The Rest Is Politics: Leading - 131. The Global Health Crisis: USAID cuts, Trump, and the limits of AI (Atul Gawande)

Episode Date: April 27, 2025

How many people are going to die as a result of American support for USAID programs being removed? What are the limits of thinking of AI as the silver bullet for healthcare? How do we bring the doubling of the human lifespan to everyone alive without bankrupting our societies?  TRIP Plus: Become a member of The Rest Is Politics Plus to support the podcast, receive our exclusive newsletter, enjoy ad-free listening to both TRIP and Leading, benefit from discount book prices on titles mentioned on the pod, join our Discord chatroom, and receive early access to live show tickets and Question Time episodes. Just head to therestispolitics.com to sign up, or start a free trial today on Apple Podcasts: apple.co/therestispolitics. Instagram: @restispolitics  Twitter: @RestIsPolitics  Email: [e-mail] Social Producer: Harry Balden Assistant Producer: Alice Horrell Producer: Nicole Maslen Senior Producer: Dom Johnson Head of Content: Tom Whiter Exec Producers: Tony Pastor + Jack Davenport Learn more about your ad choices. Visit podcastchoices.com/adchoices

Thanks for listening to The Restis Politics. Sign up to the Restis Politics Plus. To enjoy ad-free listening, receive a weekly newsletter, join our members chat room and gain early access to live show tickets. Just go to the restispolities.com. That's the restis politics.com. Welcome to the restis politics leading with me, Rory Stewart. And with me, Alist Campbell. And we are very, very privileged today to have with us Professor Dr. Atul Gawande. Now, that very grand title, he is indeed a chaired professor of surgery at Harvard University, but he's many, many more things, and one of the reasons we're so privileged to have him with us is that he's not just a very, very skilled doctor and surgeon, but he's somebody who has opened medicine to the public through extraordinary writing, very powerful, very viscerally honest writing about what it's like to be a working doctor. He's also been a real pioneer in public health, both within the United States, where he's thought very deeply about the difference between certain types of private healthcare and other lower-cost systems. He's worked with the World Health Organization internationally and thought deeply about how to

deliver healthcare to some of the world's very poorest and most vulnerable. He's been right at the heart of policymaking. He was on President Biden's COVID Task Force. And most recently, he was right at the top of USAID, the International Development Organization in the United States, which has recently been clear. closed by Donald Trump and Elon Musk since when he's become one of the most powerful, eloquent voices explaining why international development assistance matters and why this decision has been deeply, deeply damaging to real life. So there are so many directions in which we can go. But

I'd like to start maybe if we can with the question of what it felt like to become a doctor and whether you can give us a sense of something I've been struck by watching yourself and reading yourself, which is your real awareness of complexity and ignorance. I think you point out that if you'd been working in the same hospital in Harvard in the 1930s, it was a very, very different life. And now you're dealing with 13,000 different medical conditions, 6,000 different medicines, etc. So can you begin by just giving us a sense? of modern medicine and then we'll take it in many different directions.

I love that you're starting here. And first, can I just say how proud and privileged I am to be able to be on your show? I'm a fan. And number two, I have to correct a couple of things. I led global health at USAID, so I didn't run USAID, Samantha Power did. And it was wonderful working with her during the Biden administration. And then in order to go to USAID, I had to step down. from my professorship at Harvard and believe it or not I'm now applying to be back

at Harvard I reckon you'll get it during you'll get it I think you'll get it I am returned to Boston and and my old hospital to bring him a women's hospital where I'm indeed professor of surgery you know to go back to the beginning it's you know an extraordinary experience stepping into becoming a surgeon you're asking people permission to assault them, to put a knife in their body and to do it on behalf of the idea that you're going to make them better. And the bottom line about the experience is it's terrifying. And if it's not terrifying, you're worried about, you should be worried about the surgeon who is coming out from a program, not terrified about what they're setting out to do. I was attracted to it the first time I went to the operating room as a medical student.

I did not expect to go into surgery. You know, I'd come from a background. I was interested in public health, interested in policy. Last thing you think of is surgery. But when you're in the operating room, you see someone dare to open up the human body and then manage to bring competence and confidence to it. It's remarkable given that, the knowledge at any given time. is incomplete. You are fallible. Your skills are imperfect. And yet taking action is not always,

but generally the better thing to do. And I got started writing as much out of that experience of recognizing that we're fallible, that even the best surgeons have deaths and complications, avoidable deaths, avoidable complications on their hands. We meet weekly to discuss our errors and failures. And it's a remarkable culture. And I just was drawn to the people who are the best at doing it and their sense of confidence and humility in equal parts. You've written a lot about human error.

And of course, we want to have trust in our doctors and we want to believe them. And I've always been somebody who I don't want to think that my doctor's nervous. I don't want to think that my doctor is having a bad day. I want them to be perfect. I want to have total trust in them. But you seem to be saying that it would be better. That relationship between society and medicine and between doctor and patient would actually be better if we had a better understanding of the mortality that you feel and the sense of vulnerability that you feel.

