Can He Make America Healthy (and Trusting) Again? with Trump's NIH Director Jay Bhattacharya

24:29and I mean it's just flat right when I was a young researcher the question was the research question everyone wanted to know the answer is why does life expectancy keep increasing right and it was something I just took for granted our peer nations have had continuing increases in life expectancy for Americans it's flat our kids are less healthy than we were as kids to some extent and certainly the prospect is that their kids will be less healthy if we keep going in these same trends. There's higher rates of obesity, higher rates of autism. For kids, just a massive chronic disease crisis. And of course, for adults, it's the same for a different set of diseases.

25:08Metabolic disease, type 2 diabetes, Alzheimer's disease, on condition after condition after condition, Americans are in worse health than the previous generation of Americans were at the same age. Is Ozempic going to change that? Because that study came out in 2023. Ozempic obviously has been kind of made more widely available since that date. Is Ozempic a magic bullet? I don't know if it's a magic bullet. I do. I mean, there was actually a decrease in the prevalence of obesity for the first time in decades last year, I think. But the point is, like, we have seen rises in body weight continuously for decades.

25:43And I think last year was the first decrease. So it's possible. I mean, it depends. There's a lot of a lot of like uncertainties about, about those, about those chronic disease trends. I don't know, like a magic bullet necessarily will, I mean, because I think the thing is, is like the outcome is a very multifaceted thing. I don't believe it's only metabolic disease. It's at the root of it. And if it is only metabolic disease, does Ozempic solve all of the consequences of metabolic disease in the same, which is necessarily, you know, just, just because you were obese and then you'd have Ozempic and you're no longer, does that mean that you're metabolically as healthy as you were once upon a time or if you'd never you know you regularly exercise and eat right and all that i mean i think there's there's gonna be lots and lots of questions i think that can come up i do think as a as a it's a it's a call to action though like we now have um uh a clear focus with the make america healthy again movement on trying to solve i now this to solve this this chronic disease problems i don't i mean I don't want my kids to be less healthy than I am.

26:46Not at all. I want them to be healthier than me. I want them to live longer than me. And I think we need to think about policies that are going to make that come about, both in medicine, science, and generally. Do you think there'll be a time, like fast forward to 2050, where we'll all be taking, where everybody will be taking Ozempic? That seems unlikely. Everyone will take it. I mean, like there's people who like exercising and eating well. And I mean, if we have a shift in our culture where like eating well and regularly exercising becomes more like the norm, then maybe people won't want to take Ozempic.

27:24You know, Ozempic means essentially what it does is it makes you not hungry. Yeah. Right? And so that means you won't – maybe you enjoy food. But they're like – they're changing all the Ozempic now. It's going to be available in like a pill version and then they're trying to make it so that it doesn't reduce your muscle mass. And so they're kind of innovating. It's really interesting to me because, again, I'm like, oh, wow, it feels like we might have a real problem in our food supply and the way we eat and our culture around health. But now we have a, you know, Demi Moore in the substance, a magic injection or bullet to fix this for us.

27:56I don't believe in magic. So I do think that this is a real advance. It's probably good for a scientist. Yeah, I do think it's a real advance. I think with almost every technology, there's always things you haven't thought of and things that will happen that you don't expect. And so, like, I don't think that – like, thinking about it as a magic bullet is never the right thing. Like, imagine it was free. What would happen? Like, I imagine people would overdose on it. There are issues with it. Right. So it's not for everyone. Like, there are side effects to some people. Some people can't tolerate it.

28:32and again I don't know what the long term effects are of a large population of people taking it again I think for some people it's really really useful so I don't mean to say don't take it at all but I'm saying like there's no such thing as a magic bullet it seems like from where I sit in the culture it seems like it's getting more and more mainstream where I have conversations almost every day with people who are starting to micro dose it so it's really I think it's becoming a real generational shift particularly in the millennial generation There's certainly financial incentives for that to happen.

29:04Okay. Financial incentives. By that, you mean the pharmaceutical companies would like everybody to be microdosing their product? Of course they do, yeah. There's a second kind of headline that we hear often, and I want to unpack a little bit, which is what you just said right now. Life expectancy in the United States hasn't really changed in the last decade plus. kind of since 2010, 2011, 2012, we've seen this kind of mark of Americans living to about 78, 79 years old. So why is it that? Is it possible that we've just hit a max? No. Because our peer, our quote unquote, peer nations are outliving us.

29:40Yes. And the life expectancy continue to go up there, like in other countries. And is there a good indicator beyond life expectancy of like quality of life? Yeah. I mean, like there's this notion of compression and morbidity where the idea was that you live longer, but the years you spent disabled are at the very end of your life and there's only fewer and fewer of them. Actually, I was working on research on that in the 90s and early 2000s. And there are measures of quality of life built around avoiding that state of disability at the end of life. And there are things like Alzheimer's disease that rob you of your quality of life pretty fundamentally, like your ability to remember the names of your kids or to have the relationships that were meaningful to you start being harder to do.

