0:00:07 The United States is one of just two countries that allow pharmaceutical firms to freely
0:00:11 advertise their products directly to consumers.
0:00:12 The other is New Zealand.
0:00:19 So if you ever watch TV in the US, you have likely seen many ads for prescription drugs.
0:00:22 But advertising doesn’t guarantee success.
0:00:26 The research and development of these drugs is very expensive, and most of them never
0:00:28 earn back their investment.
0:00:34 The pharmaceutical industry, therefore, relies on the occasional blockbuster drug.
0:00:38 A blockbuster defined as doing more than a billion dollars a year in sales.
0:00:44 If I asked you to name a blockbuster drug from the past, you might say Lipitor, a statin
0:00:51 originally from Park Davis, or Humera, an anti-inflammatory now sold by ABV, and can
0:00:54 you name a current blockbuster?
0:01:01 The first drug that comes to mind might be this one.
0:01:05 If you watch even a tiny bit of TV, you have probably seen an ad for Osempic.
0:01:11 Their jingle is sung to the tune of the 1974 pop hit Magic by a band called Pilot, which
0:01:16 had exactly one US hit.
0:01:22 Osempic, which is sold by the Danish multinational Novo Nordisk, is not a one-hit wonder.
0:01:29 It is one of a group of drugs known as GLP-1s, and many Americans would agree that they are
0:01:31 magic.
0:01:39 GLP stands for glucagon-like peptide, which is a hormone produced in the human gut, and
0:01:42 these drugs mimic the activity of that hormone.
0:01:48 Osempic was developed to treat type 2 diabetes, which used to be called adult onset diabetes
0:01:52 to distinguish it from the more serious type 1 diabetes, which most often occurs in young
0:01:54 people.
0:01:58 But those lines have blurred, as many more people around the world, including a lot of
0:02:02 young people, are now getting type 2 diabetes.
0:02:06 Diabetes is a condition whereby the pancreas can’t produce enough insulin to modulate
0:02:09 your level of glucose, or blood sugar.
0:02:15 Over the long term, high blood sugar can lead to all kinds of problems, so any drug that
0:02:20 could help the body produce more insulin would be a blockbuster.
0:02:22 Enter osempic.
0:02:24 But wait, there’s more.
0:02:28 Osempic and other GLP-1s don’t just lower blood sugar.
0:02:36 They also help patients lose weight, primarily by slowing digestion and decreasing appetite.
0:02:42 This secondary discovery, weight loss, was a big deal, especially in the US, where more
0:02:47 than 40% of the adult population is obese.
0:02:52 Even though researchers don’t know much about the long-term effects of GLPs, whether they
0:02:58 remain effective over time, whether they have serious side effects, the take-up has been
0:03:00 enthusiastic.
0:03:05 Osempic and Wagovie, another GLP drug made by Novo Nordisk, and which is authorized to
0:03:12 treat obesity, will do a combined $65 billion in global sales this year.
0:03:17 Novo Nordisk is now worth more than the GDP of Denmark.
0:03:21 And Novo Nordisk isn’t the only company making blockbuster GLPs.
0:03:27 Another big one is Moundjaro, which was brought to market in 2022 by the American pharmaceutical
0:03:28 firm Eli Lilly.
0:03:35 Moundjaro works by mimicking two digestive proteins, GLP-1 and GIP.
0:03:40 Most of these new drugs are, for now, injectables, although that will change and some are already
0:03:42 in pill form.
0:03:45 And these drugs aren’t cheap, at least not yet.
0:03:50 In the US, they can cost more than $1,000 a month, and as we will hear today, insurance
0:03:52 coverage varies widely.
0:04:01 Still, more than 15 million Americans are already using these drugs, so is the magic real or
0:04:03 maybe too good to be true?
0:04:08 I think your skepticism is well-placed, and that’s why we do trials to find out.
0:04:14 Today, on Freakin’omics Radio, we continue our December of one-on-one conversations with
0:04:20 Ezekiel Emanuel, who is pretty excited about these GLP-1 drugs.
0:04:25 This is why people do science, because you discover something and then lots of unexpected
0:04:26 effects happen.
0:04:33 Emanuel is an oncologist, a medical ethicist, a professor, and a healthcare policymaker.
0:04:36 He helped design the Affordable Care Act, better known as Obamacare.
0:04:40 He also worked on healthcare policy in the Trump White House.
0:04:46 In today’s conversation, we talk about why many insurers don’t want to cover the GLP
0:04:47 drugs.
0:04:53 We’ve created a system that perfectly disincentivizes long-term investments.
0:05:00 We talk about progress in cancer treatment, mysteries in the gut microbiome, and flaws
0:05:02 in the US healthcare system.
0:05:03 Don’t get me started.
0:05:06 We got to have a whole ‘nother conversation about that issue.
0:05:11 And we talk about what healthcare policy looks like in a second Trump term.
0:05:14 Even Republicans want everyone to have health insurance.
0:05:16 We’re not repealing the Affordable Care Act.
0:05:32 All that and quite a bit more with Ezekiel Emanuel starting now.
0:05:38 This is Freakonomics Radio, the podcast that explores the hidden side of everything with
0:05:49 your host Stephen Dubner.
0:05:54 If the last name Emanuel sounds familiar, it may be because Zeke Emanuel has a couple
0:05:59 of brothers who, over the years, have also appeared on this show.
0:06:04 There’s Ram Emanuel, former Obama Chief of Staff in Chicago Mayor, who was serving as
0:06:09 US Ambassador to Japan when we spoke with him in 2023.
0:06:18 Ram is known to be smart, tough, and reliably combative.
0:06:23 That episode was called the Suddenly Diplomatic Ram Emanuel.
0:06:28 When there is Arielle Emanuel, who runs the entertainment and sports firms Endeavor and
0:06:34 TKO, his business is high profile, but for himself he tends to keep a lower profile.
0:06:40 This may date back to his childhood as the youngest brother in a very competitive household.
0:06:43 Ari thought of himself as the dumb one.
0:06:47 You know, the grades would come up with poor cards on the fridge.
0:06:49 I was competing with Zeke.
0:06:50 There was no chance.
0:06:54 He was the debater, shut up.
0:06:58 That episode was called Ari Emanuel is Never Indifferent.
0:07:03 Zeke Emanuel is the oldest brother, the one who took the trouble to write a family memoir
0:07:05 called The Brothers Emanuel.
0:07:09 He leans more toward collaborative than combative.
0:07:14 He has also been on Freakonomics Radio before, most recently in an episode called Who Gets
0:07:18 the Ventilator, which we published early in the COVID pandemic, when ventilators were
0:07:22 thought to be an effective frontline treatment.
0:07:23 Here’s a clip from that episode.
0:07:29 If it sounds like it was recorded in a closet because of COVID, it probably was.
0:07:36 First comfort serve is the absolute worst principle you can think of in this situation.
0:07:41 That was a really interesting conversation about how medical resources should be allocated
0:07:42 in times of scarcity.
0:07:48 In the case of ventilators, scarcity was caused by lack of physical supply.
0:07:53 In the case of this new generation of GLP-1 drugs, there has been some supply shortage,
0:07:59 but the scarcity for many would-be patients is caused by their high prices.
0:08:04 High prices and inadequate coverage in the healthcare industry are always a topic of
0:08:10 great concern as we’ve seen lately in the fallout from the murder of Brian Thompson,
0:08:15 the CEO of the insurance firm United Healthcare.
0:08:22 I knew that Zeke Emanuel could give us a 360-degree view of the GLP revolution, so I began by
0:08:28 asking him when he first became aware of these drugs, maybe in medical school?
0:08:29 No.
0:08:32 I did not come across him in medical school, even though I went to Harvard Medical School
0:08:37 and a lot of the early work was done at the Massachusetts General Hospital.
0:08:39 Which is a Harvard-affiliated hospital?
0:08:40 Exactly.
0:08:42 Just down the block.
0:08:48 One of the groups at the Mass General Hospital was taking pancreases out of fish and then
0:08:53 testing how they affect glucose in other models.
0:08:58 And they ran across what’s called the proglucogon, a very long protein that makes glucagon, but
0:09:07 it also makes the GLP-1 agent that affects the glucose levels in the blood.
0:09:12 It was the 1990s when they showed that GLP-1s normalized blood sugars.
0:09:14 That was really important.
0:09:23 And then in 1996, researchers in Britain identified that the GLP-1s caused a loss of appetite.
0:09:29 Jens Holst in Copenhagen worked with Novo Nordisk, which is one of the big pharma companies
0:09:37 that has produced insulin and was very active in the diabetes field, to make the first GLP-1
0:09:40 drug for diabetes.
0:09:43 That was done by a woman named Latti Knudsen.
0:09:47 In 2010, they created that first drug.
0:09:53 And then in 2014, the indication was expanded to obesity because they saw that, you know,
0:09:56 diabetics also lost weight.
0:10:04 The GLP-1s from Novo Nordisk, Wagovia or Osempic, they are really impactful both in terms of
0:10:05 decreasing weight.
0:10:11 With Wagovia, you get about 15%, 16% weight reduction, but also very good at bringing
0:10:14 down blood sugars for diabetics.
0:10:20 And then when you add the other component, the GIP, Monjero, that’s the lily drug, you
0:10:24 get even more weight drop, 21%.
0:10:29 And we know that Wagovia, the GLP-1, has a lot of other effects.
0:10:30 It protects the heart.
0:10:37 A 20% drop in severe cardiac death from heart attacks, number of heart attacks, strokes,
0:10:40 goes down 20%, which is pretty amazing.
0:10:43 It protects from severe kidney disease.
0:10:45 It protects from cirrhosis.
0:10:49 And we’ve got hints that there are lots of other effects, psychiatric effects.
0:10:51 Addiction, you’ve mentioned.
0:10:55 Depression, I was going to say addiction, you beat me to it.
0:11:00 Or even because obesity and diabetes are associated with increased risk of cancer.
0:11:06 Honestly, as you described that, Zeke, it sounds like this class of drugs is too good
0:11:07 to be true.
0:11:13 You’ve called them a miraculous set of drugs before we get further into the upsides.
0:11:16 What about downsides and/or side effects?
0:11:19 As I like to say, even a blood test has side effects.
0:11:24 The major side effects tend to be with the gastrointestinal tract, as you might expect.
0:11:30 As he tends to be at the top of the list, diarrhea, constipation, some fullness because
0:11:34 it slows emptying of the stomach.
0:11:40 About a quarter of people have these side effects and it’s variable in how much people
0:11:41 experience it.
0:11:44 I’ve talked to people on these drugs and they have it minimal.
0:11:49 I’ve talked to other people and they have quit the drugs because they really found it
0:11:50 intolerable.
0:11:56 As you’re describing the multiple uses, treatment, but also prophylactic for all these different
0:12:01 conditions, it sounds almost as if you would recommend that these drugs go in the water
0:12:02 supply.
0:12:08 No, I am very enthusiastic, but there are some more serious side effects.
0:12:10 One of the most serious is pancreatitis.
0:12:17 That is inflammation of the pancreas can cause severe abdominal pain and other problems.
0:12:20 It’s pretty rare, but it’s not unheard of.
0:12:24 There’s also some cosmetic side effects when you lose the fat out of your face.
0:12:29 You can get this hollow cheek look and a lot of wrinkles.
0:12:35 I do think these could be more widely used, especially for people with obesity, but unlike
0:12:39 some other drugs that I do think probably need to be in the water supply, these need
0:12:41 to be used a little more selectively.
0:12:47 I’m curious how you and others foresaw how useful they’d be, not only for weight loss
0:12:50 and diabetes, but potentially all these other treatments.
0:12:55 I’m curious what your view of them was like, what the skepticism was like, and who’s skeptical
0:12:56 now maybe.
0:13:01 First of all, I was not fully focused on how beneficial they could be.
0:13:07 I have to give credit to Novo Nordisk and Lilly for doing trials that didn’t just look
0:13:12 at diabetes or didn’t just look at obesity, but looked at more outcomes.
0:13:17 For the clinicians who identified, “Wow, we’re seeing these other positive effects.”
0:13:21 People eating less, the addictions to alcohol and drugs going down.
0:13:25 I’m sorry to interrupt, Zeke, but on something like that, when you’re talking about clinical
0:13:29 treatment, doctor treatments, and they’re saying they’re observing that their patients
0:13:35 are having fewer problems in these other realms, whether drinking, eating, I mean, how empirical
0:13:36 is that?
0:13:40 Because I could imagine that someone who feels like they are improving on one dimension of
0:13:46 their life maybe changes their behavior in response to positive feeling, a kind of not
0:13:51 quite placebo, but something that was spurred on by one positive effect that has these other
0:13:56 positive knock-on effects as opposed to actually treating addiction and so on.
0:14:01 I think your skepticism is well-placed, and that’s why we do trials, to find out we’re
0:14:03 in a huge number of trials.
0:14:07 On the other hand, there are some things like looking at livers.
0:14:10 How does the liver change with these drugs?
0:14:12 That’s not going to be a placebo effect.
0:14:14 That is actually going to be a drug effect.
0:14:18 And something like addiction, especially things like alcohol and drugs, where we know it’s
0:14:25 so hard to stop, when you do see lots of people on these drugs stopping and reporting that
0:14:28 they don’t have the craving, you have to take that seriously.
0:14:33 That doesn’t mean it can’t be a placebo effect, but it affects the gut, it affects the pancreas
0:14:38 to increase insulin, and it obviously has to affect the brain if it’s going to affect
0:14:41 these addictions and psychiatric situations.
0:14:48 And that’s what is probably the most remarkable and unexpected finding here, that this big
0:14:53 protein somehow is getting across the blood-brain barrier or somehow is being released there,
0:14:58 and being able to affect people’s mental situation.
0:15:01 On all the reading I did on this, and I have to admit a lot of the science is really hard
0:15:06 for me, at least, and maybe many lay people to understand, but it sounds as though there
0:15:12 are a couple different mechanisms, or maybe different drug classes work in different mechanisms,
0:15:18 but it sounds as though there is a body effect, a kind of cellular body effect, and a brain
0:15:19 effect.
0:15:23 Is one drug causing both of those, or are they different drugs that do that?
0:15:31 Well, we don’t know for sure, but probably the same drug or some way that it’s causing
0:15:33 a pathway effect.
0:15:36 But that’s not understood yet, you’re saying, fully.
0:15:38 Probably the brain effect.
0:15:42 Sometimes great things happen that have multiple applications.
0:15:47 Since the end of the genome project in roughly 2000, we’ve had five big breakthroughs in
0:15:49 healthcare.
0:15:51 We’ve had CRISPR, where you can edit genes.
0:15:57 We’ve had gene therapy, where I use this term, the researchers are a little more cautious.
0:15:58 Really cure blindness.
0:16:03 We’ve had CAR T therapy, where again the researchers are a little more cautious, but you cure people
0:16:06 of cancer who are on their death bed.
0:16:12 We’ve had the mRNAs, and now we’re multiple uses for mRNA items, not just vaccines, but
0:16:14 in many, many other ways.
0:16:16 And you’ve had these GLP ones.
0:16:21 Each of these have way more ramifications than we ever thought possible.
0:16:26 Let’s take a step back on that front and talk about where research funding and research
0:16:28 incentives are coming from these days.
0:16:34 The five treatments that you’ve just named are evidence of how things are working in
0:16:36 medical science.
0:16:38 As we all know, a lot of these routes are very meandering.
0:16:39 They take a long time.
0:16:44 There are all kinds of failures and dead ends when you’re doing this kind of research.
0:16:49 How do you feel about the current state of moonshot medical advances?
0:16:54 And I’m especially curious to know how you would assess the private public collaboration
0:16:55 there.
0:17:00 Well, let me say we need public and private collaboration, because each part does different
0:17:01 things.
0:17:08 Mainly, the government invests a lot in basic research and tries to create understanding
0:17:10 of how these pathways work.
0:17:15 And let’s be honest, deciding what you’re going to fund is based upon judgment of the
0:17:19 community, and the community, like any community, has prejudices.
0:17:24 It’s pursuing one avenue rather than all the avenues.
0:17:30 And we know that sometimes has been an inhibition to good and high-risk research.
0:17:34 The government often doesn’t like to have failures on research.
0:17:40 One of the criticisms I have is the government has more or less ceded most of the clinical
0:17:42 research to drug companies.
0:17:48 Now, drug companies obviously have a big investment, but they have a particular kind of investment
0:17:55 comparing different drugs in the same class or comparing one drug, like GLP-1s, with another
0:18:01 drug like the SGLT-2s that might be used for diabetes.
