So they're happily being a capitalist machine.

Lex Fridman (1:04:37.540)

And it's very difficult to know what to do with that.

Lex Fridman (1:04:43.620)

And let's just put this in perspective for folks.

John Abramson (1:04:46.580)

The best selling drug in the world has been Humira

Lex Fridman (1:04:49.660)

for a number of years.

John Abramson (1:04:51.420)

It's approved for the treatment of rheumatoid arthritis

Lex Fridman (1:04:55.500)

and eight other indications.

Lex Fridman (1:04:57.740)

And it's sold about $20 billion globally

Lex Fridman (1:05:02.140)

over the past few years.

John Abramson (1:05:03.820)

It peaked at that level.

Lex Fridman (1:05:07.140)

Pfizer expects to sell $65 billion of vaccine

John Abramson (1:05:12.940)

in the first two years of the pandemic.

Lex Fridman (1:05:16.280)

So this is by far the biggest selling

Lex Fridman (1:05:19.960)

and most profitable drug that's ever come along.

Lex Fridman (1:05:22.700)

I can ask you a difficult question here.

John Abramson (1:05:28.480)

In the fog that we're operating in here,

Lex Fridman (1:05:34.320)

on the Pfizer BioNTech vaccine,

Lex Fridman (1:05:40.340)

what was done well and what was done badly

Lex Fridman (1:05:43.460)

that you can see now, it seems like we'll know

John Abramson (1:05:47.740)

more decades from now.

Lex Fridman (1:05:50.080)

Yes.

Lex Fridman (1:05:51.380)

But now in the fog of today with the $65 billion

Lex Fridman (1:05:57.860)

flying around, where do you land?

Lex Fridman (1:06:03.060)

So we're gonna get to what I think is one of the key problems

Lex Fridman (1:06:08.500)

with the pharmaceutical industry model in the United States

John Abramson (1:06:12.220)

about being profit driven.

Lex Fridman (1:06:15.040)

So in 2016, the NIH did the key infrastructure work

John Abramson (1:06:22.440)

to make mRNA vaccines.

Lex Fridman (1:06:26.920)

That gets left out of the discussion a lot.

Lex Fridman (1:06:29.320)

And Pfizer BioNTech actually paid royalties voluntarily

Lex Fridman (1:06:35.160)

to the NIH.

John Abramson (1:06:36.000)

I don't know how much it was.

Lex Fridman (1:06:36.920)

I don't think it was a whole lot of money,

Lex Fridman (1:06:38.540)

but I think they wanted to avoid the litigation

Lex Fridman (1:06:41.200)

that Moderna got itself into by just taking that 2016

John Abramson (1:06:45.880)

knowledge and having that be the foundation

Lex Fridman (1:06:48.780)

of their product.

Lex Fridman (1:06:50.120)

So Pfizer took that and they did their R&D,

Lex Fridman (1:06:54.640)

they paid for their R&D having received that technology.

Lex Fridman (1:06:59.160)

And when they got the genetic code from China

Lex Fridman (1:07:03.800)

about the virus, they very quickly made a vaccine

Lex Fridman (1:07:09.480)

and the vaccine works.

Lex Fridman (1:07:10.920)

And President Trump to his credit launched

John Abramson (1:07:14.520)

Operation Warp Speed and just threw money at the problem.

Lex Fridman (1:07:18.120)

They just said, we spent five times more per person

John Abramson (1:07:22.400)

than the EU early on, just pay them whatever they want.

Lex Fridman (1:07:26.840)

Let's just get this going.

Lex Fridman (1:07:28.360)

And Americans were vaccinated more quickly.

Lex Fridman (1:07:32.360)

We paid a lot of money.

John Abramson (1:07:34.160)

The one mistake that I think the federal government made

Lex Fridman (1:07:37.120)

was they were paying these guaranteed fortunes

Lex Fridman (1:07:41.000)

and they didn't require that the companies participate

Lex Fridman (1:07:45.320)

in a program to do global vaccinations.

Lex Fridman (1:07:50.080)

So the companies doing their business model

Lex Fridman (1:07:53.480)

distributed the vaccines where they would make

John Abramson (1:07:56.240)

the most money.

Lex Fridman (1:07:57.240)

And obviously they would make the most money

John Abramson (1:07:59.080)

in the first world.

Lex Fridman (1:08:00.000)

And almost I think 85% of the vaccines early on

John Abramson (1:08:04.240)

went to the first world and very, very few vaccinations

Lex Fridman (1:08:08.760)

went to the third world.

Lex Fridman (1:08:10.520)

So what happened is there was such a low vaccination rate

Lex Fridman (1:08:16.440)

in May of 2021, there was all hands on deck cry for help

John Abramson (1:08:23.040)

from the World Trade Organization,

Lex Fridman (1:08:26.520)

the World Health Organization, the IMF and the World Bank

John Abramson (1:08:31.480)

made a plea for $50 billion so that we could get

Lex Fridman (1:08:36.720)

to 40% vaccination rate in the third world

John Abramson (1:08:40.520)

by the end of 2021.

Lex Fridman (1:08:44.360)

And it was unrequited, nobody answered.

Lex Fridman (1:08:48.840)

And now Africa has about a 8.9% vaccination rate.

Lex Fridman (1:08:54.440)

India is coming up, but it's been very low.

John Abramson (1:08:57.080)

The problem with all this is I believe those mRNA vaccines

Lex Fridman (1:09:02.200)

are excellent vaccines.

Lex Fridman (1:09:04.680)

But if we leave the third world unvaccinated,

Lex Fridman (1:09:07.920)

we're gonna have a constant supply of variants of COVID

John Abramson (1:09:12.720)

that are gonna come back into the United States

Lex Fridman (1:09:15.760)

and harm Americans exactly like Delta and Omicron have.

Lex Fridman (1:09:20.720)

So we've made a great drug, it reduces the risk of mortality

Lex Fridman (1:09:25.720)

in Americans who get it by a lot.

Lex Fridman (1:09:28.400)

But we're not doing what we need to do

Lex Fridman (1:09:31.080)

to protect Americans from Omicron.

John Abramson (1:09:33.320)

You don't have to be an idealist

Lex Fridman (1:09:34.760)

and worry about global vaccine equity.

John Abramson (1:09:36.960)

If you're just ordinary selfish people like most of us are,

Lex Fridman (1:09:41.280)

and you're worried about the health of Americans,

John Abramson (1:09:43.600)

you would ensure global vaccine distribution.

Lex Fridman (1:09:47.080)

Let me just make one more point.

John Abramson (1:09:49.120)

That $50 billion that was requested

Lex Fridman (1:09:51.760)

by the four organizations back in May of 2021,

John Abramson (1:09:55.240)

32 billionaires made $50 billion

Lex Fridman (1:09:59.320)

from the vaccines at that point,

John Abramson (1:10:01.440)

took it into their private wealth.

Lex Fridman (1:10:03.960)

So what had been taken,

John Abramson (1:10:05.040)

this enormous amounts of money that had been taken

Lex Fridman (1:10:06.920)

into private wealth was enough to do

Lex Fridman (1:10:10.200)

what those organizations said needed to be done

Lex Fridman (1:10:12.840)

to prevent the sub variants from coming back

Lex Fridman (1:10:15.600)

and doing what they're doing.

Lex Fridman (1:10:16.640)

So the money was there, but how does the motivation,

John Abramson (1:10:19.080)

the money driven motivation of Big Pharma lead to that,

Lex Fridman (1:10:22.600)

that kind of allocation of vaccines?

John Abramson (1:10:28.480)

Because they can make more money in the United States.

Lex Fridman (1:10:31.480)

They're gonna distribute their vaccines

John Abramson (1:10:33.080)

where they can make the most money.

Lex Fridman (1:10:34.560)

Right, is there a malevolent aspect to this

John Abramson (1:10:40.120)

where, boy, I don't like saying this,

Lex Fridman (1:10:44.520)

but that they don't see it as a huge problem

John Abramson (1:10:49.520)

that variants will come back to the United States.

Lex Fridman (1:10:53.200)

I think it's the issue we were talking about earlier on

John Abramson (1:10:56.760)

where they're in a different culture

Lex Fridman (1:10:58.560)

and their culture is that their moral obligation,

John Abramson (1:11:02.500)

as Milton Friedman would say,

Lex Fridman (1:11:04.600)

is to maximize the profits

John Abramson (1:11:06.280)

that they return to shareholders.

Lex Fridman (1:11:07.760)

And don't think about the bigger picture.

John Abramson (1:11:10.600)

The collateral damage, don't think about the collateral.

Lex Fridman (1:11:12.720)

And also kind of believe, convince yourself

John Abramson (1:11:16.780)

that if we give into this capitalist machine

Lex Fridman (1:11:20.160)

in this very narrow sense of capitalism,

John Abramson (1:11:23.160)

that in the end, they'll do the most good.

Lex Fridman (1:11:25.920)

This kind of belief that like,

John Abramson (1:11:28.560)

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

Lex Fridman (1:11:32.640)

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

Lex Fridman (1:11:36.800)

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

Lex Fridman (1:11:40.200)

When you're talking about vaccinating the third world

Lex Fridman (1:11:43.720)

so we don't get hurt,

Lex Fridman (1:11:44.920)

it's a little bit hard to make the argument

John Abramson (1:11:47.280)

that the world's a better place

Lex Fridman (1:11:48.500)

because the profits of the investors went up.

John Abramson (1:11:51.080)

Yeah, but at the same time,

Lex Fridman (1:11:54.800)

I think that's a belief you can hold.

John Abramson (1:11:58.040)

I mean, I've interacted with a bunch of folks that kinda,

Lex Fridman (1:12:01.240)

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

John Abramson (1:12:05.460)

I respect a lot of people,

Lex Fridman (1:12:07.340)

but there's a belief that can take hold.

John Abramson (1:12:10.080)

If I just focus on this particular maximization,

Lex Fridman (1:12:13.880)

it will do the most good for the world.

John Abramson (1:12:16.000)

The problem is when you choose what to maximize

Lex Fridman (1:12:19.160)

and you put blinders on,

John Abramson (1:12:20.680)

it's too easy to start making gigantic mistakes

Lex Fridman (1:12:24.680)

that have a big negative impact on society.

Lex Fridman (1:12:28.120)

So it's really matters what you're maximizing.

Lex Fridman (1:12:30.680)

Right, and if we had a true democracy

Lex Fridman (1:12:33.680)

and everybody had one vote,

Lex Fridman (1:12:36.500)

everybody got decent information and had one vote,

John Abramson (1:12:39.560)

Ayn Rand's position would get some votes, but not many,

Lex Fridman (1:12:44.040)

and it would be way outvoted by the common people.

John Abramson (1:12:48.840)

Let me ask you about this very difficult topic.

Lex Fridman (1:12:53.840)

I'm talking to Mark Zuckerberg of Metta,

John Abramson (1:13:00.640)

the topic of censorship.

Lex Fridman (1:13:03.020)

I don't know if you've heard,

Lex Fridman (1:13:04.760)

but there's a guy named Robert Malone and Peter McCullough

Lex Fridman (1:13:08.960)

that were removed from many platforms

John Abramson (1:13:10.880)

for speaking about the COVID vaccine as being risky.

Lex Fridman (1:13:14.200)

They were both on Joe Rogan's program.

Lex Fridman (1:13:17.680)

What do you think about censorship in this space?

Lex Fridman (1:13:23.600)

In this difficult space where so much is controlled by,

John Abramson (1:13:29.240)

not controlled, but influenced by advertisements

Lex Fridman (1:13:31.580)

from Big Pharma,

Lex Fridman (1:13:32.560)

and science can even be influenced by Big Pharma.

Lex Fridman (1:13:39.300)

Where do you lean on this?

John Abramson (1:13:41.280)

Should we lean towards freedom

Lex Fridman (1:13:46.700)

and just allow all the voices,

Lex Fridman (1:13:50.140)

even those that go against the scientific consensus?

Lex Fridman (1:13:54.540)

Is that one way to fight the science

John Abramson (1:13:59.540)

that is funded by Big Pharma,

Lex Fridman (1:14:02.600)

or is that do more harm than good,

Lex Fridman (1:14:05.360)

having too many voices that are contending here?

Lex Fridman (1:14:08.440)

Should the ultimate battle be fought

Lex Fridman (1:14:10.640)

in the space of scientific publications?

Lex Fridman (1:14:15.120)

And particularly in the era of COVID,

John Abramson (1:14:19.360)

where there are large public health ramifications

Lex Fridman (1:14:22.600)

to this public discourse, the ante is way up.

Lex Fridman (1:14:27.440)

So I don't have a simple answer to that.

Lex Fridman (1:14:31.160)

I think everyone's allowed their own opinion.

John Abramson (1:14:34.800)

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

Lex Fridman (1:14:38.680)

And how we develop a mechanism

John Abramson (1:14:43.100)

that's other than an open internet

Lex Fridman (1:14:45.360)

where whoever is shouting the loudest gets the most clicks

Lex Fridman (1:14:49.560)

and rage creates value on the internet,

Lex Fridman (1:14:54.240)

I think that's not a good mechanism for working this out.

Lex Fridman (1:14:58.200)

And I don't think we have one.

Lex Fridman (1:14:59.800)

I don't have a solution to this.

John Abramson (1:15:01.800)

I mean, ideally, if we had a philosopher king,

Lex Fridman (1:15:05.300)

we could have a panel of people

John Abramson (1:15:08.720)

who were not conflicted by rigid opinions

Lex Fridman (1:15:13.880)

decide on what the boundaries of public discourse might be.

John Abramson (1:15:19.640)

I don't think it should be fully open.

Lex Fridman (1:15:21.760)

I don't think people who are making,

John Abramson (1:15:25.360)

who are committed to an anti vaccine position

Lex Fridman (1:15:28.300)

and will tailor their interpretation

John Abramson (1:15:31.000)

of complex scientific data to support their opinion,

Lex Fridman (1:15:34.920)

I think that can be harmful.

John Abramson (1:15:36.780)

Constraining their speech can be harmful as well.

Lex Fridman (1:15:39.240)

So I don't have an answer here.

Lex Fridman (1:15:41.160)

But yeah.

Lex Fridman (1:15:42.160)

I tend to believe that it's more dangerous

John Abramson (1:15:45.760)

to censor anti vax messages.

Lex Fridman (1:15:49.320)

The way to defeat anti vax messages

John Abramson (1:15:53.360)

is by being great communicators,

Lex Fridman (1:15:56.420)

by being great scientific communicators.

Lex Fridman (1:15:58.320)

So it's not that we need to censor

Lex Fridman (1:16:02.060)

the things we don't like.

John Abramson (1:16:04.120)

We need to be better at communicating

Lex Fridman (1:16:06.720)

the things we do like,

John Abramson (1:16:08.240)

or the things that we do believe represent

Lex Fridman (1:16:10.760)

the deep scientific truth.

John Abramson (1:16:13.920)

Because I think if you censor,

Lex Fridman (1:16:18.400)

you get worse at doing science

Lex Fridman (1:16:22.160)

and you give the wrong people power.

Lex Fridman (1:16:27.200)

So I tend to believe that you should give power

John Abramson (1:16:30.980)

to the individual scientists

Lex Fridman (1:16:33.400)

and also give them the responsibility

John Abramson (1:16:35.720)

of being better educators, communicators,

Lex Fridman (1:16:38.880)

expressers of scientific ideas,

John Abramson (1:16:41.680)

put pressure on them to release data,

Lex Fridman (1:16:43.480)

to release that data in a way that's easily consumable,

John Abramson (1:16:46.800)

not just like very difficult to understand,

Lex Fridman (1:16:49.220)

but in a way that can be understood

John Abramson (1:16:50.760)

by a large number of people.

Lex Fridman (1:16:52.520)

So the battle should be fought

John Abramson (1:16:54.740)

in the open space of ideas

Lex Fridman (1:16:57.160)

versus in the quiet space of journals.

John Abramson (1:17:02.640)

I think we no longer have that comfort,

Lex Fridman (1:17:05.960)

especially at the highest of stakes.

Lex Fridman (1:17:08.280)

So this kind of idea that a couple of peer reviewers

Lex Fridman (1:17:11.600)

decide the fate of billions

John Abramson (1:17:14.280)

doesn't seem to be sustainable,

Lex Fridman (1:17:18.960)

especially given a very real observation now

John Abramson (1:17:24.180)

that the reason Robert Malone has a large following

Lex Fridman (1:17:30.840)

is there's a deep distrust of institutions,

John Abramson (1:17:33.020)

deep distrust of scientists,

Lex Fridman (1:17:34.940)

of science as an institution,

John Abramson (1:17:37.760)

of power centers, of companies, of everything,

Lex Fridman (1:17:41.400)

and perhaps rightfully so.

Lex Fridman (1:17:43.960)

But the way to defend against that

Lex Fridman (1:17:45.520)

is not for the powerful to build a bigger wall.

John Abramson (1:17:49.760)

It's for the powerful to be authentic

Lex Fridman (1:17:53.380)

and maybe a lot of them to get fired,

Lex Fridman (1:17:55.760)

and for new minds, for new fresh scientists,

Lex Fridman (1:17:59.840)

ones who are more authentic, more real,

John Abramson (1:18:01.800)

better communicators to step up.

Lex Fridman (1:18:03.980)

So I fear censorship

John Abramson (1:18:06.480)

because it feels like censorship

Lex Fridman (1:18:09.980)

is an even harder job to do it well

John Abramson (1:18:13.720)

than being good communicators.

Lex Fridman (1:18:16.660)

And it seems like it's always the C students

John Abramson (1:18:19.160)

that end up doing the censorship.

Lex Fridman (1:18:21.320)

It's always the incompetent people,

Lex Fridman (1:18:24.960)

and not just the incompetent, but the biggest whiners.

Lex Fridman (1:18:28.760)

So what happens is the people

John Abramson (1:18:32.960)

that get the most emotional and the most outraged

Lex Fridman (1:18:36.560)

will drive the censorship.

Lex Fridman (1:18:39.520)

And it doesn't seem like reason drives the censorship.

Lex Fridman (1:18:42.560)

That's just objectively observing

Lex Fridman (1:18:44.840)

how censorship seems to work in this current.

Lex Fridman (1:18:47.960)

So there's so many forms of censorship.

John Abramson (1:18:50.760)

You look at the Soviet Union

Lex Fridman (1:18:51.960)

or the propaganda or Nazi Germany,

John Abramson (1:18:54.040)

it's a very different level of censorship.

Lex Fridman (1:18:56.520)

People tend to conflate all of these things together.

John Abramson (1:18:59.360)

Social media trying desperately to have trillions

Lex Fridman (1:19:03.720)

or hundreds of billions of exchanges a day,

Lex Fridman (1:19:07.280)

and try to make sure that their platform

Lex Fridman (1:19:10.640)

has some semblance of, quote, healthy conversations.

John Abramson (1:19:16.980)

People just don't go insane.

Lex Fridman (1:19:18.560)

They actually like using the platform,

Lex Fridman (1:19:20.840)

and they censor based on that.

Lex Fridman (1:19:23.420)

That's a different level of censorship.

