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Like most of us, Dr. Albert Bourla remembers the first time he heard about a novel coronavirus that was spreading only in China.

BOURLA: The first thing that came to my mind is, “I have thousands of people working for us in China. I had manufacturing sites, I had research centers in China.” And we were just monitoring the situation, but with an eye that this is only China.

Of course, the situation didn’t stay in China. As the coronavirus began its march around the world in early 2020, it became clear that the disease it caused — COVID-19 — would be impossible to contain.

BOURLA: In February, things started to getting more and more visible. From Asia, things went into Europe and went straight to Italy. And I started worrying about it. And I traveled a week after, and that is when I realized things are going to be very bad. My name is Albert Bourla. I’m the C.E.O. of Pfizer since 2019.

As he flew home in early March of 2020, Albert was already forming a plan.

BOURLA: I decided to take the plane and go back immediately. And on the plane, I realized that that’s affecting the whole world. So, I was having time to reflect, what do we need to do? And what is our role?

From the Freakonomics Radio Network, this is Freakonomics, M.D.

I’m Bapu Jena. I’m a medical doctor and I’m also an economist. Today, you’ll hear my conversation with someone who, in a way, also straddles these two worlds — and a few other ones, too.

BOURLA: When I was elected as C.E.O., the first statement that I made to my board members was, “Only in America.”

We’ll talk about Albert Bourla’s unusual path to this high ranking role, and about his new book Moonshot. In it, he describes developing a COVID vaccine in record time. But, not just any vaccine.

BOURLA: My scientists came and said, “Let’s try mRNA.” And that was very counterintuitive. I challenged the decision. I said, “Are you kidding me?”

We’ll also explore why decision-making in general can be so hard, even for — and maybe especially for — people at the very top.

BOURLA: When I took the job, I felt that there is something that you can’t be prepared for, and I found it very challenging. And this is that the buck stops here.

And: Albert tells me why he thinks the way people view his industry might be changing.

BOURLA: In the pandemic, in a very profound way, we were able to show that there is a good reason for our existence.

JENA: What do you prefer to be called? Do you want to be called Dr. Bourla? Albert? Chief Bourla? Chief Albert? You just tell me.

BOURLA: Usually it’s Dr. Bourla, but for you, Dr. Albert.

JENA: Dr. Albert.

BOURLA: No, no, no. I’m kidding. Don’t — don’t even — don’t dare. No, you — Albert, please.

If there’s a typical route to becoming C.E.O. of one of the largest and most influential pharmaceutical companies in the world, it feels like Dr. Albert Bourla, or Albert, didn’t take it.

BOURLA: I’m Greek by nationality. So, I was born and raised in the second-largest city of Greece. It’s called Thessaloniki. Actually, it’s a very historic city. It’s not very well-known, but it was named after the sister of Alexander the Great. and it was founded 2,300 years ago. So, it’s a very old city. I became a veterinarian. I was 18 when I make the choice with an immense love for animals, and I liked medicine. And that’s what I felt is the best combination of the two.

JENA: So, when you were six years old, you didn’t anticipate becoming C.E.O. of a drug company. Would that be accurate?

BOURLA: Not to Pfizer, but I knew that I will be famous and great. Actually, when I was six years old, I remember telling my father I wanted to be Tarzan. And when he asked me why, I said, “Because I think Jane is very beautiful.”

Eventually, he got over Jane, as one does, and obtained his veterinary degree. But Albert was beckoned by the world of research — which is exactly where he thought he’d stay.

BOURLA: I finished my Ph.D. and all I wanted was to make a career in academia. I never felt that I will do something else, and I never thought that I would leave my city, Thessaloniki. Pfizer came with an animal health business. It was in Athens. And they tried to recruit me, and they tried really hard. And so, they put an offer in front of me I couldn’t resist. So, that’s how I joined Pfizer. I didn’t know two things. One is that within few months I will fall in love with the private sector — what I thought was the antichrist at the moment.

