Welcome to the "Lessons from the C-suite" series, featuring Advisory Board President Eric Larsen's conversations with the most influential leaders in health care.

In this edition, Alex Gorsky, chair and CEO of Johnson and Johnson (J&J), talks with Eric and OptumInsight CEO Robert Musslewhite about the two technologies that are enabling J&J to develop a novel coronavirus vaccine in "months rather than years," why he's more interested in cultivating J&J's "sustainable innovation culture" than ironing out a 30-year strategic plan, the trend he thinks will be "ubiquitous across health care going forward," and his prescription for a "new covenant for Capitalism."

Alex Gorsky, chair and CEO of Johnson and Johnson

[Editor's note: The Daily Briefing is published by Advisory Board, a division of Optum.]

Question: Alex, we have a lot to talk about, especially around your eight years helming one of the truly iconic companies in the U.S. economy. But we'd be remiss if we didn't start our conversation by addressing Covid-19. I'd like to ask in particular how Johnson & Johnson (J&J) has mobilized in its response to the pandemic, and most urgently around your vaccine candidate; yours is the fourth vaccine to advance into phase 3 trials, with arguably the most ambitious scope—60,000 enrollees across 24 states and 10 countries.  

I’d like to ask your perspective on a couple dimensions of this process. First, I'm curious to hear how J&J laid the foundation to be able to move as expeditiously as it has in advancing this vaccine candidate. And then, to get a bit more granular, perhaps you could enlarge on the technology behind the development of your vaccine—namely, using the adenovirus vector rather than messenger RNA, an approach you pioneered with Ebola, RSA, Zika, and others.

[Editor's note: On Oct. 23, J&J resumed its clinical trials for its vaccine candidate, after pausing them earlier this month to assess potential safety issues, noting that the temporary pause would not significantly alter the company's timeline for vaccine development. This interview took place before the trials were paused and was updated on Oct. 24 to reflect new developments.]

Alex Gorsky: Eric and Robert, before I get into the details, I have to say that I could not be prouder of the incredible progress our team has made in such a short time. We're trying to do in five to seven months what is normally done in five to seven years—all while prioritizing safety, efficacy, and accessibility every step of the way.

This actually started for us more than 10 years ago, when we started looking at vaccine development as part of a broader initiative to prevent rather than merely treat disease. As with many things in science, you don't always get it right the first time, so some of our early forays into vaccines weren't as successful as we had hoped. But our scientists remained committed, and while they were working, as you pointed out, in areas such as Ebola, Zika, HIV, and others, they developed the vector platform you mentioned that we're using for the novel coronavirus: Ad26, which is basically a cold virus we've used as a vector for the vaccines. It has a well-documented safety profile and is able to effectively deliver the right vaccine payload.

In the early days of Covid-19, our scientists took some of the initial data available on the genetic composition of the virus and started working on different models with our construct. They looked at a number of different combinations and permutations of not only the virus, but also our platform to try to discover and develop what they felt had the best balance of safety, efficacy, producibility, and many other factors.

They then took that information and put it in the animal models early on, and our results were robust. But animal models can only demonstrate so much; so we collaborated with external partners and regulators to take the next step, and our phase 1 trial of more than 1,000 patients was very encouraging. And now that we're in phase 3 trials, we're going to learn a lot more.

Q: As we well know, Alex, the successful creation of the vaccine is only the start of the battle—we then have the seemingly insurmountable challenges around mass production and distribution.  Perhaps you could talk about the anticipatory steps J&J has already taken to address these considerations.

Gorsky: Well, that's the other big capability we acquired, the PER.C6 technology. Rather than growing this vaccine in a big vat or in some other laborious process, PER.C6 is a protein-intensive process that basically gives us the ability to manufacture it like 1,000-liter beakers, where we can produce tens of millions of doses of our vaccine.

So early on, once we got what we felt were the appropriate signals in the animal models and were getting ready to go to human trials, we began scaling up our manufacturing and production capabilities, which is critical, as you point out.

Now, under normal circumstances, you wouldn't do it that way to mitigate risk; you do this more in a serial progression versus a parallel fashion. But we knew that to have a vaccine that was going to make a difference, it not only needed to be safe and effective, but there also had to be enough of it to go around. So that's what we're doing.