Lex Fridman (1:19:24.920)

But even there, you can really run afoul

Lex Fridman (1:19:28.040)

of the people that get the whiny C students

John Abramson (1:19:32.440)

controlling too much of the censorship.

Lex Fridman (1:19:34.880)

I believe you should actually put the responsibility

John Abramson (1:19:39.480)

on the self proclaimed holders of truth,

Lex Fridman (1:19:42.520)

AKA scientists, at being better communicators.

John Abramson (1:19:46.760)

I agree with that.

Lex Fridman (1:19:47.600)

I'm not advocating for any kind of censorship.

Lex Fridman (1:19:51.440)

But Marshall McLuhan was very influential

Lex Fridman (1:19:55.600)

when I was in college.

Lex Fridman (1:19:57.200)

And his, that meme, the medium is the message.

Lex Fridman (1:20:03.280)

It's a little bit hard to understand

John Abramson (1:20:04.840)

when you're comparing radio to TV

Lex Fridman (1:20:06.800)

and saying radio's hotter or TV's hotter or something.

Lex Fridman (1:20:09.880)

But we now have the medium as the message

Lex Fridman (1:20:12.480)

in a way that we've never seen,

John Abramson (1:20:14.200)

we've never imagined before,

Lex Fridman (1:20:16.200)

where rage and anger and polarization

John Abramson (1:20:22.800)

are what drives the traffic on the internet.

Lex Fridman (1:20:28.160)

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

John Abramson (1:20:34.120)

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

Lex Fridman (1:20:36.000)

so I'm not pretending to have a solution.

Lex Fridman (1:20:38.400)

But the commons of discourse about this particular issue,

Lex Fridman (1:20:42.240)

about vaccines, has been largely destroyed by the edges,

John Abramson (1:20:47.160)

by the drug companies and the advocates on the one side

Lex Fridman (1:20:50.040)

and the people who just criticize and think

John Abramson (1:20:54.680)

that even though the data are flawed

Lex Fridman (1:20:57.720)

that there's no way vaccines can be beneficial.

Lex Fridman (1:21:00.960)

And to have those people screaming at each other

Lex Fridman (1:21:04.080)

does nothing to improve the health

John Abramson (1:21:07.200)

of the 95% of the people in the middle

Lex Fridman (1:21:10.680)

who want to know what the rational way to go forward is

Lex Fridman (1:21:16.480)

and protect their families from COVID

Lex Fridman (1:21:18.560)

and live a good life

Lex Fridman (1:21:20.320)

and be able to participate in the economy.

Lex Fridman (1:21:22.560)

And that's the problem.

John Abramson (1:21:25.200)

I don't have a solution.

Lex Fridman (1:21:26.440)

Well, there's a difficult problem for Spotify and YouTube.

John Abramson (1:21:29.520)

I don't know if you heard,

Lex Fridman (1:21:30.360)

this is a thing that Joe Rogan is currently going through.

John Abramson (1:21:33.360)

As a platform, whether to censor the conversation

Lex Fridman (1:21:36.680)

that, for example, Joe's having.

Lex Fridman (1:21:39.120)

So I don't know if you heard,

Lex Fridman (1:21:40.080)

but Neil Young and other musicians have kind of spoke out

Lex Fridman (1:21:43.920)

and saying they're going to leave the platform

Lex Fridman (1:21:45.760)

because Joe Rogan is allowed to be on this platform

John Abramson (1:21:49.720)

having these kinds of conversations

Lex Fridman (1:21:51.320)

with the likes of Robert Malone.

Lex Fridman (1:21:54.680)

And it's clear to me that Spotify and YouTube

Lex Fridman (1:21:57.760)

are being significantly influenced

John Abramson (1:21:59.800)

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

Lex Fridman (1:22:03.400)

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

Lex Fridman (1:22:05.800)

and it was going back and forth.

Lex Fridman (1:22:07.680)

In fact, that's why Facebook has been oscillating

John Abramson (1:22:10.280)

on the censorship is like one group gets louder

Lex Fridman (1:22:12.600)

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

John Abramson (1:22:19.880)

There's several things to say here.

Lex Fridman (1:22:21.200)

So one, it does seem, I think you put it really well,

John Abramson (1:22:24.560)

it would be amazing if these platforms

Lex Fridman (1:22:26.480)

could find mechanisms to listen to the center,

John Abramson (1:22:29.360)

to the big center that's actually going to be affected

Lex Fridman (1:22:34.440)

by the results of our pursuit of scientific truth.

Lex Fridman (1:22:40.520)

And listen to those voices.

Lex Fridman (1:22:42.120)

I also believe that most people are intelligent enough

John Abramson (1:22:45.800)

to process information and to make up their own minds.

Lex Fridman (1:22:49.360)

Like they're not, in terms of,

John Abramson (1:22:54.120)

it's complicated, of course,

Lex Fridman (1:22:55.240)

because we've just been talking about advertisement

Lex Fridman (1:22:57.120)

and how people can be influenced.

Lex Fridman (1:22:58.880)

But I feel like if you have raw, long form podcasts

John Abramson (1:23:05.080)

or programs where people express their mind

Lex Fridman (1:23:08.440)

and express their argument in full,

John Abramson (1:23:12.400)

I think people can hear it to make up their own mind.

Lex Fridman (1:23:15.400)

And if those arguments have a platform on which

John Abramson (1:23:18.080)

they can live, then other people could provide

Lex Fridman (1:23:21.160)

better arguments if they disagree with it.

Lex Fridman (1:23:23.680)

And now we as human beings, as rational,

Lex Fridman (1:23:26.720)

as intelligent human beings, can look at both

Lex Fridman (1:23:29.120)

and make up our own minds.

Lex Fridman (1:23:30.560)

And that's where social media can be very good

John Abramson (1:23:33.080)

at this collective intelligence.

Lex Fridman (1:23:35.920)

We together listen to all of these voices

Lex Fridman (1:23:39.160)

and make up our own mind.

Lex Fridman (1:23:40.640)

Humble ourselves, actually, often.

John Abramson (1:23:42.840)

You think, you know, like you're an expert,

Lex Fridman (1:23:46.680)

say you have a PhD in a certain thing,

Lex Fridman (1:23:48.600)

so there's this confidence that comes with that.

Lex Fridman (1:23:50.920)

And the collective intelligence, uncensored,

John Abramson (1:23:54.320)

allows you to humble yourself eventually.

Lex Fridman (1:23:56.880)

Like as you discover, all it takes is a few times,

John Abramson (1:24:01.160)

you know, looking back five years later,

Lex Fridman (1:24:05.040)

realizing I was wrong.

Lex Fridman (1:24:07.240)

And that's really healthy for a scientist.

Lex Fridman (1:24:09.040)

That's really healthy for anybody to go through.

Lex Fridman (1:24:11.000)

And only through having that open discourse

Lex Fridman (1:24:13.880)

can you really have that.

John Abramson (1:24:15.920)

That said, Spotify also, just like Pfizer is a company,

Lex Fridman (1:24:20.920)

which is why this podcast,

John Abramson (1:24:26.760)

I don't know if you know what RSS feeds are,

Lex Fridman (1:24:29.240)

but podcasts can't be censored.

Lex Fridman (1:24:31.560)

So Joe's in the unfortunate position

Lex Fridman (1:24:33.320)

he only lives on Spotify.

Lex Fridman (1:24:35.360)

So Spotify has been actually very good

Lex Fridman (1:24:37.920)

at saying we're staying out of it for now.

Lex Fridman (1:24:41.920)

But RSS, this is pirate radio.

Lex Fridman (1:24:44.840)

Nobody can censor it, it's the internet.

Lex Fridman (1:24:47.080)

So financially, in terms of platforms,

Lex Fridman (1:24:51.840)

this cannot be censored,

John Abramson (1:24:53.640)

which is why podcasts are really beautiful.

Lex Fridman (1:24:56.760)

And so if Spotify or YouTube wants to be

John Abramson (1:25:01.680)

the host of podcasts,

Lex Fridman (1:25:04.240)

I think where they flourish is free expression,

John Abramson (1:25:10.880)

no matter how crazy.

Lex Fridman (1:25:12.880)

Yes, but I do wanna push back a little bit on what you're saying.

John Abramson (1:25:18.160)

I have anti fax friends who I love.

Lex Fridman (1:25:23.080)

They're dear, cherished friends.

Lex Fridman (1:25:26.120)

And they'll send me stuff.

Lex Fridman (1:25:28.680)

And it'll take me an hour to go through what they sent

John Abramson (1:25:34.200)

to see if it is credible.

Lex Fridman (1:25:37.720)

And usually it's not.

John Abramson (1:25:40.520)

It's not a random sample of the anti fax argument.

Lex Fridman (1:25:42.800)

I'm not saying I can disprove the anti fax argument.

Lex Fridman (1:25:46.760)

But I am saying that it's almost like we were talking about

Lex Fridman (1:25:50.960)

how medical science clinical trials,

John Abramson (1:25:54.120)

the presentation of clinical trials to physicians

Lex Fridman (1:25:56.720)

could be improved.

Lex Fridman (1:25:57.920)

And the first thing we came up with

Lex Fridman (1:26:00.520)

is to have pre publication transparency

John Abramson (1:26:04.360)

in the peer review process.

Lex Fridman (1:26:06.160)

So bad information, biased information doesn't get out

John Abramson (1:26:10.040)

as if it's legitimate, and you can't put it back,

Lex Fridman (1:26:13.320)

recapture it once it gets out.

John Abramson (1:26:16.120)

I think there's an element of that

Lex Fridman (1:26:18.360)

in the arguments that are going on about vaccines.

Lex Fridman (1:26:21.920)

And they're on both sides.

Lex Fridman (1:26:23.160)

But I think the anti fax side puts out more units

John Abramson (1:26:28.360)

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

Lex Fridman (1:26:33.480)

And I guess in an ideal situation,

John Abramson (1:26:36.480)

there would be real time fact checking by independent people,

Lex Fridman (1:26:41.120)

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

John Abramson (1:26:45.120)

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

Lex Fridman (1:26:47.960)

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

Lex Fridman (1:26:52.440)

But that's what I'm arguing.

Lex Fridman (1:26:53.800)

I agree with you.

Lex Fridman (1:26:55.040)

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

Lex Fridman (1:26:58.480)

that we have, that is the collective intelligence,

John Abramson (1:27:00.920)

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

Lex Fridman (1:27:04.000)

if you encourage people to do it.

Lex Fridman (1:27:05.920)

And the scientists, as opposed to, listen,

Lex Fridman (1:27:08.200)

I interact with a lot of colleagues,

John Abramson (1:27:10.400)

a lot of friends that are scientists,

Lex Fridman (1:27:12.520)

they roll their eyes.

John Abramson (1:27:14.040)

Their response is like, ugh.

Lex Fridman (1:27:16.480)

Like they don't want to interact with this.

Lex Fridman (1:27:18.800)

But that's just not the right response.

Lex Fridman (1:27:22.880)

When a huge number of people believe this,

John Abramson (1:27:26.440)

it is your job as communicators to defend your ideas.

Lex Fridman (1:27:30.040)

It is no longer the case that you go to a conference

Lex Fridman (1:27:33.160)

and defend your ideas to two other nerds

Lex Fridman (1:27:36.440)

that have been working on the same problem forever.

John Abramson (1:27:38.560)

I mean, sure, you can do that,

Lex Fridman (1:27:40.320)

but then you're rejecting the responsibility

John Abramson (1:27:44.040)

you have explicitly or implicitly accepted

Lex Fridman (1:27:48.040)

when you go into this field,

John Abramson (1:27:49.800)

that you will defend the ideas of truth.

Lex Fridman (1:27:52.600)

And the way to defend them is in the open battlefield

John Abramson (1:27:55.840)

of ideas, and become a better communicator.

Lex Fridman (1:27:58.920)

And I believe that when you have a lot,

John Abramson (1:28:00.960)

you said you invested one or two hours

Lex Fridman (1:28:02.600)

in this particular, but that's little ants interacting

John Abramson (1:28:06.680)

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

Lex Fridman (1:28:12.040)

At least, you know, at least I hope so.

John Abramson (1:28:14.560)

I think you're an optimist.

Lex Fridman (1:28:15.880)

I want to work with you a little bit on this.

John Abramson (1:28:17.920)

Let's say a person like Joe Rogan,

Lex Fridman (1:28:22.480)

who, by the way, had me on his podcast and let me.

John Abramson (1:28:26.040)

It's an amazing conversation, I really enjoyed it.

Lex Fridman (1:28:28.040)

Well, thank you.

John Abramson (1:28:29.040)

I did too.

Lex Fridman (1:28:29.960)

And I didn't know Joe.

John Abramson (1:28:31.480)

I didn't know much about his podcast.

Lex Fridman (1:28:32.840)

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

Lex Fridman (1:28:35.440)

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

Lex Fridman (1:28:38.440)

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

John Abramson (1:28:41.240)

he said something that was a little bit wrong,

Lex Fridman (1:28:43.080)

and I corrected him.

Lex Fridman (1:28:44.240)

And he had the guy who.

Lex Fridman (1:28:46.440)

Jamie.

John Abramson (1:28:47.280)

Jamie, he had Jamie check it,

Lex Fridman (1:28:48.920)

and was very forthright in saying,

John Abramson (1:28:51.200)

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

Lex Fridman (1:28:53.520)

We gotta modify this.

John Abramson (1:28:54.840)

In any event, in any event.

Lex Fridman (1:28:56.560)

You got him.

John Abramson (1:28:58.160)

Well, I wasn't trying to get him,

Lex Fridman (1:28:59.960)

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

John Abramson (1:29:01.640)

Totally, it was a beautiful exchange.

Lex Fridman (1:29:03.320)

There was so much respect in the room,

John Abramson (1:29:04.840)

pushing back and forth, it was great.

Lex Fridman (1:29:06.360)

Yeah, so I respect him.

Lex Fridman (1:29:08.960)

And I think when he has somebody on

Lex Fridman (1:29:13.120)

who's a dyed in the wool anti faxer,

John Abramson (1:29:16.680)

the question is, how can you balance,

Lex Fridman (1:29:21.640)

if it needs balance, in real time?

John Abramson (1:29:24.440)

I'm not talking about afterwards.

Lex Fridman (1:29:26.280)

I'm talking in real time.

John Abramson (1:29:27.680)

Maybe you record, well, he does record it, obviously.

Lex Fridman (1:29:30.800)

But maybe when there's a statement made

John Abramson (1:29:33.720)

that is made as if it's fact based,

Lex Fridman (1:29:38.000)

maybe that statement should be checked by

John Abramson (1:29:41.880)

some folks who,

Lex Fridman (1:29:45.760)

imaginary folks who are trustworthy.

Lex Fridman (1:29:48.080)

And in real time, as that discussion

Lex Fridman (1:29:51.640)

is being played on the podcast,

John Abramson (1:29:54.200)

to show what independent experts say about that claim.

Lex Fridman (1:29:59.080)

That's a really interesting idea.

John Abramson (1:30:00.200)

By the way, for some reason,

Lex Fridman (1:30:01.600)

this idea popped into my head now.

John Abramson (1:30:03.960)

I think real time is very difficult,

Lex Fridman (1:30:05.560)

and it's not difficult,

Lex Fridman (1:30:07.280)

but it kind of ruins the conversation

Lex Fridman (1:30:09.320)

because you want the idea to breathe.

John Abramson (1:30:11.800)

I think what's very possible is before it's published,

Lex Fridman (1:30:15.160)

it's the pre publication, before it's published,

John Abramson (1:30:18.400)

you let a bunch of people review it,

Lex Fridman (1:30:20.360)

and they can add their voices in post.

John Abramson (1:30:23.680)

Before it's published, they can add arguments,

Lex Fridman (1:30:29.680)

arguments against certain parts.

John Abramson (1:30:31.480)

That's very interesting to sort of,

Lex Fridman (1:30:32.880)

as one podcast, publish addendums.

John Abramson (1:30:37.240)

Publish the peer review together with the publication.

Lex Fridman (1:30:40.440)

That's very interesting.

John Abramson (1:30:43.240)

I might actually do that.

Lex Fridman (1:30:44.120)

That's really interesting.

John Abramson (1:30:45.280)

Because I've been doing more debates

Lex Fridman (1:30:47.120)

where at the same time have multiple people,

John Abramson (1:30:51.720)

which has a different dynamic

Lex Fridman (1:30:53.480)

because both people, I mean,

John Abramson (1:30:56.120)

it's really nice to have the time to pause

Lex Fridman (1:30:58.800)

just by yourself to fact check,

John Abramson (1:31:02.040)

to look at the study that was mentioned,

Lex Fridman (1:31:04.120)

to understand what's going on.

Lex Fridman (1:31:05.600)

So the peer review process, to have a little bit of time.

Lex Fridman (1:31:09.480)

That's really interesting.

John Abramson (1:31:10.600)

I actually would, I'd like to try that.

Lex Fridman (1:31:14.360)

To agree with you on some point in terms of anti vax,

John Abramson (1:31:17.720)

I've been fascinated by listening to arguments

Lex Fridman (1:31:20.640)

from this community of folks that's been quite large

John Abramson (1:31:23.800)

called the flat earthers,

Lex Fridman (1:31:25.520)

the people that believe the earth is flat.

Lex Fridman (1:31:28.080)

And I don't know if you've ever listened to them

Lex Fridman (1:31:30.920)

or read their arguments,

Lex Fridman (1:31:33.760)

but it's fascinating how consistent

Lex Fridman (1:31:36.160)

and convincing it all sounds

John Abramson (1:31:37.800)

when you just kind of take it in.

Lex Fridman (1:31:39.600)

Just like, just take it in like listening normally.

John Abramson (1:31:43.720)

It's all very logical.

Lex Fridman (1:31:46.560)

Like if you don't think very,

John Abramson (1:31:49.120)

well, no, so the thing is,

Lex Fridman (1:31:53.200)

the reality is at the very basic human level

John Abramson (1:31:57.280)

with our limited cognitive capabilities,

Lex Fridman (1:32:00.600)

the earth is pretty flat when you go outside

Lex Fridman (1:32:03.680)

and you look at flat.

Lex Fridman (1:32:04.880)

So like when you use common sense reasoning,

John Abramson (1:32:08.040)

it's very easy to play to that,

Lex Fridman (1:32:09.960)

to convince you that the earth is flat.

John Abramson (1:32:12.080)

Plus there's powerful organizations

Lex Fridman (1:32:13.640)

that want to manipulate you and so on.

Lex Fridman (1:32:16.280)

But then there's the whole progress of science

Lex Fridman (1:32:20.920)

and physics of the past,

Lex Fridman (1:32:22.600)

but that's difficult to integrate into your thought process.

Lex Fridman (1:32:26.120)

So it's very true that the people

John Abramson (1:32:29.200)

should listen to flat earthers

Lex Fridman (1:32:30.720)

because it was very revealing to me

Lex Fridman (1:32:33.400)

how easy it is to be convinced of basically anything

Lex Fridman (1:32:39.240)

by charismatic arguments.

