Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”
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Listener supported. WNYC Studios. This is the New Yorker Radio Hour, a co-production of WNYC Studios and The New Yorker. Welcome to the New Yorker Radio Hour. I'm David Remnick. Two weeks after the inauguration of Donald Trump, the new president's chief campaign funder, his consigliere, and the richest man in the world, Elon Musk, tweeted in a tone of glee, We spent the weekend feeding U.S. aid into a wood chipper.

Musk was, of course, referring to the Agency for International Development, an agency that has saved millions of lives. If the power of the United States means something positive around the world, the efforts of thousands of foreign aid workers in U.S. aid — doctors, nurses, logistics experts of all kinds — have a lot to do with that. But Musk and Trump see it otherwise, and they have decimated the agency. Into the woodchipper it has gone.

Now the courts have blocked aspects of the federal purge of U.S. aid, but the damage can't easily be undone. Atul Gawande was a senior leader of U.S. aid during the Biden administration. He ran critical health programs all over the world. Gawande is a surgeon, an author, and my longtime colleague writing for The New Yorker. He's been watching in absolute horror as the agency has been summarily pulped. We spoke last week.

Atul, President Biden appointed you as the assistant administrator for global health at USAID, and you stepped down on Trump's inauguration day. And he immediately began targeting USAID with an executive order that halted all foreign aid. Did you know or did you intuit that Trump would act the way he has? No idea.

Previous Trump administration, they had embraced what they themselves called the normals. They had a head of USAID who was devoted to the idea of development and soft power in the world. Now, they had their own wrinkle on it.

which I didn't disagree with. They called it the journey to self-reliance. They wanted to invest in Africa, in Asia, in Latin America to enable stronger economies, more capacity, and we weren't doing enough of that. And I actually continued much of the work that had occurred during that time. Well, tell me a little bit about what you were in charge of, what the good that was being done in the world. Yeah, so...

This is a job where I had 2,500 people between D.C. and 65 countries around the world working on advancing health and protecting Americans from diseases and outbreaks abroad.

And the aim was to work with country to build their systems so that we protected the global health security and improved global outcomes of everything from reducing HIV, AIDS, and other infectious diseases like malaria and TB to strengthening primary health care systems so those countries would move on from depending on aid from donors.

That work, in three years, we documented being able to save more than 1.2 million lives after COVID alone. Well, let's pause on that. Yeah. Your part of USAID was responsible demonstrably for saving 1.2 million lives. Yeah. Part of my target was reduce the percentage of deaths in any given country that occur before the age of 50.

And teams would focus on what were the top three to five killers. And in some places that would be HIV. In some places that would be TB. It would include, you know, safe childbirth was a huge part of the work. What in the world was the case against this kind of work? What could possibly be the case against it?

So one case is that it could have been more efficient, right? That Americans imagine huge sums of money going to this work that, you know, polls show that they think that a quarter of our spending goes to foreign aid. So it's a minuscule amount. Yes. On a budget for our global health work, that is half the budget of the hospital I did surgery in,

here in Boston, we reached hundreds of millions of people with programs that saved lives by the millions. It is at a level of scale I could never imagine experiencing. So the case against it is, you know, I woke up one day to find Elon Musk tweeting that this was a criminal enterprise.

that this was democratic money laundering, that this was corruption. Where would he get this idea? Where does this mythology come from? Well, what's hard to piece apart is what is just willful,

Not just ignorance, it's lying, right? For example, there's a statistic that they push that only 10% of U.S. AIDS dollars actually got to recipients in the world.

Now, this is a willful distortion of a statistic that says only 10% of USAID's funding went to local organizations as opposed to multinational organizations and others. There's a legitimate criticism to be made that that should be higher, more local organizations get the funds. I did a lot of work that raised those numbers considerably, got it to 30%.

But that was not the debate they were having. They were claiming that the money is not actually reaching people and that corruption is taking it away. When, in fact, the ability to get to enormous numbers of people has been a best buy in health and in humanitarian assistance for a long time. Now, the overall agency, as I understand it, had about 10,000 people working for it. How many are working at USAID now?

