In This Episode
The United States is on the cutting edge of prescription drug research and development, so why are we overpaying for life-saving drugs? How did we get to this point? Dr. Abdul El-Sayed explores the history of the Hep-C drug Sovaldi and inner workings of the pharmaceutical industry, investigating the glaring flaws in the system.
ABDUL VO: I want to tell you about my grandfather. His name was El-Sayed; he’s the person from whom I get my last name. He sold vegetables in a fish market in Alexandria, Egypt from the time he was in 8th grade – fending for himself and his family after his own father passed away.
I remember watching him when I was young – haul sacks of burlap bags full of potatoes with one arm, and heave them onto trucks. He was the toughest guy I ever met.
My grandfather died of Hepatitis C – a deadly infection of the liver, the organ that purifies your blood. Hep C affects 71 million people worldwide – it’s one of the most common infections in the world. It’s a silent killer – it works slowly over time, hardening and destroying your liver through a process called fibrosis.
Until recently, Egypt had the world’s highest prevalence of Hep C. One in 10 Egyptians had the disease. Now, it’s on the verge of eliminating it altogether.
See, my grandfather died in 2004 – but had he been able to hang on just a few more years, he would have had access to an incredible, life-saving drug. But only if he had stayed in Egypt.
In America, it’s nearly 10 times as expensive.
ARCHIVAL: News pieces about Sovaldi – miracle cure that is incredibly expensive for patients in the US…
ABDUL VO: And it’s not the only medication that’s way too expensive in America.
You’ve probably heard about Martin Shkreli – the crazy-eyed pharma bro – now serving 7 years for securities fraud. His company spiked the price of a drug called Daraprim, used to treat AIDS, malaria, cancer – by 5000%.
ARCHIVAL: Shkreli in jail…
ABDUL VO: There’s no doubt that he’s the worst. But the crazy high costs of prescription drugs is bigger than one asshole who could care less about the people who use the medications his corporation manufactures. You’ve probably also heard about how an EpiPen, which you need to save your life if you have an allergic reaction – now costs six times as much as it used to because of the antics of its manufacturer Mylan.
ARCHIVAL: EpiPen madness…
ABDUL VO: Or you may have heard about how people with diabetes are now having to ration their life-saving doses of insulin because they simply can’t afford it.
ARCHIVAL: Insulin prices sky-high…
ABDUL VO: Seriously, what the fuck is going on with drug prices in this country ?
This is America Dissected with Abdul El-Sayed, I’m your host.
- SERIES TITLE AND THEME
INTV – ABDUL: [04:40] I’m really excited… to have you for this conversation and you were sort of… the guy who came up when we were talking about drug prices.
I was like, look, I’ve got a friend who’s an expert on this issue and when it comes to the political economy… of a really interesting case study, nobody knows it better. So thank you for agreeing to take the time and share your expertise with us. Really appreciate it.
INTV – ROY: Definitely. Yeah.
INTV – ROY: [10:05] My name is Victor Roy. I’m a medical resident at Boston Medical Center and a sociologist who studied the political economy of drug pricing, especially with this case of hepatitis C
ABDUL VO: Victor and I go way back to grad school. We were both on the same grad school fellowship, through the Paul & Daisy Soros Fellows program. I’ve always admired his take on complex issues – about how health factors into our daily lives. Victor’s going to be our guide through the winding story of Sovaldi and Hep C in the United States–and the maze of drug development and drug financing that it follows.
But first, some basics.
3.5 million Americans currently live with Hepatitis C, making it the most common infection in America. Like we talked about up top, Hep C slowly destroys your liver over time – and without proper treatment, it can kill you. For a very long time, the only available treatment for Hep C was an injection you’d have to take almost every day for months. It wasn’t very effective–and it had awful side effects. Patients would wind up in the hospital all the time. Nobody liked it.
INTV – ROY: [14.48] The side effects were sort of akin to cancer chemotherapy, so things like hair loss, fatigue and and just really feeling in a malaise often times with that treatment.
ABDUL VO: But in 2013, Sovaldi hit the market, and completely revolutionized Hep C treatment.
CLIP: Sovaldi hits the market
ABDUL VO: Sovaldi – a daily pill – attacked the Hep C virus right in the bloodstream – no more injections, no more massive side effects. Treatment that used to take many months of regular injections and many trips to the hospital with no guarantee of cure was now reduced to an 8 week course of once-a-day-pills that were almost always effective.
