Assistant Administrator Atul Gawande’s Remarks at The Future of Health

A Conversation with USAID Assistant Administrator for Global Health Atul Gawande and WHO Foundation CEO Anil Soni

2024 Milken Institute Future of Health Summit

WATCH

Bertha Coombs (CNBC Senior Health Care Reporter): Hello, everyone. You know, I was telling Atul and Anil earlier that I was happy that I didn't have to read their resumes because it would take up the entire 20 minute session. At this point, you're both so accomplished.

Now, I wanted to start off with a quote from a young entrepreneur who tagged me, in fact, on a LinkedIn post.His name is Liban Diana, and he's the CEO of LC Agro, an agricultural startup. He says, "We all have a responsibility to move beyond focusing on what's broken. So often when we talk about global health, we talk about all of the challenges and all of the problems, but you both have really tried to harness hope and move things forward, and have a number of stories to tell about things that are actually working. As we look ahead and with the change that is going to be happening, what are some of the things that you think we need to continue to focus on in terms of what is working and what we can make work?

Dr. Atul Gawande (USAID Assistant Administrator for Global Health): Well, here's the basic thing about global health. In the last century, we have doubled the human life expectancy, so the world life expectancy went from 30 to 60 years. In the United States in 1900, we only lived to our mid 40s. Today, the actual life expectancy is approaching 80. The top 1% can live 90 years, which means with the access to public health capabilities and the health capabilities that we have developed, you can live on average, that long. But the work is to deploy that capability town by town to everyone alive. I feel that health is the space where, over and over, we've demonstrated cooperation -- across the country, across the world -- works.

Bertha Coombs: Anil, you work with the WHO foundation, but obviously the work of the WHO itself is one of the things that we all look at. It was five years ago last December that we started the beginning of a global health crisis. What are some of the things that the WHO looks at and your foundation looks at to try to get people to work together?

Anil Soni (CEO, WHO Foundation): Well, first, just moving on Atul's comments about success: there's a lot to be proud of as Americans, because Americans have supported international organizations to reduce childhood mortality by 50% in the last 20 to 25 years. That's breathtaking. That's millions of children who are alive today that wouldn't have been had it not been for the cooperation that Atul mentioned. Tens of millions of lives saved due to the efforts to fight AIDS, TB, malaria, to expand vaccination. The World Health Organization is the world's health organization. It's the piston in the engine of that international collaboration.

And today, in particular, there are a lot of diseases that the WHO was responding to preventing outbreaks. So you talked about the COVID 19 epidemic five years ago. We have mpox today in Central Africa. We have dengue that's increasing as a consequence of warmer climates. We have cholera as a consequence of flooding in many parts of the world. So responding to those disease outbreaks, responding to health emergencies, making sure that we protect all of us in this room from those diseases. That's the priority of the World Health Organization.

Bertha Coombs: You talked about the World Health Organization and their relationship with the United States. You know in many respects, the work that you do in public health is an important soft power for the United States with USAID. People may not want you telling them what to do politically or socially, but they're going to take your help if you're there to keep their kids alive.

Dr. Atul Gawande: It's so important you don't get to see the impacts. With public health the problem is, when it's going well, you don't see it. So right now we have emergencies going on. There's an anthrax outbreak in Haiti. There is Marburg in Rwanda. There's mpox. A variant of mpox which kills children at extraordinarily high rates. Three to 5% of children under the age of five are dying with this particular variant and keeping it contained, getting it under control that's the work that USAID, CDC, and the U.S. government drives the major international investments. We work very closely and invest in WHO which is able to reach countries where we don't have the relationships to make it happen. Right now that is the soft power that we're approaching countries at any moment, who will reach out to us because we're bringing expertise resources to solve problems around the world and outbreaks are just one example.

Bertha Coombs: But it seems as though when there is a crisis, that is when everyone comes together and then afterwards funding for public health, it just becomes less of a priority, both domestically and on a global scale. Have we moved too far beyond COVID to remember that there needs to be more cooperation than there needs to be more investment? Is that a difficult conversation now?