JENA: I thought you were telling me like how you met your wife, but okay. This is your second love that you fell in love with first, I guess.

BOURLA: My wife is the big love. That was the first love. And I decided to stay. So, that’s the first thing that I didn’t know. The second thing that I didn’t know is that this first reluctant relocation would be the first of nine I did with the company. I lived in nine different cities of five different countries with Pfizer. Most of my career in the 30 years — I’m having 30 years next year — 17 of them was in the animal health group, not in the pharma group. I grew up in the ranks of a division — very small — Within Pfizer. We had to fight to get resources in very different ways. We had to learn to do things in a very nimble way. So, when I joined the pharma, I was really able to see things that others that grew up in this business — they couldn’t. I think that helped me be different, at least.

As Albert moved from city to city and country to country, he climbed the ranks within Pfizer. In 2018 he became Chief Operating Officer in 2018, and the following year, C.E.O.

JENA: Do you enjoy what you do?

BOURLA: I do. I do. I don’t enjoy losing. I hear many people saying, you know, “I like challenges.” Well, I like challenges when I can win. I don’t like a challenge when we failed. I like when the study shows that the cancer patients, lived more on this drug. And when I see that we didn’t have an impact, you know, it’s a tremendous disappointment. You want to be the one that you present the solution to the cancer patients. You can stand up and say to a father or mother that “I have a solution. Don’t worry. You will see the graduation of your daughter or the wedding of your son.” It’s very bitter — the sense of failure in clinical development.

JENA: Anybody who takes care of patients probably say the same thing, because there’s a very direct attachment between who they’re taking care of. They see the pain, they see the hope, and when things don’t work out it’s very difficult to sort of remove yourself from that. But, you know, doctors and other health care providers probably learn how to detach themselves in that way. You’re obviously many, many levels higher, but the impact, potentially, is much, much greater. You’re not talking about one patient, but thousands or maybe millions of people who are affected by an up or down outcome on a drug. But still that component is there for you.

BOURLA: Oh, very accurate. Very accurate. During the studies, during the whole development of the program, usually I meet with a lot of patients. We know people that participate. And, you know, it’s really very painful when you fail. It is very, very rewarding when you are successful. I became C.E.O. in 2019. I felt that I was preparing for that the last two, three years. As part of that process, I learned not only to do a lot of the parts of the business, but I learned to speak to investors, to the press, the politicians, to the field to do all the things that maybe a C.E.O. would do. I was very surprised, however, that when I took the job, I felt that there is something that you can’t be prepared for. And I found it very challenging. And this is that the buck stops here. You can only feel it when you are C.E.O. because you are alone. You’re the ultimate decision maker. Before, I knew that there was someone above me that can stop me if there is something stupid. So, there was filters. Now I felt suddenly that there is no one that they can do that. So, I started being very conservative and started thinking and double-guessing two, three times, everything. Until someone told me, “Look, it’s not the conservatives that brought you here. It is that the board appreciated that you have an appetite for risk — that you are thoughtful. They trust you. So, don’t be conservative.” And then this is when I started realizing that I need to adapt to this level of responsibilities and do the things that I know, or I feel are the right things to do. That was the biggest thing of the adjustment.

JENA: One of the most compelling parts of the book, Moonshot, was sort of how you describe the early stages of the pandemic when we’re starting to hear news about a new virus in China, the genetic sequence was being identified. Can you walk me through that time for you both as an executive at Pfizer, and also personally?

BOURLA: The first thing that we learned with this pandemic was not a pandemic, but it was a situation in China. We realized that in China, there is a health issue. And that was the first thing that came to my mind is — as the C.E.O. of Pfizer, I have thousands of people working for us in China. I had manufacturing sites, I had research centers inside, in China. So, we formed a task force to see how we can protect what needs to be done. So, we started implementing some measures. For the first time, we told them stay home, which was unthinkable for us, and then tried to work through our systems. And we were just monitoring the situation, but with an eye that this is only China. In February, things started to getting more and more visible. And particularly, we started seeing from Asia — things went into Europe and went straight to Italy. And I started worrying about it. I had a discussion with our board that was in February. Still, no one was thinking that this is anything like that, right? We are all in the meeting room. And I traveled a week after, and that is when I realized things are going to be very bad because I am traveling to participate in a Congress. Suddenly from Italy, things are moving to other European countries, and the Congress is canceled. So, I decided to take the plane and go back immediately. And on the plane, I realized that that’s affecting the whole world. So, I was having time to reflect, “What do we need to do? And what is our role?” And I wrote down three things.

