New SF public health chief was part of McKinsey opioid-marketing operation
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> It's a lot less concerning if you actually think about what he specifically did, and what information he would've had access to at the time
> He was 23 and working on an early career project. Given how consulting teams are structured, he was not an architect of any grand scheme or plan, and was just executing the work ahead of him. Based on the evidence cited in the article, this was run of the mill business research -- interviewing experts about how pharma sales works and how to segment doctors, summarizing and framing to get to recommendations, and editing PowerPoints
> It's only bad when you consider that the product was opioids, but keep in mind that the scientific literature he would've had access to at the time would not have suggested they were especially harmful. If anything, there were compelling reasons for a 3rd party at the time to actually believe that more widespread use of these products would improve wellbeing. If it was so obvious to everyone how bad these things were, we wouldn't have ended up with the crisis we did
[1] https://old.reddit.com/r/sanfrancisco/comments/1ipgwcm/sfs_n...
If you made the same assumptions about me based on what I did in my 20s, you’d actually be assuming the direct opposite of what I believe in and how I work today. We’re all shaped by our experiences, but that shaping doesn’t always mean we grow into the behaviors that we experienced during our formative early career. Maybe this guy looks on that experience and knows exactly what he doesn’t want to see happen.
I'd like to think that most of those decisions are coming from datasets that suggest, on average, certain medications tend to lead to abuse, including from people with no prior history of abuse.
I'm quite libertarian in a lot of my views, but this particular one on lax drug controls I've never really been able to buy into.
Ok, I'll bite ;)
Let's agree that the "liberal" approach is harm-reduction -- safe injection sites, needle exchanges, free filters, test sites, community disease screening, etc.
In places where this has been tried (see: SF), it seems to provide some relief to people on the ground, but it's done nothing to address in the inflow of addicts against ever more dangerous supply.
What if the correct liberal position was actually "free pain pills for anyone that needs them, with compassion for all users", and what we think of as "liberal" policies even in SF are actually appeasement of a puritanical system?
That would make the libertarian position "you can't be giving out free pills with government money, make them buy them when they need them like the rest of us" and the world would return to order.
The right-wing position would remain "the government should use force to prevent people from doing immoral things".
As for the addicts, they will now be using a safer route of administration with controlled dosing and not be economically hindered.
As for the cartels, they will no longer find money in the drug trade.
For a while I thought I understood the dynamics of how things got the way they are, but it seems like everyone else has forgotten, so maybe we could try a new approach soon.
Now, my experience is not representative as a whole, but it's generally what fuels my thoughts on this subject. If this is the story I hear quite frequently, why would I want these drugs to be introduced legally into people's lives? That's why I've always had issues understanding people pushing for legalization.
I understand how it can come across as puritanical ("I know what's best for you"). However, when all data suggests that engaging in drug use almost universally results in poverty, why would we as a society want to unleash such a thing upon people? It's for the betterment of humanity that life-ruining drugs are illegal.
At least those are my thoughts.
The poverty is quite related to the costs, and I think that's where I challenge your take.
That said, the most compelling take i have heard in the first half of 'In the realm of hungry ghosts' by Gabor Mate`. He points out that we need to consider the fact that some people may be much more predisposed to opioid addiction, by either default wiring or by life experiences. In this case, is the freedom of the majority of folks to take what they want worth the risk to those who would suffer from it? I don't believe he supports the criminalization of the drug use, but he makes a good point that we need to think about this reality of different-risks.
The reason why I come back to legalization is that I cannot tolerate the fact we have such massive funding sources for the cartels (and police) in the illegal trade. It is deeply compelling to me that we would be better off without funding that society destroying business.
Yeah, I'm certainly not talking about this class of drugs. The context of the discussion is opioids, and I'm mainly referring to the more destructive ones. I had no issue when marijuana was legalized in my state.
> The poverty is quite related to the costs, and I think that's where I challenge your take.
I'm not sure that represents the whole picture. Beyond relationships, the main thing most people I've met in this situation lost was their job. Followed by whatever housing situation they had. Sure, cost doesn't make it any easier on them, but from my perspective, it was the drug abuse and the resulting cycles of high/low that led to their financial demise.
> The reason why I come back to legalization is that I cannot tolerate the fact we have such massive funding sources for the cartels (and police) in the illegal trade
Yeah, I agree, and I have the same feelings. I just can't, in good faith, support legalization with all I've seen. It's a complicated problem.
It isn't that they lead to abuse, it is that people who are using heroin will abuse them, and will go to doctors who facilitate that.
I had a spinal fusion in my early 20s. I was discharged from the hospital with a script for 90 days of opioid painkillers, 3x a day. $10 copay… I took like 4-5 and was done. I had a extensive support network between my lovely wife and family… people who do not develop a opioid problem like 60% of the time.
The standard of care changed because of Perdue. Dentists were handing out 30 day scripts, people were getting opioids for minor ortho issues, etc.
