-: Good afternoon.
Check, check.
Good afternoon, everyone.
Welcome, students, faculty, staff,
and friends of the college.
My name is Matt Bell, and I'm the executive director
of Programs for External Affairs here at the college.
It's an honor and a privilege to open this fourth
and final CCA of the 2022-2023 academic year, Big Pharma.
On January 17th, 1961,
President Dwight D. Eisenhower
delivered his farewell address
in which he gave his famous and prophetic warning.
Speaking of the new phenomenon
of a large military establishment
and a large arms industry in America,
he warned, "In the councils of government,
we must guard against the acquisition
of unwarranted influence, whether sought or unsought,
by the military-industrial complex.
The potential for the disastrous rise
of misplaced power exists and will persist."
In the 62 years since his speech,
we've seen the devastating fruits of allowing
and, in many cases, encouraging
this disastrous rise of misplaced power.
The quintessential example in our day
being the reckless lead up to
and the feverish funding of the war in Ukraine
by leaders in Washington, DC,
a war that could easily lead to nuclear conflict.
It is important to have a defense industry
and to be able to protect ourselves with a ready military.
But under the powerful and our current regime,
they are deforming our military, depleting our stockpiles,
and degrading our ability to protect ourselves.
Now, the topic of this seminar is not foreign policy
or the modern industrial complex.
But Eisenhower's warning is applicable today
to a variety of industries in America
that seem to have control not only over many of our state
and federal legislators
who are supposed to represent their constituents,
but also over the state and federal regulators
whose job it is, or at least was, to protect Americans.
The pharmaceutical companies are among the worst defenders.
Consider that last year the defense industry spent
$124 million on lobbying.
In that same year, the pharmaceutical industry spent
$373 million on lobbying.
They're number one on the list.
This is separate from health services industry
at 122 million
and the insurance industry at $158 million.
In 2021, big pharma spent nearly $7 billion
in direct-to-consumer spending
on marketing their drugs to Americans.
If you recall, at the end of each ad,
after a long list of potential side effects
for the new drugs,
the nice voice on the TV says,
"Talk with your doctor to see if this drug can help you."
And it should be no surprise that these companies
spend over $20 billion annually
to convince doctors to prescribe their products to patients.
This is not to say that lobbying or advertising
are inherently bad.
The rights of free speech and petitioning government
are rightfully protected by our constitution.
These become a problem when they work successfully
against the safety, health,
and general welfare of American citizens.
Since 1999, more than 600,000 have died from opioid overdose
in the US and Canada alone.
It is estimated that without serious intervention,
1.2 million more will die within the decade.
Within this decade.
The revolving door between government agencies,
some of which are funded by fees paid by the industry,
and the pharmaceutical company spins ever wider
and with more frequency.
This is plainly evident
to anyone who has been paying attention
to the tragically ridiculous rules
and exceptions declared by the bureaucratic state
during the coronavirus crisis.
Putting the absurdity
and long-term harm of social distancing, lockdowns,
and masking aside,
the experimental mRNA vaccines
did not deliver on the promises made by big pharma
and the left's hero bureaucrat Anthony Fauci.
Meanwhile, big pharma's profit soared
as any concerns about vaccine safety and efficacy
were dismissed as conspiracy theories
and as booster after booster was approved.
The government has even gone as far
as to recommend that all children
aged six months to five years,
an age group facing virtually zero risk from COVID,
get the COVID vaccine.
In short, we've gone mad.
To be clear, just as with the fence,
we need a well-functioning pharmaceutical industry.
We need good drugs and advancements in medicine
for the purpose of saving human lives.
When the opposite happens to the benefit of those in power,
we know something is seriously wrong with the system
and that it is sick.
To provide an antidote to the sickness,
we gather this week to learn.
In this, we turn back
to what President Eisenhower said was necessary
to the defense of our country and our American way of life.
And that is an alert and knowledgeable citizenry.
The student who will introduce our speaker this afternoon
is Audrey Hunsbedt,
a sophomore from Princeton, New Jersey
studying financial management.
Please welcome Audrey to the podium.
(audience applauds)
-: John Abramson is a lecturer in healthcare policy
at Harvard Medical School
where he has taught for more than 25 years.
He earned a BA at Harvard College,
a BMS at Dartmouth Medical School,
an MS at Case Western Reserve University,
and an MD at Brown Medical School.
Dr. Abramson practiced medicine
as a family physician for 20 years
and was chairman of the Department of Family Medicine
at Lahey Clinic in Burlington, Massachusetts
before he turned to research and writing
on the commercial control and distortion
of the medical knowledge available to doctors and patients.
He has served as an expert in litigation
and testified to the FBI and Department of Justice
in a case that led to Pfizer pleading guilty to a felony
and being fined nearly $1.2 billion,
the largest criminal fine in US history at the time.
He is the author of "Overdosed America:
The Broken Promise of American Medicine"
and "Sickening: How Big Pharma Broke American Healthcare
and How We Can Repair It."
Please join me in welcoming Dr. John Abramson.
(audience applauds)
-: Audrey, thank you very much for that kind introduction.
And thank you folks in the Hillsdale College community
for inviting me and for coming to listen to the talk.
Specifically, I wanna thank Doug Jeffrey,
Markie Repp, Matt Dell, and Kyle Inman
for their assistance in preparing for this talk.
Matt did an excellent job
of providing an overview with a problem.
And I'm gonna take a deeper dive in.
What I'm gonna say doesn't require
any scientific background.
It's common sense
in caring about the welfare of our country,
but I want you to know that this talk was presented
to PhD candidates at Harvard and MIT
and will be presented in grand rounds
at a couple hospitals in the next month.
So it is comprehensible, but it's not dumbed down.
And I look forward to your questions.
Let me start my talk by saying
I've had a little bit of a rough road
over the past few months, six months or so.
