Pharmaceutical Expert (8:54)

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Mike Pesca (9:57)

Thomas Goetz has a podcast out called Drug Story. It's a pharma biography. You got the EpiPen, Lepator, Zoloft just dropped. I hear Ozempics in the pipeline, but in this part of the conversation I asked him about one thing drug companies do pretty well that is self serving to a large degree, but also does serve the public. So they do. Of course drug companies take plenty of deserved criticism, pricing, marketing influence. But listening to this series raises a question for me whether some of the practices we reflexively condemn actually function as effective public health communication. Let us take Lipitor's know your numbers campaign. Yes. Why did they spend millions on the campaign? Because it prime people to worry about cholesterol and ultimately to buy their drug. But isn't that exactly what public health campaigns try to do? Maybe not. The final part, buy a specific drug but identify a risk, make it salient, change behavior. And given the costs and constraints of taxpayer funded messaging, is it possible that the profit motive is didn't just sell Lipitor, but put cholesterol awareness into the culture more effectively than the government ever would have?

Pharmaceutical Expert (11:10)

Yeah, absolutely. So. So there is a profit motive in pharmaceuticals, right? That's, that's part of the, that's part of the kind of bargain that society has made. They get a 20 year patent to own the drug, be the sole manufacturer and distributor of a drug and they, that that market is theirs because they put the money into R and D. They, they created the drug. They get to charge whatever the market will bear for that drug. After 20 years, that patent expires, it goes generic, and then other manufacturers can come in. Right. That is the kind of set of rules that society has landed on that incentivizes the drug companies to invent new drugs and rewards society with those medicines. That's the deal. But that can be exploited. It can be massaged. The know your numbers campaign that you just mentioned, that. Yes, that's good that that kind of educated the public in this idea of. Of high cholesterol and the idea of awareness and the idea of risk and the idea that there's something to do that you could take a drug. It happened to sell a lot of drugs along the way now.

Mike Pesca (12:23)

No, not. It happened. That's why. Well, that's why the company undertook those efforts. Yes, exactly.

Pharmaceutical Expert (12:28)

And I would just note that that idea of those. So those ads or those. That kind of campaigns are known as. As disease awareness ads. Okay, so that's a, that's, that's a kind of ad where the drug company is actually paying to create awareness around a disease, but they very carefully do not ever mention the name of a drug in those ads. So, so they're able to kind of inform the public, but they aren't necessarily selling a specific product. That idea, those disease awareness ads has been used a lot of times in the pharmaceutical industry to bring awareness to things that maybe aren't actually big problems and that maybe actually aren't national kind of issues of emergence health. And we can talk about those. We should talk about some of the examples there. But, you know, so that's where the balance kind of gets. Gets manipulated.

Mike Pesca (13:22)

Yeah. Like erectile dysfunction. It's a thing that happens. It's a branding campaign. It puts it on. It invents a category. And here's the drug to address the category. What drug do you think has helped the most but also had one of these campaigns, Awareness campaigns that also very much helped. So it might be the case that the drug manufacturer benefited, but clearly so did the public.

Pharmaceutical Expert (13:48)

Yeah, well, the best example at hand right now are the GLP ones. Ozempic, wegovy, Zepbound, those drugs that are approved for diabetes and more importantly for obesity, for treating obesity. They really work. They help millions of people who previously had no real, really no strategy for normalizing their weight for getting healthy again. So, so that has been incredibly helpful to the public and to this public health crisis of obesity. That said, those companies are now worth some, they're some of the most profitable companies in the world. And, and it has created a kind of bonanza of billions of dollars of riches for those pharma companies.

Mike Pesca (14:35)

But they have 20 years to keep those patents.

Pharmaceutical Expert (14:38)

Yes, yes. So, but they, but the, the deal with GLP1s, like the first GLP1 actually came out over 20 years ago. So they've been around for a while. It's just that they are refining the mechanism and they're, they're creating new drugs in the same category. They're called peptides. They're creating new kinds of, of peptides that have the same effect. And every time they can come up with a new one, the clock starts anew. So, so it's not just these are all different drugs.

Mike Pesca (15:05)

Sometimes that's illegitimate, you hear, or I've read about. They'll change one element on the chain and it doesn't really change much, but they could get a new patent on it. But with the GLPs, I'm under the impression that they actually are improving if not perfecting the drugs.

