Latest / Get Real with Jim Weiss / Dr. Robert Califf on the Future of Public Health

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Dr. Robert Califf on the Future of Public Health · Get Real with Jim Weiss

0:00
Speaker 1: Rob is this really cool dude from the Carolinas that's
0:06
Speaker 1: so accessible. And what I loved about today and was
0:09
Speaker 1: surprised pleasantly is how positive he was. I mean, yeah,
0:13
Speaker 1: he disagrees with certain policies. We had an old system
0:16
Speaker 1: and now things are breaking down, and let's challenge the
0:21
Speaker 1: status quo. How is the healthcare system set up? And
0:24
Speaker 1: are we doing things the right way? I just walked
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Speaker 1: away from that conversation feeling someone come optimistic. I always
0:32
Speaker 1: like to start with a good origin story. So bring
0:35
Speaker 1: us back to your ten years at FDA under Obama Biden.
0:39
Speaker 1: How did it happen? I mean it's not like you
0:41
Speaker 1: walked in and said, hey, I want to work with
0:43
Speaker 1: the FDA.
0:44
Speaker 2: Did you.
0:44
Speaker 3: We started out with a study group trying to figure
0:47
Speaker 3: out what to do about heart attack because we had
0:49
Speaker 3: access to computing that other people didn't have in the
0:52
Speaker 3: nineteen eighties, we became a coordinating center for the clinical trials,
0:56
Speaker 3: so we had the data that led to a lot
0:58
Speaker 3: of interactions with FDA. I still have a vivid memory
1:01
Speaker 3: of one afternoon, this young FDA person from siber named
1:05
Speaker 3: Janet Woodcock called me up to yell at me for
1:07
Speaker 3: doing something wrong in a clinical trial, and eventually I
1:12
Speaker 3: was brought up several times for FDA commissioner in previous administrations,
1:16
Speaker 3: but things didn't work out, you know.
1:18
Speaker 2: And that was fine. I was having a great career
1:21
Speaker 2: at Duke.
1:21
Speaker 3: And then right in twenty sixteen, Peggy Hamberg contacted me
1:26
Speaker 3: had a job open for deputy commissioner at the FDA,
1:29
Speaker 3: and she mentioned that she was not going to stay
1:32
Speaker 3: on much longer, that I would be a good candidate
1:35
Speaker 3: for commissioner, but of course the president has to ask you.
1:38
Speaker 3: And at that point at Duke, I had been a
1:39
Speaker 3: vice chancellor and had been on the Executive Committee of
1:42
Speaker 3: the Health System and felt like I had sort of
1:44
Speaker 3: done what I could do in that setting. So I
1:47
Speaker 3: literally went up to FDA as a civil servant and
1:50
Speaker 3: spent a year as Deputy Commissioner for Medical Products and
1:53
Speaker 3: to back on. During that time, a lot of people
1:56
Speaker 3: would stop by my office. And now, because Steve Oostrov
1:59
Speaker 3: had I'm the acting commissioner and they should have a
2:02
Speaker 3: permanent commissioner. So people would stop by and say, when
2:05
Speaker 3: are you going to be commissioner, And of course it
2:07
Speaker 3: wasn't up to me. And then one day I got
2:09
Speaker 3: a call saying we need to brief the president. That
2:12
Speaker 3: was Obama on the issue of the error rate of
2:15
Speaker 3: whole genome secretencing. And my thinking was, well, how many
2:19
Speaker 3: weeks do I have to get ready to brief the president?
2:22
Speaker 3: They said, it's tomorrow at noon. So the next day
2:26
Speaker 3: I was in there and that went well, and on
2:29
Speaker 3: the way out, he said, why don't you stop by
2:31
Speaker 3: the Oval office tomorrow.
2:33
Speaker 2: And so that next day.
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Speaker 3: I had a half an hour one on one with
2:36
Speaker 3: the President and he asked me to be nominated for
2:39
Speaker 3: the job.
2:41
Speaker 2: Two things about that.
2:42
Speaker 3: The first is and it's very important this week, this
2:44
Speaker 3: is a big week for the research triangle in basketball.
2:48
Speaker 3: But we literally spent the first half of the half
2:50
Speaker 3: an hour we had bannering about because he hates Duke
2:53
Speaker 3: and he loves you and see, and so he had
2:56
Speaker 3: asks out in order to get to the nomination.
2:59
Speaker 1: Well, it really the important things.
3:01
Speaker 3: But then on the way out there was a whole
3:03
Speaker 3: team waiting for me out there who basically their message
3:06
Speaker 3: was it's nice that you've been nominated, but you're not
3:09
Speaker 3: a commissioner unless you're confirmed by the Senate. So then
3:12
Speaker 3: all the troubles started to going through a Senate confirmation.
3:15
Speaker 3: But that eventually all worked out, and so I was
3:18
Speaker 3: commissioner until that the election happened. I think everybody was
3:22
Speaker 3: surprised by the results, and a new team was going
3:26
Speaker 3: to come in. So January twentieth, the year after the election,
3:29
Speaker 3: I went back to working at Duke, but also halftime
3:32
Speaker 3: at Alphabet or Google. When Trump comes into town, I
3:36
Speaker 3: go out of town literally January twentieth of twenty seventeen
3:39
Speaker 3: and January twentieth of twenty twenty five, you know, as
3:43
Speaker 3: a political appointee. My time was up and got in
3:46
Speaker 3: my car and drove out of Washington as the Trump
3:48
Speaker 3: folks came in.
3:50
Speaker 1: Yeah, I wanted to ask you why, Alphabet, of all
3:52
Speaker 1: the places you could have gone anywhere, why did you
3:55
Speaker 1: go there?
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Speaker 3: As I mentioned, although I'd hard on my clinician, my
3:59
Speaker 3: real at least, I hope the thing that I bring
4:01
Speaker 3: to the table is a commitment to evidence and evidence
4:04
Speaker 3: that's built on a technology base of being able to
4:07
Speaker 3: deal with data and to analyze it, and so well
4:10
Speaker 3: before my first FDA stent, a group of us had
4:13
Speaker 3: spent time going out to Google. If you remember, back
4:16
Speaker 3: in the twenty teens, electronic health records of coming into vogue.