Yes, there's a limit to that. But let me just say there was. was, you know, as I was coming through, the doctrine was preach your infallibility to, you know, with the public and with the patients you were with, you weren't honest about your, your fallibility. You weren't honest about the imperfection and the complications. You felt that you need to give people confidence, you needed to exude pure confidence. And there's, a subtle change that really occurred during my generation of surgeons in training. And I began both on the research side describing the failures in surgery and how we could engineer reductions in those failures. And that was to begin to say, you know, perfection is our aim, but we are not perfect. And to give some realistic expectation of what may be coming, what, the best outcome we can prepare for and what the worst is and how we will work together to get there.

You know, what I've ended up in my career doing is actually making a study of failure in surgery. We first began to publicize the ways that things went wrong. My first book, Complications, was somewhat controversial for really laying out the mistakes that are made and how we deal with them in the profession. and what we do to engineer them out and what we were not doing to engineer them out. And then later, because of that work, ended up leading work at the World Health Organization that got me into global health, surprisingly, by taking on the question, how do we reduce deaths in surgery globally? We do more than 300 million operations a year on human beings around the world.

It's about one in every 25 human beings on Earth is having an operation in the course of the next year. And our death rates were high enough that the deaths were bigger than childbirth. We worked with a Boeing safety engineer and designed a checklist, a two-minute checklist for the operating room. And with that checklist in London, in Seattle, in Toronto, but also in rural Tanzania and in India, we cut the death rate 47 percent by being honest about our mistakes, working together as teams to deal with that. And you do. did that at a time when culture was changing so that there was a greater trend towards litigation, towards going after doctors who made mistakes.

Did that not make it much harder to do what you were trying to do? In a way, it made it easier because litigation was not working. It's an extremely expensive way to address failures that at its presumption is about the negligence of clinicians. And part of what you really find is failure was not a problem of bad doctors. Failure, above all, was the problem of really good doctors, being among the most well-trained people in our societies that we've drawn into these professions, but put them into situations in which you cannot master it all by yourself. And so a combination of a team can't be in the save you and increasingly access to knowledge and, you know, computers and, you know, ways that

those systems can can make a difference. But above all, it's your humility and willingness to confront error and engineer it out of the game. And we've been able to do that with remarkable success. So let's use this maybe as a way of moving from, how complicated and specialized healthcare is and how big the teams need to be and how much knowledge you need to be, onto the question of cost. Because presumably one of the central issues around healthcare, one of the things that's changed over the last hundred years, is it's becoming more and more expensive. And of course, we're talking to you from the United Kingdom, where the question of how we pay for the NHS is probably the biggest question in politics. Explain just

us, why is healthcare so expensive? Well, there's a, couple of layers here. One of the reasons that health care is expensive, you started to point out one of the things I've noted. We've discovered in the last century. There was a time when health care was incredibly cheap and accomplished very little. And in a century, the last century, we've doubled the human lifespan. We've taken the average survival of someone in Europe, United States, from an average of living to your early, 40s to now eclipsing 80 years. And in order to do that, there are now 19,000 drugs. There are 4,000 medical and surgical procedures, and we're trying to learn to deploy this capability town

by town to everyone alive. So some of it is, yes, it's the cost of the drugs. It's the cost of the people doing this work. A lot of it is the cost and complexity of all these discoveries that we've made, and we are trying to bring them to everybody alive. And this is our generational challenge. It is a transformation. Just basically, in the course of a century, went from a world where our survival was largely a field of ignorance. We did not understand the nature of our conditions or have solutions to offer to them.

Now we do, and we're trying to deploy this capability. I'd say, number one, you know, the United States, we spend 13,000 U.S. dollars. per person per year for health care. And we get less survival than the UK. Our survival is currently at 78 years. The UK is closer to 80. But we have places like Costa Rica that have a higher life expectancy than the UK or the U.S. on a fraction of even the UK's spending. It's under $1,600 per person per year. And what I would say is there are two layers of the cost. Number one, One is having a sound primary health care system where you don't have a cost barrier to getting your daily needs for your first level care, whether it's preventive care or I've got a sick

child and I want to bring them in for services in your neighborhood GP. And your essential medicines need to be affordable on your basic diagnostics around preventive care and so on. That component is not terribly expensive. In Thailand, they're delivering that for $300 per person per year and achieving the same life expectancies that we're now achieving in the United States. The next level, your secondary care, your specialized cardiologists, your dermatologists and so on, and then the hospital care and the procedures that go along with that, those are extremely expensive. We are willing in the United States to spend a lot on those, right? Our cancer care is costly.

It's very timely. And the results are arguably the best in the world. So we have some of the poorest primary care functions. Britain has really struggled around some of those specialized care capabilities and affording it. Britain has continually for years under invested in your health care infrastructure. You've had a strong primary health care system. that you don't want to sacrifice, but the specialized care is where the investment needs to be. We have the flip side problem in the U.S.

We have overinvested and sacrificed primary care at the cost of overall health. And, Attle, what's your assessment of the basic model, our model against the American model? If you were to be able to be a doctor in any country in the world, which of those two models would you prefer to work in? National Health Service, free at the point of use, et cetera, or the health service of the United States, which we do see as a very market-driven healthcare system. I'm not going to choose between the two, but I will say partly because if you're like me, you know, you're in the top 2% of income in our countries, you will get great care in both countries, right? If it's, you know, if I want to be someone who's in the bottom third of income for health,

you're going to receive more consistent, more equitable, better care in the UK than you currently can access, unless you're a veteran. And then you get Britain in the United States. The VA system, the veteran system of care is a government-run hospitals, clinics, and salary doctors who do incredibly great results for the veterans. Rachel Elon Musk discovers that some of them are lesbians and then you're going to, you're going to be in trouble there. Doja's already started laying off people in the veteran system in the United States. So that sadly is a story that started at USAID but has extended to there.