0:18:05 That’s not so much in their interest unless they think they’re going to easily win that
0:18:06 race.
0:18:09 But the government should be doing a lot of that comparative assessment.
0:18:14 And yet the NIH has gotten — it’s not out of clinical research, but it’s reduced its
0:18:17 footprint in clinical research a lot.
0:18:20 And that, I think, is a bad thing.
0:18:22 You know, we need drug companies.
0:18:27 They can fund these big trials, but we have to recognize they have their own interests
0:18:33 at heart, which don’t necessarily correspond to the national public health interest.
0:18:37 We’ve got to have them because they know how to scale, they know how to market the drugs,
0:18:43 they know how to chemically adjust the drugs to increase how long they last in the body.
0:18:48 We can’t underestimate convenience is really important because for a chronic illness you
0:18:51 have to stay on the drug often forever.
0:18:57 I’ve heard you say that one big problem with medicine today is that 86% of all spending
0:18:59 goes to chronic conditions.
0:19:05 In the case of the GLP-1 drugs, widespread adoption would, I assume, over time bring
0:19:07 down those costs dramatically.
0:19:11 I know we’re talking about high costs in the short term, but I assume in the long term
0:19:13 the costs would fall a lot.
0:19:16 First of all, tell me if that’s indeed the case.
0:19:21 And second, if you look really big picture, how you think about all that money potentially
0:19:27 being reallocated to research, treatment, prevention, cure, et cetera.
0:19:32 Well, Stephen, let’s be clear with the listener.
0:19:36 We have to separate out something that is cost-saving.
0:19:41 We pay for it now, but it’ll save money over time from something that is cost-effective,
0:19:47 which means the total amount we pay is still worth it, but it doesn’t save money.
0:19:52 So far on the GLP-1, the cost analysis does not show us saving money.
0:19:54 But I think you’re right.
0:20:01 We’ve got 42% of the adult population obese, 20% of U.S. children obese, 10% of the U.S.
0:20:04 adult population has type 2 diabetes.
0:20:10 If we can treat those illnesses, reduce things like hospital admissions, hypertension, cardiac
0:20:14 disease, kidney disease, the liver disease that goes with them, maybe we will be able
0:20:16 to save money.
0:20:17 Here’s the problem.
0:20:22 Even if we could show that over a 10-year time horizon, they were cost-saving, that society
0:20:29 would get back more money than we paid for the drug by saving other medical costs, hospitalizations,
0:20:34 other drugs, replacement of hips and things like that, we’ve created a healthcare system
0:20:38 where it’s not in the system’s interest to make those long-term cost-savings.
0:20:39 What do you mean by that?
0:20:42 Are you talking about the incentives of the insurance companies?
0:20:47 Say you’re sitting at United or Humana or a Blue Cross and Blue Shield.
0:20:53 You have a person called them 30 years old who you’re insuring, you’re going to spend
0:20:58 money today for them, and the payoffs going to dribble out in five, six, seven years when
0:21:03 they’ve gone for a long time with their diabetes under control or they’ve gone for a long time
0:21:05 ceasing to be obese.
0:21:11 The problem is, by the time those positive benefits come and the cost-savings come, they’re
0:21:13 no longer being insured by you.
0:21:17 We call this in the medical health policy world churn.
0:21:24 The churn is so much in the insurance market that that investment horizon for companies
0:21:27 is not five, six, seven years.
0:21:30 It tends to be one year and maximum two years.
0:21:34 Is that primarily because health insurance is tied to employment in this country?
0:21:36 It’s a large reason for it.
0:21:40 People change jobs, lose jobs, move.
0:21:45 They get married and they switch from their insurance to their spouse’s insurance.
0:21:51 We’ve created a system that perfectly disincentivizes long-term investments, and that’s bad when
0:21:55 chronic illness is the main source of costs.
0:22:01 So we’re going to have to change how we structure the insurance marketplace, and no one’s talking
0:22:04 about that at the moment.
0:22:07 Okay, let’s us talk about it.
0:22:10 My conversation with Zeke Emanuel continues after the break.
0:22:15 I’m Stephen Dubner, and I’d like to thank you for listening to Freakonomics Radio, not
0:22:17 just today, but always.
0:22:27 We’ll be right back.
0:22:32 We’ve been talking with the oncologist and healthcare policymaker, Zeke Emanuel, about
0:22:38 the large and sudden uptake of GLP-1 drugs, which were designed to treat diabetes, but
0:22:41 have also been found to have other effects.
0:22:46 They help people lose weight, drink less, even have more sex drive.
0:22:53 This GLP revolution will no doubt produce a variety of downstream effects, not just physiological
0:22:56 and psychological, but political and economic effects.
0:23:00 There will be behavior change and social change.
0:23:03 What will all these changes look like?
0:23:04 I have no idea.
0:23:06 And no one else does, either.
0:23:09 If they say they do, you should start walking in the other direction.
0:23:16 Predicting the future is hard, uncertainty is real, and as we often preach on this show,
0:23:19 unintended consequences can be powerful.
0:23:24 So let’s plan on following those long-term effects as they unspool, but for now, let’s
0:23:28 get back to the near-term effects of these drugs.
0:23:32 One big problem with GLP-1s is that they are expensive.
0:23:35 So a big question is, who pays for them?
0:23:41 What is the responsibility of health insurers, whether we’re talking private firms or government
0:23:42 plans?
0:23:46 How much should any government directly subsidize these drugs?
0:23:50 And how much are these drugs worth to society?
0:23:54 These are some of the questions that Zeke Emanuel and several colleagues tried to answer
0:23:59 in a recent article published in The Lancet, a prominent English medical journal.
0:24:06 They offer, as their subtitle says, “a review and ethical analysis of discordant approaches.”
0:24:10 I asked Emanuel why he took on this project.
0:24:14 The prior article we published in the New England Journal was about how to ethically
0:24:21 allocate the resources of the GLP-1 drugs, and we establish a framework that puts younger
0:24:26 obese patients at the top, along with diabetic patients who aren’t responding to other treatments.
0:24:30 And so we had the natural question, what are other countries doing?
0:24:34 We always look to other countries who think they’ve got to have a better system.
0:24:38 And one of the things you learn is, well, the Germans, they got the same allocation
0:24:40 as we do in Medicare.
0:24:43 They don’t cover any of these weight loss drugs.
0:24:47 Then you stumble upon other countries, like Australia and Denmark, and they say, oh, these
0:24:52 drugs aren’t cost-effective, but in fact, they use long outdated cost-effectiveness before
0:24:55 all the benefits for heart disease and liver disease.
0:24:59 Long outdated, you mean just like 2022, two years ago.
0:25:00 Exactly.
0:25:05 But in a rapidly changing field, you have to be nimble, and you have to use the absolute
0:25:06 latest data.
0:25:11 And then we see a whole series of countries where they’re worried about the total cost,
0:25:15 and they’re just saying we’re not covering it, which is the wrong policy.
0:25:19 Drug prices might be high, but there are some people who need the drugs more than other
0:25:21 people where the benefits are going to be greater.
0:25:24 You should cover it for those people.
0:25:28 And let’s remember, these aren’t the only expensive drugs in the marketplace.
0:25:29 I’m an oncologist.
0:25:34 Every oncology drug is super expensive, none are cheap unless they’re generic.
0:25:40 We cover those, and their benefits are probably way less than Osempic or Wagovia or Mungero.
0:25:44 Because with cancer drugs, you’re sometimes talking about a life extension of just weeks
0:25:48 or months versus potentially many years with these GLP-1s.
0:26:00 The life extension for a severely obese patient could be five to ten years, and that’s real.
0:26:03 Here are some key statistics from the Lancet paper.
0:26:09 Emanuel and his colleagues analyzed GLP-1 policy in 13 high-income countries, including
0:26:15 the U.S. and the U.K. All 13 of them cover the cost of GLP-1s for at least some people
0:26:21 with type 2 diabetes, but nine of the 13 countries deny reimbursement for weight management.
0:26:27 The U.S. is perhaps the most hodgepodgey of these 13 countries, given its mix of federal,
0:26:29 state, and private health care coverage.
0:26:34 I asked Emanuel to start from the beginning and describe just how much variance there is
0:26:36 from place to place.
0:26:43 Well, almost every country covers it for diabetes, but we’ve got a lot of countries that don’t
0:26:45 cover it at all for weight loss.
0:26:53 Australia, Belgium, Denmark, Finland, Germany, Italy, Israel, okay?
0:26:54 Don’t cover it.
0:26:59 Canada also doesn’t have a national policy, so it’s a little more variable.
0:27:09 The 13 countries for France, Iceland, Japan, and then the U.K. under some conditions cover
0:27:13 ozempic, wagovi, manjaro, and the conditions vary.
0:27:19 So France, you have to have a high BMI or if a slightly lower BMI and severe comorbidities
0:27:21 from obesity.
0:27:25 The U.K., you also have to change your diet and exercise.
0:27:30 And then there’s Iceland which says, “Look, we’ll cover it, but you’re going to have to
0:27:33 have serious weight loss if you’re not actually losing weight.
0:27:34 We’re going to not cover it.”
0:27:38 So you can get started on it, but if you haven’t lost weight within a certain time, your coverage
0:27:40 will be pulled, essentially?
0:27:41 Exactly.
0:27:46 And, you know, if I had to pick one, I would say I like what France is doing and I like
0:27:52 what the U.K. does in terms of it’s not just about drugs, it’s about a whole lifestyle,
0:27:54 change, and give people help with doing that.
0:27:57 I think those are the right directions to go.
0:28:01 Since you and I and much of our audience are American and since Americans are particularly
0:28:07 solipsistic, let’s talk about the American circumstance with coverage, but also price.
0:28:12 So one thing I learned from your papers that the price is charged for GLPs in different
0:28:14 countries very massively.
0:28:21 I believe it’s around 280 some dollars in Japan to $1350 in the U.S.
0:28:25 Most of all, it shows you that there’s price flexibility, that these drug companies are
0:28:29 willing to change the price depending upon what governments or others require.
0:28:33 Was that your brother who negotiated the 283 in Japan, you think?
0:28:34 He is a good negotiator.
0:28:35 I’ll say that.
0:28:36 He’s also a cheapskate.
0:28:38 I’ll say that too.
0:28:41 So I think that’s actually a positive.
0:28:43 That makes me optimistic.
0:28:49 And if I were in charge, if I were the health czar in the United States, I would go to these
0:28:53 drug companies and I would say, “Listen, let’s get a subscription model.
0:28:56 We’re going to give you a flat fee so you make money and you’re going to give us an
0:29:01 unlimited amount of these drugs because actually to produce these drugs is not that expensive.
0:29:07 And we’re going to try to get everyone we can who qualifies on these drugs.”
0:29:10 That’s a deal I think everyone could be happy with.
0:29:15 The drug company will make a lot of money and the country will be able to treat more
0:29:18 people and will be better off.
0:29:23 It won’t also be just to first come, first serve if you’ve got a lot of money.
0:29:27 What is a budget that would be reasonable to spend on people with obesity and diabetes?
0:29:32 That’s our limit for spending and it’s probably going to be pretty good given, I think it’s
0:29:39 less, I looked, $173 billion we spend on obesity-related healthcare.
0:29:42 So we have tens of billions, you might say we could spend.
0:29:47 So we could make it enticing for a drug company but also good for public health.
0:29:51 Economists, as I’m sure you know, like to talk about what they call moral hazard, which
0:29:59 is if you make some behavior less costly by ensuring it or protecting against it somehow,
0:30:01 then people are freer to do it.
0:30:10 So I’m thinking, “Well, if I can now have my GLP-1 that is going to keep my weight down,
0:30:16 prevent diabetes and prevent all these other potential complications, heck, I can eat whatever
0:30:19 I want whenever I want because medicine has helped me out.”
0:30:24 But there’s also the idea that food is medicine, right, that nutrition is important well beyond
0:30:25 the weight component.
0:30:32 So having permission to eat garbage calories would be at best a partial victory.
0:30:34 So how do you think about that balance?
0:30:36 Here’s a positive.
0:30:43 We have focused more on obesity and we’ve also understood better that it is not simply
0:30:45 a lifestyle choice.
0:30:50 It has to do both with the body and therefore it’s very biologic and it has to do with
0:30:52 our social environment, the food.
0:30:58 You know, today we have 20% of our children are defined as obese and 16% is overweight
0:31:03 and within that obese category, 6% are severely obese.
0:31:05 That is a terrible place to be.
0:31:08 We’ve got type 2 diabetes in young kids, hypertension in young kids.
0:31:14 We have to reverse that and that isn’t going to be a Monjiro or Wadovi or Ozempic solution.
0:31:19 That has to be a solution of changing their diets and getting them more exercise.
0:31:22 There’s just no alternative to that.
0:31:28 We need to invest more in the public health of our children and encouraging their parents
0:31:35 to change their diet and maybe more than encouraging using things like taxes and other mechanisms,
0:31:38 school lunches, school breakfast to change that behavior.
0:31:44 I mean, this is a song I’ve been hearing for probably 20 or 30 years now.
0:31:45 Absolutely.
0:31:49 But, Steve, because so much attention has been focused on obesity now because of these
0:31:54 drugs and because we can realize, “Oh, you can change that by giving a drug that must
0:31:56 be a biological thing.
0:31:59 It’s not simply a weakness of will that you’re eating more.”
0:32:03 I’m hoping that changes our culture around obesity.
0:32:08 And look, when I started thinking, “Well, we’ve got a limited amount of these GLP drugs.
0:32:10 Who should get the GLP drugs?”
0:32:15 When I started doing that research, my thinking was, “It’s got to be the diabetic patients.
0:32:16 They’re going to benefit the most.”
0:32:19 And then I get into this and I begin thinking, “All right.
0:32:20 What are we trying to do?
0:32:22 We’re trying to save the most lives.”
0:32:25 And then I said, “Well, who loses the most years of life?”
0:32:28 It turns out it’s the people with obesity.
0:32:34 My own analysis changed my ethical judgment here when you look at these data.
0:32:38 The people who are really suffering are people with obesity.
0:32:41 They’re the people who are going to benefit the most from these drugs.
0:32:45 Most insurance companies don’t want to cover it because it’s a big expense.
0:32:46 Medicaid is all over the place.
0:32:47 Some states are covering it.
0:32:49 Most states are not.
0:32:52 The consequence is, you know, who’s getting GLP ones?
0:32:53 Rich people.
0:32:59 That is the totally unethical, unjust way of allocating these very important pathbreaking
0:33:00 drugs.
0:33:08 We have to change our system so that we actually do the ethical thing, and that so far is not
0:33:11 where we’re headed.
0:33:15 We recorded this conversation with Zeke Emanuel back in September before the presidential
0:33:16 election.
0:33:22 Since we spoke, the Biden administration proposed a new plan to have Medicare and Medicaid
0:33:26 cover GLP-1 drugs like Osempic and Mound jarrow.
0:33:31 As of now, Medicaid coverage varies from state to state, as we just heard.
0:33:36 And Medicare doesn’t reimburse for these drugs at all because of a law prohibiting the coverage
0:33:38 of weight loss products.
0:33:45 This proposed new coverage would cost an estimated $35 billion over a decade, or $3.5 billion
0:33:50 a year, which sounds like a lot until you put it up against what Emanuel told us the
0:33:58 U.S. spends each year on obesity-related healthcare, around $175 billion.
0:34:03 It’s too early to say what will happen to the Biden administration’s GLP-1 proposal
0:34:05 under the Trump administration.
0:34:10 Trump’s pick for director of health and human services, Robert F. Kennedy Jr., has criticized
0:34:16 GLP-1s, but Mehmet Oz, Trump’s pick to run the Centers for Medicare and Medicaid Services,
0:34:18 has expressed support.
0:34:24 I did ask Zika Manuel during our interview how big of a shift he would envision in U.S.
0:34:27 healthcare policy if Trump won the election.
0:34:34 If I were a betting man, having worked with Donald Trump, this isn’t going to be a priority
0:34:35 of his.
0:34:40 He may make another run at repealing the Affordable Care Act, but that’s a joke.
0:34:41 It’s not going to happen.
0:34:43 It’s a joke because it’s ensconced.
0:34:45 It’s just not going to happen.
0:34:49 John Republicans in Congress, I talked to him right after John McCain did his thumbs
0:34:53 down and killed the repeal, and he said, “Oh, I’m very close.
0:34:54 I’m going to do it again.
0:34:55 We’re going to get it this time.”