4:21
Speaker 3: Doctors were trying to practice by typing things in the
4:25
Speaker 3: computers and then trying to get their hands on the
4:27
Speaker 3: clinical practice guidelines to get the evidence was a real task,
4:31
Speaker 3: and so a group of us decided that we needed
4:33
Speaker 3: to find a global company that was well resourced, that
4:37
Speaker 3: was really good at information and whose mission might be
4:40
Speaker 3: to make information available. And of course that led us
4:43
Speaker 3: to Google, and what we had hoped they would do
4:45
Speaker 3: would be to develop essentially just in time information for
4:49
Speaker 3: clinicians at the site of practice, in the clinic or
4:51
Speaker 3: the hospital. They basically turned us away after a year
4:55
Speaker 3: of our trying to convince them. And then during my
4:58
Speaker 3: first stint at FDA, they started Alphabet and one of
5:01
Speaker 3: the Alphabet companies was Verily, and they hired Andy Conrad,
5:05
Speaker 3: who was really the leader of our gang who had
5:07
Speaker 3: gone out trying to get them to take this on.
5:10
Speaker 3: And so when I finished at FDA called Andy to
5:12
Speaker 3: see what was going on, and he said, Hey, why
5:14
Speaker 3: don't you come on out here.
5:15
Speaker 2: They offered me a great job.
5:17
Speaker 3: I just finished being the FDA commissioner, so I didn't
5:20
Speaker 3: want line responsibility. The title was medical strategy. But it
5:24
Speaker 3: meant basically, I was a consultant to pretty much anything
5:27
Speaker 3: that was going on that was of interest.
5:29
Speaker 1: Rob tell me about public service and how critical it is,
5:33
Speaker 1: and what in your background taught you that the president
5:37
Speaker 1: called he went to serve? What was that? What does
5:40
Speaker 1: a person what does it take?
5:42
Speaker 2: You know?
5:42
Speaker 3: I would say my parents were very civil minded. They
5:46
Speaker 3: you know, my mom was a school teacher. She volunteered
5:48
Speaker 3: a lot. My dad had served in the Battle of
5:51
Speaker 3: the Bulge. Actually talked about the ultimate service in mind too.
5:55
Speaker 3: Yepkvrey had the same parents. It's scary, all right.
6:00
Speaker 2: So it was sort of built in.
6:01
Speaker 3: And I never quite adjusted to the draft number that
6:06
Speaker 3: I got, which I was very happy to get a
6:08
Speaker 3: high draft number. I wasn't a fan of the Vietnam War,
6:11
Speaker 3: but nineteen sixty nine they went pretty high up into
6:14
Speaker 3: the hundreds in the draft, and so I had never
6:18
Speaker 3: done government service. So when the time came, I felt
6:21
Speaker 3: like I was really ready, and I'm glad I loved
6:23
Speaker 3: long enough to do it at a relatively old age.
6:26
Speaker 2: But what's great about.
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Speaker 3: It is when you wake up in the morning and
6:29
Speaker 3: your mission is the health of the people of the
6:31
Speaker 3: United states.
6:33
Speaker 2: It's hard to get better.
6:34
Speaker 3: Than that as far as I'm concerned, And it's clarifying
6:38
Speaker 3: in terms of how you conduct yourself and how you
6:41
Speaker 3: prioritize things. You're not trying to cut corners or do
6:45
Speaker 3: something special to make your little company or whatever do
6:48
Speaker 3: better or your little academic medical center. You're weighing complex issues,
6:53
Speaker 3: trying to do what's best for the country. And I
6:55
Speaker 3: think while nothing's perfect, and there's certainly government employees who
7:00
Speaker 3: didn't work hard, it's hard to fire people in the government,
7:03
Speaker 3: or at least it used to be. But overall, I
7:06
Speaker 3: would put the government workers up. And I worked everywhere
7:08
Speaker 3: I've done clinical practice, I've been executive in a health system.
7:12
Speaker 3: I've been on the boards of pharma in biologic companies
7:16
Speaker 3: and device companies, and I've worked in big tech.
7:19
Speaker 2: I would put the.
7:19
Speaker 3: Government workers up with anybody in terms of their quality
7:23
Speaker 3: and wow.
7:24
Speaker 2: Dedication to the job.
7:25
Speaker 3: So it really pissed me off to hear politicians trash
7:29
Speaker 3: government employees. It's just lazy behavior because they're an easy
7:34
Speaker 3: target and they can't fight back.
7:36
Speaker 1: I mean, maybe that helps us in industry right now
7:39
Speaker 1: there's a lot more of them available and get them
7:42
Speaker 1: out here in our world, so there's always a beneficiary
7:46
Speaker 1: to that. Yeah, I think hopefully that'll happen. So, you know,
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Speaker 1: you mentioned agentich AI and your time at Google. Is
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Speaker 1: what they were predicting then about the intersection of AI
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Speaker 1: and healthcare. Is that how happening now? I mean, do
8:01
Speaker 1: you now see this as or is it different? I mean,
8:04
Speaker 1: you know, you talked about information data diagnosis like that
8:08
Speaker 1: was so important to better treatment. I mean, are we
8:11
Speaker 1: going to see huge strides now with this evolution in AI?
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Speaker 3: I'm an enthusiast, but with reservations. I mean, I think,
8:18
Speaker 3: as I said, I feel like I've been lucky in
8:20
Speaker 3: a lot of ways. But I came along at a
8:22
Speaker 3: time when all medical records were handwritten. You know, we
8:25
Speaker 3: were among the first people to enter medical data into
8:28
Speaker 3: computers to make sense of what was going on.
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Speaker 2: And then we went.
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Speaker 3: Through this phase of as I said, of electronic health
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Speaker 3: records that were extraordinarily clunky and still are today, although
8:39
Speaker 3: they're getting better and better. And during my time at Google,
8:42
Speaker 3: you know, one of the things that I'm still trying
8:45
Speaker 3: to absorb is you could see all the possibilities and
8:49
Speaker 3: in fact, what's happening now. We were dreaming about in
8:52
Speaker 3: the late nineteen seventies early nineteen eighties, but you just
8:55
Speaker 3: couldn't do it right. And I think a thing that's
8:57
Speaker 3: very hard for people to fathom, and so I'm not
9:00
Speaker 3: a technical expert. This change that's occurred from algorithm driven
9:05
Speaker 3: procedures and computers to large language models and basic platforms.
