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If Design Govern in a Thing So Small

It will not have escaped the notice of most readers of this site that biopharma stocks have been up strongly since the election. I don’t recall anyone predicting that, but (like most predictions) it works pretty well in hindsight. I think that investors are betting on new corporate tax laws that will make it easier for the larger companies to repatriate foreign earnings, which can then be used for US operations. And one of the things one might do with this cash, if one is a large enough drug company to have significant offshore earnings piled up, is to start acquiring smaller companies.

That would seem one likely reason for the market’s behavior, and another one might be the expectation of a rather more tolerant FDA. I’m not sure where that one is coming from, other than a general feeling of “Hey, Trump’s a crazy laissez-faire guy and knows nothing about drug approvals”. The second half of that statement is surely true (although it’s just one tiny item in a very roomy duffel bag), but I don’t think that the first is. Remember, the guy comes from a real estate development background, which is not exactly a wild free market situation. In a big city, there are a finite number of places to build new buildings, and an even more bounded number of places where you really want to build a new building. Being able to realize a large project like that takes not only a willing seller and plenty of money, it also takes the time, money, and experience to navigate through what can be a maze of applications, permits, statements, filings, hearings, and negotiations with a whole list of government agencies and non-government interests.

The real estate background goes a long way towards explaining what seem to be two key parts of Trump’s worldview: everything is transactional, and everything is zero-sum. The world, in this picture, is made of of deals, nothing but deals, and in these deals someone has to win and someone has to lose. There’s no other way. Trump’s statements on trade and the economy, as far as I can tell, all spring from these ideas. This all makes some sense for a real estate developer, but doesn’t necessarily apply as well to other fields of human action.

So, insofar as he thinks about the situation at all – and he has plenty more to think about – Trump would probably look on drug regulation and drug approvals as similar to the real estate market. It’s like a building permit – you want to put up something on this spot, you go to the agency that tells you whether you can do it or not. (In real estate, you spend the money after that part, and in drug research you spend it before, but that just tells you that the real estate business makes more sense, right?) And those FDA approvals, if seen through the goggles of zero-sum deal-making, are not about science, because nothing is. You can’t evaluate whether one particular real-estate proposal is “more efficacious” than another one, not to any objective standard, nor whether it’s “safer” for the city or its economy. These considerations really don’t come in – did you get the approvals, or not? Do you have the financing, or not? Do you have the contractors lined up, or not? And so on.

So the sort of FDA commissioner, and the sort of FDA, that a Trump administration wants might be hard for many of us to get our heads around. But rather than speculate on in that way, I’d like to bring up a much more likely possibility: that this is so far down the new administration’s list of priorities that they’d just be looking for someone reasonably reliable who won’t screw things up and turn the agency and its actions into a liability. This administration has an awful lot of spots to fill and a steep learning curve, and honestly, I don’t think that the FDA commissioner’s job, and FDA policy in general, will be priorities. Not for some time. We may well be revisiting this issue later on, but for now, I can’t imagine much in the way of big changes. The counterargument to that is that it’s very hard, at this early stage, to predict what the incoming administration might do – and that really makes you wonder about the market going up. Don’t markets hate uncertainty? Might investors just as suddenly decide that none of these reasons are as solid as they look?

But overall, the here-comes-the-cash rationale for the biopharma run-up, then, might well be rational. (Is it going to be a good thing? Totally separate question.) But betting on a different kind of FDA seems to be premature. If I were putting money down on it, and since I work in this industry, I am, I’d bet that things are going to go on in about the way that they are now, for better or worse.

Bonus liberal arts moment – feel free to skip! It’s just that after writing about what’s going through Donald Trump’s head, I feel the need for something completely different, as the Monty Python guys used to put it. My thought that the FDA might be so far down Trump’s list of priorities that he won’t pay attention to it recalls Randall Jarrell’s excellent discussion of Robert Frost’s poem “Design“. Frost recounts seeing, early in the morning, a spider sitting on the top of a white flower, holding up the wings of a recently consumed moth. He’s actually shaken by the sight, since it looks to him like a crude, blasphemous burlesque of a religious ritual. The poem ends:

What had that flower to do with being white,
The wayside blue and innocent heal-all?
What brought the kindred spider to that height,
Then steered the white moth thither in the night?
What but design of darkness to appall?
— If design govern in a thing so small.

