What's Worth Living For? | Dr. Atul Gawande

31:13And what it brought home to me, if I answer the question, what are my priorities, what's a minimum quality of life I'd find acceptable, I would have said, anything that would give me dementia is not an acceptable life. And here one of her best friends had significant dementia, but she was having joy in her life. She could enjoy and play ping pong enough to have fun, turned up every day, and had lots to talk about with my mom, didn't necessarily remember everything. And my mom loved her and she loved my mom. And that was a extraordinary lesson to me. And she wasn't, you know, imprisoned. She was in a place she actually felt was her home.

32:08Most of us can remember being about 15 and feeling completely invisible or worse, extremely visible, but for the wrong reasons. I remember one year when I was a teenager, I had a pimple in the crevice of my nose for the entire year. I didn't like that. Either way, even if we have painful memories of that age, most of us tend to soften it in memory, and it was actually harder than we remember it now. That is the territory of Carrie, streaming October 7th on Prime Video, the first ever television adaptation of Stephen King's Carrie. Eight episodes from Mike Flanagan with Stephen King as an executive producer.

32:47After Flanagan had described this show as a tragedy, it's about a girl who doesn't feel seen by anyone, and about how small, everyday acts of unkindness compound into something nobody meant to cause, which happens now at a speed and scale that would have been unimaginable not long ago. What I really appreciate about the show is that the show takes Carrie seriously as a person, rather than as some sort of symbol, and the season keeps circling around one major question. Are you watching the making of a hero, a villain, or something more complicated than either of those options? Carrie is streaming October 7th, only on Prime Video.

33:44made massive amounts of progress in this regard in the past 20 years as a result of meditation and therapy and getting better at tending to my interpersonal relationships. But it's really a never-ending process, hence the name of the show, 10 % Happier. As I often argue, the 10 % compounds annually. Better is a feeling defined by you. And for BetterHelp, it's a BetterHelp therapist who really gets you. It's a focus on global emotional well-being with thousands of therapists and millions of members in over 100 countries. It's progress, and it's also getting better at regulating your nervous system or whatever's important to you.

34:22And I know that having a therapist has been very helpful to me in this regard. Sign up and get 10 % off at betterhelp.com slash happier. That's betterhelp.com slash happier. I'm relatively new to the glasses game, but my wife has been wearing glasses and contacts her whole life. And she has long struggled with the many arduous aspects of simply getting a good pair of eyeglasses. There's not only the shopping for the eyeglasses and all of the expense of purchasing them, but then there's also eye exams. Now comes Warby Parker, which is making the entire process much easier, including the eye exams themselves.

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35:37That's 20 % off any additional pairs when you purchase one pair at warbyparker.com slash happier.

35:48It's now been more than 12 years since you wrote your book, Being Mortal. Where are you in terms of processing your own mortality? I'm now past 60. So that was a different place than when I'd written a book in my mid-40s. And I would say, you know, when we looked for, we moved to DC for work in the last administration. And we actually decided that we would look for a place that's on one floor, just in case we're staying long enough that we should age and want to make it convenient. But I would say I'm still, at age 60, the average American who has access to healthcare, access to good public health as well, will live 90 years on average.

36:47So I'm aware on the one hand that I'm on the back end of the age curve, but living my life still as the way you do when you think you have an infinite amount of time. I have plenty of things I'm ambitious about, trying for, etc. But Laura Carson, since the Stanford researcher that I wrote about, has followed people as they age or as they became ill. She started her study in 1980s as the AIDS crisis hit, and it included people who suddenly became ill with HIV AIDS at a time when there was no treatment available and they had a death sentence. And what she saw was people who are older or facing their mortality behave differently than younger people who have a long time ahead of them.