9:12
Speaker 3: It's a big change that really enables a lot of
9:15
Speaker 3: things that we had hoped to do that we're still
9:17
Speaker 3: clunky in twenty twenty and twenty twenty one, and so
9:22
Speaker 3: many things can be fully automated now. So now we
9:25
Speaker 3: have the opposite problem. First of all, we don't know
9:27
Speaker 3: exactly where all this is going to go. But if
9:29
Speaker 3: you look at the anthropic US government controversy right now,
9:33
Speaker 3: there's a similar thing in medicine when you need to
9:36
Speaker 3: have the human in the loop, and it's a purpose
9:38
Speaker 3: to free up the human condition so that people can
9:41
Speaker 3: interact while the computer is taking care of all the
9:44
Speaker 3: mind numbing paperwork in the background, or is it take
9:48
Speaker 3: over what the humans were doing.
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Speaker 2: And as you might guess, I'm a.
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Speaker 3: Fan of having the computer in the background doing all
9:54
Speaker 3: the stuff that can be automated so that clinicians can
9:58
Speaker 3: actually interact with patients to all the problems that they have.
10:01
Speaker 3: And it came up at a meeting I'm attending today
10:04
Speaker 3: as part of an effort to use AI to deliver
10:08
Speaker 3: medicines to people in their homes really as an assist
10:12
Speaker 3: of primary care. I really think we're going to need
10:15
Speaker 3: to free up people because there's just so much unattended
10:18
Speaker 3: misery in the world that we don't even pay attention
10:21
Speaker 3: to now because people are so busy just getting their
10:24
Speaker 3: work done in the health systems. And I think we
10:26
Speaker 3: can make a big difference if we free people up.
10:28
Speaker 3: And when people say no, the computer can do it all.
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Speaker 2: You know. My answer is watch the pit.
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Speaker 3: If you watch the Pit, it's a very realistic depiction
10:37
Speaker 3: of how irrational in complicated people can be, which to
10:42
Speaker 3: a computer might look like, Okay, you have hypertension, take
10:45
Speaker 3: a medicine and your blood pressure comes down. Well, to
10:48
Speaker 3: a person it may be way. I got to get
10:50
Speaker 3: to the pharmacy, and I've been getting this social media
10:53
Speaker 3: that says these drugs are bad.
10:55
Speaker 1: And well, I ran into know a Wiley at the
10:57
Speaker 1: FIG Awards. I'll mention that to him.
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Speaker 2: You know.
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Speaker 1: I think what you're saying is we're making progress. We
11:05
Speaker 1: should be cautious about where it's used. I can attest
11:09
Speaker 1: as a customer now, how different it is making appointments,
11:13
Speaker 1: how much easier it's just becoming the last year, making appointments,
11:17
Speaker 1: filling up to get your medicine. It's more in the power.
11:19
Speaker 1: I mean, doesn't the consumer now it's in their hands
11:22
Speaker 1: a little bit more with all the apps and things
11:25
Speaker 1: that CBS and everyone's introduced. Do you find that that's
11:31
Speaker 1: a good thing.
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Speaker 3: Well, I was going to say, I think it's very
11:33
Speaker 3: much empowering to some proportion of the population. I don't
11:38
Speaker 3: know what that proportion is, but I've learned that my
11:41
Speaker 3: estimates of the proportion are a lot lower than the
11:44
Speaker 3: real enthusiasts. Right, let's take the US population, about a
11:47
Speaker 3: third or children. We don't want to give children total
11:50
Speaker 3: autonomy over their healthcare. About ten percent of people have
11:53
Speaker 3: significant depression. There's a overlap here, but about additional five
11:57
Speaker 3: percent will have dementia. It's over ten percent of Americans
12:00
Speaker 3: can't read above a second grade level. And even among
12:04
Speaker 3: the people who have good comprehension, a very significant proportion
12:08
Speaker 3: of them if you give them too many choices, they say, Doc,
12:11
Speaker 3: just tell me what to do. Now, you know, people
12:14
Speaker 3: can run around with people like you and me tend
12:17
Speaker 3: say the opposite, like, don't tell me what to do.
12:19
Speaker 3: I'll do my own research and I'll ask you questions,
12:22
Speaker 3: give me good answers. But that's not the majority of
12:25
Speaker 3: the population, so we've got to be careful about that.
12:27
Speaker 3: And then there's the other factor, which is I think
12:30
Speaker 3: at the core of so many problems that we have
12:31
Speaker 3: in this country today. If you look at who's got
12:34
Speaker 3: expendable income to deal with the technology invasion, half of
12:39
Speaker 3: the expendable income is in ten percent of the population.
12:43
Speaker 3: And there's this great quote that came up during the
12:45
Speaker 3: pandemic from Ed Young, who was I think one of
12:48
Speaker 3: the best writers about the pandemic. Technological solutions stripped into
12:52
Speaker 3: society's penthouses. Diseases seep into society's cracks.
12:57
Speaker 2: You know.
12:57
Speaker 3: I saw that at Google, over and over something that
12:59
Speaker 3: was good, good, wealthy, highly educated people just latched right
13:02
Speaker 3: onto it, and the people who probably could have benefited
13:06
Speaker 3: the most had the most difficulty adapting to it and
13:09
Speaker 3: figuring out how to use it. If we're really going
13:11
Speaker 3: to have this accrue of the benefit of the US population.
13:15
Speaker 3: We're going to change a lot of things about it.
13:17
Speaker 1: Yeah, so the FDA oversees a lot. Is it too
13:21
Speaker 1: much for one agency to do?
13:22
Speaker 2: Well? What do you think? I mean?
13:24
Speaker 1: And now what, there's fewer people there.