Sounds great, right? No more Hep C…or so we thought.
INTV – ROY: [16.08] When the drug came to Market in 2013 the launch price… was set in excess of $80,000.
ABDUL VO: Uh… let’s rewind that tape.
INTV-ROY: [16.08] [SOUND DESIGN: PLAY SLOWLY] … $80,000…
ABDUL VO: Gilead, the manufacturer of this revolutionary Hep C drug set the price of an 8 week treatment of pills at $84,000 dollars. The cure to Hep C would cost more than a college education. Who the hell could afford that?
INTV – ROY: [17.01] The health systems essentially buckled under the numbers that they were seeing and the costs they would have to their budgets.
ABDUL VO: The price of Sovaldi was so god damn high that if every Hep C patient got treated, the total cost would’ve bankrupted nearly every state Medicaid program in the country.
So they made a decision about who could receive the treatment. And who couldn’t.
INTV – ROY [17.10] And… so what a lot of Health Systems did, particularly Medicaid, the prison system, was to restrict access to the treatment. To the later stages of what’s called fibrosis – the scarring of the liver – and so it was patients that were in early stage of disease… weren’t able to get access to the treatment at the time.
ABDUL VO: Because Sovaldi was so expensive, health systems only offered treatment to people whose Hep C had gotten so bad it could kill them.
That would be like finding a cure for cancer, but waiting to treat people until it had spread all over their bodies. And if that sounds crazy and unethical–it’s because, well, uhh, it is. But that’s what they did. In that first year, Medicaid could only afford to treat one out of every 42 patients who needed it. But Gilead–the manufacturer? They made out with 10.3 billion dollars.
So how in the fuck does a cure like this get priced at $84,000? To learn that, my friends, step into the maze with me. We begin in 1999.
INTV – ROY: [22.33] So there’s a company based out of Emory University, based in Atlanta… [23:39] called Pharmasset…
ABDUL VO: “Pharmasset.” Get it?
INTV – ROY: [29.51] So the rationale for Pharmasset that comes right in their name, right? Ray Schinazi named the company pharma asset. And from the very beginning he thought about how would he create assets for basically big Pharma.
ABDUL VO: Smaller companies like Pharmasset that focus on designing molecular compounds with very specific purposes–like Sovaldi–are known as biotechs firms. Most of them focus all their effort–take a huge bet–on one or two compounds. They do this in the hopes that one day a company from Big Pharma will come a-knocking and acquire them for a huge sum of money.
Creating new compounds requires a lot of research and development–and that takes a lot of money. Pharmasset didn’t get that R&D money from a bank loan or some angel investor. No – they, like most companies that develop drugs – got their initial funding from you and me — our tax dollars — through the federal government.
Here, I’ll pause for a second: If you’re going to get out of a maze, you need some landmarks. And that right there is landmark number one. New drugs getting off the ground with funding from taxpayer dollars.
Pharmasett opened its doors with a combination of federal funding, including money from the NIH and the Veteran Affairs Administration.
There was little progress at first, but by 2008 Pharmasset’s Hep C compounds started to show promise. Which brings us to Landmark #2 in the maze: Like any American business with a good idea, they began to attract investors.
INTV – ROY [30:20] So as they’re presenting those clinical trials at conferences…
[26.14] these are the results are looking promising and you know Wall Street is betting that this is going to be a big winner. And so Gilead looks at its own Financial models and says, you know, this drug could make us, you know, many many billions into the future.
ABDUL VO: Gilead, a major player in the drug industry and the maker of Tamiflu and Truvada – really wanted Pharmasset’s compounds. They saw, in Pharmasset’s research – the potential for a drug that could revolutionize Hep C treatment … and make them a fuckton of money – so they looked to acquire Pharmasset.
Gilead wanted Pharmasset bad. They created an internal plan – codenames and all – called “Project Harry” – in which they, Gilead, were nicknamed “Gryffindor” and Pharmasset was nicknamed “Harry.” Fuck the sorting hat, they were gunna make Harry an offer he couldn’t refuse.
INTV – ROY: [26.26] They actually ran the numbers based on what price they thought they could charge. Based on that they said well, this is a really valuable asset and so they bought Pharmasset for 11 billion dollars in 2011.