Yeah, actually, the number is about 13,000, but over 80% of the contracts have been terminated, representing the work that is done by USAID and the for-profit and not-for-profit organizations they work with, like Catholic Relief Services and things like that.

And more than 80% of the staff have been put on administrative leave, terminated or dismissed one way or the other. So it's been obliterated. It has been dismantled. It is dying. I mean, at this point, it is six weeks in.

You have had 20 million people with HIV, for example, including 500,000 children who have received medicines that keep them alive, who've now been cut off for six weeks. A lot of people are going to die as a result of this. Am I wrong? Yeah. The internal estimates are that over 160,000 will die from malaria per year.

from the abandonment of these programs if they're not restored. That we're talking about 20 million people dependent on HIV medicines, and you have to calculate how many you think will get back on and how many will die in a year. But, you know, you're talking hundreds of thousands in year one at a minimum. Just on the reduction in immunizations, you're talking about more than a million estimated deaths. I'm sorry, Atul. I have to stop my cool journalistic questioning and say, yeah,

This is nothing short of outrageous. And how is it possible that this is happening? Obviously, these facts are filtering up to Elon Musk, to Donald Trump, and to the administration at large, and they don't care?

The logic is to deny the reality, either because they simply don't want to believe it, that they're so steeped in the idea that government officials are corrupt and lazy and unable to deliver anything, and that a group of young 20-something engineers will fix it all, or they are indifferent. And when he waves around the chainsaw, we're seeing...

what surgery on the U.S. government with a chainsaw looks like at USAID. And it's just the beginning of the playbook. This was the soft target, right? This is affecting people abroad. It's tens of thousands of jobs at home. So there's harm here.

there's disease that we'll get here, et cetera. But it was the easy target, and now it's being brought to NIH, to CDC. So the National Institute of Health, Center for Disease Control, and other such bureaucracies who do equal medical good will also get slammed. Are being slammed. From the outside, at least, Atul, and maybe from your vantage point as well, this looks like absolute chaos.

I've been reading this week that staff posted overseas are stranded, fired without a plane ticket home. From the inside, what does it look like? One example, I have had people I've spoken to, you know, one case,

pregnant woman in their third trimester of pregnancy in a conflict zone, and they have maternity leave just like everybody else. But because the contracts had been turned off, couldn't get a flight out and were not guaranteed safe passage and couldn't get care for her complications and ended up having to get cared for locally in a place without a

the setup for being able to address her needs. One person said to me that I spoke to, she said, as she's enduring these things, my government is attacking me. We ought to be ashamed. Our entire system of checks and balances has failed us. Where is the agency most active? Who is it helping? And what's been the reaction in these countries, in the governments and among the people? I mean, the sense of abandonment

must be intense on all sides. So I'll say there are broadly three areas. The biggest part of USAID is it's the FEMA for...

disasters abroad. It's called Bureau of Humanitarian Assistance. And they bring earthquake response, wildfire response in conflicts, you know, famines. These are the people who suit up and get assistance and stabilize places where things are going wrong. You know, John F. Kennedy, when he formed USAID in 1961, said it was to counter the adversaries of freedom,

and to provide compassionate support for the development of the world. And those components are the ones where, you know, it's USAID has kept Ukraine's not only health system going, but

made important, vital support to keep their energy infrastructure going as Russia attacked it, right? In Haiti, this is the response team that has sought to stabilize what's become a gang-controlled major part of the country. And our health teams kept

almost half of the primary healthcare system for the population going. So around the world, stopping fentanyl flow, all of that has been wiped out completely. And in many cases,

The people behind that work, I mean, many of the people were working with local partners to keep these things going. Those partners are being attacked in country after country. What you're describing, beyond simple human compassion, is soft power. Describe what that is, why is it so important to the United States and to the world, and what will squandering it, what will destroying it mean?