13:26
Speaker 3: You know, there's a characteristic of organizations now that I've
13:29
Speaker 3: been in so many, that you end up with these
13:31
Speaker 3: sort of in my view, you end up with these
13:34
Speaker 3: natural cross cutting tensions. If you work at alphabet, you've
13:38
Speaker 3: got the bets and you've got Google. Within Google, you've
13:41
Speaker 3: got YouTube and Search, and they're like their own things,
13:44
Speaker 3: and they're cross cutting. Software implementation is cross cutting, and
13:48
Speaker 3: so you've got at tension there. You could slice the
13:50
Speaker 3: FDA up. I'm not sure it would be any better,
13:52
Speaker 3: because the alternative is you have centers that have a
13:55
Speaker 3: lot of autonomy, and the laws are somewhat different for
13:58
Speaker 3: drugs devices by a lot, and food, so they operate
14:02
Speaker 3: under different rules, but you have a technological base and
14:06
Speaker 3: a fundamental food, drug and Cosmetics act. I thought you
14:09
Speaker 3: were going to ask, is it too much to regulate AI?
14:12
Speaker 3: And I do have a just a quick party line
14:14
Speaker 3: on that.
14:15
Speaker 2: I would love to hear that.
14:17
Speaker 3: I really think the way to regulate AIS, first of all,
14:20
Speaker 3: has already been done, divided into tranches. If it's AI
14:25
Speaker 3: embedded in a traditional medical device that's a high risk device,
14:28
Speaker 3: like a defibrillator, it should be regulated like traditional devices.
14:33
Speaker 3: If it's AI for decision support. I think the good
14:37
Speaker 3: analogy is food safety. The way food safety works in
14:40
Speaker 3: this country, and it's not perfect, but it's hard to
14:43
Speaker 3: think of a better way.
14:44
Speaker 4: It gets knocked a lot, though. Why Well, because it's
14:47
Speaker 4: an easy thing to knock. Okay, you would hope food
14:51
Speaker 4: to be entirely saved. But I don't know about you.
14:53
Speaker 4: I don't when I go out to eat, I don't
14:54
Speaker 4: really worry that I'm gonna get sick. It happens.
14:57
Speaker 2: I didn't.
14:57
Speaker 1: I thought about it on the United flight last night.
15:00
Speaker 1: I'm like, I guess this could be awful, but I'm
15:02
Speaker 1: going to eat it. I mean, you've got farms, you've
15:04
Speaker 1: got counties, you've got states, you've got the federal government,
15:07
Speaker 1: you've got grocery stores, you've got restaurants, you've got the
15:10
Speaker 1: distribution systems, and they all have to live by something
15:13
Speaker 1: called PISMA, the Food Safety Modernization Act and their ten
15:17
Speaker 1: core rules.
15:18
Speaker 3: So rules, as you know, are federal statements that have
15:22
Speaker 3: the force of law, but the rules are not highly specific.
15:26
Speaker 3: They are principles that you should live by. And then
15:29
Speaker 3: the work of auditing those rules is split up among
15:33
Speaker 3: multiple entities. But fundamentally it is the responsibility of the
15:37
Speaker 3: farm or the grocery store to make sure it's abiding
15:41
Speaker 3: by those PISMA rules, and it's just checked. Like the
15:44
Speaker 3: FDA and the states split out the inspections. It's checked,
15:48
Speaker 3: but not all that often. A farm only gets inspected
15:51
Speaker 3: every three or every five years, and the food's pretty
15:54
Speaker 3: darn saved. Not perfect, but pretty safe, I think, because
15:57
Speaker 3: AI is going to be part of everything, If you
16:01
Speaker 3: said we're going to regulate that like traditional devices, you'd
16:04
Speaker 3: need tens of thousands of FDA employees.
16:07
Speaker 2: To do that.
16:08
Speaker 3: I think an analogy like what grocery store restaurant wants
16:11
Speaker 3: to sell food that makes you sick. Right, We've got
16:14
Speaker 3: health systems which are deploying most of the AI, since
16:18
Speaker 3: most docs are employed by a health system now, and
16:21
Speaker 3: that's a unit of delivery, and those health systems need
16:25
Speaker 3: to be accountable. But we don't have a consensus on
16:27
Speaker 3: what the fundamental principles should be and I think that's
16:30
Speaker 3: where we need to focus. And the one that wouldn't
16:33
Speaker 3: make the biggest difference in my view, is if there
16:36
Speaker 3: was a principle that you got checked on that your
16:38
Speaker 3: AI had to be equitable.
16:41
Speaker 1: Yeah, fair enough.
16:42
Speaker 3: Most AI now is being used to optimize profit, not
16:46
Speaker 3: to improve health outcomes.
16:48
Speaker 2: Good point.
16:49
Speaker 1: Can it help with food allergies? You know, I wanted
16:51
Speaker 1: to come back to that, and I work with a
16:53
Speaker 1: food allergy group and we talk about it a lot.
16:56
Speaker 1: I mean, that seems like it's pretty safe over all,
17:00
Speaker 1: but we still have that problem.
17:02
Speaker 2: How do we fix that there? We have to divide it.
17:04
Speaker 3: You know, there's fundamental bacteria and viruses and food. That's
17:08
Speaker 3: what we're doing really well with because it's amenable to
17:11
Speaker 3: the systems that we currently have. If you said ultra
17:14
Speaker 3: processed food is not safe, I'd have to agree with you.
17:16
Speaker 3: We've gone the wrong direction there. But that's a different system.
17:20
Speaker 3: That's a system of putting in laws and regulations and incentives.
17:24
Speaker 3: Remember that we're incentivizing the food industry to the tunes
17:28
Speaker 3: of tens of billions of dollars to grow corn for
17:31
Speaker 3: corn syrup and to feed cows and other animals to
17:34
Speaker 3: produce meat, which is not great for the environment. And
17:38
Speaker 3: then you've got food allergies, which I think suffers. And
17:42
Speaker 3: again that's just my view of it, but I have
17:44
Speaker 3: had a chance to maybe think about it more than
17:46
Speaker 3: most people. I think the issue with food allergies is
17:49
Speaker 3: it falls in between because when you talk about like
17:52
Speaker 3: serious food allergies, that's a medical problem.
17:56
Speaker 2: The source of it is the.
17:57
Speaker 3: Food, and we don't have a good way of doing
18:00
Speaker 3: sort of large, long term studies that are needed to understand.