And that's why I'm delivering the talk remotely.
I developed a serious cardiac arrhythmia,
ventricular tachycardia.
It started seven years ago
and it increased over the months of the summer
and the early fall.
My journey has involved getting shot by paramedics
on my living room floor,
many ambulance rides and many hospitalizations.
And in November, it was critical.
And I'm glad, very grateful to be alive right now.
And the experience shows the good side
and the bad side of medicine.
On the good side,
I was fortunate enough to have the complete attention
of two world-class doctors who spent six hours,
one going on the inside of my heart,
one coming through my chest wall to the outside of my heart
to electrically map the aberrant signals in my heart
and to ablate them.
And so far, knock on wood,
since November 18th, I've not had a problem.
On the second day after the procedure,
I was in still in the intensive care unit.
And a cardiologist came by to round on me.
He's an advocate of wider use
of cholesterol-lowering statin medications than I am.
So he started to cite the literature
about why I should be taking
more cholesterol-lowering medicine than I was.
And I asked him if he had read the studies.
And, of course, he had.
And if he understood that the endpoint of the study
that he was leaning on
wasn't really appropriate for the situation.
And he said, well, he had.
And there was some debate about that.
But he wouldn't back off.
And I asked him if he was aware
that when articles are published in medical journals,
even the most reputable medical journals,
and they're peer reviewed,
and that's supposed to assure
that the articles are accurate
and represent the findings of the clinical trials fairly,
I asked him if he was aware
that the peer reviewers serving those medical journals
don't have access
to the actual data from the clinical trials.
And his advocacy of statin-lowering drugs
was based on largely
all commercially sponsored
and largely commercially influenced
medical journal articles.
And he somewhat (indistinct) said,
yes, he was aware that peer reviewers
didn't have access to the data.
And I said, "Well, you know that doctors
trust that information
because it's so-called peer reviewed."
He said, "Yes."
And I asked him,
this is a surreal scene
where I'm looking at the cardiac monitor to see,
if as I'm getting
more emotionally involved in this conversation,
if I'm starting to have extra beats
and getting into trouble,
and I wasn't,
I asked him how he could present himself
as a learned intermediary,
bringing medical science
to the education of physicians and patients,
how he could claim to be a learned intermediary
without having actual access to the data
from the clinical trials,
for which he did not have an answer.
I'll get to that in my talk,
but this gets to the heart of the problem
of the commercial takeover
of the medical knowledge that doctors believe and implement,
thinking that they're providing
the best possible care to their patients.
But I wanna remind you
that I'm here because of advancements in medical science.
And therein lies the problem.
We need medical science.
It's a blessing to have medical science,
but it's also, it needs to be in some way overseen
because it won't govern itself.
And with that, I'd like to start the talk.
Okay.
So conflicts of interest,
I think they're important
to let everybody know what they are.
I'm the author of "Sickening:
How Big Pharma Broke American Healthcare
and How We Can Repair It."
And I recently served as a plaintiff's expert in litigation
involving the drug company Celgene
regarding the drugs Thalomid and Revlimid, cancer drugs.
The easiest way to look at the health of a country
and to compare the health of a population
with other countries
is to look at life expectancy.
This is a chart,
the blue line is the average of 11 other wealthy countries.
The green line is the United States.
And what we're measuring here is life expectancy at birth
from 1980 to 2021.
If you look back in 1980,
1982 is when I went into medical practice,
the United States was just about equal
with the other wealthy countries
in terms of longevity of Americans.
And as the years have progressed, you can see
that the green line has fallen further and further
behind the blue line.
Americans, well, we were getting healthier for sure,
living longer for sure,
but we were losing ground
to the citizens of the other wealthy countries.
And then in 2020 when COVID came in,
our longevity went down.
And it went down again in 2021.
The difference between
the life expectancy in the other wealthy countries
and in the United States prior to the COVID Pandemic,
so on 2019 data,
the difference is so great
that 500,000 Americans die,
were dying before the COVID pandemic.
500,000 Americans were dying each year
in excess of the death rates
of the citizens of the other wealthy countries.
500,000.
Now, sometimes when we see this data, we think,
"Well, it's not a good thing,
but primarily the problem is
that we have such a separation
between rich and poor in this country,
that it's the poor people that have poor health.
The wealthy people are still getting
the most advanced medical care in the world and thriving."
But that's not the case.
This really very clever study
looked at white citizens,
not because there's any racism involved,
but to take out the possibility of racism,
that white citizens in the 1 and 5%
highest income counties in the country
have better health than poorer Americans,
but have worse health than the average citizens
in 12 other wealthy countries.
So it's not like wealthy folks
who are college educated, who have insurance,
who are employed,
it's not like they're getting the best
and the less fortunate Americans are getting the worst.
We're all suffering from this.
Poor people suffering more, but wealthy people as well.
And for this inferior health,
we are paying an enormous excess.
The United States,
we average $12,914 per person per year on healthcare.
The other comparable wealthy countries listed here
average $6,125.
Now, if you multiply that difference,
the 6,700,
$800,
if you multiply that by 334 million Americans,
we're spending an excess $2.1 trillion a year on healthcare.
We look at the spending
that has been the result of the Democratic president
and Democratic legislatures
with the bills, the Inflation Reduction Act,
and the COVID bills,
they will add $1.55 trillion to the federal deficit
over a 10-year period.
And healthcare is extracting
15 times more than that in excess.
$2.1 trillion a year.
And that's $21 trillion over 10 years.
So as Matt, in his introduction of me,
spoke about out of control spending,
Eisenhower was referring to the military industrial complex.
We now have a medical industrial complex
that is sucking America's wealth away
from the other things that will make us healthier
and create better lives for all Americans.