As Jarrell points out, that last line is a stinger indeed (and it shows the remarkable compression of meaning that the best poetry can provide). Frost has spent the whole short poem describing the scene and its uneasy contradictions. He wonders, if God’s eye is indeed on the sparrow, why he would arrange such a sight? If Nature is indeed evidence of a Design wrought by a divine hand, what does one say about a Divinity who sets up ugly jokes like this one?

This is the problem of theodicy. People have asked themselves the exact same question while standing next to concentration camps and terrorist explosions. One such event, the Lisbon earthquake of 1755, helped to charge up the Enlightenment: the spectacle of the most God-fearing city in Europe being hit on the morning of All Saint’s Day by a massive earthquake (between 8.5 and 9.0 by modern estimates), set on fire, and then having the flames extinguished (well, partially extinguished) by a tsunami was indeed hard to explain in terms of a just and loving God.

But Frost has something even more unsettling in mind. Maybe, he says, Design isn’t even at work here. This could have been just an accident, taking place below the level that a Deity would bother about. But don’t look for comfort in that, though: the unspoken implication is that all of human affairs, when seen from the Divine level, might also be below the threshold of notice. Theologically, an indifferent God is rather a poisonous concept, because indifference is hard to distinguish from nonexistence.

Going from a flower and a spider to such topics makes me think of fractal recursion, the near-repetition of a given motif across a huge range of scaling. Tiny Mandelbrot-set shapes appear in the boiling mathematical froth that comes off the edges of larger Mandelbrots, which are themselves motes off the edges of still larger ones. A brief glance at a flower leads to thoughts about the nature and existence of God (William Blake knew this too). Perhaps that’s a way out of Frost’s second dilemma – there may be no scale small enough to escape notice, because the same issues are present in all of them. A religious person might well say so, but a religious person would already see evidence of such notice being paid at our own scale, and wouldn’t need such a rationalization in the first place. Would they?

87 comments on “If Design Govern in a Thing So Small”

  1. Bagger Vance says:

    Shorter: “I need to show off how smart and well-educated I am, while I disparage someone (who successfully waged a campaign against virtually everyone and won) else’s intelligence.” I wonder why there’s not more scientists in politics? I’ve always been impressed with how much they think they know about all fields once they get their super-specific credentials.

    For someone who hates to talk about politics Derek has certainly developed a taste for it recently.

    1. NHR_GUY says:

      Bagger, might I direct you to the book “The Talent for Stupidity: The Psychology of the Bungler, the Incompetent, and the Ineffectual”, especially the chapter “The Incompetent”. Your lashing out has all the hallmarks of those described in this chapter.

    2. Derek Lowe says:

      Bagger, you sound like someone who has far more important things to do than read the posts here, much less leave comments on them. Back to work!

      1. Bagger Vance says:

        At the risk of declining your offer for the moment I find the salt mines here afford me a quick ten minutes for lunch and internet.

        I should be more circumspect posting “early” comments but I actually agree with the major point(s): drug industry/policy (not being in a crisis to the greater world) is a pretty low priority for the new administration. However after last week’s characterizations the question of “knows nothing” with “a very roomy duffel bag” sounds to me like a quick swipe at intellectual capacity–but perhaps only a “full plate” was intended. Combining that in quick succession with one of his literary excursions looked very much like a person trying to re-establish their Coastal Elite credentials in the fear of being associated with their Red State origins. If I’m just seeing ghosts here fine, that’s on me, but the trope of Republicans being comparatively mentally deficient (ah, I see I’ve gotten some Dunning-Kruger responses, good demo) is an old and tired one.

        I keep wondering if Derek feels the need to distance himself from the election and it’s winner to survive in a political climate so polarized. I imagine as a center-right libertarian one can find oneself a pariah if steps aren’t taken to disassociate himself. Don’t the rest of you have a facebook feed that consists almost entirely of crying and threats to boycott anything associated with Trump or the Repubs?