18:04
Speaker 3: I think one of the most interesting things that happened is,
18:07
Speaker 3: right we have all this peanut allergy and everybody thought, well,
18:11
Speaker 3: you should have kids not be exposed to peanuts, and
18:14
Speaker 3: it turns out the opposite is true. The best way
18:17
Speaker 3: to prevent peanut allergy is to expose infants to peanuts.
18:21
Speaker 3: That took real quantitative data. So two things about it.
18:24
Speaker 3: We can make progress now in those big studies because
18:27
Speaker 3: of the same advances in computing, we'll understand what it
18:31
Speaker 3: is about the basics of food and the production of allergies.
18:35
Speaker 3: But the second thing is, once you got a food allergy,
18:38
Speaker 3: this is a place where a biotech is moving quickly.
18:41
Speaker 3: I don't know what company you're working with, but we're
18:44
Speaker 3: understanding much more about the calibren system and other elements
18:48
Speaker 3: of reactivity to food that can be treated beyond just
18:52
Speaker 3: an injection of epinephrine and some long term therapies that
18:55
Speaker 3: would be preventive in between. I think we've got this
18:58
Speaker 3: really interesting hut issue now with MAHA about other things
19:03
Speaker 3: in the food environmental exposures where we have this weird
19:07
Speaker 3: thing going on now with the current administration where they're
19:10
Speaker 3: talking big, but then if you look at what's happening
19:12
Speaker 3: with the EPA, they are unleashing more environmental contamination than
19:17
Speaker 3: we've ever seen.
19:18
Speaker 1: Before, right, so that could counter the effort. It's beyond
19:22
Speaker 1: countering the effort. This glyphosphate thing that just happened. I mean,
19:26
Speaker 1: Rfk's one of his main targets in his lawsuit career
19:31
Speaker 1: of making money suing people was about that. And then
19:34
Speaker 1: he comes out saying it's okay that the EPA just
19:36
Speaker 1: relacs the standards on that pesticide. But you know, within
19:40
Speaker 1: all that, it's easy to say everything needs to be natural,
19:43
Speaker 1: et cetera.
19:44
Speaker 3: But we've also got to feed the planet and getting
19:47
Speaker 3: that right is really a matter of science on a scale.
19:51
Speaker 3: That again, because now the computing we can do, we
19:53
Speaker 3: can really begin to think about it. One of the
19:56
Speaker 3: things I enjoyed the most about being at Google was
19:58
Speaker 3: hanging out with the people who worked on Google Earth.
20:01
Speaker 3: I mean, what we can see about the Earth now
20:04
Speaker 3: from satellites and to talk about what's going on like
20:07
Speaker 3: in the surface of the Earth, the farmland, the drainage
20:10
Speaker 3: of water, and predicting the weather, all these things that
20:13
Speaker 3: would make a huge difference in health. I think we'll
20:16
Speaker 3: have the technological means if we're willing to do it
20:19
Speaker 3: to make the planet better. I'm not the only person
20:21
Speaker 3: saying this. I mean it's commonly said now, but if
20:24
Speaker 3: you want to improve healthy life expectancy, what we do
20:27
Speaker 3: with biotech companies is trivial compared to what would happen
20:31
Speaker 3: if we improve the environment and basic fundamentals of lifestyle.
20:35
Speaker 1: But can we just talk a little bit about the
20:37
Speaker 1: opiard crisis, which began well before your time as commissioner
20:42
Speaker 1: and continues presumably after. What were the biggest lessons you'd
20:46
Speaker 1: learned from that experience, and is this something we can
20:50
Speaker 1: solve at scale?
20:51
Speaker 3: During my career as a clinical trial It is one
20:52
Speaker 3: of the things I had to do is work with
20:54
Speaker 3: the NAIDO National Institute of Drug Abuse Network at a
20:57
Speaker 3: time when they needed to upscale the clinical trials network.
21:01
Speaker 3: And I was a minor player, sort of in the
21:04
Speaker 3: background at a cornating center, but I got to participate
21:07
Speaker 3: in the development of medication assist them treatment, which has
21:10
Speaker 3: made an enormous difference in for brenting people are already
21:14
Speaker 3: addicted from, allowing them to live a relatively okay life.
21:19
Speaker 3: And then I got to FDA, and I was also
21:21
Speaker 3: involved in hospitals and quality measures at the time when
21:25
Speaker 3: we were measuring pain and you know, just one example,
21:29
Speaker 3: we did a big study call support, which was end
21:32
Speaker 3: of life care. I won't go into all the details,
21:34
Speaker 3: but it was a national study and even in the
21:36
Speaker 3: area of heart failure. When we asked people what their
21:40
Speaker 3: symptoms were that were the most distressing, shortness of breath
21:44
Speaker 3: was number one in the heart failure population, but pain
21:46
Speaker 3: was number two. Now it turned out I think what
21:50
Speaker 3: that really was was people using the word pain to
21:53
Speaker 3: describe mostly an anxiety and just sphere that was going on.
21:58
Speaker 3: But the idea was to stop out the pain with opioids.
22:01
Speaker 3: It was a quality measure. Doctors were encouraged to do it.
22:05
Speaker 3: It wasn't just the drug companies, but the drug companies
22:08
Speaker 3: did not behave correctly, and unfortunately, the advertising they were
22:13
Speaker 3: allowed to do by the FDA, I think, really did
22:16
Speaker 3: stoke the fire. There's no I'm not arguing that it happened.
22:20
Speaker 3: So when I got there, the thing was in full swing.
22:23
Speaker 2: You know.
22:23
Speaker 3: One of the anecdotes was when I walked down of
22:25
Speaker 3: the Oval office that day, they took me to see
22:28
Speaker 3: four senators the first afternoon, and because I had worked
22:32
Speaker 3: with the medical products industry pharma and device companies, three
22:36
Speaker 3: of the four senators said they wouldn't vote for me
22:38
Speaker 3: because I was part of the collusion that had caused
22:41
Speaker 3: the opioid crisis. And I'm saying, wait a minute, I
22:43
Speaker 3: worked on the network that came up with one of
22:46
Speaker 3: the best solutions. As an academic, I never worked on
22:49
Speaker 3: opioids in my interactions with pharma, but that didn't see
22:53
Speaker 3: the matter. So the sort of drama in hyperbole is phenomenal,
22:59
Speaker 3: But given the number of people that were dying and
23:01
Speaker 3: the places they were dying, in the poorest parts of
23:04
Speaker 3: our country, and then the isolated cases of wealthy people's kids.