So we ask, "Well, there's this tremendous disparity
between the United States and other wealthy countries.
What ought to be the primary goal of our healthcare?"
And this is the best definition I can come up with.
If any of you can think of a better definition,
let's talk about it when we get to questions
at the end of the lecture.
But I think as a general statement,
the primary goal of American healthcare ought to be
to maintain and improve individual and population health
most effectively and efficiently.
We're not doing that.
So if that's the primary goal,
it raises two critical questions.
Why are we failing so miserably
on the achievement of this goal
and why are doctors and other concerned,
educated, committed healthcare professionals
willing to go along with this dysfunctional system?
And what I wanna propose
is that one of the fundamental reasons
for the disparity between the health of Americans
and the health of people in other wealthy countries
is that analogous to the military industrial complex,
we have the medical industrial complex.
And this medical industrial complex
has captured what doctors and the public
take for medical knowledge.
I know that's a radical statement,
and I will show you as we go on how that evolved.
If we go back to 1981,
this is an important time for me
because I was finishing my residency
and starting a two-year Robert Wood Johnson fellowship
where I learned my research skills.
And at the time,
the commercial intrusion into our medical practice
wasn't an issue.
As a fellow, we would spend hours
dissecting the articles in medical journals
and never was it an issue that there was commercial bias.
But 1981 was a pivot point.
Derek Bok was president of Harvard University
and in Harvard Magazine from the spring of 1981,
he said that university's reliance
on industry funding for research
is causing, quote, "an uneasy sense
that programs to exploit technological development,"
meaning make money from technological development,
"are likely to confuse the university's central commitment
to the pursuit of knowledge."
And why did he say that?
There were two different forces that were coming together.
Grants from the National Institute of Health
and the National Science Foundation were going down.
They had gone down through the 1970s.
And universities had to turn to commercial sources
to support their research,
saying it was not only prudent,
but it was essential for them to do that.
So universities that had been
independent of commercial money
and could pursue knowledge
for its social and scientific value
were drawn into the marketplace.
And they were producing knowledge for commercial value,
not social value.
This is a key quote here,
this article from 1982 from the journal Science.
"Scientists who 10 years ago
would've snubbed their academic noses at industrial money
now eagerly seek it out."
And you folks who are now
undergraduates at Hillsdale College,
you've grown up in this environment,
where it's normal for the professors and the academics
and the folks who teach medical school
to have commercial relationships.
But it wasn't always that way.
And I'm not sure it has to be that way in the future.
The second thing that happened
was in the late 1970s
there was a new phenomenon in the United States.
Japanese cars were starting to be imported.
We didn't have any Japanese cars before that.
And the belief was that Japan had
gotten involved in an industrial policy
where the Japanese government
was supporting the development of their cars
so that the cars could be made more
effectively and efficiently
and undermine the US car market.
The same thing, it was thought, was happening in science.
So science in the United States was,
the federal funds for scientific research
were funding the research at universities,
but those patents that were being developed in universities
weren't being commercialized
because the universities weren't gonna be able to
reap the financial rewards from those patents.
So the Bayh-Dole Act was passed in 1980
to improve American competitiveness,
and it changed the rules
so that non-profit institutions that receive federal grants
and develop products that were patented, like drugs,
could keep the profits from those patents.
The federal government would not retain those profits.
So, suddenly, with the decrease in commercial money
and the ability to make money from the patents,
for universities and medical centers
to make money from the patents,
suddenly universities were in the marketplace.
They were part of that industrial complex.
Now, how did this manifest?
The first and most obvious manifestation
was who was paying and controlling
the medical research that was being done?
Before this, it's not in this slide,
but 80% of clinical research
was being done in university medical centers.
In 1991, 80% was being done in university medical centers.
It was largely controlled by independent academics.
And the research was conducted
and analyzed and published
by the independent academic researchers.
But that situation changed so quickly
that from 80% of research being done
by independent researchers in medical centers in 1991,
by the time we got to 2004,
only 26% of the pharmaceutical industry's research
was being done in universities.
The rest was being done by for-profit research companies
that hired medical centers to conduct some of the research.
But the locus of control of the research
went from being in the academic centers
to being given back to the pharmaceutical industry.
And this was a radical change
in the way we produce knowledge.
Now, the next slide shows what the effect of that was.
Let me go back.
In 2004, 26% of pharmaceutical-funded research
is being done directly by universities.
And 74% is being done by for-profit research companies.
So if we wanna know,
the highest quality research
that's being done in that context,
the 26% of the research that's being done in universities,
the universities are going to make research contracts
with the pharmaceutical industry
to define the terms of the research.
So those university pharmaceutical company contracts
are gonna contain the most independence
and likely to produce the highest quality research.
But a really clever researcher
interviewed the contracting folks
from each of the universities
to find out the terms of the contracts
that they made with the drug companies
to see how independent that research actually was.
What they found out is,
if you look at the top circle where 80 is circled,
the question is,
in your best judgment, would your office allow a clause
in multi-center clinical trial agreement,
in a multi-centered clinical trial agreement,
saying that the sponsor, meaning the drug company,
will own the data produced by the research?
Now, in my mind,
data from a clinical trial
that doesn't have to do with manufacturing techniques
and genuinely proprietary information,
but in my mind, the data from a clinical trial
is a public good
because doctors are gonna use that data
to make decisions about how to treat their patients.
But what those contracts said
is 80% of those contracts allow the drug companies
to own the data.
Now, they weren't kidding.
This is a slide from litigation.
I was not in this litigation.
It involved Pfizer, but all the drug companies act the same.
And Pfizer was showing in internal documents
data ownership and transfer.
In other words, who owns the data and what's it for.
And Pfizer wrote in stark language,
Pfizer-sponsored studies belong to Pfizer,
not to any individual.
And they said, "The purpose of that data
is to support directly or indirectly
marketing of our product."
