USAID Global Health Leader Atul Gawande Addresses Global Partners’ Concerns Over Women’s Reproductive Rights

Atul Gawande

M arianne O’Hare : Welcome to Conversations on Health Care . This week we welcome Dr.
Atul Gawande, Assistant Administrator for Global Health at USAID, the
world's largest international aid agency on global health challenges
around COVID, the war in Ukraine a nd monkeypox .

Dr. Atul Gawande: We've not only dealt with monkeypox , we had outbreak of Ebola in
the Democratic Republic of Congo , lots of fever in Guinea.

Marianne O’Hare: F act C heck.org ’s Managing Editor Lori Robertson checks in , and we
end with a bright idea improving health and wellbeing and everyday
lives. Now , here are your host s , Mark Masselli and Margaret Flinter.

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Mark Masselli: Our guest is an accomplished surgeon, entrepreneur and author. He
even received a MacArthur Genius Award. He's now putting his
considerable talents to oversee the global health programs for the
United States Agency for International Development known as USAID.

Margaret Flinter: Dr. Atul Gawande is the USAID Assistant Administrator for Global
Health . The US government i s the largest donor to Global Health in
the world , and Dr. Gawande is the point person on that spending.

Mark Masselli: Well, Dr. Gawande, welcome to Conversations on Health Care .

Dr. Atul Gawande: Delighted to be here. Thanks for having me.

Mark Masselli: I want to talk a little bit about monkeypox cases are indeed rising in
the United States and around the world , what's our s tate of readiness
in your mind?

Dr. Atul Gawande: We know it is a painful rash transmitted by intimate contact, heavily
driven in re cent months in the gay population, among men in
particular who have multiple partners, but also spreading more widely
than that population as well. On the one hand is it an epidemic that
has spread across borders and behave the way that we see pandemics
be have? Yes . Is it formally a pandemic, which also implies a level of
severity where this is not mortal? Regardless, there is a need to if we
can to contain the spread reverse course and try to avoid what's
happened in parts of Africa where it's become endem ic, and see
whether it's possible to prevent that happening at the global level.

Part of my job, a little bit about your comments about the role I've
taken on in leading Global Health is that the role involves having --- I
have 2 , 500 people dispersed aroun d the world whose job is to help
respond to crises, and those can be outbreaks of all kinds . In the last
few months we've not only dealt with monkeypox , we had outbreak
of Ebola in the Democratic Republic of Congo , lots of fever in Guinea ,
Marburg virus, w hich has 88% mortality and behaves like Ebola, but
does not have a vaccination or treatment and two cases of that in

Atul Gawande

Ghana. W hen I think about outbreaks and their potential, those are
included in the kinds of areas that I'm most worried about, even as
we'r e addressing monkeypox . W hat matters is what happens long
before it hits the headlines and how we contain and be prepared for
these kinds of outbreaks.

Margaret Flinter: Dr. Gawande, it would be a pretty vast understatement to say that
your role is enormou s, and that the role of USAID is enormous in the
world . J ust a few months ago I understand you were at the Ukraine
Polish border . I wonder if you could share with us what you witnessed
there and how does USAID responding and helping on the medical
front of things with injuries and just the sheer level of trauma that
people are experiencing there?

Dr. Atul Gawande: Yeah, the Russian government's war on Ukraine has had devastating
effects on people's health, and that has so many different dimensions ,
and my j ob has been to lead USAID’s efforts to provide support to the
g overnment of Ukraine to enable keeping their population as safe and
have a medical response that's functional. I n the first couple of weeks,
the situation they were up against and that we immed iately dove into
help with was that 90% of the pharmacies closed, the supply chain for
medicines almost instantly evaporated , all of the liability contracts
that had European suppliers driving trucks around the country that
disappeared with the force of th e war conditions.

