The Trump Administration’s abrupt dismantling of the US Agency for International Development (USAID) has triggered a wave of already hundreds of thousands of deaths, mostly of children, around the world. Atul Gawande—former leader of global health at the agency—draws on data, historical parallels, and on-the-ground fact-finding to reveal how gains against malnutrition, infectious disease, and child mortality are being rapidly reversed. Gawande argues that this is a case of “public man-made death,” and calls for accountability and renewed commitment to lifesaving global health efforts.
EREZ MANELA: Thank, you everyone. Good afternoon and welcome. My name is Erez Manela. I'm the acting director of the Weatherhead Center for International Affairs. Welcome to all of you to the Samuel L. and Elizabeth Jodidi lecture, titled "The Mechanics of Public Man-made Death, USAID's destruction at one year.
The Jodidi Lecture is among the most prominent lecture series of the Weatherhead Center and one of the most distinguished at the University. Established in 1955, the lecture series provides for, and I quote here, "The delivery of lectures by eminent and well-qualified persons for the promotion of tolerance, understanding, and goodwill among nations, and the peace of the world," unquote.
Well, I think it's safe to say, based on this turnout, that today's speaker fulfills the requirement for eminence. We are honored to welcome Dr. Atul Gawande, renowned surgeon, author, and public health innovator. He holds the John and Cyndy Fish Chair in Surgery at Brigham and Women's Hospital, and is a Samuel O. Thier Professor of the Practice of Surgery at Harvard Medical School.
Dr. Gawande was Assistant Administrator for Global Health at USAID, the United States Agency for International Development, from January 2022 to January 2025. Prior to that, he co-founded and chaired Ariadne Labs, a joint center for health systems innovation, where he is now distinguished professor in residence, and Lifebox, a nonprofit organization making surgery safer globally.
From 2018 to 2020, he was CEO of Haven, the Amazon, Berkshire Hathaway and JPMorgan Chase health care venture. Dr. Gawande is also a longtime writer for The New Yorker magazine, and has written for the New York Times best-selling books, Complications, Better, The Checklist Manifesto, and Being Mortal.
He is a member of the National Academy of Medicine and has won two national magazine award, Academy Health's Impact Award for highest research impact on health care and a MacArthur Fellowship. He is the executive producer for three documentary films, the Emmy-nominated adaptation Being Mortal from 2016, the Oscar-nominated film To Kill a Tiger from 2024, and The New Yorker film, Rovina's Choice from 2025, which was linked in the announcement for this talk. So I hope many of you have had a chance to view it.
After Dr. Gawande delivers his remarks, he and I will be in conversation right over here for a short while. And then we'll open the floor to your questions. You will see two standing mics on the two aisles here. When we get to the question period, please form two lines behind the mics, and we will get to as many of your questions as we can.
An important final note, this lecture and Q&A are being filmed by the Weatherhead Center, and also by an independent filmmaker working on a documentary about the dismantling of USAID. By sitting in the audience and/or posing questions, you implicitly consent to being in the film.
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Sorry, that's the legal disclaimer. It's here.
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If there's anybody without a seat-- I'm not seeing anybody like that-- but if there's anybody without a seat, there's an overflow room around the corner on this floor, Room S50. Please join me in welcoming Dr. Atul Gawande.
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ATUL GAWANDE: Let's see. I think my mic is working. What an honor to be here. Thank you enormously. I see some friends in the audience and a lot of new people. And I really welcome the chance to come across the river from our hospital world to your world of grander thought. Heh. Also, I am pleased to have Samantha Power here, my boss from USAID, who made the fateful call to ask me if I would come work for her to lead global health at USAID in 2021. Didn't know it would take a year and a Senate confirmation, but we got there.
[CHUCKLES]
The moment I want to pick up is in January of 2025, when I stepped down from the role. It's a political appointment. So with the departure of the outgoing administration, the role that I was playing left. I had to leave the government on January 20 at noon, as the new administration was being sworn in. And I will say, I did not see what was coming.
Leading global health at USAID was, I've described many times, the best job in medicine you've never heard of and the most gratifying single experience in my medical career. I had 2,500 staff in 65 countries working to advance global health development, global health delivery around the world. And now I was returning to my previous life, coming back to Harvard, coming back to the Brigham and Women's Hospital and the School of Public Health.
And I spent my last days really thanking our civil service and foreign service leaders and staff. They had, in the three years that I was in this role, from January of 2022 to January of 2025, they had done extraordinary things. I'd never managed an Ebola outbreak before, and we managed 11 serious outbreaks of Ebola and other viral hemorrhagic fevers around the world. They had responded to 21 total outbreaks of deadly diseases.
We had sustained Ukraine after the attacks from Russia that cut off its supply of medicines. The loss of the medicine supply in the first week shuttered 100% of their pharmacies across the country. More people were at risk of dying than were going to die from any of the bombs, a quarter million HIV patients in the country who depended on having medicines, over a million heart patients who would not get access to medicines.
And I saw teams that, in a matter of weeks, worked with the government to successfully regain access to medicines brought in through new routes, set up systems that could arrange for 5,000 humanitarian aid organizations to fill in the gaps, and then also address the bombing of oxygen factories, the cyber attacks on the hospitals that shut down their electronic systems, and other steps like that.
I saw these teams I was working with combat, HIV, TB, polio. I saw them reduce maternal and child deaths. On a budget of $24 per American taxpayer, out of the $15,000 the average American taxpayer pays, they saved lives, contained disease threats around the world, and played a key role in helping move countries to self-sustained economic growth.
Now, the final weeks as I was getting ready to leave the role, a lot of the leaders I was meeting with were expressing concern about what might be to come. It was unclear. But I sounded a sanguine note. I pointed out that when you read Project 2025, it did not call for anything dramatic or drastic to you about USAID. It pointed to President Trump's leadership in making a goal of eradicating HIV around the world by 2030.
I also noted that it was founded out of beliefs that we still held to this day. John F. Kennedy founded USAID, proposed it to Congress, fought for it and won it out of the experience of World War II. After World War II and the defeat of the Axis powers, we did not do what victorious nations tended to do. We did not plunder the countries. We did not take over and terrorize their populations.