Lex Fridman (1:32:42.440)

And if we're arguing about whether the earth is flat or not,

Lex Fridman (1:32:46.920)

as long as we're not navigating airplanes

Lex Fridman (1:32:48.760)

and doing other kinds of things,

Lex Fridman (1:32:49.920)

trying to get satellites to do transmission,

John Abramson (1:32:53.800)

it's not that important what I believe.

Lex Fridman (1:32:56.200)

But if we're arguing about how we approach

John Abramson (1:32:59.480)

the worst public health crisis in,

Lex Fridman (1:33:02.400)

I don't know how long,

John Abramson (1:33:03.320)

I think we're getting worse than the Spanish flu now.

Lex Fridman (1:33:06.400)

I don't know what the total global deaths

John Abramson (1:33:07.800)

with Spanish flu were, but in the United States,

Lex Fridman (1:33:10.120)

we certainly have more deaths than we had from Spanish flu.

John Abramson (1:33:12.440)

Plus the economic pain and suffering.

Lex Fridman (1:33:14.720)

Yes, yes, and the damage to the kids in school and so forth.

John Abramson (1:33:19.640)

We got a problem and it's not going away, unfortunately.

Lex Fridman (1:33:23.040)

So when we get a problem like that,

John Abramson (1:33:25.000)

it's not just an interesting bar room conversation

Lex Fridman (1:33:28.520)

about whether the earth is flat.

John Abramson (1:33:30.720)

There are millions of lives involved.

Lex Fridman (1:33:34.320)

Let me ask you yet another question,

John Abramson (1:33:36.480)

an issue I raised with Pfizer CO, Albert Burla.

Lex Fridman (1:33:42.160)

It's the question of revolving doors.

John Abramson (1:33:45.400)

That there seems to be a revolving door

Lex Fridman (1:33:47.440)

between Pfizer, FDA, and CDC.

John Abramson (1:33:51.120)

People that have worked at the FDA,

Lex Fridman (1:33:53.280)

now work at Pfizer, and vice versa,

John Abramson (1:33:56.480)

including the CDC and so on.

Lex Fridman (1:34:00.760)

What do you think about that?

Lex Fridman (1:34:01.760)

So first of all, his response, once again,

Lex Fridman (1:34:03.920)

is there's rules, there's very strict rules,

Lex Fridman (1:34:06.400)

and we follow them.

Lex Fridman (1:34:08.680)

Do you think that's a problem?

John Abramson (1:34:11.140)

Hoo ha.

Lex Fridman (1:34:12.960)

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

John Abramson (1:34:16.200)

this Pfizer play by the rules.

Lex Fridman (1:34:19.480)

One at a time?

John Abramson (1:34:20.320)

One at a time.

Lex Fridman (1:34:21.160)

Okay, and this isn't even about Pfizer,

Lex Fridman (1:34:22.720)

but it's an answer to the question.

Lex Fridman (1:34:24.280)

Yes.

Lex Fridman (1:34:25.120)

So there's this drug, Ajihelm,

Lex Fridman (1:34:27.480)

that was approved by the FDA maybe six months ago.

John Abramson (1:34:31.320)

It's a drug to prevent the progression

Lex Fridman (1:34:34.920)

of low grade Alzheimer's disease.

John Abramson (1:34:38.320)

The target for drug development for Alzheimer's disease

Lex Fridman (1:34:43.600)

has been reducing the amyloid plaques in the brain,

John Abramson (1:34:47.960)

which correlate with the progression of Alzheimer's.

Lex Fridman (1:34:52.100)

And Biogen showed that its drug, Ajihelm,

John Abramson (1:34:57.760)

reduces amyloid plaques in the brain.

Lex Fridman (1:35:00.980)

They did two clinical trials

John Abramson (1:35:03.020)

to determine the clinical efficacy,

Lex Fridman (1:35:05.600)

and they found that neither trial showed a meaningful benefit.

Lex Fridman (1:35:09.960)

And in those two trials,

Lex Fridman (1:35:12.180)

33% more people in the Ajihelm group

John Abramson (1:35:15.960)

developed symptomatic brain swelling and bleeding

Lex Fridman (1:35:19.060)

than people in the placebo group.

John Abramson (1:35:22.080)

There was an advisory committee convened

Lex Fridman (1:35:27.080)

to debate and determine how they felt

John Abramson (1:35:30.400)

about the approvability of Ajihelm, given those facts.

Lex Fridman (1:35:35.080)

And those facts aren't in dispute.

John Abramson (1:35:37.120)

They're in Biogen slides, as well as FDA documents.

Lex Fridman (1:35:41.540)

The advisory committee voted 10 against approval

Lex Fridman (1:35:47.600)

and one abstain.

Lex Fridman (1:35:49.920)

So that's essentially universal,

John Abramson (1:35:52.600)

unanimous vote against approving Ajihelm.

Lex Fridman (1:35:56.240)

Now, the advisory committees have been pretty much cleansed

John Abramson (1:36:00.680)

of financial conflicts of interest.

Lex Fridman (1:36:03.240)

So this advisory committee votes 10 no, one abstention,

Lex Fridman (1:36:09.240)

and the FDA overrules the unanimous opinion

Lex Fridman (1:36:13.160)

of its advisory committee and approves the drug.

John Abramson (1:36:17.400)

Three of the members of the advisory committee resign.

Lex Fridman (1:36:21.320)

They say, we're not gonna be part,

John Abramson (1:36:22.320)

if the FDA is not gonna listen to a unanimous vote

Lex Fridman (1:36:24.760)

against approving this drug,

John Abramson (1:36:26.720)

which shows more harm than benefit, undisputed,

Lex Fridman (1:36:31.560)

we're not gonna participate in this.

Lex Fridman (1:36:33.840)

And the argument against approval

Lex Fridman (1:36:36.680)

is that the surrogate endpoint,

John Abramson (1:36:38.960)

the reduction of amyloid, the progression of amyloid plaques

Lex Fridman (1:36:43.360)

is known by the FDA not to be a valid clinical indicator.

John Abramson (1:36:48.020)

It doesn't correlate, 27 studies have shown,

Lex Fridman (1:36:50.920)

it doesn't correlate with clinical progression,

John Abramson (1:36:53.340)

interrupting the amyloid plaques

Lex Fridman (1:36:54.840)

doesn't mean that your Alzheimer's doesn't get worse.

Lex Fridman (1:37:02.000)

So it seems like it's a slam dunk

Lex Fridman (1:37:05.200)

and the FDA made a mistake and they should do whatever

John Abramson (1:37:09.000)

they do to protect their bureaucratic reputation.

Lex Fridman (1:37:12.080)

So the head of the Bureau of the FDA,

John Abramson (1:37:15.280)

the Center for Drug Evaluation and Research

Lex Fridman (1:37:17.320)

that approves new drugs, who had spent 16 years

John Abramson (1:37:21.880)

as an executive in the pharmaceutical industry,

Lex Fridman (1:37:25.300)

issued a statement and said,

John Abramson (1:37:28.000)

"'What we should do in this situation

Lex Fridman (1:37:30.920)

"'is to loosen the prohibition of financial ties of interest

John Abramson (1:37:36.820)

"'with the drug companies,

Lex Fridman (1:37:38.540)

"'so we get less emotional responses.'"

John Abramson (1:37:43.400)

Said this, it's in print.

Lex Fridman (1:37:49.400)

People are just too emotional about this.

John Abramson (1:37:51.520)

People were just too emotional.

Lex Fridman (1:37:52.960)

The 10 people who voted against it

Lex Fridman (1:37:55.060)

and the no people who voted for it,

Lex Fridman (1:37:56.720)

it's all too emotional.

Lex Fridman (1:37:58.480)

So this gets back,

Lex Fridman (1:38:00.000)

this is a long answer to your short question.

John Abramson (1:38:02.560)

I think this is a wonderful window

Lex Fridman (1:38:04.880)

into the thinking of the FDA

John Abramson (1:38:08.000)

that financial conflicts of interest don't matter

Lex Fridman (1:38:11.160)

in a situation when I think it's obvious

John Abramson (1:38:13.280)

that they would matter.

Lex Fridman (1:38:15.000)

But there's not a direct financial conflict of interest.

John Abramson (1:38:18.040)

It's kinda, like it's not, like Albert said, there's rules.

Lex Fridman (1:38:26.120)

I mean, you're not allowed

John Abramson (1:38:27.200)

to have direct financial conflicts of interest.

Lex Fridman (1:38:29.760)

It's indirect.

John Abramson (1:38:32.280)

Right, but what I'm saying is,

Lex Fridman (1:38:34.560)

I'm not denying what he said is true,

Lex Fridman (1:38:37.880)

but the FDA, a high official in the FDA,

Lex Fridman (1:38:42.020)

is saying that we need to allow conflicts of interest

John Abramson (1:38:45.480)

in our advisory committee meetings.

Lex Fridman (1:38:48.320)

Wow.

Lex Fridman (1:38:49.280)

And that, she wants to change the rules.

Lex Fridman (1:38:53.320)

Right.

Lex Fridman (1:38:54.160)

So Albert Borla would still be playing by the rules,

Lex Fridman (1:38:58.040)

but it just shows how one side of the thinking here is.

Lex Fridman (1:39:03.380)

But you think that's influenced by the fact

Lex Fridman (1:39:05.280)

that there were pharmaceutical executives

Lex Fridman (1:39:07.360)

working at the FDA and vice versa?

Lex Fridman (1:39:09.920)

And they think that's a great idea.

Lex Fridman (1:39:13.120)

Who gets to fix this?

Lex Fridman (1:39:14.520)

Do you think it should be just banned?

John Abramson (1:39:16.480)

Like if you worked.

Lex Fridman (1:39:17.320)

I don't know, two separate questions.

John Abramson (1:39:19.040)

One is should the officials at the FDA come from pharma

Lex Fridman (1:39:23.640)

and vice versa?

John Abramson (1:39:24.800)

Yes.

Lex Fridman (1:39:25.640)

That's one question.

Lex Fridman (1:39:26.460)

And the other question is should advisory committee members

Lex Fridman (1:39:28.960)

be allowed to have financial conflicts of interest?

John Abramson (1:39:31.680)

Yes.

Lex Fridman (1:39:33.120)

I think, in my opinion, and people might say I'm biased,

John Abramson (1:39:38.240)

I think advisory committee people

Lex Fridman (1:39:40.320)

should not have conflicts of interest.

John Abramson (1:39:42.080)

I think their only interest ought to be the public interest.

Lex Fridman (1:39:44.880)

And that was true from my understanding of the situation.

John Abramson (1:39:49.240)

It's the afterword in my book.

Lex Fridman (1:39:51.280)

I spent some time studying it about Ajihelm.

John Abramson (1:39:54.200)

I think it's a slam dunk that there ought to be

Lex Fridman (1:39:56.520)

no conflicts of interest.

John Abramson (1:39:57.660)

Now the head of CDER, Center for Drug Evaluation Research,

Lex Fridman (1:40:01.400)

thinks that that's gonna give you a biased result

John Abramson (1:40:04.660)

because we don't have company influence.

Lex Fridman (1:40:07.380)

And that, I think, shows how biased their thinking is.

John Abramson (1:40:14.360)

That not having company influence is a bias.

Lex Fridman (1:40:19.200)

Let me try to load that in.

John Abramson (1:40:21.200)

I'm trying to empathize with the belief

Lex Fridman (1:40:23.320)

that companies should have a voice at the table.

John Abramson (1:40:28.680)

I mean, yeah, it's part of the game.

Lex Fridman (1:40:30.440)

They've convinced themselves

John Abramson (1:40:31.400)

that this is how it should be played.

Lex Fridman (1:40:34.520)

But they have a voice at the table.

John Abramson (1:40:36.320)

They've designed the studies.

Lex Fridman (1:40:37.720)

Right.

John Abramson (1:40:38.560)

That's their voice.

Lex Fridman (1:40:39.400)

That's the whole point.

John Abramson (1:40:40.220)

They analyze the data.

Lex Fridman (1:40:41.060)

I mean, what bigger voice do you deserve?

Lex Fridman (1:40:43.080)

But I do also think, on the more challenging question,

Lex Fridman (1:40:47.040)

I do think that there should be a ban.

John Abramson (1:40:50.180)

If you work at a pharmaceutical company,

Lex Fridman (1:40:53.600)

you should not be allowed to work

John Abramson (1:40:55.400)

at any regulatory agency.

Lex Fridman (1:41:00.680)

Yes.

John Abramson (1:41:01.520)

You should not.

Lex Fridman (1:41:02.340)

I mean, that, going back and forth,

John Abramson (1:41:03.960)

it just, even if it's 30 years later.

Lex Fridman (1:41:06.680)

Yeah, I agree.

Lex Fridman (1:41:07.520)

And I have another nomination for a ban.

Lex Fridman (1:41:11.000)

We're in this crazy situation

John Abramson (1:41:12.960)

where Medicare is not allowed to negotiate

Lex Fridman (1:41:15.120)

the price of drugs with the drug companies.

Lex Fridman (1:41:17.800)

So the drug companies get a patent on a new drug.

Lex Fridman (1:41:20.840)

Unlike every other developed country,

John Abramson (1:41:22.440)

they can charge whatever they want

Lex Fridman (1:41:24.020)

so they have a monopoly on a utility

John Abramson (1:41:27.800)

because no one else can make the drug.

Lex Fridman (1:41:29.560)

Charge whatever they want and Medicare has to pay for it.

Lex Fridman (1:41:31.960)

And you say, how did we get in this crazy situation?

Lex Fridman (1:41:36.760)

So how we got here is that in 2003,

John Abramson (1:41:39.600)

when Medicare Part D was passed,

Lex Fridman (1:41:42.020)

Billy Towson was head of the Ways and Means Committee

John Abramson (1:41:45.680)

in the House, played a key role in ushering this through

Lex Fridman (1:41:48.960)

with the nonnegotiation clause of it.

Lex Fridman (1:41:52.440)

And after it was passed,

Lex Fridman (1:41:53.960)

Billy Towson did not finish out his term in Congress.

John Abramson (1:41:57.480)

He went to pharma for a $2 million a year job.

Lex Fridman (1:42:02.160)

This is incredible.

John Abramson (1:42:05.160)

You might think that a ban on that would be a good idea.

Lex Fridman (1:42:09.480)

I spoke with Francis Collins, head of the NIH,

John Abramson (1:42:12.080)

on this podcast.

Lex Fridman (1:42:13.680)

He and NIH have a lot of power over funding in science.

Lex Fridman (1:42:22.120)

What are they doing right, what are they doing wrong

Lex Fridman (1:42:24.840)

in this interplay with big pharma?

Lex Fridman (1:42:28.760)

How connected are they?

Lex Fridman (1:42:32.160)

Again, returning to the question,

Lex Fridman (1:42:33.720)

what are they doing right,

Lex Fridman (1:42:35.500)

what are they doing wrong in your view?

Lex Fridman (1:42:37.680)

So my knowledge of the NIH is not as granular

Lex Fridman (1:42:41.160)

as my knowledge of pharma.

John Abramson (1:42:44.480)

That said, in broad brushstrokes,

Lex Fridman (1:42:47.520)

the NIH is doing the infrastructure work

John Abramson (1:42:51.180)

for all drug development.

Lex Fridman (1:42:53.400)

I think they've participated in 100% of the drugs

John Abramson (1:42:56.700)

that have been approved by the FDA

Lex Fridman (1:42:58.920)

over the past 10 years or so.

John Abramson (1:43:01.480)

They've done infrastructure work.

Lex Fridman (1:43:03.080)

And what they do is not work on particular drugs,

Lex Fridman (1:43:08.160)

but they develop work on drug targets,

Lex Fridman (1:43:12.360)

on targets in the human body that can be affected by drugs

Lex Fridman (1:43:16.920)

and might be beneficial to turn on or off.

Lex Fridman (1:43:21.560)

And then the drug companies, when they find a target

John Abramson (1:43:24.560)

that is mutable and potentially beneficial,

Lex Fridman (1:43:29.360)

then the drug companies can take the research

Lex Fridman (1:43:32.020)

and choose to invest in the development of the drugs,

Lex Fridman (1:43:34.640)

specific drug.

John Abramson (1:43:36.740)

That's our model.

Lex Fridman (1:43:38.360)

Now, 96% of the research that's done in clinical trials

John Abramson (1:43:44.160)

in the United States is about drugs and devices.

Lex Fridman (1:43:47.280)

And only a fraction of the 4% that's left over

John Abramson (1:43:49.960)

is about preventive medicine

Lex Fridman (1:43:51.780)

and how to make Americans healthier.

John Abramson (1:43:54.480)

I think, again, from the satellite view,

Lex Fridman (1:43:58.520)

the NIH is investing more in science

John Abramson (1:44:04.260)

that can lead to commercial development

Lex Fridman (1:44:07.280)

rather than, as you said at the beginning of the podcast,

John Abramson (1:44:10.160)

there's no big fitness and lifestyle industry

Lex Fridman (1:44:13.480)

that can counter pharma.

Lex Fridman (1:44:15.980)

So I think at the NIH level, that countering can be done.

Lex Fridman (1:44:19.700)

And the diabetes prevention program study

John Abramson (1:44:22.560)

that we talked about before where lifestyle

Lex Fridman (1:44:24.920)

was part of a randomized trial

Lex Fridman (1:44:26.500)

and was shown to be more effective than metformin

Lex Fridman (1:44:28.940)

at preventing the development of diabetes,

John Abramson (1:44:31.000)

that is absolute proof positive

Lex Fridman (1:44:34.460)

that investing in that kind of science

John Abramson (1:44:36.140)

can produce good results.

Lex Fridman (1:44:37.900)

So I think that we're aimed at drug development

Lex Fridman (1:44:43.100)

and what we ought to be aimed at

Lex Fridman (1:44:44.880)

is an epidemiological approach

John Abramson (1:44:47.700)

to improving the health of all Americans.

Lex Fridman (1:44:49.900)

We rank 68th in the world in healthy life expectancy

John Abramson (1:44:55.060)

despite spending an extra trillion and a half dollars a year.

Lex Fridman (1:44:59.000)

And I believe strongly

John Abramson (1:45:02.560)

that the reason why we've gotten in this crazy position

Lex Fridman (1:45:06.880)

is because the knowledge that we're producing

John Abramson (1:45:10.280)

is about new drugs and devices

Lex Fridman (1:45:12.480)

and it's not about improving population health.

John Abramson (1:45:15.780)

In this problem, the NIH is the perfect institution

Lex Fridman (1:45:19.680)

to play a role in rebalancing our research agenda.

Lex Fridman (1:45:23.160)

And some of that is on the leadership side

Lex Fridman (1:45:24.940)

with Francis Collins and Anthony Fauci,

John Abramson (1:45:27.920)

not just speaking about basically everything

Lex Fridman (1:45:32.460)

that just leads to drug development, vaccine development,

Lex Fridman (1:45:34.760)

but also speaking about healthy lifestyles

Lex Fridman (1:45:36.760)

and speaking about health, not just sickness.

John Abramson (1:45:40.800)

Yes, and investing, investing in health.

Lex Fridman (1:45:43.200)

I mean, it's like one feeds the other.