30:29I mean, there's other measures of disability that we want to avoid, like type 2 diabetes leads to limb amputations, for instance. There's a whole host of things that go along with chronic disease that are not just shorter lifespans. Right. So on here, I was trying to figure out, well, is that true for everybody? But then I saw this study that was done about income. And I think the study was actually maybe partly funded by NIH because it was actually free to me on JAMA, which I think is a change that you and your predecessor under the Biden administration had made to make NIH-funded research free now for everybody, correct?

31:06Oh, I know this study. Yeah. Yeah. So Rod Chetty at Harvard and others did this study that looked at your percentile of income, basically, and your longevity of life. And what they found, the headline of this is that the richest American men live 15 years longer than the poorest American men. And the richest American women, the top 1%, live 10 years longer than the poorest 1%. And then if you look at survival rates as well across various disease states, you'll also see that kind of distinction in wealth. How do you think about that? So moving from that question of do we have pure nations, do we even have one nation?

31:44Yeah, we have one nation. I mean, there's rich and poor in the nation. I mean, it's unfortunate fact that poor people live shorter, less healthy lives than richer people. That's been true of every nation on the face of the earth forever. Do you think this is going to go up now with the kind of advances that we're seeing in longevity and off-label use of Ozempic or other things like that? Well, let's – okay. Let's just stay on it with Ozempic and let's take your premise that Ozempic will solve the life expectancy shift. It's not my premise. It's a question. The premise that you advanced as a hypothetical, right?

32:16So let's take that as given. And let's say that's true. Let's say that hypothetical is true. Then it's just a question of price, right? So if the price of access to that kind of therapy is low, then the price, the life expectancy difference between rich and poor will shrink. If it's high, then it'll get bigger. Like I did a study once looking at the effects of antibiotics, the development and discovery and the dissemination of antibiotics in post-war Italy. And what we found is that it collapsed life expectancy differences or mortality differences between rich and poor parts of Italy. So because antibiotics are available cheaply, it addressed a major problem that was more prevalent in the poorer provinces of Italy than in the richer provinces.

33:06And so not only did it extend life by sort of curing bacterial illnesses, but also shrunk life expectancy difference or mortality differences between rich and poor. It's an interesting study. I feel like Italy is always – obviously, famously, Putnam's Bowling Alone is comparing the north and south of Italy. I feel like Italy is always the destination for these kinds of studies, probably because academics like hanging out in Italy maybe. I actually did not get to go to Italy for the study. No. You're doing something wrong. Almost certainly. No ballroom. No going to Italy. What are you doing? The third headline that we see a lot in American health care is this idea that we pay double what other countries pay for lower life expectancy outcomes.

33:44So this comes this idea of expense versus effectiveness. And this chart that you've probably seen a million times in your life, which will flash up again on the screen, shows per capita expenditure on health care versus life expectancy. A lot of the, quote, pure countries, Italy, Japan, France, Canada, you see a bunch in a certain place. And then you see the U.S. living shorter lives and paying a lot more. I think it's like 18 % of our GDP is on healthcare. And I thought our peer nations spend about 10, 11, 12 % of GDP on healthcare. So that's like the difference between$1 and five versus$1 in seven or eight.

34:22And so that's a big difference. And their results are better, right? They get higher, they get their lower rates of chronic disease, lower expenditure on health. And frankly, it's bankrupting us. So why is that happening? What is your best understanding of why that happens? That's a very complicated question. I wrote a textbook on this theme. So if you want the nuanced answer, go read my textbook. If you want to read a textbook, yes. It's a very exciting textbook. So just sort of there. Give us the one minute version of it. I don't know if it's possible with a one minute version. I think fundamentally the way that we deliver healthcare and healthcare markets are incredibly inefficient.

35:10And the incentives in the system are to provide services that provide very low marginal benefits on the margin. Like on average, it's productive, but at the margin, it's very not productive. And as a result, we spend a lot of money on things that don't produce better health for people. And frankly, in health care reform debates, all of the focus has been, especially from the left, you've seen this focus on access to care and no attention whatsoever on the cost of care. All of the access to care debates I've seen as a health economist over the last several decades have happened in part because the access problems happen in part because the cost of care is so high.

35:52If the cost of care per unit were the same as it was in some of the other peer nations, then the access problems would be much easier to solve. Isn't it a chicken and egg thing? Like some people say, oh, the cost is so expensive. That's why it's exclusionary or prohibitive. And other people would say your access is such that the cost is becoming too expensive. I don't understand the opposite direction. The first direction makes sense to me. Whether you favor public or private provision, when you have a high price, there's going to be less demand for the thing, right? So I think we have a health care market in pharmaceuticals, in physicians, in hospitals, and long-term care, and a whole host of like sort of the provider side of the market.

36:35For the same good, it charges way more than you would get charged in Denmark. I had an ACL surgery here and my bills for it were about$130 ,000. Of course, insurance paid and I paid my co-pays or whatever. Or maybe it was$80 ,000. I can't recall. My friend had the same exact procedure done at Cleveland Clinic privately in London, 5 ,000. Can I modify what I said earlier? Because I'm going to correct myself and agree with you on the opposite side. When you expand insurance, you also, unless you take active steps, reduce the incentive to have lower costs. Exactly. That's what I think is the chicken and egg problem of this.

