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- [00:03]
Atul Gawande
There were half a billion deaths that occurred in the last century of smallpox and in the 21st century, zero. It's not something we have to fear at all. And that is a dividend that's paid for future generations, many to come, making its value incalculable.
- [00:26]
Andy Choi
From Rotary Magazine this is the Rotary Voices Podcast. I'm andy Choi. The U.S. agency for International Development, or USAID, is an independent federal agency that aims to increase global stability through economic development and humanitarian assistance. This mission covers everything from addressing disasters.
- [00:49]
John Huco
We can no longer do the bare minimum to address climate change and we'll.
- [00:53]
Andy Choi
All suffer consequences if we fail to maintaining democracies.
- [00:59]
Unknown
We're here in Kyiv at St. Michael Square to celebrate a new partnership between USAID and Ukrainian Railways and being a.
- [01:06]
Andy Choi
Source of expertise to save lives in Tanzania.
- [01:09]
Unknown
Democracy delivers healthy babies through a mama.
- [01:13]
John Huco
Which is an emergency system that transports.
- [01:15]
Atul Gawande
Pregnant women to health care facilities.
- [01:18]
Andy Choi
USAID has long recognized Rotary as a valued civil society partner in international development. For over 15 years, Rotary and USAID have been working together on polio eradication, expanding access to safe water, sanitation and hygiene services, and engaging with Rotary members in Eastern and Central European countries on sustainable, impactful grant projects. Dr. Atul Gawande is the Assistant Administrator of Global Health at USAID. Since assuming his role in January of 2022, he has led the agency in preventing child and maternal deaths, controlling the HIV AIDS epidemic, and combating infectious diseases globally. His leadership in public health stretches back long before his time at USAID. In addition, Dr. Gawande is also a bestselling writer. A longtime staff writer for the New Yorker magazine, he has written four books, most notably Being Medicine and what Matters in the end, published in 2014. In Being Mortal, Dr. Gawande uses both research and anecdotes from his own life and career to explore the successes and failures of society's approach to death and dying. Like Dr. Gawande, Rotary International CEO and General Secretary John Huco has spent much of his career bettering global health through Rotary, from fighting disease to promoting peace. Huco was also part of the original team that established the Millennium Challenge Corporation, a US Development agency that provides grants to well governed countries with potential for economic growth to reduce poverty and strengthen their institutions. In this episode, John Huko sits down with Dr. Gawande to discuss Rotary's partnership with USAID, the role of civil society organizations in achieving global health goals, and personalized care in end of life decision making.
- [03:38]
Unknown
Well, thanks for joining me today for.
- [03:39]
John Huco
The Rotary Voices podcast.
- [03:42]
Atul Gawande
Well John, thank you for having me on and this is such a pleasure to talk to you and to reach reach Rotarians around the country and the world.
- [03:50]
Unknown
I think many of our listeners probably aren't aware that you and your family have a very deep connection to Rotary. So can you just tell us a bit about that?
- [03:59]
Atul Gawande
Yeah. I grew up in rural Ohio. So my parents are from India. They met in New York City, and then they settled in a rural town in southeastern Ohio, Athens, Ohio. It's in the poorest county in the state. And my parents, though immigrants, wanted to be involved in the community. And the way they became involved was they were invited to a Rotary meeting. And it was in the days when it was just men. And so my dad first went, though my mother was jealous. And then the court ruling came that women could join as well, and my mother joined in. My father became president, and then my mother became president of the Rotary. And it was a major part of our lives as I was growing up. Rotary ended up doing water projects for my father's village, where he came from. Rotary members ended up being part of fundraising to build a college outside the village where he had grown up. And then the Rotary Club in that village, in that community, as a way of giving back, provided new textbooks for the kindergartens in our community because our kids didn't have the textbooks that they needed. So it was a remarkable relationship. Then my father developed a tumor in his brain stem and spinal cord. He was a surgeon. He had to give up his life in surgery, and he thought his life was over when that happened. His purpose in life had come from his life as a surgeon, but he realized what he loved was helping people. And so even though he had this tumor, he ran for and won, becoming the district governor for Rotary. And in his last year of life, he spent that year traveling with my mother, doing the visits to every one of those 66 Rotary clubs in his district. Twice, I believe they had a routine, you know, where my mother would do the driving as he became unable to drive. But it was a deep connection for my family. And Rotary's made a huge difference in many, many communities, but also in the way that we all can participate in helping communities everywhere.