We invested in disaster relief, food, shelter, medicines to get them through. We offered a helping hand, not a punch in the face. And then, with an incredible investment of the Marshall Plan, we invested in redeveloping their industry, redeveloping their systems for education, for health. And we learned from that that their prosperity led to our prosperity, that it allowed for peace and stability that would last decades.
And John F. Kennedy saw that that soft power approach, rather than the hard power approach, was better for the United States militarily, politically, as well as morally. And so he wanted to bring and made the case to the American people to bring that same approach to Latin America, to Asia, to Africa, to low-income countries around the world that did not have the advantages the United States had.
And so that approach was never completely popular, sometimes didn't poll well with the American people, but got steady bipartisan support no matter what kind of administration was in office. My own family benefited from this kind of experience. My grandmother died of malaria with my father at age 10 sitting by her bedside watching her with her recurrent high spiking fevers, getting sicker and sicker over the course of six weeks.
And in a rural farming village in Maharashtra, India, he felt that there was-- he knew in his bones, I don't know how, that there was a treatment that was out there and that she was not getting it. And when she died, he determined that he wanted to become a healer of some kind. He didn't really have the word doctor. He'd never seen a doctor in their village, and so had to move away to join other family in a city where they had a high school, and you could graduate. And he went and attended the first medical college in the state in one of the first classes that would graduate from medical school.
And in the village, it was a farming village, a subsistence agricultural village, where he was subject to all of the torment of whether the drought will make it so you don't eat that year, literally getting through a season where my grandfather spoke about having only salt and bread to get them through for one month. That was particularly devastating. They had relief, thanks to the United States. My father remembered Jackie Kennedy riding on an elephant when John F. Kennedy came to visit.
And that icon of American goodness to the world, that America meant something to everybody stuck with him, that our village would benefit not just from food aid, but then from the further investment in training agronomists around the country, supporting the ability to take on what became the Green Revolution. My grandparents' farm went from having two uncertain crops a year to three, got irrigation. And you saw problems like malnutrition disappear and saw people living longer, and much, much more.
The commitment to investment, the commitment to the helping hand was one that required an independent agency freed of short-term political goals, that could to see the interest to the country of taking on problems that take 20 years, 30 years, 40 years. The eradication of polio is now 35 years in the making. The eradication of smallpox took until 1979, and I benefited from that as well.
My parents stayed in the United States after they both met in New York City. They'd come for training as a opportunity, and as a recruitment, where the United States took 60% and UK took 60% of Indian medical graduates. And when they aimed to return, I ended up with a reaction to the smallpox vaccine, an allergic reaction, which meant that I couldn't take the further boosters required to return or to travel abroad. And so then my father trained further.
They settled in rural Ohio, working in the poorest county in Ohio, a college town called Athens, Ohio, where I was born and raised. And then, when smallpox was eradicated in 1979, in major part because of American leadership and major investment, I got to go to India and abroad for the first time. My career in global health would never have even been possible. Little did I know that I would end up leading the agency that provided the operational capacity of the United States for the smallpox eradication program.
By the time I came into office, we now had data about what this kind of work has done. The most recent data shows that from 2001 to 2021, countries that received investment from USAID averted 92 million deaths in their population, that child mortality in the countries we worked with was 32% lower, that overall mortality was 15% lower. That was the global health programs that directly worked on health, yes.
But it was also the agriculture programs, the work that lifted education of girls and boys, the work that brought electricity, for example, a program called Power Africa that's been suspended and lost, that was bringing electricity to the African continent, doing it through grants and not hidden secret contracted loans with China, with payment terms that we now know are far more onerous.
It was the totality of the work of advancing the systems and capabilities of countries around the world. And it was supported by 60 years of sustained bipartisan support. Not only had Trump ended up backing USAID after initially thinking that he was going to cut it in his first term, but Senator Marco Rubio was its strongest supporter on the Hill among Republicans. He was knowledgeable. He visited many programs. He knew just what it did.
And I could say to people, what better person to have been selected for Secretary of State? There would be skirmishes expected. There was bound to be disagreements around diversity programs, bound to be high-profile disputes around the family planning and contraceptive work. But well over 95% of what we were doing in health was going to be without any question at all. Clearly, I lacked imagination.
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The day I stepped down, within hours, President Trump signed an executive order calling for halting aid to countries around the world for 90 days. A pause, it was called, for a chance to reassess. Sounded very benign. But it was like stopping an airplane in mid-flight and saying, we'll have a pause, and having the staff-- watching them parachute out the door. There would be no funds for the partners that we worked with. They were not allowed to use the funds they had on hand. They would not to be allowed to use the medicines or the food on the shelf or in the warehouses. They could not pay staff and had to let them go.
It was immediately apparent that hundreds of thousands of lives would be lost just in that time period alone. But the administration did not reconsider. It escalated. Within weeks, the staff was purged. 80% of the contracts were terminated. They dismantled the agency. There was a supposed exception for life-saving humanitarian assistance, but it was not actually put into practice.
By the end of the year, we now know life-saving humanitarian relief spending was cut from $14 billion to $3.7 billion in 2025, a loss of extraordinary magnitude, a loss of support that was reaching millions of people in Sudan, in Bangladesh, in Gaza, in refugee camps from Kenya to Chad and elsewhere. It was money that was on hand. Congress had appropriated it. It was funded. It was ordered by Congress, and it was impounded. And neither Congress nor the Supreme Court did anything to stop it.
And now we're witnessing what the historian Richard Reeves has called "public man-made death," which he observed is perhaps the most overlooked cause of human mortality in the last century. There have been two independent estimates of the deaths that have occurred already in the last year. Boston University has built a model with extremely conservative assumptions. I believe this is where these numbers that are being flashed come from.
Their model is conservative in the sense that it focuses only on the direct investments that were made in global health. Doesn't count the humanitarian relief. Even in the ones in global health, there weren't models to estimate how many were dying from cutoff of funds for increased safety in childbirth or other programs like that. It was focused on the infectious diseases.
And even in the infectious diseases, the assumption was that the funds that had been impounded would largely be spent, which they were not consistently done, and that when they were spent, they would be used just as effectively as it was before you had purged the staff who could make it happen. And despite all of that, the estimate was that over the course of 2025, at least 750,000 people have already died, most of them children.
