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- [00:00]
Al Franken
Wondry plus subscribers can listen to the Al Franken podcast ad free right now. Join Wonder plus in the Wondry app.
- [00:08]
Nicole Byer
Craving your next action packed adventure, Audible delivers thrills of every kind on your command, like Project Hail Mary by Andy Weir, where a lone astronaut must save humanity from extinction. Narrated with stunning intensity by Ray Porter. From electrifying suspense and daring quests to spine tingling horror and romance in far off realms, unleash your adventure aside with grief. Gripping titles that'll keep you guessing. Discover exclusive Audible originals, hotly anticipated new releases and must listen bestsellers that hook you from the first minute because Audible knows there's no greater thrill than the one that speaks to you. Discover what lies beyond the edge of your seat. Start your free 30 day trial at audible.com wonderyus that's audible.com wondery us.
- [01:01]
Atul Gawande
Hey.
- [01:02]
Al Franken
Everybody, we got a great one today, you know, for a change, because Dr. Atul Gawande is my guest. Atul is one of our great Americans, a surgeon professor at Harvard Medical school, author of four New York Times bestsellers, and for three years he was the assistant administrator of USAID's Bureau of Global Health. USAID is an amazing organization which has saved millions upon millions of lives overseas since President John F. Kennedy established it in 1961. And as you may know, Trump and Musk have all but shut USAID down, which means that millions will die overseas who would otherwise have lived but for Trump and Musk, the richest man in the world killing millions of the poorest people in the world. You see, Musk called USAID a criminal enterprise, a little bleak. But in case you want yet another reason to hate Trump and Musk, today's podcast is your ticket. Of course, there is the matter of the tariffs. On Liberation Day, Trump laid out his tariff program and said it was not subject to negotiation. Remember, he said he wouldn't negotiate. And then he started to negotiate. Then he said again that he wouldn't negotiate. Then he started to negotiate again. Then this past Wednesday, he caved after the bonds market went nuts. And then the stock market had its best day since 2008, only after having its worst day since the height of the pandemic. So now we supposedly have maybe, I don't know, 80 some days until Trump tells us what he's doing. In the meantime, every American in the market has lost money. Unless, I guess, you were short selling. At the beginning of 2025, the International Monetary Fund put out its economic forecast for the coming year. The US Economy, they said, was in better shape than just about all others. And now it's even odds that we're going into a recession. We are not going to fully recover from this. In the New York Times, Tom Friedman said this is Trump's equivalent of Biden's botched exit from Afghanistan, from which he never fully recovered. Except this will have lasting effects on every American's pocketbook. Trump will never recover from this. Will our economy recover? That's the question. And why have we alienated every other country in the world, including our friends? You can blame that on Donald Trump and Donald Trump alone. Atul Gawande joins me. We start by discussing healthcare reform. I promise it's interesting. And then go into the travesty of the near eradication of usaid. It's critical we don't let this get lost in the muck of all Trump's other horrors. And it's a great one, you know, for a change.
- [04:06]
Nicole Byer
We interrupt this program to bring you an important Wayfair message. Wayfair has got style tips for every home. This is Nicole Byer helping you make those rooms flyer. Today's style tip when it comes to making a statement treatment, bold patterns like neutrals go wild like an untamed animal print area rug under a rustic farmhouse table. From wayfair.com Ooh, fierce. This has been your Wayfair style tip to keep those interiors superior.
- [04:33]
Mr. Ballin
Wayfair Every style, every home.
- [04:36]
Unknown
You know those creepy stories that give you goosebumps, the ones that make you really question what's real? Well, what if I told you that some of the strangest, darkest and most mysterious stories are not found in haunted houses or abandoned forests, but instead in hospital rooms and doctor's offices. Hi, I'm Mr. Ballin, the host of Mr. Ballin's Medical Mysteries. And each week on my podcast you can expect to hear stories about bizarre illnesses no one can explain, miraculous recoveries that shouldn't have happened, and cases so baffling they stumped even the best doctors. So if you crave totally true and thoroughly twisted horror stories and mysteries, Mr. Ballin's medical mysteries should be your new go to weekly show. Listen to Mr. Ballin's Medical Mysteries on the Wondery app or wherever you get your podcasts. You can listen early and ad free right now by joining Wondery plus in the Wondery app or on Spotify or Apple Podcasts.