0:35:01 I said, “Mr. President, what you don’t realize is that behind John McCain, if he hadn’t
0:35:06 done that, there were 10 other senators who would have rejected it because it would have
0:35:09 upset things too much in their state.
0:35:14 Every single state that has tried to expand Medicaid where the voters had to say, the
0:35:19 voters said, “Expand Medicaid,” and we’re talking about deep, deep red states, places
0:35:23 like Oklahoma, places like South Dakota.
0:35:26 Even Republicans want everyone to have health insurance.
0:35:28 We’re not repealing the Affordable Care Act.
0:35:32 You’re well-known for your involvement in the Affordable Care Act.
0:35:35 You’re also well-known for having written several books.
0:35:40 One of them published, I believe it was 2014, was called Reinventing American Health Care,
0:35:46 how the Affordable Care Act will improve our terribly complex, blatantly unjust, outrageously
0:35:50 expensive, grossly inefficient, error-prone system.
0:35:52 That’s a lot of promise for one subtitle.
0:35:55 How well do you think that promise has been met?
0:35:59 So far, I think it’s been met reasonably well.
0:36:01 Here’s how I would put it.
0:36:04 It’s dramatically increased coverage.
0:36:08 Tens of millions of people have gotten health insurance and gotten the benefits of health
0:36:13 insurance, including less mortality, less stress, less anxiety.
0:36:20 Secondly, it’s actually led to a plateau in healthcare spending as a percentage of GDP.
0:36:26 We were at 17.5% of GDP spent on healthcare when we started with the Affordable Care Act,
0:36:27 and guess what?
0:36:29 We’re at the exact same place.
0:36:31 That’s trillions of dollars of savings.
0:36:36 To be fair, that’s a larger share of GDP than any other country in the world by a long shot.
0:36:37 Don’t get me started.
0:36:39 You’ve got to have a whole nother conversation about that issue.
0:36:44 I could go on and on about it, but yes, we spend — I think Switzerland’s the next highest
0:36:47 country in terms of spending about 8,000 per person.
0:36:51 We’re close to 13,000 or maybe even over 13,000 per person.
0:36:54 So yes, we’re burning lots of money that we shouldn’t be burning.
0:36:59 In any case, those are two big accomplishments of the Affordable Care Act.
0:37:03 It’s also, by getting more people insured, led to some cost savings.
0:37:10 On the quality side, I would say much more uneven, not consistently beneficial.
0:37:12 And for me, it’s been a disappointment.
0:37:16 We still have high levels of hypertension, high levels of diabetes, worsening mental
0:37:18 health crises.
0:37:23 On the issue of equity, lots of people are concerned about minorities and others not
0:37:24 getting as much.
0:37:29 The fact is, we have narrowed the uninsured rate between minorities and whites.
0:37:32 So we’ve done okay there, I would say.
0:37:36 We haven’t evened everything out, but I think we’ve done okay.
0:37:42 I’d say the one big place where it’s gone awry is the dissatisfaction with the health
0:37:49 care system is higher, a lot more barriers and hurdles, more prior authorization, both
0:37:55 for patients and doctors, harder to find doctors for your particular condition.
0:38:00 And also, even though we have the same GDP spending, the out-of-pocket spending’s gone
0:38:05 up, employers are shifting more costs to individuals through higher deductibles and
0:38:08 things like that, that leads to frustration and stress.
0:38:13 So I do think the Affordable Care Act has achieved a lot, but the underlying defects
0:38:20 of the system prevent us from achieving all the goals we need to achieve with health care.
0:38:23 And how can those goals be achieved?
0:38:25 This is a problem in our country.
0:38:27 We have to move with the times.
0:38:29 We have to be more innovative.
0:38:33 Next coming up, after the break, I’m Stephen Dovner, speaking with Ezekiel Emanuel on
0:38:34 Freakonomics Radio.
0:38:43 We will be right back.
0:38:47 Let’s talk about the future of medicine generally, but especially I’m curious to know what you
0:38:53 think AI and machine learning and so on will do to, you know, accelerate discovery, treatment,
0:38:54 et cetera, et cetera.
0:38:59 I want to frame this with an observation I heard from Mustafa Suleiman, who’s an AI
0:39:02 entrepreneur, I guess you’d call him now at Microsoft.
0:39:09 I heard him say that if AI proceeds as he sees it, that the cost of medical diagnosis
0:39:11 will eventually drop to zero.
0:39:14 Now let’s say he’s only 30% right.
0:39:19 There’s a 30% cost savings on diagnosis, but that’s massive.
0:39:25 I’m curious how you think in a world where that’s true, how that money gets reallocated?
0:39:31 Well, first of all, Stephen, I was just at a meeting that my brother put on and every
0:39:34 panel talked about AI and the promise of AI.
0:39:36 And I do think there’s a lot of promise there.
0:39:38 Don’t get me wrong.
0:39:44 But I also think that it’s going to take longer to make it into the healthcare system, because
0:39:49 first of all, you got to spread it out over 330 million people, which means not that it’s
0:39:55 hard to scale AI, but you have to make sure it doesn’t bias you against certain populations
0:39:58 or ignore problems in certain populations.
0:40:02 And to some extent, the training systems are not good at that.
0:40:06 I also think there’s some hesitation in using it.
0:40:09 I do think the biggest advantage is going to be in access.
0:40:14 People who can’t get to the doctor, that’s actually going to turn out to be a huge benefit.
0:40:15 I should say conflict adventures.
0:40:18 I’m involved in several companies looking at that.
0:40:21 There are other huge advantages.
0:40:25 One of them is diagnoses, identifying people who are likely to have complications.
0:40:29 So you can intervene now and prevent a hospitalization and save money.
0:40:34 So I am optimistic over a slightly longer time horizon.
0:40:39 If I were reallocating that 30%, here’s my top priorities.
0:40:45 Priority number one, invest in children and as early as possible.
0:40:48 Even before they’re out of the womb, you got to invest in them.
0:40:53 We know early interventions produce the biggest social benefit.
0:41:00 So right when they’re born, have nurse family partnerships so that families are supported.
0:41:01 We have to have daycare.
0:41:04 That’s cheaper so people can afford it.
0:41:07 Mandatory, pre-K, open to everyone.
0:41:10 I would also bring down the total healthcare costs for people.
0:41:15 One of the major things is we need to put a cap on out-of-pocket expenditures, deductibles
0:41:19 and copays so people don’t go bankrupt and aren’t stressed by the cost.
0:41:27 I think a maximum of $1,000 for a family is probably a place I would like to get to.
0:41:29 You also need to spend that money and other things.
0:41:30 It’s not just healthcare.
0:41:35 We need to spend it on infrastructure so that we can have housing and people can commute
0:41:38 without having to drive hours and hours.
0:41:44 So the COVID pandemic taught pretty much everyone how to use Zoom or some equivalent.
0:41:49 And this was plainly vital for medicine at the time, what we now call telemed or telehealth.
0:41:56 I’m curious what you see as the lasting effects of that telehealth surge during COVID, pros
0:42:00 and cons of, let’s say, continuing to lean on virtual medicine.
0:42:03 I think in general, it’s positive.
0:42:08 We had a big blip up almost half of the physician engagement’s got to telemedicine and then
0:42:12 it’s come way down, not to pre-COVID levels, but way down.
0:42:17 A lot of this goes to how we pay for it and the fact that a lot of systems, doctors who
0:42:22 do it get paid half as opposed to seeing the patient in their office.
0:42:26 But we’ve also realized that we can do a lot of things out of the hospital.
0:42:29 So you’re seeing a lot of surgeries migrate out of the hospital.
0:42:34 You’re seeing more home care out of the hospital.
0:42:37 At the University of Pennsylvania, one of the things we ended up doing during COVID was
0:42:41 to go to patients’ houses and administer chemotherapy.
0:42:46 When I was training low these many years ago in the early 1990s, if you had told me, “We’re
0:42:50 going to give this chemotherapy that caused a lot of nausea and vomiting, we’re going
0:42:53 to give it at the patient’s home,” I would have said, “The psychiatric hospital, that’s
0:42:54 not far away.
0:42:56 Let’s take you over there.”
0:42:57 But that’s what we’ve been able to do.
0:43:02 Now, partly that’s because we have better drugs for nausea and vomiting, partially it’s because
0:43:08 we really understand how to do this and that’s a big, big advance.
0:43:12 Here’s why I’m really positive about telemedicine.
0:43:16 Twenty percent of our population lives in rural areas.
0:43:18 We’ve seen hospitals close there.
0:43:23 We’re going to have to get them access, not just to a primary care doc, but to specialists
0:43:26 that aren’t living nearby.
0:43:28 And telemedicine is going to be important.
0:43:34 Here again is another legacy of history that people don’t pay attention to.
0:43:38 Medical licensure and regulation is state-based.
0:43:41 That makes no sense in the modern era.
0:43:47 With Zoom, if you’re in South Dakota and you can get your treatment from Chicago or Pennsylvania
0:43:51 or New York, why should we have the licensure only in South Dakota?
0:43:56 We really need to get to the next level national licensure.
0:43:58 But states are jealous of their prerogatives.
0:44:01 They’re not going to give it up easily.
0:44:02 This is a problem in our country.
0:44:05 We have to move with the times.
0:44:06 We have to be more innovative.
0:44:12 Let me go back to administering chemo at home during COVID, which is really interesting.
0:44:16 Let me hear you speak a little bit about how cancer care and especially chemo have changed
0:44:18 over the past couple of decades.
0:44:23 But I want to frame that within a bigger question or maybe it’s just an observation, which is
0:44:24 the following.
0:44:26 There was an economics paper years ago.
0:44:29 I don’t know if you ever read it, and I’m curious to know what you think of the idea,
0:44:35 which is that the so-called war on cancer, which was begun, gosh, over 50 years ago now.
0:44:39 Some people claim it’s been nowhere near as successful as one might hope.
0:44:46 The paper argued that that argument is masking a big different trend, which is cardiovascular
0:44:53 care has become so much better that many, many, many people are not dying of the cardiovascular
0:44:57 diseases that would have killed them in an earlier generation and are living long enough
0:44:58 to get cancer.
0:45:01 I’m curious to know what you think of that framework, but I’d love you to just give us
0:45:05 the state of cancer care and especially chemo now.
0:45:09 Well, at one time, I might have been skeptical.
0:45:15 Yes, we began this under Richard Nixon in the early 1970s, and it’s now more than 50
0:45:16 years.
0:45:22 All of the progress we’ve made over the last decade or two really go back to the research
0:45:28 that was started of the war on cancer and accelerated by the human genome project and
0:45:35 figuring out where the defects are in the DNA that lead to cancer, being able now to
0:45:38 target those specific defects.
0:45:41 All of that took a long time.
0:45:45 We’ve done a marvelous job at cutting cancer death rate.
0:45:50 That means that for everyone who gets cancer, fewer people die, but I do think we’ve had
0:45:58 a huge improvement in cardiac disease, multiple factors, a lot of lifestyle factors, humongous
0:46:05 drop in smoking, changes in diet, so we are more aware of cholesterol, people on statins,
0:46:11 incredible breakthrough, drug, not to mention all the other intervention stents and things
0:46:12 like that.
0:46:16 So, we have had huge progress in cardiovascular disease.
0:46:22 Now, having said all of that, we’re seeing a big increase in younger people getting cancers
0:46:25 which we thought they never should get, like colon cancer.
0:46:32 I had a very dear friend die in her early 40s from a humongous colon cancer.
0:46:38 When I was training in the 1990s, we never would have seen that, never.
0:46:39 What do you think is going on?
0:46:40 No one knows for sure.
0:46:42 Here are some possibilities.
0:46:49 We’ve changed the human microbiome in the gut, the bacteria by eating the wrong things.
0:46:56 For processed foods that causes obesity, it also causes a decrease in the variety of bacteria
0:47:00 we have and a decrease in the good bacteria.
0:47:05 That micro environment that affects cells created by the bacteria in our gut is probably
0:47:07 critically important.
0:47:15 If you don’t eat fermented foods like yogurt, kimchi, if you don’t eat a lot of fiber that
0:47:21 comes with fruits and vegetables, you’re dramatically changing that micro-biome.
0:47:22 That’s a hypothesis.
0:47:26 Let’s be clear with your audience, it’s a hypothesis.
0:47:33 So, Zeke, I understand you had a birthday recently, yes, 67 years old, is that true?
0:47:34 Oh boy.
0:47:39 Your spies, you worked for the CIA recently?
0:47:41 Can you confirm, though, you’re 67 years old.
0:47:44 I can confirm I’m 67 years old.
0:47:50 I know that every year you set for yourself something new, radically new to do.
0:47:54 You’ve become a chocolate maker, you’ve become a serious cyclist.
0:47:57 Tell me one thing that’s on your list for the future.
0:47:58 I’ll tell you a trivial thing.
0:47:59 I want to make honey.
0:48:01 I thought bees did that.
0:48:03 We’ve just planted a lot of trees.
0:48:06 We have a lot of bees that love our lavender plants.
0:48:07 So that’s a sort of hobby.
0:48:12 But I would say, seriously, one of my life goals is, I’m a first-born and I think one
0:48:20 of my deficits, if I had to put it this way, is I can be slightly not sufficiently empathetic.
0:48:22 I can be a little too dismissive.
0:48:25 And I would like to improve those.
0:48:30 I’d like to be more empathetic to the people around me and decrease the sarcasm in my
0:48:31 responses.
0:48:35 Now, why do you care about that at this stage in life?
0:48:37 I think it makes a difference to people.
0:48:43 I’ve become more interested in how people get to where they are and also more interested
0:48:48 in what changes they’ve made, what challenges they’ve confronted, how they’ve overcome
0:48:49 their challenges.
0:48:51 And I’d like to do more of that.
0:48:57 My father-in-law makes me bookmarks, the most recent bookmark for my 67th birthday he wrote
0:49:00 on the bookmark, allergic to idiots.
0:49:05 I am allergic to idiots, but I had in the past confused that with not taking an interest
0:49:10 in people and that was probably a result of being first-born, having my brothers constantly
0:49:11 attack me, whatever.
0:49:15 Can I say all of you brothers complain about each other in exactly the same way as if birth
0:49:18 order was irrelevant?
0:49:23 But I would say being curious about the lives of other people, it’s led me to read a lot
0:49:27 of biographies and understand the challenges people have overcome.
0:49:32 I’ve read a recent biography of Hubert Humphrey and the kinds of challenges he confronted,
0:49:34 but the fact that everyone liked him.
0:49:39 That’s an interesting and very important quality, that you could be open to people, you could
0:49:44 be empathetic of people, even people who you disagreed with so much that they actually
0:49:47 liked you, we don’t have enough of that in our society.
0:49:52 And so one of the things you ask me, you know, I’m Jewish and the new year is coming up,
0:49:58 that I’m committing myself to is more empathy and less sarcasm in my voice, but also making
0:50:02 honey, making life sweet.
0:50:04 The late in life empathist, I love it.
0:50:07 And now I’m sure you get asked about this all the time and I’m sorry if it’s a pain
0:50:12 in the neck, but you did publish a piece in the Atlantic back in 2014, which got a lot
0:50:13 of attention.
0:50:17 Headline was why I hope to die at 75.
0:50:19 First of all, just rehearse the argument.
0:50:21 What was the point you were trying to make?
0:50:22 I believe it was a bit misunderstood.
0:50:25 Yeah, it’s not like I’m going to die at 75.
0:50:32 It’s that I would not take life prolonging treatments at 75, like cancer chemotherapies
0:50:34 or renal dialysis if my kidneys fail.
0:50:37 But you also said no more flu shots, for instance.
0:50:38 Right.
0:50:40 There are two things that have gotten under people’s skin.
0:50:47 One is vaccinations and the other is antibiotics that would readily cure a condition.
0:50:55 Now on the vaccines, I think COVID has somewhat changed my attitude on that because, you know,
0:50:59 you can get a shot and it would make a very big difference.
0:51:02 Why did you need the COVID vaccine to persuade you of that?
0:51:06 Wouldn’t what you just said describe just about all the vaccines that are commonly used?
0:51:10 Well, measles is not my big problem, you know, and diphtheria is not my big problem.
0:51:12 Thank you very much, Stephen.
0:51:16 If I somehow broke my hip, I would get that repaired.
0:51:18 I’m not force-wearing all medical care.
0:51:23 It was really about life saving, you know, people, oh, the golden years, all the advertisements
0:51:29 out there for Medicare Advantage health plans make the golden years look like I’m hiking
0:51:32 in Montana and beautiful vistas and all that.
0:51:33 That’s not what they’re like.
