I cried all the way through this interview ð
'It is hard to calculate all the good that Atul Gawande has done in the world. After training as a surgeon at Harvard, he taught medicine inside the hospital and in the classroom. A contributor to The New Yorker since 1998, he has published widely on issues of public health. His 2007 article in the magazine and the book that emerged from it, âThe Checklist Manifesto: How to Get Things Right,â have been sources of clarity and truth in the debate over health-care costs. In 2014, he published âBeing Mortal: Medicine and What Matters in the End,â a vivid, poetic, compassionate narrative that presents unforgettable descriptions of the ways the body ages and our end-of-life choices.
'Gawandeâs work on public health was influential in the Clinton and Obama Administrations, and, starting in November, 2020, he served on President Joe Bidenâs COVID-19 Advisory Board. In July, 2021, Biden nominated him as the assistant administrator for the Bureau of Global Health at the U.S. Agency for International Development, where he worked to limit disease outbreaks overseas. Gawande, who is fifty-nine, resigned the position on the day of Donald Trumpâs return to the Presidency.
'When we spoke recently for The New Yorker Radio Hour, Gawande, usually a wry, high-spirited presence, was in a grave mood. There were flashes of anger and despair in his voice. He was, after all, watching Trump and Elon Musk dismantle, gleefully, a global health agency that had only lately been for him a source of devotion and inspiration. As a surgeon, Gawande had long been in a position to save one life at a time. More recently, and all too briefly, he was part of a vast collective responsible for untold good around the world. And now, as he made plain, that collective has been deliberately cast into chaos, even ruins. The cost in human lives is sure to be immense. Our conversation has been edited for clarity and length.'
President Biden appointed you as the assistant administrator for global health at U.S.A.I.D., a job that youâve described as the greatest job in medicine. You stepped down on Trumpâs Inauguration Day, and he immediately began targeting U.S.A.I.D. with an executive order that halted all foreign aid. Did you know, or did you intuit, that Trump would act the way he has?
'I had no idea. In the previous Trump Administration, they had embraced what they themselves called the ânormals.â They had a head of U.S.A.I.D. who was devoted to the idea of development and soft power in the world. They had their own wrinkle on it, which I didnât disagree with. They called it âthe journey to self-reliance,â and they wanted to invest in Africa, in Asia, in Latin America, to enable stronger economies, more capacityâand we werenât doing enough of that. I actually continued much of the work that had occurred during that time.'
Tell me a little bit about what you were in charge of and what good was being done in the world.
'I had twenty-five hundred people, between D.C. and sixty-five countries around the world, working on advancing health and protecting Americans from diseases and outbreaks abroad. The aim was to work with countries to build their systems so that we protected global health security and improved global outcomesâfrom reducing H.I.V./AIDS and other infectious diseases like malaria and T.B., to strengthening primary health-care systems, so that those countries would move on from depending on aid from donors. In three years, we documented saving more than 1.2 million lives after COVID alone.'
Letâs pause on that. Your part of U.S.A.I.D. was responsible, demonstrably, for saving 1.2 million livesâfrom what?
'So, COVID was the first global reduction in life expectancy in seventy years, and it disrupted the ability across the world to deliver basic health services, which includes H.I.V./AIDS , but also included childhood immunizations, and managing diarrhea and pneumonia. Part of my target was to reduce the percentage of deaths in any given country that occur before the age of fifty. The teams would focus on the top three to five killers. In some places, that would be H.I.V.; in some places that would be T.B. Safe childbirth was a huge part of the work. And immunizations: forty per cent of the gains in survival for children under five in the past fifty years in the world came from vaccines alone. So vaccines were a big part of the work as well.'
What was the case against this kind of work? It just seems like an absolute good.
'One case is that it could have been more efficient, right? Americans imagine that huge sums of money go to this work. Polls show that they think that a quarter of our spending goes to foreign aid. In fact, on a budget for our global health work that is less than half the budget of the hospital where I did surgery here in Boston, we reached hundreds of millions of people, with programs that saved lives by the millions. Thatâs why I describe it as the best job in medicine that people have never heard of. It is at a level of scale I could never imagine experiencing. So the case against itâI woke up one day to find Elon Musk tweeting that this was a criminal enterprise, that this was money laundering, that this was corruption.'
