Atul Gawande is an American surgeon, writer, and public health researcher.
In this week’s conversation, Yascha Mounk and Atul Gawande discuss how simple checklists can boost survival rates in the operating theater, what it means to have quality of life, and our complicated relationship with mortality.
This transcript has been condensed and lightly edited for clarity.
Yascha Mounk: I am delighted that you are on. I have been reading you for a long time in your books and in The New Yorker and elsewhere. One of the things you have done for the American public is to take people inside what can seem like a black box: the medical profession, the way hospitals work, to show what determines when something goes well, when something goes badly, and how some of these things function. Before we get into the details of this, what motivated you to do that?
Atul Gawande: Well, it is hard for me to put my finger on it. I had come to medical school after having served on the Hill doing health policy. I had a stint doing that. I grew up in rural Ohio, the son of two immigrant Indian doctors for a rural community. My sister and I were the children of two doctors who were very active in being part of the community. I always grew up seeing medicine not just through the lens of the clinician but also through the lens of my parents knowing everybody they took care of in a local community. You see medicine through the community. I came to practicing medicine out of trying to see it as a citizen. When you are working on the Hill, you are thinking about it from the perspective of taxpayers and everybody else.
One more thing made a difference, which is that on the fifth day of July of my residency, my son was born and had a cardiac issue that kept him in the hospital for a month. I was physically going back and forth between being a brand new intern trying to convince people to let me join their operation to learn on them, to being on the other side as a dad with a child with a serious congenital heart defect that would require surgery and needing to navigate it from that point of view. By the time I got the opportunity to be writing about these things, I had already absorbed the idea of needing to see it from many perspectives and not accepting that it would be okay to pretend we are infallible, that everything is, leave it to us, the experts. That was changing in the modern world anyway.
Mounk: One of the things that I appreciate about those early books is that there are two rather different views of medicine, both of which are one dimensional. One is of medicine as a perfect exact science. We have the rules to apply, doctors are omniscient, and they have understood capital S science. Any questioning of them, any uncertainty, any room for ambiguity does not exist. There is also a view on the other side, which is that this is a complete art, and we should trust doctors as the most skilled craftsmen who have engaged in this profession for a long time. Their judgment is superior not because there is one clear way of doing it but because they have superior experience, knowledge, and virtue, and therefore we should defer to them.
It seems to me that you are articulating something subtle in the middle between those extremes, because you emphasize how much uncertainty and ambiguity there is. In something like The Checklist Manifesto, you also say this view where doctors are consummate professionals and it is their judgment and the practice of this craft that is superior is also wrong. In some circumstances, we should be given strict guidelines and told that even if you have done this operation a hundred times, you have to tick each checkbox off. Tell us a little about where this in-between space lies.
Gawande: You hit the nail on the head. I would characterize it as the view of doctors as heroes, which has the two extremes you describe, as craftsmen and as scientists knowing everything. There is also the view of doctors as villains, or the whole business of medicine as corrupt. There was then my experience of being a young surgery resident trying to navigate how I learn to do this thing, its complexities, and the way things go wrong. One of my first articles for The New Yorker was about making a terrible mistake that nearly killed a patient.
We had a study that I got to be part of that encapsulated this for me. We looked at 15,000 patients admitted to hospitals in two states, Utah and Colorado, and asked the question: when people have a bad outcome, when they die or leave the hospital with a serious disability, is that because the knowledge exists and we failed to apply it correctly, or is it because we are ignorant of the knowledge? What was striking was that two-thirds of the time the knowledge existed and we failed to apply it correctly.
That struck me as an incredible generational transformation. For millennia, human beings did not understand what was happening in our bodies, what the diseases and conditions were, let alone what to do about them. As early as the 1950s, we mostly did not have solutions for most problems. By the time I was in training, we had solutions but were not executing on them correctly. That can inspire outrage, malpractice lawsuits, regulations. Much of the way medicine dealt with it was by training you more and more, as if you could jam all of this into your head and know everything and be omniscient.
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What was clear is that other industries dealing with high risk were adopting systems that made it easier for people to do the right thing and harder to do the wrong thing. We had not embraced that. My book The Checklist Manifesto was about navigating coming out of residency and starting to create basic systems that became a checklist in the operating room. It was not a checklist of nineteen steps for every operation. It was nineteen things in every operation the team needs to communicate about to make sure you are prepared for whatever comes, to recognize the special issues of this patient, the goals we have that day, and work together as a better team. That is recognizing that the system is all of us coming together.