Dr. Atul Gawande: Well, it is a classic boom bust cycle. But we're in a space and time where public health emergencies are constant and around us. I would say that has been the one consistent place Republicans and Democrats have consistently sustained funding in global health, both for emergencies like the ones I named. Post-COVID the funding efforts have continued. And second of all around, you know, finishing the job, ending HIV, ending TB, ending malaria. Been hearing a lot about the polio outbreaks, including in Gaza, where WHO is able to drive, you know, even in the settings of the war, they are finishing, taking the job, and getting it done. And so I think, you know, again and again, we're able to show that this is a space that needs to be protected, is backed widely - not by everybody- and so far that sustained effort has been there. And when, you know, the last administration, when the White House said they wanted to cut this field by 30%, Republicans and Democrats came together and sustained the funding because they considered it important, including family planning funding, which is contraception --

Bertha Coombs: And controversial?

Dr. Atul Gawande: Contraception is not controversial. I mean, I will say that Republicans and Democrats for decades have come together and made the United States the leader in support around the world for advancing contraception, bringing modern methods into being, and innovating modern methods of contraception that keep changing the world.

Bertha Coombs: If the U.S. were to cut back, what would that do for other countries, for the WHO, projects that you work together with them, and overall global health?

Anil Soni:First, I want to come back to something that Atul mentioned about the bipartisan cooperation around global health, and it's because of that that I have hope. And maybe I'll go so far as to say I have confidence that the United States will not cut back. I want to remind this audience that it was the administration of George W. Bush that created PEPFAR, an incredible accomplishment of the United States government. It's Democrats and Republicans alike in the Congress and in the White House since then, for the last 20 years, that have sustained that commitment.

Today, in fact, America's generosity has inspired others. So if you look at other governments around the world, they have stepped up. Last month, I was in Berlin, and the Chancellor of Germany hosted an event that pledged a billion dollars. Not $1 was from the United States of America, but a billion dollars was pledged to the work of the World Health Organization, with countries like Germany leading the way. So in fact, over the last 20 years, what you've seen is that the efforts of the United States, which is the most generous donor by far to global health, has been replicated by others. So there is incredible collaboration. There's incredible generosity. Is it as much as the world needs? In part because of what Atul mentioned, the health emergencies are just on the rise. They may not be on the front page of The New York Times, like they were with COVID, but that doesn't mean they're not there, and we do need more resources, but I'm happy to say that others have stepped up to meet the U.S.' generosity

Dr. Atul Gawande: Can I jump in on this?

Bertha Coombs: Yeah

Dr. Atul Gawande: Imagine WHO was eliminated or significantly reduced or we were to withdraw from WHO. Your flu vaccine? The flu vaccine my mother gets is because WHO has a network around the world to gather specimens from the flu outbreaks before they get to the United States and in China, they have relations we don't have that allows them to get specimens and sequence them. As a consequence of that, several months later, we have our flu vaccines. Another example is that WHO has a system called prequalification, where for scores of countries around the world that don't have strong regulatory systems, they have approved and put the stamp on more than 1,000 drugs. As a consequence, American companies and manufacturers have access to markets that they would not otherwise have access to. You can go on down the list: cooperation around cancer -- agreements and the ways we treat and manage cancer and also set standards around cancer. If we were to break away from that we'd see harm up and down the range for Americans of the systems that we rely on.

Bertha Coombs: How important are philanthropists in all of this? Because we've certainly seen the Gates Foundation and others, and even some of the private companies step up when it comes to issues like vaccines globally. How big a role do they play these days, and how important is it for them to continue to be part of this?