- [05:33]
Atul Gawande
I think we first met in 2009. Is that kind of correct?
- [05:38]
Mr. Ballin
You know, I don't remember. You know, I was on Air America.
- [05:42]
Atul Gawande
Oh, you were. Okay, then.
- [05:43]
Mr. Ballin
It was before that one time and So I think we met then way back in that time. There was a couple times you had me on.
- [05:51]
Atul Gawande
Oh, okay. Well, then I met you before. But in 2009, you had written this article in the New Yorker about McAllen, Texas. And this is a city right on the border. Right. Of. Of Mexico, and it had very expensive.
- [06:11]
Mr. Ballin
Health care, most expensive community for health care for Medicare per person in the United States.
- [06:20]
Atul Gawande
And this is a very poor county, too, right?
- [06:23]
Mr. Ballin
That's right. I compared it to El Paso, Texas, that also is a poor county and also a border community and had half of the cost per person for healthcare with better outcomes. You're talking about, like in McAllen at that time, it was two to three times the number of cardiac catheterizations, ultrasounds, and other kinds of tests and procedures. I went there to talk to the doctors in the community to understand why. What's the difference? What's. What's happening here?
- [06:59]
Atul Gawande
And El Paso did it not unlike the Mayo Clinic. Well, in. In terms of the way they. They've charged, yes.
- [07:11]
Mr. Ballin
I mean, the. I brought places like the Mayo Clinic or Kaiser Permanente and others into the picture because they had approaches to try to control overuse unnecessary care, which was, I found. And people in the community in McAllen reported to me, you know, there was a vast business that had really developed in health care, and the business incentives had overcome the professional incentives.
- [07:42]
Atul Gawande
So this is like a corporate healthcare model.
- [07:46]
Mr. Ballin
Yes. And you, you know, had active management, scooping up people to get home health care that was unnecessary or other kinds of care. And there were many in the community, clinicians, physicians, nurses, who saw that it was happening and were extremely concerned about it. And, you know, I pointed to other places. So El Paso just didn't have as gung ho a business community driven around driving up use. I think in some ways I'm, you know, my concerns is that I don't think this issue has gotten any better. If anything, many health systems and organizations have gotten better at extracting money from people and their insurance coverage. McAllen, five years later, had the arrival of primary care clinics and systems that actually dramatically lowered the cost. And there were some prosecutions in McAllen. And so McAllen, you know, moved out of being an outlier where it was for a decade or more to moving closer to El Paso.
- [08:53]
Atul Gawande
Did you feel that your article had any effect over the debate in the Affordable Care Act?
- [08:59]
Mr. Ballin
It was striking to me. The. So it was an experience like I've never had President Obama at that time read it. They were formulating the Affordable Care Act.
- [09:12]
Atul Gawande
I had just gotten there, I think. I think he wrote this in, like, June or something like that, or. It was in the June issue, and I got there in July.
- [09:21]
Mr. Ballin
Yeah, it was early in that year, the first half of the year. And what was recognized was it wasn't going to be enough just to finance health care, that you needed to have approaches that brought prices, as well as overuse under control or inappropriate use under control. And the creation of the center for Medicare and Medicaid innovation really came out of that effort to reward places for arriving at better outcomes of care per dollar. That still is a. Is the holy grail, finding ways to do that. There's lots I learned at USAID that I thought was really powerful about the ways that that can be done. But in the decades since then, it's been more than a decade, decade and a half. Healthcare was going straight up as a percentage of GDP, and it's been paused around 18% of GDP instead of, you know, it had gone up by almost a third to a half percent of the entire economy of the United States, you know, every year or two, and had progressed. I remember under Bill Clinton in the early 90s, it was 12%. It became 18%, was projected to get to 20% within a few years back in 2009, 2010. And I do think we've seen some changes that have moderated that. And so it has not grown as a percentage of the economy now. We could get so much more out of that kind of spending.
- [10:55]
Atul Gawande
Well, it's still amazing that we're the only developed country without universal healthcare.