ABDUL VO: That $11 billion purchase gave Gilead the rights to all of Pharamasset’s drugs and, most importantly, the compound that would go on to become Sovaldi.
Okay, let’s get our bearings for a second: Sovaldi was born in a lab funded mostly by taxpayer dollars. All that hard R&D work paid by us. Then, Big Pharma swoops in and looks to make a payday. You with me?
So, once it acquired Sovaldi, Gilead steered the drug through FDA approval and by 2014 they were nearly ready to take it to market. With 3.5 million Hep C patients in the United States and a revolutionary treatment, Gilead was poised to make their investment back many times over.
INTV – ABDUL [34:01] So how does how does Gilead decide that they’re going to … charge this ridiculous sum of money for this drug? How do they set the price?
INTV – ROY [34.49] The way they thought about the price is actually… can be boiled down to this. They looked at the price of… the prior treatments. If you add up the cost, they were somewhere… in the north of $70,000 for treatment already…
ABDUL VO: That’s $70,000 for the shitty, side-effect-riddled, multi-month injection regimen that Sovaldi replaced.
INTV – ROY: [35.04] And so they their argument was: You know, our treatments are providing a benefit well over what the previous treatments are, so health systems, we as a society, would be willing to pay more for a better treatment.
ABDUL VO: Rather than tie the price of treatment to, say, the cost it took to produce that treatment, Gilead just based the price off of what people were already paying and added to it…because hey, it’s a better drug.
And that brings us to Landmark #3 in the drug pricing maze: base the cost of the new treatment on the cost of the old one, plus some–because it’s a better drug.
In the case of Sovaldi, once Gilead decided they wanted to charge more than the cost of the old treatment, they went out of their way to figure out just how much more they could charge — they even created a heat map of pricing – how high could they go before the public got too pissed off about it.
INTV – ROY: [35:59] One of the responses that they modeled for was… basically a Senate Congressional hearing and sort of public outcry. And so they basically estimated that once they went north of like $100,000 it was much more likely.
ABDUL VO: So, they settled, at this point, on that $84,000 number – $1000 per pill. Just below “public outcry” status.
INTV – ABDUL [36.52] And at any point, was there a consideration of the fact that you know, this research was publicly funded that generated this drug in the public good responsibility of actually treating people who are suffering from a deadly disease – did that factor into their consideration at all?
INTV – ROY: [40:30] No, there was no consideration around really the… struggles that would come about in terms of access and any significant kind of way in terms of a public health strategy or approach… There was no conversation really about their research and development costs. Right which is what you publicly hear about you know, why drug prices need to cost so much – there is never any consideration around their R&D costs because really for them it wasn’t about that. It was about looking at what the price of the existing treatment was and just saying, you know, what is the maximum increment above that that society would be willing to pay for, you know, an improvement in health.
ABDUL VO: HOLD UP. We’re always told that the reason drug prices are so expensive is because of the massive research and development costs that go into making a drug. But as you’ve seen through this maze, who bore the brunt of that R&D cost? Us! The taxpayers! Not Gilead. All they did was buy a sure bet in the compound that was going to become Sovaldi, knowing they could make a pretty penny. And when Gilead set that price, they didn’t give a damn about the people who needed treatment, their access. Instead, all that mattered was setting the highest possible price that would let them sneak by without a congressional hearing.
And apparently, that’s nothing out of the ordinary for Pharma. It’s the pharmaceutical industry’s MO when it comes to pricing.
INTV – ROY [43.35] I see this as sort of a pricing escalator where what we’ve got is the price of every new treatment is based off the price of the old treatment, in terms of the launch price.
[45.13 ]… And so you’ve seen this in other disease areas, like multiple sclerosis where treatments were, you know, $10,000 in the 90s and now they’re in the 60 to 70 thousand dollar range today.
ABDUL VO: It’s not just new drugs that get a higher price…it’s ALL drugs…because wall street gets involved.
INTV – ROY:[44.39] Each year, drug companies are doing annual price hikes of somewhere between 5 to 10% because they’re trying to keep up with… how they’re expected to grow, in terms of their shareholders. And so that already leads to an escalation of a price.
ABDUL VO: Landmark #4: Wall Street driving prices even higher. If drug prices stagnate, it affects a company’s future earnings. So Pharma has to keep pushing their prices even higher. See, prices have to keep going up, so the company’s stock can keep going up.
