Atul Gawande
Appearances
3 Takeaways
Top Takeaways of 2024 (#232)
Death before 50 is now largely preventable. The focus has been on individual diseases that we now have the know-how and want to make sure that we deploy solutions for HIV, TB, malaria, death in childbirth, and so on. What we now are demonstrating in countries whether it's higher income countries like the U.S.
3 Takeaways
Top Takeaways of 2024 (#232)
and countries in part of Europe or even, you know, low middle income countries like Thailand or some of the countries you named in Latin America where it's been incredible progress, that they are getting the percentage of deaths that occur before age 50 down to 10 percent or less. that we can at this point make it so less than 10% of deaths need to occur before you're 50.
3 Takeaways
Top Takeaways of 2024 (#232)
And that's an extraordinary accomplishment. We have had the goal that death in children should be rare, and we're making that the reality around the world. But now essentially death before middle age, we can make that uncommon.
Pod Save America
Trump's Art of the Fold
Well, a lot of our attention has been on, what's he saying? Is he calling for the vaccine? And that is such a low bar.
Pod Save America
Trump's Art of the Fold
three months ago if this happened, or really in any other administration, you would have had the National Security Council pulling people together across all of the agencies, including CDC, the leadership at FDA, also USAID and others working abroad because measles is a global epidemic. We have...
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Trump's Art of the Fold
cases coming from abroad and we have spread in the United States, they would have had all of their clinical people together. We had what we called the doctor's group that we get together on a weekly basis to look at crisis situations. And we don't see any of this happening, right?
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Trump's Art of the Fold
You would see the HHS secretary or the head of CDC on calls every week with the states having the outbreaks and other states, public health officials, to get on top of this. Instead, we've had spread to where A outbreak in West Texas has gone over the border to Mexico and also is cropping up in 20 states around the country. So this is not the right steps. So not good is what you're saying.
Pod Save America
Trump's Art of the Fold
Not good. And this is solvable. We eliminated measles in the United States. Our elimination status is at risk. And we have one in 1,000 kids dies, the fact that there are already three people who've died indicates that the counts that say that there might be around 500 cases are way under what the reality is.
Pod Save America
Trump's Art of the Fold
I think it starts with the skepticism and then add in the there are multiple layers of destruction going on. Right. There is the attitude towards measles and the vaccine. But then there's the fact that there has been doge cuts across the government.
Pod Save America
Trump's Art of the Fold
including pulling $11 billion from state public health programs when they rescinded funds that were allocated during COVID for strengthening public health. That shut down vaccination clinics in West Texas that were trying to vaccinate against measles. Then you have all of the work that has undone advisory groups, any independent assessment within the government on paths forward.
Pod Save America
Trump's Art of the Fold
And you've purged CDC and FDA of many of their top vaccine people. This is a systematic dismantling in a chaotic and unsystematic way.
Pod Save America
Trump's Art of the Fold
He's got a million charges that he throws at vaccines. Here's the thing to know. We have reduced child deaths in the last 50 years by 75%. 40% of that reduction in child deaths has come from vaccines. And 60% of the vaccine death reduction has come from the measles vaccine alone. We're now in a world where there is about 10 million children who are being infected by measles.
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Trump's Art of the Fold
We're over 100,000 child deaths in the world. The United States shouldn't be joining that list. And so it's critical that we are stopping the direction of travel here. I mean, we are undoing our global systems and our state and national systems for everything from NIH research on production of vaccines and improving uptake, people's willingness to get vaccines.
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Trump's Art of the Fold
We're dismantling major parts of the expertise in the FDA around approving vaccines and have actions that have, you know, one of the first actions of the FDA commissioner was to disallow approval of a Novavax COVID vaccine even though it was recommended by the technical regulators. And then you have CDC guidance now under political controls.
Pod Save America
Trump's Art of the Fold
The direction of travel we see here is where technical expertise is being removed, independence to make scientific judgments and recommendations is being undermined, and communications are being put into the offices of the secretary or top officials who are political appointees. And so you're seeing more political controls over critical decisions and less technical expertise.
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Trump's Art of the Fold
Yes, you put your finger on it. Look, moving Peter Marks out and having him go was a sign of what was to come. But changing leadership is not an abnormal thing to do. What went with him was the top regulatory capacity and many of their experts. he oversaw a wide swath of work that ranged from vaccines to getting gene and cell therapies approved for the world.