T hen add to it , there came cyber attacks from Russia to try to take
down the entire electronic record system and function of the hospital
system across the country. Supplies of oxygen were bombed on the
ways to the hospitals , and so it wa s critical to provide support to the
hospital system and the ministry there that ultimately got more than
5 , 000 humanitarian actors plugged into a common distribution system
where they could access information on what the core needs were
and then cover sup plies , and have the routing setup . We played a
important role providing assistance to enable some of those
capabilities. W ithin a matter of a month it got up to 50% of
pharmacies open. Now it's past 80% of pharmacies opened in the
a reas that are not under attack.

The second has been moving the electronic health record system into
the Cloud , and having been through our upgrade to Epic at the Mass
General Brigham, which was a couple year rollout, moving an entire
country's electronic health record system to c yberspace and
hardening it against cyber attacks , unbelievable . T he teams and the
capabilities that I get --- I'm fortunate to be able to have who can
deploy that kind of capability. It's just a small indication of what we've
had there. We've seen, in addi tion, enormous public health needs,
from addressing availability of emergency contraception for the
enormous number of rape victims to there have been cases of

Atul Gawande

diphtheria, there have been cases of polio that were being responded
to , the re were tuberculosis .

M ultidrug - resistant tuberculosis has been at already at one of the
highest levels in the world in Ukraine. And then the presence of more
than 10 million refugees internally and externally has added to that.
T he response has been tremendous as a partnersh ip we've gotten to
have with the Ukraine G overnment . B ut the needs are serious and
ongoing and taking place under tremendous instability , and so that
ongoing support is going to be necessary for a while to come.

Mark Masselli: We also know you're very conc erned about the skyrocketing COVID
cases in the Ukraine as the vaccination rates have dropped . What's
the latest in how they're dealing wi th the pandemic during the war?

Dr. Atul Gawande: Yeah, so they've been able to restore supplies of vaccines, includin g
COVID and general public health response. Another thing we did, for
example, was we were able to buy a year's worth of supply for the
250,000 HIV patients who need their medications to stay alive . On
COVID vaccination, we've ensured adequate supplies . T h en the
government has remained quite functional and maintaining primary
health care clinics and vaccination services and capabilities. The
challenges that Ukraine has long faced and that got accentuated
during the COVID pandemic has been a high rate of vac cine
disinformation that has led to low rates of routine immunization to
begin with, which is why they've been susceptible to measles
outbreaks, vaccine derived polio, and that has been no different
under COVID .

When they're under attack, and it's difficul t to make basic primary
care functions , COVID is on the list of many things that public has
access . B ut the vaccination rates have remained low for lots of
reasons with misinformation being still part of that picture , but hardly
the only part given the con ditions in different parts of the country.

Margaret Flinter: Well, Dr. Gawande , I'd like to turn to yet another area of concern. The
US Supreme Court, obviously recently overturned Roe vs. Wade .
We 're hearing from international activists that even before t his
decision, countries that were receiving US dollars were hesitant
providing abortion services, doing anything related to abortion for
fear of losing that money. Now, they believe that the court's ruling
may have a chilling effect of family planning and reproductive around
the world. What's the administration's take on that? Is there any
reassurance that we can give other countries ?

Dr. Atul Gawande: I share the concern about a threat to women's rights and threat to
those in the lesbian, gay and transsexu al communities. First of all, our
administration, the Biden - Harris Administration remains 100%
committed to securing the reproductive rights, reproductive health,

Atul Gawande

the sexual rights and health of the world's population , and we will
continue to be defending those basic rights and enabling capabilitie s
to provide support. Second, we have long been under restrictions,
that fundi ng cannot be used for abortion, a nd none of the Supreme
Court ruling has changed that. But there has been sometimes, as you
said, some instances of concern about a possible chilling effect. I've
been in touch over the last several weeks to address questions and
meet with our partners.

T he United States is the largest supporter of family planning around
the world , t here has been bipartisan support for decades that have
made us really the leading experts in how to ensure modernized
forms of family planning reach the world, making sure that women
have rights to be able to space the ir births , have timing of their births
be planned and that vol untary family planning is a critical right that
we have supported around the world. W e're getting the same kinds of
stories in ways that we're just becoming familiar with now in the
United States where the right to abortion has been eliminated by the
Supre me Court. T hat is the fear that women who come in with , say,
bleeding or sepsis from unsafe abortion, can they get appropriate
medical services, and are sometimes at risk of being denied.

