The immune system as a metaphor for the Turing Pharma mess

H/T to @DerekLowe for the initial metaphor of Turing as a virus, and to the many, many commenters and journalists who’ve covered this topic.

A few weeks ago when Turing Pharmaceuticals’ plan to jack up the price of Daraprim by 5000% hit the news, I found myself glued to Twitter and other journalistic sources as each day brought a new wave of insults, reactions, condemnations, harangues, plans and concessions. I’ve frankly never seen any piece of biopharma industry news evoke this kind of response. When even U.S. Presidential candidates—well, the Democratic ones, anyway—are compelled to offer their takes and plans for reform, it seems that something fundamental may have changed.1

The question is, what should the biopharma industry take away from this? While a few CEOs such as Biogen Idec’s George Scangos and Novartis’ Joseph Jimenez have spoken out against the price hike, and both PhRMA and BIO have taken actions to repudiate Turing Pharma’s actions, there are still demands that biopharma come out with a clearer, more unified position—or risk being labeled as hypocritical. But that doesn’t seem to be happening. Just recently Ian Read, the CEO of Pfizer, told Evercore ISI that he wasn’t worried about Democratic presidential candidate Hillary Clinton’s proposals to control drug prices. Not the most conciliatory or self-aware comment to make, especially for a CEO who went on the record last year saying Biopharma has a reputation problem. So how to influence the industry to take this problem seriously?

Behavioral economics tells us that framing can be a key component influencing decision making. Among other things, a framing approach makes choices and consequences as real as possible to people through the use of analogy and filters. So I thought to myself, we all work in biology. Maybe a biological analogy might help drive home what’s at stake. And given that immuno-oncology is so hot these days it makes plasma look cool, I thought an immune related frame might be helpful. So let me present the recent pricing fiasco through the lens of the immune system.2

An extended analogy between an immune system response and the reaction to Turing Pharma
Immune system element Analog in the recent Turing Pharma debate
Priming antigens Recent discussions about the price of Sovaldi, and several other new drugs in indications like Hepatitis C, cardiovascular disease, and oncology primed the public to discussions of drug prices. Also, the Affordable Care Act’s influence on employer-provided health plans has led to rising out of pocket costs and therefore higher visibility for prices for medications.
Subthreshold immune response The lack of response to earlier instances of companies hiking the prices of generic drugs for companies like Questcor, Valeant and URL Pharma.
Virulent, triggering pathogenic infection Turing Pharmaceuticals raising the price of Daraprim by 5000%.
Immunization adjuvant Turing CEO Martin Shkreli’s amazingly annoying and provocative internet persona and behavior.
Innate immune response Social media and other responses to the price increase. Phrases like “drug price hikes,” “vulnerable populations,” and “maximizing shareholder value” that serve as pattern recognition motifs that trigger a speedy response like a macrophage engulfing a Staphylococcus bacterium.
Adaptive immune response The various regulatory plans being proposed–price caps, single payer negotiations, transparency initiatives, etc.–to stem drug price increases long-term.
Commensal bacteria Biopharma


The response to Turing Pharma didn’t come out of nowhere; there had already been several different factors that led the public to be primed for an affront like the Turing Pharma price hike. Over the last few years several high profile, high priced drugs have entered the market and raised real fears about the affordability of new medicines for conditions like Hepatitis C and high cholesterol that affect a substantial proportion of the US population. In addition, the Cadillac tax and other requirements of the Affordable Care Act appear to be leading to higher out-of-pocket expenses for patients (which is a feature, not a bug), further sensitizing them to drug prices. These developments have created social sensitivity to drug price changes, just as exposure to potential antigens primes the immune system for a stronger later response.

So why didn’t earlier, similar actions by other biopharma companies raise the same response? I think there are two main factors: first, randomness. We live in a world where a multitude of stimuli are clamoring for our attention. In that kind of environment there’s only enough oxygen for a few things to rise to wide-spread attention. I suspect the earlier price increases, some of which were in scale similar to what Turing did, just didn’t break the surface tension of the internet. Which brings me to the other factor: Turing’s CEO.

In vaccination, there’s a continual effort to find new adjuvants. These are substances one adds to a vaccine to really jack up the immune response. Martin Shkreli’s behavior served as a kind of adjuvant, exacerbating the effect of the initial insult of Turing’s pricing change. And that led to the initial, wild, Internet-wide response.

The concept of social shaming was recently examined in Jon Ronson’s book “So you’ve been publicly shamed.” Among the many things the Internet has enabled has been the ability to rapidly pivot on perceived malfeasants and nail them to the wall with a response not unlike that big rolling stone ball that almost squashes Indiana Jones at the opening of “Raiders of the Lost Ark.” Once a negative event does enter the attention economy, vituperation is swift and merciless. However, this innate immune response predictably fades over time. The real, lingering effect is the adaptive immune system of society—regulatory policy, which we see being proposed and debated as the US Presidential election cycle proceeds. The adaptive immune system has memory for certain pathogens, and remains ready to strike them down at a moment’s notice, and society also has a memory for certain acts it wants to remain constantly vigilant against, through laws and regulations.