There's been a separate effort led by a team out of Brazil, an international consortium that have done microsimulation modeling, modeling the effects of the cuts with a different approach taken. And they came to the same magnitude of deaths, around 700,000 deaths that they estimate, for 2025. And we know the toll will only grow.
The Institute for Health care Metrics and Evaluation has made their own estimate. And they judge that, based on what they are seeing, we are going to have the first increase in child deaths since the 1960s, when Mao Zedong led the Great Leap Forward. That was, in fact, the Great Leap backward from 1958 to 1961 that led to widespread famine.
But these losses are much harder to see than those that might be of war, which was the kind of "public man-made death" that Richard Reeves was focused on. These deaths unfold slowly. When you cut off people who are getting HIV treatment or improved systems for TB or you are going on a campaign and rampage against vaccination and cutting off US assistance, the diseases that would have been prevented take months, sometimes years, to produce their ultimate deaths.
Further, the deaths are scattered, and that makes it hard to see. It's not concentrated in any one place. For example, if you have the mortality rate for children under five go from 3% to 4%, which is a very realistic possibility, that's a 1/3 increase in deaths. And yet, just walking around you would have a hard time seeing it and judging whether is this death of a child from the cutoff that just happened?
And so the administration denies the harm, and then at the same time makes it harder to recognize the harm. They're actively suppressing the data. Every year on World AIDS Day, which occurs in July of each year, that is the year that the government releases its data from the PEPFAR program, which funds much of the data collection around the world, monitoring not just the HIV deaths that occur, but how well programs are going, are what percentage of HIV patients are being diagnosed, with the target being getting to 95% diagnosed.
And then 95% should be getting on treatment, and 95% of those people should be successfully virally suppressed. We were climbing past 90%, past 90, 90, 90, to epidemic control, as it's called, and a realistic possibility of actually ending the major HIV epidemic as a public health problem by 2030, thanks to the advent of lenacapavir, a new drug, which is a single six-month enduring injection that can serve as a treatment or preventative for HIV, with new research potentially showing it could be as long as a year, a flu shot that could stop HIV.
And instead, we've not only dismantled, we did not release data on World AIDS Day. There are, I think, only three or four people who know what that data is, and I'm confident that it does not show anything good because you know they'd be releasing it otherwise. And we have indications in country by country that the systems to prevent transmission to children during child delivery, that the systems to keep men who have sex with men, sex workers, transgender populations, having their access to treatment, being able to receive preventive solutions, that those have been degraded to an extraordinary extent. And that's just HIV.
They've halted data monitoring for the demographic health survey, which is the system that the US had founded to have accurate, detailed data on conditions and health and the function of systems around the world. The US has sponsored the Census Bureau. USAID has backed the Census Bureau. I worked closely with the Census Bureau director to bring census systems to countries around the world so that they're able to monitor their vital statistics and put in place increasingly more sophisticated systems. Those have been halted.
But then, as if that's not enough, they also fired the Inspector General, who would be detecting and measuring and calling out the medicines and the food that are expiring and rotting in the warehouses, the breakdown and loss of assets, hundreds of vehicles abandoned around the world, thousands of vehicles abandoned around the world.
And the effects on the staff and infrastructure and the controls that made sure that funds were not getting in the hands of whether it's terrorists, corrupt agents around the world, there's no question there were gaps that could be closed. But they were there, and it was a constant battle to deal with issues of corruption. But things have been massively worsened.
This loss of visibility is common with man-made death. When Mao had the Great Leap Forward backfire, where they were taking village work, village farmers, having them work to make iron in their backyards and abandon the fields, they saw how bad things were getting and put out no accurate data for years on what the conditions were.
So it was known to the rest of the world that there was a hunger crisis because of the rise in the amount of grain imports that China was making. But it was not for more than two decades, until the 1980s, when they resumed their first reliable census. And you could make calculations based on that that historians recognized that 23 to 30 million people died in the course of the famine from the Great Leap Forward.
In that way, for 2025, the actual mortality statistics will not be available to us, likely until mid-2027, to know exactly what's happened. But there are other ways to begin to see the magnitude of the harm. WHO just a few weeks ago put out their update from their emergencies division. And what you can see are the kind of magnitude of the cuts in services that have occurred.
They were responding at the beginning of 2025 to 43 major emergencies in 74 countries. 20 of them are what are called grade 3, which is the highest level of emergencies. That's where deprivation of food, of safety and security, of water occurs where you have displaced populations in large scale and so on. And they were able to respond to focus on-- well, the aid was reaching 81 million people in desperate situations. The US was a major contributor, but so were other countries. The largest cause was violence. The second largest causes were climate and earthquake-related disasters.
US cuts, instead of being filled in by others filling the gap, were followed by others taking our lead. Partly, this was because of the insecurity in Europe. Once we no longer were committed friends of Ukraine, no longer putting a major investment towards the security of and the ability for them to be a free people, Europe had to increase its military commitments immediately. And one of the very first places that gets taken out of is your foreign assistance commitments.
Where JFK was trying to move us towards making small investments that averted very large costs militarily and politically, we were going and pushing other countries to go in the opposite direction. And then you had situations like Japan, where their currency has been degraded 30% over the last few years, so that even when they're flat funding, that translates into much less dollars available.
The consequences of that loss of aid with everyone following is that now, instead of 81 million people, it's 43 million people that are able to be reached. That's a loss of almost 40 million people for getting support. The cuts have halted operations of more than 2,000 health facilities as a result that have been completely halted in operations, and disrupted operations for another 3,000 plus.
There's another way you can try to see what's happening, and that is to try to actually see it. And I joined with a documentary team of American journalists and local journalists to follow what has happened, in particular in Kenya, in communities in Kenya, where USAID was active, where I had done a good deal of work directly. And we visited an advanced HIV ward in Nairobi and then continued to follow it, primary health care facilities in hard-hit communities and a refugee camp.
Kenya has been following a familiar path of development, that as we invest in everything from power to education and to building not just emergency relief on health but support in a way that can help build primary health care systems for health, it was on a path to middle income status. It's reached low middle income status. And we started to be able to dial away certain kinds of support.