37:13So let me – so yeah, I agree with you about that. So it's – but I don't think that the solution is lack of access. So I don't – because that's why I was pushing back on the chicken and egg side of it. I think the solution is interventions in the market to reduce the sort of capacity for market power to like charge higher prices, have more competition in markets would be the right way to do it. Yeah. I mean I don't know. When you're done with Dr. Paduchero's textbook, you can check out the first episode of this show, which is called Can Billionaires Save Us? And I talked to Mark Cuban about the opacity of our health care system and basically asked him the question, if capitalism and unfettered capitalism maybe fucked health care, can it unfuck the system, as he likes to say, through his cost plus drugs, et cetera.

38:00I'm trying not to use that language. Sorry, I will try not to. I'm just so shocked. I have no idea. Sorry. No, I'm just kidding. I think the thing is, if you think about the way that markets work, if they're working well, they have to price the right thing. The problem with healthcare markets right now in the United States is that they price the wrong thing. They price the service you receive rather than the outcome you want. right so like and a lot of the good health care reform ideas about uh health care markets have to do with changing what we price like changing what we pay for um are you opposed to uh public health care like provision like in terms of like a national single-payer system or i mean i'm favor of medicaid i mean i think medicaid is really important i'm favor of medicare so no the answer is no i'm not but for the general population not just medicaid and chips that's a lot of the population yeah but i'm asking you like do you think i mean you're you're sitting here with all the economic and the studies that you've done, do you think that part of the reason why our peer countries do better is because they have it across their lifetime and not just?

39:06Okay. So which countries? Are you talking about Japan and Germany, which have like this Bismarckian system? They have very odd systems. Yeah. Well, I mean, it's actually much more like the United States. What is your opinion? I think the debates over who should provide care are a dead end. And it ends up in positions where you just have these like political fights that lead to nonsense. They're impractical, but in an ideal hypothetical world. I think ideally, if you address the price of care, then the universality of coverage would solve itself, right? Whether it would be via private provision or public provision or a mix, it mixes the most likely way.

39:41That's much less interesting to me than the price of care, which is the root problem. Hang tight for a second. We'll be right back. I want you to use this break to share this episode with someone you think would enjoy or benefit from it. And leave a comment to tell me what you think. Can we restore trust in health and science, is a Zenfic going to be some kind of longevity game changer? And when it comes to this chicken and egg question, how do you think about healthcare reform? Is it about driving down costs and through more competition, like the director is describing, so that we can have more access?

40:11Or is it about expanding access, like, say, a UK, where the NHS has the buying power and the reach to really drive down healthcare costs? Or is it something else entirely? And if you want to know what Mark Cuban thinks, you should check out that episode, which is two below. But first, finish this one.

40:29The state of U.S. health care right now includes morbid obesity, rising mental health crisis, extreme excursion of costs of care, which we've just spoken about, rises in youth cancer and youth chronic, young cancer, young chronic disease, particularly in midlife, public distrust. Yet you only have a budget of$48 billion and shrinking, I believe. Not shrinking. Well, there are proposed budget cuts to that. But that's actually happening, right? Because Congress will stop them. Well, Congress has stopped them. Yeah. The Senate's proposing a 1 % increase, actually. Yeah. But they were proposed by the president.

41:02They haven't happened. Okay. Are you worried about further proposals of budget cuts? You saw this year, like the Congress, I mean, I get to, this is part of my job is I get to go talk with members of Congress on both sides to understand what they want from the NIH or their desires for the NIH. And there's pretty widespread support in Congress for the NIH. It's not an accident that the Senate is proposing a 1 % increase in the House, supposing no change in the budget. Where did the budget proposal – because the budget proposal for 2026 from the president included a 40 % reduction. Where did that come from?

41:35The Office of OMB. No, they proposed it before I got in. But I mean the thing is like it's – we have a$2 trillion deficit. I can understand why someone who's like building a budget would say, well, every part of the government has to take some hit. But the reality is the NIH is a very productive investment. And like I think most people in Congress, the vast majority of people in Congress on both sides of the else recognizes that's the reason. And it addresses a real need for the American people. Like we need better research to reduce the cost of care, right? So to address the chronic health needs of the country.

42:11The NIH in some sense is a solution to the budget deficit. So, yes. And in that sense, this$48 billion that you've got to spend with a 1 % incline now, what is the top priority or what are the three top priorities for you? So, I mean, one, I want to make America healthy. I really do that. I mean, I think addressing the health needs of the country through research is the top priority for me. um so i mean just if we already talked about some of the metabolic syndrome and other other other conditions um uh let me just talk about talk about one we haven't talked about right now so um last year there were about 40 000 people who got hiv um and uh that's a big difference 40 000 americans got hiv last year yes um even with prep and everything that exists wow uh 40 000 americans i think uh i should actually we're talking in 2026 so when you say last year 2024 I mean 2024, yeah.

43:07So it's still not updated that we're in 2026 yet. But yeah, so 2024, there were 40 ,000 Americans. We're all internet buffering in the first days of 2026, yeah. 40 ,000 Americans got HIV, right? In late, mid-2024, there was a new drug that was approved by the FDA called, actually it was approved in 2025, called Lencapavir. And it is a long-acting PrEP drug. A PrEP drug is a drug that will prevent you from getting HIV even if you're exposed. Long-acting meaning a single injection prevents you from getting HIV for six months. And very likely it's up to a year. It's kind of like a vaccine-ish. Yeah.