It cut the death rate 47% in eight cities in our original study and ultimately scaled around the world.
Mounk: Tell us about the actual differences in that approach. You are right that being trained more and more to do the same thing is not going to accomplish perfect results. I spent much of my life writing for many years, and every now and again I still stupidly misspell a word. We are all going to screw up even at things at which we are very skilled.
At the same time, a lot of the abilities of a skilled surgeon come from facing a patient with a condition that is slightly different from anything they have done before. They may discover a complication in the process of surgery that they did not expect. If you had what the title implies, a rigid checklist where it is step one, step two, step three, that is the fast path to failure. That sounds a little like the technology we had before Google Maps, which was MapQuest. It was great if you followed all nineteen instructions, but if you missed one turn, you were suddenly without a plan.
What does it look like to have a system that avoids these avoidable errors without giving you the kind of rigidity where one complication that was not anticipated leaves you lost?
Gawande: Well, on this nineteen-item checklist, there are three pause points. You pause right before the patient is put to sleep, right before the incision, and then right before you leave the room. At each step there are what I have sometimes called dumb checks. Do you have the correct patient? Are you operating on the right side of the body? Did you give an antibiotic, if you are giving an antibiotic, in the sixty-minute window when it works maximally? If you have fluid that is needed or blood, is it available in the room? Those are the very rote, just-do-it items.
Most of the power of it comes from the additional steps that the people in the room take to communicate, which you would think happen every time but do not. Most teams come together at the beginning of the day and they are entirely new. There is someone new on the team, it is an assembled team. You start by asking people to say their names and their roles. You go around and do that. It does a couple of things. The most important thing is that it activates you to have heard your name in the room. Like in a meeting, it gives you permission to speak again so that when you have a concern later, you feel you have the voice to raise it.
Another part is that you discuss the plan and the person on the table. What are the key issues for this person? What equipment is required, and is it ready? Does anybody have any concerns, including the patient? Then again, before you leave the room, what is the plan for the next twenty-four hours? Do we agree on it? Do we have our next action steps?
Mounk: Just to understand before that, it may have been the case that the surgeon themselves had an idea of this. They know what operation they are doing, et cetera, but perhaps other members of the team did not, and therefore they were not paying attention to warning signs of something going wrong. Tell us about how it has changed from what was the case before and what this kind of meeting accomplishes.
Gawande: When we designed it with the World Health Organization, we were tackling how to reduce complications in surgical care. We brought a Boeing safety engineer in. In cockpits, in airline crashes, failures of communication often occur because someone does not speak up who has information that should be known, or doubts or concerns, or is seeing things that are not seen. The surgeon may have a plan in their head, but the anesthesiologist may know more about the medical issues of the patient that you should be aware of. They were on a blood thinner that was stopped a day ago. They have a history of XYZ conditions that you need to be reminded of, which might not be foremost in the surgeon’s head or the nurse’s head or others. The nursing team may know about issues the patient may be having. They have a bad back today. They told me about XYZ. Everybody has a piece of a puzzle for making it come out with a better outcome, and they are not voicing it, they are not bringing it forward.
Mounk: I am going to ask a question that seems out of left field, but that you are practically forcing, at least for anybody who has watched the latest season of The Rehearsal with Nathan Fielder, in which he goes to elaborate lengths to suggest that what is at issue in many plane crashes is that the co-pilot is too intimidated to raise concerns about the pilot’s course of action. The way you are talking makes it sound as if that is a plausible theory, at least as it applies to medicine, that often there is somebody in the room who knows something that would be able to avoid those complications. Perhaps part of what is going on is a power dynamic in which, if you do not feel empowered to speak up, you keep that concern to yourself in a way that has adverse consequences.
Gawande: This is probably the hardest part about implementing the checklist. It was a change in the culture of the operating room because the highest value of the operating room used to be the autonomy of the surgeon. The surgeon was the fighter pilot who decided everything that happened. You call it an operating theater in many countries. It is the stage onto which the surgeon steps and everybody is expected to be working for the surgeon. When in fact, what we needed to do was move away from the fighter pilot and more toward the pit crew. We are all here in service of a goal together. All of our voices matter. We all have something to contribute and to say.
