Why Spend U.S. Dollars on Healthcare Abroad?

— Atul Gawande on how USAID's international relief helps us at home

MedpageToday
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    Emily Hutto is an Associate Video Producer & Editor for MedPage Today. She is based in Manhattan.

In this exclusive video, Jeremy Faust, MD, editor-in-chief of MedPage Today, chats with surgeon, author, and public health leader Atul Gawande, MD, MPH about his role as assistant administrator for Global Health at the U.S. Agency for International Development (USAID), and how the organization's efforts help both at home and abroad. The two also discuss the long-term repercussions of COVID-19 on the global health system.

The following is a transcript of their remarks:

Faust: Hello, it's Jeremy Faust, editor-in-chief of MedPage Today. Today we are going to be joined by Dr. Atul Gawande.

Dr. Gawande is a surgeon, a writer, and a public health leader. He was founder of Ariadne Labs, a joint center for health systems innovation. He served as a member of the Biden Transition COVID-19 Advisory Board, and from 2018 to 2020 he was CEO of Haven, the joint venture of Amazon, Berkshire Hathaway, and JPMorgan Chase.

I'll set this up by just saying that USAID has had some tremendous successes over the decades, delivering smallpox vaccines to far-flung nations, implementing PEPFAR [United States President's Emergency Plan for AIDS Relief], the highly effective HIV relief program. But I would like you to explain to a hypothetical patient in my urban ER why we are spending that money abroad and not here.

Just for scale, USAID has a budget of $50 billion per year, and it could go up to $60 billion in the next fiscal year. If we directed that money at, as you say, the poorest 5% of U.S. households, we could spend over $4,000 per person per year on our own people. How do you think about that choice that we are making as a country?

Gawande: First of all, Americans don't know much about USAID. We are well known abroad. I have in the health sector, which is somewhere under a fifth of that budget, I have 2,500 people in 63 countries touching over 100 countries in the world. We're deploying these resources around narrowing the gaps in survival in the world, in the burden of illness, and in ensuring our security.

There are two big reasons why this is an absolutely worthwhile investment. Number one is national security reasons. We, through our relationships, are able to build out the capacity around the world that is strengthening their abilities to identify outbreaks and understand how to prevent and respond to them because of our relationships in the world.

I'm shocked at the number of serious outbreaks with major global potential that occur on a regular basis on my watch. In fact, I've stood up a global health emergency response system and team here that handle at least three crises at once and do not divert from our regular work. It includes two Ebola outbreaks in the last year, including one in Uganda that reached the major international travel hub of Kampala and was predicted, with the early pace at which it started to explode, to have been the worst Ebola outbreak in history and a nightmare of spreading through international travel, since Kampala is an airline hub.

That response was able to be mounted because of a strong body of relationships, investments, that have gotten the laboratory systems and the training to healthcare workers in place, so that it was less than a hundred days that it was brought to zero, as opposed to in 2014 it took a couple years and reached the United States.

That's one reason, and that's the immediate self-interest argument. The larger one is that the United States stands for something, and what we stand for that's different in this transactional world of diplomacy, including the China's and Russia's of the world, is that we believe that, going back to a fundamental principle of medicine and a fundamental principle of our own Constitution, that all lives are of equal worth, that we are all created equal.

We're not responsible for every life on earth. We are most responsible to the people closest to us, our own family, for their lives. We're responsible to our own community. But, we still bear some responsibilities to make the world a better place.

Our contributions in the world -- yes, the eradication of smallpox, [being] the driving force in the Green Revolution that helped turn India from a food famine country into a country that is a food exporter -- have produced a, yes, more prosperous world, a more secure world, a more democratic world over time, but these contributions also strengthen our relationships in the world and the values that we are trying to project and stand for.

We don't 100% live up to them any more at home than we do abroad, but it means that we're a place that has been able in this next generation -- you know, we marshaled the largest volume of donations of vaccines in history, but also got other countries to do the same when China was only willing to sell vaccines at a profit. We have got work that is across the board.

I'd say our biggest challenge now in this pandemic phase is that coming out of the pandemic, we had the largest reduction in global life expectancies since World War II. We are now marshaling efforts around the world to aim for a recovery to better than pre-pandemic survival levels by 2025.

You simply cannot do that without a leader in the world, and for better, I think, but it is simply the state of affairs, people look to the United States to lead on global health and on human development around the world.

We have a responsibility to make this a better planet, and that's to our benefit as well.

Faust: Thank you for making the case. I'll just bookend that by saying that it's an interesting space that USAID fills, because at the end of the day, your guidance is coming from the State Department as opposed to another health entity. So this is a geopolitical concern as well and aligns need and value. So I think that we could dive deeper, but I think you make a great case for it, and I appreciate the answer.

Let's close with a little discussion of COVID. This Administration seems to get criticism on both sides of the spectrum. Some say we've done too much and made it a bigger deal than it is -- I don't agree with that. Others say that the end of the Public Health Emergency is tantamount to abandoning the high-risk populations.

I'm wondering, what do you think as a government we could be doing more of right now? I'm specifically also referring to your recent New York Times opinion in which you argued that the pandemic response going forward, the aftermath, is as important as the acute response was. So how do we maintain that focus?

Gawande: The key thing is that COVID, number one, continues to be maybe a top 10 killer, still, that is going to be with us, that has to be incorporated into our routine healthcare. So the pandemic emergency is over, but we now have a major disease that we are living with.

CDC recently just opened a coronavirus office that is now a regular [entity] alongside tuberculosis and other things. It has a new disease that they work on. And similarly, at USAID and throughout the U.S. government, we are working through incorporating this into planning for an implementation around how does this become a regular part of primary care.

WHO [World Health Organization] recommendations now have some of the roadmap, that the 20% sickest in the world and oldest in the world or most at risk in the world are where we need to concentrate now. Making sure they not only have their primary series vaccination, but are up to date on a booster to within the last 12 months since vaccination. But [there's] unclear value, given the lower rates of cases and death, that the other groups need that same level of investment and vaccination.

So I think we're needing to make those basic investments, but the larger picture is that COVID decimated our health systems in significant ways, or are putting pressures on health systems in significant ways in the United States. I mean, it's increased our volume of patients 5% to 10% in hospitals and in clinics. We have to have efficiency and surge capacity for that. Well, that's happened around the world.

Moreover, the damage done to health systems from diversion of resources, from the rising level of economic damage done, the debt that's resulted, the reduction in spending available for healthcare -- that is happening across the world. The result of that is that we are facing a squeeze for the next several years on what's happening in healthcare in ways we haven't faced before.

Part of what I'm arguing for is that many of the first places that get cut are in primary care, the frontline workforce that is necessary to execute on almost everything that are basic goals. I'll just tell you that around the world, we have a massive increase in measles outbreaks, because childhood immunizations are down. We have a report out of UNICEF ... that the levels of immunization are back to where they were in 2008.

We've lost almost 15 years of progress in immunization. That's tens of millions of children who have gone without immunization. Just take measles alone -- we now have more than 100,000 deaths a year in the world from measles. We have polio back in Africa, we have cholera in 30 countries where we thought this was now on the run.

The result of that is the workers we need, whether it's to identify the next outbreak, get immunizations back up, be able to pull people who are lost to care back into care, those are our primary care workers, and they have been the first cut in many cases and need to be the first protected if we're going to recover our lost gains in life expectancy around the world. That includes here, at home.

Watch these two other recent video interviews with Gawande:

Atul Gawande on the Importance of Palliative Care

AI and the Safe Surgery Checklist