- [11:03]
Mr. Ballin
Yes. And even the Affordable Care act approach that we have, we still have. The average worker has a $2,500 deductible or more in the country in order to have coverage. So even those who have coverage still are often left feeling that they're not able to afford basics.
- [11:23]
Atul Gawande
That's maybe one of the reasons why the Affordable Care act wasn't popular politically until Trump tried to replace it. And then that bill was terrible. A lot of people would have lost their health care. And they didn't even necessarily. States could actually opt out of saying that the insurance had to cover everything.
- [11:46]
Mr. Ballin
Yeah. There have been multiple bites at the apple of repealing the Affordable Care act.
- [11:53]
Atul Gawande
That was in 17. They tried. But for John McCain, they would have passed one.
- [12:02]
Mr. Ballin
That's right. You know, once implemented, here's a basic right. My son has a congenital heart condition and getting a preexisting condition, that would have made him unqualified for health care. On the free market, you know, as we constituted it, the Affordable Care act got rid of pre existing condition exclusions in order to access insurance.
- [12:31]
Atul Gawande
Right. So because of the Affordable Care act, he can go on the market.
- [12:35]
Mr. Ballin
That's right. And could access. But it's a different market. Right. You can buy it through healthcare.gov and get coverage or through an employer. And that's a really important thing. That huge numbers of people, anybody with diabetes, anybody with high blood pressure, anybody with any major condition, simply couldn't get coverage. And we don't have those horror stories anymore. And people are unwilling to give that up for good reason.
- [13:04]
Atul Gawande
And that was huge.
- [13:05]
Mr. Ballin
Huge, Absolutely huge. And people appreciate having the kind of coverage that we have. What we don't have good access to is basic primary care. You know, having a regular touch point with a clinician that, you know, where you don't have a massive deductible to pay in order to come in because you have a cough or a fever.
- [13:29]
Atul Gawande
How many Americans don't have that?
- [13:32]
Mr. Ballin
It's estimated around half of Americans.
- [13:35]
Atul Gawande
Jesus.
- [13:36]
Mr. Ballin
Do not have regular access to a primary healthcare specialist and are obtaining care in very fragmented ways. And that means you're being left out of all of the benefits of a consistent relationship with a clinician, which include chronic illness management control. You know, we'll get to the USAID part, but I was in a number of countries that have graduated from foreign assistance where we had assisted them to. To build their own health coverage systems. And some of them chose. They choose what they want to choose, but some of them chose to start with, because when you don't have enough money, you have to make choices instead of starting with covering hospital care first, which is the thing that bankrupts people. Right. So there's a logic to saying I want to cover the hospital costs first. Instead, they started by saying, we're going to assure universal coverage to primary care, your first point of contact for your care, and making essential medicines like insulin and high blood pressure medicines and even HIV medicines that are essential for prevention and chronic illness management made them free. And the result is Costa Rica progressed to having not only independence of needing foreign assistance, but ended up with the longest life expect among the longest in the entire Americas.
- [15:01]
Atul Gawande
In Latin America.
- [15:02]
Mr. Ballin
Yeah, in Latin America, north and South America, not just Latin America that they are, they outpace the United States on a sixth of our spending per person. I was in Thailand, where they went from having a third of their deaths in any given year occurring in people under the age of 50 in the space of about 20 years advancing to the point that they now nearly match US Life expectancy, have universal primary care, universal dental care on $300 per person per year. Now their specialized care and access to, you know, the most advanced cancer care and so on is not what we would expect here. But they are getting longer life expectancy through simply being healthy, having healthier options and easier access to primary care in the front door for very low amounts of money. And those are things that are still the steps. You know, we're not talking about this enough. Right. We're in the middle of culture wars and battles over our, over democracy.
- [16:11]
Atul Gawande
Yeah. It's just even talking about this right now feels like we haven't had this conversation at all in years. I mean, that's right. When Trump tried to memory when it failed, he said, who knew health care was so complicated.