37:39Younger people will prioritize spending time with going to a nightclub on a Friday night and hoping to meet new people will focus on their job opportunities, acquisition of contacts, income, homes, your status in the world. And as we get older, you think you're going to become unhappier, you're going to become depressed. In fact, as you get older, anxiety and depression decline. You develop capacity for a wider range of emotion. There's the bittersweet feeling of nostalgia, being able to live with a contradictory sense of things being bitter and sweet at the same time. Um, and you tend to close your circles more.

38:37You focus more on family, the closer friends you have, relationships, and less on those other things. And the interesting thing was, uh, during this study, that's the pattern you saw even when young people became sick. It wasn't a brain development thing. It was a perspective. It's whether you had a perspective that you had a shorter amount of time or essentially an infinite amount of time. And if you had less than 10 years, then you felt you had a shorter amount of time. If you had more than 20 years, you basically acted as if life was infinitely long and you really fell into these two categories.

39:17But there would be moments that came during the study, 9-11 happened and they were doing the study in Hong Kong and the SARS epidemic happened. And at that moment, everybody reverted to a life is fragile approach. They wanted to go home instead of hanging out in the nightclub. They wanted to see family. They cared about pulling together and what really matters. And they were actually relieved of some of the anxiety, depression, things like that. And then six months later, they were back to how we live. And so I'm still in the stage of trying to do stuff, going on a podcast with you. I still have things that I'm excited about and interested in solving in the world and trying to address and new things I want to try and new people I want to meet.

40:13But I am transitioning to also nurturing these friendships that have gone on now for 40, 50 years of my life and make time for staying close with them. Just came back from a weak summer holiday that we take with five other families where we've been gathering together for 40 years. And those things start to matter more and more where I was kind of liable to blow it off a couple of decades ago. It's so interesting that you can write a whole book about mortality and still kind of in the back of your mind, even though you know it's irrational, feel like you're going to live forever. because I don't have evidence every day of my mortality.

41:01I have things that, you know, they're different from my forties. I'm aware that I'm having losses, that I'm not gaining things back. I'm not as fast as I used to be. I don't think as fast as I used to think and finding ways to compensate for those things. Um, I'm an avid tennis player and I now having to change my game considerably at 60, where, you know, I was power and to some extent speed. And now I have to be much smarter. And I think I actually played better than I used to. And I'm holding my game up at least by playing smarter. It's such an interesting kind of bug in the human operating system that like, we know intellectually, we're going to die, but we don't live like it.

41:54You I think there's a great line in the Indian epic, the Mahabharata, I think that's how you pronounce it. And the line is, one character asks the other, what's the most wondrous thing in the world? And the other person says that we're surrounded by aging, illness and death, and yet we don't think it's going to happen to us. What do you think that's about? Well, I mean, the average lifespan of human beings right into the beginning of the 20th century was to your mid-40s. And the fact that we doubled the human lifespan, worked against nature, and now we're living beyond our nature. And in that period, we have an extended range of being able to live with fragility.

42:41And our management systems, our internal biological management systems are made for expecting demise to occur fairly rapidly once you start having aches and pains and limitations and and you know a cardiac condition or a lung condition whereas now you can live decades with all of those things and live a much higher quality of life than ever in history. And so we adjust our perspective based on what really Laura Carstensen's work showed is that we tune our perspective based on the evidence of whether we're actually mortal and fragile. And when we don't have immediate evidence of our own mortality, when you're not waking up and every few weeks realizing your cancer is progressing or you're your heart disease is bringing you to an end stage, then you have purpose in things that you do live for.

43:51And that's why those questions matter. One of the things I argue in the book is everybody has a loyalty, something that they're willing to sacrifice themselves for, even die for, that matters to them. And that might be your kids. It might be an idea. It might be a project, an accomplishment. It might be beauty, religion. Getting to serve, figure out those things and then serve them is what matters and can matter all the way to the very end. And I think as we get older and get to live these much longer lives than human beings had, we get to serve purposes like that for much longer periods of time.