The first was: What do we do with our people? So, we need to find solutions, how to make sure that they are not going to get affected. The second was the hospitals and I.C.U.s. I saw in China that they had tremendous surge of hospitalization. And when I asked our local guys, they told me that the main problem over there, it is that people died because they can’t give them enough hospital care. Because they don’t have enough beds. Because they are all getting sick the same time. But this made me think that we are one of the biggest supplier of injectable products in the world. Products that are used in I.C.U.s are made by Pfizer. And I was thinking, how can I maintain a supply that — the demand will go — not two or three, 40, 50 times, in some medicines, very specialized medicines — how to maintain that and the same time, work on their social distancing type of isolation. That was a very big challenge for us. And the third was I wrote down, I mean, we have the biggest research engine in the world. We need to work on vaccines and treatments.

JENA: Why did you choose the mRNA platform versus any number of ways you could have tried to develop a vaccine?

BOURLA: I was very reluctant to choose it. Moderna, the decision for them would be, shall we do a vaccine or not? There was only one way they can do it — mRNA. This is where they are good. Ourselves, we were mastering all technologies. But my scientists came and said, let’s try mRNA. And that was very counterintuitive. I challenged the decision. I said, “Are you kidding me? You want to put in a pandemic all our bets into a technology that never delivered a product? Why don’t we go with something else?”

And we sat down to discuss it. So, I was convinced by their arguments. The first one was we were working with this company — with BioNTech — to develop a flu vaccine for the last few years. And we had matured this technology significantly to make a flu vaccine. So, they were feeling that it was ready to deliver the product. The second is we focused on: What are the benefits if we are successful? And the benefits were very, very impressive. With mRNA, you can move extremely fast. You can do in weeks, things that you take months with other technologies. So, that was a very big plus. With mRNA, you feel that you can boost as many times as you want. It’s not easy to boost with adenovirus because every time you, you are boosting, you’re not creating only antibodies against the coronavirus, but also against the adenovirus, which is the carrier. And that could reduce the effectiveness of your vaccine. In terms of variants, you want it to be able to scale up manufacturing in a quick way. And in the mRNA it’s not the biological production. You don’t have some bacteria that they are making your vaccine eventually So, you can really, plug and play in the mRNA. You can take a new variant, put it in the same vaccine, and then the vaccine is completely different, although it is basically everything, the same vaccine. So, all of that were the things that convinced me to go with this bet. But it was a very difficult decision for me.

Coming up after the break: Albert and I reflect on some other difficult and big decisions he’s made during the pandemic.

BOURLA: We were in a race. We wanted to bring a vaccine, and actually, I wanted to win. I wanted to be the one that will bring the first one.

Also, how will we coexist with this virus moving forward?

BOURLA: I think the most likely scenario is that the virus will be around for years.

I’m Bapu Jena and this is Freakonomics, M.D. More of my chat with Pfizer C.E.O. Albert Bourla — after the break.

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It typically takes five to 10 years to develop and manufacture a vaccine, and often it takes even longer. It’s a process that entails not just making the vaccine itself, but testing it in phase one, two, and three trials that assess things like safety, dosage, immune response, and efficacy. Then, there’s the regulatory process, which can also take months, if not years. And finally, if it’s approved, the vaccine has to be manufactured at scale. Pfizer and the other pharmaceutical makers brought their COVID vaccines to market in less than a year.

So, what was it like to receive word that the mRNA vaccine worked?