This is what India went through as it went from a place of food aid and famine and disbelief that it would ever be anything but a basket case, to becoming a major trade partner for us, one of our top five trade partners and a food exporter and source of aid in its region of the world. That's happened to South Korea. That's happened to much of Latin America, which has gone from less than 40% of the countries being middle income or higher, to 80% being at that level, and those places being largely free of major development assistance and being partners instead. And Kenya, in particular, was on this path.
I was particularly concerned about programs or concerned to see the programs for malnutrition. In the past two decades, the US has played an important part in a major leap in our capabilities and knowledge of how to manage malnutrition. For children with the most severe form of acute malnutrition, the mortality rate in coming to a health facility was over 20%.
But with a shift in approach that moved care to community health workers upstream from the worst cases, being able to go door to door with a measuring stick and a scale, tracking children and following when they start falling off the growth curves, and in the severe acute cases being able to give ready-to-use therapeutic foods, RUTF, a formulation the US had discovered and made that you can create a bar which can have a full day's calories and nutrients for those emergency situations, and allowed 85% of the deaths to be averted just with people managing in their own homes and the hospital just there for the most severe complications.
The result was that in the countries where we were working with them to roll this out, the death rates dropped to less than 5% for the severely acute malnourished. And in the refugee camps that I got to visit, including one called Kakuma, getting it well below 1%. The US had played a central role in our research and development, in the support for the manufacturing and production, support for teaching places how to manufacture and maintain the quality controls required for that kind of therapeutic foods, the protocols in the hospitals for how to feed newborn babies and avoid refeeding syndromes. And then we provided support for key actors, UNICEF, the World Food Program, local health systems.
Globally, under-five mortality dropped by more than half since 2000, in large part due to malnutrition advances like these. And the result was it saved more than a million lives in 2023 alone. And our goal was to close the gap in those who weren't getting that kind of treatment, the advances technologically. JFK had named one of the key goals was that as we generate advancements in the high-income world, that we bring them more quickly to the rest of the world.
And our goal we had not reached the majority of children in the world yet with these discoveries over the last 20 years. But instead, we went in the other direction. WHO would report this last month that disruptions of nutrition services have affected 14 million children already alone. 2.3 million of them have severe acute malnutrition. At every place we went, we saw deaths directly due to the cuts. One of those places was the Kakuma Refugee Camp I mentioned.
I wonder if we could play the clip from Rovina's Choice. And going with a camera team, with a camera crew, allowed us to, yes, understand the breakdown in the systems, but also to piece together the story of what happens as you navigate this. We followed Sila Monthe, the clinical director of Clinic 7, which is the refugee camp's medical facility. We saw-- we'll see if they get-- this can go on. I'll let them load it while we're waiting.
EREZ MANELA: They're ready.
ATUL GAWANDE: Oh, good. Let's go ahead and start it.
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ATUL GAWANDE: Jane Sunday was just one of the children that we met. Rovina did not know, but she was sick and at death's door from starvation. The World Food Program was cut. In January, Rovina and her children were getting enough calories to stay alive. They're not allowed to work as refugees. They'd come from South Sudan across the border. That could destabilize Kenya without support for a refugee setting that can manage children and families like theirs. But the World Food Program now have made it so that their cuts left them only able to provide one meal a day, 40% of the needs of a child.
The further cuts, it also meant that the community health workers, 2/3 of them were laid off, and so no community health worker was seeing them to catch that this child was getting worse from starvation, unknown to them. Further, the nurses on the stabilization ward for those who do come, where she was going, had been laid off, with only one nurse available at any given time.
The nutritionist we interviewed that was available then was subsequently let go. Dr. Sila, the clinic director, is on a month-to-month salary as philanthropy's step in, but are only providing short-term relief. And it reveals what it's like just to follow someone and ask, what does it take when your child is sick and the world you were going through, all the systems have broken down?
There are many legitimate criticisms of what USAID does, and I suspect we'll get to talk about some of them. It could foster dependency. It could be inefficient. Too much of its funding, went to international organizations rather than to local ones to build up. Has a dark history, including episodes in which aid was bent to American military and political aims, Vietnam, Afghanistan, Iraq, and elsewhere.
And yet, the core of what it does, offering a helping hand, lifting up, building systems and capabilities and know-how, has saved more lives per dollar than arguably any other agency in the US government. It's helped move billions of people out of poverty. It's shown how to deliver results for all of humanity, including Americans, through cooperation rather than coercion.
And I would argue that the significance of the USAID closure and the disregard for the human toll that has resulted, was the first step in a dark shift in US aspirations toward naked power, extractive self-interest. The Gaza Humanitarian Foundation was the example of what aid looks like now, a private contractor with no experience in providing aid, the defunding of United Nations operations in favor of one where the infidel motorcycle group rebels were hired as security and did crowd control by shooting at people.
But that is the value that we were putting forward now, a transactional world where contractors aligned with the Israeli military rather than neutral were now the ones in charge, in Eswatini, where the HIV funds were contingent on taking deportees from the United States, and they're uncertain whether another year of funds would come.
The priority is supposedly to make US national security first, US political aims first. But it's serving neither political nor military goals, and certainly not any humanitarian goals to see what we're doing now. And it's leaving the US isolated, distrusted, and weaker, and with millions dead. With that, I think we have a lot to talk about.
But my light of confidence is it is deeply unpopular. It is deeply unpopular at home, and it's deeply unpopular abroad. Chaos, destruction, and rule by force is unstable, hated, and short-lived. I don't know if it goes away in a year or two years or 10, but these do not last. And we have to continue to make the invisible harm visible so that we can hold people accountable. Thank you.
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Thank you.
EREZ MANELA: Thank you. Thank you very much for this talk. And I have to say thank you for your service. I realized as you were talking that that's a phrase usually used for thank people who are giving service to the nation. But it occurred to me that there's no reason that it shouldn't be used for people who are giving service to humanity.
There's a number of things ask you. And one thing that struck me when you were talking at the beginning of your talk, you were giving a brief history of USAID, particularly focused on the Kennedy administration. And I'm a historian, and I noticed that you gave that history, you never once used the term Cold War, which would be the first thing that historians would think about in that context. But I'm not going to ask you about that. Maybe we can talk about that later. I don't think this audience is here for a historiographical discussion.
ATUL GAWANDE: But I will point out Russia was actually doing development at a much higher level, the Soviet Union was, at that time. And it was a response.