Q: I appreciate the commitment to be very methodical and science-based about this; I think it speaks more broadly to your efforts to "depoliticize" what's become a very contentious topic in the media and across the country.

Gorsky: All of this is why, Eric and Robert, I signed the Covid-19 Vaccine Maker Pledge that reaffirms that we'll follow the science. Given the high level of review and scrutiny this is getting in the media, we have to make sure we're reinforcing our principles—and our commitment to conduct these trials in a very diligent, robust way—with everybody.

And the good news here is that there are more than 200 vaccine candidates in development, with about 10 of those in phase 2 or 3 trials as we speak. So the big win here would be if we have four or five or six of these that demonstrate effectiveness; maybe some work better in some areas versus others, and some may not work at all. But when you combine that with the therapeutics, antibody cocktails, the monoclonal antibodies, the antivirals that stop the virus from replicating or ramp up or tone down the immune system, we're making major steps forward.

And beyond this, I really want to acknowledge what hospitals and doctors and nurses and systems have been able to do and the protocols around testing, admission, administration of steroids, and the proning of patients. While the incidence rates are troubling—and I remain concerned by what can happen over the next couple months as we enter the flu season—I am encouraged when I look at what's happening with mortality and how hospitals are doing a much better job as they've learned. So if we take all those things together, including ramped-up testing, and we continue to be diligent with hygiene and masking, we'll be in a very different place as we work through 2021.

Q: Alex, what you're speaking to here—the quick engagement and mobilization of the entire health care industry to respond to the crisis—has been one of the bright spots of the pandemic.  Of course, there are still parochial interests and perhaps not perfect collaboration and coordination across all stakeholders, but I think we can agree we are witnessing an unprecedented, multilateral international response. 

Gorsky: I agree. In my 30+ years of working in our industry, I have never seen the level or magnitude of partnering and collaboration that I'm seeing today by stakeholders around the world. In our case, that starts with our platform with Beth Israel's Dan Barouch and their team, as well as our collaboration with BARDA to make sure that we have the right kind of investments going into this.

Ordinarily, each of these vaccine approaches and submissions would be in its own little vertical, but now—since we can look across many platforms at once—we're learning much more, at a much faster rate. And by the way, this relates to working not only with the U.S. government at all levels—federal, state, and local—but also working with European governments, both at the European Union and at the country level; working with the Bill and Melinda Gates Foundation; the World Health Organization; and other international organizations. All together, we're figuring out what we need to do to produce safe, effective, accessible vaccines and therapeutics.

Globalization and the supply chain

Q: Given J&J's international reach—production facilities in 60 countries and consumers in 175 countries—I'd be interested to hear your perspective on what the pandemic has exposed about the vulnerabilities to our globalized and interdependent supply chains. While the disruptions have been especially sharp on the provider side with the scarcity and inaccessibility of PPE, it's arguably an equally consequential issue on the pharmaceutical and medtech sides as well. On the pharmaceutical side alone, we know that 40% of antibiotics come from China, and 80% of the active pharmaceutical ingredients (APIs) come from China and India combined. And to add to the complexity, this issue has become highly politicized with rhetoric around post-pandemic "de-Chinafication," deglobalization, etc.  How are you thinking about these issues?

Gorsky: There's no question that society, that economies, that health care systems around the world have benefited tremendously from globally integrated supply chains over the last several decades. If you just look at the accessibility that we have, the differences in cost, we've seen so much in terms of transformation predicated upon the system that has been built.

But like anything, taken to an extreme, I think all of us need to be cognizant that there are risks associated with that. So I believe that our entire industry should use this as a time to hit the pause button and ask, "How do we think about this differently?" And while I can understand there's been a maniacal focus on effectiveness and efficiency across health care—and by the way, that also applies to hospitals, not only health care products companies—I think evolving towards one of dependability, sustainability, and resiliency, going forward is going to be more important than ever.

And so while I think that we need to maintain a globally integrated supply chain, we need to make sure that when we're at the extremes, we are never in a position where we don't have access to certain ingredients or components, etc. So it's asking, "How do we ensure that we are never in a position, frankly, where we don't have access to certain ingredients? Certain components?" And we have to realize there may be a cost associated with that. There may be some additional capacity we're going to need to put in the system—hospital beds, for example—and we as a society, as a country, we're going to accept that, knowing that that's the only way that we will be prepared for these anomalous events that, unfortunately, are likely to occur again. We know that the consequences can be quite extensive, and therefore we must be prepared.