But I'll just say what I've looked for around the world are the outliers who get better results in survival. And, you know, you go to Spain or Portugal right now and they have delivered a combination of primary care and secondary care that's getting people 82, 83 year life expectancy and on lower levels investment because you're also bringing that level of care in the community. All of it's to say, we're on this generational journey of how you deliver this care at broad scale, where food ate up 40% or more of a budget for a family in 1900. Today, it's housing and health that are the eating up the budgets of people and making it hard to have a viable cost of living. I think a strong primary health care system is the foundation that I see across the world for better public health and better primary care results.

And there's certain features to it that make it highly successful. and then at our, you know, higher income levels where Britain has the opportunity is in that capacity for that specialized care. At all, I'm going to be cheeky now and move you on to what's happening in the United States. So one of the things that struck me is that you mentioned Doge and Elon Musk. Yeah. Dodge, roydge. Dodge, Dodge, as Alaston wants to call it. sounds like stuff that sometimes you might sympathize with.

You're interested in efficiency, you're interested in results, you're interested in technology. I guess you know many people who know Elon Musk and you perhaps met Elon Musk himself. And you probably admired the Tesla motor car. So what's going wrong? I mean, from the point of view of the public, here is this kind of genius businessman engineer. And he's coming in and he's going to think about all the right stuff and bring. efficiency and outcomes to the government and something's going wrong. Tell us what's happening, I thought. What's going on here? What's going on is that someone who does not understand the world of

healthcare, the world of delivering public services, has walked into the job, declared that he will be doing surgery with a chainsaw on the government. And the entire approach has been, we're pausing the government. You know, you're pausing a plane in mid-flight. You're purging yourself of your crew and then it's crashing and burning and you're you're shocked you know this is not twitter and twitter is simple as compared to uh sustaining the global HIV AIDS program that has reduced overall HIV in the world by three quarters sustaining the global polio eradication program that you know was down to small numbers of wild type polio moving in the world um and we're now wrecking That's just the global health side, forget the food assistance and then the other components, you know, the National Institutes of Health, the CDC damage being done.

It is, you know, it's arrogance. What is happening is arrogance and it's indifference to the cost in lives or the complexity of doing the job. And also just this is a slightly unfair question, but for international listeners who aren't following the day to day in the U.S., can you take us through, some of the individual things that have happened. We talked about the cut of USAID, but talk us through some of the other agencies, some of the other decisions, some of the other implications, even domestically within the U.S. Yeah. On January 20, which was inauguration day, is when I stepped down along with other members of the

Biden administration and handed over responsibility, in this case for global health at USAID. Foreign assistance was the first, what I call the soft target, right? It was the place that they worked out, the playbook that then they would bring through the rest of the government. And what you saw in that very first week was the sudden announcement that all assistance, all spending by USAID, the U.S. Agency for International Development, would be halted, that the staff would be purged and that the buildings would be, the lease would be. dropped. And that effectively became the playbook that then began to roll out across the government. Now, never mind that in the U.S. Constitution, the Congress establishes the offices of the government, provides the declared financing and direction, and then the executive branch executes. That was not what happened. And within about a month after that, 90% of the staff, 90% of the programs

were gone. And you had had 20 million people with HIV who were receiving medications to stay alive dropped, including 500,000 children. The entirety of the global malaria program brought to a halt. Maternal and child health programs reaching 90 million women and children dropped and on and on. Once they perfected that, you know, it's brilliant in a way. the the the um if you wanted to have a coup in the 1980s in in some small country somewhere you'd seize the the the national television station you'd seize the treasury and it sees the presidential palace and you'd be you'd you declare victory um here you know he had musk see has the social media platform feeding directly into into fox news and controlling significant part of the media

communications. They used, took over the software for the Treasury payment system and halted payments, could turn payments on it off overnight and seized the employee systems. And so as they learned to do that, they extended that now to the National Institutes of Health where the first year employees were purged, where individual programs were shut down. Right now, for example, they're shut. shutting down anything around vaccine to improve vaccine uptake, huge parts of vaccine research is being stopped, anything around racial disparities, around, you know, trying to bring down

gaps in poorer outcomes, for example, in childbirth in the United States. If you're a, if you're black, black women will have many times higher mortality rates than white women and understanding why and being able to come up with remedies. National Institutes of Health was doing that. Those there are, those grants are terminated. And then it's extending to the Department of Education, which is now being dismantled in a very similar way. Some of this is starting at NASA. Some of this is starting at, um, uh, in the social security administration. Um, it's in the name of addressing corruption, addressing efficiency. But every time they say, We're doing this because we're, you know, getting rid of corruption.