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Trump's Art of the Fold
They were the ones who figured out how to look at sickle cell. We have a cure for sickle cell with a gene therapy now. And that was because of figuring out the way that you could actually safely regulate, test, and approve such new tools. That entire infrastructure has now been weakened. It's alarmed the community, the biotechnology community.
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Trump's Art of the Fold
The United States has been the leader in gene therapy, cell therapy, and in vaccine development. Thank you. Thank you. Thank you.
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Trump's Art of the Fold
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Pod Save America
Trump's Art of the Fold
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Trump's Art of the Fold
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. There's what they say and then what they do. And what they're doing is stripping out work that is vital for addressing chronic illness, whether it's diabetes research, whether it's clean air, and now trying to open the way to repollute our cities in a way that we have not had in a long time.
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Trump's Art of the Fold
get rid of our regulation, regulatory oversight of tobacco, which is still the biggest killer in the world when it comes to cardiovascular disease. And then, you know, we have had chronic issues in the United States with lead poisoning in poorer populations and minority populations. And that's a much bigger problem than fluoride when it comes to toxic metals.
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Trump's Art of the Fold
and is a major driver of chronic illness and disease around the world. So is there work we need to do on nutrition? Is there work we need to do around addressing our diabetes and obesity? Is there work to do on pollution and clean air and clean water? Yes, they are not doing that.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So it provided 80% of the support in that area and let other countries take other components of WHO's work. And so now that money has been pulled out on measles programs around the world. And having a secretary of health who has done more to undermine confidence in measles vaccines than anybody in the world means that that's a singular disease that can be breaking out.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And we'll see many more child deaths that result from that.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Well, I've been asked to prepare to testify. So the lawsuit is the one that is making its way through the federal courts. USAID is the testing grounds for some fundamental questions. It starts with if a president decides that they're not going to pay the bills that the government has contracted with people to pay, whether that's lawful or not.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So the suit is the AIDS Vaccine Coalition, called AVAC, and the Global Health Council, along with a group of other USAID partner organizations that are suing Donald Trump to do three things. Pay their past bills, which are due, lift the freeze on foreign aid, and enable an apparatus, including the staffing, in USAID to continue the work that Congress had mandated be performed.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So it's three different questions. One is, do you abide by your contracts, which if the government can do that, can drop contracts instantly? I mean, a government invoice promising to pay is treated like cash in the world. So if the U.S. is no longer trusted to pay, that's going to have destabilizing consequences for the economy.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So that first question, the court ruled that the government had to pay its bills and put in a restraining order indicating that those bills had to be paid by such and such a date. The government sued and it went all the way up to the Supreme Court. And it's a narrow question. Does the government have to pay its bills? The court said, yes, it has to pay its bills. five to four vote.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
It was an open question whether the court would simply give carte blanche. And so that was a narrow ruling, but a big deal. And right now, you know, the government is supposed to pay the bills this week, and we'll see if they do. The second question is that whether they followed proper procedures in terminating the contracts of all of these organizations.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
There is a law about how much notice you give and not only notice that you do it for individualized cause. You cannot en masse terminate an entire agency. And so that's being tested. And then the third test is whether there is a separation of powers, that when Congress says, here are the funds that the executive branch is supposed to spend to stop HIV in the world.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
You know, these are so-called earmarked funds. They are specified what their uses are, and that the executive branch doesn't have the option to simply, you know what, that sounds like a good suggestion, but I'm going to use it in a different way. Yeah. Those are the three core questions.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And I've submitted an affidavit and potentially being asked to testify on what the normal processes were when we, in the Biden administration or in previous administrations, terminated contracts or laid off people or dealt with fraud, waste and abuse.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
I did not expect going into government would be as meaningful to me as it was. I went into government because it was the COVID crisis and I was offered an opportunity to lead the international component of response. We got 700 million vaccines out to the world. But what I found was a group of people who could achieve scale like I'd never seen, mission-driven.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
None of these people went in for the money. It's not like they had any power.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Absolutely. And, you know, many of them spent their lives as foreign service officers living in difficult places in the world. And, you know, I remember Kiev was under attack about eight weeks after I was sworn in. And I thought I was going to be working on COVID. But here is this thing erupting.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
First of all, our health team, along with the rest of the mission and embassy in Kyiv, had to flee for safety. But within a week, they already were like, we have TB breaking out. We have potential polio case. How are we going to respond? And my critical role is to say... What's going to kill people the most?