- [16:30]
Mr. Ballin
That's right. And one of the most important things like you do polls. And what did people say coming out of the last election? That it's pocketbook issues and that nobody's paying attention to the two things that make it impossible to live a middle class life on a non college education and that is housing and health care. And the core issues on health care are the massive deductibles and coinsurance. For three years I was with worked with Amazon, Berkshire Hathaway and J.P. morgan. And one of the things we did around health care was I was interested because they had a low wage population, you know, lots of people who were, you know, making $20 or so an hour in warehouses or data centers or carpet factories, et cetera. And we designed a plan that got rid of the deductible, got rid of the coinsurance on primary care. Instead, primary care was just a copay, $15, 60 drugs free. Paid for it by saying, okay, the ambulance ride for a hospital is going to be $500, $1,000 for admission to a hospital. But your basic everyday care is prioritized. And that became the most popular plan in these companies. And as one worker said, he told me, I never wanted to go into a doctor's office because I felt like I was getting in a train where I didn't know the destination and I didn't know what it was going to cost me. And I was terrified of ever going in there. And this allowed them to be able to say, okay, I know, at least I don't know where the destination goes. But I'm not afraid of it, right, Because I know I can come in the door and afford what it might be require.
- [18:13]
Atul Gawande
Just one more question. I guess And I want to get into usaid. How did Medicaid expansion affect things? It seemed like it was very popular, especially in these red states who came to it late.
- [18:30]
Mr. Ballin
Medicaid expansion was crucial to the success of the Affordable Care Act. It became a benefit that was not just to people below the poverty line, but people up to, up to four times the poverty line, which still didn't quite reach the middle class, but reached a large portion of the low wage workforce and not everybody, but it meant a world where having access to Medicaid is a system without a copay, without a deductible, without coinsurance, without a premium and has been incredibly popular for that reason. It's a state based single payer system, sustained rural hospitals, sustained communities and people across the country who could never have enough money for the high deductible plans that are out there. And it has saved lives. So you know, the, the Medicaid expansion has been demonstrated now in multiple studies, have substantially reduced to have significantly reduced mortality, to have reduced depression and improved financial outcomes for people at the bottom end of the income scale. Health care is one of the most important and powerful things you can do to improve people's not only survival, but their quality of life and their ability to live closer to a middle class life.
- [19:57]
Atul Gawande
Okay, let's move on to your service during the Biden administration In November of 2020, President Biden asked you to be on the COVID 19 Advisory Board. When was the vaccine approved? It was just right after the election.
- [20:15]
Mr. Ballin
I think the vaccine was approved. The results came out right around just after the election. That's right. And very rapidly, starting in December started rolling out in the elderly populations and the high risk folks like healthcare workers as well. First responders. In those first couple of months, how.
- [20:34]
Atul Gawande
Many people did you get the vaccination into in your time there or in the first year? Biden wasn't president yet when you joined.
- [20:43]
Mr. Ballin
That's right. So Biden was inaugurated January 2021. I was offered the opportunity to lead global health at USAID in April and the rest of the year I spent in confirmation with. Well, Marco Rubio had opposed me, accusing me of being an abortion. Not just an abortion advocate, an infanticide advocate. That's what he tried to portray.
- [21:10]
Atul Gawande
So you believe that even babies that are just born.
- [21:17]
Mr. Ballin
That's right. Infants should be put to death, was the claim. And despite there being nothing whatsoever that could suggest that that was the case, eventually I got through in December of 2022. So when I took the job, the, the president had gotten through the American Rescue plan, which paid for vaccination across the United States and also donate donated vaccines to the world. Up to a billion vaccines. You know, when I was asked about the job, there was going to be $19 billion that I could allocate and drive out into the world. And instead I arrived there and that had been spent. But the job was then, now get these distributed and distributing 700 million vaccines supporting countries to get them into arms everywhere from the archipelago, the islands of Indonesia to, to the Sahara desert was what I got to oversee and work with a whole lot of people do at USAID along with cdc, DOD and others. And it was, I mean, it was like nothing you've ever seen bringing these vaccinations to the world. And so many people did it to get it here in the United States.
- [22:38]
Atul Gawande
So when did you join USAID?
- [22:40]
Mr. Ballin
So I was sworn in at the beginning of January 2022.
- [22:45]
Atul Gawande
Okay, so that's hence three years.