44:41What are your purposes? What would I really sacrifice myself for? My family, for one, my children, my wife, my sibling, my sister. Number two, I would say is I've found purpose in trying to make the systems around health better. I've been fascinated for my whole career around the idea that we have learned how to double the human lifespan, but don't know how to deliver it affordably, effectively, give people these opportunities to achieve their loyalties. I'm interested both in the human experience and how we make our systems more effective at addressing those kinds of problems. And a lot of my work and jobs is sort of at that public level of making our systems better and more effective over time for solving these problems along the way.

45:40Those are my two big ones. For whatever reason, I get a lot of pleasure and joy out of whacking a little yellow tennis ball around a square box and that that also goes right in there it's one of my priorities i can't i can't figure it out but i'll do that for hours i buy it uh i i get tennis elbow so i can't really do it but i've when i get a chance to do it it's very fun and uh you're doing it with other people you're moving the body all those things feel good i've been talking with my friends that there's ball people and non-ball people i've decided the ball people can't make any sense of people who want to go biking three hours up a mountain or, you know, endurance running or any of those things like runners put me 10 minutes, you know, down a road.

46:26I'm like, what the hell am I doing? Why am I doing this? This seems crazy. But, but then they say the non-ball people say, why are you chasing a little yellow tennis ball around? Like what, what keeps you going for two and a half hours doing that. And the ball people just like throwing a ball in a basket or hitting one over a net, that talk about strange wiring. Both of those are bizarre. I'm non-binary in this regard. I like both. You do both. So there are people who are both, huh? Yeah. I mean, I do much more of the non-ball stuff because I have so many injuries that prevent me from playing tennis or doing other things.

47:07But I would, if left to my own devices, I would liberally do both. Speaking of aging. We're about to leave on a family beach vacation and my wife in an act of kindness and generosity went on quince.com and ordered me some more of my favorite shorts. So I'm never out of shorts to wear. A couple of weeks ago, I got this pair of shorts from Quince and I've just been wearing them like all the time. So now thanks to Bianca, I've got three pairs, which I'm very excited about. Quince focuses on high-quality wardrobe staples made with premium materials like 100 % Mongolian cashmere, organic cotton, and merino wool.

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48:45If you're a loyal listener to this show, you know that I am an avid worker outer. And if you are going to exercise on the regular, one thing you need, it's a non-negotiable, at least in my opinion. You need quality socks. You can't skimp on your socks. And one of the sponsors of this show is Bombas, and they've been sending me these socks that I use when I work out. Not only when I work out, but also when I'm out in the world just wearing sneakers and I want some good-looking socks. I go to my Bombas on those occasions as well. It's become a little bit of a source of marital discord because my wife and I compete for the Bombas socks.

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50:01After the book, you moved to Washington, as you mentioned, and you were running USAID, which is, for people who don't know it, one of the soft power wings of the U.S. government, where we spend money to help people in other countries. And we've just lived through a time where the Trump administration gutted it. One study from The Lancet, I believe, said that this conservatively has probably led or will lead to tens, if not hundreds of thousands of unnecessary deaths. I'd just be curious what your, yeah, how you're processing all this, what your thoughts are, how you think we should think about it.

50:46Yeah. And my role there wasn't leading the whole thing. I led the global health work of USAID, which is one of its biggest areas. My observations all stem from why I even took the job in the first place. Much of my work that I'm excited by, including this work around aging and the end of life, is around making it possible for people to get the benefits of everything we have discovered to enable a longer, better life. And one of those gaps comes from simply poverty in the world. The lowest income places in the world have half the survival rate of other places. And getting to USAID and getting to lead its global health work turned out to be the best job in medicine I've ever had, and likely the best job in medicine you've never heard of.

51:38I had 3 ,000 people in 65 countries and Washington, D.C., deploying on the one hand what seemed like a lot of money,$8 billion a year. On the other hand, it was about half of my hospital budget in Boston,$22 per American taxpayer out of$15 ,000 in the American tax bill. But with that, we were reaching hundreds of millions of people by strengthening systems for vaccination, for reducing deaths in childbirth, for addressing HIV, malaria, TB, for fighting outbreaks and preventing those outbreaks from reaching home. And the result of that has been documented to be, over the last 20 years, 90 million lives saved.