One of the key measures of whether the checklist is being used well is whether you hear everybody’s voice speak up to convey at critical moments, in those pause points, what the concerns and needs are and what you understand the situation to be. We have shown, as we deployed it in South Carolina for example, that every percentage increase, every one-point increase on a five-point scale in the level of teamwork, respect, and willingness to speak up translates to another reduction in mortality.
Moun: So in other words, Dr. House is a terrible guide to how to practice good medicine. What are the cultural reservations you encountered here? One of them presumably is some of your esteemed colleagues saying, no, I am the fighter pilot. I am the most important person in the room, and I do not want to hear the nurse speaking up. Another one that I have in my mind is perhaps about the status of a doctor as the kind of craftsman who really knows best and should not be constrained by artificial scaffolding like the checklist. I know this because I have a friend who is a French doctor who wanted to get The Checklist Manifesto translated into French, and he has very good English. He wanted to do this.
I don’t know if the book now has a French edition or not; this was perhaps ten years ago. However, he had great difficulty getting it published because the response from many French doctors was, we know what we are doing. Why on earth do we have to follow a checklist? This seems like a terrible American mechanistic view of the world. It does not comport with how we think about practicing medicine.
Gawande: It is an interesting cultural phenomenon, not between France and the United States but among surgeons themselves. We surveyed surgeons, and the broad response was that 70 to 80 percent would accept the checklist, but 20 to 30 percent thought it was a waste of time. They believed they did not need it, that it did not matter, and that it was merely another layer of bureaucracy.
However, when asked, if you were having an operation, would you want the surgeon to use the checklist? 94 percent said yes. Surgeons, like everyone else, have a Lake Wobegon effect: we all believe we are above average. You would not become a surgeon if you did not have confidence in yourself.
The difference between a 1 percent mortality rate—typical for inpatient surgery—and reducing that rate by half, as the studies show, is a reduction of half a percentage point. In other words, you go from 1 percent to 0.5 percent. You cannot feel that difference day to day. You cannot feel the difference between performing with a 1 percent error rate and a 0.5 percent error rate. Over time, however, virtually everyone ends up having a serious error that is caught by the checklist, and that experience is what makes surgeons believers.
The challenge is in getting people to try it, believe in it, and avoid turning it into a mere paper-documentation exercise. It is also crucial because checklists can easily become captured by bureaucracy. I have seen places where a 19-item checklist becomes an 80-item checklist, imposed from above with steps that make it harder to think, harder to engage your brain, and harder to operate effectively. This is why the people in the operating room must be part of designing the checklist.
Mounk: I think this is a really interesting point: we are, in general, very good and highly professionalized at these operations. It is incredible that we are at a time when ninety-nine out of one hundred times we undertake these complicated medical procedures, the patient ends up being safe. However, as a result, the difference between a lousy surgeon and a great surgeon is not the ninety-nine out of one hundred cases; it is the one edge case.
How do you perform when you are objectively very good at this? Ninety-nine out of one hundred times you fix some medical problem and the patient walks out of the operating room—perhaps not that very moment—alive and hopefully well. But you could actually do better. How do you get yourself to that higher level of performance beyond simply avoiding errors through something like a checklist?
I know you have written, for example, about yourself—when you were a very distinguished surgeon with a very good record—using a coach in order to get better at what you were doing. What is the lesson from that for people within and outside the medical field?
Gawande: First of all, the error rate—or rather the complication rate, not even the error rate—will be higher than one percent. We were talking about the death rate. Some of our operations might have twenty or thirty percent complication rates, and you also have, around that, a wide distribution: some people will have two- or three-times-lower rates of complications than others.
The checklist helps lift the bottom end of performance, but I became very interested in coaching after trying to understand how we train in some professions and not in others. I remember going—since I am a tennis player—and paying a former college player a hundred dollars for an hour to go over my serve.
I realized that in the culture of sports, the number one player in the world—Carlos Alcaraz or Jannik Sinner—has coaches at every step along the way. By contrast, most professions do not.
Mounk: A tennis player at the top of the game is not going to say, I’m a consummate professional, I’m at the top of my game, why on earth do I need somebody to give me advice? By contrast, that is an instinct many people in other professions are likely to have.