Where would he get this idea? Where does this mythology come from?
'Well, whatâs hard to parse is: What is just willful ignorance? Not just ignoranceâitâs lying, right? For example, thereâs a statistic that they push that only ten per cent of U.S.A.I.D.âs dollars actually got to recipients in the world. Now, this is a willful distortion of a statistic that says that only ten per cent of U.S.A.I.D.âs funding went to local organizations as opposed to multinational organizations and others. Thereâs a legitimate criticism to be made that that percentage should be higher, that more local organizations should get the funds. I did a lot of work that raised those numbers considerably, got it to thirty per cent, but that was not the debate they were having. Theyâre claiming that the moneyâs not actually reaching people and that corruption is taking it away, when, in fact, the reachâthe ability to get to enormous numbers of peopleâhas been a best buy in health and in humanitarian assistance for a long time.'
Now the over-all agency, as I understand it, had about ten thousand people working for it. How many are working at U.S.A.I.D. now?
'Actually, the number was about thirteen thousand. And the over-all number nowâitâs hard to estimate because people are being turned on and off like a light switchâ'
Turned on and off, meaning their computers are shut down?
'Yeah, and theyâre being terminated and then getting unterminatedâlike, âOops, sorry, we let the Ebola team go.â You heard Elon Musk say something to that effect in the Oval Office. âBut weâve brought them back, donât worry.â Itâs a moving target, but this is what Iâd say: more than eighty per cent of the contracts have been terminated, representing the work that is done by U.S.A.I.D. and the for-profit and not-for-profit organizations they work with, like Catholic Relief Services and the like. And more than eighty per cent of the staff has been put on administrative leave, terminated, or dismissed in one way or the other.'
So itâs been obliterated.
'It has been dismantled. It is dying. I mean, at this point, itâs six weeks in. Twenty million people with H.I.V., for exampleâincluding five hundred thousand childrenâwho had received medicines that keep them alive have now been cut off for six weeks.'
A lot of people are going to die as a result of this. Am I wrong?
'The internal estimates are that more than a hundred and sixty thousand people will die from malaria per year, from the abandonment of these programs, if theyâre not restored. Weâre talking about twenty million people dependent on H.I.V. medicinesâand you have to calculate how many you think will get back on, and how many will die in a year. But youâre talking hundreds of thousands in Year One at a minimum. But then on immunization side, youâre talking about more than a million estimated deaths.'
Iâm sorry, Atul. I have to stop my cool journalistic questioning and say: This is nothing short of outrageous. How is it possible that this is happening? Obviously, these facts are filtering up to Elon Musk, to Donald Trump, and to the Administration at large. And they donât care?
'The logic is to deny the reality, either because they simply donât want to believe itâthat theyâre so steeped in the idea that government officials are corrupt and lazy and unable to deliver anything, and that a group of young twentysomething engineers will fix it allâor they are indifferent. And when Musk waves around the chainsawâwe are seeing what surgery on the U.S. government with a chainsaw looks like at U.S.A.I.D. And itâs just the beginning of the playbook. This was the soft target. This is affecting people abroadâitâs tens of thousands of jobs at home, so thereâs harm here; thereâs disease that will get here, etc. But this was the easy target. Now itâs being brought to the N.I.H., to the C.D.C., to critical parts of not only the health enterprise but other important functions of government.'
So the National Institutes of Health, the Centers for Disease Control and Prevention, and other such bureaucracies that do equal medical good will also get slammed?
'Are being slammed. So hereâs the playbook: you take the Treasuryâs payment systemâDOGE and Musk took over the information system for the Treasury and the payments in the government; you take over the H.R. software, so you can turn peopleâs badges and computer access on and off at will; you take over the buildingsâthey cancelled the leases, so you donât have buildings. U.S.A.I.D.âthe headquarters was given to the Customs and Border Protection folks. And then youâve got it all, right? And then heâs got X, which feeds right into Fox News, and youâve got control of the media as well. Itâs a brilliant playbook.'