        1. Derek Lowe says:

          I understand your arguments, but I’ve been a longtime Republican voter (until this year), which doesn’t exactly get me in good with the power elite of Massachusetts (or the other coast, either, come to think of it). If I’m distancing myself from the election, it’s more for mental health reasons than anything else.

          1. Hap says:

            That’s mostly why I’m not on Facebook – though, to be fair, it’s mostly the foaming dishonesty the other way. I imagine I just haven’t seen enough liberal froth because of my wife’s preferences. If I want it, I know not to come here, and I don’t want it.

            Higher-level art is supposed to work on multiple intellectual levels. If you don’t like it or don’t care about it, then you can leave it. If it makes you feel inadequate – that someone’s flaunting their education by displaying and discussing it – then its disappearance is not really the solution to the problem. If you perceive arrogance based on intelligence, the solution to arrogant knowledge is the same as the solution for bad information – better information and logic, not less of them.

    3. Z says:

      Bagger, why do you feel that someone who has different interests and opinions than you do is “showing off”?

      1. anon says:

        Ooh, I know! Because Derek was too lazy to present his love of this beautiful poem in the form of a comic strip that would make Chick tracts look like high art.

    4. Barry says:

      Bagger seems not to comprehend that this is Derek’s website. Bagger is free to post whatever he likes on his own website; he gets no veto on Derek’s content.

    5. Anon says:

      I agree w Bagger – there’s been a lot of talk about politics always following the disclaimer, “I dont want to talk about politics, BUT…” and away we go.

      1. Derek Lowe says:

        As it affects the drug business, it’ll come up (as it has before around here, from time to time). My pre- and post-election posts were more free-floating nothing-but-politics ones, and that sort I hope very much to avoid.

      2. Hap says:

        Probably because everyone knows political discussions have been unproductive and dishonest but noisy. Unfortunately, significant changes to the FDA would be directly relevant to Dr. Lowe and lots of the people who read here (and lots who don’t). Whether or not political discussions are distasteful or annoying, they aren’t avoidable in this case. Reality is what doesn’t go away when you ignore it, and the consequences of political decisions, particularly if they are based on bad or incomplete models of operation, are likely to be unignorable.

    6. Earl Boebert says:

      My guess is that this site has landed on an alt-right “to be harassed” list as a consequence of Derek’s post the day before the election. If so, we can expect more Baggers showing up, not to convince anybody, but to attack individuals, change the subject if a thread strikes a nerve, and drive away participants.

      The only solution for this is moderation. This takes time and attention, and for many one-person sites it becomes too much and the site shuts down, which is, of course, the trolls’ objective. I’m a moderator several sites, and I would estimate it would take three people to keep comments here clean. Just an observation.

      1. PUI Prof says:

        Bagger is a semi-regular here.

    7. himalayannacl says:

      As a young scientist with his hand on heart, I can say I know very little about market trends and make no attempt to predict their movements. I would like for this to change. Nor would I venture to make any big calls on how a political strategy may unfold. I suspect this applies to many other scientists, also. But Derek not only has a vested interest in the area, he has run a blog for many years on the pharmaceutical industry that pertains to politics and markets, whether you like it or not. I am glad that he engages in these very relevant topics.

    8. He was 2% more successful than smart money predicted. I suppose that means that his administration will be 2% less chaotic than is being reported.

  2. johnnyboy says:

    I think the market’s reaction has less to do with Trump-enthusiasm than just a modest recovery from the effects of Hillary-fear about drug pricing. The indices are still well below what they were a year ago.

    1. Mr. Rogers says:

      I agree that this is the major driver of the runup. The recent news of predatory pricing by some generic manufacturers was tailor made to justify an Obamacare add-on that would fix drug prices. With that political risk reduces, the price of drug stocks can go up.

    2. daisyj says:

      I think you’re right that this is most of it, plus a touch of the tax thing and a general feeling of “something has happened, so we need to react in some direction.” The market started going up, so that must mean this is good news, so up we go.