43:45It acts effectively like a vaccine. It's not a vaccine, but it protects you against becoming infected with HIV even if you're exposed. And it's approved for six months, but I suspect it lasts a year based on some of the preliminary data I've seen. And there's like other long-acting PrEP where you take a pill and it protects you for a month. I mean, there were in 2024 and 2025 tremendous advances in HIV prevention. And we already have on tap a whole suite of drugs that if you do get HIV, will lower your viral load to near zero, essentially turn HIV into a chronic disease. So you're no longer going to die from AIDS.

44:27It's tremendous, right? But think about that. We have a drug that prevents you from getting it if you're exposed for long periods of time, and we have a way to reduce viral load to near zero. We have what we need to reduce the transmission of HIV to near zero in this country. And so what I'm going to do with the NIH is we're going to do research on how, which populations need this the most, what kind of interventions with these existing technologies so that in 2019, President Trump issued a challenge to the country, said, look, let's eradicate HIV in this country by or reduce transmission to near zero by 2030.

45:05With this suite of drugs that we have and research on how to sort of deploy them and good public health, good trust in public health, we actually can achieve that goal by 2030. Wow. Okay. That's decades in the making that, right? From the 1980s till now, that's the outcome of lots of NIH studies and lots of academia, et cetera. I imagine that's gotten us to this point. What is the next big leap? It seemed like there was a lot of - I mean, I want answers for Alzheimer's. Let's figure out how to actually prevent it and reverse it. I want answers for autism. I want answers for ALS. I want answers.

45:43We already have a treatment, a cure for sickle cell anemia. Really? Yeah. Oh, I didn't know that. It's incredible. To me, it looks like, we said there's no magic, but I'm telling you, it looks like magic to me, right? Now you're believing. The thing is, it's a cell-based therapy, and it will literally cure a patient of sickle cell aminia, a disease that causes pain crises. This is like an adult person can be cured of their sickle cell aminia from birth. And kids. Yeah. Wow. And it's based on gene editing technology. But this is out there? It's in the market? It costs$2 million,$3 million. So I want to invest in research that lowers the price of that so that everybody has access to it that has sickle cell anemia.

46:26Is research the answer or is regulation the answer to get prices down? I mean, it's a new therapy. It costs$2 million. I mean, the marginal prices. They need to recoup their R &D. Yeah. Well, it's not just that. It's like the marginal cost of actually making the cell is complicated and not high, right? So I want to invest in technology that reduce the price of that developing those cells. What's the next thing that you think is going to have a breakthrough? You listed, I mean, you were kind of like, Oprah, you want a car, you want a car, you want a car, everyone gets it. But like, what's the next one that's going to?

46:54I think I'm really actually quite optimistic about Alzheimer's. Like there's a colleague of mine, a former colleague of mine at Stanford, who did a study a few years back, a couple years back of a shingles vaccine, an old shingles vaccine called Zostavax. You're too young to have gotten it, but I got it. In fact, it wasn't a very good shingles vaccine because it didn't prevent shingles for very long. The new shingles vaccine, Shingrix, prevents it for much longer. He did, my colleague, Pascal Gatzinger, did a study where he looked at, actually, I think it was Denmark again, and they had a strict age threshold, like you had to be above some age in order to get it.

47:33And so he did this difference-in-difference kind of study and tracked people for many years. It turns out that if you got the Zostavax vaccine on the right side of the age threshold, you're 20%, 30 % less likely to develop Alzheimer's symptoms. Everything else is controlled in that kind of setting. It was a difference in difference, like comparing people who were 49 versus 50. 50-year-olds got the Zostavax, the 49-year-olds didn't because there was that strict threshold. So that shitty – sorry, pardon my French. But it's like this low quality – I'm so shocked by your language. I know. The shitty singles vaccine – let's make it alliteration.

48:05The shitty singles vaccine is actually a potentially – A potential way to prevent Alzheimer's. Prevention. Yeah. I mean, I think there's going to be like, I mean, who knows? It's hard to predict what the outcome of scientific studies are going to be. But one's allowed to be optimistic. And here I think I am fairly optimistic. So it sounds like you want to invest in a lot of moonshot kind of, or like a lot of innovative research that's going to break through. Yeah, we need to actually address the problems we have. And let's talk about, so let's take this outside of the U.S. We'll be humble and peerful.

48:37how is China doing on all of this kind of research? How is their biomedical research looking right now vis-a-vis America's? I mean, they're, if not the number, they're a real competitor to us. Like they have invested a tremendous amount in their biomedical research enterprise. We've invested a tremendous amount in their biomedical research enterprise. And they have, if not, it might even be the leading nation in the world in biomedicine. So China, you think, sorry, say that. They might be the leading nation in the world in biomedical research. It's possible. I mean, I think the United States. They might be better than the United States, China.