John Abramson (1:45:49.000)

One, you have to communicate to the public

Lex Fridman (1:45:51.200)

the importance of investing in health

Lex Fridman (1:45:53.880)

and that leads to you getting props for investing in health

Lex Fridman (1:45:57.840)

and then you can invest in health more and more

Lex Fridman (1:45:59.520)

and that communicates, I mean,

Lex Fridman (1:46:01.680)

everything that Anthony Fauci says or Francis Collins says

John Abramson (1:46:05.120)

has an impact on scientists.

Lex Fridman (1:46:07.240)

I mean, it sets the priorities.

John Abramson (1:46:12.120)

I don't think they, it's the sad thing about leaders,

Lex Fridman (1:46:18.680)

forgive me for saying the word, but mediocre leaders

John Abramson (1:46:22.080)

is they don't see themselves as part of a game.

Lex Fridman (1:46:26.800)

They don't see the momentum.

John Abramson (1:46:29.920)

It's like a fish in the water.

Lex Fridman (1:46:31.160)

They don't see the water.

John Abramson (1:46:32.920)

Great leaders stand up and reverse the direction

Lex Fridman (1:46:36.080)

of how things are going.

Lex Fridman (1:46:37.120)

And I actually put a lot of responsibility,

Lex Fridman (1:46:39.920)

some people say too much, but whatever.

John Abramson (1:46:43.520)

I think leaders carry the responsibility.

Lex Fridman (1:46:46.440)

I put a lot of responsibility on Anthony Fauci

Lex Fridman (1:46:48.800)

and Francis Collins for not actually speaking

Lex Fridman (1:46:51.360)

a lot more about health, not, and bigger,

John Abramson (1:46:55.920)

inspiring people in the power

Lex Fridman (1:47:01.200)

and the trustworthiness of science.

John Abramson (1:47:05.560)

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

Lex Fridman (1:47:12.240)

I'm gonna abstain from that

John Abramson (1:47:13.760)

because I'm not expert enough, but.

Lex Fridman (1:47:15.800)

Neither am I, but I'm opinionated.

John Abramson (1:47:18.040)

I am too, but not on camera.

Lex Fridman (1:47:21.080)

Yes.

John Abramson (1:47:22.520)

No, but seriously, the problem is pretty simple,

Lex Fridman (1:47:27.200)

that we're investing 96% of our funding

John Abramson (1:47:31.400)

of clinical research in drugs and devices

Lex Fridman (1:47:33.520)

and 80% of our health is determined

John Abramson (1:47:36.800)

by how we live our lives.

Lex Fridman (1:47:38.120)

Yes.

Lex Fridman (1:47:39.160)

And this is ridiculous.

Lex Fridman (1:47:42.600)

The United States is going further and further

John Abramson (1:47:45.600)

behind the other wealthy countries in terms of our health.

Lex Fridman (1:47:49.760)

We ranked 38th in healthy life expectancy in 2000

Lex Fridman (1:47:53.560)

and now we're spending a trillion and a half dollars extra

Lex Fridman (1:47:56.960)

and we rank 68th.

John Abramson (1:47:58.360)

We've gone down.

Lex Fridman (1:47:59.520)

You have this excellent, there's a few charts

John Abramson (1:48:02.400)

that I'll overlay that tell this story

Lex Fridman (1:48:06.440)

in really powerful ways.

Lex Fridman (1:48:09.720)

So one is the healthcare spending is percentage of GDP

Lex Fridman (1:48:13.600)

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

Lex Fridman (1:48:17.680)

and the United States as compared to other countries

Lex Fridman (1:48:20.800)

on average has been much larger and growing.

John Abramson (1:48:26.440)

Right, we are now spending 7% more of our GDP,

Lex Fridman (1:48:30.520)

17.7% versus 10.7% on healthcare.

John Abramson (1:48:35.200)

7% and I think GDP is the fairest way

Lex Fridman (1:48:38.840)

to compare healthcare spending.

John Abramson (1:48:40.080)

Where per person in dollars we're spending even,

Lex Fridman (1:48:43.480)

the difference is even greater

Lex Fridman (1:48:45.560)

but other costs vary with GDP.

Lex Fridman (1:48:48.200)

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

John Abramson (1:48:50.800)

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

Lex Fridman (1:49:00.760)

7% higher than the comparable country average.

John Abramson (1:49:04.800)

Right.

Lex Fridman (1:49:05.640)

17.7% versus 10.7, 7% higher.

John Abramson (1:49:09.960)

Right and 7% of $23 trillion GDP

Lex Fridman (1:49:15.160)

is more than $1.5 trillion a year in excess.

Lex Fridman (1:49:19.040)

And then you have another chart that shows

Lex Fridman (1:49:21.000)

healthcare system performance compared to spending.

Lex Fridman (1:49:25.840)

And there's a cloud, a point cloud of different countries.

Lex Fridman (1:49:29.800)

The X axis being healthcare spending

John Abramson (1:49:33.160)

is a percentage of GDP which we just talked about.

Lex Fridman (1:49:36.360)

That US is 7% higher than everyone, the average.

Lex Fridman (1:49:40.880)

And then on the Y axis is performance.

Lex Fridman (1:49:44.520)

So X axis spending, Y axis performance.

Lex Fridman (1:49:48.280)

And there's a point cloud, we'll overlay this

Lex Fridman (1:49:50.600)

if you're watching on YouTube,

John Abramson (1:49:52.400)

of a bunch of countries that have high performance

Lex Fridman (1:49:58.600)

for what they're spending and then US

John Abramson (1:50:02.640)

is all alone on the right bottom side of the chart

Lex Fridman (1:50:07.480)

where it's low performance and high spending.

John Abramson (1:50:10.760)

Correct.

Lex Fridman (1:50:12.880)

So this is a system that is abiding by spending

John Abramson (1:50:17.960)

that is directed by the most profitable ways

Lex Fridman (1:50:21.160)

to deliver healthcare.

Lex Fridman (1:50:22.480)

So you put that in the hands of big pharma.

Lex Fridman (1:50:25.040)

As you maximize for profit, you're going to decrease

John Abramson (1:50:28.400)

performance and increase spending.

Lex Fridman (1:50:31.600)

Yes, but I wanna qualify that and say

John Abramson (1:50:34.800)

it's not all big pharma's fault.

Lex Fridman (1:50:37.440)

They're not responsible for all the problems

John Abramson (1:50:39.320)

in our healthcare system.

Lex Fridman (1:50:41.200)

They're not responsible for the administrative costs

John Abramson (1:50:43.160)

for example.

Lex Fridman (1:50:44.520)

But they are the largest component of the rising,

John Abramson (1:50:49.400)

our rising healthcare costs.

Lex Fridman (1:50:51.320)

And it has to do with this knowledge issue.

John Abramson (1:50:54.160)

Controlling the knowledge that doctors have

Lex Fridman (1:50:57.640)

makes it so that doctors can live with this situation

John Abramson (1:51:01.240)

believing that it's optimal when it's a wreck.

Lex Fridman (1:51:04.880)

Yeah.

John Abramson (1:51:06.160)

Let me ask you the big, so as a physician,

Lex Fridman (1:51:10.160)

so everything you've seen, we've talked about 80%

John Abramson (1:51:13.680)

of the impact on health is lifestyle.

Lex Fridman (1:51:18.480)

How do we live longer?

Lex Fridman (1:51:20.200)

What advice would you give to general people?

Lex Fridman (1:51:22.120)

What space of ideas result in living longer

Lex Fridman (1:51:29.080)

and higher quality lives?

Lex Fridman (1:51:30.720)

Right, this is a very simple question to answer.

John Abramson (1:51:34.480)

Exercise for at least a half hour

Lex Fridman (1:51:37.800)

at least five times a week.

John Abramson (1:51:41.040)

Number one.

Lex Fridman (1:51:42.360)

Number two, don't smoke.

John Abramson (1:51:45.560)

Number three, maintain a reasonably healthy body weight.

Lex Fridman (1:51:49.320)

Some people argue that being lower than a BMI of 25

John Abramson (1:51:53.720)

is healthy.

Lex Fridman (1:51:54.800)

I think that may be true,

Lex Fridman (1:51:56.480)

but I think getting above 30 is unhealthy

Lex Fridman (1:52:00.440)

and that ought to be.

John Abramson (1:52:01.920)

Now that's largely impacted by socioeconomic status

Lex Fridman (1:52:07.600)

and we don't wanna blame the victims here.

Lex Fridman (1:52:09.920)

So we gotta understand that when we talk about

Lex Fridman (1:52:12.600)

all of these things, not cigarettes,

Lex Fridman (1:52:14.920)

but exercise and a good diet

Lex Fridman (1:52:18.360)

and maintaining a healthy body weight,

John Abramson (1:52:23.000)

we have to include in doing those things

Lex Fridman (1:52:27.000)

the impediments to people of lower socioeconomic status

John Abramson (1:52:32.480)

being able to make those changes.

Lex Fridman (1:52:34.360)

We've got to understand that personal responsibility

John Abramson (1:52:38.120)

accounts for some of this,

Lex Fridman (1:52:39.880)

but also social circumstances accounts for some of it.

Lex Fridman (1:52:44.000)

And back to your fish bowl analogy,

Lex Fridman (1:52:47.000)

if you're swimming in a fish bowl,

John Abramson (1:52:50.040)

if you live in a fish tank

Lex Fridman (1:52:51.240)

that's not being properly maintained,

John Abramson (1:52:53.960)

the approach wouldn't be to treat individual sick fish,

Lex Fridman (1:52:58.080)

it would be to fix your fish tank

John Abramson (1:53:01.560)

to get the bacteria out of it

Lex Fridman (1:53:03.040)

and whatever bad stuff is in there

Lex Fridman (1:53:05.720)

and make your fish tank healthier.

Lex Fridman (1:53:08.440)

Well, we invest far less than the other wealthy countries do.

John Abramson (1:53:12.840)

We're flipped, we have the mirror image

Lex Fridman (1:53:15.120)

in the spending on social determinants of health

Lex Fridman (1:53:19.040)

and medical determinants of health.

Lex Fridman (1:53:20.840)

We have exactly the wrong order.

Lex Fridman (1:53:23.120)

And not only does that choke off

Lex Fridman (1:53:25.800)

social determinants of health, which are very important,

Lex Fridman (1:53:28.320)

but actually just the ratio,

Lex Fridman (1:53:30.720)

even if you were spending,

John Abramson (1:53:32.920)

if we raise the social spending

Lex Fridman (1:53:35.760)

and raise our medical spending in proportion,

John Abramson (1:53:38.360)

it's the ratio of social spending to medical spending

Lex Fridman (1:53:41.280)

that's the problem.

Lex Fridman (1:53:42.920)

So, and why do we do that?

Lex Fridman (1:53:44.560)

Well, the answer is perfectly obvious

John Abramson (1:53:46.440)

that the way to transfer money

Lex Fridman (1:53:48.680)

from working Americans to investors

John Abramson (1:53:51.840)

is through the biomedical model,

Lex Fridman (1:53:54.560)

not through the social health model.

Lex Fridman (1:53:57.720)

And that's the problem for,

Lex Fridman (1:53:59.920)

and I'd like to discuss this

John Abramson (1:54:02.840)

because the market isn't gonna get us

Lex Fridman (1:54:06.360)

to a reasonable allocation.

John Abramson (1:54:08.040)

All the other wealthy countries

Lex Fridman (1:54:09.680)

that are so much healthier than we are

Lex Fridman (1:54:11.560)

and spending so much less than we are

Lex Fridman (1:54:14.040)

have some form of government intervention

John Abramson (1:54:17.120)

in the quality of the health data that's available,

Lex Fridman (1:54:20.480)

in the budgeting of health and social factors.

Lex Fridman (1:54:25.920)

And we don't, we're kind of the Wild West

Lex Fridman (1:54:28.040)

and we let the market determine those allocations.

Lex Fridman (1:54:31.080)

And it's an awful failure.

Lex Fridman (1:54:34.360)

It's a horrendous failure.

Lex Fridman (1:54:36.720)

So one argument against government,

Lex Fridman (1:54:39.800)

or sorry, an alternative to the government intervention

John Abramson (1:54:44.720)

is the market can work better

Lex Fridman (1:54:48.320)

if the citizenry has better information.

Lex Fridman (1:54:51.720)

So one argument is that

Lex Fridman (1:54:53.160)

communicators like podcasts and so on,

Lex Fridman (1:54:58.680)

but other channels of communication

Lex Fridman (1:55:01.080)

will be the way to fight big pharma.

John Abramson (1:55:03.840)

Your book is the way to,

Lex Fridman (1:55:05.640)

by providing information.

John Abramson (1:55:07.560)

The alternative to the government intervention

Lex Fridman (1:55:10.360)

on every aspect of this,

John Abramson (1:55:11.760)

including communication with the doctors

Lex Fridman (1:55:13.440)

is to provide them other information

Lex Fridman (1:55:15.400)

and not allow the market to provide that information

Lex Fridman (1:55:18.600)

by basically making it exciting

John Abramson (1:55:22.440)

to buy books, to make better and better communicators

Lex Fridman (1:55:27.000)

on Twitter, through books, through op eds,

John Abramson (1:55:30.840)

through podcasts, through so on.

Lex Fridman (1:55:32.960)

So basically, cause there's a lot of incentive

John Abramson (1:55:35.840)

to communicate against the messages of big pharma.

Lex Fridman (1:55:40.440)

There's incentive because people want to understand

John Abramson (1:55:43.640)

what's good for their lives

Lex Fridman (1:55:44.760)

and they're willing to listen to charismatic people

John Abramson (1:55:46.880)

that are able to clearly explain what is good for them.

Lex Fridman (1:55:50.920)

And they do, and more than 80% of people

John Abramson (1:55:54.000)

think that drugs cost too much

Lex Fridman (1:55:55.480)

and the drug industry is too interested in profits.

Lex Fridman (1:56:00.400)

But they still get influenced.

Lex Fridman (1:56:02.320)

They can't, you can't get the vote through Congress.

John Abramson (1:56:05.520)

You know, Democrats and Republicans alike

Lex Fridman (1:56:08.720)

are taking money from Congress

Lex Fridman (1:56:10.280)

and somehow it just doesn't work out

Lex Fridman (1:56:13.920)

that these even small changes.

John Abramson (1:56:17.200)

I mean, the pared down part of Medicare,

Lex Fridman (1:56:21.800)

the plan for increasing Medicare negotiation drug costs

John Abramson (1:56:27.640)

in Build Back Better,

Lex Fridman (1:56:29.360)

it's literally gonna reduce the number of new drugs

John Abramson (1:56:32.840)

that are beneficial, uniquely beneficial

Lex Fridman (1:56:37.720)

by about one new drug or two new drugs over 30 years.

John Abramson (1:56:42.120)

It will have virtually an indecipherable impact.

Lex Fridman (1:56:48.440)

And yet pharma is talking about the impact on innovation.

Lex Fridman (1:56:53.760)

And if you vote for this,

Lex Fridman (1:56:55.920)

if you let your Congressman vote for this,

John Abramson (1:56:58.280)

you're gonna severely slow down drug innovation

Lex Fridman (1:57:04.340)

and that's gonna affect the quality of your life.

John Abramson (1:57:07.040)

Let me ask you about over medication

Lex Fridman (1:57:17.000)

that we've been talking about from different angles.

Lex Fridman (1:57:19.680)

But one difficult question for me,

Lex Fridman (1:57:22.640)

I'll just, I'll pick one of the difficult topics,

John Abramson (1:57:25.520)

depression.

Lex Fridman (1:57:26.960)

So depression is a serious, painful condition

John Abramson (1:57:31.960)

that leads to a lot of people suffering in the world.

Lex Fridman (1:57:37.240)

And yet it is likely they were over prescribing

John Abramson (1:57:40.560)

antidepressants.

Lex Fridman (1:57:42.380)

So as a doctor, as a patient, as a healthcare system,

John Abramson (1:57:47.040)

as a society, what do we do with that fact

Lex Fridman (1:57:50.340)

that people suffer?

John Abramson (1:57:53.040)

There's a lot of people suffering from depression

Lex Fridman (1:57:57.560)

and there's also people suffering

John Abramson (1:57:59.160)

from over prescribing of antidepressants.

Lex Fridman (1:58:01.920)

Right.

Lex Fridman (1:58:02.840)

So a paper in the New England Journal by Eric Turner

Lex Fridman (1:58:06.840)

showed that the data,

John Abramson (1:58:09.200)

if you put all the data together from antidepressants,

Lex Fridman (1:58:12.320)

you find out that antidepressants are not effective

John Abramson (1:58:17.940)

for people who are depressed

Lex Fridman (1:58:19.360)

but don't have a major depression.

John Abramson (1:58:22.240)

Major depression is a serious problem.

Lex Fridman (1:58:25.280)

People can't function normally.

John Abramson (1:58:27.260)

They have a hard time getting out,

Lex Fridman (1:58:31.020)

performing their normal social roles.

Lex Fridman (1:58:35.780)

But what's happened is that the publicity,

Lex Fridman (1:58:39.460)

I mean, Prozac Nation was a good example

John Abramson (1:58:43.020)

of making the argument that why should people

Lex Fridman (1:58:45.980)

settle for normal happiness

Lex Fridman (1:58:47.580)

when they can have better than normal happiness?

Lex Fridman (1:58:49.740)

And if you're not having normal happiness,

John Abramson (1:58:52.460)

you should take a drug.

Lex Fridman (1:58:53.540)

Well, that concept that serotonin metabolism

John Abramson (1:59:00.340)

is the root cause of depression

Lex Fridman (1:59:03.520)

is really a destructive one.

John Abramson (1:59:05.500)

We have drugs that change serotonin metabolism

Lex Fridman (1:59:08.740)

but we don't know if that's why antidepressants

John Abramson (1:59:12.140)

work on major depression.

Lex Fridman (1:59:14.440)

And they certainly don't work on everybody

John Abramson (1:59:16.020)

with major depression.

Lex Fridman (1:59:16.860)

I forget what the number needed a treat is.

John Abramson (1:59:18.500)

I think it's around four,

Lex Fridman (1:59:20.820)

one out of four people have significant improvement.

Lex Fridman (1:59:23.580)

But the people without major depression don't get better.

Lex Fridman (1:59:28.160)

And the vast majority of these drugs

John Abramson (1:59:30.420)

are used for people without major depression.

Lex Fridman (1:59:33.700)

So what's happened is that the feelings

John Abramson (1:59:37.260)

of life satisfaction of happiness and not sadness

Lex Fridman (1:59:42.020)

have been medicalized.

John Abramson (1:59:43.940)

The normal range of feelings have been medicalized.

Lex Fridman (1:59:47.860)

And that's not to say that they shouldn't be attended to.

Lex Fridman (1:59:51.020)

But the evidence shows that attending to them

Lex Fridman (1:59:54.340)

by giving somebody a medicine doesn't help

John Abramson (1:59:57.020)

except that they feel like somebody cares about them

Lex Fridman (1:59:59.660)

and believes that they're suffering.

