131. The Global Health Crisis: USAID cuts, Trump, and the limits of AI (Atul Gawande)

0:28Thanks for listening to The Rest is Politics. Sign up to The Rest is Politics. you read twice because when the world wakes up you want to be two steps ahead get ahead with wsj plus offering insights from the wall street journal barons market watch and investors business daily because fortune favors the ambitious this episode is brought to you by progressive insurance fiscally responsible financial geniuses monetary magicians these are things people say about drivers who switch their car insurance to Progressive and save hundreds. Visit Progressive.com to see if you could save. Progressive Casualty Insurance Company and affiliates.

1:04Potential savings will vary, not available in all states or situations.

1:18Welcome to The Restless Politics Leading with me, Rory Stewart. And with me, Alistair Campbell. And we are very, very privileged today to have with us Professor Dr. Atul Gawande. Now, that very grand title, he is indeed a chaired professor of surgery at Harvard University. But he's many, many more things. And one of the reasons we're so privileged to have him with us is that he's not just a very, very skilled doctor and surgeon, but he's somebody who has opened medicine to the public through extraordinary writing, very powerful, very viscerally honest writing about what it's like to be a working doctor.

1:56He's also been a real pioneer in public health, both within the United States, where he's thought very deeply about the difference between certain types of private healthcare and other lower cost systems. He's worked with the World Health Organization internationally and thought deeply about how to deliver healthcare to some of the world's very poorest and most vulnerable. He's been right at the heart of policymaking. He was on President Biden's COVID task force. And most recently, he was right at the top of USAID, the International Development Organization in the United States, which has recently been closed by Donald Trump and Elon Musk since when he's become one of the most powerful, eloquent voices explaining why international development assistance matters and why this decision has been deeply, deeply damaging to real life.

2:47So there are so many directions in which we can go. But I'd like to start maybe if we can with the question of what it felt like to become a doctor and whether you can give us a sense of something I've been struck by watching yourself and reading yourself, which is your real awareness of complexity and ignorance. I think you point out that if you'd been working in the same hospital in Harvard in the 1930s, it was a very, very different life. And now you're dealing with 13 ,000 different medical conditions, 6 ,000 different medicines, etc. So can you begin by just giving us a sense of modern medicine, and then we'll take it in many different directions?

3:31I love that you're starting here. And first, can I just say how proud and privileged I am to be able to be on your show? I'm a fan. And number two, I have to correct a couple of things. I led global health at USAID, so I didn't run USAID. Samantha Power did. And it was wonderful working with her during the Biden administration. And then in order to go to USAID, I had to step down from my professorship at Harvard. And believe it or not, I'm now applying to be back at Harvard. I reckon you'll get it. I reckon you'll get it. I reckon you'll get it. I am returning to Boston and my old hospital, the Brigham and Women's Hospital, where I'm indeed a professor of surgery.

4:16You know, to go back to the beginning, it's an extraordinary experience stepping into becoming a surgeon. You're asking people permission to assault them, to put a knife in their body and to do it on behalf of the idea that you're going to make them better. And the bottom line about the experience is it's terrifying. And if it's not terrifying, you're worried about you should be worried about the surgeon who is coming out from a program, not terrified about what they're setting out to do. I was attracted to it the first time I went to the operating room as a medical student. I did not expect to go into surgery.

4:59You know, I'd come from a background. I was interested in public health, interested in policy. Last thing you think of is surgery. But when you're in the operating room, you see someone dare to open up the human body and then manage to bring competence and confidence to it. It's remarkable, given that the knowledge at any given time is incomplete, you are fallible, your skills are imperfect, and yet taking action is not always, but generally the better thing to do. And I got started writing as much out of that experience of recognizing that we're fallible, that even the best surgeons have deaths and complications, avoidable deaths, avoidable complications on their hands.

5:53We meet weekly to discuss our errors and failures. And it's a remarkable culture. And I just was drawn to the people who are the best at doing it and their sense of confidence and humility in equal parts. You've written a lot about human error. And, of course, we want to have trust in our doctors and we want to believe them. And I've always been somebody who I don't want to think that my doctor is nervous. us. I don't want to think that my doctor is having a bad day. I want them to be perfect. I want to have total trust in them. But you seem to be saying that it would be better, that relationship between society and medicine and between doctor and patient would actually be better if we had a better understanding of the mortality that you feel and the sense of vulnerability that you feel.