49:09It's possible. I mean, like, depends on what your measure of better is. Like, I mean, if you're counting, like, publications or whatnot. I mean, I think the question, like, those kinds of questions really only get answered ex-post. Okay. Right? So are there advances that they have? Will they really be more or less important in some qualitative way? You know, ex-post. It's hard to say. But the point is they have tremendous investments in biomedical research. and they are making real advances in biomedicine at levels that look like, to me, like they're quite impressive. Okay, so say in the year 2035, a very wealthy medical tourist has cancer.

49:48They can go to Boston or Beijing. Where are they gonna go in 2035? Yeah, that's what you started with. So biomedical research and where to get treatment are two different things. I mean, I assume that the way that you, the translation of these biomedical advances to treatment of people in China will be much more unequal than it is in the United States. It's hard to like project forward from the advances in treatment, the advances in scientific advances to advances in treatment and translation. I mean, it's hard. It's really, that's really hard to say. But the issue is actually a different one.

50:23The issue is like, where's the center of gravity for science in biomedicine in 2035? It could be China, right? It could be that the ideas that they have are so exciting and interesting that people will want to like look there. They're already wooing a lot of, and when you said we've been investing in China's biomedical enterprise, you mean that a lot of Chinese researchers have trained here? Almost every single top biomedical scientist in China was trained in the United States. There's some exceptions. Where you haven't retained? No, we retained some, a lot of folks stayed, but like a lot of people left.

50:59And there's also, like good evidence that essentially there's an industrial scale scale espionage right so with the chinese biomedical enterprises in part fueled by what we do here because the the the the protection of american intellectual property rights is less than it ought to be yeah it used to be that they like want to know how to make a ford i mean no one really needs to know how to make a ford but maybe what's wrong with fords i like fords my first car was a chevy it was a great great car a volt a Volt no it was not a Volt it was a 1976 Chevy Impala which I absolutely loved okay Big Blue we called it but it used to be that they wanted to know how to make a car now it's like kind of like how do you so for instance now if you are going to get some you have cancer and you have there's some cell therapy available for the cancer what will happen is you get the cells taken out of you here the cells then get sent to a Chinese you know lab or factory the modifications the cell take place in China and then they ship back here.

51:56Okay, so that's actually supply chain national security risk in some ways, potentially. Of course, they get to keep all of the sort of genetic modification data that's been, I mean, there's a whole host of problems with that kind of supply chain. So we actually, as the United States, we face a tremendous challenge from the Chinese. Yeah, and is it a top priority? Like in rooms, are you sitting down with the secretary and with the president to talk about this? Like, is a war rooming China health edition happening in DC? I have not spoken with the president directly about this, but I have spoken with the secretary about this and others.

52:29I know that the president is aware of this. I know that his science advisor, his main science advisor has spoken about this. I assume he's spoken about this with the president. When the president hired me, one of the things he wanted was to make sure that the United States stayed the leading nation in the world in biomedicine. Okay. And right now it sounds like you're saying, because what you started to say but didn't say was that if China isn't the – There's a real challenge. We have to take this challenge really seriously. I think in other places I've talked about it is a Sputnik moment. Like it really is a Sputnik moment.

52:58For us, we need to start taking seriously the Chinese challenge. And I mean, I think partly the – like if you look back at the last few decades in biomedicine in the United States, there have been big advances. Like I don't want to like downplay it. Yeah, you just told us a couple of them. This is like huge advances. And I think that those investments have been really worthwhile from a sort of like purely theoretical point of view. And some of it's translated over better lives for patients. But we haven't done as well as we could have, right? So like there's huge replication problems in our science where like we publish papers.

53:40Half the scientific literature in cancer biology and basic cancer biology isn't replicable. Independent teams look at the same thing. They'll find the same answer. Because they're not bothering to do the work. I know this has been something that you've cited when it comes to Alzheimer's research in particular. There's a replication problem. People have been relying on this thing. It's not just Alzheimer's. We're talking about in psychology, in cancer biology, in field after field. There's like a rush for people to – so the replication problem just for people following along is that basically studies happen and then they get cited over study, over study, over study over time.

54:10Maybe even medicines are developed out of these studies. And then someone might look back at the Alzheimer's amyloid research and say, hey, this isn't actually reproducible. And so what's happening in that example? I think what's happening is bad incentives. So the incentives are, if you want to advance in science, is to publish your work in a top journal. A top journal, you send it to a journal and it's sent to a couple of peer reviewers. The peer reviewers don't replicate your work. That's not their job. Their job is to read the paper, see if there's logical errors, see if they want to check something you didn't check or whatever.

54:44But they don't ever get to have your data. They just get to see the report that you gave in the paper. The peer review is a poor substitute for replication. And you publish your paper in a top journal. You publish enough papers in top journals, you get to be a fancy professor at Stanford University or something.

55:07And then maybe a few years later, someone fails to replicate your work, but it's like it's, you know, it doesn't, there's almost no return to replication. So are you building in like a safeguard where everything has to be replicated? Like wouldn't the like - I don't think you want every, I mean, I think what you want is the most important claims to be subject to replication. Like so, and you want the scientific community to determine what is most important, right? So like the things that are rate limiting, where if it turns out X post to be false and you've built a huge sort of like set of results on top of it, that would collapse, you kind of want to make sure that that thing that you're building the huge, huge infrastructure on top of is true.

