Medical Examiner

Confessions of a Washington Swamp Creature

Trump doesn’t understand the revolving door in Washington. Neither did I, until I went through it.



Like so many other things, the revolving-door process in Washington has been spoiled by Donald Trump. You know the revolving door—the trick where lifers in government, those pasty drones with sunken chests and droopy clothes, leave their cubicles after a few decades for sunshine and high(er)-paying jobs in industry. At long last, they trade up their insider expertise to help companies that need to learn how to tiptoe at the edges of some laws. They sell out, sort of, and up their annual income by $20,000 or $30,000 a year. Plus benefits.

It is an accepted if sleazy part of the American dream, the grand seduction that keeps so many crawling forward day after day and year after commuter year. It’s also the kind of stuff that compels our new president to berate the entire city of D.C. as a swamp of people just wanting to get paid—a typically unbelievable angle for a wealth-obsessed billionaire, but there you have it. (Unless one considers his “drain the swamp” mantra as step one in a real estate move—witness the Jersey swamplands where now sit a football stadium; a fake ski hill; shopping; and of course hotels, many, many hotels.)

The old, timid lifer mousing through the revolving door has served so many in government for so long that surely the trick will never die. It is too neat a fit, too satisfying a final act. But is Trump right? Does this sort of shape-shifting make D.C. an irredeemable swamp town?

Recently, I joined the ranks of government-to-industry employees, spinning through the same revolving door. Once an honorable government adviser, I became a grubby merchant of avarice. This is my story.

From 2008 to 2011, I was a formally appointed member to the U.S. Food and Drug Administration Anti-Infective Drugs Advisory Committee. In the role, I was an unpaid volunteer who used my professional expertise gained from 20-plus years as an infectious disease specialist to sit with a dozen or so of my peers and a sprinkling of FDA staff in judgment of new antibiotics. We were asked to recommend to the FDA leadership whether the new product was safe and effective enough for the American consumer.

To make these assessments, we listened to many presentations from pharmaceutical companies, analyses of the data, and citizens who had personal stories about infections or drug allergies. And then we would vote. We stood as the last chance to just say no to new drugs, a final check and balance against the forward thrust of a half-trillion–dollar industry.

I was quite sad when my term ended—I had been proud of the work and intoxicated by the bracing Mr. Smith Goes to Washington sensation of working for the public good. Plus, I liked the rigor of poring over binders full of raw data and drawing consequential conclusions.

But as my term ended, the ride was just beginning. Immediately after I got my handshake and government plaque, I started to receive emails from my pharma bros asking me to participate in “mock FDA” meetings. Given my perceived insider-trading potential, I had become a quick meal for the ever-looming vultures of industry. Their theory was that, if seated correctly with the correct slides, correct coffee, correct Danish, and correct tension in the air, I would provide the drug company with some magic insight that could move its new drug from “Maybe” to “You betcha!”

I should note that the invites contained no wink, no heh heh heh, not a whiff of self-aware “Um, I know this is weird since you just finished serving your country for no pay and without much thanks, but we were wondering if you would like to spill your beans to us for a handful of cash?” Nope, as I learned quickly, this is the way American bare-knuckled business is conducted. Das Kapital in real time. Of course they would look for any edge they could. Of course they would try to hire up anyone who knew anything about anything. After millions of bucks to get the product out of preclinical then early clinical trials, what were a few thousand more dollars handed off to some polite hang-dog specialist to twitch and mumble for a few hours? If this could push the process forward a little bit, surely it would be worth it.

Initially I deleted the emails within moments of receipt. I was disgusted that they, the pharmocrats, thought I could be bought. Shocked, in fact! Me?! I am an honest man with no desire to be a swamp creature! And after a couple of years, the offers stopped. Word apparently got around that I was a dead-ender, either too confused or too busy or maybe too hoity-toity to deal with.

But then inexplicably, a few years after the last nibble, I became hot again: The offers returned. I’m not entirely sure why. Though I once danced with industry, I don’t seem to be on any lists cataloging easy targets, though you can see how the companies report out who has sticky palms (here are the lists for Pfizer and for Glaxo). Perhaps pharma was having trouble scraping together people given new industry requirements that doctors must disclose the dollars they made doing this.