JENA: What was the email like when you got the first results from the phase-three trial? How long did that euphoria last? Was it, like, an hour, two hours, three hours?

BOURLA: No, that last quite a bit because I didn’t allow people to communicate to me after a while. It was not an email. It was actually live, waiting to hear the numbers. We gather five of us in a very small office in a Connecticut site that we have. And then, we were waiting to hear back when this committee, which is an independent committee of experts, will unblind the data and see what’s going on. They were late, so that makes you worry. You always think if they’re late, that’s bad news.

It was 20 to 2, something like that. They sent an email: “We have the data. Please assemble.” So, we went to a meeting room with a protocol, how things should be communicated. They were late. We were in a Zoom call, and they were not coming. So, again, I was very nervous. I would say, “I think they do it on purpose to punish me for everything I did to them all these months, torturing them with, ‘I want it faster, I want it faster.’” They told us the news that it was successful in an interim analysis. I jumped from my chair. It was an amazing moment. And then 10 minutes later, they — in a smaller group, even — they told us what is the efficacy. That was the most material information in the world at that time.

And then someone told me the info — the numbers, and I didn’t hear well. He told me 90, and I heard 19. And I said, “19 or 90?” He said, “90.” I said, “Nine-zero?” He said, “Yes.” I said, “So what, what is the efficacy?” And then he told me, “95.6.” And I looked our legal counsel, I said, “What is this? I mean, this is — what are you doing? And then we discussed how, and then, then we decided we need to communicate very fast and everything. Then I started going from there very fast to communicate it the next day at six o’clock in the morning.

The decision to go with the mRNA platform for Pfizer’s COVID vaccine might seem obvious in retrospect, as good decisions do. At the time, though, no one at Pfizer — including Albert — could be sure that risking so much time and so many resources would pay off. It’s hard to consider the alternative.

BOURLA: It would be a very big disappointment if we were not successful. I think if we were not successful, clearly Moderna also wouldn’t be successful a little bit later, and the world would be in a very different place right now. So, one thing it is, okay, we failed. I would have to write off 2.5 billion dollars — but that’s nothing compared to what the world would be entering in the face of darkness and the — I mean, unbelievable. So, thank God it was positive.

Albert told us that the decision do go with the mRNA platform was the hardest decision he had to make as C.E.O. So, I wondered:

JENA: What was the second-hardest decision you had to make during the pandemic?

BOURLA: Not to take the money from the government. Again, as C.E.O., it was a time that — it was the Operation Warp Speed, and they were giving money like there’s no tomorrow. Whoever was raising their hand could take as much as they wanted because people were scared. Now, why I didn’t take the money was because when you take money from someone, never comes without strings attached. The fact that these are taxpayers’ money. They better check where the money are going, and the back of the check, how you spend them. But this is what I wanted to avoid. we were in a race. We wanted to bring a vaccine, and actually, I wanted to win. I wanted it to be the one that we will bring the first one, this vaccine. And by taking the money, I knew that my scientists will have to sit in numerous committees of people from wherever — N.I.H., Operation Warp Speed, C.D.C., everyone in existence to be able to make a decision. I didn’t want that. I wanted to be isolated from all of this bureaucracy. We had enough bureaucracy internal the company. So, I said — it’s you and me. So, we will all be meeting twice a week. Everybody who is needed for a decision. And we will discuss it all together, and then there is someone who can make a call in this meeting. And it’s me. So, I could hear everyone, and then we move, we move, we move. This is how we were able to move fast.

JENA: Prior to the pandemic, have you ever made anything move so quickly with any other disease or product?

BOURLA: We had successes in our research programs, but we never have something of that speed.

JENA: it makes me think, though, what you were able to do because the stakes were so high in the pandemic — does that tell you anything about whether we should or can move quicker in other areas?