We've worked to communicate that post - abortion services are
absolute ly necessary for our partners to be able to provide that .
Second , that women who are undergoing miscarriages need life
saving services and that those should not be withheld , and maintain
support funding that those are there. T hose are just some examples
of the areas where there can be risk of great misinformation or just
fear or a chilling effect that can cost women their lives. T hat is exactly
the fear I have about the Supreme Court ruling domestically.

Finally, I'll just say, there's a lot of fear that we 're hearing that this is
just the tip of the iceberg that Clarence Thomas included in his
judgment that next the Supreme Court would look at the right to
privacy over sexual conduct and gay marriage. Abroad, there i s a great
deal of fear in the LGBT commun ity that this would affect their rights
sometimes in countries where we fight really hard to protect those
populations that their lives are literally at risk in many of the countries
that we ’re working to protect these populations. W e don't want to
see the m become even more endangered.

Mark Masselli: Well, that's such an important message. Thank you for sharing that. I
want to talk a little bit about the investment that American taxpayers
are making into global health. I think it was Fiscal Year 2021 $11
bi llion was provided. T hen I believe there was a supplemental of $ 9
billion provided for COVID - 19. W hile we know this is a very small
percentage of the overall budget, I'm wondering how you
communicate to people on Main Street that they're really getting

Atul Gawande

the ir values worth in terms of the investment that we're making?

Dr. Atul Gawande : Well, it's a lot of money, no question about it, billions of dollars. B eing
really clear that we want to fight diseases where they start, we want
to enable people to survive a n d our interconnections in the world that
enable supply chains enable jobs, we are one world that is deeply
interconnected and not just disconnected countries. W e've had
decades of bipartisan support , conservatives and liberals coming
together to sustain wo rk that has made sure that HIV , for example,
has declined in mortality and is beginning to be increasingly controlled
with countries reaching epidemic control . We 've been eliminating
malaria country by country from the world . W e have a series of
neglected diseases from elephantiasis, lymphatic filariasis to liver
cysts and other parasites that have been able to be controlled.

Furthermore, we've been not only one of the biggest donors enabling
women's rights and sexual rights and family planning access in th e
world , but our work with maternal and child survival has been critical
to work that ensures people live long enough to become healthy
members of society that enables the prosperity of the world to grow.
W e've had year after year of steady reduction in gl obal mortality, so
that life expectancy has grown enormously around the world.

What I'll point out is that we've just endured during the last few years,
the first reduction in global life expectancy in more than a century.
That's how bad that has been in t he pandemic. O nly a minority of
those deaths have come directly from infection by COVID. The
pandemic resulted in rising food prices that have led to acute
malnutrition , led to health workers being sick themselves and
therefore not being able to provide se rvices. It's made fragile health
systems around the world, even more fragile with mortality rates for
under age five children as well as mothers in childbirth. Those
mortality rates have risen for the first time in decades.

P art of our work, the critical p art of our work is ensuring that we are
in a global community where we have discovered in the last century
how to make it so that the average person can live 80 plus years of
life. That is included 6000 drugs , 4000 medical and surgical
procedures and a cou ple of thousand public health interventions. O ur
job has been to deploy that capability town by town to everyone
alive. Even with the United States, we have large parts of the
population that don't get the benefit of that capability. P art of the
reason I t ook this job is COVID made it clear how interconnected we
are , a nd there are two billion people in low income parts of the world
who simply don't have access to the basic medicines, the public
health interventions that make it possible to have that lifespa n and
that kind of productive contribution to society. W hen we don't
support and enable that capability to grow, we end up paying the

Atul Gawande

price for it in many, many ways, from direct infection to our own
political loss of support , a nd so politics matters, and then it matters
economically too.