  3. Directly from Trump’s Contract with America:

    Repeal and Replace Obamacare Act
    Fully repeals Obamacare and replaces it with Health Savings Accounts, the ability to purchase health insurance across state lines and lets states manage Medicaid funds. Reforms will also include cutting the red tape at the FDA: there are over 4,000 drugs awaiting approval, and we especially want to speed the approval of life-saving medications

    1. Derek Lowe says:

      And where that figure of 4,000 drugs awaiting approval comes from – anyone?

      1. Anon says:

        Well, technically every single drug in development is “awaiting” approval.

        1. Anon says:

          PS. Whether or not these drugs actually work is obviously not on Trump’s mind, and clearly he sees the FDA’s rejection of many drugs that don’t work as just unnessecary “red tape” that needs sorting out.

      2. Anon says:

        No source available, but the number could only include all human, vet, generic, and probably devices (everything everywhere at FDA, maybe even including the sparse regulation of supplements under ? Generic approvals were ~1000+/year in the last 4 years (STAT news), and it is too small to include all labeling changes?

      3. Anonymous FDA branch chief says:

        I believe the ‘4000 drugs awaiting approval’ comes from the old ANDA backlog before GDUFA was enacted. With the hiring of new reviewers, there basically is no backlog anymore. There may be even several thousand ANDA’s that got complete response letters instead of approvals, and the generic companies must fix the quality concerns in those applications before they can be approved. (Can’t be for efficacy or safety, generics cross reference the NDA for that data) This is not confidential, there are plenty of public slide decks out there that explain this. I don’t know how drugs can get approved faster, NDA’s already have a 10 month review clock, 6 M for expedited reviews or breakthrough drugs. ANDA’s also have a 10 M clock now, and with implementation of GDUFA II there will be a 6 M clock for 1st generics or drug shortages. Do you think maybe the public gets confused that the FDA does not actually develop drugs, only companies do that, and that it is really hard?

        1. Derek Lowe says:

          I tend to think that there is no limit to lay confusion about where drugs come from and how. . .

          1. 404 file not found says:

            Speaking of which, here’s a question I got from a cab driver once: When you go to the drug store, and you give the pharmacist your prescription, and he goes in the back, and twenty minutes later he comes out with your drug… was he making the drug? or just counting pills?

          2. Slurpy says:

            Sometimes both (sorta). Sometimes you need something compounded, so you go to an actual pharmacist, not just the ones with hands tied at CVS or Kroger (King Soopers for you Westerners).

    2. Hap says:

      Releasing lots of potential drugs to the market only helps if they do something and you know what they actually do. If you can’t tell if a drug works or what its effects are if it does (*cough* etiplirsen*cough*), then you haven’t really helped patients – you’ve given them lots of new guns to play Russian roulette with, and their insurance companies either headaches from paying for them or dodging paying for them, but you haven’t necessarily given medicine new tools or patients new life. If the trials aren’t finished (or haven’t given you sufficient data to tell if the drugs work), then to release them means either not getting data that you don’t have yet as to whether they work, or to ignore data you have that says they don’t. Neither of these sounds like a good idea.

  4. Chrispy says:

    All of us in the industry recognize that it is broken in fundamental ways. The USA pays far too much for health care and drugs and gets far too little in return. On the flip side, the price gouging does enable the world’s most productive drug discovery engine even as it also pays for corporate jets and embarrassing executive compensation. This past election was clearly a call for revolution, and revolution is long overdue in our industry, but it has become such an interconnected patchwork of issues that ham-handed fixes will have consequences that are difficult to predict. Even something as “simple” as trying to control prescription drug prices will drive down the value of R&D, with a potentially chilling effect on drug discovery, particularly at the startup companies that rely upon being able to strike it rich as a way to attract investors.

  5. Philip says:

    I would guess the new head of the FDA is going to be the ghost of Andy Grove.

    I do think the run up is due to the belief that there will be less regulation of mergers and drug pricing than with HRC. This is not a political post because I have not stated if less regulation is good or bad.