BOURLA: Well, if we were able to make a vaccine in nine months instead of eight years, you can tell what that could be the impact if we were making heart attack treatment or cancer treatment, or a rheumatoid arthritis treatment, or atopic dermatitis treatment. All of these diseases that they area big, big burden to humankind. It’s not easy, though. One it is that the conditions that we were living were truly unique. So, it was not only that we put all the money and all the resources, but everybody put their time 24/7. They couldn’t sleep for three, four weeks, maybe. Difficult to replicate something like that. So, I think you can replicate a very large part of it. And it is a question of culture, how to think big, how to do things out of the box. And there’s not only us. We’ll require the regulators to do the same. You need two to tango. Also, F.D.A. and the regulators, they will have to do the same. We can’t just say, “Now let’s go back to normal. We’ll be again, three, four months,” when you saw that you can do it in a week.

JENA: What does the future hold for the pandemic? What is your sort of lay of the land for the next few years and maybe even further? Do you have a sense?

BOURLA: We must have a vaccine that is administered annually. If we have vaccines that either we don’t know how long will last, or we know that will last, let’s say, a few months, the compliance of the people with the recommendation of the health authorities will go down. I’m certain. I think the most likely scenario is that the virus will be around for years. Thank God we have treatments also now, which we didn’t have before. It’s not only the vaccine. I think the situations that we are entering now, it’s even more important than treatment. That those that are getting sick, they will not end up in hospitals and die and will be just a few days home — hopefully, for most of them, not all, but for most of them. But this is where I think things are going. So, we need to make sure that we have treatments available, and we need to make sure that we develop a vaccine that lasts a year.

It’s been a struggle to get some people to take their first, second, and now third or fourth COVID vaccines. Only around one-third of Americans are boosted. But there’s still an entire group for whom vaccination hasn’t even been an option: children under five. Albert and I talked about this too, and he said Pfizer expects to submit its data this month on the efficacy of a three-dose series for these kids, and that adding a third dose seemed to provide substantially more protection against COVID, compared to just two doses.

Also, the treatment Albert just mentioned refers to an antiviral drug from Pfizer that you’ve probably heard of. It’s called Paxlovid. The initial approval study included symptomatic, unvaccinated people with COVID-19 who were at high risk of severe disease. When they Paxlovid early in their infection, it reduced the risk of serious illness or death from COVID by around 90 percent. After briefly being in short supply earlier this year, it’s now readily available for high-risk COVID patients over 12 years old. It’s an important tool in the fight against COVID, but I wanted to ask Albert about some recent news concerning the drug – because the makeup of the people using the drug now — mostly vaccinated people — isn’t the same as the population in which the drug was studied.

JENA: I’m sure you have seen these reports of people who take a course of Paxlovid for five days they get an improvement in symptoms, they test negative, but then they test positive and they actually notice a rebound of symptoms after day five. I know you’re not a virologist, but I’m curious what you think is going on.

BOURLA: We are looking into it. We have looked into the data that we have in our clinical trials. We show a very small percentage of this occurring. But I think the general explanation, it is that without myself being virologist, is that Paxlovid is not 100 percent effective. Right? It’s reducing hospitalization and death 90 percent. And also, you know from the start is that it’s not reducing to zero the viral load. Your immune system should also do the job after this dramatic help. So, the remaining virus, you should clean it. Not everybody will do that because not every individual is the same. I think everything will happen in biology, but 90 percent of the people will not go to hospital or we will reduce the number of people that go into hospital by 90 percent. So, let’s focus on how many lives are saved.

JENA: I want to kind of reflect a little bit on your particular sort of personality and role as a spokesperson for the company. I mean, you have a different background than many C.E.O.s do. And I’m curious, how do you think that’s helped you?

BOURLA: I come from humble beginnings. I come from a country that has a very great heritage and gave democracy to the world, but it’s not known for giving a lot of C.E.O.s to the world in the modern history. I have a very heavy accent. When I was elected as C.E.O., and they called me in the boardroom to tell me that I was elected, the first statement that I made to my board members was: “Only in America.”

JENA: There’s a perception of pharma that’s often historically been quite negative. Why do you think that is? And has that changed as a result of the pandemic?