Margaret Flinter: Well, Dr. Gawande, I think you just shone a spotlight on another
critical issue, and that is the critical role that health care workers play
in making this happen in delivering the essential health servic es and
contributing to the health of the population. T o that end, I think
President Biden has rightfully said that the COVID pandemic put an
entirely new s potlight on that issue. T he administration's pledged a
billion dollars for a Global Health W orker Ini tiative that I understand
USAID will manage . P lease share with us how this effort will protect
and also grow the health care workforce internationally?

Dr. Atul Gawande : I came in with three core priorities that I wanted to accomplish .
Nu mber one was to ma ke COVID into a manageable endemic
respiratory illness , a nd that's happening . W e have the arsenal in the
United States b ut we don't have that a rsenal rapid diagnostic test,
antiviral pills , vaccines deployed for more than two billion people of
the global p opulation. Second, is making us better prepared for the
next pandemic and responding to outbreaks. T hird, is reversing the
loss of global life expectancy. All of that work flows through one, it's
the same workforce , a nd that's the primary health care workf orce in
particular who are the backbone of the ability to respond.

That all comes down to is there a frontline workforce of community
health workers plugged into primary health care clinics where the
workers are salaried and paid on time. They're trained, they have the
technology and support capabilities that they need, whether it's
diagnostic kits or basic tools, and are they managed and plugged into
a primary health clinic in an effective way ? W here that's been
deployed , I was in Ghana just a few weeks ag o a nd in a in a
randomized trial that they actually conducted before deploying it
nationwide, they found that they had a 50% reduction in child
mortality within three years , 70% reduction within seven years .

T he fertility rate as family planning became av ailable also improved.
T hat capability, deploying that workforce capabilit y is the single best
investment we can make , not so much to pay the worker salaries, but
to provide funding that can enable everything from training --- we
have played a critical rol e in making sure that there's adequate nurses
be ing trained in school supported, physician training for primary care,
but then also that the supply chain capabilities are there and that the
systems are in place that enable all of that workforce and do it i n
coordination with everyone from the world bank to the countries on
the ground. That work is crucial. T hat's why the President's
commitment of the billion dollar investment, which is on the one
hand a tiny percentage of payments for health care in the wor ld, but

Atul Gawande

has a huge outsized impact that can leverage an enormous amount of
funding from countries themselves and trained workers who will be a
generat ion that can make a difference. We did this in South Korea at
the time that it was a rural impoverished co mmunity. We backed the
training of the physicians and nurses there. We've done it in Costa
Rica a nd it turned both of those communities into places with an
average 80 plus year life expectancy and enormous ly more economic
prosperity.

Mark Masselli: Let me get in a quick question. Your life and career have been
dedicated to redefining reimagining health care delivery system. Now
your office house s the C enter for I nnovation and I mpact. It supports
breakthrough innovations and advances efforts in digital healt h and
human centered design. What are some of the successes you're
impressed by?

Dr. Atul Gawande: I'll give one example , a nd that's the oxygen program that the Center
for Innovation and I mpact created . We saw when India got hit by
COVID people dying for l ack of oxygen. I t has been a huge missing gap
across much of the world. You can't do emergency C - sectio ns, you
can't do newborn rescue, you can't --- there's so many things as
childhood pneumonia is the biggest killer of children under age five. I n
COVID y ou need oxygen . The team was able to design an approach
that wasn't just about shipping oxygen, but about changing the
markets for oxygen .

People pay 10 times or more for oxygen in low inc ome countries. T he
access to supplies aren't there, the factories ar en't there , and so they
have enabled the distribution of the equipment to set up oxygen
production, enabling bulk liquid oxygen then to get delivered to key
clinical settings . That capability was thought to be something you
couldn't build and sustain a liv ing ecosystem to make possible. I've
seen it, I’ve seen it in places across every continent that have had
these setups put into place with training and support for the people
who then maintain ed and can continue that capability.

It’s not just about the bre akthrough innovation. It's the follow
through innovation . Oxygen , we've had available for a century , but
how you can make i t widely available in the world scale up and bring
that productive capacity to millions of people , t hat's the remarkable
thing that t he Center has been able to provide.