But from the outside, at least, Atul, and maybe from your vantage point as well: this looks like absolute chaos. Iâve been reading this week that staff posted overseas are stranded, fired without a plane ticket home. From the inside, what does it look like?
'One example: U.S.A.I.D. staff in the Congo had to flee for their lives and watch on television as their own home was destroyed and their kidsâ belongings attacked. And then when they called for help and backup, they could not get it. I spoke to staff involved in one womanâs case, a pregnant woman in her third trimester, in a conflict zone. They have maternity leave just like everybody else there. But because the contracts had been turned off, they couldnât get a flight out, and were not guaranteed safe passage, and couldnât get care for her complications, and ended up having to get cared for locally without the setup to address her needs. One person said to me, as sheâs enduring these things, âMy government is attacking me. We ought to be ashamed. Our entire system of checks and balances has failed us.â'
Whatâs been the reaction in these countries, in the governments, and among the people? The sense of abandonment must be intense on all sides.
'There are broadly three areas. The biggest part of U.S.A.I.D. is the FEMA for disasters abroad. Itâs called the Bureau for Humanitarian Assistance, and they bring earthquake response; wildfire response; response in conflicts, in famines. These are the people who suit up, and get assistance, and stabilize places where things are going wrong.
'The Global Health Bureau, which I led, is the second-largest part of the agency, and that does work around diseases and health threats, as well as advancing health systems in low- and middle-income countries around the world. Thereâs coöperation on solving global problems, like stopping pandemics, and addressing measles outbreaks, and so on.
'The third is advancing countriesâ economies, freedom, and democracy. John F. Kennedy, when he formed U.S.A.I.D. in 1961, said that it was to counter the adversaries of freedom and to provide compassionate support for the development of the world. U.S.A.I.D. has kept Ukraineâs health system going and gave vital support to keep their energy infrastructure going, as Russia attacked it. In Haiti, this is the response team that has sought to stabilize whatâs become a gang-controlled part of the country. Our health teams kept almost half of the primary health-care system for the population going. So around the world: stopping fentanyl flow, bringing in independent media. All of that has been wiped out completely. And in many cases, the people behind that workâmost of the people weâre working with, local partners to keep these things goingâare now being attacked. Those partners are now being attacked, in country after country.'
What youâre describing is both human compassion and, a phrase you used earlier in our conversation, âsoft power.â Describe what that is. Why is it so important to the United States and to the world? What will squandering itâwhat will destroying itâmean?
'The tools of foreign policy, as Iâve learned, are defense, diplomacy, and development. And the development part is the soft power. Weâre not sending troops into Asia and Africa and Latin America. Weâre sending hundreds of thousands of civilians without uniforms, who are there to represent the United States, and to pursue common goals togetherâwhether itâs stemming the tide of fentanyl coming across the border, addressing climate disasters, protecting the world from disease. And that soft power is a reflection of our values, what we stand forâour strong belief in freedom, self-determination, and advancement of peopleâs economies; bringing more stability and peace to the world. That is the fundamental nature of soft power: that we are notâwhat Trump is currently trying to createâa world of simply âMight makes right, and you do what we tell you,â because that does not create stability. It creates chaos and destruction.'
An immoral universe in which everybodyâs on their own.
'Thatâs right. An amoral universe.'
Who is standing up, if anyone, in the Administration? What about Secretary of State Marco Rubio, whom you mentioned. Whatâs his role in all of this? Back in January, he issued a waiver to allow for lifesaving services to continue. That doesnât seem to have been at all effective.
'It hasnât happened. He has issued a waiver that said that the subset of work that is directly lifesavingâthrough humanitarian assistance, disaster relief, and so on, and the health work that I used to leadâwill continue; we donât want these lives to be lost. And yet it hasnât been implemented. Itâs clear that heâs 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 federal courts have ruled that the freeze was likely illegal and unconstitutional, and imposed a temporary restraining order saying that it should not be implemented, that it had to be liftedâthe payment freeze. Instead, they doubled down. And Marco Rubio signed on to this, tweeted about it earlier this weekâthat over eighty per cent of all contracts have now been terminated. And the remaining onesâthey have not even made a significant dent in making back payments that are owed for work done even before Trump was inaugurated.'