The purpose of the scientific data they're generating
is to support the marketing of their product.
They don't say that the purpose of their science
is to make people healthier,
to improve the quality of life.
They don't say that.
They say, "It's to support our marketing."
They're gonna do this through use in label enhancements
and SND filings.
What that means is they're gonna use it to expand
the FDA-approved indications for drugs
so that they can broaden the market.
They're gonna do it through publications
for field force use.
Now, translating this into plain English,
they're gonna do it through medical journal articles,
peer-reviewed medical journal articles.
We talked about peer review in the beginning.
And field force is their drug reps.
So they're producing this data
so that the drug companies can buy reprints
of the articles that are published.
Excuse me.
Yeah, the drug companies
can buy reprints of the articles that are published.
And they can give them to their drug reps,
and the drug reps will hand them out to doctors
to convince the doctors
to abide by the conclusions in the medical journals.
And that would be a good idea,
even if only one requirement were met,
which is independent peer review.
So that we knew that there was independent analysis
of the accuracy and completeness of the report,
but we don't know that.
And through publications that can be utilized
to support off-label data dissemination.
That's a technical point
that we can get into in the question and answer.
But the drug companies are not allowed to market their drugs
for indications the FDA haven't approved.
But Pfizer is saying they're gonna use that data
to support off-label data dissemination.
And then they say, "Therefore,
commercial marketing and medical,"
not the scientific side of the company,
but the marketing side of the company,
"needs to be involved in all data dissemination efforts."
In other words, all the data
that reaches your doctors and my doctors
is gonna be filtered through
the marketing department of the drug company.
Now, if we look at the,
I gotta get my head out of the way of the bottom two lines.
The 24 that's circled
is the sponsor may include its own statistical analyses
in manuscripts.
24% of the contracts say that.
And the 50% at the bottom is the most outrageous, I believe.
The sponsor will write up the results for publication
and the investigators may review the manuscript
and suggest revisions.
What that says in plain English
is that 50% of the contracts
that academic medical centers make with drug companies
allow the drug companies to ghostwrite the articles.
And the actual researchers who are named authors
don't have the right to change the ghostwritten article,
they have the right to suggest revisions.
But the only recourse they have
if their revisions aren't accepted
is to resign from the project
and take their name off the article.
So this is not academic freedom,
and it's certainly not a context
in which medical science is going to be,
the primary purpose of medical science
is to serve the interest of all Americans.
Now, this depicts the problem.
I hope you can see this picture well enough
to see the guy in the boat is a doctor.
And he's looking at publicly available documents.
His boat is named Scientific Evidence.
He's got a little doctor bag in the back of his boat.
He's looking at the scientific evidence
that's available to him.
And that has to do with peer-reviewed medical journals,
clinical practice guidelines, drug company marketing.
But if we look at what's below the waterline,
we see where data really comes from.
If you look at the bottom,
you see completed case report forms.
That's where all the data is from each patient visit
in the study.
And that those case report forms
get put into electronic datasets.
And then they get incorporated into clinical study reports
that are about 3,000 pages long.
And then they are turned into a manuscript.
But the peer reviewers and the doctors
are not allowed to see those clinical study reports.
They remain the property of the drug companies.
So we've got a situation
where we're kind of operating
on the idea of Adam Smith's basic market,
where in the late 1700s, people go to the market
and they shop for their bread and their beer and their meat.
And there's a symmetry of information.
Purchasers can assess the quality of the information,
the quality of the product,
and they can assess whether the price is fair or not.
However, that's not what we now have
because biomedical products
are not experience goods, like bread and beer and meat.
They're credence goods
where the purchasers have to depend on
the producers for information.
But the producers have a monopoly on the information.
The value of drug is not directly experienced.
There's asymmetry of information.
We're the only wealthy country that has no formal mechanism
of health technology assessment.
Prices are not negotiated
and insured consumers pay only a small cost of the price.
So price can't act in a disciplinary fashion anyway.
Now, we're somewhat, as a country,
mesmerized by the idea of biomedical innovation.
But this quote from Jill Lepore's book,
she's a professor of history at Harvard,
the Jill Lepore's book, "These Truths,"
she says, "Innovation might make the world a better place,
or it might not."
The point was innovation was not concerned with goodness.
It was concerned with novelty, speed, and profit.
That's the situation we're in now
where we're being sold innovation,
but it's not being tested to see the value that it has
for the public.
And currently we're spending,
let me cut to the chase here a little bit,
currently we're spending
96% of our research money,
96% on medical drugs and devices,
and only 4%
on how to make the population healthier
and how to deliver healthcare
more efficiently and effectively.
Why do we do that?
Because the market is allocating the money
that's going to fund the research.
And the drug company's job is to maximize the money
that they return to their investors.
So they're going to invest their research money
in ways that are gonna have the greatest financial return.
And the greatest financial return
is not going to be from studying
the effect of healthy lifestyles,
the effect of helping people with their social needs.
That's not where the money to be made is.
It's in drugs and devices.
So we have this tremendous imbalance
in the information that doctors have.
And then even when new drugs get approved,
only one out of four of those new drugs
is actually materially better
than previously available far less expensive therapies.
But because we don't have a formal mechanism
of evaluating new products,
the doctors don't know which one of the four products
is actually better.
And they are getting marketed
and they're getting medical journal articles
supporting the use of all four.
And they can't act as learned intermediaries.
And when they turn to those journals,
we find that journal articles only have 23%,
only publish 23% of the important health outcomes
from clinical trials.
They publish 19% of benefit outcomes
and 26% of harm outcomes.
I'm gonna have to skip over this, but we can go back to it.