55:48Is there ever something that you don't, like that you don't, for example, there's this question. I know you just, the NIH has just approved, I believe, a budget for studying the - Ideology of autism. Ideology of autism. And the ideology of autism is different from the, so ideology means - The cause. What causes something, and epidemiology is not just, it's also the spread. is the range of who gets, who has the condition. Okay. So, and the NIH just has put out funding for research that will help understand the etiology of autism. There was a good piece in the Washington Post about this recently as well, about what we know and don't know.

56:25There's also been this question that people have around vaccines and autism. And there was this big Danish study that happened. Like there was a Danish researcher who's like looked at 650 ,000 children, right? Over the course of their lives. It's like longitudinal data. On MMR on autism. Yeah, on MMR. And what did they find in that? They failed to find a link. And so something like that, that is reproducible and we can trust in that study. Okay, so the question of like what should be reproduced is an interesting scientific question. It's like first, what should be reproduced is a science policy and also health policy question.

56:59If you have claims that are not widely believed, even though scientists believe them, then And from a public health point of view, it's worth doing reproduction in that area, supporting replication in that area. This is a hypothetical thing. The Etiology of Autism Project, the main focus of that has been to apply exposomics methods and a whole bunch of a range of other methods. It's very broad. So it's a different thing. You're just asking a narrow question of that MMR and autism. The question of ought one subject, those kind of studies to replication, to me is a public health question. as much as a science question.

57:38Like, should we invest in it? Yeah, because if people don't believe the answer, then I believe the only real way to do this is like a good faith attempt at replication. To do it again. Yeah, to see, not just specifically with those same data, but like in other settings, with other circumstances, do you tend to find the same answer, right? If you approach the same question from a different point of view, do you find the same answer? That's how science generally advances, is by consilience. Like you have different approaches and different people, different ideas aiming at the same parameter at the same answer comes up over and over and over again then you have a lot of confidence in it right i think that's that and again whether you should do that or not for a question is a public health question it's a and it's a science it's a science question what is your public health answer to that specific question for mmar and autism i don't i think it's unlikely that there's a link yeah it's uh you know but i do also see a lot of people that disagree with me in in um in you know in society at large and i want to provide Are there scientists who disagree with you, like reputable scientists?

58:36Okay, when you say reputable, I don't know what you mean. I mean, people who have to are accredited scientists. So some people say that if you disagree with what I just said about the link between MMR and autism, that you're automatically, by definition, not reputable. Okay, a scientist. Let's just say scientist. So you have to be really careful here, right? And I'm seeing a loss of confidence by the public at large, evidently in the reduction in the percentage of babies that get the MMR vaccine, right? So the answer then isn't to say, look, those people are not reputable. The answer is to do science in good faith to try to address the questions that they have in their heads.

59:13Or to bring out the past science and explain it in a way that helps make sense of it, right? Like if the science already exists. I think you should do good science, right? So it would take a long time to do this again, to study something that - It depends on the methods. I mean, you could use existing data potentially and ask the question again. I mean, it depends on the - There's a whole thing you have to ask about the validity of the science, but that's different than should you ask the question at all. One more thing on the replication. You focused on autism and vaccines, but I want to just emphasize it's in field after field after field after field that you have this replication crisis.

59:49Cancer biology, right? So drug developers, they will conduct their own private replication efforts before they decide whether to invest in development of a drug. Because they don't trust the published biomedical literature. It's a major problem. Because they have financial stakes in place. They're not just getting tenure or whatever it is. And of course, they know what parts of the literature are false and true. That's a trade secret. It's a trade secret? Yeah, of course. So for the Alzheimer's study that couldn't be replicated, for example, was it the pharmaceutical companies that broke that, that understood that was the case?

1:00:22I mean, that's a whole other complicated – there's a book by Charles Piller, Doctor, which is a really interesting book. I mean, I think the entire field actually sort of went down a path, and it was based on essentially a fraudulent set of results that people took as true. In field after field after field, if there's replication crisis, there is insufficient returns to doing replication, right? So if I devote my career – Yeah, the incentives are not there, you're saying. Exactly. Unless you're a Novavartis or someone, then you have an incentive to figure out the truth. Yeah, you have some incentive, right?

1:00:55But let's say you invested a lot in developing a drug based on the faulty theory, and it only sort of doesn't – kind of doesn't work. Yeah, it's like that bad shingles vaccine. It's like you kind of keep giving it to people. Because you want to make up the – so the point is like it creates pathologies down the line that actually affect people. So I want to solve that problem with the NIH, right? We can give incentives to people due to replication work. Actually more, I want – I mean essentially second scientific revolution. I want replication to be the standard of deciding whether a claim in science is true or false in biomedical sciences.

1:01:31So for instance, you asked me about the Chinese biomedical sciences. I don't know how much of it replicates. Neither do they, right? And they're not making that public. What I'd like to see is I'd like to see when you publish, when you're searching for a study, some reporter goes and searches for a study, they find the study and there's the replication button in PubMed or wherever. You click it and all the related relevant replication studies pop up maybe with an AI summary to say what it says. And you can click on buttons and you see each study yourself. Replication should become the standard of truth, not is it published in a top journal.

