D (5:44)

Yeah. And you picked, you had a reason. You said you picked, you decided to go look at refugees and look at refugees in Kenya just real quickly. How did you zero in there? Why go there?

E (5:54)

Yeah, well, I was interested in Kenya because I'd actually spent a fair amount of time working with the Kenyan government in my role. Kenya is on the path. It just has reached low Middle income status. It's on a path that we've seen many countries follow. We aided Korea after the Korean War, we aided India in famine and then sent lots of technical assistance and training that turned their agricultural economy into they became an agriculture exporter. We have done the same in Latin America where countries went from less than 40% were reaching even middle income status. Now it's 80% are middle or high income status with only a tiny fraction needing assistance along the way. So Kenya is on that path, but they are in a powder keg region. South Sudan, Somalia are on their borders. And USAID as well as other countries have been part of supporting, keeping that country stable by having refugee supports in the, in, in those regions. And I visited one of the camps there, but I've also visited HIV wards in Nairobi, primary health care centers in malaria ridden zones. And I was particularly interested, however, in where our progress was against malnutrition. Here was in the last two decades an area where we've had extraordinary progress. Severe acute malnutrition, deaths of children when they would come into a hospital. They had a 20% or higher mortality rate 20 years ago. We have changed the protocol that has now pushed care out of the hospital into community health. Workers visiting homes with young children, having a measuring tape and a scale, catching the severe acute malnutrition cases earlier, being able to give a fortified therapeutic food, a peanut paste sometimes called plumpy nut, that can reverse the starvation and the worst effects and save lives. In the first few years of deploying it, it dropped the mortality rate from over 20% to under 5%. In the areas where we were working, we had achieved a 1% or less mortality. And understanding how that program was working, you still had other things you did at the hospital level, you had things done at the community level. And this had been responsible. One of the biggest reasons why in the last 20 years child mortality was dropped by half. And so I went to see where is this system now?

D (8:38)

Yeah, I mean it was a remarkable progress. It never, I think there's this sense people have that, oh, this is all just money going in the drain. And we were making incredible, taking incredible strides forward. Let's go ahead, Dante, let's go ahead and let's roll the clip from the document. I will say just, I've watched it twice now. It's really well done. The title, the title is Rovina's Choice. Tell me, tell us a little bit about Ravena, who is Robina.

E (9:56)

Rovina is a woman who with her family had fled South Sudan after they Saw relatives killed in the political instability and violence there. She has seven children of her own. She's taken in two other children for supporting them from her family. Her husband was. You know, in a refugee camp, you can't make an income. It's hard to make ends and you can't make ends meet. You can try to find some work in and around. This is actually they'd moved to a resettlement part of the camp where they were beginning to be able to do work, but there weren't enough jobs. And so he went back into the violence in South Sudan to try to make a living and enable some money to come back for them and was killed in that process. So she then has remained in the camp with her children. They. They do. They were receiving food rations in the camp from the World Food Program. Those. The funding support from the United States for those was cut to zero. And then the US was pushed other countries to shift their funds from aid to military, such as in Europe as the US shifted its position on Russia. So the consequences were that World Food Program dropped to only 40% of the minimum calories required for children being available. It even dropped further after our filming that particular section. You see, we continue to be following along and filming in regions of Kenya and elsewhere. And the consequence of that was you had one child who became sick with diarrhea. And I won't tell the conditions that baby Jane had, but she was. She was severely ill. And Ravena's choice evokes the Sophie's choice of the fact that the other children, who ranged from quite young to teenagers, were at home with some supplies of food, but soon were not going to have food themselves and she was going to have to face, under the current circumstances, a terrible set of choices. We also meet the clinic staff and the team who are seeing their own staff cut by two thirds because of the losses of aid while facing an incoming surge of people having great difficulties in illness.

D (12:44)

Yeah, yeah, I was going to. I was going to ask you if that the. I assumed it was the title was meant to evoke that. And again, I don't want to say too much about what's in the documentary, but that, that, that was. That was clear.

E (12:56)

I'll just say you can see it on YouTube as well as the New Yorker. And thank you for letting having a chance to discuss that clip.