The tools of foreign policy, as I've learned, are defense, diplomacy, and development. And the development part is the soft power part. We're not sending troops into Asia and into Africa and into Latin America. We're sending hundreds of thousands of civilians without uniforms who are there to represent the United States,

to pursue common goals together, whether it's stemming the tide of fentanyl coming across the border, addressing climate disasters, protecting the world from disease. And that soft power is a reflection of our values, what we stand for, our strong belief in freedom, self-determination, and advancement of people's economies,

bringing more stability and peace to the world. That is the fundamental nature of soft power, that we're not what Trump is currently trying to create, a world of simply might makes right and you do what we tell you, because that does not create stability. It creates chaos and destruction. I'm speaking with Atul Gawande. More in a moment.

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Or something like that. So Tax Act offers expert assist with live tax experts to make filing taxes less scary. Now you can just have pleasant dreams about being chased by other giant, non-threatening paperwork. Tax Act. Let's get them over with. Now, what about Secretary of State Marco Rubio? What's his role in all of this? Back in January...

He issued a waiver to allow for life-saving services to continue. That doesn't seem to have been at all effective. It hasn't happened, right? So it's clear that he's not in control of the mechanisms that make these things happen. Doge does not approve the payments going out and has not approved the payments going out to sustain that work. Atul, we're talking about public health, and here at home we've got a measles outbreak in Texas and New Mexico.

RFK Jr., whose views I think our listeners are familiar with by now, has advised some people to use cod liver oil. Where could the United States be in a couple of years from a health perspective? What worries you the most about what's going on? Measles is a good example. There's actually now been a second death. We haven't had a death from measles in the United States in years. We are now back up globally to over 100,000 child deaths worldwide.

And as you start seeing what happens is we not only pull the rug out from an organization like USAID, handcuff CDC, but then also ban even communication, let alone funding for with the World Health Organization.

I was on the phone with officials at the World Health Organization. The U.S. had chosen measles as a major area that it wanted to support. So it provided 80% of the support in that area and let other countries take other components of WHO's work. And so now that money has been pulled out.

measles programs around the world. And having a secretary of health who has done more to undermine confidence in measles vaccines than anybody in the world means that that's a singular disease that can be breaking out. And we'll see many more child deaths that result from that. Atul, on another subject, I understand that you've been called in to testify about

in a lawsuit. What's the case and what's at stake there? Well, I've been asked to prepare to testify. So the lawsuit is the one that is making its way through the federal courts. USAID is the testing grounds for some fundamental questions. It starts with if a president decides that they're not going to pay the bills that the government has contracted with people to pay, whether that's lawful or not. Who's filing the suit?

So the suit is the AIDS Vaccine Coalition, called AVAC, and the Global Health Council, along with a group of other USAID members.

partner organizations that are suing Donald Trump to do three things, pay their past bills, which are due, lift the freeze on foreign aid, and enable an apparatus, including the staffing in USAID, to continue the work that Congress had mandated.

be performed. So it's three different questions. One is, do you abide by your contracts, which if the government can do that, can drop contracts instantly? I mean, a government invoice promising to pay is treated like cash in the world. So if the U.S. is no longer trusted to pay, that's going to have destabilizing consequences for the economy. How did the Supreme Court get involved?

So that first question, the court ruled that the government had to pay its bills and put in a restraining order indicating that those bills had to be paid by such and such a date. The government sued, and it went all the way up to the Supreme Court. And it's a narrow question, does the government have to pay its bills? The court said, yes, it has to pay its bills.

five to four vote. It was an open question whether the court would simply give carte blanche. And so that was a narrow ruling, but a big deal. And right now, you know, the government is supposed to pay the bills this week, and we'll see if they do.

The second question is that whether they followed proper procedures in terminating the contracts of all of these organizations. There is a law about how much notice you give and not only notice that you do it for individualized cause. You cannot en masse terminate an entire agency.

And so that's being tested. And then the third test is whether there is a separation of powers, that when Congress says, here are the funds that the executive branch is supposed to spend to

stop HIV in the world. These are so-called earmarked funds. They are specified what their uses are, and that the executive branch doesn't have the option to simply, you know what, that sounds like a good suggestion, but I'm going to use it in a different way.