- [06:14]
John Huco
And how did Rotary personally affect you? Obviously, vicariously through the benefits you saw your father receive from membership in Rotary. But I suspect it probably had an impact on you as well and perhaps your life and your career choices.
- [06:29]
Atul Gawande
All my parents were both doctors, so I went into medicine. But their commitment, that really was reflected in Rotary, to giving to the community and to thinking about how you leave your community A better place led me down the road of also doing public health. So I became a surgeon, but also did public health simultaneously. That was not a common thing to put together. You know, I had an allergic reaction to the smallpox vaccine. When my parents were originally going to go back to India, they met in New York. I was born in Brooklyn. And then it turned out that my anaphylactic reaction to smallpox vaccine meant I was not allowed to travel and they couldn't return. And they ultimately settled in rural Ohio. And, you know, it's not a coincidence that, first of all, smallpox was eradicated and the role of civil society organizations and was very important in making that possible around the world. And my parents were huge beneficiaries because after 1979 smallpox eradication, I was able to travel to India. And USAID was the operational agency that helped get the smallpox campaign off the ground around the world. And then the polio program, with its close ties to usaid. And I got to be part of seeing what those polio programs were. And in fact, when I began writing, I became a writer for the New Yorker magazine. One of my earliest articles was about traveling with polio workers aiming to try to get to the end of polio. That was some 20 years ago. And here I am now, actually at the agency that is helping oversee that work for the US Government. It's an extraordinary thing and clearly influenced by seeing what a group of people in a community in rural Ohio could do, committed to making a difference locally, regionally, and globally.
- [08:30]
John Huco
When you were talking about your father and your parents, it really resonated with me. Both my parents, as yours, were immigrants. They came to the United States in 1949 after the Second World War. And that feeling of giving back to your community. And my father, as yours, was a very, very active Rotarian for many, many years in Michigan and where I grew up. And in fact, I have this job as Rotary CEO and general secretary thanks to my father, because he was reading the Rotary magazine I'd just come out of. The administration at the Millennium Challenge Corporation, was figuring out what to do next. I was with a think tank in Washington. And then my father's reading the Rotary magazine and he saw an advertisement that the Rotary was looking for a new CEO. He ripped it out of the magazine and wrote across the corner, john, you seem to have all the qualifications, mailed it to me, and the rest is history. So it's funny how sort of serendipity and the circular nature of things sometime can affect people's lives dramatically. And so your story with your father really, really resonated with me.
- [09:28]
Atul Gawande
And my mother is still alive. She's 87 now in Maui. And I'm sure she'll be listening to this podcast and I'll get to say hi mom, and thanks for everything that you did and got me here.
- [09:44]
John Huco
Well, Latul, you are the Assistant Administrator for Global Health at usaid, the United States Agency for International Development. Some of our audience may not really know that much about usaid. Can you just give us a brief introduction and tell us about the scope of your work at aid?
- [10:00]
Atul Gawande
Well, I came into USAID because of its long history of impact on health, but USAID as a whole is our agency for foreign assistance in supporting the advancement of solving some of the biggest problems in the world, which includes humanitarian assistance for disasters, being able to address how to advance economies and democracy in low and low middle income countries, and also how to improve education and health. I oversee the agency's foreign assistance for health and I have the privilege of having 2,500 people that I work with, about 800 in the Washington area headquarters, 1700 in more than 65 country offices around the world, touching north of 100 countries. And we deploy in the range of $9 billion in assistance per year that goes towards programs in HIV, AIDS, TB, polio, malaria, and then also addressing prevention and response to epidemic outbreaks and pandemics. The fundamental mission is reduce the drivers of premature mortality, but we have made a focus on reducing deaths before 50 as a percentage of deaths in the countries where we work.