EREZ MANELA: Oh, yeah, it was a competition, yeah, absolutely, absolutely. And actually, the competition incentivized, in certain sense, both sides to--
ATUL GAWANDE: The Russians proposed the smallpox eradication program.
EREZ MANELA: That's right.
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Thank you for giving a boost to my one publication on this topic.
[LAUGHTER]
I do want to ask you, though, about the future. I've got a couple of questions in that vein. One is about the short-term future, let's say, the next three years, assuming that there's no change of heart in the current administration about its support for international development.
Is there any kind of constellation that you can see, you can imagine, of other forces, let's say, other governments, international organizations, NGO foundations, some kind of combination of that type that might step in or maybe is already stepping in, not to fully do what USAID is no longer doing, but to do some of it? Are you seeing any of that? Do you hope for some of that? If USAID doesn't come back, how do you see that reforming, let's say, the international development establishment?
ATUL GAWANDE: So a multilayered answer. First of all, as I noted, they've not been stepping in at this point. The fact of American leadership, America has tended to be often the one proposing, let's solve this big problem in the world and rally others. And then we've often provided the infrastructure to make it happen.
An example of that has been I prioritize work to really invest in primary health care systems, which we've not done enough of. And in each country, we ended up negotiating agreements with the governments where they would set the priorities around where their health workforce and systems gaps were. And the US would put money towards it, for example, in Kenya, getting community health workers all mobile phones and onto electronic records linked to primary health care and trained.
And we provided support. We rallied other countries to join in doing that. And so we would be 20%, and other countries would come in with another 50%. And the government would put in the big chunk, as much a chunk as they could, depending on how well off they were. And when that leadership stepped away, you did not see the others step up and say, oh, let's just keep this going. Instead, they pulled their investments out as well. And the systems collapsed, in part because the human infrastructure to make it happen, sign the contracts, do all that, do the oversight and due diligence, disappeared.
We had the big footprint on the ground. I mentioned 2,500 people in global health. There's 10,000 people that were doing this work spread all across the world for USAID, backing hundreds of thousands of people in NGOs, both local and otherwise. So that is a gap that needs to be rebuilt. It's an opportunity for those who do step up, and China has ended up being one of those who's got now more consulates in Africa than the United States has now.
But I don't see China-- they are not embracing the vision of let's work together to solve big problems in the world. They're not saying, OK. We'll rally the world around meeting the HIV 2030 goal. I would love to see some country in the world take that on and shame us for what we've abandoned now.
But a further thing is Congress, just on Monday last week, passed a minibus, a bill that nearly maintained full global health funding for foreign assistance. Instead of the 50% cut in overall foreign assistance, the total was 17%. And it maintained virtually all of the global health work. Humanitarian and food aid was not at the same levels, and that's a deep concern. But the funds are there. It also put more controls in to try to force the administration to spend the money because, as I mentioned earlier, the money was there. It's not been spent. It's been impounded. And so the showdown this year is over whether we actually put the funds out.
And I think one of the things we're seeing is that as they're being forced to spend the money, they're putting on poison pill requirements, like Gavi, for example RFK, Jr. facing Congress saying you have to cut a check to Gavi, the Global Vaccine Alliance that supplies vaccines at a massive scale, saying we won't provide it unless Gavi stops providing thimerosal-containing, preservative-containing vaccines, on the argument that it causes autism. 20 studies have shown that it doesn't. But the cost would be you can have US money if you cut off your measles, mumps, rubella vaccines that you were providing.
And so we're going to be in this difficult space. But it's deeply unpopular. I don't know that in the next one or two years-- I think there will be more investment. I think it'll be poorly done, with little controls and often in a nakedly extractive, transactional way, agreements in DRC, the Democratic Republic of Congo, that critical minerals would be required to be paid to the US in return for HIV support or pandemic prevention systems and things like that. But I think that there is a likely return because it is ultimately in our interest to not be a country that is leading with dominance and force. And it's deeply, and it's cheap. It's markedly less expensive than any military expense.
EREZ MANELA: So this actually sets up my next question, and I think it might be my last question. So if you are in the audience and you have questions, you, I think, maybe can start approaching the microphones in anticipation of our transition to that stage of the event. But my second question follows on from what you just said, the potential return of USAID or something like it. You also cued up that question from the podium toward the end of your talk. And I know your former boss is here. Thank you, by the way, for being here. And so I don't know if you feel constrained--
ATUL GAWANDE: I can phone a friend?
[LAUGHTER]
EREZ MANELA: But the question is, you mentioned the critiques that had been leveled, have been leveled at USAID and in international development more broadly. And I'm wondering, if at some point, let's say, three years from now, there's a new administration that decides to bring back USAID, how would you design it differently? What would you put in place that's different from what you left behind?
ATUL GAWANDE: Well, what I'd say is it clearly will not be the same. There are two ways in which it's bound to have to be different. We're no longer a reliable partner. And the idea that we can make long-term 20, 30-year investments, something that we were counted on for before, we seem to be a country of regime change with each election. And if there were someone coming back, there would not be confidence that we would be in it for the long haul. We've lost 60 years of investment in trust that that would be the case.
And so it's bound to be different, and it's bound to be much more led by those countries. And that may make it less money. Invariably, when you take money from anybody, they invariably end up having some voice in what happens. And there's often a desire to really see a strong return. I gave the example when we were chatting earlier that the National Institutes of Health, we all want it to be around research on systems, not diseases.
And the diseases are always the most popular, most vivid ones. And you miss a fewer investments in tuberculosis, much more in more prominent-- I won't name diseases that are more popular. But that's because taxpayers want to know that I can see results that you get from it. And for taxpayers to support that around the world, it will often be in things that are we're getting rid of polio? Are we able to stop HIV?
Making it so what countries want is that we can invest in advancing their primary health care systems and things like that. It's a longer conversation, but I do think there are ways to make it so you can see how those systems, by investing in them, making them stronger, help solve driving HIV down, TB down. You can see results that get vaccine rates up and stop diseases. Before Trump came into office, there were still over 100,000 measles deaths for children every year. And we can find ways that we're making those investments and connect the dots.