J&J as an icon—and as a pioneer

Q: I'd like to broaden the discussion and ask your reflections on J&J more broadly.  J&J is one of the preeminent names in U.S. industry—35th on the Fortune 500, a market capitalization of nearly $400 billion, and 130,000 associates. And you happen to be only the 7th combined J&J CEO and chairman, and one of just nine leaders in total, going all the way back 134 years to the celebrated Robert Wood Johnson. Pretty rich history. I have to think you're mindful of that inheritance all the time, but at the same time looking to evolve and refresh the organization. What does the next decade for J&J look like?

Gorsky: At J&J, we go where the science goes and where we see unmet need; ultimately, we go where we can make a difference. So, while I admire those who can chart out a 10- or 20- or 30-year strategic plan, I think that for most companies, it rarely arcs that way. It's a series of starts and setbacks, lurches forward and moves sideways—a lot of uncertainty and a lot of risk—before it leads to the sort of progress that, on a chart, may look like a fairly linear, well-planned progression.

That's the way that it's been at J&J. It comes down to a few fundamental principles; namely, understand what you are good at. And at J&J, we're really good at taking early science—whether it's under pharmaceutical, medical device or consumer—seeing the insights around how it relates to the needs of customers, patients, and health care systems; applying a lot of technical backing, including clinical development, to get those products approved; and then scaling them globally through our commercial organization or reimbursement teams.

In short, we take germinations of ideas and create multibillion-dollar platforms. In fact, across J&J, we've got 26 different billion-dollar platforms—about 12 in our pharmaceutical group, 12 in our medical device group, and two in our consumer group. It's amazing. And there are relatively few companies that have that kind of depth and breadth and size and scale.

So, if you ask me, "How does that evolve going forward?" I think there's tremendous opportunity within each one of our sectors, and there are going to be new and emerging areas in health care, undoubtedly. But what stands out to me is the technology—whether it's digital, AI, cloud, data sciences, the Internet of Things, it will be ubiquitous across health care going forward.

Q: I agree completely, especially with some of the digitization and automation advances we're seeing in the industry. I know this has been an area of aggressive and sustained investment for J&J on your watch—across all three of your primary divisions (pharmaceuticals, medtech, and consumer).

Gorsky: That's exactly right. I mean, you cannot be a cutting-edge pharmaceutical discovery and development shop today if you don't have world-class data sciences. And in terms of medical devices, again, I think we're just in the early days of embedding in technology—whether it's robotics or digital surgery, next generation. And it's not just enabling you to get into a tighter space with more precision; it's also about improving outcomes. And consumers nowadays don't just want a product; they want an experience, a relationship—they want you to come to them on their terms, on their desired format, not just global kind of CPMG approach was 10 years ago.

So, if I look 10 years down the road, I think those types of technologies and capabilities will be ramped up significantly in all those spaces. And I think there's going to be new spaces that occur in between. For example, post-Covid, I think the expectation about doing things such as in-home diagnostics and in-home remedies, is going to go up significantly. Similarly, we're going to need to learn how to do more clinical trials at an accelerated rate without compromising safety or efficacy, and hospitals may need to work differently in this new world.

So I think that this will be an important inflection point. I think it's a very exciting time for the health care industry, to not only really bring about change with patients and health care systems, but also to use some of these new technologies to head in new directions.

Q: Alex, we work closely with you through Optum on some of these data aggregation and analytics areas, especially in taking these huge data repositories and extracting actionable insights from them. Where would you push us and other key partners on where we can accelerate and advance these initiatives?

Gorsky: One is how do we integrate so much of this data that's out there right now. Too often in our world, people tend to think in these artificial verticals—this is pharma, this is medical device, this is consumer, etc.—but I'm sorry, the patients and consumers don't care how we classify it. So how do we do we use data to think more holistically around that patient experience and, ultimately, outcomes?

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Because many health care leaders will say, "I want outcome-based service," but even determining an outcome is much more complex than we think. So, what does an outcome mean when somebody has a certain type of cancer? Is it just 100%? Is it another certain number of years? What seems like a very fundamental or easy question suddenly can become quite complex.