- [11:29]
John Huco
Well, you know, I had the privilege of being part of the original team that established another US Development agency, the Millennium Challenge Corporation, during the Bush George W. Bush administration. And I think one of the challenges we faced at the time when we would interface with US Taxpayers was a feeling that all this money is just building roads to nowhere and waste of taxpayer money. And our foreign assistance budget is 25% of the US budget. Huge misconceptions. How do you answer those critics that are questioning the need for US Global engagement and the usefulness of our various foreign assistance agencies and programs?
- [12:11]
Atul Gawande
Number one is, you know, the U.S. government and our assistance. USAID is a hugely recognized brand around the world and it is a major part of our diplomacy showing that we don't just show up with militaries, we show up as partners helping to achieve critical goals, whether it's keeping democracies going, addressing disaster and being a source of expertise and assistance to save lives. And that creates enormous goodwill. That's of incalculable value to the United States. Second, the security of Americans depends on our ability to detect and respond to diseases well before they get to the United States. I've been in this role for a little over two years and we have an outbreak almost every other week that we have to ensure that there is operational capacity for response. I've had six Ebola outbreaks where any one of those could have been like the 2014 outbreak that reached all the way around the world, including the US shores. The third thing for people to understand is the assistance we provide has been critical in achieving what has been a decades long steady improvement in survival in the world. We have been supportive of modest levels of assistance at country level so that they are building the right systems and capabilities that have produced massive reductions in deaths from hiv, from tb, from malaria, improved child survival enormously, and continue to make progress on the eradication of polio.
- [14:00]
John Huco
Well, you know, the civil society obviously plays a role in helping you and other agencies achieve your goals. And you mentioned the polio eradication effort. And I think that's a fantastic example of the power that a civil society organization, for example, can have. Because it was really rotary, you know, really a non profit, not a multilateral institution, not a ministry of health that had the audacity back in 1985 to say we're going to eradicate a disease from the face of the earth, polio. But when I'm out in the certainly non rotary world, I very often hear, well, wait a minute, shouldn't we be repurposing all this money to for other global health initiatives, hiv, aids, tuberculosis, malaria, where many, many more people are being effective. I know my answer when I hear that question. What is yours?
- [14:50]
Atul Gawande
I'll be curious to hear yours. My answer is I still meet people in the United States who are now older but have experienced polio and been paralyzed by the disease. There are younger people around the world who knew what it was like when there were millions upon millions of cases and hundreds of thousands of people paralyzed. It's extraordinarily difficult to wipe out. And you know, as you are on the path to eradication, you will spend the most money on that last handful of cases. But then you've eradicated it forever. There were half a billion deaths that occurred in the last century of smallpox and in the 21st century, zero. It's not something we have to fear at all. And that is a dividend that's paid for future generations, many to come, making its value incalculable and so giving up. Just as we're on the threshold would be the mistake just before you've won the game to walk away. How do you tell the story, John?
- [15:54]
John Huco
Yeah, I tell it in very similar to the way you do. And your point about the fact that the last few smallpox cases were on a per case basis, probably extraordinarily expensive. But just look at all the benefit we have now on all the levels you just mentioned. And so we need to get across the finish line. And we're delighted to be working with our partners and we're delighted to be working with the US Government, which is the largest bilateral donor to the polio eradication effort. And a lot of that money comes through CDC and through usaid. So thank you to you and your team for your support of this, for this effort. You know, talking about partnerships, how do you see organizations like Rotary or other nonprofits partnering with aid? I know we're working with you on water and sanitation issues, on obviously polio in Eastern Europe. We've got a very strong collaboration, but just perhaps some additional insights into that.
- [16:47]
Atul Gawande
Well, wherever you are working in the community to make a difference, we will be with you. Because Rotary has demonstrated over decades now that you will identify community needs where local leaders will help deliver. Let me give an example. That sounds really simple. Getting rid of open defecation. That is an area where Rotary has partnered to set up sanitation systems so that people have toilets and then not only have the toilets, but use them. And that last part needs local leaders who will help people get through a cultural change, who will say we don't do this anymore and that this is not safe, it's not clean and we don't have to be embarrassed. This is something that we will take on as a community and make it happen. And Rotary has been partners in helping make this kind of dramatic change that saves hundreds of thousands of lives. Because you bring the voice of local leaders and the mobilization at an extraordinary scale. Rotary sits in a very special place. You bring together religious leaders, company, you know, small business leaders, local town, village elders, and bridge across communities, religions and even forms of government to help give an on the ground presence that where you're prioritizing needs, we are almost always prioritizing the same areas. And it will be more effective when we come together with Rotary.