Pharmaceutical Expert (15:21)

Yeah, exactly. They are getting better. They are, they are having fewer side effects. Like for instance, just, just this week, a new pill version of Wegovy is available for prescription in pharmacies. Before, it was only available as an injection. And people, a lot of people probably would prefer, prefer to take a pill. So that's a new patent, that, that is a brand new formulation and they now have whatever, whatever number of years left to, to sell that at full price.

Mike Pesca (15:53)

Yeah. And we've had public health officials on the show talking about the risk and reward of subsidizing the purchase of these drugs because obesity and all of the concomitant problems with that are extremely dangerous for people and the public's health. On the other hand, the drugs are expensive. So I did want to ask you this. What do you think is the most apt. And then I'll ask you the most exaggerated critique of pharmaceutical companies in general.

Pharmaceutical Expert (16:27)

Well, so I think the, I think the, probably the most appropriate critique of pharma companies is that, is that they don't necessarily solve the problem. Right. Like, let's stick with obesity for a second. The problem with obesity in this country has its root causes really in the food system, in the way we have created a food supply that is very unhealthy for most people. And we've incentivized food companies to create products that taste really good but are really unhealthy for us. And Then along the way, we create drug companies or drugs that treat those. That is a problem that actually drugs are not solving. They're treating the problem, but they're not solving this larger problem that we have in society.

Mike Pesca (17:15)

Let me interrupt you. Could they. They just choose not to.

Pharmaceutical Expert (17:19)

Could the drug companies.

Mike Pesca (17:20)

I mean. Well, there are some drugs that could just totally take away an underlying condition, but.

Pharmaceutical Expert (17:25)

Right.

Mike Pesca (17:26)

We don't look to. Is it a critique of the drug companies that they don't do something that they can't possibly do and weren't made to do?

Pharmaceutical Expert (17:34)

Yeah, fair enough, fair enough. That. That isn't. You're right. That isn't necessarily the responsibility of the drug company. I guess. I guess when I think about kind of legitimate complaint about drug companies, it's that they're exploiting these problems. It's that they're creating kind of creating syndromes or diseases that actually are not in fact diseases. Right. That they're lifestyle issues. I think a great example is, is the idea of testosterone replacement therapy. It's created this disease called low T, which is actually just what happens when men age. Their testosterone levels fall off. And, and so what they've created though, is this whole idea of, of that being a malady, that being something wrong for you, and then, then they have a drug, thankfully handily, that, that will treat it and that will raise your testosterone levels and that will put money in, in their pockets. So that was kind of a, a prolonged campaign that was very effective for that, for those, for that drug company.

Mike Pesca (18:40)

Yeah, I think that's having a drug. It's like having a drug to treat. Dad Rock. Do you like Jethro? Do you like. Yes, we've got a drug for that here. Have some. Chapel Roan.

Pharmaceutical Expert (18:50)

Yeah, exactly.

Mike Pesca (18:51)

Chapel Rowan X would be the drug name. But what about the critique that they do invent these drugs and then they press their advantage to hold consumers via the mechanism of the insurance companies over a barrel that they just, they. Since there's no limitation except for maybe the occasional senatorial shaming which, which you play on the show, there is no real mechanism to keep them in line.

Pharmaceutical Expert (19:15)

Right. So drug pricing. So. So yes, so there is a very legitimate critique to, to make about how the, about the price of drugs, especially in the United States. So in the United States, we pay much higher prices for prescription pharmaceuticals than in other countries. That's because of our unique and bizarre health care system where insurance ends up paying very high costs for the drugs. We have these PBMs. It's a messy system. I don't think your listeners want to get into it, but what has happened is that the pharma companies have been very good at exploiting that mess and charging extremely high prices for drugs. That probably is exorbitant and that certainly other countries don't pay anything like that, those prices for those medications.

Mike Pesca (20:06)

So what do foreign drug companies do? AstraZeneca is a Swedish British firm and Bayer do they also use the United States as their huge profit center and then sell it to their own people at a discount?

Pharmaceutical Expert (20:20)

Yeah, yeah, that, I mean again that's, that's kind of the global marketplace of drugs is, the big target is in the United States, for instance, the GLP1s. Most of the sales of those drugs is happening in the United States. We happen to have a lot of obesity, but we also happen to be willing to pay full market value for those drugs. But it, the system does work in some ways for other countries. So, so in Africa for instance, a lot of these drugs are extremely low price if you can, they're not as easy to access. But when, when you can get access to them, the cost of those drugs is, and that's good for, for people in those low income countries. So, so there are pros and cons. The US ends up subsidizing a lot of the rest of the world though on these, on the cost of these drugs.

