Vas Narasimhan

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0:34Voss Narasimhan is the CEO of Novartis, a major Swiss-based pharmaceutical company. Born in the United States to Indian immigrant parents, he was educated at Harvard Medical School but chose not to practice medicine. Instead, he chose to go into the pharmaceutical industry and is now leading the transformation of Novartis to one of the most important pharmaceutical companies in the world. Had a chance to sit down with Voss in New York recently to talk about this transformation. So many people know the names of the drugs that they use, but they don't know the names of the drug companies or pharmaceutical companies that produce them.

1:05So for people who may not know much about Novartis, tell us what drugs or pharmaceutical products are produced that people would have heard of. There's a couple of major drugs we have right now. Entresto is a medicine for heart failure. Another drug, Cosentix, for a whole range of immunology indications. We have a drug called Cascali for breast cancer. As you know, these names are not always tying to what the drugs actually do. But yeah, we have a pretty broad portfolio of medicines, over 15 medicines, over a billion dollars of sales. By the way, speaking of their brand names, who comes up with these brand names?

1:38Because they're names that I can't pronounce sometimes. You don't know what they mean. Do you have a team of people that come up with these names? It's a whole industry. Maybe private equity would be interested to get into it. But there's a whole industry of people who basically try to find word permutations that might tie to the drug. And then you have to send it to the regulators. And they have to be sure that this word will not be confused in any number of different languages for some other medicine or something else. People who don't follow this industry carefully may not recognize it. But the way the industry works, as I understand it, is that large pharmaceutical companies either develop internally or through an acquisition a drug or pharmaceutical product that they can sell.

2:20And it's patented. And the patents last for 17 years? 17 years. 17 years. And after 17 years, it becomes what's known as a generic, which means that it's not patented and you can get it for presumably a lower price. So is that a good way to make a business? You build products and 17 years, they're kind of gone. It's a tough way to make a business for sure. It means you're on a constant treadmill and you have to constantly have the innovation capacity to have what we call replacement power. You have to replace your sales with the next medicines, the next innovation. So the only winners in the long run are companies that have the R &D firepower, R &D capacity to keep inventing medicines to rejuvenate almost their entire portfolio.

3:03So you think of a company like us,$45 billion in sales. Every year, we can have anywhere from$2 to$8 billion plus going off patent. And we have to generate enough sales to replace that and grow on top. And that's why you have a relatively limited number of very large biopharma companies. When somebody develops a drug or pharmaceutical product in a company like you do, you have a big lab, I assume, is it all over the world or you have it in Switzerland? We invest about$9.5 billion a year in R &D. Research headquarters are in Cambridge, Massachusetts and Basel, Switzerland. All right. So when you get the product and what do you do?

3:38You test it first on animals and then you test it on small subset of humans and then a large subset of humans. Is that how it works? Roughly that's how it works. And it's a long journey. First thing we have to do is we have to discover or find what we call a target in the human body that we want a drug. We think this target has some ability to impact human health and the disease we're interested in. Then we have to design a drug to either inhibit or promote that target. And that takes some time. AI might help us do that faster. We'll see. And then once we have that target drug optimized, we take it into animals, make sure it doesn't cause any preclinical safety signals.

4:14And then we finally move into humans. And from the time we move into humans to when we get it to people, it's usually around nine years. Last year, 2023, we saw an enormous increase in drugs being taken that reduce your weight, and they seem to work quite well. There are two drug companies, one in the United States and one in Europe, that seem to dominate that business. Are you going to get into that business, and why not? It seems to be extremely profitable. It is a business we're interested in. And we're working on really the next wave of medicines, because I think these GLP-1 medicines that you're talking about are very well serviced by the current companies.

4:48It's a fascinating story. It goes back actually to the early 1990s. It took us almost 25 years to realize the potent effect that these types of drugs would have on obesity. But we think there's opportunity to improve on them. And we hope it's very early stage within Novartis. But can we come up with drugs that better preserve muscle or maybe easier to take and more infrequently taken? And one area of where Novartis is one of the leaders is in what are called small interfering RNA therapies. It sounds like a fancy word, but really what it allows you to do is take drugs that you normally would take every single day and make them drugs you only have to take twice a year.

5:25So in cholesterol lowering, we have a medicine that you only have to take twice a year to lower cholesterol 60%. We're working on similar medicines for hypertension, high blood pressure, other risk factors for cardiovascular disease. And the idea is, can you get to very infrequently dosed medicines? Because most people don't stay on their drugs. As I get older, the drug that I'm most interested in is one that deals with Alzheimer's or dementia, because I'm always wondering, am I going to be getting this disease? What are you doing in that area? So we're active. And I think what we're really interested in is, again, the next wave of what might be effective therapies for Alzheimer's disease.