So the consequences of our drug policy
are that the US doctors can't identify
the one out of four new drugs
that truly provides previously unavailable benefits,
that less effective drugs,
because of the marketing
that Matt was talking about in his introduction,
less effective drugs are actually marketed more heavily
than more effective drugs
and they get into the marketplace more quickly.
The United States is the only wealthy country
that doesn't control the price of brand name drugs.
So when drug companies get patents on brand name drugs,
they have a monopoly.
And that leads to high prices.
Brand name drugs in the United States
cost 3 1/2 times more than other OECD countries.
And that creates a situation where between 2/3 and 3/4
of pharmaceutical company profits
are coming from the United States,
global profits are coming from the United States.
So in 2008,
the average price of a new drug was $2,115.
Now I'm gonna ask you to think in your mind
what you think the average price of a drug was in 2020.
And we can talk about this in the questions and answers,
but here's the answer.
180,000.
It's gone from $2,000 to $180,000.
This the median price of newly launched drugs.
And it went up again to $257,000.
To sum up, 86% of our clinical trials
are now commercially funded.
97% of the most frequently cited articles
in the literature are commercially funded.
And that means those are the articles
that have the most influence on practicing physicians.
We know the commercially sponsored studies
find that the drug is more effective,
that it's less harmful,
and the overall conclusions are that it's better.
The majority of physicians continuing medical education
is funded by industry.
And 59% of the authors of clinical guidelines
are receiving money from drug companies
that are making drugs in those guidelines.
The bottom line here,
and, again, we can talk about this
in the questions and answers,
but the bottom line here is we have market failure
in medical knowledge.
The pharmaceutical industry is making a ton of money.
That's their job, to make money.
The medical journals
are dependent on the pharmaceutical industry
for advertising and to buy reprints.
The academic medical centers
and researchers are dependent on pharma.
The regulatory agencies,
as Matt mentioned in his introduction,
are dependent on pharma.
And, in fact, the FDA, the division of the FDA
that approves and oversees the marketing of human products,
75% is paid for by the drug company itself.
The guidelines have financial influence.
The patient advocacy groups have financial influence
from the drug companies and the nonprofits.
So we have a situation
where all of these sources of information
are making money.
They're thriving by receiving pharmaceutical company money.
But there's no mechanism
for assuring that the public is being served
by this self-serving activity.
So how do we go forward?
Number one, we have to accept pharma's true role in society.
The big pharma companies are for-profit companies.
The job of for-profit companies
is to maximize the profits they return to their investors.
To accuse pharmaceutical companies of being greedy
is like accusing zebras of having stripes.
It's their job, it's what they do.
And that has to be understood in society
so that there are guardrails,
so that in maximizing their investors' return,
they're maximizing the social benefit.
That we don't have.
Pharma's primary strategy to achieve that goal
is controlling healthcare professionals'
beliefs about the products.
So how do we change this?
We've got to restore the epidemiological balance
to medical research.
So doctors' medical knowledge
isn't 96% about drugs and devices.
Actually, if you look at the determinants of health,
80% of health is determined by how we live our lives,
the circumstances in which we live our lives,
and not by medical care.
At most, 20% of our health is determined by medical care.
We need to ensure that the evidence base of medicine
is accurate and complete.
And that requires transparent peer review.
We need to implement health technology assessment
and we need to control the price of brand name drugs.
These solutions are not like rocket science.
They're obvious solutions.
Why doesn't it happen?
It doesn't happen
because the one thing in this country
that is the most bipartisan,
it's our legislators and leaders
taking money from the drug companies.
And it is truly bipartisan.
The money from the drug companies flows
about equally to Democrats and Republicans.
So what must we do?
Doctors require adequate information to function
as learned intermediaries.
And now folks, students at Hillsdale,
now back on your shoulders.
True reform will require a coalition
that includes the public healthcare professionals
and businesses that purchase health insurance.
We cannot have a true health reform
that overcomes the enormous amount
of pharmaceutical political contributions and lobbying.
So I'd leave you with a thought.
Oliver Wendell Holmes in 1869
said, "The state of medicine
is an index of the civilization of an age and country,
one of the best, perhaps, by which it can be judged."
I wanna speak to the students exclusively right now.
I wanna say, if you are considering
a job in the health professions,
if you're considering it
and you genuinely have the call to be of service,
then I would heartily recommend that you do it.
It's been a wonderful career for me.
I wouldn't think for a moment
about not having gone to medical school
and had the opportunity to be of service
and have the pleasure of service that I've had.
So if you're thinking about doing it
because you have the calling,
please go ahead and do it.
Do it to the best of your ability
and become the most effective you can be.
But if you're thinking of going into the health professions
because it's guaranteed employment
and you'll make a good salary,
that is not a good reason.
And I can guarantee
that you'll be angry and frustrated your entire career.
And with that, I wanna leave you with one more thought.
One dog is saying to another forlorn dog,
"All true, but their kind did invent the can opener."
And we have to remember that medical science is a wonderful,
a wonderful gift that we have,
but we have to use that gift wisely
so that it serves the American people optimally,
provides the best care, the most efficient care.
And we can't allow it to become part
of the medical industrial complex.
Thank you very much.
(audience applauds)
-: Thank you Dr. Abramson.
We now have time for some Q&A.
If you have a question,
please make your way to the microphone.
And student questions will be given preference.
-: Good afternoon.
Thank you very much for your fine talk.
-: Thank you.
-: Hypothetical, suppose an executive from Pfizer
were here in the audience
and was standing where I am and asked you to question,
how might he respond to your talk?
-: He would say that Pfizer employs
hundreds of thousands of people who are dedicated
to the service of bringing better therapeutics
to the American people.
He would probably cite the COVID vaccines and boosters
as the primary example.
(audience laughs)
My response to him would be, people have different opinions
about the vaccines.
But the facts are that Pfizer sold
$34 billion worth of vaccine last year.