23:08
Speaker 3: It was like a very combustible mix.
23:11
Speaker 1: But it was a very few companies. I mean, it
23:13
Speaker 1: wasn't every company in pharmah my god. It was a
23:16
Speaker 1: very small number.
23:18
Speaker 3: That's true. But they were also in the background. There
23:20
Speaker 3: were some big companies, so you know who were could
23:24
Speaker 3: have stopped it, and they didn't. So you know, we
23:27
Speaker 3: did a number of things that FDA at the time
23:29
Speaker 3: to try to help stem the tide within what was
23:32
Speaker 3: allowable by law. But it's also a fact that if
23:35
Speaker 3: you have severe post operated pain or you're in a
23:38
Speaker 3: horrible car accident, opioids are an effective treatment for pain.
23:43
Speaker 3: So you got that balance of a drug which is
23:45
Speaker 3: addictive and effective in certain circumstances, and then you have
23:49
Speaker 3: the illicit market that involves and had to deal with that,
23:53
Speaker 3: and the combination of education, medication, assistant treatment finally are
23:58
Speaker 3: in by about twenty twenty three. We started making real
24:01
Speaker 3: progress in twenty twenty four, and now in twenty and
24:04
Speaker 3: twenty five we've seen a pretty dramatic drop, although there's
24:07
Speaker 3: still about eighty thousand people I think dying from overdose
24:11
Speaker 3: every year, so there's still work to do. Part of
24:14
Speaker 3: what I'm doing now in my spare time is trying
24:16
Speaker 3: to stimulate companies to work on alternatives for pain. And
24:20
Speaker 3: that's been a rough road. That really hasn't been a
24:22
Speaker 3: highly successful alternative yet, but eventually we'll figure it out.
24:26
Speaker 3: And I think that's a really important thing to do.
24:28
Speaker 3: I also feel like I need to mention we could
24:30
Speaker 3: do all the bombing we wanted to in South America.
24:33
Speaker 3: China also plays a major role, but the fundamental issue
24:37
Speaker 3: is that the demand in the US is higher than
24:40
Speaker 3: anywhere else in the world, and that is telling us something.
24:43
Speaker 2: About our country that we need to pay attention to.
24:46
Speaker 3: And I believe as long as there's a demand, someone
24:49
Speaker 3: will figure out how to supply. Chemistry has come a
24:51
Speaker 3: long way, and anybody can make opioids and math in
24:55
Speaker 3: their garage these days. And microdos is a fenanyl the
25:00
Speaker 3: to be sent in the mail. No one could detect it.
25:03
Speaker 3: So we've got to work on both the supply side and.
25:05
Speaker 2: The demand sign No, that's good advice, all right.
25:08
Speaker 1: We got to talk about Vaccines are taken a hit, obviously,
25:12
Speaker 1: can we build rebuild trust in them?
25:15
Speaker 2: Yeah?
25:15
Speaker 3: And I was saying the best way to build trust
25:18
Speaker 3: is to act trustworthy. I think there's an interesting thing
25:21
Speaker 3: going on right now that I'm working on a great deal.
25:24
Speaker 3: Part of it is misinformation, but part of it is
25:27
Speaker 3: taking advantage of something that's very real. Health systems in
25:31
Speaker 3: the US all advertise that they're patient centric. I can't
25:34
Speaker 3: find a single human being on the face of the
25:36
Speaker 3: US who believes that the health system they're trying to
25:39
Speaker 3: get care from is patient centric. It's impossible. You can't
25:43
Speaker 3: get an appointment. You're shuffled around the primary interests of
25:47
Speaker 3: financing the health system, not patient outcome. We've built a
25:51
Speaker 3: system which is a machine for producing mistrust, and so
25:55
Speaker 3: along come the misinformation to people. And there's a great ad.
25:58
Speaker 3: You're in the business. So my advertising friends that I've
26:01
Speaker 3: talked to is say, the best ad this year was
26:04
Speaker 3: a Super Bowl ad of Hems and Nurse and it
26:06
Speaker 3: starts out, it's only one minute. I'd urge people to
26:09
Speaker 3: just go to YouTube and pull it up. Basically says
26:12
Speaker 3: the health gap is a wealth gap. Healthcare comes to
26:15
Speaker 3: the wealthy, and then it says we're going to bring
26:17
Speaker 3: it to you. But what Hems the Nurse was selling
26:19
Speaker 3: was dietary supplements hormones and injections of proteins. Here's a
26:25
Speaker 3: real thing that plays that people can say that's true
26:29
Speaker 3: and that it says we're going to fill in the gap,
26:31
Speaker 3: but it's not filling in the gap with what really
26:33
Speaker 3: is most important for bringing you good health. And so
26:36
Speaker 3: I think when it comes to building trust, we're going
26:37
Speaker 3: to have to get to the point where the system
26:40
Speaker 3: gets revamped. Before I say the next thing, I'll just
26:43
Speaker 3: point out I've been a political appointee twice, so I
26:45
Speaker 3: can't say I'm not going to be political and I'm
26:48
Speaker 3: not looking for an NIH grant or a job, so
26:50
Speaker 3: I can say what I think the current administration may
26:52
Speaker 3: have done a favor by creating such a mess with
26:55
Speaker 3: the health system and the universities, because if they need
26:58
Speaker 3: to change, I just think other than going the direction
27:01
Speaker 3: of MAHA, which is beef tallow, unpasteurized milk, all that stuff,
27:05
Speaker 3: we need to go to evidence based healthcare as a
27:09
Speaker 3: habit which is reinforced by the system, rather than the
27:12
Speaker 3: system just trying to optimize its finances when you get sick.
27:16
Speaker 3: And that's what we'll build trust in the system. So
27:20
Speaker 3: as I've been working on this, I got approached by
27:22
Speaker 3: a group of students who said, we're frustrated because social media.
27:27
Speaker 3: And here's another construct. We have the public health system
27:30
Speaker 3: over here, which is a real mess in the US.
27:33
Speaker 3: Way over here, we have these enormous buildings at big
27:36
Speaker 3: academic medical centers and health systems, five trillion dollars a
27:39
Speaker 3: year going into sick care, drugs, devices, all this stuff.