D (13:06)

Oh, yeah. And we're going to make sure people know where to find it. It is again, I've seen it twice and really worth watching.

C (13:11)

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D (14:37)

In practical terms, food rations down to 40% or more. What does that look like? I mean what are we talking about here?

E (14:43)

We're talking about the family ended up having no more than one meal per day. That meal they weren't assured that they could get protein. The mother is not well nourished and baby Jane became so weak from lack of protein that she began to not even be able to breastfeed with the mother nor taken, you know, nor understand that they were that she wasn't getting adequate protein. The when you don't have adequate protein you see some really terrible things happen. Loss of skin integrity, swelling and and when you have a community health worker who's visiting and especially for children that might be sick, you catch those issues and you're able to bring them in earlier. You also see the family situation and can assess and bring to attention where particular food supplements might be needed for other children in the family. The ones that are old enough to go to school do get one meal a day. The Kenyan government pays for virtually all of that school supplied nutrition. That's one of the most life saving steps that has been taken as well. With the support of USAID and others is to implement wide school feeding programs that goes back all the way to the 60s when USAID started. And part of what was brought to Latin America and as one of the first steps USAID helped show how to do in other countries.

D (16:20)

You know, one thing what really struck me listening to when I was watching the documentary and there's a little sense of it in that clip and you just referred to it also. I, I have to say, and I, you know, I did not fully understand the effects of malnutrition and I, I cover healthcare. I just, I, something I'd focused on. Can you talk a little bit just, just to describe to people? Again, I don't want to go into too much detail, but when you mentioned skin integrity, why is that, what are we talking about here and why is that dangerous?

E (16:47)

Yeah, so severe acute malnutrition is the most severe form of malnutrition. And one of the forms it can take is protein deficiency. You're you, you may get some calories, but you may not get protein. And without protein and basic vitamins, you can't create skin. You start losing the ability to form collagen. So skin wounds don't repair. And then at a certain point you reach the point where the skin simply starts sloughing off and you stop, you become unable to maintain your body temperature where you also get skin infection because there isn't a barrier between you and infection. In the outside world. They had not seen cases like that while they had an in the system in place and they've had the system in place now for two decades. So seeing children come in and she was not the only one. You know, I was seeing other, other children in this ward. But you could see the world in this one person and case. You know, we have made severe acute malnutrition deaths A, a rarity that they do not need to happen. Those solutions had reached many, many people in the world. They're still, you know, more than half of children are not yet getting this kind of access to what the modern management is, which is actually lower cost management as well. But rather than close that gap and maintain the programs that have been successful as countries transition to middle income status and take on those costs themselves, they were, they were ripped away. They were simply removed with no conscience, no willingness to wrestle with the harms being done, working to prepare the governments for what might be coming, answering questions, offering some approach to transition. None of that. Instead a complete denial that anything has been done.

D (19:01)

Yeah, I mean there was a way to do this. I mean gradually Right. I mean, that's typically what you would tend. I mean, I don't know typically, but I mean, I feel like. I mean, that was part of this. It was so sudden, it was just cut off. I mean, I think that my sense was that itself created disruptions and even into the extent you could turn things back on, which they didn't really do, in the end, things happened so suddenly. There was just this sort of blast wave of damage.

E (19:23)

Yeah. I think the thing to understand is that there is an assault on the idea of cooperation to solve big problems in the world and instead a belief that domination, predatory transactions are how the US Wins. And the thing is, they don't. It doesn't even win on its own terms. It doesn't make us more prosperous. It doesn't win us more respect. It ends up costing lives. You end up funding the most expensive parts of aid, which is disaster relief, or you end up abandoning people, being an unreliable partner, and having nobody trust you in the world. USAID was formed in out of the lessons of the Marshall Plan. The Marshall Plan was the instance where we'd had a world war. And instead of enslaving the enemy, we invested in Germany, in Japan, in Italy. We made them into peaceful, stable partners by helping them build their prosperity. And that built our prosperity. And John F. Kennedy said, we need to do that not just for Europe and Japan. We can do that around the world to our benefit. And it resulted in the eradication of smallpox, resulted in the. The vanquishing of famine for a couple billion people in the world, and turning places like Korea, India, major parts of Latin America into our. Some of our biggest trade partners and sources of strength.