- [22:47]
Mr. Ballin
Yes, right. I was there three years until the transition.
- [22:51]
Atul Gawande
I think your title was assistant Administrator for the Bureau of Global Health for usaid.
- [22:58]
Mr. Ballin
Correct. Basically I got to oversee our global health work. I had 2,500 people, about 900 in Washington and 1600 in 65 countries around the world. Had the budget of about half of my hospital system in, in Boston.
- [23:16]
Atul Gawande
Wow.
- [23:17]
Mr. Ballin
We reached hundreds of millions of people and saved lives by the millions. And it was, it's the best job in medicine that no one.
- [23:26]
Atul Gawande
It's kind of a dream job for you.
- [23:28]
Mr. Ballin
It is. The scale is like nothing conceivable and the opportunity for impact. This was 20 million people with HIV and ensuring they get life saving medications, stopping malaria, trying to eradicate polio.
- [23:46]
Atul Gawande
What was the range of stuff the USAID did?
- [23:49]
Mr. Ballin
Yeah, so the core of the work is reducing premature deaths, which I measured by tracking that. The measure of that was reducing deaths before 50. The percentage of deaths in any country before 50 was goal one. And goal two was stopping deadly diseases around the world that could threaten the US and the world. And you know, so a place like Ukraine. Ukraine was February 24th of 2022, a few weeks after I was sworn in. I expected the COVID job. I did not expect that I'd be on the border in Zizhiv, Poland to oversee plans around how we were going to help keep the health system alive. And in Ukraine, Russia cut off its access to medicines. So pharmacies for the entire country lost access to medicines. Most of them were shuttered. In the initial week of attacks, hospital systems were under attack, not just with Bombs, but also cyber attacks had taken down the electronic systems of the hospitals and they bombed the oxygen supplies, the factories that made oxygen.
- [25:03]
Atul Gawande
They bombed the oxygen.
- [25:04]
Mr. Ballin
They bombed the oxygen, yeah. And that's when I learned what this agency was capable of. 40 people on the global health team scrambling to safety and within a week they're working with the government and had been able to support them to move the entire country's electronic health record system to a cloud based system that was cyber protected against attacks, able to get a supply chain up and running. More people would die if there was lack of access to medicines than any bombs would kill get. There were 250,000 HIV patients, a million heart patients, and they were able to fashion a supply chain that was served by now 5000 humanitarian aid organizations as well as private sector partners and get medicines to a warehouse in Jijif that could get across the border to l'viv that could get through citizen transporters putting boxes in the back of their pickup trucks and trunks of their cars and moving them to nodes around the country. And they got 50% of the pharmacies open nodes in that first month. Wow, two months. Got 80% of them open. And wow, the supply for every HIV and TB patient in the country for the next six months. I mean it was, it, was it that capability? USAID is the largest civilian ground force America has for doing work in our mutual interests and for the development of the countries that we are partnered with. And that, you know, what they call soft power is just simply being able to get stuff done that our goals from stopping HIV to keeping the energy program, you know, energy supplies going in Ukraine.
- [26:58]
Atul Gawande
So more than just healthcare?
- [27:01]
Mr. Ballin
Yeah, far more than healthcare. The biggest component of USAID is the Bureau of Humanitarian Assistance, which is basically the Fema of the US's FEMA for disaster around the world and global health, those are the two largest and they're somewhere around a little over half, I think of the budget. But then you also have programs around agriculture. This is the agency that helped move countries like India from being chronically famine and food aid dependent to being an agricultural exporter.
- [27:37]
Atul Gawande
And how did USAID do that?
- [27:40]
Mr. Ballin
Trained thousands of agronomists in India, helped bring the technical know how of the green revolution and support and loans that could help farmers get, you know, the investments needed to make that go well. In fact, that's the kind of thing we did so that, you know, the majority of our trade partners, our top 20 trade partners, are ones that once received USAID assistance that help them achieve economic development often it could be agriculture and food based, but it also goes to developing democratic institutions and financial institutions that can allow them to grow into prosperity.
- [28:21]
Atul Gawande
Sounds like a criminal enterprise to me.
- [28:23]
Mr. Ballin
Exactly. Time to feed it into the wood chipper.