As abuse became more prevalent, sourcing prescription pills got expensive. Heroin was more available and cheaper - the use of this stuff became way broader than the stereotype of hypes selling plasma, etc.
It's a massively common procedure and defaulting to "here's some addictive painkillers just in case you want them" was an insane thing to do, even if only 1% of cases turn out badly.
Interesting experience was signing a form in triplicate (white copy me, yellow copy walgreens, pink copy DEA) to pick it up.
Never took any.
include me out of your of your assumptions, please. I knew the Purdue pharma stuff was bad from the get-go, and it's not because I'm prudish about drugs or a huge believer in regulating everything to the point of paralysis. It was because the combination of high physical potential for abuse + strong economic incentives to monetize that leads to bad results. Wars have literally been fought over this in the past.
https://en.wikipedia.org/wiki/Opium_Wars
You might be familiar with Adam Smith's famous economic example of the pin factory. Here's Rudyard Kipling's description of an opium factory operated by the British colonial power in 19th century India, an equally brilliant illustration of commercial logic but applied in service of perverse incentives.
https://ota.bodleian.ox.ac.uk/repository/xmlui/handle/20.500...
Would that be user error, or would it be the doctor’s fault for not telling me how addictive the benzos were? I was mentally ill. He told me to take them every day. I didn’t take them excessively. I took them as prescribed. It was only after the addiction got out of control that I started drinking again. Mentally ill people make bad decisions. The doctor made no effort to ensure I was safe. He kept upping my dose.
It’s worth watching the documentary “As Prescribed”[0], which is about benzo addiction. A lot of people go through what I went through. Some don’t survive. We blame drug dealers for ODs but not psychiatrists. Why?
I think the ADHD drugs are probably next. My conspiracy theory is too much of the professional class (including doctors) is using them regularly, so it's much hard to crack down on.
https://en.wikipedia.org/wiki/Opium_den
https://en.wikipedia.org/wiki/Opium_Wars
I’m still struck by how deeply immoral it is to start a war and say “You WILL allow us to sell you opium!”
Others have talked about the question of innocence but I think your comment illustrates not getting the dynamic of regulatory capture. The situation of regulatory capture is about there being "revolving door" between industry and regulators, so that the regulators use same criteria as companies for regulatory decisions. This dynamic results in broad regulatory capture regardless of the individual bad deeds.
Only if you pretend to be blind. McKinsey knew exactly the effects of opioids which is why they were condemned as well
“ In a March 2008 PowerPoint presentation, Tsai outlined a marketing strategy for the drug that included guidance on targeting “specific physician segments to grow high-prescriber group (i.e., physicians more sensitive to patient needs)” and an idea to introduce “coupons” for the drug as part of a pilot program.”
The high-prescribers were people operating out of strip malls, often with unclear credentials, and whose main clientele were opioid addicts. Many of these people (I am choosing not to use the word doctors) ended up in prison...consultants who were advising them, not so much.
There are a large number of people who could do this job, it is reasonable to ask whether the person you want doing this job is someone who, at best, was unaware that these people were breaking the law. And, to be clear, he was Partner of their Healthcare practice whilst this was going on...he wasn't just making Powerpoints.
The revolving door between consultancies and government must continue. No-one is more skilled than running government than lawyers and consultants who have lots of experience in...advising other people how to run things.
I think this is an assumption. May be right but for all doctors who “listen to patients needs” to be pill pushers deserving prison time seems a little too inconvenient. At the end of the day he is asked to optimize a business in a consultancy not to play to his moral principles and get replaced on the project for someone who will optimize it for business needs. At least he is potentially seeing all the inputs with these relationships and a side of the healthcare industry a lot of people wouldn’t have any experience with without holding these positions themselves to be able to be in these rooms where these conversations are held.
Correct. Instead of targeting just people that medically need it, this quote paints him as specifically advertising to and targeting the addicted patients of less-than-reputable doctors who would over-proscribe this, get the patient addicted, and thus have them in the loop of buying more painkillers.
It's the same punitive impulse that causes the permanent second-class citizenship bestowed upon anyone who finishes a prison term.
Our society is very forgiving if you propagate “faceless” evil. It’s unforgiving if there’s a human face to it. Part of this ties into the power of monetary capital over social capital.
How does this track with your assertion that "the issue is that our society is not more damning of people involved in the low-level actioning of great injustices"?
Isn't your impulse to damn now that there's a low-level face to the faceless evil the exact same impulse as the one people have to condemn a low-level drug runner for the rest of their life?
First, there’s a disconnect here in my opinion: the low level drug offender deals with headwinds entering professional society writ large, not specific industry. This is much more consequential and, in my opinion, unfair. Being a drug runner doesn’t imply you would be a bad sales rep, but that’s how our society operates. If we were considering that low-level drug dealers face a specific impediment to becoming public health officials, I would argue that’s at least more sensible.