Gawande: Most professions—surgeons, lawyers, musicians—do not have coaches. They gain their years of practice and experience, their 10,000 hours, and then they are launched into the world with the expectation that they are the masters of their own improvement. They are assumed to be the best judges of how to make that happen. I remember that when I was writing for The New Yorker, I became interested in the subject.
I had an excuse to call people up, so I called Itzhak Perlman, the greatest violinist of his generation, and asked why violinists do not have coaches. He said he did not know, but that he always had one. He married a fellow concert-level violinist from Juilliard, his wife Toby, and she would follow him, observe his performances, and give him feedback: what he was doing well, what he was not doing well, where he sounded a little wooden, and so on.
That led me to say, you know what, I am going to try this. I was at mid-career. My complication rates had plateaued. I had been steadily improving, and then I had hit a wall. I had done more than a thousand of the operations I performed, and it did not feel as though there was any more room to go.
So I brought in one of my former professors to observe me. He stood and watched, and I thought the operation had gone great. We went back to the surgeon’s lounge, and he had twenty minutes of notes. He said, did you notice the light swung out of the wound, and for thirty minutes you did not have adequate lighting? Did you notice the anesthesiologist was struggling with the blood pressure at one point but never told you what was going on?
We worked together, and he would periodically observe and coach. The difference between teaching and coaching is that a coach has an external view of your reality. They observe you, or they have data about your performance, and they make you confront your external reality, rather than rely on your internal perception. We all have blind spots.
We have now introduced this at Harvard hospitals. Our malpractice insurer offers a ten percent discount to surgeons who take on a coach or train to coach others. Many departments have started training everyone in how to coach, because it represents another cultural shift—a mindset of growth and humility that you bring to your work.
Mounk: There is a collective action problem. You were a very good doctor with significant prominence, and you were writing about this in The New Yorker. For you to say, I am taking on a coach, was not embarrassing. For someone who feels insecure—someone in the middle of the pack, or even a little below it—taking on a coach might feel like a signal that they do not trust themselves or that they believe they are doing something wrong. That becomes a major disincentive to adopting the practice.
If, however, it is normalized—if it becomes part of what consummate professionals in the field do—or even if there is an external incentive, such as getting ten percent off malpractice insurance, it becomes much easier for people to take that step.
Gawande: Really crucial. Many of the chairs of surgery that I’ve spoken to who’ve instituted it report that their quickest to jump in and do it are their best performers. That they are the most interested in hearing and have the most confidence about taking on a coach. Many people react by saying, that’s just for beginners. That’s for the new surgeons. That’s not for me.
But they’re able to win people over by creating it as a norm, except for their bottom performers who often feel the most exposed because they have issues that are exposed by entering their operating room. In many ways, it makes it easier for the surgeons, the chiefs, to deal with the low performers because now you have a pathway into those operating rooms where you don’t really have the line of sight into what’s happening, even though as a surgical chief you’re responsible for the quality of your teams.
Mounk: That’s fascinating. I think it transposes to other fields as well. People at the top of their field often are very good because they have that self-critical mindset and they always want to improve. They also just have the self-confidence to say, sure, I’m happy for somebody to observe me work. If they point out some way that I can improve, all the better. Whereas it’s people who already are insecure, who perhaps are lying to themselves, are telling themselves, I’m great, but they somehow have doubt and they realize perhaps it’s not the case, who really worry about what if somebody observes me and I do something embarrassing or they catch me doing something that exposes the fact that I’m actually not that good. So that makes a lot of sense to me psychologically.
We are at a moment in which medicine is more politicized than it has ever been in our living memory probably. Part of that is the pandemic and the way that played out, part of it is of R.F.K. Jr. being the secretary of health and human services. How do you message the realities of medicine where in the descriptions, including in your audiobooks, there is often ambiguity, often uncertainty about what to do. Better outcomes depend on these systems, but those aren’t fail proof either. Humility is the right thing for the medical field. At the same time, it’s absolutely clear that at scale, medicine delivers incredible outcomes for people, that we have extended the human lifespan in an astonishing way over the course of the 20th century, that the ability to get good medical care is very predictive of a longer life and a better life. Is there a way for us culturally to hold those two truths in our heads at the same time, especially in a moment that’s increasingly polarized?