So the lesson I hope biopharma takes from this extended analogy is the following: it’s too late to keep on doing the same things and hope no one notices. The system’s primed now and already starting to develop its long-term defenses. You’ll note I liken biopharma to commensal bacteria. I do think the industry serves a vital, important, useful role in helping society, just as our commensal microorganisms perform a host of beneficial functions for us. But as these kinds of rent-seeking behaviors proliferate—and not just on the side of generic drugs—the system as a whole will begin treating biopharma as more of a pathogen than a friend and the results could be very unpredictable. After all, the immune response doesn’t think about long-term consequences for the whole; it operates quickly and locally, often with unforeseen consequences. When excessively agitated by certain stimuli, the immune system can enter a chronic state of autoimmunity, creating long-lasting pain and fatigue.

The biopharma industry is blessed with the gifts of intelligence and foresight, and can take actions to head off a more stringent adaptive response from society by being more transparent and ramping down its most immunogenic actions—namely, pricing drugs to the limit of what the market will bear rather than based on a reasoned consideration of innovation and value. Because the alternative, as Robert Nelson of Arch Ventures laid out so starkly in Forbes, could be a crushing of all the good things biopharma can do in the rush to punish for the sins of a few.


1Maybe. The internet is notorious for its short attention span. Still, Bernie Sanders already had been calling out for reform on drug prices, so it may well be that this is a controversy that won’t get swept away by the next noisy thing. And, it must be said that at least one Republican candidate did respond to Turing’s price hike. Donald Trump, the candidate with the most experience as a provocateur, felt compelled to call Martin Shkreli a “spoiled brat.”

2I’m not an immunologist by training—I’m a geneticist. But I’ve been working with immunologists for the last seven years, which I think qualifies me to make broad, overly generalized and not entirely accurate analogies for the sake of a good story hook.

Baseball, regression to the mean, and avoiding potential clinical trial biases

This post originally appeared on The Timmerman Report. You should check out the TR.

It’s baseball season. Which means it’s fantasy baseball season. Which means I have to keep reminding myself that, even though it’s already been a month and a half, that’s still a pretty short time in the long rhythm of the season and every performance has to be viewed with skepticism. Ryan Zimmerman sporting a 0.293 On Base Percentage (OBP)? He’s not likely to end up there. On the other hand, Jake Odorizzi with an Earned Run Average (ERA) less than 2.10? He’s good, but not that good. I try to avoid making trades in the first few months (although with several players on my team on the Disabled List, I may have to break my own rule) because I know that in small samples, big fluctuations in statistical performance in the end  are not really telling us much about actual player talent.

One of the big lessons I’ve learned from following baseball and the revolution in sports analytics is that one of the most powerful forces in player performance is regression to the mean. This is the tendency for most outliers, over the course of repeated measurements, to move toward the mean of both individual and population-wide performance levels. There’s nothing magical, just simple statistical truth.

And as I lift my head up from ESPN sports and look around, I’ve started to wonder if regression to the mean might be affecting another interest of mine, and not for the better. I wonder if a lack of understanding of regression to the mean might be a problem in our search for ways to reach better health.
Continue reading

An Open Standard for APIs Could Lead us to Better Health

There’s a parable about the elephant and the rider that’s been used by Chip and Dan Heath, and that originated with Jonathan Haidt, to describe how humans make decisions. A person’s mind can be thought of as consisting of a rider, representing the rational part of human thinking, and the elephant she’s riding, representing emotion. Both of these play a role in how a person decides things, and many of us believe the rider–the rational part–is in charge. The rider taps the elephant with her guide stick, and the elephant obediently moves in that general direction or does a specific task, like carrying lumber from place to place.

Except that’s not how a lot of decisions actually get made. Instead, the elephant sees a bunch of bananas, or a herd of other elephants, or a nice cool river to bathe in, and goes that way instead. And the rider…well, the rider can’t do much about it except, after the fact, rationalize how she always wanted to go in that direction to begin with. Yeah, it was time for a bath, sure

This framing has stuck in my mind for years and it’s a really helpful way of looking at many of the odd things that people do or say, ranging from climate change denial, to believing genetically modified organisms are inherently evil, to smoking despite everything we know about the harms that result, to even saying that Paul Blart, Mall Cop II is really, you know, not that bad–really. And it also speaks to one of the more vexing problems we have in human health. Why do people keep doing things they really probably shouldn’t, and know they shouldn’t, if they want to stay healthy?