Anil Soni: They play a critical role, but it's not a role that can replicate or duplicate what governments do. What often we see is that philanthropists will take risks. So the Gates Foundation is a good example. Wellcome Trust is another where they invest in basic science, early research to test whether product A, Product B, product C, is going to be efficacious against particular disease. Once that research is done, you need manufacturers. You need companies to actually make those products. So Atul's point about American companies is a really good one. American companies depend on the philanthropists to take risks that they can't necessarily bear because of how they have to allocate their R and D costs, and they depend on international organizations to improve those products that can then sell them to markets around the world. Governments help that international system approve those products and ultimately pay for those products around the world. That's a system that's working together. So our philanthropists important? Absolutely, but no single entity can make the system work on its own.

Bertha Coombs: Atul, you have another 60 days, perhaps.

Dr. Atul Gawande: Sixty-eight but who's counting?

Bertha Coombs: All right, not that anyone's counting. What is your top priority as you finish up.

Dr. Atul Gawande: First of all, you know, it's one President at a time, and there are a series of emergencies that have to get done. And we're just at the completing the end of the current budget cycle. So there's programs that have to be planned and completed for this part of the fiscal year. So a lot of it's boring, like budget work, and really not so boring emergencies that need pressing the foot to the floor right up to the very end, and then hand off and know that that handoff is going to be there because there are serious threats all around the world. I'd say the second priority is a world class transition. We'll do our part to make sure that everybody is prepared and that we're able to support continuity of the operations for the U.S. government.

Bertha Coombs: It's one of the themes we keep coming back to given the timing of this event, but what would be your advice, or, you know, guidance for your successor?

Dr. Atul Gawande: Well, we set in place some basic metrics, and the metrics are: number one, metrics around stopping health threats. Within seven days of outbreaks coming out, we should be able to recognize that a virus or some kind of infectious threat is out there, that within one day after that, an emergency response has started. And within seven days after that, the early phases get it under control. We don't always succeed, but we have improved every time. The next administration will need to continue that work of making progress against those goals and not go backwards.

Second, our other metric is that we are aiming to advance these systems and capacities of the world to reduce premature deaths. Our basic metric here is that the percentage of deaths in any given country that are below the age of 50, that those should be reduced. That inequities in that number really get reduced. In many countries where we work, 40% or 50% of deaths in any given year are below the age of 50. That means that their population don't have leaders who live long enough, don't have companies, and all kinds of abilities that foster their economy. They're not able to grow, not to mention all of the heartache and suffering. So you know, the health investments that reduce premature mortality are critical to country development, stability, and economic growth of the world.

Bertha Coombs: And Anil same question to you, what would you say to the incoming leader?

Anil Soni: Implicit in something that Atul just said, which I want to emphasize, is that we do what we measure, setting metrics, and holding international organizations, or development agencies in the United States, accountable to standards. Focus on performance. So I don't think it's a binary. My advice is it's not do we participate or do we withdraw? It's how do we ensure the performance of these organizations so that they are efficient and they are delivering on American interests? And I think that's advice that we can all agree on. I'll give you an example.

Bertha Coombs:Bertha Coombs: How do you decide what is efficient? You said a lot of people would say we spend a lot of money on certain things in this country, we spend a lot of money, but a lot of it, oftentimes on healthcare, is taken up on administration, rather than about actual care.

Anil Soni: Well, I think you can look at what is the cost per life saved or effective. You can look at the cost of the product. You can look at how fast you respond to an emergency. I'll give you a couple of examples. HIV medicine that's bought by U.S. taxpayer money and supplied around the world is currently bought for $60 -- I know it's come down -- but around $60 per patient per year. The cost of that same therapy in the United States is $30,000 per patient per year. It's 98% less when American taxpayer money is buying it for supply to people in Africa and other parts of the world. That's pretty efficient. That's a pretty good standard.

Bertha Coombs: For people in Africa, not for people in the United States

Anil Soni: Not this panel.

Bertha Coombs: I was just gonna say that is pretty outrageous.