Both the drug dealer and this guy have probably caused outsized social health impacts (and, don’t forget, deaths) through their actions. That invites scrutiny.
Second, I have no delusions. Yes, I think this guy should be heavily scrutinized. Perhaps it’s not exactly fair that your actions follow you for your life, but if you have a hand in one of the worst public health crises of recent years, that’s damning if you want to run a public health office. Civil servants necessarily should be held to a higher standard. All that said, I doubt he will be disqualified from the office.
There’s a wider question: what are we prioritizing? Individual fairness or public health (more generally, public good)? I think from that frame (and a similar framing in many industries) more people should be made an example of if they have worked against the interests of an office they seek. Airline lobbyists should not be heads of transportation (and heads should be legally disallowed from entering lobbying for a period after office), food magnates who seek to dilute and adulterate their products as much as legally allowable should not run the USDA, the parallels are numerous. These people hold the wrong incentive (making money) highest. By making examples of these people and disqualifying them, you right the scale to some degree and influence the actions of others.
I don’t have the time at the moment to make a wider argument of systems, but if you look at China vs. the US…
1. steer far clear of,
(incl. steering clear of *the fruits of*), or
2. mitigate/neutralize/counter the effects of...
I'd recommend reading the book, it is a bit of a downer though
The majority of McKinsey employees are fundamentally risk-averse kids choosing a safe brand name instead of doing anything entrepreneurial. To write books about them as if these PowerPoint jockeys are doing anything more than providing political cover for executives on a prostitution billing model is beyond funny.
I wish people would stop building the McKinsey brand by falling for their own marketing BS. Experts in business don’t need sell non-scalable human labor in hourly chunks, they create successful businesses themselves.
An addictive painkiller has product market fit by default and is possibly the easiest product to sell on the planet. You don’t need evil geniuses to get the opioid epidemic, it was an inevitability given the US model.
Even the senior management have never actually done or accomplished anything other than Googling stuff and pasting it on PowerPoint slides.
Consulting firms like this are a one way street for young grads, up or out. It’s not like McKinsey is recruiting successful founders or corporate executives with actual business acumen to sell PowerPoint slides by the hour.
There is no there there. Ironically, the scandals they're supposedly "behind" only serve to build their brand. It gives cover to the morally bankrupt executives at the actual company, while signaling to other executives that McKinsey will take the fall for you.
This is San Francisco we're talking about where the former mayor was funneling bribes to her boyfriend(?), pressuring to get her brother out of jail early and had her buddies managing diversity programs funnel millions elsewhere.
No medical degree or scientific background. Background reads like an accountant from McDougal & McDouglass (w/e firm that took over Boeing).
It’s no wonder people have no confidence in our health system. It’s filled with nepo babies and neoclassical economic types that min/max cost.
..and o/w your point is well-taken, thank you for the instructive comment.
I see it as, "Destroyed an engineering safety culture."
Their response to our issues is kindly, gently strong-arming us to ditch our EHR to join the Epic monopoly if we want to keep our contracts. And this when last time I went to SFDPH in person I literally had to step over junkies shooting up on the street a couple blocks away.
On the bright side, Epic seems more functional than the Avatar system it replaced (made national headlines for its botched implementation, SFDPH made it even worse when they completely borked their internal Avatar server migration around 2019 because they didn't know how to properly load-balance using NGINX, maybe 1 in 200 access attempts would succeed).
Even then, it seems like this headline is a little sensationalist. But optically, not good. Even then, this is something that everyone should be aware of. It is easy to jump to conclusions, but we should also do our due diligence here to verify these connections. This can end similar to how Bernie Sanders was painted as a health industry "shill" when in reality it was just the way political donations are categorized.
Nurses and such had donated X amount of dollars to his campaign and that was twisted as him taking money from "the healthcare lobby" when in reality he is basically one of the 3 people in government who don't accept super pac and lobbying money, proving that you can indeed survive off of grassroots donations. So we have to be careful here. Optics is not enough to make a conclusion, and people will try to use that against you.
Just based on his resume he shouldn’t be managing state/federal medical resources. He should be managing a franchise of fast food chains. He has no medical background. LinkedIn only mentions graduating from Harvard. Out of college he joins the parasites at McKinsey. Then fails upward from there.
Current administration is doing this across all departments.
This quote at the end is particularly funny cope:
> "Just like [Tsai] distributed the drugs, maybe he can distribute the solution to the drugs,” Beal said. “Hopefully, he can use the knowledge he has from helping to create the monster to figure out how to solve it."
Yeah, ok. I guess this is also why we usually hire people arrested for carjacking to head police task forces on auto theft. /s
Hiring people with intimate knowledge of Bad Thing to try to fix Bad Thing is not necessarily a bad strategy.
Just need them to have very legible incentives. That’s less clear to me in this case.