And I think that's where we will have to meet in the middle. The single most important thing, for example, in global health is that we have underinvested in primary care in our own country. And we have to make it so we all have political and public visibility that helps us understand that when you invest in primary care, it's one of the most life-saving results that we achieve. And finding ways to do that, I think, will be an example of the kind of thing that we'll have to be working together while following other countrys' leads.
EREZ MANELA: When I used to talk to CDC folks who worked in global health, the mantra that came up often was germs know no borders. So you either do it globally, or you don't do it at all.
ATUL GAWANDE: 100%. We will not be able to solve-- we are going to have a future pandemic again. We're going to have a worsening HIV and TB crisis under current conditions. And we will need to be able to work across the world and across borders in cooperation. Also, germs don't know borders. They also don't care if we're fighting with each other or not. And so cooperation is the only effective way forward. Health is our best demonstration of that.
EREZ MANELA: Thank you. OK. We'll go to the audience now. And please, introduce yourself and ask your question. And we do ask-- we know you're all going to do this anyway, but we do ask that you keep your question brief. Please.
AUDIENCE: Thank you. Thanks for a wonderful talk and incredibly important work. My name is Jessica Haberer. I'm a professor at Harvard Medical School, and I've been working in global health for 20 years in many of the same areas you talked about. And as a thought experiment, I've been trying to do a lot of advocacy in this area myself. But if you were not in that chair and it were Marco Rubio or Jeremy Lewin or somebody who is currently dictating our policy right now, I'm wondering what would you say? If we're trying to make change now, your question was, what would this look like in three years? But what would it look like now if we were able to have that kind of conversation and to do something practical with the situation we're in now?
ATUL GAWANDE: I'd be so angry.
AUDIENCE: Can you repeat the question?
AUDIENCE: The question is really what would we do now if the people who are making these policies were willing to have the same kind of conversation that we're having today?
ATUL GAWANDE: A, I'd be so angry, number one. But number two, they're not having an honest conversation. They're taking the lead from their boss. Marco Rubio knows very well when he says-- he continues to claim that no person has died. If you can't agree that there are hundreds of thousands of people now who have died, you can't even begin to have the conversation. And he knows it's happened. He's made a calculation. Other people are blissfully and willfully ignorant of what's happening. He's not.
Jeremy Lewin is the current head of USAID, of foreign assistance for the government, not just USAID, a 28-year-old graduate from law school who-- here-- who has no background whatsoever and betrays it every time he-- the handful of times he's spoken publicly. If it were a meaningful conversation saying let's solve these problems, I have colleagues who had that conversation with Jeremy Lewin, with Marco Rubio, with Pete Morocco.
There's a book coming out in April by a government worker named Nick Enrich, who took my job in my place and describes those very conversations. And it was refusal to acknowledge clear facts about you're defunding maternal death programs. You're defunding child health programs. And here's the harm.
So it's not a conversation about rationality. It's a conversation where the deeper issue is not about USAID. It's about whether you want to be in a world that is guided by solving problems through dominance, force, and extractive transactions. Or you are willing to work patiently in cooperation with others to solve things together.
And that approach-- USAID was just the first example. It's turned up in the ways we're treating our own people, how we're approaching immigrants, how we're approaching small businesses that are getting support, how we're approaching states that didn't vote for Trump and taking away their bridges or their tunnels.
AUDIENCE: Hi. Thank you for your talk and for all that you've done. I'm Sophia Anastazievsky. I'm a PhD--
EREZ MANELA: Can you come closer to the mic?
AUDIENCE: Sorry. Is this better?
ATUL GAWANDE: Yeah.
AUDIENCE: OK. I'm Sophia Anastazievsky. I'm a PhD student in the Department of Government. My question is actually similar to the one that preceded, and it's maybe more tactical. So I understand that the Trump administration is not willing to have the conversations we're having here on those terms, but is there a way to frame these issues as being hypothetical and of national security? Strategically, is there a way forward?
And just to put a point on it, wouldn't actually whatever came out of an agreement with the Trump administration be more durable because it would be stress tested against adversity? And then I also invite you to comment further on what you mentioned about the critique of USAID in that it creates dependency. So are we not seeing the fallout of that also? Thank you.
ATUL GAWANDE: Great. Thank you. So I'll say a couple of things. In terms of approach, how do we-- this was branded as a criminal enterprise, a money laundering operation accomplishing nothing. And the reason why they're denying that lives are lost is because confronting the fact that lives are lost is deeply unpopular, that what has happened, it will not be supported.
So step one, we cannot make progress if the problems are invisible. And making the invisible visible, the harm and what's happening and how and the actions that cause them, is what I see as step one, which is why I've not only been writing and publishing and getting the numbers out that way but needing to capture it visually and in other ways as well.
I'd say the second thing is there is the reality that making that public has helped Congress get to a place where the Republicans strongly rejected the Trump approach. They did not follow through. They fully funded family planning programs, which Trump has completely cut off entirely. It is flat funded. So the idea that we need to convince people that contraception is OK and needed in the world, it's not true.
It is an effort that is being painted by the administration to say these are controversial, unsupported programs, un-American. And that is simply not true. And in the same way that with RFK, Jr. saying that the American people do not want vaccines, that school requirements are at slavery, 90% of Americans support vaccines and support having school requirements. And as measles cases and other diseases return to the United States, that pressure will heighten.
So it is a vital role that we play to keep these issues visible, to force those in power to confront what's happening. And that's how you drive change. But you will not necessarily change their minds, but they will start realizing their voters are not with them. And when that happens, when you start seeing deaths and you start seeing the complications, then the lesson gets learned again.
And so I do see that as the central critical aspect. It's less about is there-- that we fostered dependency, yes. But let me also say we have demonstrated-- Latin America has graduated from development assistance largely. It's small populations now. Haiti is the most stark example. Bangladesh another example. Africa is where we are shifting a continent toward helping them move towards a middle income status, where they are increasingly freed of needing donor assistance. And we've demonstrated that, family planning programs, for example.
During my time, we have ended family planning programs for 19 countries and demonstrated that they did not backslide at all, that contraceptive use continued and rose even further. Gavi is built on a model-- that's a vaccine program-- that every country pays something. It starts at $0.20. And as they climb to middle income status, they are graduated from the program. And so yes, it takes a long time. It can take 20 years, 30 years. And you can call that dependency, but that is how the world progresses and we are able to move on to a different relationship other than a donor relationship.