What about competition? Shouldn’t competition bring those prices back down? You’d think so. But instead, as one company raises its price on something – like insulin – other companies raise their prices in tandem. And that screws people who need those drugs to survive.
ARCHIVAL: skyrocketing price of insulin
ABDUL VO: Like the maze that it is, it’s all a bit dizzying – as our treatments get better, costs keep going up. Even for products already on the market, Wall Street will keep pushing those prices higher still, with reverberations throughout the industry. For Big Pharma, it’s not about the greater good – it’s about the bottom line.
But what about generics–shouldn’t they help solve this problem? And how come the government allows all this to go on? We’re not out of the maze yet. We’ll get there, after the break.
- MID-ROLL BREAK
ABDUL VO: We’re treating the pharmaceutical industry–the folks we rely on to make the medicines we need to survive–like any other corporation. And what do we, the patients, get in return? Higher drug prices.
Across the board, America has the world’s highest drug prices. The cost of Viagra? We’re number one. Crestor? Number one. Avastin? Number one again. It doesn’t matter what the drug is — chances are Americans are paying more for it. Hey, I guess we gotta be number one at something in healthcare, right?
To help us find our way out of this maze of drug pricing in the US, we called someone whose been thinking about this for a long time.
INTV – ABDUL: Can you introduce yourself? Just… for the tape?
INTV – ROSENTHAL [00:09] I’m Elizabeth Rosenthal. I’m editor-in-chief of Kaiser Health News and author of an “American Sickness: How healthcare became big business and how you can take it back.”
ABDOL VO: Dr. Rosenthal used to be a professor at my medical school. She’s going to shepherd us along through some more landmarks, and help us break down why pharma sucks, especially in the US. She starts where Victor left off – with the power of market forces.
INTV – ROSENTHAL: [05:57] I think what we’re seeing now is … the prices will rise to whatever the market will bear and the market will bear almost anything because if you have a kid who’s sick with CF you’re going to pay whatever it takes to try and help your child, even if you think it’s bonkers, right?
ABDUL VO: Right. There’s no shopping around in the drug market. If your kid’s sick, you buy the drug that makes them better. Economists call these inelastic demand curves–they don’t bend on price because you have literally no other option. Drug manufacturers know this–and they take advantage of it… Well, at least in America.
INTV – ROSENTHAL: [6.18] Every other developed country does regulate drug pricing and determines what seems like a logical price – and that doesn’t mean that new drugs can’t be, you know, expensive. A country like Germany will say, when a brand new, you know, blockbuster drug comes on the market – and I don’t mean blockbuster as we use it in the US Pharma Market, which is to say big money, I mean blockbuster… in the terms of you know, it will cure a disease that hasn’t been cured before…
INTV – ABDUL: [6:48] So a disease buster.
INTV – ROSENTHAL: [6:49] –disease buster, right. They’ll say yeah, you can charge a lot for it. But well, what other countries do, even the ones that start off with high prices, is say, okay, but once it gets a little older the prices should come down over time because you know, it’s not as new anymore.
[7.12] There are often competitors that come into the market. What we see in the US, with no price controls and no real market forces at work – because you’ll pay what you need to to treat your kid or yourself – is exactly the opposite.
ABDUL VO: We are an outlier in this respect. In other countries, like Germany–for example–when a drugmaker has a new drug, they don’t go straight to market with it — they have to go to the government first, who then tasks a federal agency with assessing the value of the new drug and negotiating with the pharma company for the best price. So when companies come to their doorstep and say “we want to sell this lifesaving treatment for a ton of money” the government can say “fuck you, bring the price down.” By contrast, in the US, we just let drug companies – like Gilead – set whatever the fuck price they want.
Landmark #5 – a biggie: the federal government does not regulate or negotiate the cost of prescription drugs in the US. Period. End of sentence. Stay with me here as we break this down.
Part of the reason that these governments can negotiate these lower drug prices is because they – unlike us, of course – often have a centralized health care system and they see prescription drugs–and healthcare in general–like a *public utility* – something their citizens literally can’t live without. Like insulin.