- [28:28]
Atul Gawande
That's Elon Musk you're quoting. And you too. The woodchipper part.
- [28:35]
Al Franken
Okay, we're gonna take a quick break. We'll be right back with the tool. Gamaandi.
- [28:43]
Unknown
Some people get a wild haircut or book a spontaneous trip when life throws them a curveball. But Molly, well, she dove headfirst into a world of no strings attached sex, secret rendezvous, forbidden affairs and unforgettable adventures. And together, we tell every juicy detail in Dying for Sex, Wondry's award winning podcast that's now streaming on a TV near you, starring Michelle Williams and Jenny Slate. And to top it off, we're dropping brand new bonus episodes where I sit down with the cast to spill all the spicy secrets, desire, friendship, self discovery, and the ultimate bucket list of pleasure. This is a story that had everyone talking. Listen to the original Dying for Sex and brand new episodes on the Wondery app or wherever you get your podcasts. You can binge the original series before anyone else and completely ad free on Wondri.
- [29:42]
Atul Gawande
So you turn in your resignation and how long did it take Musk and Trump to attack usaid?
- [29:53]
Mr. Ballin
It took about four days. The initial move there was an executive order that pulled the United States out of who. And it had a wrinkle because the normal part of pulling, in order to pull out of the World Health Organization Congress had stipulated that it needed to be a one year process, a kind of waiting period before you could do it. And so Trump had added on that all funding immediately stopped. That goes to who, even any support for active emergencies that were underway, including an Ebola outbreak in Uganda at that time, a MPOX outbreak killing children in the Congo.
- [30:33]
Atul Gawande
What is that disease?
- [30:35]
Mr. Ballin
Mpox, what used to be called monkeypox but got renamed since it doesn't actually come from monkeys.
- [30:43]
Atul Gawande
Okay.
- [30:45]
Mr. Ballin
And so the WHO pullout seemed alarming enough in and of itself, right? Trying to wreck an institution that eradicated smallpox in the world and is on the verge of eradicating polio. But then he also had included what sounded like a kind of not an abnormal order that said foreign assistance, new disbursements and contracts and foreign assistance were ordered to be stopped. And that's not totally unusual that you say, I'm not going to make any new commitments until we've reviewed policy. And that. But then Marco Rubio who just got sworn in that week as Secretary of State, put out an order on Friday the 24th that was a stop work order that said not only are there no more, no new contracts or commitments, but the existing payments and commitments needed to stop immediately didn't matter if the medicines were on the shelf or the food for starving children are on the shelf.
- [31:52]
Atul Gawande
Now, is your suspicion that that order came from Trump and Musk or that Rubio had this.
- [32:01]
Mr. Ballin
To this day? I mean, Rubio signed it. To this day I'm uncertain because he seemed genuinely shocked by the consequences of it. And the pattern has been across the government that Doge Elon Musk has been the driver of taking the chainsaw to entire agencies. And this is in line with that.
- [32:26]
Atul Gawande
Well, let's talk about the consequences that he was shocked about. How many did in those three years that you were at usaid, how many lives did USAID save?
- [32:39]
Mr. Ballin
So we actually quantified that during my time there, the countries where we worked had at least 1.2 million lives saved from work associated with work that we were doing. In addition, there was a vaccine campaign and set of work underway that was in the midst of expanding, reducing measles and addressing HPV. For every 70 girls in low income countries who are vaccinated against cervical cancer from hpv, one life is saved. It's one of the most life saving things in our portfolio. That's hpv. So it's human papillomavirus. So there's a bunch of vaccine programs we had that would have saved an additional 8 million lives over the next five years. So massive impact underway. 20 million people with HIV on medications supplied by the United States. And all of it suddenly was suspended and paused, making it sound very benign, like it just, you know, hold on just a minute. But this is like stopping a plane in mid flight for a pause, as would happen. They purged the staff. So you're firing the crew and then expecting not to have a catastrophe.
- [34:03]
Atul Gawande
How many people worked in USAID?
