In this episode of the Pharma Perspective podcast, I spoke with Professor Jerry Avorn, a Harvard physician and one of the founders of the field of pharmacoepidemiology, whose work over the last four decades has fundamentally shaped how we think about medicines, evidence, and regulation. With more than 600 publications and over 130,000 citations, Jerry has spent his career asking an uncomfortable but essential question: Are we really using medicines in the best possible way?

Our conversation was anchored in his recent book, Rethinking Medications, but quickly expanded into a wide-ranging discussion about power, incentives, and the erosion of evidence standards in modern drug policy.

Jerry traced his intellectual roots back to the student protest movement of the late 1960s. That early experience of challenging institutional authority shaped a lifelong scepticism toward official narratives—whether in foreign policy or pharmaceutical regulation. A recurring theme in his work is the idea that important information exists, but isn’t always transparently shared, and that better decisions would follow if evidence—not power or profit—were placed at the centre.

One of Jerry’s most influential contributions is academic detailing—an evidence-based alternative to pharmaceutical sales reps. The idea is simple but radical: use the same one-to-one, behaviourally informed techniques as industry, but to promote independent clinical evidence, not products.

Rather than lecturing doctors from a podium, academic detailers engage clinicians in conversations about why they prescribe the way they do—and tailor evidence accordingly. This approach has repeatedly shown that clinicians are not anti-evidence; they’re often constrained by time, patient expectations, and information overload. When those constraints are acknowledged, prescribing behaviour can change meaningfully.

A major focus of the discussion was the use—and misuse—of surrogate endpoints in drug approval. Jerry emphasized that accelerated approval was originally a morally sound response to the AIDS crisis: patients were dying, and waiting for long-term outcomes wasn’t acceptable.

The problem, he argues, is what happened next. Regulators increasingly allowed drugs to remain on the market without timely confirmatory trials—and companies were permitted to charge full prices even when real clinical benefit had not been demonstrated. This, Jerry warned, doesn’t just expose patients to ineffective drugs; it actively lowers the standard for innovation, encouraging mediocrity rather than meaningful breakthroughs.

Another striking theme was the broken social contract between public research funding and drug pricing. Much of the riskiest early-stage research is funded by public institutions like the NIH, yet once a drug succeeds, pricing power rests almost entirely with private companies. Unlike other industries, there is little attempt to align rewards with who bore the original risk.

Despite acknowledging the limitations of cost-effectiveness analysis, Jerry was unequivocal on one point: doing nothing is the worst option. In the US, the situation is particularly stark—cost-effectiveness considerations are effectively excluded from federal pricing decisions. His view is pragmatic: no single metric is perfect, but any structured attempt to link price to value is better than leaving prices entirely to manufacturers.

Jerry remains deeply concerned about the weakening of regulatory institutions, particularly in the US. But he’s also hopeful. Outcomes research, real-world evidence methods, state-level drug affordability boards, and independent evidence-based consortia are all gaining momentum.

When asked what he’s most proud of, his answer wasn’t a paper or a policy—it was building communities: spaces where clinicians, economists, lawyers, and ethicists work together to improve how medicines are evaluated and used. And the work, he says, is far from finished.

If you’re interested in how evidence, regulation, and incentives collide in modern medicine, this conversation is well worth your time—and Rethinking Medications is an essential read.