52:24In the countries where we worked, we cut the child mortality rate 32 % and the overall mortality rate by 15%. It was great for the people we were serving and supporting. it strengthened countries to get onto their own feet and i saw this from indy in india where my parents grew up and where i would visit as a kid um that you know not only did we give food aid but we provided the technology scientific training and so on for what's called the green revolution where india went from a food recipient country country to the fourth largest exporter of food in the world, feeding the rest of the world and not only itself.

53:14And those kinds of accomplishments I got to build on. It was incredible as an experience. So to come out the day that I left, noon on inauguration day as the great American tradition, the election changed the president and we peacefully handed over power and responsibility to the Trump administration. And then within hours, Trump had signed an order to freeze and halt all of the work of USAID. Like overnight, a complete dead stop. Food aid left to rot in warehouses, medicines on the shelf not allowed to be used, staff pulled out and sent home. I've been bearing witness to what has happened. It was on an argument that USAID was a criminal enterprise, was corrupt, didn't accomplish anything.

54:18And what's difficult is that was just a lie. The work immediately had consequences. And there have been now two different estimates that have put it in the ballpark of about 700 ,000 lives lost in 2025 from the shutdown of everything from HIV drug distribution to TB programs to outbreak prevention and surveillance. So we are still in the bomb blast radius. There is more ongoing damage. There's some of the work that has come back. Then there's been a strong backlash, not only from liberals. This has been a longstanding bipartisan supported effort over 60 years since John F. Kennedy formed USAID.

55:17And I don't think it's for nothing that on the one hand, there's been a cut of$40 billion for overall assistance to countries, but a rise of half a trillion dollars in the war costs that we have. because we've walked away from the idea that we offer a helping hand first before we show a fist of domination to how we approach the world. And it's not only unpopular abroad, it's unpopular at home. We see America as being a force for good in the world. USAID was one of the ways that did that. And people want to have those kinds of efforts continued. So the Republicans and Democrats came together to vote a budget that restored funds for foreign assistance and keeping the shell of USAID intact.

56:09The administration is not necessarily going to spend that. They have held that funding back, but we'll see what happens. One last question for me before we get to our final segment. What's your take on AI in medicine and how we as patients should be interacting with AI, if at all, when it comes to our health? The best description I've heard is to say that AI is not going to replace your doctor, but doctors who use AI are going to replace doctors who don't use AI. And as an intelligence at our side, I already see the ways that it can be dramatically useful. You know, many clinicians have adopted AI.

57:02They call them ambient scribes that will record and do your note-taking for you, and it's reduced the time that doctors require to write their medical notes and spend more time with patients. you'll see patients getting more, you know, people turning to AI can get better information and more clarity. Taking it as gospel is a bad idea. I often, when I'm asking questions of an AI bot, will ask multiple ones so that I'm triangulating among different sources. It might be Claude, it might be Gemini, it might be OpenAI. So I think there's important value that AI is bringing. I'm not seeing the signs that AI is different from other technology breakthroughs that have come before.

57:54We have had technology breakthroughs that gave us the GLP-1 drugs, for example, for controlling obesity that have replaced surgery for ulcers with a pill. and AI is going to be another one of those things. It might be very soon the best reader of your mammogram. It may be the best initial diagnostic for some dermatologic conditions. But knowing which ones it's going to be the best for, which ones it's not, and what to do now based on what It's advising how to deal with the risk of being wrong, et cetera. Those are still things that you want to have a co-pilot with. And I'd want a clinician who uses these capabilities alongside.