- [34:05]
Mr. Ballin
So if, when you include the contract workers, about 13,000 people, most of them working abroad. You know, it started with 58 people in the top leadership who were initially purged in the first week. Then terminations of the contract workers, which were several thousand people. Half of the Global Health Bureau disappeared in that first two weeks and then ended with two weeks ago. Now a final termination of virtually every single person left in the agency.
- [34:41]
Atul Gawande
And what happens to those people? They're overseas, they're in, they're serving in third world countries. In many cases, in the beginning, it.
- [34:51]
Mr. Ballin
Was extremely chaotic because many of them were immediately put onto administrative leave or terminated and they did not have access to. They didn't have plans for how to return home. You had people with medical issues not being addressed.
- [35:06]
Atul Gawande
Well, you shouldn't feel sorry for them because there are people involved in a criminal enterprise.
- [35:11]
Mr. Ballin
Right. You know, as one of them said to me, you know, she said, I don't. My kids are in school. I have no understanding of my pulling them out of school. I have no understanding of what my future will be. She said, my country is attacking me. It's frightening inside usaid, we should be ashamed of ourselves. Our system of checks and balances have been broken in some countries. They were doing work upholding human rights, addressing, challenging corruption, and now were being faced with genuine attacks, and it was terrible. Now, the plan, Scott, over time, they learned a little bit and got the plan so that they now have an exit path of they're leaving by July 1 or September 1 and are being sent home and fired. It is slightly more humane than it was, but it's also illegal. This is a agency constituted in law by Congress and it's going through the court processes, but it's already dismantled to a point that it's not going back to the way it was before.
- [36:31]
Atul Gawande
Now, I think you said that your budget was half that of your hospitals.
- [36:36]
Mr. Ballin
That's right. Half of my hospital systems.
- [36:38]
Atul Gawande
Okay, So a lot of people think that the United States spends incredible amount on foreign aid.
- [36:48]
Mr. Ballin
That's right.
- [36:49]
Atul Gawande
In terms of a percent of the budget, what are we talking about?
- [36:54]
Mr. Ballin
Here's the better way to express it. So it's like 0.35%, but that doesn't help you. Right. So the average American has $14,600 in taxes in 2024. The amount that went to USAID is under $50. And when you think of what we get for that, you get control of an HIV epidemic that is at minuscule levels compared to what it was before we had control of measles, where we've had for going on two decades, elimination of measles in the country. Only we're now seeing outbreaks that have reached so far 20 states. And now three deaths, three now three total deaths. Now two children.
- [37:46]
Atul Gawande
At first, Bobby Kennedy, Robert Kennedy Jr. Wouldn't say, you gotta get vaccinated. He finally has. I think he went to service or a funeral for one of the children who died in Texas and said, get vaccinated. But that took him a while.
- [38:06]
Mr. Ballin
And we're all fixated on whether he says it or not, here's what would have happened. What would have happened when I was there three months ago would have happened in any administration. You would have all of the different agencies meeting on a weekly basis. You'd have the Secretary of Health and Human Services meeting with the public health directors of the states on a weekly basis and coordinating a response. That got vaccination rates up in vulnerable communities and, you know, got the messaging across, taught everybody repeatedly and offered the chance for vaccination to children who are at severe risk. You know, this is primarily in communities that are below 90% vaccination. Some of these communities, often religious communities, are, you know, in the. In the 20% range of vaccination and. And working with local clerics, working with communities. You can get these vaccinations up. This is what we did. At the beginning of the Biden administration. There was a polio outbreak in Rockland County, New York, in a Orthodox Jewish community that was very set against vaccination. But with patient and concerted work coordinating across the US Government repeatedly. You know, it wasn't just what somebody said once or twice at a funeral, right? They were able to bring support that got vaccination happening and stopped the polio outbreak. That is not what's happening now. And that's the. The alarming thing is that the normal functions have been decimated and the leadership is not taking the actions that could stop this. And we could lose our malaria elimination status. Which means that to go into countries with that, if we lose that status, then to travel into places that don't have measles anymore, if we lose our status, then travel becomes an issue for people.
- [40:10]
Atul Gawande
So it feels. I've known you for a while, and you seem. I'm getting a different affect from you than normally. Normally, you're pretty upbeat, and this must have been. Just knocked the stuffings out of you.