Mike Pesca (21:12)

Have you ever seen any well done studies that estimate if you put price caps and limit the ability of the drug companies to make money from the US market, how much would it impact their sorry, affect their R and D? This is their argument. Like yeah, yeah, we got to use the United States and we got to have these blockbuster drugs otherwise we' not going to be spent, able to spend all this money to invent new drugs. I don't know how you would prove how true that is, but have you seen anyone studying that?

Pharmaceutical Expert (21:41)

Oh, there's, you're, you're putting me back in the classroom in my health economics one on one course where, where my economics professor, you know, there are charts and studies galore that explore that the, the evidence is mixed. It's largely hypothetical. Obviously. It's, it's, you know, it's, it's, it's, it's chalk on a, on a blackboard. But it is probably true, it is probably true that there would be less drug development. Not no drug development but less because the profit motive would be curtailed somewhat by, by lowered price of drugs. So, so it wouldn't entirely kind of destroy the pharma industry like the industry might claim, but it definitely would probably have some impact on, on how many drugs are actually created and brought to market.

Mike Pesca (22:32)

Yeah, and the, I guess not the straw man version of this argument is to take a winner, a successful drug company and say, oh really, without Viagra Pfizer, you're saying you wouldn't have done any research into the coronavirus vaccine. Like you're making so much money on this drug we could cut out half your profits. There's no plausible case you, it still wouldn't be worth your time to invest in R and D. But what that doesn't do is look at the drug companies that aren't gigantic winners and they're still doing R and D in the hopes of having that giant payout. And I think you're probably right, though I don't know exactly what the calibration is of how much you can limit their profits though. There are also, as we talked about in this interview, some mechanisms to limit their profits like the 20 year time frame on the monopoly of the drugs. Are there any other suggestions out there that you think would work that would balance the ability of drug companies to make a lot of money and fund research, but also keep things at a relatively lower cost for consumers?

Pharmaceutical Expert (23:37)

Yeah, I mean, well, I think, you know, you could see it with, with what happened with the COVID vaccines, right? Those, those companies were incentivized and given, given a kind of very fast track to drug development and a promise that they would have a market ready for them in order to incentivize them to develop those vaccines. There are actually a lot of diseases that, for which there are vaccines. But there's very little incentive for the vaccine developers to actually make those vaccines because they aren't there, because they're generic. There's just not enough profit out there. And, and so, so there's a lot of subsidization by governments to get companies to actually make those medicines. There's a whole class of diseases that are called orphan diseases where, where there probably are good treatments or somewhat effective treatments. But the, but the economics just don't pencil out there aren't enough patients with the disease and so there isn't enough incentive to produce those drugs.

Mike Pesca (24:39)

And it's the character, the characteristics of those diseases. Too few people suffer from them.

Pharmaceutical Expert (24:43)

Them. Exactly, exactly. And the price of the drugs isn't high enough to justify making them.

Mike Pesca (24:48)

Or every once in a while the suffering is concentrated in a non rich area. I think maybe something like guinea worm disease which has been eradicated, but through the efforts of the Carter foundation and nonprofits. But that's the kind of disease like the economics have to price out. That's interesting. In the time you've been doing it, do you think or the public's perception of drug companies has changed, especially in light of what we went through with the pandemic. And it may have changed to appreciate them more or maybe the backlash against vaccines and mandates made them, you know, hurt them in people's eyes. What's your sense of that?

Pharmaceutical Expert (25:26)

Yeah, I think it goes to, but goes back to what you were saying earlier. I think, I think we get a lot of benefit from drugs and we also have a lot of problems and, and a lot of complaints about drugs and drug companies. I think there are, there are, it's a yin and yang, right? There are pros and cons. We are, and the FDA as a, as a kind of regulatory agency is right in the midst of this. People want more drugs. People want drugs for, to be approved more quickly. But we also want to be safe. We don't want to have drugs out there that will have unknown side effects that will unwitney, unwittingly injure us or cause us harm. We want drugs to be safe and effective. That's kind of the bar that we set. So that's just a process by which we muddle through the pros and cons, the benefits and risks. And I think that's, that's something that we wrestle with as a society and it's also goes all the way down to an individual patient and an individual patient making those decisions in the doctor's office. It's always a, it's always a two sided coin.