- [18:26]
John Huco
Perhaps as background for, for some of our audience who may not be familiar with Rotary's relationship with aid, it's fairly extensive. We're working very closely in Central and Eastern Europe on significant projects. We received from aid a $5 million grant for Covid response activities in Italy We've also been working since 2009 on a number of water, sanitation and hygiene projects around the world, so it's been a very fruitful and important relationship.
- [19:08]
Andy Choi
After the break, John Huko and Dr. Gawande explore how USAID deploys limited resources for maximum benefit across the globe. Plus, Dr. Gawande gives his perspective on the end of life care at the center of his acclaimed book Being Mortal. Stay with us.
- [19:35]
Unknown
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- [20:26]
John Huco
Well you just talked about sort of prioritization and you've got a really tough job Atul, because there's obviously a whole panoply of global health challenges out there and issues and obviously funding resources are limited. In your job, how do you prioritize, where to allocate resources, attention, et cetera? I know a lot of Congress does earmark a lot of the spending for aid, but walk us through your thought process as you think about how best to deploy limited resources to tackle this panoply of challenges out there.
- [20:56]
Atul Gawande
Well, we've made as a critical measure for prioritization. When I referred to earlier, what is the percentage of deaths that occur in a country under the age of 50? And our aim is to drive those to reduce substantially. In Europe it's about 5% of deaths occur in people under the age of 50. In the US it's closer to almost 10%. Japan has it down to 2%. That is a major driver of having a long life expectancy and a long healthy life as well. And in the middle income countries it's closer to 30% of deaths occur before the age of 50 and in the lowest income countries, including most of Sub Saharan Africa it is 60% of deaths occur before the age of 50 which is an extraordinary burden level. The causes vary from place to place. We have Directed smoke Congress to spend the money in some areas which are really big killers driving that. HIV TB is the biggest infectious disease killer in the world. Malaria is one of the biggest infectious disease killers of children, particularly in Africa. Maternal and child health needs, especially around childbirth and nutrition, those are a major area. But what we've recognized is whatever we're investing to address particular indicators, whether it's malaria or maternal child health, where we are enabling a stronger primary healthcare system, those places do extraordinarily well. One example is Thailand. In Thailand, 20 years ago, 35% of deaths occurred in people under the age of 50. That was the same in Philippines, Vietnam and elsewhere. But our partnership with them, they prioritize the building of primary health care, including access to their doctor's visits and community health. Workers who would do home household checks at least once a month to make sure people knew what was critical for preventive needs, could also make sure they were getting their immunizations. Pregnant women were getting services. They went from 35% of deaths occurring before the age of 50 to closer to 10%.
- [23:31]
Unknown
Well, you know, in addition to being a great surgeon and a doctor and a senior government official, you've also done a great deal of writing and you wrote a book, Being Mortal, which by the way, is a terrific book. And I think you raise a number of really profound issues, particularly on some of the dilemmas we face in our modern healthcare system. You know, medical technologies, therapeutics are really advancing and I think you're right about how doctors often try to do the maximum, you know, whatever it takes to help the patient, and that may not necessarily lead to the best results for patients. So what do you see as the principal failures in our system and what are some of the key solutions that you see in terms of how we, you know, how we provide healthcare in this country.