So I think there's a lot of opportunity, particularly between health care products and services companies like ours and companies like yours, where we can avoid thinking in silos in terms of our data and look into how we can use that holistic approach to drive the right outcomes.

Innovation and self-disruption

Q: Earlier in our conversation, Alex, you spoke admiringly about the heroism of the frontline physicians and nurses and the enormous creativity that health systems showed in their procurement of sufficient PPE, etc. With this in mind, I'm struck by how "partnerable" J&J has been with hospitals, namely your partnership with Beth Israel and Harvard in vaccine development, as well as your partnership with Prisma Health on 3D printing advances and enabling a ventilator to treat two patients rather than just one—and I'm sure there are countless more. Would you expand on how you see the partnerships between J&J and outside entities evolving?

Gorsky: We've known for some time at J&J that there's no way we can be successful, to execute, to innovate without strong, deep-seeded partnerships across all of our businesses, not just with hospitals as you pointed out, but in all of our functions. Just consider a company like J&J being about $85 billion in sales, and let's just say you have a goal of growing in the mid-single digits—you do the math on that, keeping in mind that every year, there's about 5% to 10% loss in our portfolio due to patent expiries or other issues. That means you've got to introduce $10 billion of new products every year—and that's in a negative pricing environment. So over a five-year period, we need to have a plan to replace 25% of our portfolio.

There's no way we can do all that internally. That's why at J&J, about 50% of our innovation takes place externally. And the overwhelming majority of these are smaller deals, where we see a unique mechanism, device, or a burgeoning new area in the consumer space; we go in for hundreds of thousands or a million or more dollars; we'll apply our scientific, clinical regulatory expertise; and then build it out.

In fact, over the last 10 years, over 90% of our deals have been under a billion dollars. And most of those have been much, much smaller scale. And so we've developed our innovation centers around the world, our JLABS, where we actually house startups to develop out this ecosystem, realizing that's the only way we can stay competitive—by being agnostic on what are we doing internally versus externally, while, ultimately, staying focused on getting the best science that can make the greatest difference. You have to take multiple bets on multiple platforms for that to come to fruition.

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Take Verb Surgical, as an example. We said we're never going to be able to do this internally, and we're never going to be able to do it inside of Google. So let's create the right kind of joint venture, let's have them—Verb Surgical and Google—work together, get it to a certain point in development, and then bring it in-house at J&J to take the rest of the way. That's a classic approach.

And just a couple of years ago we did an interesting deal with Actelion, which gave us access to insights into pulmonary arterial hypertension and an area of great unmet need. And in that agreement, we created a new R&D-focused organization, Idorsia, that we're working with as we speak.

So we're committed to this concept of how to partner and collaborate in order to innovate, stay relevant, and make a difference. And in all these cases, it's as important for us as leaders in health care or in business, to be as innovative about the way we innovate as we are about innovating the products and services themselves. For a company our size, that's the only way to do that in a sustainable way.

Q: It would be interesting to hear you thread all of these seemingly discrete growth engines into one centralized theme: How you foster innovation. J&J has a well-earned reputation as an innovator—perennially one of the highest industry R&D budgets ($11 billion annually just within your pharmaceutical division), and an active acquirer of companies (such as Momenta, Verb, Auris Health, and others). How do you strike that equilibrium between honoring a 134-year history and relentlessly driving the enterprise forward? I've heard you say you essentially try to operate the company as a 134-year-old startup.

Gorsky: It is, Eric and Robert, and look, it's a careful balancing act between knowing as an organization what we want to do and where we want to go, versus letting new, interesting opportunities come from the ground up. Because, as we know, everything in phase one and phase two can be very promising; you can easily get caught up in the interesting biology, chemistry, engineering du jour that can, eventually, lead you down a very challenging pass. But on the other hand, if you don't take the leap once in a while—if you hold on only to what you have today—then someone else who's willing to take that leap is going to make you obsolete.

And in an organization like J&J, we've got to be able to do both. We're not that $1 million, $10 million startup that is just maniacally focused on one particular area. We've got hundreds of platforms; we're among the top five companies in R&D in the United States, and among the top 10 in the world. And so getting that balance right between, look, here's where we're going to definitely allocate the enterprise's resource to ensure success, while also providing the autonomy, responsibility, and agility at the local level to seize and fund new opportunities internally or externally—that's critical.