0:51:37 What happens for most people is they end up watching a lot more TV.
0:51:39 They tend to be homebound.
0:51:43 They get a lot of disabilities over time.
0:51:49 They’re not filled with the joys that everyone imagines if they’re going to get 10 more years.
0:51:53 The other thing is they’re also filled with a lot of cognitive decline.
0:51:55 Yes, it is true.
0:51:59 The rate of Alzheimer’s disease has actually gone down, but the total number of people
0:52:03 with Alzheimer’s gone up, I think the number is, and I haven’t checked this recently, by
0:52:07 80 years old, about 30% of people have some cognitive decline.
0:52:09 That’s a huge number.
0:52:10 So you want to get out while the getting’s good?
0:52:18 I see no reason in prolonging that if I’m not being creative, I’m not interacting.
0:52:23 I don’t watch TV, so I wouldn’t want to be spending my time watching TV, even good movies.
0:52:25 That seems like a very passive life.
0:52:29 I’m not a passive person, and I don’t think anyone wants or should want to be a passive
0:52:30 person.
0:52:36 But for all your optimism about intellect and technology generally, whether it’s AI, machine
0:52:42 learning, or just the way the brain can come up with things, who’s to say that all the
0:52:48 downsides that you see of aging won’t be mitigated to some degree by various technologies
0:52:52 and that maybe, heck, you could at 100 be doing things.
0:52:57 Now maybe you’d be doing them quasi-virtually, but do you entertain those kind of thoughts?
0:53:02 I entertain those thoughts, but I haven’t seen that actually be a reality.
0:53:09 I think people are delusional when they imagine, “I’ll be like I am now when I’m 90,” probably
0:53:10 not.
0:53:14 Maybe AI, regenerative medicine, maybe those things will happen, then I’ll reassess.
0:53:15 But they’re not happening now.
0:53:20 We’re seeing greater disabilities and people having a lot of cognitive decline.
0:53:23 I am not wild about that kind of life.
0:53:26 You have to ask yourself, “What is the purpose of my life?
0:53:27 Why am I living?
0:53:29 And how does that relate to age?”
0:53:33 Most people will say, if you just ask them, “Oh, I want quality over quantity,” but then
0:53:38 when they actually behave, they are taking quantity even when the quality of their life
0:53:40 is not what they actually want.
0:53:42 Of course I think my view is the right view.
0:53:45 I’ve spent a lot of time thinking about this, but I will tell you, Stephen, it’s a decade
0:53:48 of people writing to me.
0:53:51 About a third of people say, “Dr. Emmanuel, you’re 100 percent right.”
0:53:54 A third of people say, “Well, you’ve made me rethink.”
0:53:56 They don’t necessarily endorse my view.
0:54:01 If I’ve just made you rethink how you’re going to live your life and examine what you’re
0:54:03 living for, that’s a really good thing.
0:54:06 And a third of people think, “I’m off my rocker,” and maybe I am.
0:54:10 It’s quite a legacy, though, that you’ve made so many people rethink something as fundamental
0:54:11 as the end of their life.
0:54:16 I don’t want to pat myself on the back, but I don’t mind being what Socrates called
0:54:17 the Gadfly.
0:54:22 Part of what I do as a professor is challenge people about their views, and I want them
0:54:24 to rethink their views.
0:54:27 They might embrace their views wholeheartedly.
0:54:28 That’s fine.
0:54:30 As long as it’s, as Socrates says, an examined life.
0:54:35 As long as you can defend and justify where you’ve come down, that’s the place people
0:54:36 need to be.
0:54:38 And I hope everyone gets there.
0:54:40 I hope they think through, “What am I living for?
0:54:42 What good am I doing in this world?
0:54:45 Whose lives am I making better?”
0:54:49 In the end, that’s why we’re here.
0:54:54 My thanks to Zika Manual for a conversation that I found informative, challenging, occasionally
0:54:55 inspiring.
0:54:58 I’m curious to know how you felt.
0:54:59 Let me know.
0:55:02 Our email is radio@freakonomics.com.
0:55:08 Coming up next time on the show, another one-on-one conversation, this one with Adam Moss, who
0:55:12 is widely considered the best magazine editor of his generation.
0:55:17 He also happens to be my former editor and boss.
0:55:22 I learned a lot from Adam, especially how to be direct.
0:55:28 I just thought this was bullshit, and I thought it was bullshit over a long period of time.
0:55:30 That’s next time on the show.
0:55:35 Until then, take care of yourself and, if you can, someone else too.
0:55:37 Freakonomics Radio is produced by Stitcher and Renbud Radio.
0:55:43 You can find our entire archive on any podcast app also at Freakonomics.com, where we publish
0:55:46 transcripts and show notes.
0:55:48 This episode was produced by Zach Lipinski.
0:55:53 The Freakonomics Radio network staff also includes Alina Kulman, Augusta Chapman, Dalvin
0:55:58 Abouaji, Eleanor Osborne, Ellen Frankman, Elsa Hernandez, Gabriel Roth, Greg Rippen,
0:56:03 Jasmine Klinger, Jason Gambrell, Jeremy Johnston, John Schnarrs, Lyric Bowditch, Morgan Levy,
0:56:07 Neil Coruth, Rebecca Lee Douglas, Sarah Lilly, and Theo Jacobs.
0:56:13 Our theme song is Mr. Fortune by the Hitchhikers, and our composer is Luis Guerra.
0:56:14 As always, thank you for listening.
0:56:25 I know we have approximately 75 minutes I want to use every day on one of them, so we’ll
0:56:26 just get going.
0:56:29 Oh my god, I’m not sure I can talk that long.
0:56:31 Yeah, you can.
0:56:32 You caught me.
0:56:33 Alright.
0:56:45 The Freakonomics Radio network, the hidden side of everything.
0:56:48 (bright music)
0:56:50 you

0:00:08 Hey there, it’s Stephen Dubner with a bonus episode of Free Economics Radio.
0:00:13 Our most recent regular episode was an interview with John Sullivan, former U.S. Ambassador
0:00:14 to Russia.
0:00:18 We didn’t really talk about the Cold War, but as a result of that conversation, I’ve
0:00:21 been thinking a lot about the Cold War.
0:00:26 And that got me thinking about an episode we made some years ago called How the Supermarket
0:00:28 Helped America Win the Cold War.
0:00:33 So I went back and listened to it, I really liked it, if I do say so myself, and I thought
0:00:35 you might like to hear it again too.
0:00:39 So here it is, we have updated facts and figures as necessary.
0:00:45 As always, thanks for listening.
0:00:49 When you think about propaganda campaigns, I am guessing you don’t think of this.
0:01:07 After World War I and World War II came the Cold War between the U.S. and the USSR.
0:01:13 It featured a space race, an arms race, and a farms race.
0:01:18 Things like chicken breeding and hybrid corn took an outsize and somewhat surprising role
0:01:21 in U.S. propaganda in the early 1950s.
0:01:24 The farms race had an obvious winner.
0:01:27 We clearly won the abundance war.
0:01:33 But the American victory was, to some degree, a puric victory, whose after effects are still
0:01:35 being felt.
0:01:43 Economists who don’t do U.S. agricultural policy are horrified by what they see in terms
0:01:45 of distorting markets.
0:01:51 Today on Freakinomics Radio, how a sprawling system of agriculture technology, economic
0:01:56 policy, and political will came to life in the supermarket.
0:02:00 Tell me who could possibly afford to buy food in a place such as this?
0:02:02 Well, this is just an ordinary food market.
0:02:24 This is Freakinomics Radio, the podcast that explores the hidden side of everything with
0:02:49 your host Stephen Dovner.
0:02:50 That’s Shane Hamilton.
0:02:54 He’s an American historian who teaches at the University of York in England.
0:03:00 I’m the author of Supermarket USA, Food and Power in the Cold War Farms Race.
0:03:04 Was the supermarket a purely American invention?
0:03:06 I argue yes.
0:03:12 The easy answer is that the first declared supermarket was built in the United States.
0:03:19 I think the broader answer is that what makes a supermarket a supermarket is the industrial
0:03:25 agriculture system that enables the affordability of mass-produced foods.
0:03:29 The predecessor of the supermarket was the dry goods store.
0:03:31 So they didn’t have fresh produce.
0:03:36 They didn’t necessarily have milk or meat or a bakery in-house.
0:03:40 That’s what a supermarket did, is it put all those food items and often many other things.
0:03:42 You could get auto parts.
0:03:44 You could get your shoes shined in the early supermarkets.
0:03:49 It was a kind of one-stop shopping and service emporium.
0:03:52 Another big difference, supermarkets were self-serve.
0:03:57 In a dry goods shop, you’d ask a clerk for something and they’d fetch it in a supermarket.
0:04:03 You could ogle the meat and produce yourself, even handle it, and then put it in your basket.
0:04:08 The supermarket chain Pigley Wiggly is credited with having pioneered the self-service retail
0:04:09 model.
0:04:13 It is still operating today in 18 states.
0:04:17 The biggest supermarket chain for much of the 20th century was A&P, the great Atlantic
0:04:19 and Pacific Tea Company.
0:04:27 A&P, as of the 1940s, was the world’s largest retailer by any measure, by sales volume,
0:04:29 by number of outlets and so forth.
0:04:36 Between 1946 and 1954 in the U.S., the share of food bought in supermarkets rose from 28
0:04:39 percent to 48 percent.
0:04:43 By 1963, that number risen to nearly 70 percent.
0:04:49 A&P had so much market power that the Department of Justice went after it for anti-competitive
0:04:51 practices.
0:04:56 This was an interesting development, considering that the U.S. government played such a significant
0:04:59 role in the creation of supermarkets in the first place.
0:05:06 The original goal had been to use the supermarkets to drive down the cost of food for urban consumers.
0:05:12 The U.S. becomes a majority urban nation by, I think, 1920.
0:05:17 And there’s a lot of anxiety among leaders, political leaders, thought leaders about whether
0:05:24 or not U.S. agriculture is going to be productive enough to feed this growing urban population.
0:05:28 That is Ann Effland, a former senior economist at the USDA.
0:05:34 The U.S. Department of Agriculture, established in 1862, had a long history of funding and
0:05:36 conducting scientific research.
0:05:42 You know, a lot of the seed development and livestock breeding, one good example would
0:05:49 be the research done in the 1890s on animal disease, on bovine tuberculosis, for example,
0:05:55 to identify the causes of those diseases and then to develop ways to treat that.
0:06:00 There was also research on developing new kinds of machinery that would be less heavy
0:06:04 on the ground or less damaging to crops.
0:06:08 The USDA’s promotion of agriculture went even further than farm machinery and animal
0:06:09 breeding.
0:06:14 There was a need for better transportation from the farms to the cities.
0:06:21 So USDA had a unit that did engineering research on the best road materials and road construction
0:06:22 methods.
0:06:27 The Rural Electrification Administration was part of the New Deal USDA.
0:06:33 The private electrical companies didn’t see a profit in expanding out into rural areas
0:06:36 and so that was taken on by USDA.
0:06:42 But perhaps the biggest changes to American agriculture were mechanization and automation.
0:06:49 If I may say so, I lived through the structural transformation of the agricultural economy.
0:06:52 That’s Peter Timmer, an economist who used to teach at Harvard.
0:07:00 I’m a retired professor, have worked on agriculture and food policy, poverty reduction, economic
0:07:04 development for well over 50 years now.
0:07:08 And before that, Timmer was a farm boy in Ohio.
0:07:13 He worked for the Tip Top Canning Factory, which was founded by his great-grandfather,
0:07:14 and the Factory’s Tomato Farm.
0:07:21 I’m old enough to remember when we handpicked all of our tomatoes and we hand peeled all of
0:07:22 our tomatoes.
0:07:24 But that, of course, changed.
0:07:31 When I was in grade school or junior high school, if we could pack 40 or 50,000 cases
0:07:37 of canned tomatoes and product in a year, that was a pretty successful year.
0:07:43 By the time I had graduated from graduate school, the company was putting out a million
0:07:45 cases a year.
0:07:50 This was thanks in large part to a mechanical tomato harvester, which came out of the engineering
0:07:56 school at the University of California, Davis, with the help of federal research money.
0:08:00 It had taken years to get the harvester right, mostly because they first had to get the tomato
0:08:06 right, breeding a new variety that could withstand the rough treatment of the mechanical harvester.
0:08:12 I remember when we bought our first one, it was a huge expense, and it just revolutionized
0:08:13 our operation.
0:08:20 I was just in a microcosm of what turned out to be very general trends in the entire US
0:08:26 food system at the time.
0:08:33 The general trends could best be characterized as high volume and standardized agriculture.
0:08:38 If you would describe US agriculture policy as aggressive in earlier decades, then in
0:08:42 the Cold War era, it was pretty much on steroids.
0:08:47 This wasn’t just about feeding a growing US population.
0:08:52 This had a political thrust, meant to show the Soviet Union and the rest of the world
0:08:55 just how mighty the US was.
0:08:56 Shane Hamilton again.
0:09:02 I don’t mean to deny the power and the might of these weapons systems that were deployed
0:09:08 in the space race and all that, but fundamentally, this was a contest to demonstrate that either
0:09:13 communism or capitalism was a superior political economic system.
0:09:17 After Sputnik, when the United States was trying to understand why it was falling behind
0:09:21 in the space race, or why it thought it was falling behind in the space race, many of
0:09:27 the commentators said, “The problem is we’re not funding basic research.”
0:09:32 After 1957, the budgets of not only organizations like the National Science Foundation, but
0:09:37 also specific government departments like the Department of Agriculture, their budgets
0:09:41 for research increased dramatically on the theory that this is how the United States
0:09:45 would win the Cold War by doing the best science.
0:09:46 That is Audra Wolf.
0:09:49 I’m a writer, editor, and historian.
0:09:55 Wolf’s latest book is called Freedom’s Laboratory, The Cold War’s Struggle for the Soul of Science.
0:10:01 And it really looks at the ways that science as an idea became a tool for propaganda in
0:10:04 the Cold War, especially on the American side.
0:10:08 There’s this idea that you can change hearts and minds, and you can establish a climate
0:10:13 of opinion that makes people more willing to accept the American way of life as the
0:10:14 better choice.
0:10:19 And one of the things that made America so great, it’s agricultural system.
0:10:25 Things like chicken breeding and hybrid corn took a outsize and somewhat surprising role
0:10:28 in U.S. propaganda in the early 1950s.
0:10:29 But there was a tension.
0:10:35 The United States wanted to promote personal exchanges, scientific and technical exchanges
0:10:37 as a way to promote American values.
0:10:41 But at the same time, it was very, very nervous that by doing so, it would lose the advantages
0:10:44 that it had, particularly in grain production.
0:10:48 In 1955, the U.S. government unexpectedly had its hand forced.
0:10:54 A newspaper editor in Iowa named Lauren Soth invited Khrushchev to the United States to
0:10:56 see the wonders of American agriculture.
0:11:00 That’s Nikita Khrushchev, then leader of the Soviet Union.
0:11:03 And somewhat to everyone’s shock, Khrushchev said yes.
0:11:07 Now, Khrushchev didn’t come himself until 1959.
0:11:13 But in 1955, a group of 12 Soviet agricultural experts came to the United States to see the
0:11:15 wonders of American agriculture.
0:11:17 They saw how contour farming worked.
0:11:19 They saw the wonders of hybrid corn.
0:11:20 They saw the chicken breeders.
0:11:26 And what were those chicken breeders working on?
0:11:27 The chicken of tomorrow.
0:11:28 That’s coming up.
0:11:29 I’m Stephen Dubner.
0:11:31 This is Freakonomics Radio.
0:11:44 We’ll be right back.
0:11:48 Chicken in the 1920s was pound for pound as expensive as lobster.
0:11:54 By the 1960s, it was so cheap that it was quickly becoming America’s most popular meat.
0:12:00 That again is Shane Hamilton, a historian and the author of Supermarket USA, Food and
0:12:03 Power in the Cold War Farms Race.
0:12:07 In the book, he tells the story of a project called the chicken of tomorrow.
0:12:13 Really, the chicken of tomorrow is the chicken of today in that we’re all eating the kind
0:12:17 of genetic progeny of the original chicken of tomorrow.
0:12:23 What it was was a contest to produce the most efficient chicken using genetic techniques,
0:12:24 basically.
0:12:30 And it not only had to be an efficient chicken, but very heavy breasts, very light colored
0:12:34 feathers so that when it’s plucked, it would look good under cellophane and then later
0:12:36 plastic packaging.