- [24:19]
Atul Gawande
So thank you for that question, and I didn't put you up to it. You know, a core public health need is ensuring that people have their best chance at basic survival. And so that's why the things we've been talking about at USAID are all about needs for child immunization and the capabilities of primary health care and making sure we have those people. Those kinds of gains have allowed the average person to live 80 years and longer, doubling the global life expectancy of a century ago, managing the fact that we are going to spend half our lives with chronic illnesses and face serious life threatening illnesses that have treatments that can be offered. What we have not developed great competence at is how to manage in the situation where people have priorities in their life besides just living longer. They have priorities that we need to understand. Our best way to understand them is to ask. When you ask, you learn, what's the minimum quality of life you'd find acceptable? What are your fears and hopes for the future? How can we understand what you're willing to endure and what you're not willing to endure for the sake of more time? When we don't ask those questions, the result is that our care is often out of alignment with what you want. And it's not just us as clinicians who aren't asking. It's us as family members. When we do not ask those questions and the care is out of alignment with what matters to you, the result is suffering. Now we are getting better. And many people, and I've learned a lot from palliative care physicians and geriatricians and others who have recognized that there are ways to make sure we're improving and sustaining the quality of life that matter to people. So when I told the story of my father navigating having a brain tumor, one of the goals he had was how talking to his clinicians about what are the choices that allow me to finish my goals as district governor of Rotary, literally having that conversation saying, I want to get to these clubs. This matters to me. If I have to take a pause from some radiation treatment, okay, but it should be because it's going to help me achieve that goal. And he found there were certain treatments that were sacrificing that goal and not giving him any confidence in extra time. And being able to have those conversations was so important to his, being able to make choices that maintained control over not only his care, but over his life to the extent possible.
- [27:05]
John Huco
You talked about the conversations doctors need to have with their patients. And when I was reading your book, I was struck by the example of Dr. Benzel at the Cleveland Clinic, who was the surgeon that actually ultimately operated on your father. And he took a given approach, and then you contrasted that with the approach taken by the neurosurgeon at your hospital and subsequently, when your father had other health issues, the radiation oncologist and the oncologists that were treating him, two very disparate approaches. Tell us a bit about that contrast. Which of the two do you think is the better one? And how do we get more clinicians, more doctors, more surgeons, more specialists operating in the doctor, I guess, benzel vein than with the other doctors that you had mentioned?
- [27:50]
Atul Gawande
Well, the common approach, it's the one I learned in medical school, is that when people have choices, you lay out for them the options. There's option A, option B, option C. Here are the risks and benefits, the pros and cons. And then you say, now what do you want? And I was a cancer surgeon in my practice. The most common answer they would give me is, well, what would you do, doctor? And then I'd learned in medical school how to answer this question. You say, no, no, no, no. This is not a question for me to answer. This is a question for you. There's no right or wrong answer. You just tell me what you want. And people felt lost. They wanted a recommendation. Now, learning how do you give that recommendation? Dr. Penzel did it by saying, well, what matters in your life? What are your goals? What's important to you? For my father, it was in the beginning, it was try to operate as long as he could and not have side effects from his treatment. That would mean he had to stop practice. And then when the tumor made it so he couldn't practice, then it was, how do I not have side effects or treatment requirements that would sacrifice my ability to be in my district governor role? Because the tumor he had was incurable, right? At best, treatments might slow it down, but at the cost of being able to do things that mattered to him. That set of choices, being able to think in terms of what is your goals, and then let me give you a recommendation about what treatment would be most successful. Dr. Benzel became the one we could rely on to say, here's what my experience tells me here. Now, how do you inculcate that? You know, part of my work before coming to USAID was getting medical schools to getting a protocol in place. We tested how to have these conversations, could be done efficiently and produce better results. A win win of the patients felt better. Their life was not shortened. In some cases, it was actually lengthened by being able to make better choices about when to stop chemotherapy or those kinds of things. And overall, the people did better. So then that's become a standard part of curriculum in medical schools and increasingly in residencies in many medical schools. That hasn't reached everywhere, but those tools and approaches are there, and we're getting better at recognizing that. These are not conversations to fear. This is not a conversation about taking things away. It's a conversation about how do you have control in a situation where choices are limited and full control is not completely possible.
- [30:20]
John Huco
You've written about the United States health system and health systems around the world. Let's focus particularly on the United States. If you were the health Czar and had a magic wand that you could wave. What would a good health system look like? You know, there's the German model, the Australian model, the Canadian model. From your perspective, taking a 30,000 foot view, what should our health system look like?