The previously best selling drug in history
was Humira at 20 billion.
So they've sold 70% more money's worth
of COVID vaccines than have ever been sold.
And that they, A, are extracting
excess money out of the American public.
And, B, which is more important, what should be A,
is that they have not been forthright with their data.
And if they want to claim
(audience applauds)
to be dedicated to benefiting Americans,
I say that their scientific data has to be transparent.
It was critical in vaccines,
especially when there were mandates on the table.
I mean, craziness to have mandates without transparent data.
But it's almost as crazy
to be having doctors prescribe drugs
without having access to transparent data.
So I would accept him at face value.
I would say that his job
is very clearly to maximize
his investors' return on their investment.
And about 60% of his reimbursement comes from stock options
so that he's got skin in the game
of increasing the stock value.
And I would say, "Let's work together
to figure out how Pfizer's expertise
and experience in commercializing new medical science
can best serve the American people in a transparent way
with guardrails on the prices they're charging
and their marketing policies."
(audience applauds)
-: Dr. Abramson, thank you for speaking for us.
I'm wondering if it would be fair to say
that in the period that we talked about in this lecture
where prices increased so much
and the life expectancy
didn't increase as much as comparable countries,
if it would be fair to say that during that period,
the government involvement in healthcare industry
increased substantially.
And if so, if it isn't possible
that regulation might be the problem,
not the cure to this issue.
-: That's a very interesting question.
I don't think you can conclude that.
And the evidence is that the 11 comparable countries
whose life expectancy has increased so much more,
and they're spending half as much as we're spending,
they have far more government regulation.
You get the National Health Service in the UK
and Canadian single-payer healthcare.
And all the European countries
have government regulation that mandates universal care
and controls the price of drugs.
They're not perfect.
There can certainly be problems
with the government oversight of recommendations,
but, clearly, the other wealthy countries
have far more government influence.
A plea I wanna make
is that we're not gonna solve this problem
of Americans spending twice as much on their healthcare
and having progressively inferior health.
We're not gonna solve this problem until people like you
who have a tendency against government intervention
and people like me who might be overzealous in my belief
that some kind of oversight is absolutely necessary.
I don't think you're wrong,
and I hope you don't think I'm wrong.
But I think we must work together.
What's happening right now,
the reason why the medical industrial complex
has taken over American healthcare
and Americans are suffering and paying a lot to suffer
is because there's not a coalition
of the public, of healthcare professionals,
and of the purchasers of healthcare.
There's not a coalition
to offset the drug company's influence.
So the challenge I would present to you,
and I would be happy to come out at some point
and do a workshop,
and figure out how we could come to an agreement
where there would be guardrails
put on pharmaceutical company profiteering
that did not intrude into the freedom
that we want to preserve
for people to make their own choices.
But we've got to find a way to come to the middle,
to build a middle on this
so that there can be a big public coalition.
There's not enough people on the right
to make that coalition,
and there's not enough people on the left.
And what we've gotta do is stop focusing on our differences
and start focusing on the ideals that we share
to make American life better.
We've got to find that common ground.
If we don't, then the pharmaceutical companies
are gonna continue to run rampant.
(audience applauds)
-: Dr. Abramson, thank you for joining us today.
I found out on Friday
that I was accepted into medical school.
-: Congratulations.
-: Thank you. (audience applauds)
(chuckles)
Your talk has not given me a whole lot of hope. (laughs)
I wanted to ask you, if not the medical journals,
where can I go to find reliable information
and what can I do as such a young student
to help fight the problem
and maybe even be part of the solution?
-: Yeah, yeah.
So, first of all,
you have a lifetime of service in front of you
that is gonna be infinitely meaningful
to yourself and the people you serve.
There are problems in the medical care system.
That doesn't mean that you can't be of service,
that you can't maintain your sights on true north
of what you wanna do with your career.
That's number one.
Number two is, this is a mess.
And I would ask you to read my book "Sickening."
If you don't wanna pay for it,
I'll send you a PDF manuscript of it.
(audience laughs)
But the people in the medical schools,
the students and the faculty don't understand
how critical this situation is.
How much of what we think of as medical knowledge
has been captured by industry.
And until there's a critical mass of folks
from inside the medical world, like you will be,
and from the concerned public on the outside,
until there's a critical mass,
we're not gonna be able to make progress.
It's not gonna work.
When you get to medical school,
one of the first things you're gonna learn
is before you start treating a patient,
you have to make an accurate diagnosis.
So this information that I've shared with you today
is part of making a diagnosis
of why Americans are so much less healthy
than the citizens of other wealthy countries.
Now, you may ask, "Why isn't this commonly discussed?
Why isn't this top aligned in medical school?"
And the answer is, it's pretty much
there's almost a canceled culture going on
with honest discussion
of what's really going on with American healthcare.
Docs are trying their best,
but they just plain don't understand,
and they're busy
and they've been taught to read their medical journals,
and they'll be
fulfilling their responsibility to their patients
by reading their medical journals and following guidelines.
And they don't understand
how these sources of information
that they're taught to trust
are biased towards commercialism.
So I would ask you to read my book.
Again, happy to send it to you.
You know, just a PDF file, no charge.
But I would ask you to understand that.
But I would also caution you
that you have to be very careful with this information
because the doctors will get very defensive
when you say, "Do you know that Americans live 6.3 years
less than the citizens of other wealthy countries?"
The practicing docs who think that they're teaching
the right way to approach healthcare
aren't gonna be real happy to hear that,
especially from a medical student.
So you have to be judicious
in how you deal with this information
because the hierarchy of authority
can react overly strong to these concerns.
And, frankly, I was gonna be in a debate
with one of the leaders of scientific entrepreneurship.
And it was going to be
in front of all the first year medical students at Harvard.
The person who I was gonna debate backed out of the debate.