Thereâs always been skepticism, particularly on the right, about foreign aid. I remember Jesse Helms, of North Carolina, would always rail about the cost of foreign aid and how it was useless, in his view, in many senses. I am sure that in your time in office, you must have dealt with officials who were skeptical of the mission. What kind of complaints were you getting from senators and congressmen and the like, even before the Trump Administration took over in January?
'It was a minority. Iâll just start by saying: the support for foreign-aid work has been recognized and supported by Republicans and Democrats for decades. But thereâs been a consistentâit was a minorityâthat had felt that the U.S. shouldnât be involved abroad. Thatâs part of an isolationist view, that extending this work is just charity; itâs not in U.S. interests and itâs not necessary for the protection of Americans. The argument is that we should be spending it at home.
'Theyâre partly playing into the populist view that huge portions of the budget are going abroad, when thatâs not been the case. But itâs also understandable that when people are suffering at home, when there are significant needs here, it can be hard to make connections to why we need to fight to stop problems abroad before they get here.'
And yet we only recently endured the COVID epidemic, which by all accounts did not begin at home, and spread all over the world. Why was COVID not convincing as a manifestation of how a greater international role could help?
'Certainly that didnât convince anybody that that was able to be controlled abroadâ'
Because it wasnât.
'Because it wasnât, right. And COVID did drive a significant distrust in the public-health apparatus itself because of the suffering that people endured through that entire emergency. But I would say the larger picture isâevery part of government spending has its critics. One of the fascinating things about the foreign-aid budget, which has been the least popular part of the budget, is that U.S.A.I.D. was mostly never heard of. Now it has high name recognition, and has majority support for continuing its programs, whether itâs keeping energy infrastructure alive in Ukraine, stabilizing conflictsâwhether itâs Haiti or other parts of the worldâto keep refugees from swarming more borders, or the work of purely compassionate humanitarian assistance and health aid that reduces the over-all death rates from diseases that may yet harm us. So itâs been a significant jump in support for this work, out of awareness now of what it is, and how much less it turns out to cost.'
So it took this disaster to raise awareness.
'Thatâs human nature, right? Loss aversion. When you lose it is when you realize its value.'
Atul, thereâs been a measles outbreak in West Texas and New Mexico, and R.F.K., Jr.âwhoâs now leading the Department of Health and Human Servicesâhas advised some people, at least, to use cod-liver oil. We have this multilayered catastrophe that youâve been describing. Where could the United States be, in a couple of years, from a health perspective? What worries you the most?
'Measles is a good example. Thereâs actually now been a second death. We hadnât had a child death from measles in the United States in years. We are now back up, globally, to more than a hundred thousand child deaths. I was on the phone with officials at the World Health Organizationâthe U.S. had chosen measles as a major area that it wanted to support. It provided eighty per cent of the support in that area, and let other countries take other components of W.H.O.âs work. So now, that money has been pulled from 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 thatâs a singular disease that can be breaking out, and weâll see many more child deaths that result from that.
'The over-all picture, the deeper concern I have, is that as a country weâre abandoning the idea that we can come together collectively with other nations to do good in the world. People describe Trump as transactional, but this is a predatory view of the world. It is one in which you not only donât want to participate in coöperation; you want to destroy the coöperation. There is a deep desire to make the W.H.O. ineffective in working with other nations; to make other U.N. organizations ineffective in doing their work. They already struggled with efficiency and being effective in certain domains, and yet they continue to have been very important in global health emergencies, responding and tracking outbreaks. . . .
'We have a flu vaccine because there are parts of the world where flu breaks out, like China, that donât share data with us. But they share it with the W.H.O., and the result is that we have a flu vaccine thatâs tuned to the diseases coming our way by the fall. I donât know how weâll get a flu vaccine this fall. Either weâll get it because people are, under the table, communicating with the W.H.O. to get the information, and the W.H.O is going to share it, even though the U.S. is no longer paying, or weâre going to work with other countries and be dependent on them for our flu vaccine. This is not a good answer.'