6:45Yes, there's a limit to that. But let me just say, there was, you know, as I was coming through, the doctrine was preach your infallibility to, um, you know, with the public and with the patients you were with, you weren't honest about your, um, your fallibility. You weren't honest about the imperfection and the complications you felt that you need to, to get, give people confidence. You needed to exude pure confidence. And there's a subtle change that really occurred during my generation of surgeons and training. And I began both on the research side describing the failures in surgery and how we could engineer reductions in those failures.

7:33And that was to begin to say, you know, perfection is our aim, but we are not perfect. and to give some realistic expectation of what may be coming, what the best outcome we can prepare for, and what the worst is and how we will work together to get there. You know, what I've ended up in my career doing is actually making a study of failure in surgery. We first began to publicize the ways that things went wrong. My first book, Complications, was somewhat controversial for really laying out the mistakes that are made and how we deal with them in the profession and what we do to engineer them out and what we were not doing to engineer them out.

8:21And then later, because of that work, ended up leading work at the World Health Organization that got me into global health, surprisingly, by taking on the question, how do we reduce deaths in surgery globally? we do more than 300 million operations a year on human beings around the world. It's about one in every 25 human beings on earth is having an operation in the course of the next year. And our death rates were high enough that the deaths were bigger than childbirth. We worked with a Boeing safety engineer and designed a checklist, a two-minute checklist for the operating room. And with that checklist in London, in Seattle, in Toronto, but also in rural Tanzania and in India, we cut the death rate 47 % by being honest about our mistakes, working together as teams to deal with that.

9:17And you did that at a time when culture was changing so that there was a greater trend towards litigation, towards going after doctors who made mistakes. Did that not make it much harder to do what you were trying to do? In a way, it made it easier because litigation was not working. It's an extremely expensive way to address failures that, at its presumption, is about the negligence of clinicians. And part of what you really find is failure was not a problem of bad doctors. Failure, above all, was the problem of really good doctors being among the most well-trained people in our societies that we've drawn into these professions, but put them into situations in which you cannot master it all by yourself.

10:12And so a combination of a team can save you, um, and increasingly access to knowledge and, you know, computers and, you know, ways that those systems can, can make a difference. But above all, it's your, um, humility and willingness to, uh, confront error and engineer it out of the, out of the game. And we've been able to do that. with remarkable success. So let's use this maybe as a way of moving from how complicated and specialized healthcare is and how big the teams need to be and how much knowledge you need to be onto the question of cost. Because presumably one of the central issues around healthcare, one of the things that's changed over the last hundred years, is it's becoming more and more expensive.

11:02And of course, we're talking to you from the United Kingdom, where the question of how we pay for the NHS is one of probably the biggest question in politics. Explain to us, why is healthcare so expensive? Well, there's a couple of layers here. One of the reasons that healthcare is expensive, you started to point out one of the things I've noted. We've discovered in the last century, there was a time when healthcare was incredibly cheap and accomplished very little. and in a century the last century we've doubled the human lifespan we've taken the average survival of someone in europe united states from an average of living to your early 40s to now eclipsing 80 years and in order to do that there are now 19 000 drugs There are 4 ,000 medical and surgical procedures, and we're trying to learn to deploy this capability town by town to everyone alive.

12:03So some of it is, yes, it's the cost of the drugs. It's the cost of the people doing this work. A lot of it is the cost and complexity of all these discoveries that we've made, and we are trying to bring them to everybody alive. And this is our generational challenge. It is a transformation. Just, you know, basically in the course of a century, went from a world where our survival was largely a field of ignorance. We did not understand the nature of our conditions or have solutions to offer to them. Now we do. And we're trying to deploy this capability. I'd say, number one, you know, the United States, we spend 13 ,000 US dollars per person per year for health care.

