I hate regulatory capture as much as anyone, but this makes for a more damning-sounding headline than it actually is. To steal a comment from Reddit[1] user NewInThe1AC:
> 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
It's been widely understood since the 1970s, if not longer, that opioids have a high potential for addiction and that long term use tends to be harmful. Sure, he seems to have been quite a junior employee, but I knew opioids were a high risk category of drugs when I was in high school. I don't think he's the worst guy in the world, but I do think McKinsey style consulting and this experience in particular is a net negative.
When I was in my mid to late 20s I was at a consulting firm and later in government directly. I wasn’t assigned to anything particularly objectionable or anything, but I’ve looked back on it a lot and it’s heavily influenced how I operate in the tech industry now, 20 years later. In government and in consulting I saw a lot of misaligned incentives that led to empire building, duplicative efforts, and treatment of individuals that I didn’t really find to be effective. And today, I’m really good at spotting that and stopping it quickly, because I think much of that was not the best way to operate. But I didn’t immediately get into it and realize it wasn’t how I would run things - and experiencing being part of the machine for a bit first taught me lessons that I would not have learned as an outside observer.
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.
Potential for addiction yes but we are looking at it from the lens of a post Purdue media bias. People abuse plenty of drugs that aren't opioids and we aren't say seeing a big push against Xanax for example because that wasn't in any crosshairs of media spectacle. People die on Xanax but it doesn't seem to matter because people write them off as combining with alcohol or that they were addicts. And indeed most drugs of this sort are not particularly harmful if they are used within recommendations. At a certain point a doctor can't control what you chose to do at home with your prescription and that doesn't mean you shouldn't have people who would use it responsibly not receive it even if it means some will abuse it.
> At a certain point a doctor can't control what you chose to do at home with your prescription and that doesn't mean you shouldn't have people who would use it responsibly not receive it even if it means some will abuse it
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.
> 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.
I spend a good portion of my time in community service, mostly in areas where drug abuse is rampant. During this time, I've talked with a fair number of addicts, and I'd say over 90% of them stem from either being introduced to drugs by a friend (peer pressure) or following after the drug addiction of an existing family member. Generally, within a year or two, they were on the streets resorting to crime to fuel their addiction.
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.
I have never heard of someone on the streets directly for marijuana usage. Opioids are actually cheap to produce, expensive to buy.
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.
> I have never heard of someone on the streets directly for marijuana usage
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.
You have it exactly backwards. People got hooked by the doctors, and pivoted to heroin when they were tagged as pill seekers.
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.
Dentists were handing opioid prescriptions out like candy to teenagers getting their wisdom teeth out. How many of those kids were previously on heroin and were picking dentists who would hook them up?
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.
I got my wisdom teeth out at 16 or 17 and was given a prescription for oxycodone. I was really excited because I had read about oxy online and wanted to try it. But also I knew it was referred to as hillbilly heroin because of how addictive it was, so I had to be careful. I didn't take any of the oxy after the surgery and just took ibuprofen, so I could save the oxy for later on. I got high off it a few times and loved it. Later on I got a chance to try some hydrocodone and I thought that was even better, because the oxycodone was a little too much for me. I didn't nod off on the hydros. Anyway, opiates are great, that's why I haven't used them since high school.
we are looking at it from the lens of a post Purdue media bias
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.
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.
I have first hand experience of being addicted to benzos and drinking at the same time. I could have died. This was the Heath Ledger era, so I knew what could happen, but benzo addiction is so horrible that I didn’t care. I would go to bed some nights not knowing if I’d wake up. Fuck it. At least I could sleep.
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'm surprised your doctor didn't warn you about that. Growing up, I knew about benzos not from anyone taking it as prescribed, but as a recreational drug
Also the opioid epidemic actually did make benzos much harder to get. Atleast where I live, your primary doctor is very unlikely to prescribe them and instead will refer you to a psychiatrist. The people I know who were on Ambien or Atvian have been cut off.
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.
I hate regulatory capture as much as anyone, but...
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.
Opioids are not a particularly harmful to most people. The harm is in the addiction not the chemical. Opioids are useful for treating acute pain, such as after surgery. They are less useful for chronic pain but if the doctor and patient are able to responsibly manage dose escalation as tolerance develops they are also useful for chronic pain.
Yeah he was just an innocent marketing consultant:
“ 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.”
Are you trying to say this quote is painting him as not innocent? That really doesn't seem so sinister. Sinister would be buying billboard space in west virginia like something out of newport cigarettes playbook.
Yes, it is fairly obvious that he wasn't innocent based on that quote.
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.
> The high-prescribers were people operating out of strip malls, often with unclear credentials, and whose main clientele were opioid addicts.
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.
"Are you trying to say this quote is painting him as not innocent?"