It's because they're corrupt. At USAID, for example, in those first three weeks, half a billion dollars in food aid went rotting on in warehouses, in on ships. And when the inspector general, a independent auditor did a report, a rapid report pointing out that not only had half a billion dollars in mismanagan, aid, you had $8 billion in audit functions shut down to oversee and prevent loss of aid to terrorist organizations and things like that. So that playbook was perfected at USAID and is now moving across significant parts of the US government. That's what you said how this was sort of started with USAID, then moved over.

Just sticking with USAID for a moment. Musk very proudly says that, you know, this is just sort of rooting out waste. People aren't going to die as a result of this. Just, you know, the PEPFAR program, the malaria program, what sort of numbers are we talking about that actually might die as a result of American support for these programs being removed? Well, we know because USAID itself and their teams made estimates of how long it would take for damage to be done. You know, it's estimated that 160,000 new malaria deaths would appear if this aid was turned off for the next year, remained off, mostly children.

It's estimated the biggest impact will be in immunization if it's not turned on again. you know, we have succeeded in the world in lowering the death rate of children under five by 75%. 40% of that benefit comes from vaccines alone. And 60% of the vaccine benefit comes from the measles vaccine alone. So right now we're already seeing some of the consequences of two months of, lost health workers, lost programming, lost cooperation together, shut down communications with WHO, shut off funds for the measles program at WHO and so on. And we're already up a, we're started the year up above 100,000 deaths in children from malaria again. And we will see that

rise even more. The estimated numbers from USA's own internal numbers is two to three million more deaths a year, again, mostly children because of the loss of cooperative programs that the U.S. was a major driver in. That's not even taking account. I want to add, the Trump administration has declared they will no longer fund or participate in the World Health Organization. That is a huge damage. And then add to it that switching their stance on Russia and not committing to some

support NATO has meant that defense spending has had to rise in Europe precipitously. And the first place that that cut is coming from is Europe's cooperation and the UK's cooperation in foreign assistance as well, that the same programs for HIV, for maternal child health, for malaria, for food security and malnutrition are being cut right now in the UK and in Europe as well as a consequence. So this is a calamity. This is a disaster for for human public health. You talk about it very, very calmly. But the way you sort of lay that out,

and then when you think through the consequences, this becomes accepted and then normalizes, I mean, we're sort of, are we not talking kind of crimes against humanity here when we know that the programs exist to save those lives? And literally overnight, without it seems any kind of real analysis done

by the government. And then with this guy in charge with his chainsaw, they literally just pull the plug on all of these programs. And as you say, you take just that one disease malaria, 160,000 predicted to die. How do you find the words and how do you find the kind of wherewithal to get out of bed and keep going and trying to get this thing back on track? It's shameful on so many levels, Alasher.

I don't even know where to start. Let me just give you an example from a conversation with a minister of health we would not want to be named, but that I had just a few days ago. And he said, look, if the United States had come to us and said, you know, funding is going to get a severe cut. And, you know, your country, we will work with you to figure out how to navigate forward. That would be one thing. It would be understandable. You'd get on a glide path.

You'd figure out what to do. You'd cooperate. But here you're talking about overnight. a stop work order going out that said, food on the shelves can't be given to children. HIV meds in the warehouses can't be brought forward. Your staff cannot be paid anymore. They're going to be laid off. Billions of dollars in U.S. assets, whether it's investments in laboratories,

investments in data systems, people capacity is going to be thrown away. Vehicles, thousands of vehicles left parked. You know, what are we going to do with these things? Ships arriving in port with insecticide treat and malaria nets where no one's picking them up, food rotting in trucks. He said, you know, the indifference to the lives of our people is to be treated as subhuman, to not care enough to be able to make a phone call and say, you know, we have to find a way to make this work properly. we care about your lives and, you know, everything being dropped overnight. Another example, women in clinical trials with medical devices, a vaginal ring that might be effective in preventing HIV, but we don't know, abandoned in trials with no one to remove the devices

from them. Children in TB programs with drug resistant TB in a research trial to stay alive with new medications dropped in the middle of treatment. It's against every ethic. It is against every piece of morality. And so, yeah, you know, how do you wake up? You wake up to bear witness to the reality of what's happening because the other side, the people doing this are gleefully making the cuts saying it's all corruption.

It was never doing any good and, you know, not a single life is being. lost when we are pointing out numerous of them and putting names to these people. It's a very striking pattern. I had development people say to me when this was beginning, well, surely, Rory, you know, you agree that there are things that aren't great about international development and that could be improved. And my sense was that you've got this wrong. This is not good faith.

Trump and Musk are not trying to improve the international development system. they just don't want to give the money away. And the reason why this resonates is you'd probably get the same conversation if you were talking to European allies about defence and NATO. If you were actually serious about Europe taking over the cost of defending Ukraine, when French, President and British Prime Minister come and say, OK, we'll find the money, we'll find $50 billion, but can you still sell us the kit, you'd have a glide path, but there isn't a glide path.

but there isn't a glide path. They cut off intelligence sharing. They disable the missiles. Everything stops on a dime. And it implies that in the end, they don't really care about the result. They don't care about the lives lost. They don't actually care about what happens to Ukraine. They're not serious about Europe taking responsibility for its own defense.