I must ask you this, more generally: Youâre watching a President of the United States begin to side with Russia over Ukraine. Youâre watching the dismantlement of our foreign-aid budget, and both its compassion and its effectiveness. Just the other day, we saw a Columbia University graduateâyou may agree with him, disagree with him on his politics, but who has a green cardâand ICE officers went to his apartment and arrested him, and presumably will deport him. Itâs an assault on the First Amendment. Youâre seeing universities being defundedâstarting with Columbia, but itâll hardly be the last, etc. What in your view motivates Donald Trump to behave in this way? Whatâs the vision that pulls this all together?
'What I see happening on the health side is reflective of everything you just said. There is a fundamental desire to remove and destroy independent sources of knowledge, of power, of decision-making. So not only is U.S.A.I.D. dismantled but thereâs thousands of people firedâfrom the National Institutes of Health, the C.D.C., the Food and Drug Administrationâand a fundamental restructuring of decision-making so that political judgment drives decision-making over N.I.H. grants, which have been centralized and pulled away from the individual institutes. So the discoveries that lead to innovations in the worldâthat work has a political layer now. F.D.A. approvalsânow wanting a political review. C.D.C. guidanceânow wanting a political review. These organizations were all created by Congress to be shielded from that, so that we could have a professional, science-driven set of decisions, and not the political flavor of the moment.
'Donald Trumpâs preference, which heâs expressed in those actions and many others, is that his whims, just like King Henry VIIIâs, should count. King Henry VIII remade an entire religion around who he wanted to marry. And this is the kind of world that Trump is wanting to createâone of loyalty trumping any other considerations. So the inspectors general who do audits over the corruption that they seem to be so upset aboutâtheyâve been removed. Any independent judgment in society that would trump the political whims of the leader. . . . The challenge isâand I think is the source of hope for meâthat a desire for chaos, for acceding to destruction, for accepting subjugation, is not a stable equilibrium. Itâs not successful in delivering the goods for people, under any line of thinking.
'In the end, professionally organized bureaucraciesâthat need to have political oversight, need to have some controls in place, but a balance that allows decision-making to happenâthose have been a key engine of the prosperity of the country. Their destruction will have repercussions that I think will make the Administration very unpopular, and likely cause a backlash that balances things out. I hope we get beyond getting to the status quo ante of a stalemate between these two lines of thinkingâone that advances the world through incremental collective action thatâs driven around checks and balances as we advance the world ever forward, and one in which a strongman can have his way and simply look for who he can dominate.'
Right now, Robert F. Kennedy, Jr., is the head of H.H.S. His targets include not only vaccine manufacturers but the pharma industry writ large. But heâs talked a lot, too, about unhealthy food in the American dietâto some extent, heâs not wrong. Do you see any upside in his role in pushing this so-called Make America Healthy Again idea?
'Of course there is good. I mean, we as a country have chronic illness that is importantly tied to our nutritional habits, our exercise, and so on. But for all our unhealthiness, weâve also had an engine of health that has enabled the top one per cent in America to have a ninety-year life expectancy today. Our job is to enable that capacity for public health and health-care delivery to get to everybody alive, I would argue, and certainly to get it to all Americans.
'Whatâs ignored is that half the country canât afford having a primary-care doctor and donât have adequate public health in their communities. If R.F.K., Jr., were taking that on, more power to him. Every indication from his history is that this is an effort to highlight some important things. But how much of itâs going to actually be evidence-driven? Heâs had some crazy theories about whatâs going to advance chronic illness and address health.
'Iâd say the second thing is the utter incompetence in running things and making things work. Theyâve utterly destabilized the National Institutes of Health, the Centers for Disease Control, the F.D.A.'
Explain that destabilizationâwhat it looks like from inside and what effects itâll have.
'One small example: DOGE has declared that all kinds of buildings are not necessary anymore. That includes the headquarters of the Department of Health and Human Services. Theyâre saying, âOh, everybody has to show up for work now, but you wonât have a building to work in anymore.â
'No. 2 on the list is F.D.A. specialized centers around the country. Thereâs a laboratory in St. Louis where they have specialized equipment for testing food and drugs for safety. And so that whole capabilityâto insure that your foods and your medications are able to be tested for whether they have contaminants, whether they are counterfeitâthatâs a basic part of good nutrition, good medicine, that could be pulled away.