Anil Soni: Well, that's another conversation. But certainly if you're looking at organizations like mine, the World Health Organization, or USAID, those are the types of metrics that matter. In other words: how quickly you respond to a disease outbreak. I was in Nairobi not long ago, where the WHO has established an emergency hub, in part with U.S. money. That emergency hub means that you can respond to a disease outbreak within 24 to 48 hours, both with first responders and with lifesaving medical supplies. The faster you respond to an outbreak, the faster you contain it, and that, again, is in America's interest. That's something you can measure. How quickly did we respond? How quickly did the first responder arrive? How quickly did the lifesaving supplies arrive? Measure us. Make sure that people we're performing.

Bertha Coombs: You both are talking about that. But I wonder about that again. Five years ago, we didn't get the information that we needed to really recognize the true threat. Do you feel like we're in a better position?

Dr. Atul Gawande: So COVID was an example where clearly, China did not reveal that virus was circulating with human to human transmission. And one of the things we've done with USAID that I've led to make happen is that we've now got a network of 50 countries around the world to cover some of our blind spots. For example, in Central Asia, we work with Mongolia, we work with Kazakhstan, we work Tajikistan because they sit between Russia and China. And if we're not getting information, we have now programs that pick up on diseases in those areas, in those hubs, if we're not seeing it. It gives us a chance of seeing things sooner when countries are trying to hide information. And so it's not foolproof, but that was the disaster, that a virus circulated for two months that could spread through respiratory illness without the world being alerted in time.

Anil Soni: Another couple of examples because I like how you started. Let's start with hope. Let's start with success. First, even going back five years ago, there were improvements during the COVID response. So it was actually data that was shared out of South Africa and Botswana that helped the United States and others respond more quickly to some variants, in fact, variants that killed most Americans. But since then, something that the World Health Organization has done in the support of the German government, has set up an epidemic hub in Berlin that's monitoring on a daily basis millions of bits of information so that we can catch more quickly when there is in fact an outbreak.

Bertha Coombs: So with the little bit of time that we have left, I told you I was going to ask you a three part question. That was very esoteric, but we are wrapping up, so give us a good note to end on as you get ready to pass the torch.

Dr. Atul Gawande: Well, the one thing I will say is that health is the evidence that cooperation matters and cooperation works. We're at a moment where there's debate about whether we are best by an us versus them strategy. Everybody can go it alone, but this is one space where we have to be able to work together. We can't stop diseases, we can't and we won't be able to make progress through anything except cooperation.

Bertha Coombs: Our lives literally depend on it.

Dr. Atul Gawande: Yes.

Bertha Coombs: Anil, anything to add?

Anil Soni: I'm just remembering, for those who don't travel like Atul or myself, I'm just remembering what it ultimately matters in terms of individual lives that are at stake. When I was in Nairobi, I visited the Maasai community that's suffering from millions of livestock being killed as a consequence of changing weather. And there was a WHO health care worker who was assessing malnutrition, and I met a boy who was the same age as my son, but he was half my son's weight, severely malnourished. And ultimately, what I would share to everyone here is that we're all connected, and that what's happening at any point in the world will ultimately affect us. That Nairobi hub that I mentioned, the emergency hub, there's a woman there named Fatima, who's helped set it up over the last couple of years, who's from northern Nigeria. What she told me is that one of the reasons that Boko Haram has been so popular in northern Nigeria is because it shows up with food. It shows up as an NGO. Whether we're talking about migration, about conflict, showing up, and ultimately, when we show up, what we're doing is helping children, men, and women, just like us -- just like our sisters or brothers or mothers or fathers, the people we love most in the world. So it's in our interest, and it's in the interest of humanity for us to keep doing what we're doing and then measure the performance, make sure it's more efficient. That's great, but in the spirit of continuing to do this work that's already saved so many lives.

Bertha Coombs: On that note, we are out of time, gentlemen. Thank you very much for a wonderful conversation.

Dr. Atul Gawande and Anil Soni: Thank you.

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