0:12:42 And the birds had to be relatively disease resistant so that they could be put in intensive
0:12:47 rearing operations without dying too quickly.
0:12:54 This agricultural bounty, those heavy breasted cheap chickens, those millions of cases of
0:12:59 tomatoes, all this was a good candidate for the U.S. propaganda machine.
0:13:01 The U.S. Information Agency.
0:13:08 We’re searching for concrete forms of propaganda to display America’s wealth.
0:13:13 After one of the most concrete forms of display imaginable, the supermarket.
0:13:19 The supermarket is not just a retail box, but actually the endpoint of an industrial agriculture
0:13:21 supply chain.
0:13:26 A supermarket can’t exist without the inputs of mass produced foods.
0:13:31 The Farms Race was about how do you get the food from industrially productive, technologically
0:13:38 sophisticated farms to, you know, this display of abundance and the display was really crucial.
0:13:43 Since the average citizen living under communism wouldn’t have access to a piggly wiggly or
0:13:48 an A&P, the U.S. government brought the supermarket to the communists.
0:13:54 The 1957 supermarket USA exhibit in Zagreb, Yugoslavia, which was then a communist country.
0:13:59 It was a fully operational 10,000 square foot American supermarket filled with frozen
0:14:02 foods and breakfast cereals and everything else.
0:14:06 They airlifted in fresh produce from the U.S. because they didn’t think Yugoslavian produce
0:14:08 was attractive enough.
0:14:13 It was about this display of affordable abundance available to American consumers.
0:14:18 For anyone who didn’t get the message, there was also a sign touting, quote, “The knowledge
0:14:21 of science and technology available to this age.”
0:14:26 In other words, if you like our breakfast cereal, just think how much you like the rest
0:14:27 of our capitalism.
0:14:31 There were quite a few people who thought that if you showed that American consumers
0:14:38 could access affordable food, you know, strawberries in December without having to wait in line,
0:14:41 that that might actually cause the whole communist system to collapse.
0:14:45 The supermarket USA exhibit proved tremendously popular.
0:14:48 More than one million Yugoslavs visited.
0:14:51 Some received free bags of American food.
0:14:55 Immediately after seeing it, Marshall Tito, the leader of the country at the time, ordered
0:14:57 the whole thing to be purchased.
0:15:01 And it was bought wholesale from the United States exhibitors and used as a model.
0:15:06 They hired a consultant from an Atlanta supermarket firm to come over and teach them how to build
0:15:10 their own chain of socialist supermarkets.
0:15:15 So Yugoslavia, along with other European countries, started building American style supermarkets,
0:15:20 which created new buyers for processed and frozen foods from America.
0:15:26 This did not, however, lead to a wider embrace of American culture, much less the downfall
0:15:28 of communism.
0:15:32 But just a couple years later, the Americans took another shot this time in Moscow at the
0:15:35 American National Exhibition.
0:15:41 They built a split level ranch style American house, its kitchen stocked with food and the
0:15:44 latest labor saving appliances.
0:15:45 The message was clear.
0:15:51 The American economy, based in free market capitalism, was capable of producing things
0:15:56 that the Soviets command and control economy simply couldn’t.
0:16:02 The exhibition opening was attended by Nikita Khrushchev and then U.S. Vice President Richard
0:16:03 Nixon.
0:16:06 They engaged in what came to be known as the kitchen debate.
0:16:08 You must not be afraid of ideas.
0:16:27 Richard Nixon and Nikita Khrushchev are two of the most explicit users of this Cold War
0:16:29 Farms Race language.
0:16:34 Khrushchev declared that by outproducing the U.S. in per capita meat and milk production
0:16:40 that would be the Soviet equivalent of hitting American capitalism with a torpedo.
0:16:43 Nixon retorted that if there was going to be a torpedo fired, it was going to be by America’s
0:16:48 farmers and ranchers to which the farmers and ranchers listening to his speech applauded
0:16:49 very mightily.
0:16:54 A few months afterward, Khrushchev finally visited the U.S. and he got to see for himself
0:16:57 the sprawling cornfields of Iowa.
0:17:01 But this was of little help to the Soviet farmers back home.
0:17:10 The fact is they were unable to modernize Soviet agriculture with the economic structure
0:17:12 and strategy that they were following.
0:17:15 The economist Peter Timmer again.
0:17:18 It was not a technological problem.
0:17:21 It was a management and marketing problem.
0:17:27 There was a total divorce between what consumers wanted and what the managers of the big state
0:17:29 farms were told to produce.
0:17:34 Before it was part of a World Bank team that visited the Soviet Union, he saw for himself
0:17:37 their agricultural system and supermarkets.
0:17:38 Oh gosh.
0:17:40 I mean, the shelves were empty.
0:17:42 It was just weird.
0:17:48 We stayed at a government hotel and there was hardly anything to eat to talk with the
0:17:54 staff of the research agencies in places like that who would struggle just to come up with
0:17:56 basic foods.
0:17:58 They knew it could be better than that.
0:18:05 Khrushchev, despite his bravado, was ultimately forced to buy imported grain from the US.
0:18:09 Some historians would argue that this was one of the crucial factors that led to his downfall,
0:18:14 that it was just embarrassing on the world stage for the Soviet Union, this vast country
0:18:20 with enormous agricultural resources having to turn to its arch enemy for grain.
0:18:25 Khrushchev’s successor, Leonid Brezhnev, continued the policy of importing food from
0:18:28 the US to cover domestic shortfalls.
0:18:32 If the two countries had been normal trading partners, this wouldn’t have been a big deal,
0:18:35 but they weren’t normal trading partners.
0:18:41 They were Cold War adversaries, the global icons of capitalism and communism.
0:18:45 And it was becoming clear which system would prevail, at least on the food front.
0:18:48 Peter Timmer’s final analysis.
0:18:54 It was a fundamentally failed strategy for agriculture that brought down the Soviet Union.
0:18:56 They didn’t grow enough and they didn’t grow the right things.
0:19:01 And there were no price signals telling you what’s expensive and what’s cheap.
0:19:08 They wasted a lot of what they were producing on the land and never got into the supermarkets.
0:19:12 Timmer was actually in Moscow when the Soviet Union collapsed.
0:19:18 The neat thing is I have a passport going in stamped Soviet Union, but my passport coming
0:19:21 out, the exit stamp, is Russia.
0:19:27 People were so optimistic about what was going to happen.
0:19:32 They knew that American supermarkets were a miracle.
0:19:36 They had seen it on television.
0:19:42 That point had clearly gotten through at least to everybody that I talked to.
0:19:47 And so it seems as though the mighty supermarket may indeed have played a role in America’s
0:19:48 Cold War victory.
0:19:49 Yeah.
0:19:55 I mean, this is, it’s central to the kind of lie really of the supermarket as a weapon.
0:19:57 The historian Shane Hamilton again.
0:20:03 So when the supermarket is upheld as this, you know, effectively missile this concrete
0:20:10 consumer weapon against the claims of communism, it’s built on this idea that supermarkets
0:20:14 are producing this affordability just through the workings of supply and demand.
0:20:19 But you know, it’s unfettered markets that are somehow making food so affordable for
0:20:26 American consumers where the reality is for everything from milk to beef to grain to processed
0:20:33 foods of all kinds, there’s massive government investment in the science and technology that
0:20:39 enables the productivity of American farms from fertilizers to frozen food processes
0:20:42 to distribution and so forth.
0:20:44 And that’s all erased.
0:20:48 The image is that it’s just the supermarket itself that is the source of abundance.
0:20:52 So when you describe it like that, it’s certainly, I mean, you use the word lie and you talk
0:20:56 about the hidden components and you make it certainly sound nefarious.
0:21:01 But couldn’t you argue that, you know, the role of a government is to invest in science
0:21:06 and technology that’ll benefit private industry and ultimately the citizenry?
0:21:07 Yeah.
0:21:10 I actually don’t have a problem with the U.S. government investment in science and
0:21:14 technology and encouraging, you know, more productivity.
0:21:20 The concern is with, you know, that being disguised as a free market when it’s not
0:21:21 particularly free.
0:21:25 I mean, taking that to a propaganda level and attacking another country for not having
0:21:31 free markets, it’s just duplicitous, right?
0:21:36 You may or may not be as disturbed as Shane Hamilton is by what he calls the duplicity
0:21:41 of the U.S. government for promoting the supermarket as an emblem of free market capitalism.
0:21:48 To me, the big question is this, what was the ultimate cost of this supermarket victory?
0:21:53 What are the economic and political and health consequences of more than a hundred years
0:22:00 of agriculture policy that encouraged industrialization, standardization and low prices?
0:22:14 It’s coming up right after this.
0:22:19 So the U.S. won the so-called farms race with an industrial approach to agriculture
0:22:23 that was heavily influenced by government policy and funding.
0:22:27 What were the long-term results of that victory?
0:22:31 We need to go back about a hundred years to figure that out.
0:22:35 That is on the advice of Ann Effland, the former USDA economist we’ve been hearing
0:22:36 from.
0:22:42 Effland thinks there’s one key event that really drove U.S. food policy.
0:22:46 That is, production increases around World War I.
0:22:49 Farmers expanded their production to meet wartime goals.
0:22:53 And there were some price supports during that time that provided incentives for increased,
0:22:57 especially wheat and pork and some of these other staple commodities.
0:23:03 But there was no real planning for the aftermath after the increased demand and the price supports
0:23:06 that are set up for war go away.
0:23:11 And it left a number of farmers who had, in good faith, developed larger farms and more
0:23:14 productive farms with very low prices.
0:23:18 So after the war, farmers were producing more food than was necessary.
0:23:22 Then came the Great Depression, the economist Peter Timmer.
0:23:29 I mean, demand collapsed, but agricultural productivity did not.
0:23:32 And what that meant was prices just collapsed.
0:23:42 And so that so totally set the mind frame for U.S. agricultural policy.
0:23:47 That’s when we see the beginning of real price policies for agriculture.
0:23:52 Price policies for agriculture would take many forms over the ensuing decades, from
0:23:55 crop insurance to loans and direct payments and many more.
0:23:59 Now, you can understand why the government would want to make agriculture financially
0:24:02 viable and remove some of the uncertainty.
0:24:06 A national food supply is a pretty important thing.
0:24:11 One key policy tool the government used was a price support system, guaranteeing farmers
0:24:16 a certain minimum price for a specific crop at a specific time.
0:24:20 There was an idea of something called parity, which was that the price should be such that
0:24:25 it would give farmers the same purchasing power in comparison to workers and others
0:24:29 in the economy that they had had before World War One.
0:24:33 And that was the guideline for what those price support levels ought to be.
0:24:38 But if you increase the price being paid without limiting the amount being produced,
0:24:40 well…
0:24:45 One of the problems with this is that it leads to a large surplus.
0:24:50 This would leave the federal government to buy and store excess produce.
0:24:55 In the early 1930s, when the U.S. government guaranteed farmers 80 cents per bushel of
0:25:01 wheat, the government wound up buying and storing more than 250 million bushels.
0:25:05 These things all take place in the context of their own times.
0:25:10 Having policies that found a way to increase farm incomes in the 1930s, I think would be
0:25:16 seen as a good thing, but there are also consequences of that over time as they get embedded.
0:25:22 If you ever wonder why the USDA’s old food pyramid, the diagram of recommended servings
0:25:28 of different foods, why the biggest category at the bottom of the pyramid was bread, cereal,
0:25:34 rice, and pasta, well, the U.S. had an awful lot of all those foods.
0:25:41 And if you, as the USDA instructed, there’s a good chance you put on a few pounds.
0:25:45 You can’t think about nutrition without thinking about agriculture policy.
0:25:50 And U.S. agriculture came to be driven by financial incentives.
0:25:56 Incentives that, given how government funding often works, weren’t always entirely sensible.
0:26:06 You know, economists who don’t do U.S. agricultural policy are usually horrified by what they
0:26:15 see in terms of distorting markets, picking, okay, corn, soybeans, wheat, you guys get
0:26:23 big subsidies, apples, grapes, fresh fruits and vegetables, you’re on your own.
0:26:29 We incredibly regulated both federally and at the state level just a mess, just an awful
0:26:30 mess.
0:26:36 With price guarantees for certain crops and the resultant glut of supply, the government
0:26:41 sometimes paid farmers to plant fewer crops, but even this wasn’t fully successful.
0:26:46 So we have controls on how much can you plant on an acre, but not on how much your yield
0:26:49 is on the acres you are planting.
0:26:50 There’s a huge boom.
0:26:55 Lots of new chemicals, fertilizers, machinery that make farms more productive.
0:27:00 So even though we’re trying to control by reducing the acreage, there continues to be
0:27:04 increasing production and surpluses don’t go down.
0:27:11 But Anne Eflin says this was a problem the USDA wasn’t all that unhappy about.
0:27:16 Problem solving on the scientific and technical and engineering side tends to run on its own
0:27:19 track and be seen as a positive outcome.
0:27:25 I don’t think there’s ever a point at which the policy side is saying, “Oh, stop providing
0:27:30 good science and better agricultural practices so we don’t have these surpluses,” because
0:27:35 when you do that, what you’re saying is then stop this economic development.
0:27:43 Solving problems and making farming more efficient are still seen as good projects to continue.
0:27:49 The fact that they also create these surpluses is sort of a different track of problems that
0:27:53 the farm policy then is trying to figure out solutions to.
0:27:59 One solution was to use surplus grain for animal feed.
0:28:00 Shane Hamilton again.
0:28:06 This massive surpluses of cheap corn and later soybeans encourages the rise of industrial
0:28:14 meat production, concentrated animal production, livestock feeding operations that’s enabled
0:28:16 by cheap grain production.
0:28:21 Industrial meat production fueled by cheap grain meant cheap meat too, and helps explain
0:28:26 how the U.S. became one of the world’s biggest consumers of meat per capita.
0:28:34 Today, more than 30% of corn, more than 50% of soybeans grown in the U.S. goes toward
0:28:36 feeding cattle and other livestock.
0:28:39 But even that left a lot of surplus production.
0:28:41 So, what happened?
0:28:49 High fructose corn syrup, yep, you’ve got surplus corn and you’ve got a demand for easy
0:28:55 convenient sweetener in the food sector, and that was just a perfect storm.
0:29:01 That syrup revolutionizes food processing because instead of a powdery sweet thing,
0:29:06 it’s a liquid, and liquids are way easier to handle in food processing.
0:29:12 If I had only one thing to say about the impact of our agricultural programs on what you see
0:29:18 in the supermarket and subsequent health issues out of the diet, I would have said the fact
0:29:24 that we use so much high fructose corn syrup, that’s the example of how things can go badly
0:29:26 wrong even if well intended.
0:29:33 I mean, don’t get me started on ethanol, because that’s the next step in reducing
0:29:39 the surplus, but I don’t want to go there.
0:29:45 The rise in agricultural productivity tended to favor larger, more industrial farms.
0:29:50 It didn’t hurt that they often received the government price supports designed for smaller
0:29:51 family farms.
0:29:56 As you can imagine, this began to put a lot of small farms out of business.
0:30:04 We didn’t manage that process very well, but I think just basic economic forces would
0:30:06 have pushed us in that direction.
0:30:08 It just wouldn’t have pushed us as far.
0:30:13 Peter Timmer, you will recall, grew up working on the tomato farm and cannery founded by
0:30:15 his great-grandfather.
0:30:19 You’ll also recall when the Tip Top Canning Company got their first mechanical tomato
0:30:21 harvester.
0:30:24 It just revolutionized our operation.
0:30:29 When the mechanical harvester was introduced, there were around 5,000 tomato growers in
0:30:30 the US.
0:30:35 Within five years, 4,400 had gone out of business.
0:30:40 The Timmer family farm and canning factory made the cut, and they lasted for decades.
0:30:49 But between 1940 and 1969, 3.4 million American farmers and their families stopped farming.
0:30:56 Right a few historians suggest that this all-out push to productivity killed the family farm,
0:30:57 effectively.
0:30:59 Shane Hamilton again.
0:31:01 It’s hard to deny that.
0:31:07 On the other hand, we don’t apply the same kind of metrics to industrial manufacturing,
0:31:11 where similarly there’s been massive US government investment in science and technology to support
0:31:14 economic growth and productivity.
0:31:19 I’m sympathetic to those who see it as overall in that positive gain.
0:31:23 However, the pain is real.
0:31:28 Peter Timmer says this massive consolidation on the production side was driven by what
0:31:34 was happening on the consumption side, the growth of supermarket chains.
0:31:39 Supermarkets were able to manage the supply chains all the way back to farmers, but they
0:31:41 didn’t want little tiny farmers.
