First Do No Pharm is a 2024 film collaboration between Aseem Malhotra and a few other like-minded people in the health influencer sphere that covers several topics, with the general theme of antipathy towards the actions of pharmaceutical companies. As is common in the health influencer ecosystem, their talking points start with kernels of truth which morph into outright misrepresentations, lies, lack of understanding of the topic they are opining on, or failure to disclose significant financial conflicts of interest. In the film, Aseem laments the deliberate deception of the conventional medical system in order to make money. I will quote that right back at him – normally, if you are concerned about such deception, the moral high ground isn’t to do more deception, it is to do less.  My expertise is similar to Malhotra’s (I deal with the heart problems of babies, kids and adults), so I’m reasonably positioned to show you all the logical mistakes in his arguments. 

Antipathy to statins using several patients of cardiologists who have had known heart artery blockages –
This is a highly harmful stance to take on patients who have had heart attacks or really significant heart artery blockages. If the reader is hearing about the statin controversy for the first time, I’ll take the liberty to share a little introduction. Statins are meant to decrease blood levels of cholesterol and decrease heart artery inflammation, which in turn is meant to decrease the risk of future heart attack from a heart artery blockage. The root cause of heart artery blockage is complicated, but it is a mixture of blood clot, cholesterol deposition, the immune system’s efforts to remove the cholesterol, calcium deposition, and an abnormal balance of inflammatory molecules. Statins get a lot of press because they are the easiest medicine to take that directly addresses a few of these problems. The issue is figuring out which patients benefit the most and which patients stand to gain very little.

Malhotra leaves out so many critical pieces of information – by multiple studies over multiple decades, people who have already had heart attacks, stand to gain the most benefit from statins (citation American College of Cardiology). People who have had heart attacks and then stop statins, have more heart problems compared to those who rigorously adhere to their statins. It is of course advisable for patients to figure out lifestyle optimization, but Malhotra leaves out that most cardiology specialty clinic consultations are very short, and don’t necessarily leave time for an in depth discussion (even if the patient and doctor both wanted such a discussion). It is misrepresentation to imply that most physicians don’t care about lifestyle change.

Next up, Malhotra completely misses the fact that other groups of cardiologists have specifically come up with a PREVENT score (https://professional.heart.org/en/guidelines-and-statements/prevent-calculator), to try and focus the use of statins towards those who really need it, and cut down on overprescription. They next try to confound the issue further by attempting to introduce the Number Needed to Treat (NNT) for statins. A small NNT is good meaning, you don’t need to give medicine to that many people to see a benefit. While it is reasonable for a physician to know this number, when a patient has already had a heart attack, focusing on this number and having blinders to the rest of the clinical situation does not result in optimal care. The speakers also gloss over the fact that the NNT depends on the population that you pick from (The number of people needed to receive statins, to see one person benefit, when the population has the worst heart disease, is way smaller than the NNT taken from the general healthy population).

Academic centers collaborating and taking money from “big pharma” –

it is reasonable to want to have a lesser degree of pharmaceutical financial control over academic centers, but the speakers again leave out the fact that universities go to great lengths to require all their employees to disclose all their conflicts of interest. The simplest reason academic centers and pharmaceutical companies collaborate is because there is a mutual intersection of needed talent – academic centers who are interested in designing medicines usually don’t have the equipment to scale up medication production, and pharmaceutical companies do not necessarily have all the basic science professionals they need to think up new ideas for new medications. A new independent funding source for these very expensive endeavors is certainly going to be welcome by many – but the film authors make no effort to explain if they were to abolish all relationships between academia and pharma, what the replacement would be. Researchers like Peter Hotez who actually brought a homegrown vaccine to market would be eager to listen what the practical source of funding would be, that is truly independent of pharma. While people like RFK Jr continue to make quite a bit of money sharing antivax products, I have yet to see them put their money where their mouth is and fund clinical trial research on a medication they would approve of.

Antipathy towards the chemicals used in fertilizers –

The speaker here is unaware of or shows lack of understanding of the demands on the agricultural ecosystem that demanded industrialization in the first place. As the world’s population continues to grow, we collectively will need more and more food for more and more people, with less and less land to carry out that agriculture. This is further complicated by climate change (being only one of the many pressures on modern agriculture). As it is currently carried out, regular organic farming or home gardening is not capable of meeting the demands of the future planet. Just switching to organic food in its current iteration would cause a significant increase in food prices (which is only one of the possible disadvantages). This film fails to provide any thoughtful solutions (they could have cited the BBC which has discussed vertical farming). Typically in the same paragraph, health influencers use this kind of soap box to demonize genetically modified plants – while failing to understand that many of the modifications are to make plants provide more vitamins, be more resistant to disease, or be more resistant to certain climate conditions. These are all desirable traits in crop plants that have to be grown time and time again in large quantities. If in the future, these film authors has any actionable solutions that can feed large populations affordably (or better than what we currently do), the agriculture community would like to hear them. 

Lamenting how there are always drug side effects –

the reason there are always drug side effects is because there are subtle changes in genes that change how different people process different medications. Some of these changes are well characterized like clopidogrel resistance, but others are less well studied. The speakers in the video leave out efforts by the conventional medical community to research and produce personalized medical products (some cancer therapies are like this). They also leave out the medical community’s ongoing efforts to teach patients about side effects and efforts to avoid side effects in their own prescribing. More can be done, but the speakers should take their own advice, which is to not throw the baby out with the bath water. 