'Whether itâs maintaining the building infrastructure, maintaining the staff who are being purged sort of randomly left and right, or treating them not like theyâre slaves but actually bringing good work out of everybody, by good managementâthat is whatâs not happening.'
I have the feeling that you, even in a short time, loved being in the federal government. What I hear in our conversation is a sense of tragedy that is not only public but that is felt very intimately by you.
'I did not expect that 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 the response. We got seven hundred million vaccines out to the world. But what I found was a group of people who could achieve scale like Iâd never seen. It is mission-driven. None of these people went into it for the money; itâs not like theyâve had any powerâ'
I assume all of them could have made more money elsewhere.
'Absolutely. And many of them spent their lives as Foreign Service officers living in difficult places in the world. I remember that Kyiv was under attack about eight weeks after I was sworn in. I thought I was going to be working on COVID, but this thing was erupting. 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 were already saying, âWe have T.B. breaking out, we have potential polio cases. How are we going to respond?â And my critical role was to say, âWhatâs going to kill people the most? Right now, Russia has shut down the medical supply chain, and so nearly a hundred per cent of the pharmacies just closed. Two hundred and fifty thousand H.I.V. patients canât get their meds. A million heart patients canât get their meds. Letâs get the pharmacies open.â And, by the way, theyâve attacked the oxygen factories and put the hospitals under cyberattack and their electronic systems arenât functioning.
'And this team, in four weeks, moved the entire hospital record system to the cloud, allowing protection against cyberattacks; got oxygen systems back online; and was able to get fifty per cent of the pharmacies open in about a month, and ultimately got eighty per cent of the pharmacies open. That is just incredible.
'Yes, are there some people that I had to deal with who were overly bureaucratic? Did I have to address some people who were not performing? Absolutely. Did I have to drive efficiency?'
As in any work . . .
'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, in that job, was that I had to speak for the U.S. government. I couldnât write for you during that time.'
Believe me, I know!
'I couldnât tell the story. Iâve got a book Iâm working on now in which I hope to be able to unpack all of this. It is, I think, a sad part of my leadership, that I didnât also get to communicate what we doâpartly because U.S.A.I.D. is restricted, in certain ways, from telling its story within the U.S. borders.'
If you had the opportunity to tell Elon Musk and Donald Trump what youâve been telling me for the past hour, or if they read a long report from you about lives saved, good works done, the benefits of soft power to the United States and to the world and so onâdo you think it would have any effect at all?
'Zero. Thereâs a different world view at play here. It is that power is what matters, not impact; not the over-all maximum good that you can do. And having powerâwielding it in ways that can dominate the weak and partner with your friendsâis the mode of existence. (When I say âpartner with friends,â I mean partner with people like Putin who think the same way that you do.) Itâs two entirely different world views.'
But this is not just an event. This is not just something that happened. This is a process, and its absence will make things worse and worse and have repercussions, including the loss of many, many, maybe countless, lives. Is it irreparable? Is this damage done and done forever?
'This damage has created effects that will be forever. Letâs say they turned everything back on again, and said, âWhoops, Iâm sorry.â I had a discussion with a minister of health just today, and he said, âIâve never been treated so much like a second-class human being.â He was so grateful for what America did. âAnd for decades, America was there. I never imagined America could be indifferent, could simply abandon people in the midst of treatments, in the midst of clinical trials, in the midst of partnershipâand not even talk to me, not even have a discussion so that we could plan together: O.K., you are going to have big cuts to make. We will work together and figure out how to solve it.â
'Thatâs not what happened. He will never trust the U.S. again. We are entering a different state of relations. We are seeing lots of other countries stand up around the worldâour friends, Canada, Mexico. But African countries, too, Europe. Everybodyâs taking on the lesson that America cannot be trusted. That has enormous costs.'
Itâs tragic and outrageous, no?
'That is beautifully put. What I say isâIâm a little stronger. Itâs shameful and evil.'
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