0:31:43 Just one supplier please.
0:31:47 It’s just way too complicated to contract with 50 or 100.
0:31:54 That has changed then the nature of production, right down at the level of Tip Top Canning
0:32:02 Company and how we would be able to provide the kind of regular quality and supply and
0:32:07 low price that a Walmart or a Kroger or a Publix would need.
0:32:12 I mean, Walmart really came in and looked at the landscape of American supermarkets and
0:32:15 saw inefficiencies everywhere.
0:32:21 What Walmart did was build on its successful model of general merchandise sales with hyper-efficient
0:32:26 logistics and distribution, brought that into the supermarket industry and really shook
0:32:27 things up.
0:32:34 I used to ask my class, I’m talking 1985, where is the world’s largest supercomputer?
0:32:37 And the correct answer was, it’s at the Pentagon.
0:32:42 Okay, where is the world’s second largest supercomputer?
0:32:51 Bentonville, Arkansas, home of Walmart, they used that computer to track every single item
0:32:55 on every single Walmart shelf.
0:33:04 That information technology is what revolutionized food marketing and it was pretty much invented
0:33:06 by Walmart.
0:33:12 This technology would spread across the world, affecting not just the demand side, supermarkets,
0:33:14 but the agriculture supply side.
0:33:21 So the U.S. experience is formative and it’s formative for two reasons.
0:33:31 One, U.S. universities train so many ag economists, food scientists, food policy people to go back
0:33:37 to other countries that the U.S. model is pretty well ingrained intellectually.
0:33:47 But the other thing, of course, is the biological and mechanical technologies mostly came out
0:33:49 of the United States.
0:33:53 Another consequence of the scaling up of American agriculture?
0:33:55 More standardization and less variety.
0:34:01 So apples, in the early 20th century, consumers in say New York state would have access to
0:34:05 literally hundreds of varieties.
0:34:10 Even in mass retail markets, by the mid 20th century, it’s down to just a handful and red
0:34:13 delicious really dominates the whole market.
0:34:18 And apples became remarkably tasteless by the mid 20th century.
0:34:24 So certain qualities were given up in order to gain that advantage of price and abundance.
0:34:31 We clearly won the food wars in terms of supply and abundance.
0:34:34 We won the abundance war.
0:34:44 What we may be in the process of losing is the health and quality dimensions going forward.
0:34:50 I think today we’re certainly witnessing, perhaps especially among millennials, an attempt
0:34:54 to kind of reconfigure values.
0:34:58 What are you actually looking for when you go to a supermarket?
0:34:59 It’s not just price.
0:35:06 Price does not contain all relevant information for many shoppers in a contemporary supermarket.
0:35:12 So the costs of pollution, of degraded animal welfare that are currently not being borne
0:35:17 by either producers or consumers of food would have to be borne.
0:35:25 If we had worried much, much more about the quality of farmland, of sustainability, about
0:35:31 environmental side effects from heavy fertilization on corn, we got a dead zone in the Gulf of
0:35:37 Mexico that is directly attributable to putting fertilizer on corn up in the Midwest.
0:35:42 I accused my brothers of poisoning the Gulf of Mexico, and they said, “Well, what are
0:35:43 we going to do?
0:35:45 We have to get high yields.”
0:35:52 There was this sense of everybody being trapped in an old paradigm, and now how do we break
0:35:53 out of that?
0:35:57 I hate to say it, but the current government seems to be trying to take us back to the
0:36:03 old paradigm rather than a more sustainable, environmentally friendly, let’s make agriculture
0:36:05 do more on organic and natural processes.
0:36:10 That doesn’t seem to be the political driver right now, but it has to come back.
0:36:20 We have to make agriculture green, which is a strange thing to say.
0:36:25 Peter Timmer has seen a lot of change in the farming business over his lifetime, and who
0:36:29 knows, maybe he’ll see the change he’s hoping for now.
0:36:34 But it’s going to be hard to break the status quo, at least in terms of how financial incentives
0:36:36 drive food production.
0:36:40 For instance, when the first Trump administration placed billions of dollars of tariffs on
0:36:46 Chinese imports starting in 2018, China responded with their own tariffs on imported American
0:36:50 crops like soybeans, alfalfa, and hay.
0:36:56 American crop exports to China fell dramatically, as did, of course, farmers’ revenues.
0:37:02 In response, the U.S. government announced a $16 billion welfare package to U.S. farmers.
0:37:07 That was followed by more farm aid tied to the COVID-19 pandemic.
0:37:13 Together, the Trump and Biden administrations have authorized over $157 billion in direct
0:37:16 government payments to farmers and ranchers.
0:37:21 And now Trump is promising more tariffs in his second term, which means the cycle may
0:37:29 start again.
0:37:30 And that’s it for this bonus episode.
0:37:34 From our archive, we will be back shortly with a new episode.
0:37:36 Until then, take care of yourself.
0:37:40 And if you can, someone else too.
0:37:42 Freakonomics Radio is produced by Stitcher and Renbud Radio.
0:37:46 You can find our entire archive on any podcast app.
0:37:51 It’s also at Freakonomics.com, where we publish transcripts and show notes.
0:37:55 This episode was produced by Matt Hickey and updated by Theo Jacobs.
0:38:00 Freakonomics Radio network staff also includes Dalvin Aboulagi, Alina Cullman, Augusta Chapman,
0:38:05 Eleanor Osborne, Ellen Frankman, Elsa Hernandez, Gabriel Roth, Greg Rippon, Jasmine Klinger,
0:38:10 Jason Gambrel, Jeremy Johnston, John Snars, Muirak Bowditch, Morgan Levy, Neil Carruth,
0:38:14 Rebecca Lee Douglas, Sarah Lilly, and Zach Lipinski.
0:38:20 Our theme song is “Mr. Fortune” by the Hitchhikers, and our composer is Luis Guerra.
0:38:23 As always, thank you for listening.
0:38:28 When I was a Fulbright scholar and had to explain myself to the cohort when we got to
0:38:32 London, I said, “Well, my background is tomatoes,” and everybody just laughed.
0:38:48 I hadn’t realized that it was not such a normal background.
0:38:49 Stitcher.
0:38:52 (upbeat music)
0:39:02 [BLANK_AUDIO]

0:00:08 Hey there, it’s Stephen Dubner. Before we get to our episode, I’d like to invite you
0:00:14 to come see Freakonomics Radio Live. I will be in San Francisco on January 3rd and in
0:00:20 Los Angeles on February 13th. For tickets, go to Freakonomics.com/LiveShows. They are
0:00:29 selling riskily, I believe is the word, so hustle up. Again, that is Freakonomics.com/LiveShows.
0:00:34 One more thing, the episode you’re about to hear is what audio people call a two-way,
0:00:40 what normal people call a one-on-one conversation. Most Freakonomics Radio episodes aren’t like
0:00:46 this. We typically feature multiple voices, multiple angles, sometimes even multiple stories,
0:00:52 but there is a real opportunity to be had by going deep with one person. So, for the month
0:00:56 of December, we are featuring some one-on-one conversations. You will be hearing about the
0:01:01 revolution in the GLP-1 weight-loss drugs. You’ll hear from one of the best magazine
0:01:08 editors of this generation. And in a special episode of the podcast “People I Mostly Admire,”
0:01:12 you’ll hear a mind-blowing conversation between Steve Levitt and an astonishingly creative
0:01:19 neuroscientist. In today’s episode, a conversation with a political figure who, several times
0:01:25 over his career, has been in the room where it happened with Donald Trump, with Joe Biden,
0:01:31 and with Vladimir Putin. And one last reminder about our upcoming live shows with very special
0:01:42 guests. San Francisco, January 3rd, Los Angeles, February 13th. You can get tickets at Freakonomics.com/LiveShows.
0:01:50 As always, thanks for listening.
0:01:55 We begin this story on June 16th of 2021.
0:02:01 This is a one-on-one meeting in Geneva, nothing else going on. Both presidents fly in just
0:02:02 for this meeting.
0:02:06 The two presidents are Joe Biden and Vladimir Putin.
0:02:13 So let me set the scene for you. For Biden, he has, I think, five days of meetings before
0:02:20 this in London and Brussels, G7, NATO leaders, etc. Biden looks great, he flies in. Putin
0:02:30 flies in. He’s coming from Moscow. He lands. He looks great, physically. Was relaxed. Cracking
0:02:34 jokes. Some of them at our expense.
0:02:38 The one-on-one meeting isn’t truly a one-on-one. It’s what State Department folks call a one-plus
0:02:46 one. It’s Biden, with Secretary Blinken sitting next to him, but not speaking. Putin and his
0:02:50 foreign minister, Lavrov, sitting next to him.
0:02:52 The timing was significant.
0:02:58 It’s been a rocky spring between the United States and Russia. We expel some Russian diplomats.
0:03:05 They expel some of my colleagues from embassy Moscow. Biden calls Putin a killer. Navalny
0:03:06 is imprisoned.
0:03:10 The one-plus one would be followed by a second meeting.
0:03:15 They have what’s called an expanded bilat, an expanded bilateral meeting. Those of us
0:03:20 who were going into the expanded bilat, there was a break. Secretary Blinken told us what
0:03:24 the two leaders had talked about in the one-on-one meeting.
0:03:26 What did they talk about?
0:03:31 Biden gave a reassurance to Putin, look, I’m not looking for regime change in Russia. We’re
0:03:37 looking for the phrase that was used at the time was guardrails for our relationship with
0:03:38 Russia.
0:03:42 And what did Biden and Putin talk about in that second meeting?
0:03:49 The headline is, what did they not talk about? Ukraine. I look back now and I say, the way
0:03:57 Putin conducted himself, he had decided he was going to invade Ukraine. He was going
0:03:59 to take what he thought was his.
0:04:06 As we all know, Putin did invade Ukraine several months after that sit-down. Today, on Freakinomics
0:04:11 Radio, a conversation with John J. Sullivan, a lifelong Republican who has served under
0:04:16 five U.S. presidents, including Donald Trump and Joe Biden, Sullivan happened to be on
0:04:23 duty in Moscow as U.S. ambassador during the 2022 invasion of Ukraine. He’s just published
0:04:29 a book called Midnight in Moscow, a memoir from the front lines of Russia’s war against
0:04:37 the West. It reads a bit like a thriller, spies and subterfuge threats and bluffs enormously
0:04:44 high stakes. The bulk of the book explains from inside the house the Russian Federation’s
0:04:49 decision to escalate its war in Ukraine. It is a train wreck that you can’t look away
0:04:56 from. And it left John Sullivan thinking that U.S. foreign policy these days is a bit of
0:04:57 a mess.
0:05:01 Our politicians aren’t leading Republicans or Democrats.
0:05:09 He sees frequent miscalculations. If you think cutting off Ukraine is going to assist your
0:05:16 pressure campaign on Iran, you’re crazy. And he sees multiple flashpoints. These are
0:05:24 countries governed by leaders and governments that are immensely hostile to the United States.
0:05:31 In the book, Sullivan isn’t quite an alarmist, but in conversation, different story.
0:05:37 There may not be a Pearl Harbor-like incident, but my fear is that it’s going to come and
0:05:39 we’re not prepared.
0:05:43 I learned a great deal from this conversation with John Sullivan, and I suspect you will
0:05:56 too. Let’s get it started.
0:06:02 This is Freakonomics Radio, the podcast that explores the hidden side of everything with
0:06:12 your host, Stephen Dubner.
0:06:16 John Sullivan now splits his time between Washington, D.C. and Connecticut. He grew
0:06:22 up in Boston, attended Brown University, and then Columbia Law School, and launched a
0:06:29 perfectly respectable, but if we’re being honest, slightly dull career as a corporate
0:06:35 lawyer. There were already a lot of lawyers in his family, even a family law firm in Providence.
0:06:41 But there was also an uncle, Bill. He was a combat naval officer during World War II,
0:06:44 and afterward he joined the Foreign Service.
0:06:49 He was a three-time ambassador. He served in Saigon during the early part of the Vietnam
0:06:55 War, ambassador of the Philippines, and then the last U.S. ambassador to Iran.
0:06:58 This had made an impression on his nephew.
0:07:05 He’s a young kid. I remember just being hooked on this conception of public service. Don’t
0:07:11 get me wrong. It’s not an easy life. It’s hard on family life, but boy, the rewards
0:07:17 are fantastic. Serving the United States abroad and standing for the United States
0:07:23 and all that we aspire to stand for and seeing the American flag flying over a mission in
0:07:26 a country like Russia, it’s really gratifying.
0:07:30 Sullivan has spent the past several decades toggling between corporate law and government
0:07:35 service. He worked in the Justice Department under the First President Bush, and in commerce
0:07:41 and defense under the Second Bush. In 2016, he was back in private practice when Trump
0:07:47 was elected. I was as surprised as many were, he writes in his book. I was not an active
0:07:51 Trump supporter, but I did still believe in Ronald Reagan’s famous 11th commandment,
0:07:56 “Thou shalt not speak ill of any fellow Republican.”
0:08:01 Sullivan had voted for Trump with no thought that I would ever be invited to work in his
0:08:06 administration, he writes. He adds that his wife, Grace, also a high-powered lawyer who
0:08:11 has since died, had not voted for Trump and would not have been supportive if I were going
0:08:17 to work for him at the White House. But it wasn’t the White House that called, it was
0:08:22 the Defense Department. Secretary Jim Mattis wanted Sullivan as his general counsel, and
0:08:29 that’s where Sullivan was heading until he got a better offer. Deputy Secretary of State
0:08:36 under Rex Tillerson. That job he took, and when Tillerson was fired by Tweet after barely
0:08:41 a year on the job, Sullivan became acting secretary. He reverted to deputy when Mike
0:08:47 Pompeo took over as secretary. Sullivan liked Pompeo, and they worked well together. But
0:08:55 that first Trump administration was an exercise in chaos. Nothing like its Republican predecessors,
0:09:02 Sullivan writes, undisciplined and unconventional. So, when he learned that the U.S. Ambassador
0:09:08 to Russia was resigning, Sullivan put himself up for the post. It’s hard to emphasize how
0:09:14 unusual this was, trading in a high-status job in Foggy Bottom for a diplomatic post
0:09:19 in Moscow. What did President Trump think of this move?
0:09:24 He thought Secretary Pompeo wanted to get rid of me, and the look on his face said, “If
0:09:28 that’s not the reason, then why would anybody in their right mind want to do that?”
0:09:33 But Sullivan made it clear to Trump that no, he wasn’t getting fired by Pompeo. He was
0:09:35 just ready for a new challenge.
0:09:43 So that was my last conversation with him in August of 2019. Never spoke to him as ambassador.
0:09:49 The last time I spoke to him was, he asked me if I really wanted to go to Russia. Did
0:09:53 have a lot of interactions with him, though, as deputy secretary.
0:09:56 And what were Sullivan’s impressions then?
0:10:04 President Trump looks at our overseas relationships, entanglements, whatever you want to call it,
0:10:10 looks at it purely from a transactional economic standpoint. If it makes sense for the United
0:10:17 States economically, and he defines economically narrowly, and a lot of economists disagree
0:10:21 with that, but Putin’s got a very similar outlook if you think about it.
0:10:27 And so it was that John Sullivan gave up the chaos of Washington, D.C. for a new chaos
0:10:32 in Moscow. Here’s how he puts it in his book, “I believed the Russian government did not
0:10:37 want any physical harm to come to me while I was in Russia. On the other hand, the Russian
0:10:43 government devoted a huge number of personnel and resources to try to annoy, provoke, criticize,
0:10:46 frustrate, embarrass, and compromise me.”
0:10:51 I mean, I knew what the Russians were about because I’d been deputy secretary of state
0:10:58 for three years. What I saw when I went there, it was a government different from any other
0:11:07 government I dealt with before. Their characterization of us as an enemy, they are at war with us.
0:11:12 And we in the United States, and particularly in Washington, it’s hard to get people to
0:11:20 really believe it, including at the State Department. We in Moscow at Embassy Moscow would be looking
0:11:27 for support for reciprocity. If the Russians did something to our mission, we’d be looking
0:11:33 for Washington to give a little payback to the Russian side. The response, well, geez,
0:11:40 that’s really kind of nasty. We’d never do, I’m like, you have no idea what we’re dealing
0:11:49 with here. That’s my message. We don’t understand how different these governments in Moscow
0:11:58 and Beijing are from us with leaders that are willing to use military force.