12:45And we get less survival than the UK. Our survival is currently at 78 years. The UK is closer to 80. But we have places like Costa Rica that have a higher life expectancy than the UK or the US on a fraction of even the UK's spending. It's under$1 ,600 per person per year. And what I would say is there are two layers of the cost. Number one is having a sound primary health care system where you don't have a cost barrier to getting your daily needs for your first level care, whether it's preventive care or I've got a sick child and I want to bring them in for services in your neighborhood GP. And your essential medicines need to be affordable and your basic diagnostics around preventive care and so on.

13:41that component is not terribly expensive. In Thailand, they're delivering that for$300 per person per year and achieving the same life expectancies that we're now achieving in the United States. The next level, your secondary care, your specialized cardiologist, your dermatologist, and so on, and then the hospital care and the procedures that go along with that, those are extremely expensive. We are willing in the United States to spend a lot on those, right? Our cancer care is costly. It's very timely. And the results are arguably the best in the world. So we have some of the poorest primary care functions.

14:23Britain has really struggled around some of those specialized care capabilities and affording it. Britain has continually for years under invested in your healthcare infrastructure. You've had a strong primary health care system that you don't want to sacrifice, but the specialized care is where the investment needs to be. We have the flip side problem in the US. We have over-invested and sacrificed primary care at the cost of overall health. And Atul, what's your assessment of the basic model, our model against the American model? If you were to be able to be a doctor in any country in the world, which of those two models would you prefer to work in?

15:09National Health Service, free at the point of use, et cetera, or the Health Service of the United States, which we do see as a very market-driven healthcare system? I'm not going to choose between the two, but I will say partly because if you're like me, you know, you're in the top 2 % of income in our countries, you will get great care in both countries, right? If I want to be someone who's in the bottom third of income for health, you're going to receive more consistent, more equitable, better care in the UK than you currently can access, unless you're a veteran. And then you get Britain in the United States.

15:59The VA system, the veteran system of care is a government-run hospitals clinics and and salaried doctors who do incredibly great results for the veterans you wait a little must discovers that some of them are lesbians and you know then you're gonna you're gonna be in trouble there doge has already started laying off people in the veteran system in the united states so you know that that that sadly is is a story that started at usaid but has extended to there but but i'll just say what i've looked for around the world are the outliers who get better results in survival. And, you know, you go to Spain or Portugal right now, and they have delivered a combination of primary care and secondary care that's getting people 82, 83 year life expectancy and on lower levels of investment because you're also bringing that level of care in the community.

16:51All of it's to say we're on this generational journey of how you deliver this care at broad scale, where food ate up 40 % or more of a budget for a family in 1900. Today, it's housing and health that are eating up the budgets of people and making it hard to have a viable cost of living. I think a strong primary healthcare system is the foundation that I see across the world for better public health and better primary care results. And there's certain features to it that make it highly successful. And then at our higher income levels, where Britain has the opportunity is in that capacity for that specialized care.

17:42That's all. I'm going to be cheeky now and move you on to what's happening in the United States. So one of the things that struck me is that you mentioned Doge and Elon Musk. Yeah. Dodge, Rory. Dodge. Dodge. Dodge, as Alistair wants to call it. Sounds like stuff that sometimes you might sympathize with. You're interested in efficiency. You're interested in results. You're interested in technology. I guess you know many people who know Elon Musk, and you perhaps met Elon Musk himself. And you probably admired the Tesla motor car. So what's going wrong? I mean, from the point of view of the public, here is this kind of genius businessman-engineer And he's coming in and he's going to think about all the right stuff and bring efficiency and outcomes to the government.

18:29And something's going wrong. Tell us what's happening at all. What's going on here? What's going on is that someone who does not understand the world of health care, the world of delivering public services, has walked into the job, declared that he will be doing surgery with a chainsaw on the government. And the entire approach has been we're pausing the government. You know, you're pausing a plane in mid-flight, you're purging yourself of your crew, and then it's crashing and burning and you're shocked. You know, this is not Twitter and Twitter is simple as compared to sustaining the global HIV AIDS program that has reduced overall HIV in the world by three quarters, sustaining the global polio eradication program that, you know, was down to small numbers of wild type polio moving in the world.