1:02:04I can see the app that you're going to create when you leave this current job. No, I think we're going to do it with this job, actually. Oh, really? That would be – Yeah, PubMed, I think we do that. I'm being told we don't have a lot of time. What is the actual – Five more minutes. Can we do – can we stretch to 15? If we could keep you until 45, I would be very happy. 40. All right, let's do 40. Okay, let's do it. Okay. So there's a question right now when you talk about the downstream impacts of things, there's a question about funding because there's been a lot of pushback on some of the changes in research that are happening at NIH.

1:02:31I believe there was like a Bethesda proclamation. Well, they wanted to like have more DEI funded again. Yeah, well, I mean, we can get to that. But there have been - I'm not telling you, like I met with them because they wrote some like a petition and I've met with them and what they wanted was more DEI. Okay, well, here - And we're not gonna fund that. I mean, I don't think that was very productive research. It didn't translate over to better health for people. Well, here's the question for you. The funding, like there's a conversation around research pipeline in the United States and whether or not like, if there's less money for research because there have been - But there isn't.

1:03:02Hasn't there been changes to the pay line from 20 % to 5 % for various research, for cancer research, for example? I mean, 20 % was like in the 70s or something. I mean, it's been for decades since we've had a 20 % pay line. Like what we have done is we've removed the pay lines. There's a, when you send a proposal into the NIH, there's a study section, which are peer reviewers that will like grade your proposal. I served as a peer reviewer for many decades. They grade the proposals. on a whole bunch of bases, including are the methods strong? But they tend to emphasize the methods rather than how innovative is the proposal idea.

1:03:46They actually tend to downgrade things that are really innovative. And so we've removed pay lines and we've allowed the institute directors to select promising. It's kind of like a VC. I would like to have an institute select projects. if they pick 50 promising projects and 49 of them fail and the 50th cures Alzheimer's, that's a successful portfolio. Right, so that's what we've moved away from. You want to be like a venture capitalist. I mean, to some extent, I guess, a little bit. There's a lot of companies that are publicly traded right now who are overvalued in their VC stages, but. Well, I mean, I think, but you don't need all the companies to succeed.

1:04:24You just need one in your portfolio to be Google and you have a successful portfolio. I think if you are asking every single project to fail, the portfolio as a whole will fail because you will end up picking projects that are too conservative. Like I did work a few years back asking how old are the ideas supported by NIH-funded research. In the 1980s, the NIH was funding research that was zero or one years old. In the 2010s, it was funding research that was seven or eight years old. We need to fund cutting-edge frontier research. There's also been like conversation about moving away from the elite university architecture of funding.

1:04:59Is that something that is a priority of yours? It absolutely is. And what does that mean? I mean, there are great scientists all across the country and there's great desire for to do science. I've now visited a whole bunch. I visited Oklahoma. I visited Alabama. I think I'm headed to Iowa. I've been to like I've been to Montana. And there are amazing scientists with great ideas. And what they tell me is that when they apply to the NIH, often, sometimes they'll move from, like I had a scientist who moved from Harvard to Tennessee. He's like, well, I sent in this basically the same application. I got a worse score in Tennessee than I did when I sent it in as a Harvard professor.

1:05:34So wait, is this like DEI for like University of Nebraska at Lincoln? You wouldn't want to call it that. It's not DEI. I think it's the wrong thing. I think identifying highly impactful ideas, promising ideas that have a chance of actually advancing the health of people, no matter where they are, is a major part for the NIH. I wouldn't call it DEI. I call it merit-based funding of research. Like you want great scientists, no matter where they are, to get research dollars. We spoke at the top of this conversation about the Great Marrington Declaration, the challenge of having conversations at that time.

1:06:08I don't know a lot about science and health, but I know something about foreign policy. And in foreign policy, there's this idea of the failure of the last analogy, right? Like you go to war. Yeah, generals fighting the last war. Yeah, you go to war in Somalia because you think it's Rwanda. And there's also groupthink, like Bay of Pigs was a disaster because everyone kind of agreed with what was happening. How are you avoiding that right now? Because you were excluded by your description in the conversation of the pandemic early on and shadow ban on Twitter. And there was a lot around that. How do you not hold on to that and become that person that shuts out another point of view?

1:06:41I mean, I don't have all the answers in science. I think that to me, the most important reason I took this job was to help advance the healthy American people. And if I decide that I am the science and I'm going to authoritatively say this is good, this is bad, or this is right, this is wrong, that I won't be able to do that. The science depends on self-correction, on correction, like on people checking each other's work. It depends on humility. It depends on, and so like if the thing I actually want to accomplish, which is support science that advances health of people, I can't accomplish if I do what you just said.

1:07:18Right? I think the problem, the reason why we had bad outcomes during COVID is that you had a few people that decided that they knew about plexiglass, about masking, about vaccine mandates, about school closures, about topic after topic after topic. And because they did not allow self-correction, they got everything wrong. And now people don't trust scientists and they don't trust public health and they don't trust medicine. They got everything wrong? Yeah, they got almost everything wrong. Do you think that those people went into public health? For example, I've interviewed Dr. Fauci. Right. Do you think he got into public health to help?