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Right now, Russia has shut down the medical supply chain, and so 100% of the pharmacies just closed. 250,000 HIV patients can't get their meds. A million heart patients can't get their meds. Let's get the pharmacies open. And by the way, they've attacked the oxygen factories and put the hospitals under cyber attack, and their electronic systems aren't functioning.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And this team in four weeks were able to move the entire hospital record system to the cloud, allowing protection against cyber attacks, got oxygen systems back online, and were able to get 50% of the pharmacies open in about a month. And it ultimately got 80% of the pharmacies open. That is just incredible. Like, yes, I mean, are there some people I had to deal with who were overly bureaucratic.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Did I have to address some people who were not performing? Absolutely. And did I have to drive efficiency? And in every place you have to do that. But this was America at its best. And I was so proud to be part of that. And what frustrated me was in that job, I had to speak for the US government. I couldn't write for you during that time. Believe me, I know. I couldn't tell the story.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
I've got a book I'm working on now that I... hope to be able to unpack all of this. But it is, I think, a sad part of not getting to be part of my leadership that I didn't also get to communicate what we do, partly because USAID is restricted in certain ways from telling its story within the U.S. borders.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Zero. There's a different worldview at play here. It is that power is what matters. Not impact, not the overall maximum good that you can do. And having power, wielding it in ways that can dominate the weak and partner with your friends. When I say partner with friends, I mean partner with people like Putin who think the same way that you do.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
This damage has created effects that will be forever. It will not come back. Like, let's say they turned everything back on again and said, oops, I'm sorry.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
I had a discussion with a minister of health just today, and he said, I've never been treated so much like a second-class human being.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Yes, this is a minister of health in another country, let me just say. And for decades, America was there.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
I never imagined America could be indifferent, could simply abandon people in the midst of treatments, in the midst of trials, clinical trials, in the midst of partnership, and not even talk to me, not even have a discussion so that we could plan together, okay, you're going to have big cuts to make. We will work together and figure out how to solve it. That's not what happened.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And never will trust the U.S. again. And we are entering a different state of relations. You know, in some ways, I think there will be, we are seeing lots of other countries stand up around the world. Our friends, Canada, Mexico, but, you know, African countries too, Europe. Everybody's taking the lesson that America cannot be trusted.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
That is beautifully put. What I say, I'm a little stronger. It's shameful and evil.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
No idea. previous Trump administration, they had embraced what they themselves called the normals. They had a head of USAID who was devoted to the idea of development and soft power in the world. Now, they had their own wrinkle on it. which I didn't disagree with. They called it the journey to self-reliance.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
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The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
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The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
They wanted to invest in Africa, in Asia, in Latin America to enable stronger economies, more capacity. And we weren't doing enough of that. And I actually continued much of the work that had occurred during that time.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Yeah, so this is a job where I had 2,500 people between DC and 65 countries around the world working on advancing health and protecting Americans from diseases and outbreaks abroad.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And the aim was to work with country to build their systems so that we protected the global health security and improved global outcomes of everything from reducing HIV, AIDS, and other infectious diseases like malaria and TB to strengthening primary healthcare systems so those countries would move on from depending on aid from donors.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
That work, in three years, we documented being able to save more than 1.2 million lives after COVID alone.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Yeah. Part of my target was reduce the percentage of deaths in any given country that occur before the age of 50. And teams would focus on what were the top three to five killers. And in some places, that would be HIV. In some places, that would be TB. It would include, you know, safe childbirth was a huge part of the work.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So one case is that it could have been more efficient, right? That Americans imagine huge sums of money going to this work that, you know, polls show that they think that a quarter of our spending goes to foreign aid. So it's a minuscule amount. Yes.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
On a budget for our global health work, that is half the budget of the hospital I did surgery in here in Boston, we reached hundreds of millions of people with programs that saved lives by the millions. It is at a level of scale I could never imagine experiencing. So the case against it is, I woke up
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
one day to find Elon Musk tweeting that this was a criminal enterprise, that this was democratic money laundering, that this was corruption.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Well, what's hard to piece apart is what is just willful ignorance. Not just ignorance, it's lying, right? For example, there's a statistic that they push that only 10% of immigrants US AIDS dollars actually got to recipients in the world. Now, this is a willful distortion of a statistic that says only 10% of US AIDS funding went to local organizations.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