- [40:31]
Mr. Ballin
Yeah, I would say so. Look, this is an enormous. This is a massive loss of life that is already underway. I have a daily conversation with people in countries around the world where they're saying to me, you know, just. Just from a conversation yesterday, that they have a community health worker who has been working in a community where US assistance has meant that HIV has been under control. One person who had HIV had. Had it for 10 years and has been under control, got TB and was able to get the TB treated, but lost access to the medicines. With the. With the suspension of aid, the HIV surged again in him, meaning he could transmit as well. But that took, you know, that killed his immune system. The TB overtook him and he was gone just like that.
- [41:39]
Atul Gawande
And there's no, there's no, gee, if I could talk to Rubio, gee, if I could only talk to Musk. Or. I mean, there's. That's stupid.
- [41:54]
Mr. Ballin
I'm saying there's no sense that anybody has really taken seriously the fact that there are hundreds of thousands of deaths that we are projected to be facing in the course of the next year. That there have been for three months, total cessation of malaria programs as we're going into malaria season. TB back surging, the biggest infectious disease killer setbacks in measles around the world. Measles were back. We were already back up. Over 100,000 child deaths a year globally and looking at that to increase. And they're defunding core programs where the US has led the way in bringing many countries around the world to increase vaccination, support vaccination to happen everywhere, lower costs, and enable countries to stand up their health systems to get better results. The alarming thing is the gleeful indifference to the loss of life and mismanagement of billions of dollars of funds.
- [43:04]
Atul Gawande
The gleeful indifference.
- [43:07]
Mr. Ballin
Yeah, gleeful joy in smashing the system down and destroying the careers of people in the process as well.
- [43:24]
Atul Gawande
Let me ask you about Harvard and the administration going after a lot of funding at Harvard. I think they're talking about cutting, because of anti Semitism at Harvard, cutting up to $9 billion in funding. That's a lot of money and that's research, right?
- [43:56]
Mr. Ballin
Yeah. So I can't speak for the university, I'm not a spokesman for the university, but I will say that the pattern has been that it was $400 million in grants at Columbia, 800 million at Johns Hopkins, 9 billion at Harvard. And they are attacking the universities for what? On sort of trumped up charges. But it's in order to punish these universities and try to severely damage them. The funding is predominantly research funding. It's cancer awards, it's Alzheimer's disease, it's maternal mortality work. It's across the board. It has no connection to what the claims are. And more to the point, it's part and parcel of a project I actually see as very connected to what's happening at usaid. The, the playbook at USAID was finding out the systems that you could use to terminate contracts, purge staff, tear down programs, offices, remove buildings, etc. That's been then applied now at NIH, at CDC, at FDA and to universities. And it is putting into place political controls over what were otherwise independent agencies. That were deliberately protected when they made choices like what kinds of research to recommend, what kinds of FDA approvals would be had after the research generated drugs and devices and solutions. And then the guidance that CDC sends out and then the deployment that Medicare, Medicaid, USAID have for the United States and abroad and that whole system, that infrastructure of health and science that added 30 years to Americans lives and the world's is under severe attack right now. It's not just losing a generation of scientists. It is abandoning a critical engine of our prosperity since World War II. Well, so it's hard to be upbeat.
- [46:23]
Atul Gawande
I, I hear you. I hear you. But there's gallows humor, I suppose. There's always that.
- [46:31]
Mr. Ballin
There is always that.
- [46:32]
Atul Gawande
Yeah. Thank you, Atul.
- [46:37]
Mr. Ballin
Thank you. It's great to get to talk to you.
- [46:40]
Atul Gawande
Great to talk to you, man.
- [46:42]
Al Franken
Well, I hope you enjoyed listening. That beautiful music is by Leo Kotke, the great Leo Kottke. I want to thank Peter Ogburn for producing this podcast. We'll talk again next week.
- [47:09]
Mr. Ballin
If you like the Al Franken podcast, you can listen to all episodes ad free right now by joining Wondery in the Wondery app or on Apple Podcasts. Prime members can listen ad free on Amazon Music. Before you go, tell us about yourself by filling out a short survey@wondery.com survey.