6:02Today, there are one drug licensed, another drug coming, targeting the plaques in the brain. anti-amyloid drugs, as they're called. But we think the next generation opportunities are going to be to target other elements that accumulate in the brain. One is called tau. There are other targets as well. But I would say Alzheimer's is a really tough space. I mean, one of the things that's very hard is you need to intervene very early because it's a very slowly progressing disease. And identifying which patients to intervene on and then figuring out what to treat the patients with is really, really difficult.

6:34On cancer-related drugs, there are some cancer-related drugs, and I guess you have some as well, but they tend to deal with cancer. Once you have cancer, they try to ameliorate the side effects of it or the effects of it. What about something that prevents cancer? Is that realistic in my lifetime? That is something that's a heavy interest of the field and also at our company. We actually just got great data on a breast cancer drug, which can be given to women who have had their breast cancer resected, but then to prevent it recurring. Now, where there's a lot of interest right now is can you identify things in the blood, things are circulating, so circulating tumor DNA, that would show that the cancer is starting to happen in the body, but well before it would be detectable in any kind of scan.

7:15If we can get those tests up to an adequate level of precision and start to treat patients well before the cancer shows up, that would be the big opportunity. But that's still some time away. So you produce medicines that presumably help people with their lives, the better and live longer and so forth. So why aren't you a more popular industry? You know, the private equity industry has its attractors, there's no doubt. But the pharmaceutical industry is not right too far behind us. Why do people not love you for the drugs you're producing? You know, it's a long story in terms of the history of this industry.

7:46Even if you go back to the 70s or 80s, we were a much more popular sector. I think one of the things that happened is as we brought more and more medicines forward and patients got on more and more therapies, the one thing we weren't watching carefully enough as an industry was what was happening at the pharmacy counter. There's a lot of focus in congressional hearings and other places on list prices. But list prices mean very little in the sector because you have pharmacy benefit managers, you have retail pharmacies, you have wholesalers. But what really matters is at the end of the day, when somebody comes to the pharmacy counter, can they afford their medicines?

8:18And we're starting to address that. Some recent legislation addresses it. We're thinking a lot about it. But that's what we've got to figure out how to solve. Let's talk about your background. So your parents came from where? They came from Tamil Nadu in southern India. Okay. And when did they come to the United States? They came in the late 60s and early 70s. And were they educated? They were. They actually, you know, my father was alongside his brothers, were some of the first people in our family to go to college in India. Father did his PhD in India, was able to work his way up, and then was one of the first people to come to the United States.

8:52My mother came to Carnegie Mellon. She did a degree in nuclear, becoming a nuclear engineer. And, yeah, it was, I think, a pretty extraordinary story in that they were able to come from relatively modest beginnings, sort of beginning with my grandparents in relatively small places in India, and ultimately find a way to the United States. So you grew up in the Pittsburgh area? I grew up a Pittsburgh Steelers fan, indeed. And I assume you did well in high school? Did well, did well. So you went to the University of Chicago? Went to the University of Chicago. And why did you go there as opposed to other good schools?

9:24Well, it's an interesting story. I actually applied to all of the IVs and applied to a number of schools. I didn't get in anywhere. Actually, the one school that actually did admit me was University of Chicago. And it ended up being such an incredible gift in the end because University of Chicago, I would still credit, perhaps more than any other educational experience, taught me how to think, how to synthesize, how to be relentlessly curious. It was really positive. Okay. So Harvard, recognizing its mistake from before, admitted you to the medical school, right? They did. And so you went to Harvard Medical School.

9:54I assume your immigrant parents were saying, great, my son is going to be a doctor. Yes, absolutely. So when you told them you weren't going to be a practicing doctor, what did they say? They were very confused. They were very, very confused. You know, I had this idea in my mind. I did a lot of work in public health. I had some great mentors at Harvard. And I really wanted to see how could I have a bigger impact beyond individual patient care. And so I wanted to, I first went to the World Health Organization. Then I went to McKinsey. But all of this time, I certainly think my parents were assuming I was going to go back and do a residency and become a cardiologist and kind of finish the journey.

10:28And it never actually worked out that way. For a while, you were, I guess, a protege of Paul Farmer, the famous doctor who was at Harvard for a while, among other places. And you then did other things to help people in India. You went back working with street children in India. That's right. Right. So did your parents say you have a Harvard Medical School degree and you're making no money in India? India is a great country, but why don't you go practice medicine? My father would ask, I worked so hard to get out of these places. Why are you working so hard to go back to them? It was certainly a confusion he had in his mind.

11:04But overall, my parents were very supportive of this public health goal I had. So you ultimately came to McKinsey after some public health work. And why did you not stay at McKinsey? You know, McKinsey was a great training ground for a physician who didn't know anything about a P &L, a balance sheet, knew nothing about M &A or valuation. I learned a lot very quickly, but I just felt like I was a little bit detached from the real action. And I had an opportunity presented to me to join Novartis Pharmaceuticals to really try to look at our R &D strategy at Novartis at the time. And it was a little bit of a whim, sort of a gamble to try to see how that would work out.