Q: That's a big one.

Gorsky: So I'm proud of the sustainable innovation culture we've created and maintained; how we are, as you mentioned, still very much that 134-year-old startup. For instance, back in 2009, J&J had only one therapeutic for oncology—VELCADE, which was maybe a $300 million product—but today, we're among the very top oncology companies.

And few companies have launched as many game-changing therapeutics, whether it's ZYTIGA, IMBRUVICA, DARZALEX—I can go right down the list. And how did that get done? By providing people the freedom to innovate, by following the science, by going internal, by going external, by partnering in new and creative ways.

New 'Covenant for Capitalism'

Q: Alex, I'd like to pivot a bit and talk about your championship at the national level around what we might call the "new capitalist covenant"— a declaration, co-authored with 184 other prominent CEOs (such as Jeff Bezos, Tim Cook, Jamie Dimon, and others) as members of the Business Roundtable, on the "purpose of a corporation." I'd like to hear you explain what animated that, as I think it's more relevant than ever in this pandemic environment.

Gorsky: I'm very proud of the evolution and the direction we've taken with the Business Roundtable (BRT) as it relates to the new Statement of the Purpose of a Corporation, and particularly proud that we did so prior to the pandemic, because I think this affords us an opportunity to bring it to life.

So, several years ago, I got a call from Jamie Dimon asking me to take on responsibility for the governance committee at BRT. And I remember saying, "Jamie, what'd I do wrong? Governance Committee?" Because this was really sexy stuff, all these esoteric governance and administrative issues. But I agreed, and while we were working on a number of those platforms, the executive committee of BRT said, "Look, we experienced some criticism because the Statement of a Purpose of a Corporation had not been revised since the 1990s. It's still on our website."

And Jamie said, "Well, I think that falls under governance." But we realized that we had a lot to learn first, so we conferred externally—with academics, thought leaders, and others—and internally, within the committee, and we finally got to this outcome where we talk about our commitment to our customers, to our employees, to the communities, and to our shareholders. And I'm not shy about the fact that there are a lot of similarities between that statement and J&J's own Credo.

And what I found interesting was that when I went back to the main body of the BRT, there was almost unanimous support. And the fact that when we went out and launched it, we were criticized that same week the right and the left—we were in the editorial section of the Wall Street Journal, the New York Times, and The Economist—means we struck a vein. We spurred a different kind of discussion and, frankly, it was at the right time in our country.

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And I understand emotions run high, and that people feel strongly about, on one side, shareholder primacy, that we're ensuring that the purpose of business is not hijacked by the issue du jour. But I also have tremendous respect for the other side, where people say, "Wait a minute, if it's just all about the shareholder and money, what about the rest of us?"

So what we tried to say is that first, this is about long-term shareholder value, and that to do what's best for our system, for our country, and for our stakeholders is taking that long-term view. Second, it's an "and/and" philosophy, not "either/or"; it's how do you think about these things simultaneously, and when you do that with a long-term point of view, the likelihood of success is going to be much, much higher. And, last but not least, I think it's an important recognition that if we don't evolve our Credo and our purpose, there will come a time when society is going to say, "Are you really representing our best interests?"

Now, all of this was a year ago in August, and I think the timing was prescient, in many ways, because when we got hit with all this, Doug McMillon, who picked up leadership of BRT from Jamie, has done an excellent job of picking up that mantle, being much more explicit and involved in some issues, such as racism and social injustice. And while criticism comes with the territory—and, frankly, keeps us honest—I think if we step back at a higher level, look at the different approach that the business community is taking now versus before, I'm really pleased to see the progress being made. There's more than needs to be done, for certain, but there's definitely a new way of thinking.

Final thoughts, reflections

Q: Alex, we've been able to sit down with nearly every one of the top 100 Healthcare CEOs for this series, but you're the first biopharmaceutical leader with whom we've had the privilege of doing this. So before we close, I want to reflect with you about your career and ask about some of the "inflection moments" that shaped you and the leader you've become. I'd like to start with your family, because you were one of, I believe, six siblings?