D (21:07)

What about the idea? I mean, I remember when this was all playing out initially and you and I talked about it back then, you know, there was this argument that, oh, you know, this is too expensive. There's tons of waste in the system. The USAID is. There's. They're funding, you know, ideological agendas and that could be cut. And, you know, frankly, the Europeans could step up more. You know, why are we bearing this burden? Was. What do you say when you hear that? I mean, I know you heard that from people. What was your answer?

E (21:36)

There is legitimate criticism of usaid. I've made much of the criticism. Too much money goes to international organizations instead of local organizations there. Sometimes it will create dependency. And having pathways out of dependency is, Is a constant necessity. There are spaces where you see waste that can be remedied. But let me tell you a couple of critical things. Number One was I said, this is $24 per American taxpayer where American taxpayers are already paying $15,000 in taxes to US government. It's a tiny fraction of our spending. The total amount for USAID is less than half of the budget of my hospital in Boston. And it's saving. It's reaching hundreds of millions of people and saving lives by the millions. It is the highest impact agency in the US Government per dollar. So is there more efficiency that you can get? Yes. Compare it to our own American health system, however, and what we, what we are achieving out of our own health system. What I saw and experienced was people doing extraordinary things at usaid. There have been areas of great policy disagreement, and we make the shifts from administration to administration. You know, the Biden administration did woke things like wanting to back climate change prevention and renewable energy by helping build economies that are future proof against climate catastrophes. Wanting to improve diversity, equity and inclusion in our programs rather than more homogeneity, inequity, exclusion. Those are policy differences. And a new administration is perfectly within its rights to make shifts in those priorities. And we'll have an argument about that. But the destruction of USAID has nothing to do with any of that critique. It's made the ability of the United States to do work around the world without needing the cost of the military phenomenally higher. Right. We've hobbled an entire system that gave us a foothold and influence in every part of the world. As a case in point, I had helped oversee the expansion of our pandemic prevention capacity, our ability to have surveillance and response to 50 countries around the world to create a network that eliminated blind spots. For example, opening up relationships with three countries in Central Asia, Kazakhstan, Mongolia and Tajikistan, where, working with virologists and laboratories, we had access to specimens. We don't have line of sight into Russia or China sitting on either side of them, but when disease comes through those areas, we can see it. We were tracking bird flu. We were tracking all kinds of disease that might be passing. All of that's been dismantled, which only makes us weaker.

D (24:51)

Does bird flu spread? Does that go across? Yeah. Really? Last thing. It's a very disheartening story to watch. It's a disheartening story to know what's going on. Someone watching this, they want to do something. What should they do?

E (25:07)

Well, so a couple things. Number one, I would say is the. The reason I made this film, reason I wrote the pieces in the New Yorker that I have been, the reason I keep talking everywhere I can, is because they're trying to make the loss of life invisible. They're trying to deny the reality. And the first task is making the invisible visible. And so I ask you to spread the word around about the, the documentary and make sure that, you know, we're holding people to account simply by acknowledging what the reality is. The second thing is there are international programs and local programs that do work, such as in malnutrition. You know, I can call out unicef, the International Rescue Committee, Helen Keller International, the Word World Food Program. And your support would mean a great deal to programs like that at every level because, you know, a few dollars is another life saved. And, and so I do think that that work is there. The third is this ties in with our larger job in democracy, which is that we have to hold these people to account. You know, Rubio Musk, Richard Reeves, the historian, uses the term public man made death for, you know, introduce that as. And he was referring to war, but also Mao Zedong's great leap forward, which would be found to kill 50, at least 25 million people through famine. We are in the face of a public man made death now at large scale. And it is our opportunity to hold people accountable for that. And we can do that in the way we vote and the way we turn out to call out what's being done.

D (27:06)

Well, the documentary is called Raveena's Choice. You can see it at the New Yorker website. You can see it on YouTube. It's from Atul Gawande. Atul, thanks for joining us. Thanks for doing this work. And if you're following this, think about some of those organizations that he mentioned. They could probably use your support. Thanks, everybody.

E (27:29)

Thank you. John.