And the department couldn't find anybody else
who was willing to debate me.
And they gave that hour away
to somebody who had much less controversial things to say.
So it's not easy
to have what looks like straightforward information.
I mean, I would challenge you,
print out a set of my slides and show them to anybody.
These are not biased slides, these are straight up facts.
But these facts are not known.
It's like we pretend that this isn't true.
And it is true.
And 500,000 Americans are dying in excess each year
because it's true.
So you've got a difficult path ahead.
But I would encourage you
to become as knowledgeable as you can.
And you'll learn a lot about where the sources are
from the book.
And be very careful about that.
Graduate.
Don't get on a campaign
to straighten out the healthcare system
before you graduate and finish your residency
because you can be undermined.
You have to be very skillful.
But I would really encourage you to do that.
It's essential.
It's essential, our country needs people like you
who wanna do the right thing in healthcare.
(audience applauds)
-: Hello, Dr. Abramson.
Thank you for your speech.
So regarding some of the concerns of the exorbitant costs
of American healthcare,
of course, your theory is a prevailing one,
but I was just wondering
if you had any comments on a variety of other
commonly cited reasons
for the increased cost of American care.
For example, of course, here in America most people,
they have private or semi-private rooms
as opposed to being in a ward.
We tend to have reduced wait times for operations.
And also concerns regarding,
like for example like you talked about
the separation of cost from the end consumer
and the people paying the insurance.
I've heard of cases of additional,
most likely unnecessary tests being run
and billed to the insurance.
So I was just wondering regarding
some of these different theories,
why you hold that the main problem
is due to the influence of pharmaceutical companies?
-: Well, the problems you've mentioned are all problems.
There's no question.
It is a fact that the greatest contributor
to the rise of medical costs recently
have been the increased cost of pharmaceuticals.
And as I showed you, the median price of a new drug
going from 2,000 and change to 180,000 and change
is a good example of that.
So all those factors are included.
And you get a perverse incentive when you have insurance
because people then don't have a disincentive
to access excess care
and doctors don't feel the breaks of their patients'
economic pain.
So that's all true,
but what we've gotta do is figure out a system
where we can deliver the necessary care to people
and yet stop wasting the amount of money we're wasting.
And, again, I challenge you folks.
And I repeat my offer to come out there and hold a workshop
because there's got to be a way,
we've got to find a middle ground
between getting the government out of healthcare
and letting the market decide it
because I'm certain that's gonna be a disaster.
We've gotta find a middle ground
between getting the government out of healthcare
and making the government
totally responsible for healthcare.
There's got to be a middle ground, we have to find it.
Maybe we need to develop a new language to find it.
I would propose that people who wanna meet that challenge
should come together,
understanding that there are political differences
between them.
But we've got to find that middle ground.
We've gotta stop focusing on what we disagree about
and figure out what we agree about.
I think we all agree that it would be better
if Americans were healthier
and didn't spend twice as much money
as citizens of other wealthy countries on healthcare.
I think we agree on that.
Now let's figure out how to get there
in a truly bipartisan negotiated way
so that the values of those folks
who think the free market should be left to do
what it does and it will best serve the public,
those values need to meet the values of,
we think that everybody should have healthcare
and that the primary focus
should be on improving Americans' health.
We've got to find that middle ground.
And if we can't find that middle ground,
the drug companies' lobbying,
which Matt told you about at the beginning of the talk,
and their political contributions
are gonna continue to carry the day with politicians.
There's no pushback against those politicians.
Let me ask you a question.
Right now 2/3 of our legislators
are taking money from drug companies.
Would you support a mechanism
to get the political contributions and lobbying
away from our politicians for healthcare
and have some mechanism for
(audience applauds)
providing information to them
that doesn't have a commercial source?
-: Dr. Abramson, thank you.
As someone who's interested in pursuing medicine
in postgrad,
your speech has granted me a lot of valuable information
and a glimmer of hope.
But I just wanted to ask,
so my father is a family physician.
And one of the big problems he has
with the research industry is regardless of peer reviews
not actually being peer reviews today,
even when there's a publication for some drug
and it has some correlated probability value
that it will do what it is intended to do,
maybe it's like .6,
.6 like 60% of the time or something like that.
Where does the culture of physicians pushing medications
that only have a slight chance
of actually doing what they're intended to do
while simultaneously producing
a bunch of unwanted side effects that are might be unknown?
Where does that culture in the medical industry
originate from?
-: Yeah, thank you so much for that question.
That's just wonderful.
I was a family doctor, too.
And I probably see the world through the same lens
your dad does.
The problem is that the medical students
are not taught to look at the world like that.
In my book, I talk about a drug called Trulicity.
It's a diabetes drug.
And there was a study exactly like you described
that showed if you treat a large number of people
with Trulicity
and a large number of people with a control,
that the people who took the Trulicity
have statistically significantly less heart disease develop
than the people who didn't take the Trulicity.
Diabetics are at high risk of heart disease.
So it's an important issue.
So they advertise on TV
and they marketed to doctors
that they should treat their
diabetic patients with Trulicity
because it decreases the risk of heart disease.
Well, exactly as you posed in your question,
you have to treat,
it's called the number needed to treat, NNT.
And for those of you who are going into medicine,
keep your eye on number needed to treat.
That's how many patients you have to treat
for one to benefit.
So the study was large enough.
If you do a big enough study,
small differences become statistically significant.
In that study that showed that Trulicity
statistically significantly reduces
the risk of heart disease,
it turns out that you have to treat 327 people
with Trulicity for I think three years
for one non-fatal heart event not to happen.
And that that would cost the public $2.7 million.
Trulicity didn't control blood sugar any better.
The advantage is that it decreased cardiovascular risk.