- [30:41]
Atul Gawande
Ideally, when we talk about the German model, the Japanese model, the French model, Swiss model, we are only talking about financing systems. And there are many ways to finance healthcare and we can kind of pick any one of them around the financing side. You know, we have a mixed system where between Medicare and Medicaid, the VA and private insurance, it is possible to have everybody have financing of their care. And we need to close the loop and finish that job in the states that haven't yet adopted the aca, the Affordable Care Act. But the larger picture is it doesn't address what matters to whether you get the value out of the system. And I described in Thailand the basic components of that system, which is that you need people to have primary care. It has a few key elements. It needs to be low cost to get your primary care visits and basic services with access to your essential medicines. And then the other component is that you need to have an outreach capability at the community level with people coming to check on people who haven't made their way to the health system on a regular basis. So when you put those pieces in place, you can get very high rates of ensuring people have their blood pressure control, they have their immunization needs met and so on. And when you don't have it, you have a situation. You know, in the United States when Covid happened, we could not get to 95% of the elderly vaccinated until we brought 150,000 community health workers going door to door, assessing whether people had received immunization and offering in high risk communities that the vaccine appointments could be set for you or it could be even brought to you if you're disabled. That's what got us to 95% vaccination. And by the way, that was regardless of whether you were Democrat or Republican over the age of 65, we got there simply by making sure that it was easy and offered to you. And that's so important. That is an indication of what that system looks like, that the livers could be doing that around high blood pressure, where it's our biggest killer in less than half our population has their high blood pressure recognized under appropriate control. So the financing is important, but not as nearly important as having that basic primary care infrastructure which delivers in multiple countries around the world. As I'm meeting 80 year add up life expectancy matching ours are better at a fraction of the cost that we have.
- [33:19]
John Huco
Well, perhaps we can close on sort of what's become a unfortunately a controversial issue, and that is just vaccinations in general. We wouldn't certainly have eradicated smallpox, saw the vaccine. There's a whole slew of diseases that we no longer have to deal with thanks to effective and safe vaccines. And yet after the COVID pandemic, there's obviously a significant division in many parts of the world about vaccines. When you address audiences and you're met with people who are skeptical or they're rejecting vaccines or considered a government plot to microchip people, what's your sort of elevator pitch on vaccines in general?
- [33:56]
Atul Gawande
Well, there is a factual story to tell and I emphasize that all of the last 50 years of gains that have dramatically reduced child mortality, out of all of those gains, 40% of the gains came from vaccines. And ensuring that children are getting their routine vaccinations is just absolutely critical. And if we're going to have a debate about COVID let's not let it bleed over into the routine immunization systems that right now continue to protect against outbreaks of measles and pneumonias and other things that are so critical. And I will tell you, people think measles is gone. There are more than 100,000 child deaths in the world because of measles still to this day. In fact, we've gone backwards in measles outbreaks because of the slip in confidence in vaccines and that could be very costly for the gains we have. But I think the second part of this is recognizing that this is not just about facts and needs to be about people who are trusted. Coming forward, Rotary has committed to embracing the life saving value of vaccines and it's local community members and local clinicians who are key to our confidence in the importance of this irreplaceable tool for human health and survival.
- [35:19]
John Huco
Well, thank you so much Atul for joining us.
- [35:21]
Atul Gawande
It's great to talk to you, John, and thank you to Rotary International Fashion.
- [35:26]
John Huco
Atul Gawande is the Assistant Administrator of the United States Agency for International Development. He was a longtime staff writer for the New Yorker magazine and has written four New York Times best selling books including the Checklist Manifesto and Being Mortal.
- [35:45]
Andy Choi
This episode of the Rotary Voices Podcast was produced by Joe Desot and J. AP Swenson and edited by Wen Huang. Yusu Kim and Timothy Capp provided additional production support. I'm Andy Choi. If you enjoyed the show, please rate us five stars on Apple Podcast and Spotify and share it with your friends. The Rotary Voices Podcast is produced by Rotary Magazine, the official monthly publication of Rotary International. Thanks for listening, SA.