John Abramson (20:01.320)

to maximize the effect of his advertising,

Lex Fridman (20:04.560)

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

John Abramson (20:07.640)

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

Lex Fridman (20:11.940)

So the people that survive in the company,

John Abramson (20:13.620)

the people that get raises in the company,

Lex Fridman (20:16.720)

move up in the company are the ones that play by the rules,

Lex Fridman (20:19.200)

and that's how the game solidifies itself.

Lex Fridman (20:21.560)

But the game is within the bounds of the law.

John Abramson (20:24.360)

Sometimes, most of the time, not always.

Lex Fridman (20:26.960)

We'll return to that question.

John Abramson (20:29.240)

I'm actually more concerned

Lex Fridman (20:31.680)

about the effect of advertisement

John Abramson (20:34.360)

in a kind of much larger scale

Lex Fridman (20:39.520)

on the people that are getting funded

John Abramson (20:43.040)

by the advertisement in self censorship,

Lex Fridman (20:46.320)

just like more subtle, more passive pressure

John Abramson (20:50.920)

to not say anything negative.

Lex Fridman (20:52.980)

Because I've seen this, and I've been saddened by it,

John Abramson (20:57.980)

that people sacrifice integrity in small ways

Lex Fridman (21:03.160)

when they're being funded by a particular company.

John Abramson (21:06.600)

They don't see themselves as doing so,

Lex Fridman (21:09.440)

but you can just clearly see that the space of opinions

John Abramson (21:12.880)

that they're willing to engage in,

Lex Fridman (21:15.240)

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

John Abramson (21:18.480)

is one that doesn't include negative,

Lex Fridman (21:22.460)

anything that could possibly be negative about the company.

John Abramson (21:25.560)

They just choose not to.

Lex Fridman (21:27.160)

Because, you know, why?

Lex Fridman (21:28.880)

And that's really sad to me,

Lex Fridman (21:30.620)

that if you give me a hundred bucks,

John Abramson (21:33.640)

I'm less likely to say something negative about you.

Lex Fridman (21:38.520)

That makes me sad.

John Abramson (21:39.920)

Because the reason I wouldn't say something negative

Lex Fridman (21:42.600)

about you, I prefer, is the pressure of friendship

Lex Fridman (21:45.600)

and human connection, those kinds of things.

Lex Fridman (21:48.360)

So I understand that.

John Abramson (21:50.700)

That's also a problem, by the way,

Lex Fridman (21:52.160)

sort of having dinners and shaking hands,

Lex Fridman (21:54.340)

and oh, aren't we friends?

Lex Fridman (21:56.260)

But the fact that money has that effect

John Abramson (21:58.520)

is really sad to me.

Lex Fridman (22:00.220)

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

John Abramson (22:05.320)

that's scary to me.

Lex Fridman (22:06.920)

But of course, the direct advertisement to consumers,

John Abramson (22:09.240)

like you said, is a potentially very negative effect.

Lex Fridman (22:11.320)

I wanted to ask if what you think

John Abramson (22:14.480)

is the most negative impact of advertisement,

Lex Fridman (22:17.100)

is it that direct to consumer on television?

Lex Fridman (22:20.320)

Is it advertisement of the doctors?

Lex Fridman (22:22.300)

Which I'm surprised to learn,

John Abramson (22:24.780)

I was vaguely looking at,

Lex Fridman (22:26.320)

is more spent on advertising to doctors than to consumers.

John Abramson (22:32.680)

That's really confusing to me.

Lex Fridman (22:34.040)

It's fascinating, actually.

Lex Fridman (22:35.640)

And then also, obviously, the law side of things

Lex Fridman (22:38.960)

is the lobbying dollars,

John Abramson (22:40.960)

which I think is less than all of those.

Lex Fridman (22:42.660)

But anyway, it's in the ballpark.

Lex Fridman (22:44.680)

What concerns you most?

Lex Fridman (22:46.540)

Well, it's the whole nexus of influence.

John Abramson (22:49.760)

There's not one thing, and they don't invest all their,

Lex Fridman (22:53.960)

they don't put all their eggs in one basket.

John Abramson (22:55.560)

It's a whole surround sound program here.

Lex Fridman (23:01.160)

But in terms of advertisements,

John Abramson (23:04.480)

let's take the advertisement.

Lex Fridman (23:06.120)

Trulicity is a diabetes drug,

John Abramson (23:09.640)

for type two diabetes, an injectable drug.

Lex Fridman (23:12.560)

And it lowers blood sugar just about as well

John Abramson (23:15.680)

as Metformin does.

Lex Fridman (23:18.520)

Metformin costs about $4 a month.

John Abramson (23:21.060)

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

Lex Fridman (23:25.760)

So $48 a year versus $6,200.

John Abramson (23:29.480)

Trulicity has distinguished itself

Lex Fridman (23:31.600)

because the manufacturer did a study

John Abramson (23:35.080)

that showed that it significantly reduces

Lex Fridman (23:37.340)

the risk of cardiovascular disease in diabetics.

Lex Fridman (23:41.080)

And they got approval on the basis of that study,

Lex Fridman (23:44.380)

that very large study being statistically significant.

Lex Fridman (23:47.560)

So the ads obviously extol the virtues of Trulicity

Lex Fridman (23:53.360)

because it reduces the risk of heart disease and stroke,

Lex Fridman (23:56.840)

and that's one of the major morbidities,

Lex Fridman (23:59.360)

risks of type two diabetes.

Lex Fridman (24:01.600)

What the ad doesn't say is that you have to treat

Lex Fridman (24:03.680)

323 people to prevent one nonfatal event

John Abramson (24:08.120)

at a cost of $2.7 million.

Lex Fridman (24:11.600)

And even more importantly than that,

Lex Fridman (24:13.840)

what the ad doesn't say is that the evidence shows

Lex Fridman (24:17.720)

that engaging in an active, healthy lifestyle program

John Abramson (24:22.040)

reduces the risk of heart disease and strokes

Lex Fridman (24:24.600)

far more than Trulicity does.

John Abramson (24:28.640)

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

Lex Fridman (24:32.160)

there's never been a study that compared Trulicity

John Abramson (24:37.440)

to lifestyle changes.

Lex Fridman (24:39.760)

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

John Abramson (24:42.680)

You would think in a rational society

Lex Fridman (24:45.360)

that was way out on a limb as a lone country

John Abramson (24:50.320)

besides New Zealand that allows

Lex Fridman (24:52.320)

direct to consumer advertising,

John Abramson (24:54.360)

that part of allowing direct to consumer advertising

Lex Fridman (24:59.120)

would be to mandate that the companies establish

John Abramson (25:03.080)

whether their drug is better than,

Lex Fridman (25:05.520)

say, healthy lifestyle adoption

John Abramson (25:07.960)

to prevent the problems that they claim to be preventing.

Lex Fridman (25:11.820)

But we don't require that.

Lex Fridman (25:13.800)

So the companies can afford to do very large studies

Lex Fridman (25:17.560)

so that very small differences

John Abramson (25:19.560)

become statistically significant.

Lex Fridman (25:21.840)

And their studies are asking the question,

Lex Fridman (25:23.880)

how can we sell more drug?

Lex Fridman (25:25.640)

They're not asking the question,

Lex Fridman (25:27.320)

how can we prevent cardiovascular disease

Lex Fridman (25:30.620)

in people with type 2 diabetes?

Lex Fridman (25:32.720)

And that's how we get off in this,

Lex Fridman (25:34.240)

we're now in the extreme arm of this distortion

John Abramson (25:38.560)

of our medical knowledge of studying

Lex Fridman (25:41.400)

how to sell more drugs than how to make people more healthy.

John Abramson (25:45.480)

That's a really great thing to compare to,

Lex Fridman (25:48.920)

is lifestyle changes.

John Abramson (25:51.400)

Because that should be the bar.

Lex Fridman (25:53.240)

If you do some basic diet, exercise,

John Abramson (25:56.680)

all those kinds of things,

Lex Fridman (25:58.420)

how does this drug compare to that?

John Abramson (26:00.240)

Right, right.

Lex Fridman (26:01.420)

And that study was done, actually, in the 90s.

John Abramson (26:04.080)

It's called the Diabetes Prevention Program.

Lex Fridman (26:06.080)

It was federally funded by the NIH

Lex Fridman (26:09.160)

so that there wasn't this drug company imperative

Lex Fridman (26:13.240)

to just try to prove your drug was better than nothing.

Lex Fridman (26:16.800)

And it was a very well designed study,

Lex Fridman (26:19.660)

randomized controlled trial

John Abramson (26:22.440)

in people who were at high risk of diabetes,

Lex Fridman (26:25.000)

so called pre diabetics.

Lex Fridman (26:26.840)

And they were randomized to three different groups,

Lex Fridman (26:30.040)

a placebo group, a group that got treated with metformin,

Lex Fridman (26:34.760)

and a group that got treated

Lex Fridman (26:36.200)

with intensive lifestyle counseling.

Lex Fridman (26:38.860)

So this study really tested

Lex Fridman (26:42.200)

whether you can get people in a randomized controlled trial

John Abramson (26:46.000)

assigned to intensive lifestyle changes,

Lex Fridman (26:49.280)

whether that works.

John Abramson (26:50.680)

Now the common wisdom amongst physicians,

Lex Fridman (26:54.640)

and I think in general,

John Abramson (26:56.080)

is that you can't get people to change.

Lex Fridman (26:57.960)

You know, you can do whatever you want,

John Abramson (26:59.240)

you can stand on your head,

Lex Fridman (27:00.320)

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

Lex Fridman (27:02.640)

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

Lex Fridman (27:05.040)

and not waste any time.

John Abramson (27:06.440)

Except this study that was published

Lex Fridman (27:08.280)

in the New England Journal, I think in 2002,

John Abramson (27:11.080)

shows that's wrong.

Lex Fridman (27:12.900)

That the people who were in the intensive lifestyle group

John Abramson (27:16.200)

ended up losing 10 pounds,

Lex Fridman (27:18.080)

exercising five times a week, maintaining it,

Lex Fridman (27:21.240)

and reduced their risk of getting diabetes by 58%,

Lex Fridman (27:26.320)

compared to the metformin group,

John Abramson (27:27.920)

which reduced its risk of getting diabetes by 31%.

Lex Fridman (27:32.000)

So that exact study was done

Lex Fridman (27:34.920)

and it showed that lifestyle intervention is the winner.

Lex Fridman (27:38.520)

Who, as a small tangent, is the leader,

Lex Fridman (27:44.840)

who is supposed to fight for the side of lifestyle changes?

Lex Fridman (27:49.140)

Where's the big pharma version of lifestyle changes?

John Abramson (27:54.600)

Who's supposed to have the big bully pulpit,

Lex Fridman (27:57.240)

the big money behind lifestyle changes?

John Abramson (28:00.040)

In your sense, because that seems to be missing

Lex Fridman (28:03.400)

in a lot of our discussions about health policy.

John Abramson (28:06.280)

Right, that's exactly right.

Lex Fridman (28:08.080)

And the answer is that we assume

John Abramson (28:12.800)

that the market has to solve all of these problems.

Lex Fridman (28:15.760)

And the market can't solve all of these problems.

John Abramson (28:18.320)

There needs to be some way of protecting the public interest

Lex Fridman (28:23.240)

for things that aren't financially driven.

Lex Fridman (28:26.520)

So that the overriding question has to be

Lex Fridman (28:28.760)

how best to improve Americans health,

John Abramson (28:31.420)

not companies funding studies to try and prove

Lex Fridman (28:36.200)

that their new inexpensive drug is better

Lex Fridman (28:39.240)

and should be used.

Lex Fridman (28:40.880)

Well, some of that is also people sort of like yourself.

John Abramson (28:45.460)

I mean, it's funny, you spoke with Joe Rogan.

Lex Fridman (28:48.800)

He constantly espouses lifestyle changes.

Lex Fridman (28:50.960)

So some of it is almost like understanding the problems

Lex Fridman (28:55.960)

that big pharma is creating in society

Lex Fridman (28:58.160)

and then sort of these influential voices

Lex Fridman (29:02.440)

speaking up against it.

Lex Fridman (29:03.560)

So whether they're scientists or just regular communicators.

Lex Fridman (29:08.600)

Yeah, I think you gotta tip your hat to Joe

John Abramson (29:11.320)

for getting that message out.

Lex Fridman (29:13.120)

And he clearly believes it and does his best.

Lex Fridman (29:17.360)

But it's not coming out in the legitimate avenues,

Lex Fridman (29:21.040)

in the legitimate channels that are evidence based medicine

Lex Fridman (29:26.040)

and from the sources that the docs are trained to listen to

Lex Fridman (29:32.040)

and modify their patient care on.

John Abramson (29:34.320)

Now, it's not 100%.

Lex Fridman (29:36.480)

I mean, there are articles in the big journals

John Abramson (29:40.160)

about the benefits of lifestyle,

Lex Fridman (29:42.160)

but they don't carry the same gravitas

John Abramson (29:45.800)

as the randomized controlled trials

Lex Fridman (29:48.240)

that test this drug against placebo

John Abramson (29:50.320)

or this drug against another drug.

Lex Fridman (29:52.360)

So the Joe Rogans of the world keep going.

John Abramson (29:55.680)

I tip my hat.

Lex Fridman (29:57.040)

But it's not gonna carry the day for most of the people

Lex Fridman (2:00:01.420)

But there are problems in living

Lex Fridman (2:00:04.060)

that give rise to much of this symptomatology

John Abramson (2:00:07.740)

of less than major depression.

Lex Fridman (2:00:10.100)

And let's call it what it is

Lex Fridman (2:00:12.380)

and figure out a way to help people

Lex Fridman (2:00:14.780)

in visual therapy, group therapy.

John Abramson (2:00:17.980)

Maybe lifestyle modification would work.

Lex Fridman (2:00:19.880)

We gotta try that.

Lex Fridman (2:00:21.920)

But let's call it what it is instead of saying,

Lex Fridman (2:00:24.760)

oh, you're in this vast basket of people who are depressed

Lex Fridman (2:00:29.860)

so we'll give you an antidepressant

Lex Fridman (2:00:31.540)

even though the evidence shows

John Abramson (2:00:33.340)

that people who are suffering from your level of depression

Lex Fridman (2:00:36.620)

don't get better.

Lex Fridman (2:00:38.220)

And that's a consequence of not focusing

Lex Fridman (2:00:42.540)

on preventative medicine, the lifestyle changes,

John Abramson (2:00:46.060)

all that kind of stuff.

Lex Fridman (2:00:47.140)

Well, yes, but it's really a consequence

John Abramson (2:00:49.660)

of the drug companies creating the impression

Lex Fridman (2:00:53.060)

that if you're sad, take a pill.

John Abramson (2:00:56.620)

If you're nonmajor depression,

Lex Fridman (2:01:01.140)

how do you overcome depression?

John Abramson (2:01:03.460)

Well, you have to talk about what the problem is.

Lex Fridman (2:01:06.700)

So talk therapy, lifestyle changes.

John Abramson (2:01:09.900)

Well, no, I'm not jumping to that.

Lex Fridman (2:01:12.260)

I'm saying that you ought to,

John Abramson (2:01:15.100)

A, the way you feel must be respected.

Lex Fridman (2:01:19.420)

Yeah, acknowledge that you're suffering.

John Abramson (2:01:21.140)

Acknowledge that you're suffering

Lex Fridman (2:01:22.660)

and deal with healthcare providers

John Abramson (2:01:24.700)

who acknowledge that you're suffering.

Lex Fridman (2:01:27.220)

So let's take that first step.

Lex Fridman (2:01:30.180)

And then. Big first step also.

Lex Fridman (2:01:32.260)

Big first step, yeah.

John Abramson (2:01:33.540)

Family docs are pretty good at that.

Lex Fridman (2:01:36.220)

That's kind of the arena

John Abramson (2:01:38.980)

that caused me to go into family medicine.

Lex Fridman (2:01:41.880)

The subjective experience of the patient.

John Abramson (2:01:44.260)

Okay, so you're a person

Lex Fridman (2:01:46.700)

who is not getting the enjoyment out of their life

John Abramson (2:01:49.620)

that they feel they ought to be getting.

Lex Fridman (2:01:52.040)

Now let's figure out why

Lex Fridman (2:01:54.620)

and whether that means some time with a social worker,

Lex Fridman (2:01:57.300)

some time with a psychiatrist,

John Abramson (2:01:59.020)

some time with a psychiatric nurse.

Lex Fridman (2:02:02.220)

I'm not sure how you'd best do that

John Abramson (2:02:04.100)

most effectively and efficiently,

Lex Fridman (2:02:05.760)

but that's what you need to do.

Lex Fridman (2:02:07.500)

And it may be that there's a marital problem

Lex Fridman (2:02:11.680)

and there's something going on

Lex Fridman (2:02:13.620)

and one of the spouses can't find satisfaction

Lex Fridman (2:02:18.580)

in the life they have to live within their relationship.

John Abramson (2:02:21.500)

Maybe there's a past history of trauma or abuse

Lex Fridman (2:02:24.640)

that somebody is projecting onto their current situation.

John Abramson (2:02:28.820)

Maybe there's socioeconomic circumstances

Lex Fridman (2:02:31.100)

where they can't find a job

John Abramson (2:02:33.100)

that gives them self respect and enough money to live.

Lex Fridman (2:02:36.540)

All, you know, an infinite range of things.

Lex Fridman (2:02:39.700)

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

Lex Fridman (2:02:42.080)

The diagnosis isn't that the person feels sadder

John Abramson (2:02:45.460)

than they feel, than they want to feel.

Lex Fridman (2:02:48.620)

The diagnosis is why does the person feel sadder

Lex Fridman (2:02:51.980)

than they want to feel?

Lex Fridman (2:02:54.500)

You mentioned this is what made you want

John Abramson (2:02:56.340)

to get into family medicine.

Lex Fridman (2:03:00.980)

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

Lex Fridman (2:03:03.100)

save one life, save the world?

Lex Fridman (2:03:05.380)

This was always moving to me about doctors

John Abramson (2:03:13.780)

because you have like this human in front of you

Lex Fridman (2:03:17.700)

and your time is worth money.

John Abramson (2:03:22.340)

Your, what you prescribe and your efforts

Lex Fridman (2:03:26.220)

after the visit are worth money.

Lex Fridman (2:03:28.820)

And it seems like the task of the doctor

Lex Fridman (2:03:31.860)

is to not think about any of that.

John Abramson (2:03:34.760)

Or not the task, but it seems like a great doctor,

Lex Fridman (2:03:42.480)

despite all that, just forgets it all

Lex Fridman (2:03:45.080)

and just cares about the one human.

Lex Fridman (2:03:47.020)

And somehow that feels like the love and effort

John Abramson (2:03:51.260)

you put into helping one person

Lex Fridman (2:03:53.220)

is the thing that will save the world.

John Abramson (2:03:55.460)

It's not like some economic argument

Lex Fridman (2:03:58.420)

or some political argument or financial argument.

John Abramson (2:04:03.420)

It's a very human drive that ultimately

Lex Fridman (2:04:09.580)

is behind all of this that will do good for the world.