EREZ MANELA: Please.
AUDIENCE: Thank you. My name is Neal Boyer. I'm from across the river from Roxbury. And I'm the former development advisor for USAID in DRC working on Mpox in refugees. My questions are, and I have two, in the context of the US withdrawal from the World Health Organization and significant reduction in US support for other global health bodies, California, Illinois, New York City, and other US localities have signaled their intent to collaborate with the World Health Organization's Global Outbreak Alert and Response Network program. Would you recommend that Boston and Massachusetts follow their counterparts in California, Illinois, and NYC in joining the Global Outbreak Alert and Response Network? That's my first question.
My second question, in the context of an aging population and a projected rise in the demand for health care services in Boston and surrounding communities, our city, as with many other areas of the Global North, are increasingly dependent on health care workers originally trained in the Global South. If left unaddressed, the continued exodus/brain drain/extraction of skilled health professionals for greener pastures in Boston and elsewhere risks depleting countries of the very skill sets required to operationalize national early warning systems that identify, track, and alert the presence of disease outbreaks of global significance.
My question, then is how can we initiate a conversation with municipal leaders, local health care service providers, training institutions, and other relevant stakeholders to review globally accepted best practices for increasing the supply of health care staff in affected countries, and discuss their applicability to Boston?
For example, the World Health Organization has issued guidance on bilateral agreements to provide a structured approach to mitigating the negative effects of brain drain. For example, in Germany's Triple Win program, Germany recruits nurses from countries with a surplus of nurses, such as Bosnia and Herzegovina, Tunisia, Philippines, and others, but also collaborates with those governments to invest in skills development and employment opportunities to ensure that the recruitment does not negatively affect local workforces.
ATUL GAWANDE: Yes, Boston the Massachusetts should join the--
AUDIENCE: Global Outbreak Alert and Response Network.
ATUL GAWANDE: Yeah, go on. Yes, should join GOARN. Thank you for your work and your service. And lastly, I agree. On the one hand, we are revoking the visas of 330,000 Haitians, who are legally here in the country, many of them health workers, a lot of them in Massachusetts. And returning to Haiti, they will not have work. They will not have safety. And they will impoverish their own population because many of them send remittances that are vital.
And in a similar way, my parents got to not only send back support that was helpful in their community but built a college and did other things. Where Philippines and India have therefore built capacity to supply nursing around the world. We see in Ghana, for example, that they've established nursing to supply to Saudi Arabia in this way.
The US has not always been a responsible party though. Jamaica was an example of a country who was not able to get agreements with the United States around rapacious recruiting that were depriving them of capacity of nurses needed. And these are solvable ways. As you point out, Germany and others have a framework for responsible partnership with countries around recruitment and building. And I think those are the right ways forward. These are solvable problems by coming together. If you decide that you don't care and you're going to not do things through cooperative frameworks, that is where things then fall apart.
AUDIENCE: Hello. My name is Laura Jagla. I'm a former civil servant from USAID. And my question is something I've been thinking about for some time now in how do we reach domestic audiences across the US on the effectiveness of foreign aid? And this could be an action item for each and every one of us in this room and also more broadly. Thank you.
ATUL GAWANDE: Where did you work?
AUDIENCE: I worked in the Office of the Administrator and also in DDI, Democracy, Development, and Innovation.
ATUL GAWANDE: Thanks for your work as well.
AUDIENCE: Thank you.
EREZ MANELA: Yeah. So partly, understand we have been reaching the American people, all of you who have been laid off and speaking out at USAID people. Well, in many ways, I think USAID has been able to be a model of what I wish other government agencies had done. Within about a month of the attack on USAID, the messages that had been 50 to 1 on social media against USAID, dominated by what Elon Musk was saying and the lies that were being told, shifted the other way.
And there's been a 25-point jump in US support for global health programs and things like that abroad because of that. Actually, the levels have never been higher for the support of this kind of work. You don't know about it until you lose it. We see that with Obamacare now being under threat. It cost Obama the control of the House in 2010, getting Obamacare through because of fear of what they would be. But then once people had the benefits, the last thing they wanted now today is taking it away. And it's deeply unpopular.
So I'd say the work that we still have is to continue to talk across kitchen tables and to people. Social media is not enough. It really is people who know what the benefits have been, know how this operates, and knows that programs whether it's for measles or polio or others, that they are at risk and have been damaged, that being able to tell that story is crucial in the ways that you do. Yes, it's writing to Congress and all of those things.
But I also think it's vital for people who are in these fields to recognize that even though a lot of this industry has gone away, that it is likely-- I'm confident it will come back. And the reasons why is the problems are only getting worse. And you're going to need people who understand how to advance, again, growing food and agriculture around the world, improving democratic systems, and certainly, advancing against the losses of health as over the next couple of years we start to see how much has been lost.
AUDIENCE: Thank you.
AUDIENCE: Thank you for your service. My name is Michael. I'm a student at the law school, and I now work very closely with Nida Parks on lead poisoning, which is an initiative I know you helped spearhead. My question is actually quite similar and is partly about diagnosis and partly about the solution. To what extent did the destruction of USAID result from a perfect storm, such that it was just exactly the wrong time and exactly the wrong people?
And if it had happened three months later, it wouldn't have been possible, and Congress and others would have stepped in. Versus the destruction of USAID revealed the long erosion of a constituency, such that it was actually quite fragile. And to the extent that it's the latter, as we think about rebuilding USAID programmatically, how can we think about rebuilding a constituency that is stronger and more muscular and perhaps more DC-based, that would be capable of defending it from a future administration who wants to destroy it?
ATUL GAWANDE: So I think both things are true. On the one hand, I'll point out that-- so I talked about the executive order was signed on January 20. On the Friday after that, Marco Rubio, so it's January 24, sent a cable shutting down all work related with USAID funds. So all foreign assistance was stopped going out the door. On the following Monday, January 27, most people don't recall this, but OMB then issued a memo saying all domestic assistance would also be shut down. That was for Meals on Wheels. That was for Head Start programs. That was for research programs. It was for firefighters, FEMA, you name it.