What is going on here? I think there's a couple of things going on. One is that power comes first over outcome and being able to exert power over the over the government, over society, over culture, is seen as a good in of itself that makes whatever the costs worthwhile. Second is, you know, drinking their own Kool-Aid and believing that this is all corruption, that what, that the lives save, the programs that the government rolls out, that that these will not be as bad. as claimed because these are folks who come in with very little experience with government and

proud of it and believing that, you know, the people who work in these agencies are lazy, incapable, and there's certainly inefficiencies. There's certainly some low-performing bureaucrats. But I came into an agency that I discovered had extraordinary levels of expertise were incredibly hardworking, mission-driven people who did not come into it for the money, did not come into it for the perks, believe me, were willing to travel to conflict zones on a budget of less than half of what my hospital system spends. Our global health team was reaching hundreds of millions of people in saving lives by the millions. That, you know, is the reality, but it is denied on the basis of

both ideology and willful in curiosity. Okay, as well, I'll say a quick break and then back for more. Hey, this is Michael and Hannah from Gollhangers, the rest is science. This episode is brought to you by Cancer Research UK. We often think of beating cancer as treatment, but imagine stopping it before it begins. After years of work, cancer research UK scientists are launching a clinical trial of lung Vax, the first vaccine designed to prevent lung cancer. It builds on Tracer X, the world's largest cancer evolution study, which tracked lung cancer

cells over many years to uncover the disease's earliest warning signs. Lung Vax is designed to train the immune system to spot these signs early on, destroying 40 cells before cancer develops. So it's not treatment, but preventative, with the potential to stop lung cancer before it's starts. The first stage of the trial starts this year, focusing on people at higher risk. It shows what long-term research makes possible. For more information about Cancer Research UK, their research breakthroughs and how you can support them, visit cancerresearchuk.org forward slash the rest is science. Hi everybody, it's Dominic Samark here from The Rest is History.

Now, some of you may have heard me on your show, The Rest is Politics when Rory was away and I was filling in and enjoying Alistair Campbell's tremendous banter. And I'm back to tell you about our new series on The Rest is History, which is all about Britain in the 1970s, a period with a lot of uncanny resemblances to our own. So right now we're living through a moment when oil shocks generated by war in the Middle East are rippling through the world economy,

when Britain feels like it's sunk in a bit of a malaise. People are arguing about Europe. The government has got a few issues with the, trade unions, and we have a kind of, I suppose you'd say governing elite, a kind of political class that is really struggling to come to terms with all of these issues. And people are asking if Britain is governable at all. So there are a lot of parallels between that Britain that I'm describing, which is our Britain and the Britain of the mid-1970s. So in this series that's coming out on the rest is history, we're looking at these and other issues. We'll be talking

about the rise of Margaret Thatcher, obviously a colossal figure in our political life even now. whether you love her or loathe her. We'll be talking about the very first Brexit referendum of 1975, a subject that I'm sure Rory and Alistair will have strong opinions about. We'll be talking about the fall of the Labour Prime Minister Harold Wilson and we'll be talking about one of the grimmest moments in Britain's economic history, the moment in 1976 when we had to go cap in hand, as people said at the time, to the International Monetary Fund, the IMF, for a then record bailout. Now, if that sounds good to you, how could it not sound good to you? Of course it sounds good to you. We have a clip for you to listen to at the end of this episode. And if you want to hear more,

just search for The Rest is History wherever you get your podcasts. What was your experience of politics and politicians before this? And you were healthcare lieutenant. You might even explain what a healthcare lieutenant is, because I don't know, but that was with the Clinton administration. Then as Rory said, in his introduction. You had a number of roles under the Biden administration. So what's been your kind of interaction with politics? And what has your feeling been about politics and the political system? So number one, my whole career has been about the problem that we started talking about at the very beginning. How do we get health and this system to deliver for the entirety of our

country and of humanity and make it possible. I think this incredible, the most ambitious thing that human beings have ever attempted to do is make this possible for everybody. And so I've approached it with people across the political spectrum. I led health for the Clinton campaign way back in 1991 and 92 and then joined the White House. And my experience has been mirrored by some of the experience. then, which is that, you know, it was really fun being in the campaign and making the arguments

and winning. And then when we got to implementation, it was chaos and people with sharp elbows, you know, people leaking that a med student is briefing the president in the Roosevelt room and getting kicked out. And, you know, those were the people on my side of this argument. The, you know, whereas, you know, all of the usual challenges and difficult. of negotiating in a democracy, people coming from all different perspectives and trying to drive things forward. And I had very little patience or skill at that then, and then coming to it

again 30 years later, finding I had a little more tolerance for the process of winning people. You know, you have to win people of varying points of view to come with you. You have to reach a decision point and then move forward and take your chances. And I had more respect coming 30 years later into it again for what that kind of process is. Then you have a person who believes that winning people over getting collective capacity moving forward as a whole country and as a whole world is anathema. That either it's either you're with me or we crush you. Just help us understand a little bit about maybe the underlying culture. I mean, Trump won an election.