John Abramson (2:04:13.020)

Yes, I think that's true.

Lex Fridman (2:04:15.600)

And at the same time, I think it's equally true

John Abramson (2:04:19.660)

that all physicians need to have a sense of responsibility

Lex Fridman (2:04:23.660)

about how the common resources are allocated

John Abramson (2:04:28.660)

to serve the whole population's interest best.

Lex Fridman (2:04:34.180)

That's a tension that you have as a physician.

John Abramson (2:04:36.420)

Let's take the extreme example.

Lex Fridman (2:04:38.500)

Let's say you had a patient in front of you

John Abramson (2:04:41.460)

who if you gave one $10 billion pill to,

Lex Fridman (2:04:46.380)

you would save their life.

John Abramson (2:04:49.180)

I would just be tortured by that as a physician

Lex Fridman (2:04:52.420)

because I know that $10 billion spent properly

John Abramson (2:04:56.140)

in an epidemiologically guided way

Lex Fridman (2:05:00.260)

is gonna save a whole lot more lives than one life.

Lex Fridman (2:05:03.580)

So it's also your responsibility as a physician

Lex Fridman (2:05:06.380)

to walk away from that patient.

John Abramson (2:05:08.700)

I wouldn't say that.

Lex Fridman (2:05:10.540)

I think it's your responsibility

John Abramson (2:05:12.060)

to be tortured by it.

Lex Fridman (2:05:14.020)

That's exactly right.

John Abramson (2:05:17.100)

The human condition.

Lex Fridman (2:05:21.460)

That's a tough job, but yeah, yeah.

John Abramson (2:05:24.700)

To maintain your humanity through it all.

Lex Fridman (2:05:27.220)

Yeah, but you've been asking at different points

John Abramson (2:05:30.260)

in this conversation, why are doctors so complacent

Lex Fridman (2:05:35.980)

about the tremendous amount of money we're spending?

Lex Fridman (2:05:38.860)

Why do they accept knowledge from different sources

Lex Fridman (2:05:41.460)

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

Lex Fridman (2:05:45.300)

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

Lex Fridman (2:05:48.380)

for their patients.

Lex Fridman (2:05:49.500)

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

Lex Fridman (2:05:56.340)

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

Lex Fridman (2:06:00.740)

And that's a sort of future project.

Lex Fridman (2:06:03.420)

And maybe people will read my book

Lex Fridman (2:06:06.140)

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

Lex Fridman (2:06:08.100)

become more legitimate in practice.

John Abramson (2:06:10.140)

I would feel like my life was worthwhile if that happened.

Lex Fridman (2:06:13.620)

But at the same time, they've got to do something

John Abramson (2:06:17.140)

with the patient in front of them.

Lex Fridman (2:06:18.740)

They've got to make a decision.

Lex Fridman (2:06:21.100)

And they probably, there are not many weirdos like me

Lex Fridman (2:06:24.820)

who invest their life in figuring out

John Abramson (2:06:27.300)

what's behind the data.

Lex Fridman (2:06:28.300)

They're trying to get through the day

Lex Fridman (2:06:29.780)

and do the right thing for their patient.

Lex Fridman (2:06:31.620)

So they're tortured by that decision too.

Lex Fridman (2:06:34.980)

And so if you're not careful,

Lex Fridman (2:06:38.460)

big pharma can manipulate that drive

John Abramson (2:06:43.460)

to try to help the patient,

Lex Fridman (2:06:44.940)

that humanity of dealing with the uncertainty of it all.

Lex Fridman (2:06:49.700)

Like what is the best thing to do?

Lex Fridman (2:06:51.940)

Big pharma can step in and use money

John Abramson (2:06:53.780)

to manipulate that humanity.

Lex Fridman (2:06:55.500)

Yeah, I would state it quite differently.

John Abramson (2:06:57.500)

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

Lex Fridman (2:07:00.940)

Big pharma will do that.

Lex Fridman (2:07:02.820)

And you need to opt out of it.

Lex Fridman (2:07:07.980)

What advice would you give to a young person today

John Abramson (2:07:11.300)

in high school or college

Lex Fridman (2:07:13.100)

stepping into this complicated world

John Abramson (2:07:17.020)

full of advertisements, of big powerful institutions,

Lex Fridman (2:07:22.540)

of big rich companies,

Lex Fridman (2:07:24.900)

how to have a positive impact in the world,

Lex Fridman (2:07:27.100)

how to live a life they can be proud of?

John Abramson (2:07:30.860)

I would say should that person

Lex Fridman (2:07:34.580)

who has only good motives go into medicine.

John Abramson (2:07:38.140)

They have an inclination to go into medicine

Lex Fridman (2:07:39.740)

and they've asked me what I think about that

John Abramson (2:07:42.060)

given what I know about the undermining

Lex Fridman (2:07:45.420)

of American healthcare at this point.

Lex Fridman (2:07:47.660)

And my answer is if you've got the calling,

Lex Fridman (2:07:50.660)

you should do it.

John Abramson (2:07:52.420)

You should do it because nobody's gonna do it

Lex Fridman (2:07:54.340)

better than you.

Lex Fridman (2:07:56.220)

And if you don't have the calling

Lex Fridman (2:07:58.780)

and you're in it for the money,

John Abramson (2:08:01.020)

you're not gonna be proud of yourself.

Lex Fridman (2:08:03.260)

How do you prevent yourself from doing,

John Abramson (2:08:07.700)

from letting the system change you over years and years,

Lex Fridman (2:08:12.940)

like letting the game of pharmaceutical influence affect you?

John Abramson (2:08:20.820)

It's a very hard question

Lex Fridman (2:08:22.620)

because the sociologic norms are to be affected

Lex Fridman (2:08:28.060)

and to trust the sources of information

Lex Fridman (2:08:32.980)

that are largely controlled by the drug industry.

Lex Fridman (2:08:36.340)

And that's why I wrote Sickening,

Lex Fridman (2:08:38.220)

is to try and help those people in the medical profession

John Abramson (2:08:46.020)

to understand that what's going on right now looks normal

Lex Fridman (2:08:50.620)

but it's not.

John Abramson (2:08:52.380)

The health of Americans is going downhill.

Lex Fridman (2:08:55.460)

Our society's getting ruined by the money

John Abramson (2:08:57.580)

that's getting pulled out of other socially beneficial uses

Lex Fridman (2:09:02.580)

to pay for health care that is not helping us.

Lex Fridman (2:09:08.060)

So fundamentally, the thing that is normal,

Lex Fridman (2:09:12.580)

now question the normal, don't.

John Abramson (2:09:17.820)

If you conform, conform hesitantly.

Lex Fridman (2:09:21.820)

Well, you have to conform.

John Abramson (2:09:23.700)

You can't become a doctor without conforming.

Lex Fridman (2:09:26.620)

I just made it through.

Lex Fridman (2:09:30.100)

But there aren't many and it's hard work.

Lex Fridman (2:09:35.300)

But you have to conform.

Lex Fridman (2:09:38.060)

And even with my colleagues in my own practice,

Lex Fridman (2:09:40.580)

I couldn't convince them that some of the beliefs they had

John Abramson (2:09:44.300)

about how best to practice weren't accurate.

Lex Fridman (2:09:47.220)

There's one scene, a younger physician

John Abramson (2:09:51.100)

had prescribed hormone replacement therapy.

Lex Fridman (2:09:53.580)

This is back in 2000, 2001.

John Abramson (2:09:56.220)

Had prescribed hormone replacement therapy for one of my patients

Lex Fridman (2:10:00.380)

who happened to be a really good personal friend.

Lex Fridman (2:10:03.220)

And I saw that patient covering for my colleague at one point

Lex Fridman (2:10:08.780)

and I saw that her hormone replacement therapy had been renewed.

Lex Fridman (2:10:13.340)

And I said, are you having hot flashes or any problem?

Lex Fridman (2:10:15.580)

No, no, no, no.

Lex Fridman (2:10:16.660)

But Dr. So and So said it's better for my health.

Lex Fridman (2:10:21.220)

And I said, no, it's not.

John Abramson (2:10:23.060)

The research is showing that it's not, it's harmful for your health

Lex Fridman (2:10:26.180)

and I think you should stop it.

Lex Fridman (2:10:27.980)

So my colleague approached me when she saw the chart and said,

Lex Fridman (2:10:32.780)

wait a minute, that's my patient.

John Abramson (2:10:34.780)

Maybe your friend, but it's my patient.

Lex Fridman (2:10:37.180)

And I went to a conference from my alma mater, medical school,

Lex Fridman (2:10:43.900)

and they said that healthy people should be given hormone replacement.

Lex Fridman (2:10:47.940)

And I said, there's got to be a way to get rid of it.

Lex Fridman (2:10:51.500)

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

Lex Fridman (2:10:55.300)

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

John Abramson (2:10:57.700)

It was not a drug company thing.

Lex Fridman (2:10:59.900)

We didn't go to a Caribbean island.

Lex Fridman (2:11:02.380)

I said, do you have the syllabus?

Lex Fridman (2:11:03.860)

She said, yeah.

Lex Fridman (2:11:05.140)

And she went and got the syllabus and sure enough,

Lex Fridman (2:11:07.660)

it was sponsored by a drug company.

John Abramson (2:11:10.380)

They're everywhere.

Lex Fridman (2:11:11.340)

They're everywhere.

Lex Fridman (2:11:12.220)

And it's back to Kuhn that groups of experts

Lex Fridman (2:11:16.340)

share unspoken assumptions, and in order to be included

John Abramson (2:11:21.740)

in that group of experts, you have

Lex Fridman (2:11:23.140)

to share those unspoken assumptions.

Lex Fridman (2:11:25.260)

And what I'm hoping to do with my book, Sickening,

Lex Fridman (2:11:27.900)

and being here having this wonderful conversation with you

John Abramson (2:11:31.900)

is to create an alternative to this normal

Lex Fridman (2:11:36.220)

that people can pursue and practice better medicine

Lex Fridman (2:11:45.060)

and also prevent burnout.

Lex Fridman (2:11:47.220)

I mean, about half the doctors complain that they're burned

John Abramson (2:11:49.900)

out and they've had it.

Lex Fridman (2:11:51.260)

And I think that this is subjective.

John Abramson (2:11:54.180)

I don't have data on this.

Lex Fridman (2:11:55.300)

This is just my opinion.

Lex Fridman (2:11:57.540)

But I think that a lot of that burnout

Lex Fridman (2:11:59.900)

is so called moral injury from practicing in a way

John Abramson (2:12:04.380)

that the docs know isn't working.

Lex Fridman (2:12:08.420)

It's not actually providing an alternative to the normals,

John Abramson (2:12:12.020)

expanding the normals, shifting the normal,

Lex Fridman (2:12:13.860)

just like with Kuhn.

John Abramson (2:12:15.220)

You're basically looking to shift

Lex Fridman (2:12:19.420)

the way medicine is done to the original,

John Abramson (2:12:24.340)

to the intent that it represents the ideal of medicine,

Lex Fridman (2:12:29.860)

of health care.

John Abramson (2:12:30.580)

Yeah, in Kuhnian terms, to have a revolution.

Lex Fridman (2:12:33.620)

And that revolution would be to practice medicine

John Abramson (2:12:36.860)

in a way that will be epidemiologically most

Lex Fridman (2:12:40.620)

effective, not most profitable for the people

John Abramson (2:12:43.660)

who are providing you with what's called knowledge.

Lex Fridman (2:12:47.420)

You helped a lot of people, as a doctor, as an educator,

John Abramson (2:12:53.220)

live better lives, live longer.

Lex Fridman (2:12:56.540)

But you yourself are a mortal being.

Lex Fridman (2:12:59.180)

Do you think about your own mortality?

Lex Fridman (2:13:02.260)

Do you think about your death?

Lex Fridman (2:13:03.660)

Are you afraid of death?

Lex Fridman (2:13:06.020)

I'm not.

John Abramson (2:13:06.540)

I've faced it, been close.

Lex Fridman (2:13:12.100)

Yourself?

John Abramson (2:13:12.780)

Yeah, yeah.

Lex Fridman (2:13:14.980)

How do you think about it?

Lex Fridman (2:13:16.220)

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

Lex Fridman (2:13:19.780)

the fact that the whole thing ends?

John Abramson (2:13:23.060)

It's liberating.

Lex Fridman (2:13:25.780)

It's very liberating.

John Abramson (2:13:26.740)

I'm serious.

Lex Fridman (2:13:27.460)

I was close, and not too long ago.

Lex Fridman (2:13:34.060)

And it was a sense of, this may be the way it ends.

Lex Fridman (2:13:41.820)

And I've done my best.

John Abramson (2:13:45.780)

It's not been perfect.

Lex Fridman (2:13:48.220)

And if it ends here, it ends here.

John Abramson (2:13:51.180)

The people around me are trying to do their best.

Lex Fridman (2:13:54.460)

And in fact, I got pulled out of it.

Lex Fridman (2:13:57.860)

But it didn't look like I was going to get pulled out of it.

Lex Fridman (2:14:01.540)

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

John Abramson (2:14:07.420)

Well, it's a little odd.

Lex Fridman (2:14:11.940)

I think so.

John Abramson (2:14:13.140)

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

Lex Fridman (2:14:18.820)

It's not the real ride.

John Abramson (2:14:19.940)

It's just a ride.

Lex Fridman (2:14:22.140)

But having gone through the whole thing,

John Abramson (2:14:25.220)

I definitely freed me of a sense of anxiety about death.

Lex Fridman (2:14:31.260)

And it said to me, do your best every day,

John Abramson (2:14:35.540)

because it's going to end sometime.

Lex Fridman (2:14:38.460)

I apologize for the ridiculously big question.

Lex Fridman (2:14:40.820)

But what do you think is the meaning of life,

Lex Fridman (2:14:45.780)

of our human existence?

John Abramson (2:14:52.140)

I think it's to care about something and do your best with it.

Lex Fridman (2:14:56.900)

Whether it's being a doctor and trying

John Abramson (2:14:59.620)

to make sure that the greatest number of people

Lex Fridman (2:15:03.180)

get the best health care.

John Abramson (2:15:06.460)

Or it's a gardener who wants to have the most beautiful plants.

Lex Fridman (2:15:09.380)

Or it's a grandparent who wants to have a good relationship

John Abramson (2:15:12.780)

with their grandchildren.

Lex Fridman (2:15:13.820)

But whatever it is that gives you a sense of meaning,

John Abramson (2:15:19.260)

as long as it doesn't hurt other people,

Lex Fridman (2:15:21.900)

to really commit yourself to it.

John Abramson (2:15:24.980)

That commitment, being in that commitment for me

Lex Fridman (2:15:27.940)

is the meaning of life.

John Abramson (2:15:29.860)

Put your whole heart and soul into the thing.

Lex Fridman (2:15:34.540)

What is it, the Bukowski poem, go all the way.

John Abramson (2:15:38.860)

John, you're an incredible human being, incredible educator.

Lex Fridman (2:15:42.500)

Like I said, I recommend people listen to your lectures.

John Abramson (2:15:45.060)

It's so refreshing to see that clarity

Lex Fridman (2:15:47.980)

of thought and brilliance.

Lex Fridman (2:15:49.380)

And obviously, your criticism of Big Pharma

Lex Fridman (2:15:51.900)

or your illumination of the mechanisms of Big Pharma

John Abramson (2:15:56.420)

is really important at this time.

Lex Fridman (2:15:58.500)

So I really hope people read your book, Sickening,

John Abramson (2:16:02.820)

that's out today, or depending on when this comes out.

Lex Fridman (2:16:07.820)

Thank you so much for spending your extremely valuable time

John Abramson (2:16:11.140)

with me today.

Lex Fridman (2:16:12.260)

It was amazing.

John Abramson (2:16:13.100)

Well, Lex, I wanted back to you.

Lex Fridman (2:16:15.460)

Thanks for engaging in this conversation,

John Abramson (2:16:18.700)

for creating the space to have it,

Lex Fridman (2:16:21.420)

and creating a listenership that is

John Abramson (2:16:24.260)

interested in understanding serious ideas.

Lex Fridman (2:16:27.380)

And I really appreciate the conversation.

Lex Fridman (2:16:29.460)

And I should mention that offline,

Lex Fridman (2:16:30.940)

you told me you listened to the Gilbert Strang episode.

Lex Fridman (2:16:34.060)

So for anyone who don't know Gilbert Strang,

Lex Fridman (2:16:35.980)

another epic human being that you should check out.

John Abramson (2:16:39.020)

If you don't know anything about mathematics

Lex Fridman (2:16:41.260)

or linear algebra, go look him up.

John Abramson (2:16:43.260)

He's one of the great mathematics educators of all time.

Lex Fridman (2:16:46.700)

So of all the people you mentioned to me,

John Abramson (2:16:49.060)

I appreciate that you mentioned him,

Lex Fridman (2:16:50.780)

because he is a rockstar of mathematics.

John Abramson (2:16:54.100)

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

Lex Fridman (2:16:56.220)

Great, thank you.

John Abramson (2:16:57.900)

Thanks for listening to this conversation with John Abramson.

Lex Fridman (2:17:00.740)

To support this podcast,

John Abramson (2:17:02.140)

please check out our sponsors in the description.

Lex Fridman (2:17:04.980)

And now, let me leave you some words from Marcus Aurelius.

John Abramson (2:17:09.900)

"'Waste no time arguing about what a good man should be.

Lex Fridman (2:17:14.740)

Be one."

John Abramson (2:17:15.740)

Thank you for listening and hope to see you next time.

Lex Fridman (30:00.920)

until it has the legitimacy of the medical establishment.

John Abramson (30:04.240)

Yeah, like something that the doctors

Lex Fridman (30:05.960)

really pay attention to.

John Abramson (30:07.160)

Well, there's an entire mechanism established

Lex Fridman (30:09.700)

for testing drugs.

John Abramson (30:11.320)

There's not an entire mechanism established

Lex Fridman (30:14.400)

in terms of scientific rigor of testing lifestyle changes.

John Abramson (30:17.600)

I mean, it's more difficult.

Lex Fridman (30:20.520)

I mean, everything's difficult in science.

John Abramson (30:23.440)

That science that involves humans, especially.

Lex Fridman (30:27.120)

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

John Abramson (30:30.640)

They're difficult.

Lex Fridman (30:31.960)

It's difficult to find conclusions

Lex Fridman (30:33.400)

and to control all the variables.

Lex Fridman (30:35.480)

And so it's very easy to dismiss them

John Abramson (30:37.360)

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

Lex Fridman (30:40.960)

And so maybe the doctors just lean

John Abramson (30:42.840)

towards the simpler studies over and over,

Lex Fridman (30:45.740)

which is what the drug companies fund.

John Abramson (30:48.040)

They can control more variables.

Lex Fridman (30:50.400)

See, but the control there is sometimes

Lex Fridman (30:56.960)

by hiding things too, right?

Lex Fridman (31:00.920)

So sometimes you can just say

John Abramson (31:03.480)

that this is a well controlled study

Lex Fridman (31:06.420)

by pretending there's a bunch of other stuff.

John Abramson (31:09.240)

It's just ignoring the stuff that could be correlated.