as opposed to multinational organizations and others. There's a legitimate criticism to be made that that should be higher, more local organizations get the funds. I did a lot of work that raised those numbers considerably, got it to 30%. But that was not the debate they're having. They're claiming that the money is not actually reaching people and that corruption is taking it away.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
When, in fact, the ability to get to enormous numbers of people has been a best buy in health and in humanitarian assistance for a long time.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Yeah, actually, the number is about 13,000. But over 80% of the contracts have been terminated, representing the work that is done by USAID and the for-profit and not-for-profit organizations they work with, like Catholic Relief Services and things like that. And more than 80% of the staff have been put on administrative leave, terminated or dismissed one way or the other.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So it's been obliterated. It has been dismantled. It is dying. I mean, at this point, it is six weeks in. You have had 20 million people with HIV, for example, including 500,000 children who have received medicines that keep them alive, who've now been cut off for six weeks.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
The internal estimates are that over 160,000 will die from malaria per year from the abandonment of these programs if they're not restored. That we're talking about 20 million people dependent on HIV medicines. And you have to calculate how many you think will get back on and how many will die in a year. But you're talking hundreds of thousands in year one at a minimum.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Just on the reduction in immunizations, you're talking about more than a million estimated deaths.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
The logic is to deny the reality, either because they simply don't want to believe it, that they're so steeped in the idea that government officials are corrupt and lazy and unable to deliver anything, and that a group of young 20-something engineers will fix it all, or they are indifferent. And when he waves around the chainsaw, we're seeing... what surgery on the U.S.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
government with a chainsaw looks like at USAID. And it's just the beginning of the playbook. This was the soft target, right? This is affecting people abroad. It's tens of thousands of jobs at home. So there's harm here. There's disease that we'll get here, et cetera. But it was the easy target. And now it's being brought to NIH, to CDC, to
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
One example, I have had people I've spoken to, you know, one case, a pregnant woman in their third trimester of pregnancy in a conflict zone, and they have maternity leave just like everybody else, but because the contracts had been turned off,
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
couldn't get a flight out and were not guaranteed safe passage and couldn't get care for her complications and ended up having to get cared for locally in a place without the setup for being able to address her needs. One person said to me that I spoke to, she said, as she's enduring these things, my government is attacking me. We ought to be ashamed.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Our entire system of checks and balances has failed us.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
So I'll say there are broadly three areas. The biggest part of USAID is it's the FEMA for disasters abroad. It's called Bureau of Humanitarian Assistance. And they bring earthquake response, wildfire response in conflicts, you know, famines. These are the people who suit up and get assistance and stabilize places where things are going wrong. You know, John F. Kennedy, when he
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
formed USAID in 1961, said it was to counter the adversaries of freedom and to provide compassionate support for the development of the world. And those components are the ones where it's USAID has kept Ukraine's not only health system going, made important, vital support to keep their energy infrastructure going as Russia attacked it, right?
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
In Haiti, this is the response team that has sought to stabilize what's become a gang-controlled country. major part of the country. And our health teams kept almost half of the primary health care system for the population going. So around the world, stopping fentanyl flow, all of that has been wiped out completely.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And in many cases, the people behind that work, I mean, many of the people were working with local partners to keep these things going. Those partners are being attacked in country after country.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
The tools of foreign policy, as I've learned, are defense, diplomacy, and development. And the development part is the soft power part. We're not sending troops into Asia and into Africa and into Latin America. We're sending hundreds of thousands of civilians without uniforms who are there to
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
to represent the United States, to pursue common goals together, whether it's stemming the tide of fentanyl coming across the border, addressing climate disasters, protecting the world from disease.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And that soft power is a reflection of our values, what we stand for, our strong belief in freedom, self-determination, and advancement of people's economies, bringing more stability and peace to the world.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
That is the fundamental nature of soft power, that we're not what Trump is currently trying to create, a world of simply might makes right and you do what we tell you, because that does not create stability. It creates chaos and destruction.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And wound up killing 20, 30,000 people or so before it was over with.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
It hasn't happened, right? So it's clear that he's not in control of the mechanisms that make these things happen. Doge does not approve the payments going out and has not approved the payments going out to sustain that work.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
Measles is a good example. There's actually now been a second death. We haven't had a death from measles in the United States in years. We are now back up globally to over 100,000 child deaths.
The New Yorker Radio Hour
Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
And as you start seeing what happens is we not only pull the rug out from an organization like USAID, handcuff CDC, but then also ban even communication, let alone funding with the World Health Organization. I was on the phone with officials at the World Health Organization. The US had chosen measles as a major area that it wanted to support.