When medical students are taught to look at the p-value,
the statistical significance at the bottom of the abstract
and to find it significant,
and then say, "Well, I'm gonna do that for my patients
because it's statistically significant
and I want them to have the best medical care,"
what they need to be asking
is exactly the question that you ask.
What's the number needed to treat?
And then how much is this gonna cost?
And then how much do we know about side effects?
So people argue about statins.
I know a lot about statins.
Should I take a statin or shouldn't I take a statin?
So for somebody who already has heart disease,
there's no question
that there's a statistically significant benefit of statins.
So the p-value is significant.
It's less than .05.
But the number needed to treat,
you have to treat 33 people
who have a history of heart disease with a statin
in order to prevent another cardiovascular event.
The number needed to treat is 33.
Now, I'm not saying,
as a physician, I didn't say
whether that means my patient should take a statin
or not take a statin.
But my patient should sure know
that they have a 1 out of 33 chance
of benefiting from that statin.
And the chance of having a significant side effect
isn't even known
'cause the companies didn't monitor it
in their clinical trials,
'cause they paid for the clinical trials.
Only 1 out of 41 trials actually
prospectively monitored side effects.
So the real answer to your question
is that medical students aren't taught
to look at number needed to treat, number needed to harm,
and the cost to the public.
They're not trained to do that.
And I think it's a sin.
I think that we've got a situation
where the teachers in medical schools
aren't aware of how much the way they look
at how to choose therapies
is now manipulated
by pharma and by the medical device companies.
They don't understand that.
They're good people, they wanna do the right thing,
they wanna practice medicine,
they wanna practice evidence-based medicine.
They don't understand
that the evidence in evidence-based medicine
isn't backed up by data.
And that's why there needs to be
a broad coalition of the public of healthcare professionals
and companies that purchase healthcare
because the medical establishment doesn't understand this.
And there's gotta be a reawakening.
So thank you for that question.
-: Yup. (audience applauds)
We have time for one final question.
-: Thank you very much, sir.
This has been very, very useful. (chuckles)
And thank you so much.
Much like a lot of the students here,
I would also like to pursue medicine as my career,
specifically with veterinarian medicine.
And I was just wondering if these trends and statistics,
do they correlate or overlap with veterinary medicine at all
or is that...
-: Oh, that's a good question.
I don't know about veterinary medicine,
but I know it's the same drug companies.
So I think that they're gonna
(audience laughs)
have a bias towards newer and more expensive medicines
that the clinical trial results aren't fully transparent on.
So please keep it on your radar screen.
-: We have time for one more question.
-: As part of the young generation coming up
that could potentially turn this around
and make the system better,
would you hope to see our generation
fix the institutions that exist and fix the system,
specifically institutions that
have proven to be quite corrupt,
or would you hope to see us build new,
reputable institutions from the ground up?
Keeping in mind that our generation,
I'm 20 years old,
people of my age have never known these institutions
to be credible in any real sense.
(audience laughs and applauds)
-: Yeah.
That's a wonderful question.
I think that you've gotta push the current institutions
as far as you can.
And let me give you an example.
I showed you that slide about market failure
and the relationship between drug companies and journals.
So I asked an editor,
not an editor-in-chief, but an editor,
of one of the most respected journals in the world,
why they don't simply,
I went over the iceberg diagram very quickly,
but under the water
is clinical trial reports that are 3,000 page
tabulations of the data from the electronic datasets
and the case report forms.
And when there's a clinical trial,
the drug companies put together
one of those clinical study reports.
When they're searchable,
which they should be and can be made searchable,
you can get through 'em pretty quickly.
I did a lot of litigation.
And I learned how to find out what the study was about.
It's not perfect because the drug company
is presenting tabulated data
and it's not access to the raw data,
but most of of the time, it's good enough.
So I asked an editor
of one of the world's most respected medical journals,
"Why don't you simply require
that when a manuscript is submitted,
reporting a clinical trial about a new drug,
why don't you just require
that the drug companies submit
the clinical study report as well?
It would cost them very little.
Occasionally, there's something that needs to be redacted
where a patient could be identified
or there's a manufacturing secret in it,
but it's easy to redact.
Why don't you do that?"
And the editor responded without missing a beat,
"That would be a death spiral for the journal."
Now, that is so profound.
What he was saying to me
is that he understands the problem,
but the medical journals
need to get the big clinical trials
so that they maintain their prestige
with their impact factor
and their number of citations.
And they wanna sell those reprints.
The drug companies want the journals to buy the reprints.
And so the journals make money
selling the reprints to the drug companies
for the drug reps to hand out.
Now, this is not a small amount of money.
In 2005, the Lancet,
which is one of the most prestigious journals in the world,
had 41% of its income came from selling reprints.
So the reason why going into this detail
is to say, "Well, medical journals
are probably one of the most respected institutions."
Well, why won't they require
that clinical study reports aren't submitted?
And the answer is because it's gonna cost them economically.
Well, what incentive do they have
to change their rules when it's gonna cost them economically
if there's not an outcry by doctors in the public
not to make that change?
Let me use harsh language.
It's stupid for journals not to require that,
in sense, from the public health point of view,
but it makes perfect sense
when we realize their job
is to maximize their investors' return on investment.
So I would say
if enough people understood like you now do
that the journals aren't doing the job
that the public and the doctors think they're doing,
and that in order to earn back
the trust of the doctors and the public,
they need to demand more transparency
in the clinical trials that they publish
and they need to demand transparent peer review.
But they won't do that.
This market failure won't get corrected
until there's a constituency demanding it.
And it's more in their interest to do the right thing
than to do the wrong thing.
Right now, it's in their interest to do the wrong thing.
So I think we can change the institutions,
but there needs to be a broad based constituency
that's informed about these issues before that can work.
-: Please join me in thanking Dr. Abramson.
(audience applauds)