0:12:04 When Donald Trump was first elected in 2016, he spoke warmly of Vladimir Putin. If Putin
0:12:11 likes Donald Trump, I consider that an asset, not a liability. By the time John Sullivan
0:12:17 got to Moscow in early 2020, things had changed. The Trump administration had imposed a variety
0:12:23 of sanctions on prominent Russians and on Russia itself. One sanction came after a Russian
0:12:29 malware attack on US financial institutions, another after attempted Russian interference
0:12:36 in the 2018 US elections. Trump included more sanctions in a 2019 executive order in response
0:12:42 to a Russian assassination attempt in Salisbury, England. The target was a former Russian spy
0:12:47 who was exposed to a nerve agent that had been applied to his front door. He survived,
0:12:52 but a British civilian died when she reportedly sprayed herself with perfume containing the
0:12:58 same nerve agent. Her boyfriend had found it in a collection bin. In addition to imposing
0:13:04 these sanctions on Russia, the Trump administration had been backing Ukraine as it faced increasing
0:13:10 Russian aggression. This was a few years after Russia annexed Crimea and started backing
0:13:16 Russian separatists in the Donbass region of Ukraine, but it was a couple years before
0:13:22 Russia’s full-scale invasion of Ukraine. Then, in 2020, Trump lost the election to
0:13:29 Joe Biden. John Sullivan was asked by the Biden administration to stay on as their man
0:13:35 in Moscow. Biden announced that the US would be pulling out of Afghanistan.
0:13:42 Biden, always skeptical, going back to his days as vice president in the Obama administration,
0:13:49 skeptical of the US being a presence in Afghanistan, he decides in the spring we’re getting out.
0:13:56 He’s following through on the plan that had been negotiated in the Trump administration.
0:14:03 He says, “We’re out by September 11th. 20 years from the attack on September 11th, 2001,
0:14:08 we’re out of Afghanistan.” And this brings us back to that meeting in Geneva between
0:14:15 Biden and Putin. It’s the summer of 2021. It’s been a rocky spring between the United
0:14:20 States and Russia. This was only the second time that Putin and Biden had met face-to-face.
0:14:26 The first was in 2011, when Biden was vice president under Barack Obama. After that meeting,
0:14:32 Biden had said that Putin had no soul. And now recently, as president, Biden had called
0:14:38 Putin a killer. Like John Sullivan said, it had been a rocky spring.
0:14:43 By the way, the Russians are increasing their troop presence in Southwestern Russia, threatening
0:14:54 an invasion of Ukraine. And out of it all, Biden suggests a meeting with Putin in Geneva.
0:15:03 Good note, in April, after Biden called Putin a killer, Putin withdrew his ambassador from
0:15:10 the United States. And the Russian government said to me, “You need to go home too.” I
0:15:16 said, “Are you declaring me persona non grata? Are you expelling the U.S. ambassador?” And
0:15:20 they said, “Oh, God, no. But you do need to go home because no one is going to talk
0:15:26 to you.” Putin said this at one of his phone calls during this period with Biden. He said,
0:15:29 “You should bring your ambassador home because he’s going to have nothing to do because no
0:15:33 one will talk to him.” Biden says, “Let’s meet.” Putin agrees.
0:15:38 So they meet in Geneva at an 18th-century villa. People asked me, you know, what was
0:15:44 Biden like? Was he healthy? Was he with it? Biden shows up in Geneva and he looked great.
0:15:51 I mean, he looked like a healthy man in his late 70s. I did not see any of the decline
0:15:58 which was then obvious a few years later. So the meetings, there were two meetings.
0:16:04 We heard about this earlier, the one-plus-one and then the expanded bilateral meeting. John
0:16:09 Sullivan was in that second meeting. And what did the U.S. want out of this meeting?
0:16:16 I got the sense both under the Trump and Biden administrations, we want to pivot to Asia,
0:16:22 make this Russia problem go away, tell them to put a sock in it, put this guy, Progosian,
0:16:30 in a cage. Just calm down, calm, right? We and you can move on to bigger and better things.
0:16:35 And what was your impression of that message? Well, with the benefit of 2020 hindsight, let
0:16:41 me tell you what I saw. In the expanded bilateral meeting, they spent more time talking about
0:16:48 Afghanistan than they did Ukraine. Biden’s asking for the Russians not to oppose the
0:16:54 U.S. having a counterterrorism presence in Afghanistan. This will help Russia. We’re
0:17:01 going to keep al-Qaeda, the Taliban, we want to keep them under wraps. And that helps Russia.
0:17:06 We will cooperate with you. That sounds like a pretty smart ploy, right? Let’s create a common
0:17:11 enemy team up on this. We’ll get over our differences and move on. If you were dealing
0:17:16 with a normal country and a normal leader and you’re not, so what does Putin do? Putin says,
0:17:24 “Okay, well, we’re not a big fan of that, but just spitballing here. Maybe we’ll let you share
0:17:32 our 201st base in Tajikistan, which is right on the border with Afghanistan.” That is a huge
0:17:40 Russian military base in Central Asia, one of their key military installations. This is not
0:17:47 some little counterterrorism intel monitoring. This is a big, important Russian military facility.
0:17:55 Putin says it. I’m sitting directly across from Colonel General Gerasimov, who is not KGB-trained.
0:18:04 His eyes widened and he sort of gasped a little bit like, “Whoa.” And it’s clearly a joke. Putin
0:18:09 starts to chuckle. Did Biden take it as a joke? So Biden is, we’re all on our side like, “What the
0:18:16 heck?” And then his foreign minister Lavrov is talking about something else. Putin interrupts him,
0:18:23 puts his hand over Lavrov’s mouth and looks at Biden and says, “Be careful negotiating with this
0:18:30 guy. He’s Armenian.” It’s an ethnic joke, right? It’s like he’s going to fleece you. He’ll pick your
0:18:40 pocket. He’s Armenian. He chuckled and how loose he was. This is not a man who sat down and said,
0:18:48 “I’ve got a serious problem in Ukraine that’s threatening the existence of my country.
0:18:54 Let’s talk, buddy.” But fast forward, in November, that was his position.
0:18:59 So listening between the lines to you now, John, and please correct me if I’m wrong,
0:19:04 at that meeting in Geneva, the US was getting ready to pull out of Afghanistan. That ended up
0:19:12 happening in August of 2021. And then Russia ends up going into Ukraine about six months after in
0:19:18 February of 2022, correct? Correct. So listening between the lines, what I hear is that Putin is
0:19:23 sizing up Biden here and saying, “Well, he’s not very substantial. He doesn’t seem to have much
0:19:31 of a plan or a spine. And therefore, I’m going to take this meeting. We’ll joke a bit. I’ll tease
0:19:35 him a bit. I’ll see how he pushes back. Sounds like he doesn’t push back very much.” And it
0:19:40 sounds as though you’re saying that even though Putin had decided long ago that he would be going
0:19:46 into Ukraine hard with force, that this meeting, if nothing else, assured him that he wasn’t going
0:19:51 to get a lot of trouble from the US. Is that right? I would quibble. I think it’s unfair to Biden.
0:19:56 I think Biden, and he said this in his press conference after the meeting in Geneva, he said,
0:20:03 “Look, I’m giving this guy one last chance. Can we stabilize this relationship?”
0:20:06 But isn’t that a little bit like telling your seven-year-old, “Listen, you’ve got one more
0:20:12 chance to put down the paint?” After the meeting, they did back-to-back press conferences.
0:20:18 The first question that’s asked by Russian state media, so this is Putin asking himself the question,
0:20:24 “What did you talk about the most important issue for all of Russia is Ukraine? What did
0:20:28 you discuss with Biden about Ukraine?” And Putin says, “Well, really didn’t come up that much.”
0:20:33 Biden said he wants Ukraine to enforce the Minsk agreements, and if that’s his view,
0:20:37 that’s productive, but we really didn’t talk about it. But let’s talk about Afghanistan and
0:20:42 how that factors in, because some people make the claim once Putin saw Afghanistan—
0:20:44 But that was the green light.
0:20:50 No, no, no, no, no. He decided to do this long ago. What I will say is, in criticism,
0:20:59 I clued myself in this. As I look back, maybe he had decided, but he hadn’t yet pulled the trigger.
0:21:06 Could we have stopped him? I think Afghanistan was the nail in the coffin. The withdrawal
0:21:16 is underway while we’re meeting in June. What really has an impact is the calamity that starts
0:21:25 in July and then into August. The culmination is the terrorist attack on the 26th of August,
0:21:30 and then the missile strike that killed 10 innocent Afghans.
0:21:31 The US missile strike.
0:21:37 The missile strike. One of Putin’s most senior and important advisors, a guy named
0:21:42 Nikolai Patreshov, he gives an interview, again, to Russian state media in Russian,
0:21:52 directed to Ukraine. He says, “I have no idea why you people think it’s in your interest to
0:22:00 associate with the United States and its vassals. Look what they’re doing to their major non-NATO
0:22:07 ally in Kabul. Do you think they’re going to defend you? Absolutely not. You’re crazy. We’re
0:22:15 your Slavic sisters and brothers. Why are you shunning us looking for protection from this
0:22:23 feckless North American giant who goes around the world and creates wars and problems and then
0:22:28 leaves disasters in its wake? Look what they’re doing in Afghanistan.”
0:22:34 Donald Trump said during this campaign, the 2024 campaign, he said Russia would not have
0:22:39 invaded Ukraine if he had been president. I’m curious what you make of that claim generally.
0:22:47 That’s just as wrong as it can be. Putin is going to achieve his aims in Ukraine,
0:22:54 which he and everyone who speaks for his government have said consistently since the day the special
0:23:02 military operation began. February 24th, 2022, we’re going to denazify and demilitarize Ukraine.
0:23:11 He was going to achieve those means either by Ukrainian capitulation or by what the Russians
0:23:19 call military technical means, which is an invasion. Maybe if Trump had been reelected
0:23:27 instead of Biden winning in November 2020, if he had changed course, stopped supporting Ukraine,
0:23:32 maybe Ukraine would have had a capitulate. Putin was going to accomplish his war aims
0:23:38 by hook or by crook, by capitulation or by invasion. So what I say particularly to my
0:23:44 Republican friends, okay, you don’t support Ukraine. What’s your Russia policy? If your
0:23:51 Russia policy starts with cutting off Ukraine, not only is your Russia policy going to fail,
0:23:59 but if you think cutting off Ukraine is going to assist your pressure campaign
0:24:07 on Iran, you’re crazy. And oh, by the way, how is this going to influence President Trump’s friend
0:24:13 Little Rocket Man and Pyongyang and Xi in Beijing? And how would you say Trump’s winning the 2024
0:24:19 election will affect Putin’s thinking and at least the short-term future for Putin and Russia?
0:24:26 They’re celebrating Trump’s victory, but there are a fair number of people around Putin
0:24:32 who say, wait a minute, let’s not get carried away. We remember what the first Trump administration
0:24:37 was like. He wanted to have conversations in a relationship with Putin, but they imposed
0:24:42 all these sanctions. The other thing they’re concerned about is Trump’s energy policy.
0:24:48 What if it reduces dramatically the price of oil? That could have a bigger effect
0:24:53 on the Russian economy than all the sanctions and export controls, which I support that the
0:24:58 Biden administration has imposed. Could reduce the price of oil by producing much more in the US?
0:25:05 Exactly, exactly. From the Russian perspective, it’s all about the price of oil. If that price of
0:25:12 oil dips significantly, that affects their ability to continue to fund the war. There’s a political
0:25:17 scientist at the University of Chicago, Robert Pape, who argues that these economic sanctions
0:25:23 at the US levy is against Russia. Trump used sanctions, as did Obama before him and Biden
0:25:29 after him. Pape argues that sanctions essentially don’t work, that they’re a nice fallback for
0:25:35 folks like you, people in state, for ambassadors, et cetera, to feel like you’re doing something.
0:25:41 What’s your view on that? That’s a great question. The obvious answer, and anyone who says anything
0:25:48 different is just blinking at reality. Sanctions did not and will not, unless they’re much more
0:25:57 vigorously enforced, influence Russia’s policies with respect to, you name it, Ukraine, Iran,
0:26:04 North Korea, et cetera. A couple of things, though, they are necessary but not sufficient.
0:26:10 It’s not as though, okay, well, then we should just continue to do business with Russia and forget
0:26:15 that they committed a murder in Salisbury, England, an innocent woman, Don Sturgis.
0:26:23 They sent an FSB colonel who committed a cold-blooded murder on the streets of Berlin, shot a person
0:26:30 to death, a Chechen opposition leader, election interference, cyber. Are we then just supposed
0:26:38 to ignore it? I think sanctions have had a significant impact on the Russian economy.
0:26:45 The current prime lending rate in Russia is 21%. It reminds me a little bit of the United States
0:26:52 in the ’60s and ’70s with the great society spending on Vietnam and the price the US economy
0:26:58 pays in the ’70s and into the early ’80s is rampant inflation. That’s what Putin’s doing now.
0:27:03 They’re pumping money into their defense industrial base. They’re paying off their own people,
0:27:09 those who are being killed, their families, average Russians seeing pensions, salaries,
0:27:14 et cetera, increasing because he doesn’t want to lose popular support. The Russian people
0:27:18 in their economy, they’re going to pay a price for it. So he’s gritting his teeth
0:27:23 and he’s going to accomplish his goals in the special military operation,
0:27:28 but the Russian economy five, 10 years from now is going to pay the price.
0:27:36 Coming up after the break, how does Vladimir Putin sell this story to the Russian public?
0:27:45 I may be a peasant, but boy, I’m part of a special country with a special mission in the world.
0:27:50 More from John J. Sullivan coming up. I’m Stephen Dubner and you are listening to Freakonomics Radio.
0:28:06 John Sullivan was US ambassador to Russia from February 2020 until September 2022.
0:28:12 So he was on duty when Russia launched what it called a special military operation in Ukraine.
0:28:18 The rest of the world calls it a war. The war has lasted nearly three years and has killed tens of
0:28:25 thousands on both sides. The US has invested in the Ukrainian cause significantly, but also
0:28:32 cautiously. When it comes to poking a bear, the Russian bear is perhaps the worst bear to poke.
0:28:37 Embassy Moscow was John Sullivan’s last government posting and he has since retired
0:28:42 from the Foreign Service. I asked if he would accept a role in the new Trump administration.
0:28:49 I can assure you that I will not be taking a role in the Trump administration as evidenced by the
0:28:54 fact that two people I remain close with have been ruled out as potential candidates for a new
0:28:59 administration, Mike Pompeo and Nikki Haley. I’m on that list, I’m afraid.
0:29:05 For anyone old enough to remember or anyone who’s read some Russian history or literature,
0:29:12 there is this deep sense of loss. This was a country and a culture full of brilliant writers,
0:29:19 thinkers, artists, scientists, philosophers, a lot of dissidents too, of course, but it seems
0:29:25 from the outside at least as though that history has been paved over entirely, that the Russian
0:29:32 Federation of today bears no resemblance. It’s tragic. I went to Russia as an amateur Russell
0:29:39 file for all the reasons you said. All live accomplished in science, technology, engineering,
0:29:45 medicine, etc. During the pandemic, instead of working for the betterment of humankind,
0:29:53 they’re falsely promoting their Sputnik V vaccine, which was never properly tested.
0:29:59 It was seized by the Kremlin as an instrument to promote Russian nationalism. Look, we’re the
0:30:06 best. That’s the Kremlin hijacking the strengths of the Russian people, whether it’s in science,
0:30:13 technology, their religion, the Russian Orthodox Church is now an instrument, I’m sorry to say,
0:30:23 of the Kremlin, of Putin. He has turned all of those strengths to his purpose of recreating this
0:30:28 Russian Empire. There are a lot of Russian people who agree with him who are saying, “Ada boy,
0:30:34 you go and do that for us.” You write about the famous idea that Putin really has three advisors,
0:30:37 Ivan the Terrible, Peter the Great, and Catherine the Great.
0:30:43 Correct. Other than his nostalgia for the Russian Empire, what are his goals, would you say?
0:30:52 It’s not nostalgia. He is looking to recreate. There are a lot of ordinary Russians who lament
0:30:59 the weakened state of their Russia. Just as hope is a powerful tool in the United States,
0:31:08 that vision of empire, yeah, I may be a kulak, I may be a peasant here in Russia, but boy,
0:31:15 I’m part of something big. I’m part of a special country with a special mission in the world.
0:31:19 I don’t know if you’re a betting man, but given his position at this moment, given his
0:31:25 accomplishments at this moment, and given the lack of ability of the US, the UN, and others to
0:31:28 fight back, what do you think are his chances of achieving that goal?