Lex Fridman (31:13.280)

It could be the real cause of the effects you're seeing,

John Abramson (31:15.560)

all that kind of stuff.

Lex Fridman (31:17.360)

So money can buy ignorance, I suppose, in science.

John Abramson (31:21.720)

It buys the kind of blinders that are on

Lex Fridman (31:24.720)

that don't look outside the reductionist model.

Lex Fridman (31:28.040)

And that's another issue is that we kind of,

Lex Fridman (31:31.480)

nobody says to doctors in training,

John Abramson (31:34.320)

only listen to reductionist studies and conclusions

Lex Fridman (31:39.360)

and methods of promoting health.

John Abramson (31:42.080)

Nobody says that explicitly.

Lex Fridman (31:43.980)

But the respectable science

John Abramson (31:47.640)

has to do with controlling the factors.

Lex Fridman (31:49.760)

And I mean, it just doesn't make sense to me.

John Abramson (31:54.200)

I'm gonna pick on trulicity

Lex Fridman (31:55.440)

because it's such an obvious example,

Lex Fridman (31:57.240)

but it's not more egregious than many others.

Lex Fridman (32:01.320)

It doesn't make sense to me to allow a drug

John Abramson (32:03.720)

to be advertised as preventing cardiovascular disease

Lex Fridman (32:06.960)

when you haven't included lifestyle changes

John Abramson (32:09.960)

as an arm in the study.

Lex Fridman (32:11.660)

It's just so crystal clear that the purpose of that study

John Abramson (32:15.980)

is to sell trulicity.

Lex Fridman (32:17.420)

It's not to prevent cardiovascular disease.

John Abramson (32:21.280)

If we were in charge, I would try to convince you

Lex Fridman (32:24.720)

that anywhere that study, the results of that study

John Abramson (32:27.640)

were presented to physicians,

Lex Fridman (32:31.040)

it would be stamped in big red letters,

John Abramson (32:33.560)

this study did not compare trulicity to lifestyle changes.

Lex Fridman (32:37.680)

They need to know that.

Lex Fridman (32:38.960)

And the docs are kind of trained,

Lex Fridman (32:40.640)

these blinders get put on,

Lex Fridman (32:42.680)

and they're trained to kind of forget that that's not there.

Lex Fridman (32:46.320)

Do you think, so first of all,

John Abramson (32:48.240)

that's a small or big change to advertisement

Lex Fridman (32:51.320)

that seems obvious to say,

John Abramson (32:54.080)

like in force that it should be compared

Lex Fridman (32:56.500)

to lifestyle changes.

Lex Fridman (32:59.040)

Do you think advertisements, period,

Lex Fridman (33:01.240)

in the United States for pharmaceutical drugs

Lex Fridman (33:04.200)

should be banned?

Lex Fridman (33:05.920)

I think they can't be banned.

Lex Fridman (33:07.520)

So it doesn't matter what I think.

Lex Fridman (33:09.200)

Okay, let's say you were a dictator,

Lex Fridman (33:13.200)

and two, why can't they be banned?

Lex Fridman (33:15.200)

Okay.

John Abramson (33:16.720)

Answer either one.

Lex Fridman (33:18.700)

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

John Abramson (33:22.800)

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

Lex Fridman (33:27.280)

is such that you can't ban them,

John Abramson (33:29.360)

that you could ban cigarettes and alcohol,

Lex Fridman (33:33.300)

which have no therapeutic use,

Lex Fridman (33:35.640)

but drugs have a therapeutic use,

Lex Fridman (33:37.680)

and advertisements about them can't be banned.

John Abramson (33:41.600)

Let's assume that they can't be,

Lex Fridman (33:43.680)

because we know they won't be anyway,

Lex Fridman (33:46.860)

but let's assume they can't be,

Lex Fridman (33:49.120)

and especially our Supreme Court now

John Abramson (33:51.840)

would be unlikely to take that seriously.

Lex Fridman (33:55.900)

But that's not the issue.

John Abramson (33:57.360)

The issue is that if the drug companies

Lex Fridman (34:00.260)

want to spend their money advertising,

John Abramson (34:02.640)

they should have to have independent analysis

Lex Fridman (34:06.880)

of the message that the viewers are left with

John Abramson (34:10.440)

about the drug, so that it's realistic.

Lex Fridman (34:13.400)

What's the chance the drug will help them?

John Abramson (34:15.520)

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

Lex Fridman (34:19.000)

322 people aren't gonna benefit

John Abramson (34:21.120)

from the cardiovascular reduction, risk reduction.

Lex Fridman (34:25.080)

What's the true cost?

John Abramson (34:26.880)

When drugs advertise that you may be able to get this

Lex Fridman (34:30.640)

for a $25 copay or something,

John Abramson (34:33.900)

tens of thousands of dollars a year drug,

Lex Fridman (34:35.960)

for a $25 copay, what an enormous disservice that is

John Abramson (34:40.120)

to misrepresent the cost to society.

Lex Fridman (34:42.600)

That should not be allowed.

Lex Fridman (34:44.040)

So you should have to make it clear to the viewers

Lex Fridman (34:48.680)

how many people are gonna benefit,

Lex Fridman (34:49.960)

what's your chance of benefiting?

Lex Fridman (34:51.680)

How does it compare to lifestyle changes

Lex Fridman (34:53.560)

or less expensive therapies?

Lex Fridman (34:55.860)

What do you give up if you use a less expensive therapy

Lex Fridman (34:58.440)

or gain, perhaps?

Lex Fridman (34:59.960)

And how much it costs.

Lex Fridman (35:01.160)

How much it costs.

Lex Fridman (35:02.280)

Now, that can go either way,

John Abramson (35:03.560)

because if you say Humira costs $72,000

Lex Fridman (35:06.760)

and it's no more effective as a first line drug

John Abramson (35:08.960)

than methotrexate, which costs $480,

Lex Fridman (35:12.320)

people might say, I want the expensive drug

John Abramson (35:15.040)

because I can get it for a $25 copay.

Lex Fridman (35:17.740)

So you'd have to temper that a little bit.

John Abramson (35:21.640)

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

Lex Fridman (35:25.560)

They don't care.

John Abramson (35:26.400)

Their insurance is gonna cover it and it's a $25 copay,

Lex Fridman (35:29.440)

but we could figure out how to deal with that.

John Abramson (35:31.840)

The main point is that if we assume

Lex Fridman (35:35.240)

that advertisements are gonna keep going, and they are,

John Abramson (35:38.760)

we could require that there be outside evaluation

Lex Fridman (35:45.480)

of the message that reasonable, unbiased viewers

John Abramson (35:48.900)

take away from the ads,

Lex Fridman (35:50.980)

and the ads would have to tell the truth about the drug.

Lex Fridman (35:55.720)

And the truth should have sub truth guardrails,

Lex Fridman (36:00.720)

meaning like the cost that we talked about,

John Abramson (36:03.700)

the effects compared to things that actually,

Lex Fridman (36:07.060)

lifestyle changes, just these details,

John Abramson (36:11.820)

very strict guardrails of what actually has to be specified.

Lex Fridman (36:16.500)

And I would make it against the law

John Abramson (36:19.380)

to have family picnics or dogs catching Frisbees in the ads.

Lex Fridman (36:23.340)

So, you mean 95% of the ads, yes.

John Abramson (36:28.340)

I mean, there's something dark and inauthentic

Lex Fridman (36:32.620)

about those advertisements, but they seem,

John Abramson (36:34.500)

I mean, I'm sure they're being done

Lex Fridman (36:36.240)

because they work for the target audience.

Lex Fridman (36:43.500)

And then the doctors too.

Lex Fridman (36:46.060)

Can you really buy a doctor's opinion?

Lex Fridman (36:48.740)

Why does it have such an effect on doctors?

Lex Fridman (36:52.260)

Advertisement to doctors, like you as a physician,

John Abramson (36:55.460)

again, like from everything I've seen, people love you.

Lex Fridman (36:58.460)

And I've just, people should definitely look you up from,

John Abramson (37:04.880)

there's a bunch of videos of you giving talks on YouTube,

Lex Fridman (37:09.300)

and it's just, it's so refreshing to hear

John Abramson (37:14.700)

just the clarity of thought about health policy,

Lex Fridman (37:17.460)

about healthcare, just the way you think

John Abramson (37:19.660)

throughout the years.

Lex Fridman (37:20.660)

Thank you.

Lex Fridman (37:21.500)

So like, it's easy to think about like,

Lex Fridman (37:23.700)

maybe you're criticizing Big Pharma,

John Abramson (37:25.360)

that's one part of the message that you're talking about,

Lex Fridman (37:28.820)

but that's not like, your brilliance actually shines

John Abramson (37:33.020)

in the positive, in the solutions and how to do it.

Lex Fridman (37:35.440)

So as a doctor, what affects your mind?

Lex Fridman (37:40.900)

And how does Big Pharma affect your mind?

Lex Fridman (37:43.120)

Number one, the information that comes through

John Abramson (37:46.500)

legitimate sources that doctors have been taught

Lex Fridman (37:50.300)

to rely on, evidence based medicine,

John Abramson (37:52.560)

the articles in peer reviewed journals,

Lex Fridman (37:55.420)

the guidelines that are issued.

John Abramson (37:57.020)

Now, those are problematic,

Lex Fridman (37:59.220)

because when an article is peer reviewed

Lex Fridman (38:03.240)

and published in a respected journal,

Lex Fridman (38:06.340)

people and doctors obviously assume

John Abramson (38:10.340)

that the peer reviewers have had access to the data

Lex Fridman (38:15.820)

and they've independently analyzed the data,

Lex Fridman (38:18.420)

and they corroborate the findings in the manuscript

Lex Fridman (38:21.900)

that was submitted, or they give feedback to the authors

Lex Fridman (38:25.740)

and say, we disagree with you on this point,

Lex Fridman (38:28.220)

and would you please check our analysis

Lex Fridman (38:30.740)

and if you agree with us, make it.

Lex Fridman (38:32.420)

That's what they assume the peer review process is,

Lex Fridman (38:35.580)

but it's not.

Lex Fridman (38:36.900)

The peer reviewers don't have the data.

John Abramson (38:39.220)

The peer reviewers have the manuscript

Lex Fridman (38:41.800)

that's been submitted by the,

John Abramson (38:44.340)

usually in conjunction with or by the drug company

Lex Fridman (38:49.340)

that manufactures the drug.

Lex Fridman (38:51.500)

So peer reviewers are unable to perform the job

Lex Fridman (38:57.320)

that doctors think they're performing

John Abramson (38:59.700)

to vet the data to assure that it's accurate

Lex Fridman (39:03.260)

and reasonably complete.

John Abramson (39:05.060)

They can't do it.

Lex Fridman (39:07.300)

And then we have the clinical practice guidelines,

John Abramson (39:09.460)

which are increasingly more important

Lex Fridman (39:11.280)

as the information, the flow of information

John Abramson (39:15.840)

keeps getting brisker and brisker,

Lex Fridman (39:18.660)

and docs need to get to the bottom line quickly.

John Abramson (39:22.020)

Clinical practice guidelines become much more important.

Lex Fridman (39:25.680)

And we assume that the authors

John Abramson (39:28.780)

of those clinical practice guidelines

Lex Fridman (39:30.380)

have independently analyzed the data

John Abramson (39:32.380)

from the clinical trials and make their recommendations

Lex Fridman (39:35.880)

that set the standards of care based on their analysis.

John Abramson (39:39.140)

That's not what happens.

Lex Fridman (39:40.860)

The experts who write the clinical trials

John Abramson (39:44.180)

rely almost entirely on the publications

Lex Fridman (39:49.460)

presenting the results of the clinical trials,

John Abramson (39:51.940)

which are peer reviewed,

Lex Fridman (39:52.980)

but the peer reviewers haven't had access to the data.

Lex Fridman (39:56.340)

So we've got a system of the highest level of evidence

Lex Fridman (40:01.140)

that doctors have been trained over and over again

John Abramson (40:03.780)

to rely on to practice evidence based medicine

Lex Fridman (40:06.420)

to be good doctors that has not been verified.

Lex Fridman (40:10.860)

Do you think that data that's coming

Lex Fridman (40:14.300)

from the pharma companies,

Lex Fridman (40:17.100)

do you think there,

Lex Fridman (40:19.420)

what level of manipulation is going on with that data?

Lex Fridman (40:22.520)

Is it at the study design level?

Lex Fridman (40:25.940)

Is it at literally there's some data

John Abramson (40:28.140)

that you just keep off, keep out of the charts,

Lex Fridman (40:33.860)

keep out of the aggregate analysis that you then publish?

John Abramson (40:38.580)

Or is it the worst case,

Lex Fridman (40:41.380)

which is just change some of the numbers?

John Abramson (40:44.640)

It happened.

Lex Fridman (40:45.480)

All three happened.

John Abramson (40:46.300)

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

Lex Fridman (40:48.540)

but I spent about 10 years in litigation.

Lex Fridman (40:51.660)

And for example, in Vioxx,

Lex Fridman (40:54.900)

which was withdrawn from the market in 2004

John Abramson (40:57.380)

in the biggest drug recall in American history,

Lex Fridman (41:02.280)

the problem was that it got recalled

John Abramson (41:06.080)

when a study that Merck sponsored

Lex Fridman (41:08.580)

showed that Vioxx doubled the risk,

John Abramson (41:10.580)

more than doubled the risk of heart attacks,

Lex Fridman (41:12.740)

strokes, and blood clots, serious blood clots.

John Abramson (41:16.760)

It got pulled then.

Lex Fridman (41:18.100)

But there was a study, a bigger study

John Abramson (41:20.660)

that had been published in 2000

Lex Fridman (41:22.740)

in the New England Journal of Medicine

John Abramson (41:24.660)

that showed that Vioxx was a better drug

Lex Fridman (41:28.580)

for arthritis and pain,

John Abramson (41:32.820)

not because it was more effective.

Lex Fridman (41:34.240)

It's no more effective than Aleve or Advil,

Lex Fridman (41:37.460)

but because it was less likely

Lex Fridman (41:40.220)

to cause serious GI complications,

John Abramson (41:43.220)

bleeds and perforations in the gut.

Lex Fridman (41:46.180)

Now, in that study that was published

John Abramson (41:48.140)

in the New England Journal that was never corrected,

Lex Fridman (41:51.620)

it was a little bit modified 15 months

John Abramson (41:55.960)

after the drug was taken off the market,

Lex Fridman (41:57.540)

but never corrected, Merck left out three heart attacks.

Lex Fridman (42:01.540)

And the FDA knew that Merck left out three heart attacks,

Lex Fridman (42:05.600)

and the FDA's analysis of the data from that study

John Abramson (42:10.400)

said that the FDA wasn't gonna do the analysis

Lex Fridman (42:14.680)

without the three heart attacks in it.

Lex Fridman (42:16.920)

And the important part of this story

Lex Fridman (42:19.640)

is that there were 12 authors listed on that study

John Abramson (42:23.080)

in the New England Journal.

Lex Fridman (42:24.320)

Two were Merck employees.

John Abramson (42:26.240)

They knew about the three heart attacks

Lex Fridman (42:27.760)

that had been omitted.

John Abramson (42:29.600)

The other 10 authors, the academic authors,

Lex Fridman (42:34.440)

didn't know about it.

John Abramson (42:35.420)

They hadn't seen that data.

Lex Fridman (42:38.000)

So Merck just, they had an excuse.

John Abramson (42:41.940)

It's complicated, and the FDA didn't accept it,

Lex Fridman (42:44.240)

so there's no reason to go into it.

Lex Fridman (42:46.800)

But Merck just left out the three heart attacks.

Lex Fridman (42:48.800)

And the three heart attacks,

John Abramson (42:50.000)

it may seem three heart attacks in a 10,000 person study

Lex Fridman (42:52.720)

may seem like nothing,

John Abramson (42:54.160)

except they completely changed the statistics

Lex Fridman (42:57.540)

so that had the three heart attacks been included,

John Abramson (43:00.020)

the only conclusion that Merck could have made

Lex Fridman (43:02.600)

was that Vioxx significantly increased

John Abramson (43:04.700)

the risk of heart attack.

Lex Fridman (43:06.360)

And they abbreviated their endpoint

John Abramson (43:09.600)

from heart attack, strokes, and blood clots

Lex Fridman (43:12.380)

to just heart attacks.

John Abramson (43:13.800)

Yeah.

Lex Fridman (43:14.720)

So those are, maybe in their mind,

John Abramson (43:17.120)

they're also playing by the rules

Lex Fridman (43:18.300)

because of some technical excuse that you mentioned

John Abramson (43:20.400)

that was rejected.

Lex Fridman (43:22.240)

How can this, because this is crossing the line.

John Abramson (43:24.040)

No, no, let me interrupt.

Lex Fridman (43:25.080)

No, that's not true.

John Abramson (43:28.080)

The study was completed.

Lex Fridman (43:30.440)

The blind was broken, meaning they looked at the data.

John Abramson (43:34.460)

In March of 2000, the article was published

Lex Fridman (43:37.400)

in the New England Journal in November of 2000.

John Abramson (43:40.120)

In March of 2000, there was an email by the head scientist

Lex Fridman (43:45.960)

that was published in the Wall Street Journal

John Abramson (43:49.680)

that said the day that the data were unblinded,

Lex Fridman (43:53.840)

that it's a shame that the cardiovascular events are there,

Lex Fridman (43:58.660)

but the drug will do well and we will do well.

Lex Fridman (44:08.680)

But removing the three heart attacks,

Lex Fridman (44:10.840)

how does that happen?

Lex Fridman (44:12.360)

Like who has to convince themselves?

Lex Fridman (44:16.840)

Is this pure malevolence?

Lex Fridman (44:19.520)

You have to be the judge of that,

Lex Fridman (44:21.440)

but the person who was in charge of the Data Safety

Lex Fridman (44:24.560)

Monitoring Board issued a letter that said

John Abramson (44:28.440)

they'll stop counting cardiovascular events

Lex Fridman (44:32.400)

a month before the trial is over

Lex Fridman (44:35.120)

and they'll continue counting GI events.

Lex Fridman (44:38.420)

And that person got a contract to consult with Merck

John Abramson (44:43.360)

for $5,000 a day, I think for 12 days a year,

Lex Fridman (44:47.580)

for one or two years that was signed, that contract

John Abramson (44:53.880)

was signed within two weeks of the decision

Lex Fridman (44:58.220)

to stop counting heart attacks.

John Abramson (45:00.480)

I wanna understand that man or woman.

Lex Fridman (45:04.440)

I wanna, I want, it's the, I've been reading a lot

John Abramson (45:08.040)

about Nazi Germany and thinking a lot

Lex Fridman (45:10.960)

about the good Germans because I want to understand

Lex Fridman (45:15.960)

so that we can each encourage each other

Lex Fridman (45:20.000)

to take the small heroic actions that prevents that.

John Abramson (45:23.800)

Because it feels to me, removing malevolence

Lex Fridman (45:27.140)

from the table where it's just a pure psychopathic person,

John Abramson (45:31.240)

that there's just a momentum created

Lex Fridman (45:34.120)

by the game like you mentioned.