I’ve touched before on how the power of digital tools can help make it easier for us to make good decisions. OPower is doing this for power consumption and conservation, and with the advent of tools like Apple’s Healthkit and the proliferation of activity trackers, the time is right to do this for health. Continue reading

Making Change

And now for something completely different! Short fiction in honor of the recent unveiling of the Apple iWatch and Healthkit.

“I wouldn’t eat that if I were you.”

Sylvia paused, bacon cheeseburger halfway to her mouth, and peered at the neon green band wrapped around her wrist. The wraparound touchscreen was currently showing a cat emoji. It had a frowny face, expression halfway between puzzlement and alarm.

“What did you say?”

“I’m just saying,” said her Best Buddy wristband, “that when we met a few weeks ago, you mentioned wanting to keep your weight in a specific range.” The emoji shrugged. “Little friendly reminder. You know?”

Sylvia carefully put the burger back down and resisted the urge to lick grease off her fingers. She fumbled for her napkin, her fingers leaving translucent streaks on the thin, white paper.

“I–well, yeah. But, I mean, you’ve never said anything like this before like when–” She broke off, remembering the milkshake, the onion rings, the King-size Choconut bar…

“Well it’s not the first thing you do, is it? When you meet someone and you’re just getting to know them?” The cat had morphed into a light pink, animated mouse, standing on its hind legs, bashfully kicking one leg. “But now, we’re friends!” Continue reading

Baseball, Bayes, Fisher and the problem of the well-trained mind

One of the neat things about the people in the baseball research community is how willing many of them are to continually question the status quo. Maybe it’s because sabermetrics is itself a relatively new field, and so there’s a humility there. Assumptions always, always need to be questioned.

Case in point: a great post by Ken Arneson entitled “10 things I believe about baseball without evidence.” He uses the latest failure of the Oakland A’s in the recent MLB playoffs to highlight areas of baseball we still don’t understand, and for which we may not even be asking the right questions. Why, for example, haven’t the A’s advanced to the World Series for decades despite fielding good and often great teams? Yes there’s luck and randomness, but at some point the weight of the evidence encourages you to take a second look. Otherwise, you become as dogmatic as those who still point to RBIs as the measure of the quality of a baseball batter. Which they are not.

One of the thought-provoking things Arneson brings up is the question of whether the tools we use shape the way we study phenomena–really, the way we think–and therefore unconsciously limit the kinds of questions we choose to ask. His example is the use of SQL in creating queries and the inherent assumptions of that datatype that objects within a SQL database are individual events with no precedence or dependence upon others. And yet, as he points out, the act of hitting a baseball is an ongoing dialog between pitcher and batter. Prior events, we believe, have a strong influence on the outcome. Arneson draws an analogy to linguistic relativity, the hypothesis that the language a person speaks influences aspects of her cognition.

So let me examine this concept in the context of another area of inquiry–biological research–and ask whether something similar might be affecting (and limiting) the kinds of experiments we do and the questions we ask.

Continue reading

Some MLK Day thoughts about evolution, teachable moments, and being human

Maybe my favorite episode of Northern Exposure is the one where Maurice Minnifield (played by the great Barry Corbin), the bigoted, pompous, ex-astronaut is surprised to discover he has a son, Duk Won, conceived during service time in Korea. After grudgingly admitting that Duk Won’s claim is real, Maurice has a conversation with Chris, the town’s DJ and amateur philosopher, about how difficult this is. Their conversation concludes something like this:

Maurice: I wouldn’t have had such a problem with this if only…

Chris: If only he were white?

Maurice: …Yeah…

Chris: Well, that’s a reason for hope.

Maurice: What? What are you talking about?

Chris: Because racism is a learned behavior. And that means it can be unlearned. Continue reading

Could pro sports lead us to wellness?

Comment From Bill
St. Louis is being hindered in the stretch drive by some kind of GI bug passing through (so to speak) the team. Reports have as many as 15 guys down with it at once. That seems a lot, but given the way a baseball clubhouse works, my question is why don’t we see more of that? Answering that baseball players are fanatically interested in sanitation and hygiene ain’t gonna cut it, I don’t think…

Dave Cameron: They have access to a lot of drugs.

–comment from a chat at Fangraphs, September 24, 2014

So this comment caught my eye. Ever since I began following sites like and, and reading things like Moneyball, I’ve found myself thinking about efficiency and unappreciated or unexplored resources in different situations.

I realize this was a throwaway line in a baseball chat. But it piqued my interest because it seems to point out something that’s maybe underappreciated and understudied about how sports teams go about their business–specifically, the kinds of things they do to keep their athletes healthy.

My question is, does this represent a potential source of “Found Research” data that could help the rest of us reach wellness? Continue reading