And within 17 hours, the Supreme Court ruled that that was-- they put an injunction against it, and they could not do it. There was rapidly outrage, and it spread within hours. Medicaid-- states discovered that the portal that allowed for Medicaid payments was being shut off. And it was clear that their assumption was government would be so unpopular that you could shut it down, and they could just rail against the government and say that it would work, that it would-- anyway, it did not work.
Part of the reason-- so the Supreme Court did not make any such ruling on the foreign aid side. Part of the reason is that there is what's called the foreign aid exception, which is that the president has much more say over what happens outside the US borders. And that's going to be litigated because Congress does get to have its say as well with the power of the purse. And we'll see how that battles out.
And so I would say it was caught in a perfect storm where they came into office ready to start taking down major pillars of fundamental functions in government. And USAID, because the direct beneficiaries are largely abroad, because of the foreign aid exception, it was left more vulnerable. Another reason it's more vulnerable is the same reason why vaccines and public health and other things like that are vulnerable is that the benefits are invisible. You're making investments now for gain often years into the future. It's why they could also attack climate change.
They're what I call slow ideas. You have pain now for gain later. And the promise of this administration is you don't have to have any pain now, and there won't be any loss or cost in the future. Just do what you want. Demand what we want to do, and things will work out. And I don't see it as-- so yes, is there more we could have been doing to have tried to help everybody remember what it was like to have measles, and to remember what it was like to have 50,000 paralyzed people with polio, and to have HIV as something that was routinely feared in our country?
And it is the natural consequence of successful programs that you don't remember what these things are like. And no amount of trying to market it is the same as watching the harms come back. I do think that the losses already have generated levels of harm that has made it unpopular to continue to sustain this level of damage. And I think we'll make it so. We are trying to roll back. You're seeing the administration unpeeling many of the items that they had stopped. But the damage has waves that will go out for a long time to come.
So I'm not being sanguine in saying there's nothing to do. It's already damaging. I do think that the reaction to it is to try to cover up the harm. But I think we're often in this situation, people pay for me, a surgeon, very well to take care of problems that are already there manifesting in front of you. But taking your high blood pressure medication for a problem that's not going to appear for the next 10 to 20 years is always hard to do. And that's the most life-saving, important work, and it'll always be the uphill battle that we have to fight.
AUDIENCE: Hi. My name is Sitara. I've worked in global health for a couple of years now, malaria, immunizations, lots of stuff you mentioned. My question to you, so mostly from being in the field, it has felt to me that USAID-- and building on a couple of the questions here-- USAID, the wonderful work that was going on was more popular outside of the US than it was in the US.
Everyone knew what it was. Everyone knew the impacts. But back home and within the constituents here, no one really knew what was going on, and no one really knew the impact of their taxpayer money. And to me, at least, that seems like one of the reasons it was so easy to dismantle and to paint as this big monster that was gobbling up money.
And yeah, a lot of the comms was centered towards Congress, the USAID comms. If you had to go back and change that, would you change the way USAID was communicating, I don't know, to center more towards the American public? And do you think any version that spins out in the future should change to reach more Americans? Yeah, that's my question to you.
ATUL GAWANDE: I'll say a couple of things. One is many of my colleagues will point to there is a law-- part of the formation of USAID was that its funds cannot be used to market towards Americans. And so there is a formal legislative barrier. I actually don't think that that was a major driver. I had no problem getting a message out to Americans and saying, here's what we're doing and what the value is. And there were farmers getting billions of dollars for the food that they were sending abroad and other things like that that was recognized on the Hill and elsewhere.
I will say CDC has not been-- people are not weeping tears over CDC either at a broad American level because you don't see the impacts of these things, even as CDC is a highly present and known brand in the United States. If anything, the conflicts over COVID have complicated and soured more constituencies on some of that brand of public health.
You're correct. USAID is well understood and recognized around the world, not always popularly, I will say. Plenty of people have criticisms around whether it's a form of colonialism and things like that. And with money comes power, and so there's winners and losers and all of those things that come from that.
But in the United States, people largely have not heard of it. The name at least tells you what it did. But the case for why aid is a vital component of our foreign policy, why it's enormously more effective, remembering the lessons out of our experience after World War II, and the reasons why investing and providing a helping hand gets you far better results for far less money, for our own benefit, as well as the world's benefit, compared to military and transactional solutions is always hard to sell. It's hard to sell even when we want to do it in the United States, right?
So all that said, over time, we have invested more and more in those kinds of solutions because they work. We're less violent as our own society, even though we're awash in guns. We're more understanding of the connections and do better investing in our own future health and our own future education. Over time, human beings actually do progress. We've doubled our own human lifespan. Our quality of lives have improved. And throwing that away is a gamble that the administration is making that is going to backfire on. And it already is.
EREZ MANELA: I'm actually really curious to jump in here on what you just said. How did you respond to people abroad who accused USAID of being a form of colonialism because in the world I live in that's a common critique?
ATUL GAWANDE: Absolutely. So basically, how I did here. It's always the trade-off, right? If you are a society whose life expectancy has just been slashed by HIV, became the number one killer, took countries that had a over 65-year life span down to 55 years, and you were losing your seed corn in life, and you had a choice of taking HIV funds or not, that is your choice. And the difficulty of how much are the controls that are put in.
So our HIV program is probably our most stringent program. Everybody's measured on those statistics I talked about. Are you getting to 90% of your people diagnosed, et cetera? It's a global system using WHO-based recommendations. I very much wanted to organize around metrics and goals that we had committed to as part of World Health Organization or other UN commitments, where we had jointly agreed on those kinds of commitments. And the US has to live up to them like everybody else. Even when we sometimes don't, we at least are having to admit we're falling short. That's part of the story.
There's no question that when many of the governments and people that I would talk with would say, just give us the money and let us solve it, some people with the colonial criticism would say even giving the money puts power in the hands of whoever you give the money to in a way that is disempowering of the people, and that we should be simply pulling out and countries should get along on their own.
So my question always was, what is the counterfactual? What is the other alternative that we would be going forward with? Many of them would be ones where taxpayers just would become less willing, Congress would become less willing to provide the funds if there are not measures against corruption and against achieving poor results.
EREZ MANELA: Dr. Atul Gawande, thank you very much.
ATUL GAWANDE: Thank you.
EREZ MANELA: Thank you all of you for coming.
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