Mike Pesca (26:36)

I get the sense that drug companies or big pharma, especially if you phrase like that as a category extremely unpopular because there's no one. Big Pharma itself doesn't have an ad campaign about themselves as an industry. So in the aggregate, as a concept, there are a lot of people who are making a lot of critiques and those critiques seem to have landed. But if you ask people not just do you want to keep taking this drug that saves your life, but if you ask people about the actual relationship with the drugs they take, if they credit the drugs for changing their lives, they would acknowledge that they do. And especially if you ask wives about their husband's drugs and husbands about their wives treatments, it's the sort of thing, it's a little like, well, it's a cousin of we hate congress but love our congressmen. But it's also, I think similar to the brand itself, the concept as an abstraction is viewed terribly, but as a revealed preference, as the economists would say. There's a lot of indication that drugs are quite appreciated if you don't think of them abstractly.

Pharmaceutical Expert (27:46)

Yeah, 100%. I mean, I think, I think, you know, we, we do get a lot of benefits from medications. They have saved millions of people, millions of lives. But I think it's also, you know, we take them when something is wrong, we take them when we're sick, when there's a problem, and we expect, we hope that the drug will solve that problem. In reality, they don't actually really always solve the problem. They ameliorate it. Right. They make it a little better, they take care of some of our symptoms, they make it less bad, they help us kind of keep going. But there's a lot of frustration and struggle, I think in that process. There's a lot of facing our own mortality when we're taking drugs. So these, these are like very, a mixed cauldron of emotions. And so I think, I think drugs are just like, I mean, I think your Congressman example is a great one. There's a lot of conflicting emotions when it comes to medications and, and the role they play in our lives. That's part of the tension that I, that I had so much fun with in the show was, was just kind of looking at the trade offs, the benefits and the, and the kind of compromises we make.

Mike Pesca (29:03)

And also, if you consider history, I mean, no one Alive now lived 120 years ago or 200 years ago, but if they did, 200 years ago, you scrape your leg and you die because there's no such thing as antibiotics or 100 years ago. They don't know anything about the causes of heart disease or how to stop it. They have no clue. But the thing is, we can't compare our experience to that. We could read about it in a textbook or maybe hear about it on a podcast, but there is no way to credit these great advances in. I'll use the phrase in a lived experience way.

Pharmaceutical Expert (29:39)

Yeah, well, I mean, I would just look at vaccines. We get a lot of benefit as a society and individually from vaccines, but we don't see those diseases anymore or we didn't used to see those diseases anymore. So we took it for granted. There's a lot of taking for granted. There's a lot of invisibility when it comes to health and public health. A lot of things that we, that don't happen to us, that we, because they don't happen to us, they're invisible. So. So being reminded of some of those kind of benefits that we're getting, even if they're, even if they're invisible, that's part of, I think that's part of what medicine and public health have kind of failed to do in terms of making sure that the public recognizes that there's something going on in the background. And so when that job isn't done, you get situations like what's happening in certain parts of the country now where people are stopping taking vaccines and these diseases that hadn't been on the kind of in the population for decades or all of a sudden back.

Mike Pesca (30:42)

Thomas Goetz is the journalist behind the new podcast that tells a story not just through chemical compounds, but you'll meet people who are either sufferers or in the case of the guy who ate a lot of cheese, tortellini, wonder why they have high cholesterol. And the name of the podcast is Drug Story. Tom, thanks a lot, Mike.

Pharmaceutical Expert (31:02)

Thank you so much. This is great.

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Mike Pesca (32:12)