11:42I would have never imagined it would have unfolded the way it did, but it was really great. So you work your way up. And then at the age of 40, somebody at Novartis says, we have a 40-year-old who didn't go to business school, is not from Switzerland, and he's a medical doctor who's never practiced medicine. Let's make him the CEO. That's right. So were you surprised? I was shocked. I was shocked when they first asked me to even be part of it. I mean, I had been head of drug development. I had the opportunity to do so many different roles at Novartis in developing vaccines. I worked in our vaccines division, leading a little bit of our generics unit, working in drug development for many, many years.

12:20And I think part of the reason they were interested is because I had gotten a background in R &D. But I think it was also not only my age, but also the fact that I think no other major pharmaceutical company had an R &D head or a development head as their CEO. Your strategy has been different than the strategy you inherited. Novartis was in many different areas. They had a generic drug business and you sold that. Yes. Why did you get out of that business? It seems to be a reasonably profitable business. As you know, when we have these conglomerates, you have to ask, is there value in the conglomerate?

12:55Is there value in building all these different businesses together? And then the question is, what are we really great at? And when I came into the role as CEO, I looked, we were in consumer health. We were in eye care devices. We were in generics. We had a broad range, a broad portfolio. And I think what our company is really great at is discovering these novel breakthroughs and then getting access to over 280 million patients, which is our reach today, largest, we believe, of any pharma company, to all of these patients. And so in order to do that well, I didn't think we could allocate capital successfully across all of these different businesses.

13:27So we spun Alcon, the largest public market spin in recent memory in Europe. We spun out Sandoz. We sold our consumer health business. It's about$130 billion of transactions later. We come out as a pure play medicines company, which I think we're best positioned for the long run. So you're the CEO and you go to the board and say, you know, we've been in the generics business. We're in the consumer drug business and we're going to get out of all these except we're going to be in the one business that we are now in. Did they say, you know, you weren't qualified to make that judgment or what did they say?

13:56Well, I think they went along and I think they generally were aligned, but I think it also was a stepwise journey. I mean, first we did consumer health and we saw how that went. And then two years, a year later, we did Alcon. Then the pandemic came. Then we did Sandos. Because I think the fear comes back from what we discussed earlier. When you have a business in innovative medicines and you have these patent cliffs, if you have these other businesses which are much more stable, there's a feeling like you can offset your risk. You have stable businesses and then you have this one business where you face these cliffs every 15 to 17 years.

14:29I take the view that the only way you're going to generate enough medicines to keep growing is you focus your capital on innovation. So last week, as we're talking now, last week you made another acquisition, I think for roughly$5 billion. You bought a company that is dealing with blood cancer. So why was that a good acquisition? And how long does it take you to make an assessment of whether an acquisition is good or not? And do you come up with the ideas yourself? Or does some investment banker come along and tell you this is a great idea? So we limit our use of investment bankers in general.

14:57What we try to look at is in the therapeutic areas we're in. So we're in blood cancers. We've been in blood cancers for over 20 years. Some of the most pioneering drugs in blood cancers have come from our research labs. And we say, if this is an area we're in, we have deep understanding. Therefore, this makes sense to actually add another medicine to that portfolio. And so we make that assessment. If it's a good strategic fit, in this case, a good financial fit, we'll make the bet. one of the things we've tried to be much more disciplined on is to try to go at the lower end of the range, under$5 billion for acquisitions, and really ensure that they're in areas we have deep understanding.

15:33Generally, when we've gone too far away from our core, the value creation hasn't been there. In 2023, AI burst onto the scene. Everybody's now excited about AI. How is AI affecting your company? And do you think it's going to help your company? I think AI is going to have a big impact, but I think it's going to take more time than most people expect. I think first, in productivity areas, AI has immediate applications. And I feel like in productivity, we can use AI for document management, document generation. Not really sexy areas, but things that are really tractable. In our sector, most uniquely, the big question is can you speed up or increase the efficiency of drug R &D?

16:12And there we're doing a couple of things, working on clinical trials and optimizing our clinical trials. But the big bets we've made are with Palantir, Microsoft Research Labs, Google DeepMind, and a few other partners to say, could you really discover novel drugs that maybe weren't discoverable without AI? Can you optimize drugs much more quickly? And this is all building on the pioneering work that Google DeepMind did on a technology called AlphaFold. There's a huge opportunity here, but I think we also have to acknowledge that we only understand about 5 % to 10 % of what is going on in the human body.