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.
If you buy the assumption that “listens to patiens needs” = pill pusher maybe. I don’t think that is so black and white. The coupons also make sense to get ahead of competitors in a world of copays for most prescriptions.
No it's not. The issue with our society is allowing the people who built the system and created the incentives that caused it to get off without jail time.
A far bigger issue with our society is our willingness to brand someone forever based on what they did decades prior—we (as a society) pay lip service to the idea that people change, but we don't truly believe it.
It's the same punitive impulse that causes the permanent second-class citizenship bestowed upon anyone who finishes a prison term.
Generally, that problem is separate. The impact of little Eichmanns everywhere is greater than the loss of productivity from people convicted of crimes who can’t get a job later imo.
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.
> Our society is very forgiving if you propagate “faceless” evil. It’s unforgiving if there’s a human face to it.
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?
> 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…
But I do feel we as society participants should not be bkinkered from recognizing social-scale pathologies in the atomic units that form our society. Those atomic units are individuals - their decisions, actions, and yes their career-paths.
I'm reading a book on McKinsey now titled "When McKinsey Comes To Town". Given the firms track record finally coming to light it's amazing that working at McKinsey is a career booster instead of a black mark. Hopefully more people start to realize that putting the most ruthless business minds in charge of public healthcare leads to poor outcomes.
I'd recommend reading the book, it is a bit of a downer though
Calling the 20-somethings who choose the MBA route and all start their career in consulting “the most ruthless business minds” is giving them wayyy too much credit.
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.
You're acting as if the 20-somethings were holding the reins. They absolutely were not -- they were looking to the higher-ups for guidance and authority. The term 'banality of evil' comes to mind in regard to the limited knowledge the underlings had and how firmly they were held under control by those directing their actions.
The “higher-ups” you speak of are just the top PowerPoint jockeys who get promoted extremely fast — all professional services firms are highly incentivized to give people fancy titles so they can bill them at higher rates.
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.
The interesting question is why the mayor is sticking with him. That seems like a major change in the embrace of corruption recently. What does the mayor gain politically by sticking with this guy?
> That seems like a major change in the embrace of corruption recently
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.
This guy is a classic example of failing upward. Goes from parasitic consultant at McKinsey. Consulting/devising strategy to market opioids to masses. Then to _medical_ director at MassHealth. Then to director of Medicaid and CHIP. And now a public health chief.
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.
(I believe the firm you're referring to is the aerospace company McDonnell Douglass which in hindsight may be being seen as having brought a more financial accounting orientation to Boeing)
..and o/w your point is well-taken, thank you for the instructive comment.
SFDPH in general has been moving in a more corporate/consulting-BS direction in last several years, guessing that will accelerate with this individual. Their transition to Epic EHR across the system has heralded a new era of squeaky-clean product/project managers who sling massive Agile jargon but don't actually understand the technical/compliance processes involved that affect orgs like mine who have to integrate with their systems (basics like not understanding the limitations of numerical precision in Excel data types affecting .CSVs, Unix vs. Windows line endings, BOMs, leading zero truncation, demanding tons of excess PHI in billing records for de-duplication).
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).
The people doing the bulk of the corruption here in the US just decided to stop even trying to hide it. Why would they hide it at this point? They aren't even worried about the optics anymore, they are sending a clear message imo. There's like a handful of people in high positions who aren't corrupt, and all of the ire is aimed at low level employees. I wish I could say that I didn't know why, but it is pretty clear.
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.
What I am concerned about is the increasing number of bean counters and MBA-flunkies filling positions where technical or medical expertise should be required.
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.
Say something spicy on Facebook: lose your job. Make a living pushing prescription painkillers triggering an opioid epidemic: awww shucks guys, he deserves another chance.
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
I have never seen an SF news publication being truly critical of the politicians that lord over the city and state. These publications will criticize the situation and blame factors, but never individuals and their actions. Never expect accountability from them.
In my experience people think 'the media' is biased, etc., but when they examine a particular article (from a quality source) they think it's good. That seems to be human nature: Politicians are corrupt but I like my local representative. Obamacare is terrible but I like my ACA health insurance.
The reason we hire established hackers for pentesting/red teaming is because the work is the same no matter which side you're on. This isn't the case with drug distribution or whatnot; like doesn't cure like when it comes to most problems. To me, this is akin to hiring a mass shooter to solve gun violence.
This looks bad of course, but isn’t he also someone who knows about how this stuff works and has lots of relevant experience building messaging strategies to achieve a goal? Sounds like the guy you’d want handling the opioid epidemic.
Illegal drug markets are a bit more complex than you seem to believe they are. Please read more deeply on the topic, it's not something I can just inform you about in a HN comment.
> 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...