Gawande: You’ve asked a lot in that question. Let me start by saying doubt and concern about medicine is not new. If anything, people have more confidence in medicine than they did in the 19th century, when you would go to doctors and you would be bled or you would be subject to treatments that often left people worse off rather than better off. Today we are in a space where between public health and what medicine has been able to do, we have essentially doubled the human lifespan. People spend about half their life dealing with a chronic illness now.
After age 40 or 50, most people have one or more chronic illnesses to navigate, and you have specialists to navigate that with. The further difficulty is that the most challenging debates are around the parts of medicine where what we are doing is invisible. It might be a vaccination. It might be a medication. It does not have an immediate effect. Maybe I am helping prevent an infectious disease or address high blood pressure, which is not going to kill you for 20 years, and then persuading people that a sacrifice now for an invisible problem is going to produce a better outcome later.
There are often people who will mount attacks saying that the solutions coming forward are harmful. When they are invisible, it can be difficult to try to get people to come on board. When Joseph Lister came up with a system of antisepsis that cut surgery’s death rate by 80%—washing hands, using antiseptic solutions—surgeons did not believe it, believed he was trying to ruin the profession, and did not adopt for a couple of generations the basics of antiseptic treatment and behavior.
It was because you were asking them to use an antiseptic, which in his case was dilute carbolic acid. It was literally pain now for someone else’s gain later. When you turn to vaccines today, we have eliminated the diseases that killed huge numbers of children. We have cut child mortality by 75%. Since the 1960s, 40% of that gain has come from childhood vaccines. Maintaining that protection when the diseases do not frighten people anymore but you can cast the vaccines as a villain is always going to be a challenge.
The difference in this moment is that the people who have been given power, people like R.F.K. Jr., but also President Trump himself, have defended and been the conveyors of the conspiracy theories. Where you normally have the leaders of our major medical institutions—the National Institutes of Health, the CDC, responses to pandemics and so on—who normally will be honestly trying to weigh the pros and cons of the evidence as it is, what is known and what is not known, and do it in a systematic way with scientists who have had a track record in the field really trying to weigh it out, that is very different at this moment.
The CDC process, for example, involves doing a full review of the literature around any given topic that they weigh. There is a vote upcoming on whether they will remove hepatitis B vaccination for babies out of concern that there is no proof there is no harm. However, the second part of the process is that any change that is made is weighed against the evidence that it might cause harm. That second part has been removed as part of the CDC process. So now when they are weighing whether they should remove the hepatitis B vaccine, you will only hear questions about whether the evidence is incomplete.
We know we have reduced hepatitis, a killer of children in particular, by enormous amounts since we have instituted childhood vaccines for hepatitis. The constant refrain of “there is no proof of no harm” is not being weighed against the consequence of removing such vaccines. I think the way we navigate science is understanding that no one scientist has a monopoly on knowledge and evidence. Science is a series of approximations. The power that science has given us in the last century for public health and health care delivery has been a doubling of the human lifespan. That has occurred not because any one solution is perfect, but because we are continually evaluating, studying, driving evidence, testing our hypotheses, and approximating our way to better and better answers.
The counter is always these lines of argument that cherry-pick evidence, come up with people who may be scientists but often have not had a track record really doing the work in the field and weighing the evidence carefully, and go in the face of the larger community’s assessment of where the evidence has led us.
Mounk: I am sort of torn on the subject. I think it is absolutely clear that vaccines have saved myriad lives, vaccines in general, like that for measles and the COVID vaccine in particular. At the same time, I can understand people who looked at some of the actions of public health authorities during the pandemic, including some of the statements they made to the public, and concluded, actually, this all seems rather less professional and rather more politicized than I imagined. So I just do not know whether to trust all of you. I think about this in different discussions today as well.
I am a professor at a university. I think that universities in the United States do incredible amounts of good, and I think that they provide a very good education to students. I also think that there are some genuine problems in universities.
It was striking to see recently one of your colleagues, I believe both at Harvard and The New Yorker, Jill Lepore, say that she considered quitting academia and quitting her job at Harvard because she felt constrained by some of the strictures of wokeness at the height of 2020. It seems to me that we need to do a better job of acknowledging where things go wrong and where we have screwed up, and defending the institution.
A lot of the time we are put in this position where it feels like it is either one or the other. There are people who want to point out all of the mistakes and all of the problems with institutions like Harvard or Johns Hopkins, where I teach, in order to dismantle those institutions. There are people who want to defend those institutions, and the way they do that is to deny that there are any real problems. Is there a way of communicating that middle path about public health and about medicine more broadly?