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It's that we have to offshore and outsource so much of our mental processes just to keep in touch with and up with the flood that's always occurring. Luckily, we have help. We have help in this electronic, computerized help. But is it really help, I ask you? Let me take you inside the process by which I quote, unquote, think and remember. And you know what? I bet many of you will recognize this process as similar to something you do and you have to do and you don't love doing. But really, is there any other alternative than a hundred times a day to do a thing that you used to or maybe our ancestors once did off the top of our heads? Well, our ancestors didn't have all these obligations at their fingertips. So I will tell you what I do. We'll start with just saying the words either January 27th or January 28th. And I'm going to take you inside. I think what's not a unique, but a quite annoying or at least cognitively taxing process to help think, remember and produce. It's Monday, Jan. 26, 2026, from peach fish Productions. It's the gist. I Mike Pesca, I said that well, didn't I? It flowed. You would think, oh, he says a version of those words every day. He knows what to say and I do know what to say. I could just remember it. But I think out of a sense of responsibility that I should have a script day. And the script's important because we also note whenever there are sound clips to play, I have to note that for my producer. So to get to the script, I'm going to take you through my process. As fascinating to you as it is to me. I had finder on my computer. It brings up a menu on the left side. The gist is on that menu I go to just scripts. And under just scripts, I go to January and then I go to January 26th. So maybe I should just remember the date and the day of the week. That often doesn't go well, though I have to say but that is just like what, six clicks. Then I have to record this, what I'm saying to you now. So I click on audio hijack. I'm not going to bore you with everything. But it's at least five more clicks because I have to pick the input device. Then I have to click the actual record button thing. Then I have to. It becomes its own file. Then I have to right click. There's a right click involved and relabel the file. And then I have to drag that, I drag, drag that into Slack. Oh, remember when I said I wouldn't bore you? I clearly lied. But then you get into Slack and wow, this is bad in terms of demands and your attention because on the Slack channel there's a whole left column with all the different channels and some of them, if they're lit up, it's okay. The promo swaps, fine. But if just list is lit up or maybe substack it gotta get there. That's exciting, interesting, pressing stuff. Mike Pesca that substack.com just list every day. So I get distracted with that. And then if I'm going to say Twitter or Instagram, not for fun, but for professional purposes, you know, to put up a video there. Oh my God. What? It's like a 35% chance that I will see another tweeter video that I like. I mean, these guys know what they're doing. It's the attention economy. Their jobs depend on it. I tell myself, oh, I'm just there because of the job. I should read this tweet or listen to this video. You know, it's probably something you tell yourself too. I'm not unique. Even if you don't have a show which has to do fascinating things like detail your click map just to record the show. If you're a forensic accountant, I bet you're doing the exact same things. So this gets me to my theory about distraction. The things we can't even pay attention to. Think about some of the things that we couldn't stop paying attention to that you haven't thought about in a long time. East Palestine, Ohio. What happened to them? I mean, it's still there. Are they still coughing? I don't know. Does anyone care? Was it mostly an anti Pete thing? I'm sure people from West Palestine are paying attention. And is it Palestine? I remember it wasn't Palestine, which is in the tradition of American places named after foreign places, but pronouncing it wrong, Cairo, Georgia and Lima, Ohio. But East Palestine, or perhaps Palestine, our hearts are with you. If they need to be. If that wasn't just the whole panic. Nanotechnology. Remember nanotechnology? Remember the Internet of Things? It was supposed to be good or bad or something. Did it happen? Didn't it happen? Maybe it happened that we just stopped calling it the Internet of Things because someone realized that was a really dumb phrase. Vivek Ramaswamy, that guy, he seems to have gone away. My point is with every click there's like, I don't know, a 4 to 12% chance of distraction. And since I click on, and not just a click, but press on a screen, 4,000 things a day, that would be a good, that would be a good metric to actually generate. There's a gigantic chance I'm distracted 100 times a day. And this brings me to Donald Trump. There's a theory that he knows what he's doing and he's going from NPR to Greenland to prosecuting Jack Smith. But I don't think he knows what he's doing. I think he's just on the Internet a lot. We know this from his late night truth social posts. He's probably a lot like you. If you're doing anything other than working outside on a work crew or even if you are, you're taking your phone out during break. So this is my grand theory. We live in a distraction age. That's not unique to me. But Donald Trump is a symptom of it, not someone taking advantage of it. You're probably just as distracted as he is. You probably would say to yourself, but if I was the president, I'd have an actual staff around me. I mean, you'd like to think so. Maybe you have a staff around you now. Is it really stopping you from all the clicking? So he flits from Greenland to Somali IQs and it has a giant, giant impact. I read the Just List Slack channel and I don't know, maybe it results in me being able to offer you a story about camels in Australia who are thirsty. Really? If the camels are thirsty, you know, the drought's pretty bad. And that's it for today's show. Cory War is the producer of the Gist. Kathleen Sykes helps me with the Gist list. Jeff Craig is in charge of moving images. You know, he also does some audio editing. I don't like to brag too much about Jeff. Multi talented fellow Leah Yan is the production coordinator of Peach Fish Productions. And Michelle Pesca is the COO in quite a coup for Peach Fish Productions, Ooparuji, Peru. Do Peru. And thanks for listening.

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