Many people in his team are still astonishingly popular or more popular than you'd expect. And there's something clearly that really resonates with a section of the public about this way of proceeding. And partly, I guess it is that a lot of the things that you care about most, which is explaining, number one, why it's difficult to get things done, but how you can get things done by sweating small details like checklists, explaining how you build teams, explaining how a non-dramatic cheap intervention can have an astonishing impact and save hundreds of minutes of lives. These things seem in the modern political space pretty boring and technocratic. And along comes somebody who says, I've got. energy, this old system was completely passive and inert. I'm going to shake it up and I'm going to bring in the disruptors and the tech bros, and we're going to sort of all that. And it's very

appealing. Can you, I mean, obviously, you're horrified by it, but can you just try to explain to us a little bit what it is these people feel and why it's popular, at least with one section of the public, why it's appealing. Here I'm going to reach past my doctor role to, you know, I grew in rural Ohio, the son of two Indian immigrant doctors in a county in Ohio that is the poorest county in the state. It's Appalachia. And I grew up with, you know, a slice of America, which is very much like America, right? Half of my high school class did not go to college. Half my high school class did. And I still go back home on a regular basis. And the reality was that, and remains that if you don't have a college degree, we don't have a pathway to middle-class life

the way that people did without a college degree in the 70s, let's say. You know, there was a time when the average American without a high school degree would own a home by the age of 30, would have a steady job, and could be married and have two children. And that was like, that is so far out of reach for people. And the recognition that that is out of reach and the sense that there is nobody listening and there's nobody attempting to address this. I mean, I think the fact is that the political classes across all of the spectrum don't have that clear pathway laid out and stand for it. it is a ripe opportunity, just as an invisible, you know, virus and COVID could be a ripe opportunity because it's this unseen villain. But this sort of invisible worldwide phenomenon

of a knowledge economy that's failing people is a ripe opportunity to scapegoat. It's the kind of atmosphere you'd have for populism with, you know, really wide levels of wealth accumulation and deprivation at the same time. And so, you know, you do have the sense that people were not feeling seen. You know, many of the people that I grew up with did not hear people speaking to them in ways that connected. And Trump offered a path that made them feel seen and heard, at least those who voted for him. and chaos, destruction, and rule by patronage and loyalty trumping outcomes does not deliver the goods.

And it's really important that we have capacity and approaches that show we can deliver more of the goods and make people feel heard and included in the process. You know, the Democrats have become a party of the technocrats of college educated people like me. And we're going to need more. We did a good job. You know, Democrats did a good job of bringing soldiers and military people in. We have to go even broader and bring more people who are coming from working class families and know what this is like. You mentioned COVID there. which of the countries that you've looked at handled COVID well?

And what was your experience being kind of in the heart of it for part of it? And then, of course, you know, Trump came in and we all started drinking bleach, but, and then we all got better. What I'd say is, you know, the aftermath, we're five years out now, showed that countries that had a well of pre-existing trust in their national institutions did better and stayed together, were able to navigate the ups and downs of uncertain information, controversial choices, and navigate that without it ripping society apart. In a technical sense, the U.S. clearly struggled.

I think our weak primary care system made it more difficult to do simple things like get messages out to the community, get people to understand wearing masks and what it might mean, being able to make the vaccines available and move quickly. And we paid some significant price around doing that. There's lots of ways in which people's lives were so disrupted. we're still paying the price of, you know, the one telling statistic to me was that you had 60% of the world go into elections in this past year. And it did not matter who was running. Incumbents over 90% lost vote share. And most incumbents lost if they had been present during COVID. And I think that the consequences of COVID on people's lives.

the hangover of inflation and debt there, and we're still paying some price for acceleration of trends that were already there, because the people who were most hurt were the people who couldn't escape into a knowledge economy. You could work through your laptop and make it in the world. The UK is still processing how we responded to COVID, partly because Boris Johnson was right at the heart of this and him breaking his own COVID regulations. But there are people looking at Sweden and saying Sweden didn't lock down, didn't shut down its economy, didn't shut down its schools and ended up with outcomes that were pretty similar to Britain, which took a huge economic and educational hit doing these very dramatic measures around lockdown. How do you assess this now?

How do you evaluate the kind of decisions people were making in those early days? Well, five years on, we don't have that assessment. And I actually was in a meeting last week making the strong case that this is at the moment to actually really, you know, especially before a bird flu comes, understand what the professional consensus is on these areas. At the end of the day, I'm a surgeon, not an epidemiologist, but I'll render my judgment anyway. What the hell? I would say that the evidence was very strong that masks played an outsized role in being able to control the disease. And the reason I know is because in the first few months of COVID, it spread and really disabled hospitals, whether it was in Korea or in Spain or in Italy or in New York City. In Boston, we made the decision against initial advice of WHO and others that we would do universal masking.

And we, I went to work every day, saw plenty of people with COVID and, you know, we did not get spread of COVID in the hospital. I did not get COVID until, you know, one of my kids got it. And that was the way that I got my COVID later on. So that's number one. Number two, I think the, you know, the jury is out on whether there's an immediate role on lockdowns, but clearly beyond a certain point, it's not clear was. adding much more value, it was not slowing matters down. You know, I think we have now pretty strong evidence that shutting down schools did not help slow transmission and had enormous impacts on the mental health and educational outcomes

of children. And that brings home one additional, I think a key point. Public health people will always have a critical role to play in having you, in being able assess the evidence of saying, you know, here is the gain in survival of wearing masks or doing XYZ. What people in public health cannot do is say what I talk about when I see my cancer patients. What are you willing to sacrifice and what are you not willing to sacrifice for the sake of more survival? And there will be a different calculus with the next virus, but the humility to recognize that the role of the political community is to say, you know, what are we willing to sacrifice? What are we

not willing to sacrifice? And public health to then inform that is important. I'll just add one thing, which is, you know, we made a decision. There was a time in the United States when under Jimmy Carter, we lowered the speed limit to 55 miles per hour. He did it in order to save energy and reduce about 5,000 deaths a year. And everybody said, this is too goddamn slow. And, and the That's legitimate choices to make, right? That's, and we have to be capable of doing that. And there's a role for public health and politics in sorting through those things. Can I raise a couple of other big issues, one of which was a lot bigger a few years ago and seems to be going backwards, which is climate.