Gawande: I feel in many ways that our earlier discussion about surgery is exactly that. Pretending surgeons are infallible, that we do not have complications, that we do not have serious error rates, and that it does not have damage that does exist is insane. It does not serve us any good, and it does not build trust. We are never going to be 100 percent trusted. That said, every time I am amazed when people see me and they have barely got to know me and will, in the course of a half-hour discussion, trust me to put them to sleep and open up their body and remove an organ or a cancer that they have. That is because we have been able to demonstrate results in general.
We have continually demonstrated improved results over time, even as we acknowledge we have high rates of error, we have areas where we do not have adequate knowledge, and that we are sometimes mistaken in serious ways, that we can be prone to orthodoxy and hold on too tight to some ideas and not tight enough to others.
The answer comes from being a profession that is constantly analyzing the mistakes, constantly striving for perfection, but understanding you never achieve it. In the pandemic, there were teams needing to make, whether at the state level, public health officials, federal officials, and so on, judgment calls that they were going to get wrong in the face of rapidly evolving information. Early on we did not move to masks fast enough. I disagreed with CDC recommendations and wrote an article reviewing the evidence indicating that we should be instituting universal mask requirements in hospitals if that would stop COVID spreading in the hospital. We adopted that and moved quickly, even against CDC and WHO recommendations. It then became the CDC and WHO recommendation to move in that direction.
It was clear we did not get adequate effect from school closures. We caused enormous damage that was not acknowledged or weighed, whether to the mental health of children or their educational outcomes. We are paying a price for that even now that people are justifiably angry about.
That said, a world without the CDC, a world where I came back from working at USAID, where I led global health and saw the dismantling of an institution that saved 90 million lives over the last 20 years, is resulting in hundreds of thousands of deaths already from dismantling by accusing it of being a criminal enterprise, a money laundering operation, having never accomplished anything of significance, even as it was playing a pivotal role in controlling HIV and TB and reducing child mortality. That is a recipe for our own self-destruction.
Mounk: Obviously, this is a moment in which public health and science are under attack in the United States. I think for people who are outside of the field, it is hard to evaluate how big and how serious the damage is. If we step back for a moment and look at how much funding has been cut, what the changes have been that have been made over the last 10 months, the question becomes: do you think these are things that are very concerning because they are going in the wrong direction, but there is still world-class research and medicine and other fields going on in the United States today, and that by and large newborns are still continuing to get the same vaccines that they were a year ago?
Or are we already at a place in which there have been such big changes that they have a very measurable impact on people? Let us start by saying within the United States, and then I want to get into the cuts to USAID that I know you have been working on a lot in a moment.
Gawande: We will start in the United States, but I do think it was significant that the pattern was set outside the country in populations that we did not see as Americans here at home, but it had devastating effects. When you extended many of those policies, for example cutting back on and cutting confidence in vaccines, you have seen the dismantling of HIV prevention programs at the CDC. You have stopped all federal research funding to Harvard and a bunch of other universities. We slashed and stopped HIV vaccine research and development funded by the federal government.
I can go down the list, but it has been devastating. It is devastating in a very particular way. As a case in point, our research training budgets have been slashed, and that has meant that we have dramatically reduced the number of PhD students and doctoral students being trained in science, and post-doctoral graduates who are then getting their early experiences in science. I have said before that this has suddenly become the worst time to be a young person who dreams of a career in science. Neuroscientists are driving Ubers, and the result of that is a sacrifice of our seed corn for what has made the United States one of the most important leading countries in advancing human lifespan and capability.
This last century, we have been the country that has invested the most in research and developed the leading population of science and clinical researchers. That capacity is now seriously damaged. That is the first level of harm. The second is that we have suddenly determined that major areas of really important work are verboten. If they are not blocked entirely, they are severely damaged. HIV research work and prevention efforts have been slashed severely. Work on the development of new vaccines, an entire platform of mRNA vaccine development that would be critical to our readiness for any future pandemic, has been abandoned.