Alex Gorsky: There were several bookends or chapters in my life that were really seminal in making me who I am and the leader I've been fortunate enough to become—but you're right, it all starts with my family.

You see, my grandparents immigrated from Eastern Europe, eventually establishing themselves in America by working in meatpacking plants or opening up grocery stores in Kansas. In turn, my father, a Korean War veteran, worked his way up at Gerber, eventually becoming one of its top executives, while also becoming a two-star general in the Army Reserve, and my mother worked as a special education teacher.

With those role models, my siblings and I learned that's there's nothing you can't do if you're willing to work hard enough—and that there's nothing more important than family. They also created an environment where we could argue, so long as you have your facts, but you always loved and supported each other. And in many cases, those are the same fundamental values I try to use every day in my personal and professional life.  

Q: One of your friends relayed an anecdote about how you, at a very young age, heard a neighbor talking about West Point and the Army, and right then and there you resolved to go exactly that path. 

Gorsky: That's right. I remember visiting some family friends when I was in sixth grade, opening up a West Point yearbook, and seeing their eldest son in there—I was immediately smitten with the Academy, the duty-honor-country concept, the idea of being challenged academically, physically, and emotionally. From that day on, I knew that was where I was going to go; even when I was recruited for other places, I didn't fill out the applications, because West Point was what I wanted.

That was really the next chapter for me. And the grit, the resilience, the discipline I need to manage my life and workload, that I learned there, are skills I rely on all the time.

Q: What about after graduation? I know you advanced quickly through the military, ultimately finishing your military career with the rank of captain, a Ranger tab, and Airborne wings.

Gorsky: After graduation, I was a 23-year-old lieutenant stationed in Macedonia, in a unit with only about 40 Americans and about 400 NATO soldiers. By the time I was 27, like you said, I was a captain and an Airborne Ranger. So, at a very early stage, I learned about getting people to work together, how to earn the trust and respect necessary to motivate people—to help them become something that none of them think they're likely to achieve alone.

Ultimately, though, I realized that while I had this good career path ahead of me in the Army—and although I was working with great mentors and leaders—it was time to explore my options. I had just gotten married, and my next assignment would have automatically incurred an additional commitment. So, I started interviewing with companies in technology and health care, looking for something—based on the advice of my mentors—that was both a growing industry, because that's where there will be opportunities, and one I felt passionate about, because you're going to be doing a lot of it. And that's how I ended up with J&J.

Q: What was that like? Transitioning from captain in the Army to a sales representative at J&J?  

Gorsky: Humbling. But the development program I was in at J&J insisted on that, and I'm so glad it did, because it helped me understand the customers, the health care systems. And learning the health care system from the ground level—developing that empathy about customers and what they're experiencing, what their priorities are—shaped and continues to shape who I am.

Then, of course, I had a chance to get into a marketing role within Janssen, where I went from managing one product to becoming president of an expanding segment within our pharma group at the time. And then I got a chance to move to London and run Europe, the Middle East, and Africa, which was a big step; that was a tremendous experience, but it ultimately wasn't the right fit for me—I left and went to Novartis, where I worked for four years. But I knew, deep down, that J&J was still a part of me, and when I had the opportunity to come back in a medical device division, that was something I felt good about. And soon after, I was provided the opportunity to be considered for this role. And the rest is kind of history.

Q: Alex, allow me to wrap up our conversation by asking one of my favorite questions: as you look back over the course of your career, what are you most grateful for?

Gorsky: Look, I don't want to become too retrospective yet, because I want to feel like I've got a lot more that I can and must do. But ultimately, I'm probably most grateful for is being able, for the better part of my career, to work for two organizations—the Army and J&J—that were so value- and principle-driven.

If you ask me how to define success, I would say, look, if we've done a good job in helping patients and consumers live longer, healthier, and happier lives; if our employees feel they've been able to be their best and make a difference in a way that they couldn't imagine doing on their own; if our communities look at us as not only a successful business, but as an organization that gives back in the right way; and if our shareholders realize a benefit that says, gee, this is sustainable, this is going to help us carry on with our endeavor, then that's the true measure of success—and that's what I would be most grateful for. And to do that in a company that I think is as much of a family as a company, where I feel part of something bigger than myself? What more can I ask for? 

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