INTV – ROSENTHAL [19:00] I spoke to a young woman who has Type 1 diabetes who is doing a graduate degree in Germany now, and she would love to stay there because having type 1 diabetes in Germany and needing insulin, it’s really affordable – because… the government considers that you know, it’s not your fault that you got it. You didn’t ask for it. We have national pricing. So, you know, you can you’ll get what you need…
[19.30] Here, she would have to make sure she had a job with good insurance and then there would be co-pays and deductibles, and it would be a nightmare frankly… you know, your insurer could change the kind of insulin it had contracted with for the year or the kind of pump it was using, so I think we put patients in a terrible bind, and you have to remember… [20:19] if you don’t have good insurance or you don’t have the kind of backbone to fight with an insurer about an expensive drug, it’s a terrible situation.
ABDUL VO: In the US, patients have little recourse when it comes to the predatory cost of prescription drugs. It all points back to the structure of our healthcare system, which relies on a bunch of health insurance corporations of variable sizes and a few huge government insurers–medicaid and medicare. Private health insurers can sometimes negotiate small rebates for their patients, but without the size or power of the federal government, they lack the negotiation power they need to really make a dent. And the only insurer with the negotiating power to really make a dent in prices, and set the standard for every other insurer is Medicare. but guess what — here’s the kicker! — it legally CAN’T! Like there is a law on the books which literally makes it illegal.
Here’s Victor again.
INTV – ROY: [19.50] That’s due to the way the Medicare prescription benefit was negotiated and put into law back in the… early 2000s under the Bush Administration… Really the pharmaceutical Lobby really got behind in influencing the ability of the government then to not to be able to negotiate prices.
INTV – ABDUL: So our legislators – our government – willingly negotiated away their ability to negotiate with the drug manufacturers. And so they’re stuck trying to pay… these exorbitant prices.
INTV – ROY: Yes, absolutely. Yep. That’s the influence of the pharmaceutical lobby over the last 30-40 years.
ABDUL VO: And that’s Landmark #6 – Pharma spends more money on lobbying the US government than any other sector in the country.
That’s why the federal government can’t negotiate drug prices. Back when the Medicare prescription drug benefit was worked out, Pharma lobbied Congress to eliminate the government’s ability to negotiate drug prices. As Victor just shared with us, since George W., it’s been illegal for Medicare to negotiate lower drug prices with drug makers. So now, Medicare just pays whatever price the drug company wants to charge.
Okay, okay – but what about generic drugs? Once drug patents are up, won’t generics flood the market and drop costs?
INTV – ROSENTHAL: [09:40] We have had this faith in the market that the market will solve this, that when we get competitors and you know, they’ll all fight with each other on pricing and the price will come down and that does happen in cars, right?… because competition brings prices down in cars. It doesn’t in drugs.
[10:08] You know for a long time in the US our solution, which was fairly effective, was we had a pretty robust generic drug industry… [10:23] It worked pretty well here because generics would come in, often in a reasonable amount of time after patents expired, and then the price would come way down, and that’s how we see, you know, a lot of the cholesterol-lowering drugs being, you know, $5 scripts at Walmart and Target. Now… that traditional solution has not worked in recent years because the generic drug makers, like the brand drug makers before them, said, ‘I don’t know, there’s – it’s not like a law of the universe that generic drugs have to be cheap.’ You know, they’re, ‘why don’t we just try raising the prices and seeing what happens?’
ABDUL VO: Landmark #7 – the generic drug market won’t save us. It’s been just as co-opted like the rest of the industry.
And as if this shit couldn’t get more perverse, there’s a less obvious consequence to the out of control profits of Big Pharma. Landmark # 8 in the maze: Pharmaceutical companies have almost zero incentive to make drugs that actually CURE disease. Instead they’re focused on generating drugs that will make money. Those are drugs that *manage* diseases – so you know, you’re taking them every day for a long, long time.
INTV – ROSENTHAL: [21.34] Would you want to spend a whole lot of money developing an antibiotic where someone’s going to take it for, you know, five days and get better? Would you want to develop a drug that cured diabetes that someone could take once and they would never have diabetes again?
ABDUL VO: Umm…yes. But the incentives in the industry are fucked. And what Dr. Rosenthal mentioned about antibiotics – keep that in mind. Cause we’re gonna spend next week digging into it.
We’ve created an entire system that prioritizes the bottom lines of the corporations selling the drugs, rather than treating illness among people who need them to survive. A system where there’s no incentive to cure people and where the government is impotent to stand up and negotiate on our behalf.