58:46And as a patient, I want to use this kind of information with people I trust as clinicians. A lot of promise, a lot of peril, a lot to be figured out. Let's do this. We've been doing this closing segment. We're just a couple of weeks into trying this. It's called What's Good. And we just ask the guests, you know, what are you excited about? It could be a book, movie, record. Don't say anything in tennis. You've already used up all of your tennis chits here. Could be just some little practice or habit you've formed in your life. And then I'll give you one for mine. The first thing I thought of was the lunch I had today where my wife has showed me that if you put chimichurri on a ham and cheese sandwich, it's amazing.

59:34And it is amazing. So there's that. That sounds disgusting. What are you talking about? It's absolutely delicious. But life is good right now because I've finished my first draft of my next book. I've got a cool project we're working on to find new ways of addressing our shortage of mental health beds for people. I still get excited by things like that. And a little chimichurri. What's the next book? The next book, and I haven't learned how to describe it really adequately, but the topic is how minds change. So how do people change their minds about things? At a time when we feel kind of hopeless that anybody is going to change their minds.

1:00:26It is mining and understanding how did we do things like we got cigarettes out of bars and restaurants and airplanes. We have solved many problems and are in fact continuing to solve many problems. And so it's understanding how people actually get things done in the face of resistance, including things that I've tried to get done. There's many failures I talk about along the way as well, but that's the next book. That's fascinating. Will you come back on when the book comes out? Yes. I'm going to hold you to that. It's not till probably till the end of next year, but I do have the first draft done.

1:01:07Great. Congratulations.

1:01:11I'll give you one from my side. It's a TV show that I just started watching with my wife called Furious. It's on Hulu. It's incredibly well done. All of the performances are just incredibly powerful, but the writing and the subject matter are very powerful. It's really about female rage. It's about female rage. It's about a female serial killer and the female cop who chases her down. And in that, when I first heard the conceit, I was like, I don't know, but actually it's extremely well done. Not again, not only just on the level of the performances, but on the issues it explores. Elizabeth Merriweather is the woman who created and wrote it.

1:02:01She wrote a, she also wrote and created a show called The Dropout, which was about, what's the name of that woman who had that bullshit blood testing company? Oh, Elizabeth Holmes? Yes, yes. So she did that when that won all the awards a couple of years ago, and now she's back with Furious. And I'm annoying my wife because as we watch it, I just keep saying, this is so good. This is so good. That's amazing. Well, that's a great recommendation. I always end up watching these, you know, mainly cop shows, especially British cop shows. I'm watching this Irish, well, Northern Irish cop show called Blue Nights now, which is...

1:02:44Blue Nights or Blue Lights? Blue Lights, you're right. Blue Lights. I've been meaning to check that out. It's harrowing, but it is, I'm completely absorbed. I might use that on a future What's Good segment after watching it. It's such a pleasure to finally meet you again. I heard about you decades ago and have read you in The New Yorker, and it's great to meet you, and I really appreciate your time. Thanks for having me on. Look forward to it again. One last thing before I let you go. If you want to listen to this show without ads, check out 10 % Happier Plus, which is a subscription that is available right inside Apple Podcasts.

1:03:20If you become a subscriber, you'll get every episode ad-free. That's new episodes and all the episodes from our vast 10-year-plus archive. Look for 10 % Happier Plus in Apple Podcasts and just hit subscribe. And a quick heads up, if you're already a subscriber to my app, 10 % with Dan Harris, you've already got access to ad-free podcasts. Ad-free listening is baked right into your app subscription along with everything else, so please don't pay twice. You can check out the app at danharris.com, and you can check out 10 % Happier Plus inside Apple Podcasts. Thank you very much for listening to the show.

1:03:57I deeply appreciate it. See you soon. Deuces. Thank you so much to everybody who worked so hard to make this show. 10 % Happier is produced by Tara Anderson, Marissa Schneiderman, DJ Kashmir, David Hart, and Hayden Broom. Our recording and engineering is handled by the great folks over at Pod People. And Nick Thorburn of the indie rock band Islands wrote our theme. Thanks for listening. Peace.