You can go down the list. Anything around dealing with racial disparities and trying to understand what we can do to reduce a higher rate of death in black women who are pregnant has been slashed. That is insanity in many respects and deeply harmful to our future. The translation into lives lost immediately is unclear. We are seeing now, for example, in Maine, an outbreak of 30 cases of HIV in a homeless population, and not having the CDC released to allow emergency support during the government shutdown. Those are ways in which this translates into genuine harm, and we are not prepared and do not have the systems in place if we do face major outbreak spreading.
Mounk: Let’s go to the international side of this. You were assistant administrator of USAID. I feel like that is one of those agencies that people knew existed, knew it was doing something, and probably suspected it was doing something important, but probably could not have described very well what it actually does. When you were assistant administrator of the agency, what did it do?
Gawande: USAID is in the name: You aid other countries to develop. It is our country’s investment in a certain model of thinking. It was founded by JFK, taking the lessons of the Marshall Plan. The Marshall Plan was where we did this very unusual thing in history of coming out of a war and, instead of plundering the people for their riches, we invested in the countries we had defeated. We brought a Marshall Plan to help them redevelop their economies, whether it was Germany, Japan, Italy, and so on. It paid off spectacularly. We ended up fostering peace and stability. We also grew important trade partners for us in the world. It helped lift our own prosperity.
So John F. Kennedy founded USAID on the principle that we would do the same in other parts of the world. It was the agency that drove the eradication of smallpox around the world and ended a killer that had cost half a billion lives in the previous century. It was the agency that took countries like India, brought them food aid to get through famine and terrible humanitarian crises, but then also invested in building their expertise and agricultural strength so they would become a food exporter and free of aid in the world.
The translation of a largely low-income Latin America into becoming a middle- and high-income Latin America for 80 percent of the countries was because of 20 to 30 years of US leadership and investment in supporting development instead of destroying development. So what USAID did when I came in was that I found a place where it was the best job in medicine that you have never heard of. I had 2,500 people in 65 countries. Our job was to deploy resources to reduce mortality and improve lifespan as optimally as we could.
The budget, out of a fifteen-thousand-dollar American taxpayer payment in taxes per year—so for every American, we pay about fifteen thousand dollars each in taxes on average—twenty-four dollars was what we received as a budget. It amounted to less than half of my hospital’s budget. We deployed it in ways that reached hundreds of millions of people and saved lives by the millions. So that was HIV control, TB, malaria. It was maternal and child health improvement and systems for getting better vaccination, addressing diarrheal illness, addressing deaths in childbirth. It was family planning. It was a variety of things around the biggest killers for human beings, saving lives now and improving systems later. That translated into the 90 million lives saved in the last 20 years.
There is legitimate criticism that USAID could be more efficient, that it focused too much on international nonprofit organizations and not enough on building local organizations, that there was a dark history at times where its aid was used to pursue political and military aims in Vietnam, Iraq, and Afghanistan.
None of what happened was addressing any of those issues. USAID had the highest impact in lives saved of any agency per dollar in the US government. Its dismantling was initially a pause that the president put in place on his first day in office, a pause on foreign assistance. Within weeks, it was apparent that hundreds of thousands of lives would be lost by the end of the year. Instead, they doubled down. There was no curiosity. It was the gleeful swinging of the chainsaw by Elon Musk. They purged the staff, terminated 86 percent of the programs, impounded the funds, and then shut the agency down. The result is 600,000 lives lost so far, estimated as of the beginning of November.
Mounk: 600,000 lives lost is a huge tragedy. It is also such a big number that it seems very abstract. Tell us about some of the direct impacts that had on people and how we can be sure. I am sure that some estimates say 500,000, some estimates say 700,000, but how can we be so sure that there really are a large number of lives that have been lost as a result?
Gawande: Yeah, it can be hard to see. After the Great Leap Forward of the late 1950s in China, it was 23 years before people actually got the mortality statistics released in China that showed 50 million people died. We currently are not getting measurement because the aid cutoff has cut off measurement of many of these programs. They fired the inspectors general who would be auditing and showing where the damage was done. The UN mortality estimates will not be available for two years to tell us what happened in 2025.
But there are several ways we know. One way is that researchers are tracking based on what we know has happened when individual countries were cut off from aid. We have seen the pattern of the mortality reductions. So they have made estimates. A Boston University mathematical modeler named Brooke Nichols has made estimates based on those kinds of studies and made very conservative assumptions, for example that only 25 percent of the HIV funds that have been cut will be sustained as cuts through the end of the year, and that 75 percent would be restored. That has not happened. The impounded funds that remained would be released and sent around. The number of 600,000 is based on a conservative estimate.