  6. Fenichel says:

    Trump seems to be considering various appointments of people who were helpful to him during the campaign (e.g., Bannon and Giuliani). For FDA Commissioner, he might turn to Dr. Oz.

    1. Humble Scrivener says:


  7. 10 Fingers says:

    The shift in biopharma stocks is really quite striking (^BTK is up much more than most large pharma stocks, and some of the smaller public biotechs are up c.a. 50% since the Friday before election day). I originally thought that this was more about relief over the waning probability of price controls. However, I think the suggestions that M&A movements might be unleashed specifically and that anti-trust sentiment might be reigned in generally make a lot of sense. Might be more “value engineering” for stockholders, but it seems hard to imagine that it will have any benefits for patients or those of us working to make new medicines. Applying a “sloganeering” approach to the challenges of reforming the regulatory environment is liable to do more harm than good, in my view.

    And, Derek, I very much appreciate your wide-ranging and interesting remarks! It has been hard to control the path of reflection, these days. I have found that it doesn’t take long before my train of thought derails and meanders off a distance in an unexpected direction….Thanks for providing some context and sanity, and for building a home for critical thought.

  8. Humble Scrivener says:

    Theodicy risks being a self-injurious activity in most any century; I avoid reading some of its formulations lest I end up with less faith or less reverence than before. There’s more space for human and cosmic going-on-being in a fractal divine attention span.

  9. MoMo says:

    Here’s what I hope the Trump admin does:
    1) Get the prices of drugs down to what other countries pay- we have been raped enough by higher prices
    2) Stop the flow of technology to Communist countries through CRO entities. Every drug we make is subsequently knocked off and counterfeited anyway so why give them a start. And tax the US companies that hire off-shore CROs for so that it makes them think twice.
    3) Stop direct to consumer advertising. Children don’t need Viagra commercials during cartoon hour, and we as Americans are severely overdrugged anyhow.
    4) Stop the flow of illegal immigrants that started with the recent Democratic parties. Coincidently, the heroin and overdose epidemic started with the Obama policies and 95% of all heroin comes from Mexico.
    5) Limit the amount of donations Drug companies can donate to political candidates. You want to see who is influencing who-go to Opensecrets dot org and type in your favorite drug company.

    That’s enough for now.

    1. Frank says:

      1) Other countries have lower drug (and wider healthcare) prices because of universal health care and the negotiating power that comes along with it. Specific laws and xenophobia aren’t going to change the drug pricing situation in the US. I imagine you think that is too “socialist” though.

      2) Unnecessary communism mentions aside, yes this would be nice.

      3) Yep, that is necessary.

      4) Lol.

      5) Absolutely, and not just from drug companies but ALL companies. But, political donations aren’t going to be stopped without support from the major political parties.

        1. Frank says:

          And that has what to do with Democrats exactly?

          1. MoMo says:

            The Democratic government under Obama allowed the relaxation of the borders, and with it came tons of heroin that flooded the streets of the USA. Go look up the subject yourself on the amount of heroin seized at the border- it escalated during this time period 2009 on. Meantime in Canada it stayed the same .

            In an effort to allow illegals into this country, to become future Democrats the Obama administration coerced the flooding of the USA with cheap heroin along with cartels that invaded the rural and destitute cities of America.

            But read for yourself where heroin seizures at the border tripled after Obama took office. Those are the drugs that got in- imagine what didn’t. Seizure rate is only 4-8% on a good day.

            One other weird thing happened. The DEA stopped publishing these statistics the year Obama took office- Why?


          2. Frank says:

            Again, lol.

          3. Phil says:

            Momo: Maybe the supply is coming from Mexico, but the demand comes from overprescription of opioids.

            “At the time, it wasn’t understood how addicting these prescription pain medications were,” said Michelle Lofwall, associate professor at the Center on Drug and Alcohol Research at the University of Kentucky School of Medicine. “But they really hurt people here and across the nation. These were not safe medications with no abuse potential.”


            Also John Oliver had a good piece on it, if you’ve got 20 minutes to spare watching it.