I'd be interested in your views on the impact of climate change on public health. And the second is, am I right that you're quite skeptical about the ability of artificial intelligence to make these. health transformations that we quite often hear the politicians saying that they will. Boy, those are too far afield. Yeah. So from a health point of view, climate is one of our biggest killers. Number one, air pollution is a driver of somewhere around seven million deaths a year globally. It's about four million that are from ambient air pollution.

and, you know, you see it in cities like Delhi and, you know, Lagos, Nigeria, and so on, in particular. Those are extreme examples. But, you know, I saw it in rural communities in, you know, my father's from a village in India, and I visited there, and it was 105 degrees, and haze and extremely high, poor air quality levels in rural India because of factories nearby. And then you have indoor air pollution. which is its own set of issues as well. Then you add in the deaths and complications of extreme heat. And, you know, so there's, I think the reason climate change has become real to people

is we're now experiencing those deaths. We've, you know, we've had forest fires that blotted out the sky. We've experienced catastrophic extremes of heat waves waving through. And so there's enough people around the world who've seen the health consequences to, to have had health become a driver of awareness and willingness to recognize now climate is not theoretical, this is real. And so that changes, I think, the public resonance and willingness to take action, but we still have some distance to go.

Let's bring you on to AI atoll. I'll pick up Alice's question there and maybe develop it a little bit. So clearly, AI is going to be very helpful. but what would be really interesting is to hear where you think it's going to be helpful, where it isn't going to be helpful, where the limits of it are, and how this whole notion that we suddenly have a silver bullet that will completely, on its own, transform health productivity and outcomes and save the National Health Service, to what extent that's true or isn't.

Yeah, so there's a couple of things. One is there's a fantasy of AI that it's going to be able to replace you know, major parts of the health system, you know, I've had Silicon Valley people waving their phones at me for years saying, this is going to replace you. I keep wanting to say, you know, is this going to deliver my baby? It's a fundamental misunderstanding of what the role of clinicians in healthcare is. It's not just whether you get the right diagnosis. That's really important. I think we're already at a point where, you know, the capacity of AI to be an incredible tool for physicians and potentially artists and lots of other people, that there's a high

headroom on that. On the idea that it will therefore displace your major relationships, that you won't need your primary care clinician or others, the challenge is that when you sit in an office taking care of people, they come to you unable to explain what their issues are and needing to navigate what are the tradeoffs you're willing to make and not willing to make. And in my community, you know, how available is the PET scanner? How available is the interventional radiology option versus the, the, you know, surgery option or whatever else? And so, you know, I'm hopeful about a future that's needed.

where this reduces the burdens of the paperwork. Like there's two hours of documentation time in the average clinic for every hour of patient time. I don't see it going away fast enough, but it should go away. I think the second part is coping with the hallucinations and the ways that these tools are not entirely reliable. And you need a human beings who become good at working with these tools to recognize when the tool's going to do better than I will, and when the, when you need to be stepping in and

correcting course along the way. I see it much more likely to be what Reid Hoffman has called us a super agent, you know, an agent alongside me as a professional clinician. My last question, Athol, thank you so much for all your time. You've written a lot in your career, books and articles and so forth. Do you find that writing helps you be a better doctor? I do. It's the one part I missed by going into government was I had to leave the operating room for the first time. In every other job I'd had, I didn't have to leave the operating room. And I didn't miss it as much as I thought I would because I got much more medicine.

I'd never dealt with the bull outbreaks and, you know, malaria and all these things. And so I was on a learning high and I loved that. But the part about writing, I really missed writing. First of all, you know, when you have to write, you have to think harder than you would if you were just making decisions without needing to put them out into the world, right? Second, when you're telling a story, it leads me to get closer and into people's shoes in ways that, you know, that you don't otherwise have to do. And it's that empathy part of it. It makes me listen more closely to people. The third part is writing allowed me to go to people that I take care of and do really weird things like saying,

hey, I'm writing this article. Can I visit you in your kitchen and talk about, you know, what's going on? Or can I follow you at work? And I would learn so much more about the consequences of our own work by getting to follow people out of the office into their home. into their work lives and seeing, holy crap, we are not, we are missing whole components of their experience

and ways that we're failing people along the way. At all, my final question. You've spent a lot of your career facing some pretty tricky stuff. You know, big, rigid government bureaucracies, the deaths of individual patients, massive, horrifying global problems, Ebola, malaria, and now the destruction of so much