27:43
Speaker 3: We have a little tiny sliver of primary care. And
27:46
Speaker 3: then in that gap is what people are doing with
27:48
Speaker 3: ninety nine point five percent of their time, which is
27:50
Speaker 3: living their daily lives, making decisions about what am I
27:54
Speaker 3: going to eat?
27:54
Speaker 2: Am I going to go to.
27:55
Speaker 3: An oncologist when I have cancer? Or like I just
27:58
Speaker 3: saw yesterday, am I going to to take an extraction
28:01
Speaker 3: of alo and get a massage to treat my cancer?
28:05
Speaker 3: And that part of the playing field has been abdicated
28:08
Speaker 3: by the health system. So the student said, what's influencing
28:11
Speaker 3: our patients is what's happening on social media and all
28:15
Speaker 3: the communications that they now have with friends and family.
28:18
Speaker 3: When I'm getting educated in Madison or pharmacy or nursing
28:21
Speaker 3: our public health, I'm getting nothing that's helping me deal
28:24
Speaker 3: with that. So philanthropists gave us funding to put together
28:28
Speaker 3: a national organization that'll be student based and the goal
28:32
Speaker 3: is to get as many health science as centers that
28:34
Speaker 3: are educating the six hundred thousand students in medicine, nursing, pharmacy,
28:39
Speaker 3: public health pas, nurse practitioners, PhDs in biomedical science postdocs
28:45
Speaker 3: and work with them to understand what people are concerned about,
28:49
Speaker 3: put the evidence together, and then put it back out
28:52
Speaker 3: in social media messages, not in press releases or academic manuscripts,
28:57
Speaker 3: but messages said will influence people. So we're now busy.
29:01
Speaker 3: We're just in startup mode and we're working on that.
29:04
Speaker 3: But I don't know how you can win a battle
29:06
Speaker 3: if you're not even on the battlefield.
29:08
Speaker 1: I mean, you're going to get out there.
29:10
Speaker 2: That's a plan. We'll see.
29:13
Speaker 1: I mean, I'd love to help it. It's what we do,
29:15
Speaker 1: you know, It's what I've always done. I think it's doable.
29:18
Speaker 1: Tell us how we get involved. Are you looking for
29:21
Speaker 1: sponsors for it or you're just forming this initiative?
29:24
Speaker 2: What do you need? Yeah, we're just forming it right now.
29:27
Speaker 3: We're a public benefits corporation, so it's and we'll probably
29:31
Speaker 3: go nonprofit once all the paperwork is done. It's not
29:34
Speaker 3: a for profit corporation, so we are looking for sponsors
29:38
Speaker 3: and philanthropy, but we're also looking for partners of all types.
29:42
Speaker 1: So a question I always ask, because we're getting near
29:45
Speaker 1: the end here, what's something you're trying to get real
29:49
Speaker 1: honest about right now like never before.
29:52
Speaker 3: That's an interesting question since my personality assessment in leadership
29:56
Speaker 3: classes keep saying that you have a personality where you're
29:58
Speaker 3: compelled to say what I other people won't say, even
30:01
Speaker 3: though you know you shouldn't. But maybe a way to
30:04
Speaker 3: say it is this, I want to influence our health
30:06
Speaker 3: systems to be honest about what the issues really are
30:10
Speaker 3: that are affecting people's health, and I think they have
30:12
Speaker 3: a hard time doing that because most of what incentivizes
30:16
Speaker 3: them in our current payment system, it's not bad stuff
30:19
Speaker 3: like it's good to treat a heart attack, that sort
30:21
Speaker 3: of thing, but they're not incentivized to help with the
30:25
Speaker 3: things that may be most important. You know, like we
30:28
Speaker 3: got thirty million combustible tobacco users in the US. What academic,
30:32
Speaker 3: big health systems are really focused on dealing with that?
30:35
Speaker 3: And if you ask why wouldn't they, it's that in
30:37
Speaker 3: hypertension the two leading or remediable causes of death. The
30:41
Speaker 3: reason is because you don't make money if you start
30:43
Speaker 3: a smoking cessation clinic, same with hypertension. I hope that
30:47
Speaker 3: I can be an influence to help people get honest
30:50
Speaker 3: about that.
30:51
Speaker 2: Awesome.
30:51
Speaker 1: I'll end with a speed round. We'll call it the
30:54
Speaker 1: healthcare hot seat, where I get your hot takes on
30:57
Speaker 1: some trending topics.
30:58
Speaker 2: You're ready to go.
30:59
Speaker 1: Sure GLP ones in the future of obesity.
31:03
Speaker 3: Well, obesity is here to stay. I don't know that
31:06
Speaker 3: GOLP ones will not cure obesity, but they sure are
31:09
Speaker 3: making a difference and their benefits will continue to expand
31:13
Speaker 3: well beyond obesity per se. There was just a big
31:16
Speaker 3: study from the VA, very well done but observational. It
31:19
Speaker 3: really showed this dramatic difference in veterans of addictive habits, smoking, opioids,
31:26
Speaker 3: et cetera as a function of being on GLP ones.
31:30
Speaker 3: So we're going to see more and more benefits. And
31:32
Speaker 3: GLP one is just one of multiple pathways in this
31:35
Speaker 3: cud brain access that can be exploited.
31:38
Speaker 2: Ye, more to come there.
31:39
Speaker 1: Mental health on demand.
31:41
Speaker 3: The biggest unmet need in the United States is a
31:44
Speaker 3: mental health need.
31:45
Speaker 2: It's very difficult.
31:47
Speaker 3: I think there will be an expanding role of digital
31:50
Speaker 3: support of AI, chatbots, et cetera. A lot to be
31:54
Speaker 3: worked out there. They're not totally safe. My greatest hope
31:57
Speaker 3: is that with AI, as we talked about before, all
32:01
Speaker 3: this mind numbing paperwork will be taken care of. And
32:04
Speaker 3: when you look at what a real interaction between the
32:06
Speaker 3: patient and a clinician is in a clinic, it's mostly
32:09
Speaker 3: about behavioral and mental health issues, and hopefully we'll be.