        2. Phil says:

          MoMo: I assume you’re a scientist and should therefore know that correlation does not imply causation. The most likely cause of the heroin epidemic (and now fentanyl, coming in from Canada primarily, not Mexico), is the overprescription of opioids.

          John Oliver did a pretty good piece on it as well.

          1. MoMo says:

            Know all about it Phil. We all know who the legal drug pushers are and why they are allowed to do it.

          2. drsnowboard says:

            The BBC version

            bloody liberals, coming in here with their facts…

          3. Phil says:

            MoMo: If you know that 75% of heroin addicts started on prescription opioids, why is trafficking from Mexico your first scapegoat? It’s not like the cartels are taking out Superbowl ads for heroin. Addicts go looking for the illegal drugs after they’re already addicts.

            I’m not defending them, but traffickers increased the supply to keep up with demand. They are not the ones creating demand.

      1. FriendofMoMo says:

        Death funny to you Frank? You a Democrat or a Communist?

    2. Ted says:

      You lost me at “rape as a rhetorical device.”


    3. NoNo says:

      @2: Hey India is not a communist country, although it could also do what you mentioned, so wtf.

  10. MoMo says:

    Forgot a major, major issue affecting our US children.

    6) Send in trained mercenaries and assassins to take out the owners and labs that are flooding the streets with legal and published yet antiquated drugs found in the literature that are killing our children by mail order.

    1. c says:

      Derek’s blog is attracting a whole new readership lately! How exciting!

      1. johnnyboy says:

        Nah, MoMo’s been here for a while, he’s the resident crazy uncle in the basement. Been silent for a while, but it looks like he’s off his meds now.

        1. Kent G. Budge says:

          I know of no better reason for skepticism about the efficacy of our antipsychotic medications than the comment threads at most Internet sites.

        2. MoMo says:

          Better to be crazy than follow the herd johnnyboy. Have a good time when its your turn to lemming yourself off a cliff.

          1. drsnowboard says:

            …and that would be because Disney convinced you that was what happened.
            The power of media eh?

          2. Hap says:

            I wonder if it’s some sort of online interview for upper management at Breitbart?

  11. MoMo says:

    How wrong you are C- been reading and posting here for years. Nothing has changed either. Maybe with Trump now it will.

    1. MoMo says:

      Glad you are up on your Disney myths Snowboard. You wearing your princess dress too?

      1. drsnowboard says:

        It does seem to be a characteristic of pro-Trump supporters , that they do like to lapse into ‘insults’ when anyone points out a flaw in their postings. An ugly, innate, trollness.

        1. FriendsofMoMo says:

          You are the one bringing up Disney and snide remarks aimed at MoMo. Besides MoMo being funny youll need to find a safe space now.

          1. drsnowboard says:

            You kind of make my point by replying. Well done.

          2. Drsnowboard says:

            Having now read up on ‘safe space’ and acknowledging that probably momo assumes I’m male and hence a princess dress is outside his norm , I can just say you guys have the best words , I mean everyone acknowledges you have the best words , we all know that , am I right? Of course I’m right .
            To paraphrase, first they came for the Mexicans , and you said nothing…

        2. MoMo says:

          Don’t melt down on this blog Snowboard, you are blathering again about nothing.

          The FDA is the least of Pharmas worries. I’d be worried by those large donations to the Dems so that they leave high cost drugs alone. Plenty of execs outside the 95 beltway are sweating this out, screaming in their sleep, and wondering when Trump will expose them. And the sooner the better.
          So stop the crying and get to work America! Some of us work hard to innovate, keep your sorry asses employed, and add to the economy and its not by blogging-that’s for sure.

          1. drsnowboard says:

            ha, I wouldn’t trust you to pull the magic beans out of your arse with both hands. You are the A in alaskan pipeline. Good luck with your innovation fairytale.

  12. loupgarous says:

    One thing Trump could do is vet his short list of nominees for FDA Commissioner for holdings in Big Pharma. Obama either didn’t do that with Margaret Hamburg (married to a co-CEO of Renaissance Technologies, which had huge holdings in Johnson & Johnson, just in time for blacx-boxing of fluoroquinolones like J&J’s Levaquin (through one of their subsidiaries) to be considered.