of what you care about under the Trump administration, I guess my question is, how do you see your vocation? How do you see yourself moving forward out of this world? How do you think about what you're doing with the next decade of your life? One of the things that I tell young people who come to me for career advice is something that a clinician, once told me would just say yes to everything before you're 40 and say no to everything after you're 40. And what you meant by that was you don't know what you're good at. You don't know what you're going to be excited by. You don't know what the world will offer. Half the jobs that exist now didn't exist when I was in college, right? And so you say yes to everything and give stuff a

try and pay attention to what exhausts you and to what energizes you. And so the advantage after 40 is you can commit to projects for the next 10 years or 20 years because you know they energize you. And so at this stage in my career, I all turn 60 this year. I know what energizes me. And for the last 25 years, it's been the question we started with, which is how do we bring the doubling of the human lifespan to everybody, deploy it town by town to everyone alive, in ways that it can be humane, it can be reliable, and it can actually deliver without bankrupting our societies and and and understand that in in humane terms as well like where

where is the art where is the science where does it stop and start and i'm still on that journey that is not changing i've done it in an academic setting i've done it in in a for-profit setting i've done it in in public benefit corporations in government you know so i'm platform agnostic I will be doing this work trying to advance the story and the outcome as much as possible. And so, you know, in the next year, there's a book I'm working on. I've returned to my academic role at Harvard. There's a film project. I've done a couple of documentaries and have a couple of film projects, one narrative, one not.

And those will go forward. And yet the most important thing I feel at this moment in time I have to do, is address the dismantling of the major contribution of the United States to the human health enterprise, the science, the public health outcome. This is a dire threat for humanity. It's as big a threat as a pandemic. And so, you know, for now, this is where I got to be. Well, good luck in that.

Love it to talk, Jaddle. Thank you for yours indeed. So great to meet you both. It's very kind of you, very generous. Lovely to see you. Have a great evening. Well, what a guy. What a guy. I mean, I don't like the idea of doctors not being infallible. But if I did have, if I was going to have my body cut open, I'd quite like him to do it. I mean, I felt by the end, I felt reassured, mainly because I think his heart is so clearly in the right place, because he's, he sinks carefully and he writes things down, which is very important, as you know. No, I thought he's a very, very impressive guy. I thought he was wonderful.

It is quite unusual, isn't it? He's a writer, he's a policy person, he's a doctor, and he brings it all together. And he does something which is quite rare, which is being able to explain it patiently and carefully without sounding too arrogant. I mean, it is amazing. I took a lot from him. I first came across him when I was the prisons minister. And he'd written a book called The Checkless Manifesto. And as he pointed out when we did the interview,

introducing these very simple checklists had this incredible impact on mortality. I think he said it decreased by 43% saving hundreds of thousands of lives. And in a very simple way, that was also very important to reducing violence and prisons, having a very simple set process

for inspecting a prison cell, door, switch, callbell, skin, wall, made huge improvements. I also loved the thing that he sort of cares about government, but maybe in a slightly different way to the way that we sometimes think about it or sometimes think about the way that we normally talk about it when we talk to politicians. I think he is somebody who cares about government, cares about public service, cares about outcomes, but it's all articulated in a different way. Yeah. You know, I was,

I was interested, we didn't really get into his take on the various politicians that he'd, that he dealt with. I found his analysis of what's going on now with USAID pretty heartbreaking, to be honest, because you could sort of feel his pain. And it's so much a part of this sort of gaslighting around the whole thing. I did an event earlier today, you know, full hour talking to this business audience, lots of Americans there. And I don't think we even mentioned USAID. And of course, that was such a big thing in the early days. But of course, there's been so much stuff since then that people wanted to talk about. And what I I felt listening to was somebody who had not just seen, but also being part of something that the

American government did that actually brought an awful lot of good in the world. And just seeing it completely vandalized. And I thought he actually was incredibly reflective and sympathetic about, not sympathetic, but his way of, he was genuinely trying to think through why Elon Musk might be behaving the way that he is. He ended up at arrogance. But I think there's something far more dark and dangerous than that. This felt like really, really dangerous vandalism of something that they neither understand nor care about. And I think to have that sense of public service, which came out again in the end in his final answer to your final question, I'm basically going to keep going, doing the things that I believe is sort of what he was saying.

I think that's pretty hard to do when you're surrounded by this noise right now. Yeah. And he touched him. We didn't get fully. into it and we should do it sometime. What's happening to agencies inside the United States. I mean, he touched on the fact that there are now massive cuts to health funding. He did talk about cuts to maternal health care in the United States. Yeah. But its research programs have been cut, vaccination programs being cut, the food and drug administration's being cut, emergency services has been cut. I mean, it's a whole system thing where the horrors of what we're seeing in USAID are then replicated, not at the same scale because you're not dealing with people

dying in their hundreds of thousands of malaria, but across the United States. And yeah, I mean, and I think what's going to happen with these films is we'll find that they will be films trying to make the case again for global health, maybe, explain what these USAID cuts mean and try to bring home to people. I mean, he's still obviously praying that some of this stuff is salvageable. It's going to be reversed. But as he's pointed out, for a lot of the vaccine, a lot of the food, it's just too late. Yeah.

And, of course, Mr. Robert F. Kennedy is the guy in charge of the whole health department anyway. So that must make him feel even worse. Well, listen, I thought it was very good. I hope listeners enjoyed it. And see you again soon. See you soon. Thank you, Alison. Bye.

Bye-bye.