Lex Fridman (45:35.680)

And so it takes reversing the momentum within the company,

Lex Fridman (45:40.680)

I think requires many small acts of heroism.

John Abramson (45:46.880)

Not gigantic, I'm going to leave and become a whistleblower

Lex Fridman (45:50.640)

and publish a book about it.

Lex Fridman (45:52.480)

But small, quiet acts of pressuring against this.

Lex Fridman (45:57.060)

Like, what are we doing here?

John Abramson (45:59.200)

We're trying to help people.

Lex Fridman (46:00.480)

Is this the right thing to do?

John Abramson (46:01.680)

Looking in the mirror constantly asking,

Lex Fridman (46:03.380)

is this the right thing to do?

John Abramson (46:05.240)

I mean, that's how, that's what integrity is.

Lex Fridman (46:07.620)

Acknowledging the pressures you're under

Lex Fridman (46:11.220)

and then still be able to zoom out

Lex Fridman (46:13.100)

and think what is the right thing to do here.

Lex Fridman (46:16.620)

But the data, hiding the data makes it too easy

Lex Fridman (46:21.180)

to live in ignorance.

Lex Fridman (46:22.660)

So like within those, inside those companies.

Lex Fridman (46:29.540)

So your idea is that the reviewers should see the data.

John Abramson (46:34.760)

That's one step.

Lex Fridman (46:36.380)

So to even push back on that idea is,

John Abramson (46:40.980)

I assume you mean the data remains private

Lex Fridman (46:43.340)

except to the peer reviews, reviewers.

John Abramson (46:47.040)

The problem with, of course, as you probably know

Lex Fridman (46:49.620)

is the peer review process is not perfect.

John Abramson (46:53.060)

You know, it's individuals.

Lex Fridman (46:55.460)

It feels like there should be a lot more eyes on the data

John Abramson (46:58.740)

than just the peer reviewers.

Lex Fridman (47:00.440)

Yes, this is not a hard problem to solve.

John Abramson (47:03.500)

When a study is completed,

Lex Fridman (47:06.660)

a clinical study report is made.

Lex Fridman (47:10.220)

And it's usually several thousand pages.

Lex Fridman (47:12.300)

And what it does is it takes the raw patient data

Lex Fridman (47:15.940)

and it tabulates it in the ways it's supposedly and usually

Lex Fridman (47:22.060)

in the ways that the company has pre specified.

Lex Fridman (47:25.620)

So that you then end up with a searchable,

Lex Fridman (47:28.420)

let's say 3000 page document.

John Abramson (47:30.740)

As I became more experienced as an expert in litigation,

Lex Fridman (47:36.160)

I could go through those documents pretty quickly.

John Abramson (47:39.680)

Quickly may mean 20 hours or 40 hours,

Lex Fridman (47:42.040)

but it doesn't mean three months of my work.

Lex Fridman (47:45.280)

And see if the companies,

Lex Fridman (47:49.120)

if the way the company has analyzed the data

John Abramson (47:51.640)

is consistent with the way,

Lex Fridman (47:53.640)

with their statistical analysis plan

Lex Fridman (47:55.800)

and their pre specified outcome measures.

Lex Fridman (48:00.080)

It's not hard.

Lex Fridman (48:01.280)

And I think you're right.

Lex Fridman (48:02.800)

Peer reviewers, I don't peer review clinical trials,

Lex Fridman (48:06.200)

but I peer review other kinds of articles.

Lex Fridman (48:09.320)

I have to do one on the airplane on the way home.

Lex Fridman (48:11.520)

And it's hard.

Lex Fridman (48:12.360)

I mean, we're just ordinary mortal people volunteering to.

John Abramson (48:15.640)

Unpaid, the motivation is not clear.

Lex Fridman (48:19.160)

The motivation is to keep,

John Abramson (48:23.520)

to be a good citizen in the medical community

Lex Fridman (48:27.920)

and to be on friendly terms with the journals

Lex Fridman (48:31.120)

so that if you wanna get published,

Lex Fridman (48:33.280)

there's sort of an unspoken incentive.

John Abramson (48:37.320)

As somebody who enjoys game theory,

Lex Fridman (48:39.840)

I feel like that motivation is good,

Lex Fridman (48:42.200)

but it could be a lot better.

Lex Fridman (48:44.560)

Yes, you should get more recognition

John Abramson (48:46.540)

or in some way academic credit for it.

Lex Fridman (48:50.280)

It should go to your career advancement.

John Abramson (48:53.000)

If it's an important paper

Lex Fridman (48:54.400)

and you recognize it's an important paper

John Abramson (48:56.600)

as a great peer reviewer,

Lex Fridman (48:58.440)

that this is not in that area

John Abramson (49:01.240)

where it's like clearly a piece of crap paper

Lex Fridman (49:05.920)

or clearly an awesome paper

John Abramson (49:08.320)

that doesn't have controversial aspects to it

Lex Fridman (49:10.880)

and it's just a beautiful piece of work.

John Abramson (49:13.120)

Okay, those are easy.

Lex Fridman (49:14.640)

And then there is like the very difficult gray area,

John Abramson (49:17.720)

which may require many, many days of work

Lex Fridman (49:20.240)

on your part as a peer reviewer.

Lex Fridman (49:21.920)

So it's not just a couple hours,

Lex Fridman (49:24.400)

but really seriously reading.

John Abramson (49:27.280)

Like some papers can take months to really understand.

Lex Fridman (49:30.720)

So if you really wanna struggle,

John Abramson (49:33.600)

there has to be an incentive for that struggle.

Lex Fridman (49:35.920)

Yes, and billions of dollars ride on some of these studies.

Lex Fridman (49:41.280)

And lives, right, not to mention.

Lex Fridman (49:44.680)

Right, but it would be easy to have full time statisticians

John Abramson (49:49.680)

hired by the journals or shared by the journals

Lex Fridman (49:55.280)

who were independent of any other financial incentive

John Abramson (50:00.280)

to go over these kind of methodological issues

Lex Fridman (50:04.000)

and take responsibility for certifying the analyses

John Abramson (50:08.880)

that are done and then pass it on

Lex Fridman (50:11.200)

to the volunteer peer reviewers.

John Abramson (50:14.080)

See, I believe even in this,

Lex Fridman (50:15.920)

in the sort of capitalism or even social capital,

John Abramson (50:19.400)

after watching Twitter in the time of COVID

Lex Fridman (50:23.560)

and just looking at people that investigate themselves,

John Abramson (50:27.440)

I believe in the citizenry.

Lex Fridman (50:30.040)

People, if you give them access to the data,

John Abramson (50:32.440)

like these like citizen scientists arise.

Lex Fridman (50:35.880)

A lot of them on the, it's kind of funny,

John Abramson (50:39.320)

a lot of people that are just really used

Lex Fridman (50:40.960)

to working with data,

John Abramson (50:43.160)

they don't know anything about medicine

Lex Fridman (50:44.600)

and they don't have actually the biases

John Abramson (50:46.800)

that a lot of doctors and medical

Lex Fridman (50:48.880)

and a lot of the people that read these papers,

John Abramson (50:51.040)

they'll just go raw into the data

Lex Fridman (50:53.240)

and look at it with like they're bored almost

Lex Fridman (50:56.120)

and they do incredible analysis.

Lex Fridman (50:58.320)

So I, you know, there's some argument to be made

John Abramson (51:01.080)

for a lot of this data to become public,

Lex Fridman (51:04.080)

like deanonymized, no, sorry, anonymized,

John Abramson (51:08.360)

all that kind of stuff, but for a lot of it to be public,

Lex Fridman (51:11.120)

especially when you're talking about things

John Abramson (51:14.520)

as impactful as some of these drugs.

Lex Fridman (51:16.960)

I agree 100%, so let's turn the micro,

John Abramson (51:19.960)

let's get a little bit more granular.

Lex Fridman (51:22.160)

On the peer review issue,

John Abramson (51:24.200)

we're talking about pre publication transparencies

Lex Fridman (51:27.800)

and that is critically important.

John Abramson (51:29.600)

Once a paper is published, the horses are out of the barn

Lex Fridman (51:33.600)

and docs are gonna read it,

John Abramson (51:34.840)

take it as evidence based medicine.

Lex Fridman (51:36.800)

The economists call what then happens as stickiness

John Abramson (51:41.040)

that the docs hold on to their beliefs

Lex Fridman (51:43.360)

and my own voice inside says,

John Abramson (51:47.280)

once doctors start doing things to their patients bodies,

Lex Fridman (51:52.000)

they're really not too enthusiastic

John Abramson (51:53.640)

about hearing it was wrong.

Lex Fridman (51:55.440)

Yeah, that's the stickiness of human nature.

John Abramson (51:57.880)

Wow, so that bar, once it's published,

Lex Fridman (52:01.880)

the doctors, that's when the stickiness emerges, wow.

John Abramson (52:05.120)

Yeah, it's hard to put that toothpaste back in the tube.

Lex Fridman (52:08.200)

Now, that's pre publication transparency,

John Abramson (52:11.520)

which is essential and you could have,

Lex Fridman (52:14.520)

whoever saw that data pre publication

John Abramson (52:17.440)

could sign confidentiality agreements

Lex Fridman (52:19.960)

so that the drug companies couldn't argue

John Abramson (52:22.480)

that we're just opening the spigots of our data

Lex Fridman (52:24.680)

and people can copy it and blah, all the excuses they make.

John Abramson (52:28.880)

You could argue that you didn't have to

Lex Fridman (52:30.520)

but let's just let them do it.

John Abramson (52:32.400)

Let the peer reviewers sign confidentiality agreements

Lex Fridman (52:35.160)

and they won't leak the data

Lex Fridman (52:36.760)

but then you have to go to post publication transparency,

Lex Fridman (52:39.840)

which is what you were just getting at

John Abramson (52:41.720)

to let the data free and let citizens

Lex Fridman (52:47.000)

and citizen scientists and other doctors

John Abramson (52:50.520)

who are interested have at it.

Lex Fridman (52:53.640)

Kind of like Wiki, Wikipedia, have at it.

John Abramson (52:57.680)

Let it out and let people criticize each other.

Lex Fridman (53:01.280)

Okay, so speaking of the data,

John Abramson (53:03.120)

the FDA asked 55 years to release Pfizer vaccine data.

Lex Fridman (53:08.120)

This is also something I raised with Albert Bourla.

Lex Fridman (53:11.600)

What did he say?

Lex Fridman (53:13.200)

There's several things I didn't like about what he said.

Lex Fridman (53:16.200)

So some things are expected

Lex Fridman (53:17.760)

and some of it is just revealing the human being,

John Abramson (53:20.520)

which is what I'm interested in doing.

Lex Fridman (53:23.160)

But he said he wasn't aware of the 75 and the 55.

John Abramson (53:27.520)

I'm sorry, wait a minute.

Lex Fridman (53:29.240)

He wasn't aware of?

John Abramson (53:30.520)

The how long, so here I'll explain what he.

Lex Fridman (53:33.120)

Do you know that since you spoke to him,

John Abramson (53:36.800)

Pfizer has petitioned the judge to join the suit

Lex Fridman (53:42.120)

in behalf of the FDA's request

Lex Fridman (53:45.000)

to release that data over 55 or 75 years?

Lex Fridman (53:50.040)

Pfizer's fully aware of what's going on.

John Abramson (53:52.200)

He's aware.

Lex Fridman (53:53.280)

I'm sure he's aware in some formulation.

John Abramson (53:56.280)

The exact years he might have not been aware.

Lex Fridman (53:59.080)

But the point is that there is,

John Abramson (54:02.520)

that is the FDA, the relationship of Pfizer and the FDA

Lex Fridman (54:06.600)

in terms of me being able to read human beings

John Abramson (54:11.000)

was the thing he was most uncomfortable with,

Lex Fridman (54:14.320)

that he didn't wanna talk about the FDA.

Lex Fridman (54:17.440)

And that really, it was clear

Lex Fridman (54:20.080)

that there was a relationship there

John Abramson (54:22.280)

that if the words you use may do a lot of harm,

Lex Fridman (54:26.440)

potentially because like you're saying,

John Abramson (54:28.520)

there might be lawsuits going on, there's litigation,

Lex Fridman (54:31.360)

there's legal stuff, all that kind of stuff.

Lex Fridman (54:33.480)

And then there's a lot of games being played in this space.

Lex Fridman (54:36.600)

So I don't know how to interpret it

John Abramson (54:40.040)

if he's actually aware or not,

Lex Fridman (54:41.560)

but the deeper truth is that he's deeply uncomfortable

John Abramson (54:49.600)

bringing light to this part of the game.

Lex Fridman (54:53.080)

Yes, and I'm gonna read between the lines

Lex Fridman (54:56.000)

and Albert Borla certainly didn't ask me to speak for him.

Lex Fridman (54:59.960)

But I think, but when did you speak to him?

Lex Fridman (55:02.480)

How long ago?

Lex Fridman (55:03.440)

Wow, time flies when you're having fun.

John Abramson (55:05.800)

Two months ago.

Lex Fridman (55:06.640)

Two months ago.

Lex Fridman (55:07.480)

So that was just recently it's come out,

Lex Fridman (55:12.040)

just in the past week it's come out

John Abramson (55:14.480)

that Pfizer isn't battling the FDA.

Lex Fridman (55:18.920)

Pfizer has joined the FDA in the opposition to the request

John Abramson (55:24.880)

to release these documents in the same amount of time

Lex Fridman (55:29.880)

that the FDA took to evaluate them.

John Abramson (55:33.200)

Yeah.

Lex Fridman (55:34.080)

So Pfizer is offering to help the FDA

John Abramson (55:43.740)

to petition the judge to not enforce the timeline

Lex Fridman (55:51.560)

that he seems to be moving towards.

Lex Fridman (55:54.120)

So for people who are not familiar,

Lex Fridman (55:55.600)

we're talking about the Freedom of Information Act request

John Abramson (55:59.120)

to release the Pfizer vaccine data, study data

Lex Fridman (56:05.200)

to release as much of the data as possible,

John Abramson (56:07.240)

like the raw data, the details,

Lex Fridman (56:08.920)

or actually not even the raw data,

John Abramson (56:10.560)

it's data, doesn't matter, there's details to it.

Lex Fridman (56:14.620)

And I think the response from the FDA is that of course,

John Abramson (56:20.200)

yes, of course, but we can only publish

Lex Fridman (56:25.200)

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

John Abramson (56:29.720)

500 pages.

Lex Fridman (56:31.000)

500 pages of data.

John Abramson (56:32.720)

It's not a day though, it's a week I think.

Lex Fridman (56:36.440)

The point is whatever they're able to publish is ridiculous.

John Abramson (56:39.400)

It's like my printer can only print three pages a day

Lex Fridman (56:45.520)

and we cannot afford a second printer.

Lex Fridman (56:48.000)

So it's some kind of bureaucratic language for,

Lex Fridman (56:52.320)

there's a process to this, and now you're saying

John Abramson (56:56.160)

that Pfizer is obviously more engaged

Lex Fridman (57:00.320)

in helping this kind of bureaucratic process prosper

John Abramson (57:04.160)

in its full absurdity, Kafkaesque absurdity.

Lex Fridman (57:08.880)

So what is this?

John Abramson (57:11.860)

This really bothered people.

Lex Fridman (57:13.800)

This really.

John Abramson (57:14.640)

This is really troublesome.

Lex Fridman (57:15.680)

And just to put it in just plain English terms,

John Abramson (57:19.660)

Pfizer's making the case that it can't,

Lex Fridman (57:24.860)

the FDA and Pfizer together are making the case

John Abramson (57:27.460)

that they can't go through the documents.

Lex Fridman (57:29.820)

It's gonna take them some number of hundredfold,

John Abramson (57:33.700)

hundreds of folds more time to go through the documents

Lex Fridman (57:37.140)

than the FDA required to go through the documents

John Abramson (57:39.860)

to approve the vaccines,

Lex Fridman (57:42.300)

to give the vaccines full FDA approval.

Lex Fridman (57:44.940)

And the FDA's argument, talk about Kafkaesque,

Lex Fridman (57:48.940)

is that to do it more rapidly

John Abramson (57:51.340)

would cost them $3 million.

Lex Fridman (57:54.820)

$3 million equals one hour of vaccine sales over two years.

John Abramson (58:01.980)

One hour of sales.

Lex Fridman (58:04.340)

And they can't come up with the money.

Lex Fridman (58:05.900)

And now Pfizer has joined the suit

Lex Fridman (58:08.020)

to help the FDA fight off this judge, this mean judge,

John Abramson (58:11.140)

who thinks they ought to release the data.

Lex Fridman (58:12.900)

But evidently Pfizer isn't offering

John Abramson (58:15.020)

to come up with the $3 million either.

Lex Fridman (58:17.300)

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

John Abramson (58:21.740)

maybe the FDA should do a GoFundMe campaign.

Lex Fridman (58:25.500)

Well, obviously the money thing,

John Abramson (58:28.420)

I mean, I'm sure if Elon Musk comes along and says,

Lex Fridman (58:31.380)

I'll give you $100 million, publish it now,

John Abramson (58:35.500)

I think they'll come up with another.

Lex Fridman (58:37.900)

So, I mean, it's clear that there's cautiousness.

John Abramson (58:43.660)

I don't know the source of it from the FDA.

Lex Fridman (58:47.140)

There's only one explanation that I can think of,

John Abramson (58:50.580)

which is that the FDA and Pfizer

Lex Fridman (58:53.020)

don't wanna release the data.

John Abramson (58:55.420)

They don't wanna release the three

Lex Fridman (58:57.940)

or 500,000 pages of documents.

Lex Fridman (59:03.180)

And I don't know what's in there.

Lex Fridman (59:05.380)

I wanna say one thing very clearly.

John Abramson (59:08.140)

I am not an anti faxer.

Lex Fridman (59:10.140)

I believe the vaccines work.

John Abramson (59:11.940)

I believe everybody should get vaccinated.

Lex Fridman (59:15.220)

The evidence is clear that if you're vaccinated,

John Abramson (59:17.620)

you reduce your risk of dying of COVID by 20 fold.

Lex Fridman (59:20.900)

And we've got new sub variants coming along.

Lex Fridman (59:23.460)

And I just wanna be very clear about this.

Lex Fridman (59:26.620)

That said, there's something I would give you 10 to one odds

John Abramson (59:32.420)

on a bet that there's something in that data

Lex Fridman (59:35.100)

that is gonna be embarrassing to either FDA or Pfizer

John Abramson (59:40.460)

or both.

Lex Fridman (59:41.300)

So there's two options.

John Abramson (59:42.140)

I agree with you 100%.

Lex Fridman (59:43.740)

One is they know of embarrassing things.

John Abramson (59:46.700)

That's option one.

Lex Fridman (59:48.180)

And option two, they haven't invested enough

John Abramson (59:51.740)

to truly understand the data.

Lex Fridman (59:54.180)

Like, I mean, it's a lot of data

John Abramson (59:56.420)

that they have a sense

Lex Fridman (59:58.140)

that might be something embarrassing in there.