  13. loupgarous says:

    finishing that thought (typing this in the shotgun seat of my wife’s Nissan Versa on the way back from New Orleans), “…or Obama didn’t care that the woman he put forth as FDA Commissioner, who told the Senate she had no conflicts of interest actually was married to someone who stood to lose money when the fluoroquinolone antibiotics were black-boxed, or greater restrictions placed on their use.”

  14. IRS says:

    I think the other highly relevant policy is the promised repeal of Obamacare. That said, I would not care to bet money on what that will look like, even if he does stick to it–I doubt there is a way to just roll back the regulatory framework to 2009. More likely, I think, is a combination of new law and repeal of some of the funding and most consumer-visible features (such as the individual mandate and cadillac tax), and I do not see that as a surefire windfall for any part of the industry.

    1. Frank says:

      The answer is universal healthcare, but its far too socialist for the GOP and would be bad for pharma profits in general. Bad for a lot of the people visiting here too job-wise, but good for everyone else and the economy.

      1. Emjeff says:

        Interesting how, after a government programs fails in spectacular fashion, so many people think the answer is more government programs…

        1. Frank says:

          Interesting how, when something has worked for so many western countries and saves them money and improves health access and results, so many people think that it’s a bad idea…

          1. Nick K says:

            People who actually live in Europe are often rather more cynical about universal healthcare than one might suppose. Many healthcare systems such as the French and the British are close to bankruptcy.

          2. Frank says:

            Of course people question the system in place if they feel it isn’t perfect. That’s not an argument for or against the system.

            The US spends even more than they do per capita on public healthcare while covering less of the cost. The US spends the same amount again on private healthcare, far and away the highest spend per capita in the world. You could effectively give everyone in the US with healthcare (or their employers) on average ~$10,000 dollar per year pay rises if you could get the same efficiency. And that’s without considering the fact that the US is getting worse patient outcomes than either country in spite of the higher spend. 50% worse infant mortality, 2-3 years lower life expectancy than both countries.

            The UK and France would be in a far worse position with the US system. The US having a stronger economy and being willing to spend a higher proportion of GDP on healthcare is the difference. That’s money that could be straight-up saved with at worst no difference in outcomes.

            *All data is from the WHO.

          3. Emjeff says:

            Well, yes, when the people in those countries dislike their system and in fact carry private insurance, if they can afford it. This fact, of course, is never mentioned by anyone favoring socialized medicine.

          4. Hap says:

            Website didn’t like the linkage, so…

            1) Less than 9% of Britons carried private insurance as of 2014 (and that fraction was decreasing. (

            2) Canada and France, for example, use hybrid systems – the government pays for major healthcare, while private insurers cover the rest. Both those systems are explicitly designed as such, so private insurance expenditures don’t necessarily imply dissatisfaction with the healthcare systems (in the expat article on France, for example, France’s healthcare system has a high level of satisfaction).

            3) Complaining that Obamacare is a three-legged, flatulent, mean, useless mule (from Jonah Goldberg, via Dr. Lowe) is somewhat disingenuous when the people following your policies were responsible for cutting off the fourth leg.

          5. Tom Womack says:

            People in the UK don’t often carry private _medical insurance_.

            They will quite often use private hospitals for elective procedures, paying for it out of savings or on a credit card, because the queue for a cataract operation on the NHS is the order of a year whilst in a private hospital you can get it done in two weeks for a single payment of £3000 or so.

            The American horror is that common but serious medical conditions – heart attack, pregnancy, cancer – can bankrupt you; that’s much less of a problem with an NHS.

          6. Hap says:

            Sorry. I guess that makes this a “Scylla or Charybdis” issue, Maybe your position depends on what option you fear most or least, or maybe the one you don’t know.

          7. Dionysius Rex says:

            The German healthcare industry (from hospitals, through to doctors and all the way down to Apothekers) is a totally corrupt and horrendously expensive mess of quackery, unnecessary treatment-pushing and institutionalized robbery. Not something I would recommend the US model any new system on.