1:07:49Like when he got into public service 40 years ago? I don't want to speculate about that. You've kind of come out and spoken against the prosecute Fauci. Yeah, I don't want to talk. I don't know specifically about his situation. I'll just tell you that I think when someone is in a leadership position like I am in science, to act in an authoritative way essentially undermines science. And it'll undermine my main goal, which is to help make Americans healthy. I think that is way more important to me than getting my way in science. If people come to me with science that changes my mind on something, I'm going to celebrate that.

1:08:27When's the last time you had a disagreement? Your boss, Secretary Kennedy, is one of those. We disagree all the time about it. What is the last disagreement you had on something? I mean, we talk about all kinds of topics. I mean, the kind of disagreements we have have to do with scientific questions, have to do with policy questions. He respectfully listens. He makes decisions based on that. Does he defer to you on the scientific? On some things, yeah. And then right now, right now there's a bit of a vacuum in NIH in terms of there's, I think it was 11 to 13 of the directorships have to be filled of the 27 or so institutes.

1:08:58We're open to like hiring. Right now we're hiring. Those are all open positions. If you're an excellent scientist and want leadership, please apply. Are you seeing people vote with their feet because they disagree with this administration? No, we're seeing lots and lots of amazing people applying to those positions. But they're still not filled because? Because I have to vet them. There's a lot of people. The government shut down. I mean, it's normally those positions take a long time to fill. Like we've been moving a very fast rate to try to fill them. We're going to, you're going to start to see in the next month some of them get filled.

1:09:27I end every episode of Smart Girl Done Questions asking my guest a question that they don't have the answer to. So you named a bunch of studies, et cetera. What is a question that you don't have the answer to, Dr. Bhattacharya? I don't know how to put this. Like, I think I want to restore trust in public, like the public's trust in science. I have a faith that if we can address the health problems that people have and reverse the life expectancy problems, address the chronic disease problems, that we can do that. But I don't know for certain that that's going to be enough. I think scientists, we need to like come together and remember what we're in this for, right?

1:10:03So I don't know. I mean, I think, I hope that that's enough. and that's been my focus and it's going to continue to be my focus but I don't know how to get scientists to come along with us on this what I've seen is a lot of scientists essentially entrench themselves and oppose the changes that they've seen because it's not the way they're used to doing things and I don't know if I can get them to come along I hope I could but we'll see So can we restore public trust? Yeah That's a big question Thank you so much Dr. Bhattacharya for joining us today I really appreciate your time Thank you and your patience Thank you

1:10:42So here's my big takeaway, and I want to hear yours too. Every time we spoke about the science and the research, I felt like I was learning more. And then when the conversation veered to politics or personalities, I felt like I was learning less. So the great unlock for trust in science and health, which, as the director said, is so important. I think it's about stripping out the party politics from all of it, which I know is Pollyannish and impossible. but we will never have trust if we cap an audience at 50%. Whether it's blue or it's red, it's just not going to work. And so I think we have to make science and health purple again.

1:11:15We have to Mishpah. We're going to Mishpah, guys. That's the acronym. It's kind of like Maha. I appreciated that Dr. Bhattacharya made the time and extended the time for us to have that back and forth where we could discuss and push and try to understand and sometimes misunderstand understand each other. I think we need more of those long form conversations. And obviously, I also love textbooks. I really liked when he was talking about the textbook. I mean, I love a textbook, but the reality is that we live in this meme generating and meme consuming culture where there isn't that big a difference sometimes between what's marketed or what's messaged and what's reality.

1:11:51I mean, the director himself spoke about that. We have all these studies between the MMR vaccine and autism to disprove the link, but people don't believe it. So we might have to do those studies again, right? The messaging or what they've seen or read has become a reality. So that's why I worry. It's not about oversimplifying science. It's about misleading messaging that risks sowing even more distrust. And that's particularly problematic when it comes from our government, no matter which party is in power. I also think that there are lots of causes of optimism in that conversation. I mean, the breakthroughs that we're having and things like sickle cell disease and HIV, I mean, I didn't know about any of that.

1:12:29and what decades of research can do to change a thing. I mean, talking about Alzheimer's and if we could solve that is amazing to think about. I also am very interested in the shift towards chronic illness. Like I do wanna know the ideology for all of these things, for autism, for why we're seeing more cancer, for even why we have distrust. We should do an ideology and also an epidemiology study on that. That would be a good use of taxpayer money. And I'm also optimistic about this bipartisan support for science and health in Congress which is pushing back against these proposed budget cuts. And I guess the big question I leave this with that I don't know is with this kind of big agenda shift, how do you not throw out the baby with the bathwater?

1:13:10I think it has to do with having a culture of hearing people out in disagreement and dissent. And that's where Dr. Bhattacharya started. So I hope that stays alive in a world of party lines and all of those things. I hope we can have more data-driven discussion about science and also settle science and message it right. It is so important. because otherwise we're all going to have to move to Beijing in 2035, guys. That's it for this episode of Smart Girl Dumb Questions. I'm Naeem Araza. This episode was produced with Dana Balut and Desta Wunderad. It was edited by Darlena Chiem and mixed and engineered by Johnny Simon.

1:13:42The theme music is by David Kahn. And we'll see you next week for Smart Girl Dumb Questions, Less Politics.

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