Another factor in my slew of offers was likely that the vexing trend toward FDA-pharma miscegenation had entered the minds of those worried about such things as the public interest and fairness and democracy. The New York Times published a scalding editorial entitled “Conflicts of Interest at the FDA” detailing a way too cozy back-and-forth between the FDA and industry experts in the field of dietary supplements—an area already rife with sleaze-onomics. The fox, it suggested, was now guarding the henhouse. In the hubbub around this controversy, likely many doctors felt too embarrassed to grab the pharma handout—ergo my reborn popularity.

At any rate, I decided to go for it. What better way to sort all this out than to go inside the belly of the beast and see what was what, then let Slate readers know just how slimy the slime actually is.

So I said yes to two offers, and off I went, flight crisply arranged by a travel agency, seat selected, limo driver awaiting me with the correct spelling of my name, (faintly) swank hotel at the ready. For an entire two days, I was a mock adviser for two actual products and paid many thousands of dollars for my trouble (since donated to Planned Parenthood).

My mornings on the sellout circuit included a bounteous breakfast complete with hot food, juice selection, and cloth napkins; a comfy chair at a U-shaped table; and one of those familiar 300-page notebooks full of data. I sat with a handful of my swampy academic colleagues and a retired FDA vet or two listening to presentations by the drug company pushing the product. We then pored over its clinical trial results—slowly, painfully, thoroughly. Then lunch. Then more presentations and more clawing and scratching through tables and figures. Then discussion.

By the end of the all-day exercise, I came to appreciate that though the premise, the surroundings, and the means of arrival surely were problematic, the actual work was anything but. No one gave spin suggestions or posited clever ways to hide warts. We were not the predebate prep team.

Rather we the sellouts were as nasty, peeved, dismissive, frowning, and impatient as we had been when we hadn’t been paid to be present. We spit back empty claims and harrumphed at half-assed “maybes.” In other words, we treated the data from the mock review with the same hard-boiled cynicism that we had treated data presented during the real FDA meetings. Sure, having a handful of embarrassed-for-their-greed academics together might have made each too ashamed to really shill, but I doubt it—we liked being tough and mean and fair.

And once I finished, I was done—no calls or emails or baskets of fruit; no visits from ex-cheerleaders. Perhaps my compadres were hustled up, but I doubt it. There was a clear distancing between the talent (us) and the dollars (them) that seemed to hold.

So I completed my stint as an underground man with even more certainty that it is (or was—we shall see just how Trump tries to twist this venerable agency) just about impossible to sneak a lousy medicine through the FDA approval process (unless the company lies). This is not to say all is rosy in the world of drug development in the United States. We have numerous pressing problems: the absurd cost for new agents (pricing, however, sits outside FDA purview); too many me-too drugs that help no one but investors; medication shortages; and the ethically complex problem of what to do about understudied, possibly dangerous drugs that represent a patient’s last hope.

But witnessing the system from inside and out and inside again, I felt that odd uplift you feel from serving on jury duty—initial doubt and dread, soon replaced by a throb of patriotism and respect for the clumsy process. It was nice to know that even in the phony hothouse of a mock survey, the bedrock power of accurate information will prevail.

If Washington is a swamp, it is not because of this particular revolving door. Yet Trump will continue to demonize these little-guy losers all after proudly nominating zillionaires to run his Cabinet. His will be a government defined not by officials getting rich after the fact by using information they learned serving, but by officials who will use their time in government to clear the tangle of regulatory nonsense to allow themselves—once this dang government service thing is over in a few years, or even during it, because why not—to go out and really make some bucks.

And they have the power to do that. The government committee I served on originally, the FDA advisory committee, is only that: advisory. Trump’s to-be-named FDA commissioner has the right of all FDA commissioners: to ignore the advice and decide about drug approval by himself or herself, as has happened now and again through the years. The Trump people recognize no moral imperative greater than the inalienable right to make a profit, a concept that, when applied to medicines, has the following tragic logic: No one has to take medications—it is a decision, not a decree. By swallowing a pill, you make a decision to accept risk.

Given what is at stake, it is possible that such a free-market approach to the FDA, though miles from the sadistic Affordable Care Act cannibalism now on display, will end up claiming more lives than any other mistake the new president will make.