Ninety million lives saved is a well-documented description, and we know that that translates over 20 years to many millions of lives from these programs. So it is not inconceivable that this could be happening.
The other way that I pursued trying to find out what is really happening was by actually visiting the places where the aid cuts had happened and seeing it for myself. A film crew followed me as I traveled. We made a short film, a 22-minute film that has been released by The New Yorker and is also on YouTube called Rovina’s Choice.
One of the things I particularly wanted to see was primary health centers. I visited an AIDS referral center, and there was a refugee hospital in a refugee settlement along the border of Kenya, surrounded by unstable countries like South Sudan and Somalia. One of the things we had been able to implement at USAID was findings that came out of US research and research abroad showing that you could cut the mortality rate of children with severe acute malnutrition from 20 percent when they arrived in hospital facilities to under 1 percent. Mortality did not need to happen by giving a therapeutic food, an especially formulated peanut-based paste that could rescue the children. You could do it at home, and community health workers, simply having a measuring tape and a scale, could identify children before they got to the worst stages and do interventions cost effectively, train people in these systems, and make sure these basic approaches were deployed. We brought significant parts of the world to get their mortality rates down below 1 percent for severe acute malnutrition.
I wanted to see what was happening to those systems. I did a lot of work in Kenya as part of my work. What I saw was the total breakdown in those systems. The movie is simply following the experience of the people in the clinic where this was happening and the experience of a mother with a child who is sick and starving and trying to navigate a broken system to get the care that that child needs. She is forced to make a terrible choice that no one should have to face. I am not going to give it away. I implore people to go on YouTube or The New Yorker website and see it.
Now it is not hard to envision how there are tens of thousands of people, just from the malnutrition cutoff of training and support systems alone, who are in harm’s way, let alone from the cutoff of vaccines and the cutoff of training and systems in other domains of global health.
Mounk: I have not yet seen the movie, and I look forward to doing so. I am not sure that is the right term. It sounds harrowing but important.
Do you think that if there is a Democratic administration in 2028, they are going to rebuild USAID? If they do, should they rebuild it as it was, or are there changes that they should make? Is there a way to use this horrible suffering that resulted from the dismantling of USAID to build an institution that might transform even more lives positively when and if it is rebuilt?
Gawande: I think there is action that is possible even sooner than that. If the Congress can pass a budget, the House and Senate Republicans have backed higher levels of foreign assistance and global health work in particular than has been provided by the administration. It is an open question whether they can pass a budget. There is a lot of pessimism that they will not be able to, and then it leaves it for Trump to do whatever he wants. I have no great hope that there is going to be a change there.
Even in the midterm, if there is any shift of power, the ability to move budgets forward that would refund not just USAID but CDC and NIH could return. These are popular programs. They are not under attack except by this administration. So that can change even sooner.
Building a development agency and development capacity is a crucial part of what I think any administration will need to do coming in after Trump. Foreign policy rests on a three-legged stool, as people often say, of defense, diplomacy, and development. It is less costly and more effective in winning hearts and minds and building influence, as well as bettering humanity, to include development expertise and capacity. USAID was our largest civilian operational capacity around the world. We have lost a footprint that had more than 10,000 people around the world, with networks that reached hundreds of thousands, likely millions, of people whom we were able to deploy.
One of the things I did, for example, when Ukraine was invaded by Russia again was respond when Russia cut off the supply of medicines to the country and bombed the oxygen factories. With a team of about 40 people, we were able to work with the Ukraine government, without military involvement, and restore a system that could supply medicines from their western border. That system ensured that 250,000 people with HIV and almost a million people with heart disease could get their medications that month. The casualties otherwise would have dwarfed anything that the bombs would have done.
We got oxygen support back to the hospitals and things like that. That capacity is already missed now. It is going to be missed and needs to be rebuilt. It will not come back quickly. You cannot dismantle that entire network and build it back in the space of months. This will take years, but we will absolutely be rebuilding it. It is in our interest as a country, and it is too stupid not to address the issue.
In the rest of this conversation, Yascha and Atul reflect on our relationship with mortality, both as individuals and as a society. This part of the conversation is reserved for paying subscribers…