I’ll let Dr. Rosenthal sum it up for you…
INTV – ROSENTHAL: [22.17] You know, someone said to me, and I mean, if you think of the polio vaccine, right – which… wasn’t patented, so – and it was cheap – so everyone got it. It mostly eliminated polio from the world, but, you know, if we use the drug development mechanism we use today, someone joked with me, we wouldn’t have a polio vaccine. Instead, we would have iron lungs in 10 colors with iPhone apps.
ABDUL VO: 10 colors with iPhone apps.
Okay, so we’ve traversed most of the maze, passing all our landmarks along the way: government funded drugs get bought up by Big Pharma, who sells them to the public at rates that always exceed those of the previous treatment. This pricing and wall street pressure to keep growing drives up the costs of drugs even higher – and the federal government is impotent to stop any of it. Generic drugs follow the same path as patented ones. And all of it throws the incentives of the industry totally out of whack.
The question remains: is there actually a way out of this fuckery? Well, aside from a complete overhaul of our healthcare system – which we’ll get to eventually in this series – there is some hope.
State and local governments are stepping up where the federal government hasn’t. The state of Louisiana is one of them.
Louisiana has 39,000 Hep C patients on Medicaid or in prison. To supply them all with a generic of Sovaldi would cost almost a billion dollars – more than the state pays for K-12 Education, Veteran’s Affairs, and Corrections combined.
Faced with that price tag, Health Secretary Rebekah Gee was forced to think outside the box. And so, she came up with a plan to negotiate with Gilead. Though the federal government can’t negotiate with drug manufacturers for fairer prices, that limitation doesn’t extend to the states. The result is a new model that Gee calls “the subscription model” – basically the state of Louisiana is paying Gilead a subscription fee for access to unlimited Hep C drugs for its Medicaid and prison populations.
ARCHIVAL – story of Louisiana’s new plan for Sovaldi… featuring Gee…
ABDUL VO: Think of it like Netflix–but for meds for the whole state. Whether you binge-watch Netflix every night, or watch a few episodes every month–its the same price, and Netflix has you covered.
Instead of forcing Louisianans to go right to the manufacturer to try and buy the drug, what they’ve said is – as a state, we’re going to buy an unlimited subscription to this drug, and then we’re going to offer it to anybody on Medicaid or in prison. It’s a win-win: under this plan, Louisiana gets to save the lives of tens of thousands of its citizens and stop the spread of a deadly disease, while Gilead stands to make more money than they would have otherwise – see, Louisiana wasn’t buying all that much of these meds from Gilead before because they were too expensive.
This is a model that could be replicated across other states – with a multitude of drugs. If we’re going to deal with the absurdly high cost of prescription drugs in the United States, it’s going to take government leaders like Rebekah Gee – thinking outside the box, standing up to the corporations, to help those under her care.
But at some point, we’re going to have to decide that the federal government should do it’s damn job and stand up for us. We don’t usually think about prescription drugs as a campaign financing issue, but they’re related. When corporations like Gilead line the pockets of candidates for congress, you better believe they’re expecting something in return.. They want to be able to sell us back the products of the research that our taxpayer dollars paid for at prices we can’t afford.
We can do better. But it starts with getting the corporate money out of politics.
This week, we talked about what happens when people can’t afford their meds. Next week, we’ll talk about what happens when people overuse them. We’re talking about antibiotic misuse–and the rise of the superbus. Next time, on Healthy Skepticism.
America Dissected is a production of Crooked Media. Our producers are Austin Fisher, Cary Junior II, and Katie Long. Andrea B. Scott is our story editor. Our sound designer is Daniel Ramirez. Production support from Alison Falzetta (Fall-ZET-ta), Elisa (AY-lisa) Gutierrez, Kara (CARE-ah) Hart, Daniel Porcerelli (PORE-sir-el-ee), and Tara Terpstra. Fact-checking by Dr. Nicole Aiello (aye-YELL-low). The theme song is by Taka Yasuzawa (TAAK-ah Yaas-oo-ZAH-wah) and Alex Sugiura (SOO-ghee-er-ah). Our executive producers are Sarah Geismer (GUISE-mer) and Mukta Mohan (MO-haan). Special thanks to Jon Favreau, Jon Lovett, Tanya Somanader (SOW-men-ay-der) and Tommy Vietor. And I’m your host Dr Abdul El-Sayed. Thanks for listening.