16:44So to expect AI to use that 5 % to 10 % to extrapolate and come up with big discoveries is going to take time. So other than AI, what medical technologies do you think are coming along that in the next one, two, or three years are likely to change what you do or change the medical world? I think a couple of things. One, RNA therapeutics, as I mentioned earlier in the broadcast, or RNA therapeutics, siRNAs, these are really coming to life now. Now, what this allows you to do is treat diseases that were not treatable or treat them with very infrequent drug dosing. And if you could imagine if we could take on blood pressure and cholesterol with once-a-year dosing, hugely transformative.

17:21Another one is cell therapy for immune diseases. We've seen extraordinary results in early phase studies that if you can reset somebody's immune system, their autoimmune disease actually goes away. And we'll see if this sustains. But these are some of the most impressive results that we've ever seen in early stage clinical studies. And then the last is we're very big in an area of cancer called radioligand therapy. This is the idea that can you bring nuclear particles right next to a cancer in the body and deliver the radiation very locally? And this has the opportunity to treat a whole range of solid tumors in ways that we couldn't.

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18:39For all types of jobs and a variety of reasons, choosing Express Employment Professionals is the move to make this year. With more than 870 locations, find the one near you at ExpressPros.com. That's expresspros.com What do you do to kind of lower your global footprint, carbon footprint? What do you do? Our big topic on sustainability is much more on access to medicines. And so we have a big effort on global access to medicines, trying to make sure our innovations are accessible. The work we do in areas like malaria, on leprosy, sickle cell disease, to ensure populations around the world can get access to these medicines.

19:19How do you pay for that? So it's all part of our sustainability efforts. And we view it as part of our core mission to deliver these global health therapies to patients around the globe. So we have a huge effort in global health R &D. We invest$250 million, actually, in trying to discover the next wave of medicines to treat these global health conditions. What about DEI? On DEI, we're on a good track here. We actually have about 48 % women in management. Median pay for women and of artists is higher than for men. So we have more work to do at the upper levels of the company, but we're overall doing really well, I think.

19:52What skill set do you think somebody should develop in order to rise up to be a CEO? I think the biggest thing I think about is curiosity, just relentless, relentless curiosity. I think whatever position I was put in at Novartis, it was usually a place where I didn't know anything. Had to learn, teach myself, be relentlessly curious, and then apply it. And having experiences in a range of different parts of the business world is going to be a huge success. How many employees does Novartis have now? 76 ,000. 76 ,000, that's a lot of employees. So you frequently get a chance to meet them in some organization somewhere or some meeting.

20:27How do you deal with all those employees? I think the most valuable thing I find in my job is to go around the world and meet our people, be able to have town halls and interactions. It used to be, before we spun off all these businesses, 135 ,000 people. So we've definitely slimmed down. But I think there's nothing that can replace showing up face-to-face and describing why we do what we do. So as the CEO of Novartis, do you tell your subordinates, these are the areas that I think we should work on and see if you can come up with a pharmaceutical product in that area? Or do they come to you and say, we have a prospect here and you bless this?

21:01How does that work? Well, in general, I have a philosophy that we call in our culture unbossed. And we try to unboss our people. We want our people to actually bring the ideas up. And then we, of course, have to challenge them. But then we make the call. So I really believe that in our sector where, you know, some of our scientists are world class. Many of our scientists are world class. They should be bringing up the ideas and we have to curate them. But certainly I'm not sitting on some mountain here knowing what the right thing to do is. So if somebody is saying I'm graduating from college or graduate school in the next year or so and I want a nice career, why should somebody want to be in the pharmaceutical industry?

21:36Why not go into something sexy like private equity or investment banking or something like that? You know, despite some of the things people have, concepts people have about our industry, in the end, what we do is we create these miracles that fit in the palm of your hand, these little medicines that can transform a human being's life. And if you look at the arc of history, in the last 130 years, we've been able to move through the power of medicine, life expectancy, from 30 years to 80 years. We're now able to cure diseases. We're able to give people with debilitating disease their lives back.

22:09So if you're part of that kind of enterprise, you can get up every day knowing you're moving the needle for society. You're moving the needle for mankind. I think we do reimagine medicine with the medicines we create. I think that's a pretty inspiring way to spend your time. So suppose a president came along to you and said, I know you're living in Switzerland, but you'd be great to be the secretary of health and human services or head of the FDA or something. What would you say? I would think hard about it. At the moment, it would feel like a really daunting task given the politics. But on the flip side, I do think public service, of course, has so much power.

22:44And I think if you're in the right context, you could do a lot of good for the world. But I think it's very context dependent. As you know, it can be a very short time in some of these roles with some of the recent cabinet members. Suppose I said I'm a stock market picker and I want to be buying good stocks and companies that are going to grow and so forth. why should I want to invest in the pharmaceutical industry? Is it going to continue to grow as it did last year? And what about your own company? Do you think it's going to have good growth prospects over the next couple of years? We do. We've signed up for 5 % plus growth, 40 % plus margins, and very consistent growth over time.