Need for raw data from statin trials –

Statin side effects have been studied from multiple perspectives and by multiple academic centers. The speakers in this film did not put in any obvious effort to read any of those articles. More than enough information on statin side effects is available to help patients stay informed. Theoretically if the film authors already don’t trust pharma, why are they complaining that pharma didn’t release a dataset? Plenty of other organizations have already taken up the challenge of looking at statin side effects.

FDA panel and its ties to pharmaceutical industry –

the speakers here illustrate their lack of understanding that FDA panel members that approve medications always have to disclose their conflicts of interest. The core issue is that employment on one of these committees demands a high level of understanding of laws governing bringing drugs to market, biostatistics, medicine, and pharmacy/ chemistry. The number of people qualified in all these areas is rather slim. Again, a practical actionable solution is welcome, but none is provided. The reader can always reach for his/ her medical team to help explain a recently approved medication or, go to a discussion forum to gather more information about a brand new medication as an extra safeguard to avoid taking a medication that has too many side effects. 

Ralph Snyderman and Purdue Pharma actions in prolonging the opioid epidemic –

Physicians of many stripes can agree that the opioid epidemic was and still is a big problem that needs to get under better control (in its current form in the US it is narcotic-related overdoses and deaths). The speakers in this film do not disclose that Purdue Pharma was in fact punished by going into Chapter 11 bankruptcy. It is debatable if this was sufficient punishment, but that’s for a toxicology professional like Ryan Marino to discuss. 

Polderman’s report of 800 000 deaths – 

The context here is that in 2014, the European Society of Cardiology recommended patients with coronary artery disease or those who had suffered a heart attack take beta blockers after surgeries that did not involve the heart. The thinking was to decrease demand on the heart in order to avoid postoperative heart attacks in those who came to the hospital with pre-existing heart disease. However, subsequent investigations found that some patients did in fact suffer severe side effects from this approach. The person who recommended this practice was a physician by the name of Don Poldermans, who was later academically punished when his conflicts of interest were discovered (you can see the links with other points raised by Dr. Malhotra). The European Heart Journal

, which published the work, quickly responded and retracted the article. Furthermore, the actual figure of 800 000 deaths may itself be an overestimate. If one delves more deeply into the research that claims to have demonstrated beta blockers harm patients, an experienced cardiologist would quickly see that the beta blocker doses used were likely too high. Current cardiology guidelines in both Europe and the United States recommend efforts to minimize perioperative risk in patients with heart disease, where one of the ways this can be accomplished is by using lower doses of beta blockers, in moderation. It would be seriously incorrect to conclude that this research means patients should “be scared of all the beta blockers all the time”. It would also be seriously incorrect to avoid mentioning all the checks and balances that resulted in the correction of the beta blocker policy.

IQWIG regulator action against riboxetine –

The German Institute for Quality and Efficiency in Healthcare did indeed block the approval of this medication in Germany, but the authors fail to notice all the drugs that the United States FDA did not approve, like thalidomide – which averted a large number of medication related adverse events. I approve of drug regulators around the world playing more hardball with teams seeking approval of new medications. 

Calley Means on obesity and genetic/ environmental causes –
The statements here are an oversimplification. Medications are sometimes necessary to aid weight loss in a patient who has a genetic predisposition to gain weight (for example, the MC4R pathway). The statements here are a form of fat shaming that do not do anyone any favors. A complete weight loss program probes both genetic and environmental factors to help someone lose weight, it’s not one or the other, and never has been. 

Something is not right just because it is ancient –

Here the speakers praise different types of exercises including yoga, and suggest this is one of the ways out of chronic disease. However, they present this as a generalization that no longer has an evidence base when extended to many modern chronic diseases. For example, it is helpful to exercise in hypertension, but it is not a promise the hypertension will go away. It is also important to exercise in heart artery blockages, but the results presented in the film (people gradually having less blockages) ignores whether or not they took medication or whether or not they are generalizable.

The allegation that doctors don’t read research papers or understand statistics –

The ability of practicing physicians to perform these tasks varies. Some have prior experience with formal training, and others study what is required in medical school. Making the extreme point that physicians never read studies is factually incorrect. 

Conclusions

Overall – the authors and participants in this film have financial incentives to create even more mistrust against conventional medicine and pharmaceutical companies. While it is reasonable to speak out against malpractice and seek justified punishment against companies like Purdue Pharma, these authors do not communicate that the very medicines they are criticizing have legitimate uses. They also don’t communicate that new medications have the potential to be scrutinized by multiple medically trained readers with different viewpoints – which results in better medical care for the patient. Yes pharmaceutical companies can be trusted to praise their product, but other universities or investigators can look with a fresh eye to find what they might have missed. The worst mistake the speakers make is to imply that natural means better – this is a tactic that has been used by alternative medicine doctors since the beginning of time. In ancient times, and when conventional Western medicine was in its infancy, there was considerably more morbidity and mortality. If you go back far enough in time, there were no vaccines, and considerable mortality from infectious diseases. People who think like the movie authors rarely thoughtfully think through the limitations of alternative medicine – and people get hurt as a result. This is why people like me, continue to push back.