0:31:34 Well, he thinks he’s in, and it’s probably true in the short term, a better position than he was,
0:31:43 say, in early 2023, roughly a year after the war had started, the Russian military had not just
0:31:52 failed but been embarrassed. So things were really looking bad for him. In September of ’22,
0:31:59 he had to order mobilization. It included some conscription, which was very unpopular.
0:32:04 It’s a different world now, and it’s not just the election of Trump. It’s what’s happened in
0:32:10 Berlin with the breakdown in the current coalition, Chancellor Schultz going to have to stand for
0:32:17 reelection, and the Germans themselves, the German government, announcing that it’s not going to be
0:32:23 providing as much support for Ukraine as it had earlier in the war. So from Putin’s point of view,
0:32:29 things are a lot better now than they were a year or a year and a half ago.
0:32:34 So John, I can imagine some Americans who didn’t vote for Trump listening to this and saying,
0:32:37 you know, I don’t see much daylight between Trump and Putin.
0:32:44 That’s a misunderstanding of who Putin is and what Putin does. It’s not rhetoric. It’s reality.
0:32:54 Look, Donald Trump, when he gets confirmed on January 20th, 2025, at 12.01 p.m., he’s a lame duck.
0:32:59 Now, he’ll have lots of influence. He’s got coattails, but he’s never running again,
0:33:05 and the jockeying for who succeeds him is going to start. And, you know, he’s going to be limited
0:33:14 by Republicans in the Senate. There are Republicans in the Senate, even with the 53-vote majority,
0:33:20 who are, and I don’t know what the Secretary of Defense nominee would say if asked about,
0:33:28 for example, the importance of our NATO alliance. But I guarantee you that any nominee who said
0:33:34 we should withdraw from NATO would never get confirmed by a wide margin. The Putin-Trump
0:33:42 analogy, I mean, that’s a vast overstatement. And that type of political rhetoric, in fact,
0:33:49 undermines marshaling the American people and leading the American people to oppose Putin.
0:33:53 But if Trump just wants to cut Ukraine loose, what’s to stop him?
0:34:00 There are things he can do as Commander-in-Chief that Congress wouldn’t be able to stop. The
0:34:07 military cooperation, the intelligence cooperation can all be cut off. If that happens, and more
0:34:12 importantly, the American leadership that’s influenced the Europeans, if that goes away,
0:34:20 how long can the Ukrainians hold out, then maybe this Russian special military operation after,
0:34:25 you know, three years of failure, they accomplish what they originally set out to do
0:34:30 on February 24, 2022. That’s certainly possible.
0:34:37 But it sounds as though you have a substantial amount of hope that the constitutional separation
0:34:38 of powers remains intact.
0:34:44 Oh, absolutely. I guess the right way to characterize me as an institutionalist,
0:34:50 and particularly the federal judiciary. I never traveled to the PRC when I was
0:34:56 Deputy Secretary of State. I traveled there a lot 10, 12 years before when I was Deputy
0:35:03 Secretary of Commerce. And what the Chinese government could not understand was they would
0:35:10 never accept the concept of an independent judiciary. The idea that a single federal judge
0:35:16 or a court of appeals or even nine justices on the Supreme Court could issue an order
0:35:23 in, for example, a matter of national security that a court could order the president to do
0:35:28 something and that he would have to do it. They could not believe that that would happen.
0:35:34 So I do have faith. You know, people ask me all the time, you know, he’s going to stay
0:35:37 after his term. He’s not going to stay after his term.
0:35:41 This is Trump you’re talking about. But what makes you say that? Because he certainly
0:35:42 tried last time.
0:35:48 Well, he certainly tried last time, but he has, by the terms of the amended constitution,
0:35:53 is limited to two terms. He says things off the top of his head. I’ve seen it in person
0:35:59 that he knows can’t happen like that big beautiful wall on the southwestern border of
0:36:05 the United States that was going to be paid for by Mexico. Trust me, he’s got one term left
0:36:12 and that’s it. He’s 78 years old. What condition is he going to be in at the end of his term?
0:36:13 Think about what happened to Biden.
0:36:19 After the break, we hear about some worst case scenarios.
0:36:22 I am not Winston Churchill and I hope I’m wrong.
0:36:29 And some mildly encouraging news. I’m Steven Dubner. This is Freakonomics Radio. We will be right back.
0:36:46 John Jay Sullivan, former State Department official and U.S. Ambassador to Russia,
0:36:52 still has a lot to say about American foreign policy, especially when it comes to China or
0:36:57 what he calls the PRC, the People’s Republic of China and, of course, Russia.
0:37:04 There are no opposition leaders left in Russia. There literally is no independent media left.
0:37:09 It is a police state just as the Soviet Union was, even more so.
0:37:13 Let’s say that for whatever reason, Putin vanished tomorrow.
0:37:17 What would happen? Who would be running the Russian Federation? What would that look like?
0:37:21 Because you do make the argument that Putin has kept a lid on certain kinds of things.
0:37:30 There are some, I believe, who have been urging him to use a tactical nuclear weapon in Ukraine,
0:37:36 or maybe an unconventional weapon. I thought they might use a chemical weapon in Mariupol,
0:37:42 the last holdout in southern Ukraine. So my answer to that question is,
0:37:48 if Putin doesn’t wake up tomorrow, the war continues. The war is not unpopular.
0:37:52 Once the war starts, the average Russian
0:38:00 doesn’t want to see, as they call it, their boys slaughtered or lose in Ukraine.
0:38:03 Given the state of Russian media, how much information do people get?
0:38:08 Very little. And you have to work hard to get anything other than the state media.
0:38:12 What they do see, though, is bodies coming back.
0:38:17 How surprised would you be if you woke up tomorrow and Russia did use nuclear weapons against Ukraine?
0:38:18 I’d be shocked.
0:38:19 Because why?
0:38:26 Well, first, as I understand it from military experts, there isn’t a real practical use for a
0:38:33 tactical nuclear weapon. So it’s strictly a political use of the weapon. And if it’s a political
0:38:42 use, if Putin were, for example, to decide, all right, my mission to denazify Ukraine hasn’t
0:38:48 proceeded quickly enough, I’m just going to nuke Kiev. What is his dear friend in Beijing going
0:38:56 to think? I come back to the PRC as a key. Putin meets with Xi at the start of the Olympics in
0:39:04 2022. They issued this extraordinary document, lengthy statement, page after page, declaring how
0:39:11 they’ve got this, it’s stronger than an alliance. Dear friends, the Russians have since used that
0:39:19 phrase frequently. My recollection is that Xi and his government haven’t used that phrase since.
0:39:29 And what happened since? It started the day of the invasion. Putin’s threats to use a nuclear
0:39:37 weapon. Xi has said more than once the use of nuclear weapons in this conflict, the PRC would
0:39:46 not support. If a portion of Kiev disappears under a mushroom cloud, that’s heat, and Putin doesn’t
0:39:55 want that. That’s the type of shock that’s going to wake up the American people. We spend, if you
0:40:04 include the Department of Defense and the budgets for the intelligence community, we spend a trillion
0:40:12 dollars a year to defend our country. The two principal threats to the United States,
0:40:22 1A, the PRC, 1B, the Russian Federation. The amount of money we already spend to defend ourselves
0:40:29 against Russia is astronomical. My ultimate point is we need to oppose Russian aggression
0:40:37 that is now exhibiting itself in brutal form in Ukraine. We need to recognize that the Russian
0:40:44 Federation is as aggressive, maybe more aggressive than the Soviet Union. Anybody who’s got a heart
0:40:52 or a brain wants this violence to stop, but it’s not going to stop because the Russians aren’t going
0:40:59 to quit until they accomplish their war aims. Their war aims, I guarantee, are broader than
0:41:05 just Ukraine. You know, there’s a history here. There are 15 Soviet republics that Putin thinks
0:41:10 are his. That’s what he’s looking to reestablish. Let’s pretend for a minute that you’re not on
0:41:14 the outs with the Trump crowd and that you were invited back. Let’s say you were invited back
0:41:20 as Secretary of Defense or Secretary of State. Put three things on the table that we can do
0:41:24 to turn the heat down or to change the leverage that Russia is pursuing.
0:41:32 Yeah, it’s a little difficult to do that without also engaging the PRC. The North
0:41:40 Korean sending troops to fight with the Russians in Europe not only has unnerved and infuriated
0:41:44 the South Koreans, but Beijing isn’t happy about this.
0:41:48 And you think there’s an avenue there for Trump and Xi to discuss?
0:41:49 Possibly.
0:41:52 If you were advising Trump, what would you offer as an incentive?
0:41:54 An incentive for the Chinese?
0:41:54 Yes.
0:42:02 Well, you know, there are a lot of things on the table. My fear is we can’t offer Taiwan.
0:42:08 You know, they’re worried about would he really come and defend us and not just the Taiwanese,
0:42:13 the South Koreans too. So what I would say to the incoming Trump administration,
0:42:21 we have to let them know that the war that they’re supporting and perpetuating in Europe
0:42:27 has now become globalized in ways that adversely impact them because you see quotes from the South
0:42:34 Koreans now saying, you know, can Trump be trusted? Can the Americans be trusted, not just Trump?
0:42:37 And do we need a nuclear weapon to protect ourselves?
0:42:41 What kind of deal do you think Trump will pursue with Putin over Ukraine?
0:42:46 Because he seems to see it as a mess on his desk that he just wants to get rid of.
0:42:53 Right. So that’s been the attitude going back to the Obama administration,
0:43:02 maybe even the Bush 43 administration. My charge as ambassador was make the Russia problem go away.
0:43:10 We want guardrails. Now there’s been this horrific war in Ukraine. We got to make it stop.
0:43:16 Why? Because we got to pivot to Asia. So here’s my problem with the political discussion in the
0:43:23 United States. Our leaders, Republicans and Democrats, don’t talk about these types of issues.
0:43:32 Rewind 44 years. The Carter administration has started to rebuild, reinvest post-Vietnam in
0:43:38 the Defense Department, right? We don’t go to the Summer Olympics in Moscow. Our leaders,
0:43:44 our presidents, talk to the American people about these issues, whether it was Reagan with
0:43:50 the Evil Empire, the Strategic Defense Initiative, putting intermediate-range nuclear missiles in
0:43:57 West Germany. Presidents used to talk in detail about security issues, and the American people
0:44:06 knew about them. We don’t have that discussion. It’s childish. It’s not serious. President Biden
0:44:12 himself, I’ve not heard him say this, but it’s been reported that he has, since the war started
0:44:22 in Ukraine, said we in the Obama administration, we sort of blew it in 2014. We let this guy get
0:44:27 away with it. Crimea you’re talking about. Crimea and in the Donbas. Remember, there’s real conflict
0:44:34 in the Donbas with Russian military units involved shooting down a commercial airliner
0:44:42 that kills a couple hundred people. We have not taken seriously this threat that an aggressive
0:44:48 nationalist Russia opposes a country that’s the largest landmass in the world with the largest
0:44:55 stockpile of nuclear weapons with a seat as a permanent member of the UN Security Council.
0:45:00 Russia is one of just five permanent members of the UN Security Council, but that certainly didn’t
0:45:07 keep them from invading Ukraine. What does that say about the UN? Should we consider it as toothless,
0:45:12 as obsolete as critics say? Yeah, I’m as big a critic. I haven’t gone so far as my friend John
0:45:18 Bolton and say we can cut off the top half of the headquarters and save the money. My State
0:45:24 Department colleagues, particularly those who have worked on international organizations issues for
0:45:33 decades, devoted their careers to it, wince when I say this, but it’s just completely ineffective.
0:45:44 We now have had the UN Secretary General go to the BRICS summit in Russia, shake hands with Putin,
0:45:56 imagine if there were such a thing, if the League of Nations still existed, and in January of 1940,
0:46:01 the Secretary of the League went to Berlin and shook hands with Hitler.
0:46:07 So John, it strikes me that most Americans, probably most people everywhere, are primarily
0:46:13 concerned with short-term problems, right? We get very distraught if the price of gas goes
0:46:19 up 50 cents a gallon, but in terms of elections or policy decisions halfway around the world
0:46:25 that may affect things five or ten years later, we don’t have much patience for that.
0:46:30 And I’m curious if you’re calling for a significant reassessment, realignment of how
0:46:35 we think about foreign policy and downstream effects. You know, I go back to Syria,
0:46:41 the Obama administration’s red line in Syria, which it then essentially ignored later, triggered
0:46:46 this massive outflow of refugees from Syria into Europe, which further destabilized those
0:46:51 countries that were already turning against immigrants. The list goes on and on. So I’m
0:46:56 curious what kind of decisions you see on the near horizon that we should pay attention to now,
0:47:03 because they will reverberate. It’s coming. Something is coming that is going to shake
0:47:10 the establishment and the American people. If there is a greater global conflict,
0:47:16 for example, between Israel and Iran that closes the Persian Gulf, that makes the
0:47:21 Houthi violence in the strait that leads into the Red Sea, you know, increases that,
0:47:28 and God forbid, with Taiwan, the effect on the global economy, you talk about supply chain
0:47:37 disruption. Oh my God. The analogy I draw to where we are today is the late 1930s. If you
0:47:43 look at the old movie tone newsreels, and you got, you know, the man on the street in the United
0:47:50 States being interviewed, you know, the chancellor, yeah, he’s rough around the edges. What he’s
0:47:56 doing with the Jews, that’s really bad. But look, Germany was in tough straits after the war and,
0:48:02 you know, the peace treaty and, you know, once Germany gets back on its feet, it’ll soften.
0:48:10 At the same time, Churchill, much more closely observing. And in harm’s way, let’s say. And in
0:48:20 harm’s way, Churchill gives these speeches warning about what’s coming. And they’re combined into a
0:48:25 book that’s published in the United States, and the title of it is “While England Slept.”
0:48:29 So you’re saying we’re asleep now? We’re asleep. And our politicians aren’t leading
0:48:36 Republicans or Democrats. Now, I don’t know, I may be completely wrong, there may not be a
0:48:42 Pearl Harbor-like incident. But my fear is that it’s going to come. And we’re not prepared. And
0:48:50 the American people haven’t been told how serious these risks are. Putin calls the United States
0:48:56 Russia’s enemy. J.D. Vance was asked recently, would he call Russia an enemy? And he said no.
0:49:02 Well, Putin calls you an enemy. So you’re trying to shake us all by the shoulders and wake us up?
0:49:07 I am not Winston Churchill. And I hope I’m wrong. But it’s more dangerous than you think.
0:49:15 The only place befitting an honest man in Russia at the present time is a prison.
0:49:23 That’s a line written in the late 19th century by Leo Tolstoy. I have a feeling John Sullivan can
0:49:29 identify. My thanks to him for this conversation. Again, his book is called Midnight in Moscow.
0:49:36 The last time we had a U.S. Ambassador on the show, it was Rom Emanuel, who had been posted in
0:49:42 Japan. You can hear that episode number 553 wherever you get our show. It’s called
0:49:49 The Suddenly Diplomatic Rom Emanuel. Meanwhile, next week on the show, we go one-on-one with
0:49:56 Rom’s big brother, Zeke Emanuel, to talk about one of the biggest medical advances in recent history.
0:50:03 You know, this is why people do science. What does the GLP-1 revolution mean for you
0:50:08 and for the U.S. healthcare system? Don’t get me started. We’ve got to have a whole
0:50:12 another conversation about that issue. That’s next time on the show. Until then,
0:50:18 take care of yourself and if you can, someone else too. Freakonomics Radio is produced by Stitcher
0:50:25 and Renbud Radio. You can find our entire archive on any podcast app, also at Freakonomics.com,
0:50:30 where we publish transcripts and show notes. This episode was produced by Zach Lipinski,
0:50:35 with help from Dalvin Abouaji. Our staff also includes Alina Cullman, Augusta Chapman,
0:50:40 Eleanor Osborn, Ellen Frankman, Elsa Hernandez, Gabriel Roth, Greg Rippin, Jasmine Klinger,
0:50:45 Jason Gambrel, Jeremy Johnston, John Schnars, Lyric Bowditch, Morgan Levy, Neil Caruth,
0:50:50 Rebecca Lee Douglas, Sarah Lilly, and Theo Jacobs. Our theme song is “Mr. Fortune”
0:50:55 by the Hitchhikers. Our composer is Luis Guerra. As always, thanks for listening.
0:51:07 I don’t know what got me off on this rant, but pardon me, I’ve kissed the Blarney Stone twice.
0:51:16 The Freakonomics Radio Network. The hidden side of everything.
0:51:24 Stitcher.