19:22Um, and we're now wrecking, that's just the global health side, forget the food assistance and then the other components, you know, the national institutes of health, the, the CDC damage being done. Um, it is, you know, the, it's arrogance. What is happening is arrogance and it's indifference to the cost in lives or the complexity of doing the job. And just, um, this is a slightly unfair question, but for international listeners who aren't following the day-to-day in the U.S. Can you take us through some of the individual things that have happened? We talked about the cut of USAID, but talk us through some of the other agencies, some of the other decisions, some of the other implications, even domestically within the U.S.

20:07Yeah. On January 20, which was inauguration day, is when I stepped down along with other members of the Biden administration and handed over responsibility, in this case for global health at USAID, foreign assistance was the first, what I call the soft target, right? It was the place that they worked out the playbook that then they would bring through the rest of the government. And what you saw in that very first week was the sudden announcement that all assistance, all spending by USAID, the US Agency for International Development, would be halted, that the staff would be purged and that the buildings would be, uh, the lease would be dropped.

20:55Um, and that effectively became the playbook that then began to roll out across the government. Now, nevermind that in the U S constitution, the Congress establishes the offices of the government provides the deck declared financing and direction. And then the executive branch executes that was not what happened and within about a month after that 90 of the staff 90 of the programs were gone um and you had had you had 20 million people with hiv uh who were receiving medications to stay alive dropped including 500 000 children the entirety of the global malaria program brought to a halt maternal and child health programs reaching 90 million women and children dropped and, uh, and on and on.

21:46Once they perfected that, you know, it's, it's brilliant in a way. The, the, um, if you wanted to have a coup in the 1980s, in, in some small country somewhere, you'd seize the, the, the national television station, you'd seize the treasury and seize the presidential palace and you'd be, you'd, declare victory. Um, here view, you see the, you know, he has Musk has the social media platform feeding directly into Fox news and controlling significant part of the media, um, uh, communications. Um, they used, took over the software for the treasury payment system and halted payments could turn payments on and off overnight and seize the employee systems.

22:35And so as they learned to do that, they extended that now to the National Institutes of Health, where the first year employees were purged, where individual programs were shut down. Right now, for example, they're shutting down anything around vaccine to improve vaccine uptake. Huge parts of vaccine research is being stopped. Anything around racial disparities, around trying to bring down gaps in poor outcomes, for example, in childbirth in the United States. If you're black, black women will have many times higher mortality rates than white women. And understanding why and being able to come up with remedies, National Institutes of Health was doing that.

23:23Those grants are terminated. And then it's extending to the Department of Education, which is now being dismantled in a very similar way. Some of this is starting at NASA. Some of this is starting in the Social Security Administration. It's in the name of addressing corruption, addressing efficiency. But every time they say we're doing this because we're getting rid of corruption, it's because they're corrupt. At USAID, for example, in those first three weeks, half a billion dollars in food aid went rotting on in warehouses, in on ships. And when the inspector general, a independent auditor did a report, a rapid report pointing out that not only had half a billion dollars in mismanaged aid, you had eight billion dollars in audit functions shut down to oversee and prevent loss of aid to terrorist organizations and things like that.

24:30So that playbook was perfected at USAID and is now moving across significant parts of the U.S. government. That's why you said how this was sort of started with USAID, then moved over. Just sticking with USAID for a moment, Musk very proudly says that, you know, this is just sort of rooting out waste. People aren't going to die as a result of this. just you know the pepfar program the malaria program what sort of numbers are we talking about that actually might die as a result of american support for these programs being removed well we know um because usaid itself and their teams made estimates of how long it would take for damage to be done.

25:15You know, it's estimated that 160 ,000 new malaria deaths would appear if this aid was turned off for the next year, remained off, mostly children. It's estimated the biggest impact will be in immunization if it's not turned on again. You know, we have succeeded in the world in lowering the death rate of children under five by 75%. 40 % of that benefit comes from vaccines alone. And 60 % of the vaccine benefit comes from the measles vaccine alone. So right now we're already seeing some of the consequences of two months of lost health workers, lost programming, lost cooperation together, shut down communications with WHO, shut off funds for the measles program at WHO, and so on.