Those are the three core questions. And I've submitted an affidavit and potentially being asked to testify on what the normal processes were when we

in the Biden administration or in previous administrations, terminated contracts or laid off people or dealt with fraud, waste, and abuse. You know, I had the feeling that you, even in a short time, loved being in the federal government, which always sounds funny to people's ears because the federal government and bureaucrats and pointy heads and all that are made fun of constantly in political rhetoric. Right.

But what I hear in our conversation is a sense of tragedy that is not only public, but that is felt very intimately by you. I did not expect going into government would be as meaningful to me as it was. I went into government because it was the COVID crisis and I was offered an opportunity to lead the international component of response. We got 700 million vaccines out to the world.

But what I found was a group of people who could achieve scale like I'd never seen. Mission-driven. None of these people went in for the money.

It's not like they had any power. I assume all of them could have made more money elsewhere. Absolutely. And, you know, many of them spent their lives as foreign service officers living in difficult places in the world. And, you know, I remember Kiev was under attack about eight weeks after I was sworn in. And I thought I was going to be working on COVID. But here is this thing erupting.

First of all, our health team, along with the rest of the mission and embassy and Keeve, had to flee for safety. But within a week, they already were like, we have TB breaking out. We have potential polio case. How are we going to respond? And my critical role is to say,

what's going to kill people the most? Right now, Russia has shut down the medical supply chain, and so 100% of the pharmacies just closed. 250,000 HIV patients can't get their meds. A million heart patients can't get their meds. Let's get the pharmacies open. And by the way, they've attacked the oxygen factories and put the hospitals under cyber attack, and their electronic systems aren't functioning. And this team, in four weeks...

We're able to move the entire hospital record system to the cloud, allowing protection against cyber attacks, got oxygen systems back online, and we're able to get 50% of the pharmacies open in about a month. And it ultimately got 80% of the pharmacies open. That is just incredible. Like, yes, I mean, are there some people that I had to deal with who were

Did I have to address some people who were not performing? Absolutely. And did I have to drive efficiency? And in every place you have to do that. But this was America at its best. And I was so proud to be part of that. And why?

What frustrated me was in that job, I had to speak for the U.S. government. I couldn't write for you during that time. Believe me, I know. I couldn't tell the story. I've got a book I'm working on now that I hope to be able to unpack all of this. But it is, I think, a sad part of not getting to be part of my leadership that I didn't also get to communicate what we do, partly because USAID is restricted in certain ways from telling its story within the U.S. borders.

Atul, if you could tell Elon Musk and Donald Trump directly what you're telling me about lives saved, good works done, the benefits of soft power to the United States and to the world, and so on, do you think it would have any effect on them at all? Zero. There's a different worldview at play here. It is that power is what matters, not impact, not the overall impact.

maximum good that you can do. And having power, wielding it in ways that can dominate the weak and partner with your friends. When I say partner with friends, I mean partner with people like Putin who think the same way that you do. Well, a final question then. Is it irreparable? Is this damage done and done forever? No.

This damage has created effects that will be forever. It will not come back. Like, let's say they turned everything back on again and said, oops, I'm sorry. I had a discussion with a minister of health just today. And he said, I've never been treated so much like a second class human being. This is a foreign minister of health.

Yes, this is a minister of health in another country, let me just say. And, you know, for decades, America was there. I never imagined America could be indifferent, could simply abandon people in the midst of treatments, in the midst of trials, clinical trials, in the midst of partnership, and not even talk to me, not even...

have a discussion so that we could plan together. Okay, you're going to have big cuts to make. We will work together and figure out how to solve it. That's not what happened. And, you know, never will trust the U.S. again. And

We are entering a different state of relations. You know, in some ways, I think there will be... We are seeing lots of other countries stand up around the world. Our friends, Canada, Mexico, but, you know, African countries too, Europe. Everybody is taking the lesson that America cannot be trusted. It's tragic and outrageous, no? That is beautifully put. What I say, it is...

I'm a little stronger. It's shameful and evil. Atul Gawande, thank you. Thank you. Atul Gawande was assistant administrator of the U.S. Agency for International Development until January. He's a surgeon, a professor of health policy, and a longtime contributor to The New Yorker. This is The New Yorker Radio Hour. I'm David Remnick. Thanks for listening. See you next time.

Thank you.

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