BOURLA: It was very bad. The the reputation of the pharmaceutical companies was as bad as the reputation of government in polls. It’s actually in many cases, government was higher. How can you lose from government in that? It’s admirable. It was for multiple reasons. Let me start. It was because a lot of the companies were not doing the right thing at certain points. So, we start with the responsibility of us not doing the right thing — in pricing, in the way that they were promoting things. The second is that health is in the forefront of every political debate. And in the political debates, it’s easy to find someone to blame. And it’s much easier to blame someone who is unknown — there is no face of pharma company — than, for example, to blame a hospital, when you know the nurses, you know the doctors. So, for multiple reasons, the reputation was very bad, and the pharma was not able to demonstrate to the world the value that they can bring until pandemic. In the pandemic, in a very profound way, we were able to show that there is a good reason for our existence. And there are so many good things that can come out of us. And that raised the reputation very, very high. Now, the reputation is something that you are earning in drops, typically, but you can lose in buckets. But I know that we need to earn this trust and the reputation every single day.

JENA: So, all four of us in my house — with my wife, who’s a doctor, and two kids — actually have Covid this week. And I’m sure you’re thinking about Paxlovid in kids, but I will tell you that I have a new discovery that you should consider, and it’s an iPad. I have found that the iPad reduces symptoms of the kids and there is an interaction with ice cream and popsicles that I’m sure is perhaps maybe 25 percent as effective as Paxlovid or any other drugs in kids. So, you just keep that in the back of your mind for a little bit.

BOURLA: I’m going to try to make a deal with Apple to see if we can bring that to market.

JENA: Yeah. All right. Perfect. It might be hard to get an I.P. on it, but you know, you could try. All right, well, thank you so much. I appreciate this.

BOURLA: Thank you. Thank you, Bapu, and I enjoyed this discussion a lot.

That’s it for today’s show. My family and I are feeling better now, by the way, and we’ve managed to wean the kids off their iPad/ice cream regimens. I want to thank Dr. Albert Bourla for taking the time to talk with me. And, check out his book Moonshot: Inside Pfizer’s Nine-Month Race to Make the Impossible Possible. It’s really quite a page-turner, even though we already know the ending.

And coming up next week — a rebroadcast, with some twists, of an earlier episode of Freakonomics, M.D. on whether barbershops can improve health care — and health outcomes — for Black men.

MUHAMMAD: I noticed some guys would come and get their hair cut and stay. And then you just said to yourself, “Why is he still here?” Well, there’s a vibe here. There’s a community here. There’s a conversation going on. This is the community hub.

We’ll also discuss some new research of mine that looks at why representation is critical in medicine — and why it can be so hard to find.That’s all coming up next week on Freakonomics, M.D. Please, let me know what you thought about today’s episode. I’m at BAPU at Freakonomics dot com. If you want to learn more about the show or check out the transcript for this episode, that’s all at Freakonomics dot com. Thanks for listening.

Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, People I (Mostly) Admire and Off Leash. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Julie Kanfer and mixed by Eleanor Osborne. Our staff also includes Neal Carruth, Gabriel Roth, Greg Rippin, Rebecca Lee Douglas, Zack Lapinski, Morgan Levey, Ryan Kelley, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, Jacob Clemente, Alina Kulman, and Stephen Dubner. Original music composed by Luis Guerra. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

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JENA: So, how do you unwind after a busy day? Like, do you have time to relax in the evenings at all?

BOURLA: Oh, yes. I do have time to, to relax, and I wish I could say I’m reading German literature, but I’m not that sophisticated. Or philosophy.

JENA: So, do you watch Netflix or —

BOURLA: I watch Netflix a lot.

JENA: All right. So, you watch Netflix — by the way, you don’t share your Netflix password with other family members, right? Just to be clear.

BOURLA: It was stolen, unfortunately.

JENA: It was stolen. Yeah, exactly, yeah. Say it was stolen by my close personal friends and family.

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