26:20And we're already up, we started the year up above 100 ,000 deaths in children from malaria again. And we will see that rise even more. The estimated numbers from USAID's own internal numbers is two to three million more deaths a year. Again, mostly children because of the loss of cooperative programs that the US was a major driver in. That's not even taken into account. I want to add view, you know, the Trump administration has declared they will no longer fund or participate in the World Health Organization. That is a huge damage. And then add to it that switching their stance on Russia and not committing to support NATO has meant that defense spending has had to rise in Europe precipitously.

27:14And the first place that that cut is coming from is Europe's cooperation and the UK's cooperation in foreign assistance as well, that the same programs for HIV, for maternal child health, for malaria, for food security and malnutrition are being cut right now in the UK and in Europe as well as a consequence. So this is a calamity. This is a disaster for human public health. You talk about it very, very calmly. But the way you sort of lay that out, and then when you think through the consequences, this becomes accepted and then normalizes. I mean, are we not talking kind of crimes against humanity here when we know that the programs exist to save those lives?

28:01And literally overnight without it seems any kind of real analysis done by the government. And then with this guy in charge of this chainsaw, they literally just pull the plug on all of these programs. And as you say, you take just that one disease, malaria, 160 ,000 predicted to die. How do you find the words and how do you find the kind of wherewithal to get out of bed and keep going and trying to get this thing back on track? It's shameful on so many levels, Alistair. I don't even know where to start. Let me just give you an example from a conversation with a minister of health who would not want to be named, but that I had just a few days ago.

28:42and he said, look, if the United States had come to us and said, you know, funding is going to get a severe cut and, you know, your country, we will work with you to figure out how to navigate forward. That would be one thing. It would be understandable. You'd get on a glide path. You'd figure out what to do. You'd cooperate. But here you're talking about overnight, a stop work order going out that said food on the shelves can't be given to children hiv meds in the warehouses can't be brought forward your staff cannot be paid anymore they're going to be laid off billions of dollars in in u.s assets whether it's investments in laboratories investments in data systems people capacity is going to be thrown away vehicles thousands of vehicles left parked, you know, what are we going to do with these things?

29:38Ships arriving in port with insecticide treated malaria nets where no one's picking them up, food rotting in trucks. He said, you know, the indifference to the lives of our people is to be treated as subhuman, to not care enough to be able to make a phone call and say, you know, we have to find a way to make this work properly. We care about your lives. And, you know, everything being dropped overnight. Another example, women in clinical trials with medical devices, a vaginal ring that might be effective in preventing HIV, but we don't know, abandoned in trials with no one to remove the devices from them.

30:31Children in TB programs be with drug resistant TB in a research trial to stay alive with new medications dropped in the middle of treatment. It's against every ethic. It is against every piece of morality. And, um, and so, yeah, you know, how do you wake up? You wake up to bear witness to the reality of what's happening because the other side, the people doing this are gleefully making the cuts saying it's all corruption it it it was never doing any good and you know not a single life is being lost when when we are pointing out numerous of them and putting names to these people it's a very um striking pattern i had development people say to me when this was beginning well surely rory you know you agree that there are things that aren't great about international development and that could be improved.

31:22And my sense was that you've got this wrong. This is not good faith. Trump and Musk are not trying to improve the international development system. They just don't want to give the money away. And the reason why this resonates is you'd probably get the same conversation if you were talking to European allies about defense and NATO. If you were actually serious about Europe taking over the cost of defending Ukraine, when French president, British prime minister come and say, OK, we'll find the money, we'll find$50 billion, but can you still sell us the kit? You'd have a glide path, but there isn't a glide path.

32:03They cut off intelligence sharing. They disable the missiles. Everything stops on a dime. And it implies that in the end, they don't really care about the results. They don't care about the lives lost. They don't actually care about what happens to Ukraine. They're not serious about Europe taking responsibility for its own defense. What is going on here? I think there's a couple of things going on. One is that power comes first over outcome and being able to exert power over the government, over society, over culture is seen as a good in and of itself that makes whatever the costs worthwhile. Second is, you know, drinking their own Kool-Aid and believing that this is all corruption, that the lives save the programs that the government rolls out, that these will not be as bad as claimed because these are folks who come in with very little experience with government and proud of it.