32:13
Speaker 2: Free to up to spend more time on that.
32:16
Speaker 1: Awesome HRT's comeback and some pushback on that.
32:21
Speaker 3: Yeah, I think we need more evidence. I was very
32:24
Speaker 3: involved earlier on. People don't talk about it much now,
32:27
Speaker 3: but before the Women's Health Initiative, which was a big
32:30
Speaker 3: NIH study, there was a big outcome study funded by
32:34
Speaker 3: the main company that made HRT, and the reason the
32:38
Speaker 3: study was done was because there was a belief that
32:41
Speaker 3: clinicians were not following the guidelines. It said give HRT
32:45
Speaker 3: to every woman who's postman apausal because it will prevent
32:49
Speaker 3: heart disease. And we did the trial and that was
32:52
Speaker 3: not the answer we got. It was quite shocking. Then
32:55
Speaker 3: the WHI found the same thing. The argument now is
32:58
Speaker 3: if you start early, that there's a benefit, but there's
33:01
Speaker 3: no high quality of evidence that shows that to be true.
33:04
Speaker 3: But it's plausible based on the observational studies, so we
33:08
Speaker 3: should never forget that. For a lot of the symptoms
33:11
Speaker 3: of menopause, topical HRT is highly effective, and that's come
33:16
Speaker 3: along since then. So I think for the most part,
33:19
Speaker 3: we're not in a bad spot now, which is use
33:22
Speaker 3: it when they're symptoms, don't use it to prevent heart
33:24
Speaker 3: disease because that's unproven, and let's do some clinical trials.
33:28
Speaker 3: But then, of course, now we have the onslaught of
33:31
Speaker 3: direct consumer compounded hormones, and that needs to be dealt
33:37
Speaker 3: with with evidence generation and reasonable care. And of course
33:40
Speaker 3: it's not just the estrogenes, it's also and women the
33:43
Speaker 3: testosterone being used by a lot of work.
33:46
Speaker 1: Talked a lot about it here, so I'm glad to
33:48
Speaker 1: hear well. I mean, I'm not surprised to hear what
33:50
Speaker 1: you're saying, but sounds like we need more evidence.
33:54
Speaker 3: And I think for men in the low testosterone as
33:56
Speaker 3: you age is a real thing. And I was part
33:58
Speaker 3: of the National Institute of Aging push to do good
34:01
Speaker 3: clinical trials. Those have been done now and the answer is,
34:04
Speaker 3: on average, it's not a big improvement, but there is
34:07
Speaker 3: some improvement and it's not dangerous. So I think we'll
34:10
Speaker 3: see more supplementation of testosterone based on measuring levels, not
34:15
Speaker 3: just welly knelling high doses.
34:18
Speaker 2: Got it.
34:18
Speaker 1: And the new food pyramid, you did talk about it,
34:21
Speaker 1: but you referred to it.
34:23
Speaker 2: What do we think of that?
34:25
Speaker 3: The other food pyramid hadn't been used in fifteen years,
34:29
Speaker 3: So the sort of positioning as we fix the food
34:32
Speaker 3: pyramid is not great. I think the good parts of
34:35
Speaker 3: it we should all embrace, like people should eat the
34:38
Speaker 3: whole food if they possibly can. Fruits and vegetables are
34:41
Speaker 3: good advice, eating beef, using beef tallow and eating a
34:46
Speaker 3: lot more meat. I don't think the evidence supports either
34:50
Speaker 3: of those at all. So if we stick to the
34:52
Speaker 3: things that are agreed upon between the new folks and
34:55
Speaker 3: the old folks, I think you got a pretty good foundation.
34:58
Speaker 3: I'm a big fan of and I would recommend his
35:02
Speaker 3: book on food and the point he basically makes is
35:05
Speaker 3: that what we eat is we position it as a
35:08
Speaker 3: moral issue of willpower, but it's really mostly a biological
35:12
Speaker 3: issue of what our gut hormones are telling us and
35:15
Speaker 3: the environment that we're seeing. And we got this part
35:18
Speaker 3: of our brain that's trying to balance those things and
35:22
Speaker 3: telling us.
35:23
Speaker 2: We're hungry or not.
35:24
Speaker 3: And so this is why I'm upset with the RFK
35:27
Speaker 3: thing of making all these recommendations but not fixing the environment.
35:31
Speaker 3: We've got to change what's subsidized to I mean, if
35:35
Speaker 3: you live in a food desert, or you live in
35:37
Speaker 3: a part of the country. I've been in the Midwest
35:39
Speaker 3: a couple of times recently and the size of the
35:42
Speaker 3: place is just overwhelming.
35:43
Speaker 2: And what are you going to do? And you're presented
35:45
Speaker 2: with that day after day you're going to eat more.
35:48
Speaker 2: It's not just willpower.
35:50
Speaker 1: That makes sense to me.
35:52
Speaker 2: All right.
35:52
Speaker 1: I always ask one last fun question. If there was
35:55
Speaker 1: a soundtrack to your life, what would it be. In
35:58
Speaker 1: my mind, I'm going to Carolina perfect drop the mic.
36:02
Speaker 2: It's not just.
36:02
Speaker 3: About Carolina, but it's about life really.
36:06
Speaker 1: Yeah, all right, I'm gonna go listen to that. Well, Rob,
36:08
Speaker 1: thanks so much for coming on here. Thanks for all
36:12
Speaker 1: you've done and all you do, and I look forward
36:15
Speaker 1: to collaborating.
36:15
Speaker 2: With you on some of this stuff. Let's do it.
36:18
Speaker 2: Thanks Jim, take care all right, take care.
36:23
Speaker 1: Hey everyone, thanks for joining me on the Get Real podcast.
36:26
Speaker 1: You know, I hope you feel a little healthier hanging
36:28
Speaker 1: out with me. You know it's gonna be a lot
36:31
Speaker 1: of fun. Passing this along to others. Please subscribe below,
36:35
Speaker 1: Please share. I'm excited not just to talk about healthcare,
36:39
Speaker 1: but a lot of other fun topics. It's about making
36:43
Speaker 1: healthy talk about healthcare. It's not a lecture. This is
36:47
Speaker 1: supposed to be fun. And look forward to spending more
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Speaker 1: time with you in the future.