On average, only 1 out of 20 medicines works when we actually bring them into human beings, and these rates of success haven't moved much in the pharma industry overall in the past 15 years despite much scientific progress. Because if you really think about it, it's incredible that we find any human medicine at all, given the human body -- the product of billions of years of evolution -- is an incredibly complex system we do not fully understand. Yet the business of the pharma industry and Novartis in particular -- which covers everything from generics to innovative medicines (next-gen therapeutics such as cell and gene therapies like CAR-T for cancer and more) is not that different from other large enterprises when it comes to managing R&D, pipelines of ideas and pipelines of talent, and more. So how does the world's largest producer of medicines in the world in terms of volume -- 70. billion. doses. a. year. -- balance the science and the business of innovation? How does an enterprise at such vast scale make decisions about what to focus on, what to build vs. buy? Given the fast pace of science today, what happens to deep expertise that would normally take many decades to build up? In this conversation, a16z bio general partners Jorge Conde and Vijay Pande with Sonal Chokshi interview Vas Narasimhan, CEO of Novartis. Narasimhan takes us on a sweeping tour from small molecules to large molecules to proteins and other modalities for making medicines. In other words, we're moving from chemistry to the cell and gene-engineered world. So where does tech come in? How can small startups engage such big pharma companies? How can bio entrepreneurs work backwards not just from trials and approvals but from reimbursement/ payers/  market value signals? And finally -- what should all scientific (and technical) leaders know when it comes to leadership? We discuss all this and more in this episode of the a16z Podcast, recorded recently on the road while at the J.P.M. health conference in San Francisco.