All-In with Chamath, Jason, Sacks & Friedberg
Can We Trust the FDA? Marty Makary on Science, Power & Patients
15 Jan 2026
Chapter 1: How has the FDA changed under Commissioner Marty Makary?
Marty Makary, Commissioner of the FDA. Welcome to San Francisco.
Great to be here, Dave. Good to be with you.
Yeah, thanks. It's JP Morgan Healthcare Conference this week in San Francisco, considered, I think, probably the biggest, most important biotech conference globally. Very important week.
Chapter 2: What are the implications of the U.S. losing the biotech race to China?
So you're visiting this week for the conference?
Yeah. 120,000 people. Great conversations. You hear from everybody. Just not enough time to meet with everybody you want to meet with, but it's a great time.
Chapter 3: How can drug approval timelines be accelerated safely?
Well, thanks for sitting down with me. You and I have gotten to know each other a little bit over the last year or so. Yeah. And I'm really excited to hear a little bit about how things are going. It's been almost a year since you've been in the role. I think maybe for our audience, you could share a little bit about how you got this role. How did you get involved with this administration?
How did you get connected with them? And maybe we can go all the way back to your very outspoken views during the COVID pandemic and maybe how that brought attention to you and your philosophies that drove this role.
Yeah, so my interest in academia, I went to graduate school for public health and served on the faculty of the Johns Hopkins School of Public Health as I also had a clinical practice in GI and cancer surgery at Johns Hopkins. And my interest was always in the root causes of our healthcare system problems, from quality, transparency, and price.
And in the work on price, I led sort of a national effort to try to get more price transparency of hospital prices, I wrote a book on it that did very well. It took me to the White House where they had read the book, invited me in. And in that first Trump administration, we had a lot of great conversations. And then they implemented the idea. And I was so impressed. This makes sense.
We want common sense ideas. And so we got the hospital price transparency executive order signed by the president.
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Chapter 4: What changes are being made to the Food Pyramid and why?
That's where I developed some of the relationships and got to know the folks. And then when President Trump got reelected, he gave me a call days after the election. And I was very honored to be offered this role. So it's been awesome. COVID, you mentioned COVID. It was a crazy time. I mean, the sort of sociology of medical dogma is a fascinating thing.
historical thing, and we still suffer from it.
Chapter 5: How do GLP-1 drugs address America's obesity epidemic?
Paternalism, the sort of suppressing ideas that are not the legacy ideas, the sort of sacrificing the basic principles of science to question everything, to have no sacred cows. And you saw the worst of that bad behavior during COVID. Cloth masks on toddlers for three years.
vaccine mandates for young college students, recommending COVID boosters with such absolutism in young, healthy children, ignoring natural immunity, one of the most scientifically dishonest things a scientist could possibly say about the virus and the immunity.
and shutting kids out of school for nearly two years, which I fought tooth and nail, along with Jay Bhattacharya and others, starting in the fall of 2020. Initially, we were OK just doing stuff while we didn't understand it. But once the data emerged, we made a strong case to reopen the schools. And to some degree, I feel like we lost that battle.
Chapter 6: What new perspectives are being considered in vaccine development?
But people now see that the data has caught up with public health officials. And so I'm proud to be in office now to be a part of an effort to rebuild public trust in our health institutions.
And you must be having a lot of conflict then, because you really are fundamentally trying to rewrite the way these institutions operate, have operated. And in some sense, you are degrading the success and the career and the authority that some have vested themselves over time in those roles. How has that been? And what's the pushback been like as you've kind of gone through this exercise?
So I meet with folks at the FDA, and if you meet with them with their bosses and everybody in the room to get a briefing on a topic, then they give you one glowing story. But if you meet with one individual scientific reviewer and give them the safety of anonymity and say, look, I want to hear how is it going on the ground?
Or what big ideas do you have that you've always wanted to do but not been able to do? Four out of five people, or sometimes more, will not really give you anything interesting.
Chapter 7: How can AI help in lowering drug prices?
But then somebody will say, you know, it makes no sense that we do it this way, and we could do it better, and we could do it this way. Something they wouldn't feel comfortable offering if their supervisor were in the room. And so we've been running with these ideas. We have announced 42 major reforms in my 10 months in office at the FDA.
And it has challenged the status quo of doing things, but we have to. I mean, why does it take 10 to 12 years for a new drug to come to market? We've become so lukewarm and passive, accepting that horrible timeline that has just become the status quo. We've got to challenge these deeply held assumptions, and we're doing it.
We are doing it with new programs, new priority reviews, new pilots, new forms of transparency. We made our rejection letters public so that if the FDA does not approve a drug, the public deserves to know why. And it creates accountability.
And that was not the case before.
They talked about it for 30 years and we got it done. They talked about banning one food dye for 35 years. Within weeks of coming into office, we took action to remove all nine artificial petroleum-based dyes. So we're getting stuff done. We're not afraid to move fast.
And in that role, some people have left the FDA, and then they've been outspoken critics of yourself.
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Chapter 8: What are the current theories regarding the causes of autism?
Maybe you can respond to some of the criticisms, that it's chaotic, that there's a lot of turmoil. I've worked at many startups. I know that when you move fast, things feel, or they may feel too busy, or they may feel like there's too much going on. It's overwhelming at times, but at the end of the day, progress is what matters.
Maybe you could just comment on some of the reports made by employees that have quit the FDA, left, and provided some comments on how things are going.
There were 2,000 HR people at the FDA just before I got there. There were 1,500 IT people. And so- Sorry, for a staff of how many total? 20,000 employees just before I got there. And so there was a goal to say, hey, we're going to go back to 2019 staffing levels and the cuts are not going to be to scientists or reviewers. No scientific reviewer was laid off.
But there were significant consolidations in HR, procurement, IT, and the duplicative services that were out there.
Now, anytime you do something in government, you take headline risk, but we felt it was the right thing to do, and so I came in right after that massive sort of change, and since then, we've had a great culture, we've had more teamwork, we have new leaders, and they believe in this new vision. The number one priority of the commissioner that preceded me, he said, was to fight misinformation.
Well, my number one priority is not to censor Americans. It's to deliver more cures and meaningful treatments faster to the American public and healthier food for children. And I think every employee at the FDA knows that mission. We have incredible teamwork. Our turnover rate is at the baseline 5% to 7% that has been there for the last 10 years at the agency. So there's no exodus.
There's no mass departures. We are actually hiring 1,050 new scientists because we have very ambitious goals on our new pathways, accelerated type pathways. And so we're building up capacity to have a whole new line. of pathways so that we can deliver faster for the American people.
Great. Well, look, let's start with a framing. The framing is the US versus China. I want to read this report that came from the Congressional National Security Commission on Emerging Biotechnology. We're here at a biotech conference, so I figured we could start here because everyone's talking about China and the race against China.
The US, according to this commission, has a three-year window to act to keep up with Chinese innovation and the speed in biotech. In 2022, Chinese companies were just 5% of licensing deals. 2025, 42%. And recently, one of the biggest licensing deals ever was 3S Bio, $1.25 billion upfront with a $6 billion total with Pfizer.
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