  15. Emjeff says:

    I think the FDA will not rate as important enough to see any serious reforms. That, in itself, might be cause for joy- we might be left alone for the next four years.

  16. Wallace Grommet says:

    Mexico was festooned with posters featuring Obama imploring Mexicans to come to the US to become democrats. He had to beg them because Mexico is a workers paradise. But who can resist the siren call to leave home and hearth to vote in US as a democrat? These cranks posting propaganda are akin to giving someone a box of a nails ansd saying, “look,I bought you a house!” Begone, ye smarmy
    sophists of skullduggery

  17. AndyM says:

    The strong bump in biopharm was due to the specter of Ben Carson serving as Secretary of Health and Human Services 😉 But Ben declined the offer … thank you, Ben Carson.

  18. Anon says:

    My guess is Trump won’t do much or anything with the FDA, but he’ll screw up a lot of other things with healthcare and the Dems will come back with a vengeance and their own extreme populist policies that will finally pop the US drug pricing bubble.

  19. sudaka says:

    I see the results of this presidential election impacting society in a similar way to what happened in pharma as more beancounters and fewer scientists have influenced the decisions made in our industry.
    The results for us, the people, are fewer jobs for scientists in the US, which leads to less innovation.
    The “low-information” nature of our elected political leaders has to have an impact, sooner or later. The time is near…

    Oh well… it was nice while it lasted…

  20. Vader says:

    “The world, in this picture, is made of of deals, nothing but deals, and in these deals someone has to win and someone has to lose. There’s no other way.”

    I think you’ve sized Trump up pretty well, Derek. And, if you’ll forgive me for a further political observation, this is not at all a conservative or classical liberal position, since the kind of economics both support understands that a deal can be good for both sides. They can both be winners, and usually will be, in any system tending towards Pareto efficiency. But I’m not sure Trump really understands comparative advantage.

    It is, however, a position popular with the extremes of both the political left and right. Which can be surprisingly hard to tell apart, at times.

  21. Tom Garnett says:

    Dear Dr. Lowe,
    Please continue doing exactly what you have been doing with this blog for so many years. I have learned so much from you about chemistry, pharmacology, drug development, the drug company market, and the difference between human design and natural selection. And your “meanderings” to Robert Frost and fractal reality are especially welcome.

  22. Hap says:

    I imagine another solution is to assume that the story is incomplete – that there are things not understood that would explain why the moth was eaten, and that there is a sensible and not evil narrative for it. We don’t like not knowing things, though, and assuming that we don’t or can’t know what is going on around us can be a license to do what we want and hope for the best, a sort of selfish disengagement from the world.

    Indifference could be confused with nonexistence, but sometimes it could also be taken as an indication of a universe run by someone who doesn’t like us much, That is also less than comforting.

  23. MCS says:

    With two wars ongoing, three or four more a possibility, The FDA, NASA or the Parks Service don’t come near the priority that deserve notice in the first two weeks of a competent administration. Short of the whole sale carnage, it’s not realistic to believe that any choice of administrator will have an effect over a period of years.

    While some of us might look forward to such carnage in the Justice Department, for example, the FDA is functioning. While there are no shortage of people that would tear down the whole thing and start over, the most likely candidate will want to nibble around the edges at most.

  24. Rich Rostrom says:

    “…Trump’s worldview: everything is transactional, and everything is zero-sum. The world, in this picture, is made of of deals, nothing but deals, and in these deals someone has to win and someone has to lose.”

    ISTM this is exactly wrong. “The art of the deal” is finding an outcome that benefits both parties. Robbery by force is not a deal.

    Also, there are reasons for the elaborate permitting system around construction: every construction project has secondary effects which have to be considered, and every construction project has serious potential risks from quality failure. I would be very surprised if Trump doesn’t understand both of these factors very well. AFAIK, there has never been a significant quality problem with any of Trump’s construction projects. (Surely it would have been reported in the last three months.)

    So I don’t think Trump is quite as unfamiliar with the sort of constraints that affect pharma (and reasons for them) as our host fears.

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