Margaret Flinter: We've been speaking today with Dr. Atul Gawande, the USAID
Assistant Administrator for Global Health. I want to thank you for
joining us. I want to thank you for your decades ’ career long
championing of health and health care for all. And thanks to our
audience for joining us. You can learn more about Conversations on
Health Care and sign up for our email updates at www.chcradio.com .
Dr. Gawande, thank you again an d best of luck in this enormous role

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that you've taken on .

Mark Masselli: Absolutely.

Dr. Atul Gawande: T hank you for taking the time. It's been really great to talk to you.

[ Music ]

Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of dece ption in US p olitics. Lori,
what have you got for us this week?

Lori Robertson: The Food and Drug Administration and numerous peer reviewed
academic studies have concluded that medication abortions are safe
and effective, and that serious adverse events fo r medication
abortions are relatively rare. Recent research was conducted on
women who received abortion pills through the mail after a video
conference with a clinician rather than in - person from a medical
clinic. That research didn't appear to show an in crease in “ serious
safety concerns ” the FDA said . But South Dakota Governor Kristi
Noem, who opposes abortion, defended her state's ban on
prescriptions via telemedicine appointments by calling medication
abortions “ very dangerous medical procedures ” and c laiming a
woman is five times more likely to end up in an emergency room if
they're utilizing this kind of method for an abortion.

Noem’s press office said, Noem meant to say four times more likely,
and it cited research on emergency room visits by women with
Medicaid coverage who got medication abortions. The governor isn't
citing the study correctly however. It found that women who got
medication abortions were 53% m ore likely not four times to have a
subsequent emergency room visit for an abortion relat ed reason than
a woman who received a surgical abortion. But other researchers
warn that the study only tracked ER visits, not whether those visits
required medical intervention. One researcher noted that many
people may visit emergency rooms because they don't have a primary
care doctor , a nd this is particularly the case with Medicaid enrollees.

Other research published in 2015 on women in the California
Medicaid program tracked ER visits as well as diagnosis and
treatment. It found that major complicatio ns meaning cases that
required hospital admission surgery or blood transfusion were
relatively rare in both medication and surgical abortion. Medication
abortions are done early in pregnancies and now account for more
than half of abortions in the United S tates a ccording to the
Guttmacher Institute, which researches reproductive health. In

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September 2021 the Biden A dministration announced that the FDA
would allow women to receive abortion pills by mail instead of in -
person at a medical clinic or hospital fo r the du ration of the COVID 19
pandemic. In South Dakota Noem signed into law the state's ban on
medical abo rtion by telemedicine in March. T hat's my fact check for
this week. I'm Lori Robertson, m anaging editor of FactCheck.org.

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Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com , we'll have
FactCheck.org's Lori Robertson check it out for you here on
Conversations on Health Care.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. While the
world grapples with a global pa ndemic, public health experts have
been simultaneously battling a nother ongoing health threat.
Mosquitoes are considered one of the deadliest animals on earth
leading to hundreds of millions of illnesses and some 2.7 million
deaths per year globally. D iseases such as malaria, dengue f ever, and
Zika are on the rise.

Dr. Scott O’Neill: There is one mosquito called Aedes Aegypti that transmits a range of
different viruses to people. They include viruses like yellow fever,
dengue fever, chikungunya, Zika, and the consequences can be very
dire from a loss of life through to crippling social and economic cost.

Margaret Flinter: Dr. Scott O'Neill is the Director of the World Mosquito Program , which
has developed an innovative appr oach to eradicating the threat.

Dr. Scott O’Neill: I was particularly interested in this bacterium called Wolbachia. This
bacteria is present in up to 50% of insects naturally, but not this one
mosquito t hat transmits all these viruses. When we put the bacterium
into the mosquito the viruses couldn't grow any longer in the
mosquito. W e're seeding populations of mosquitoes with our own
mosquitoes that contain Wolbachia . We are able to spread the
mosquitoes across very l arge areas very quickly. Once the mosquitoes
have it they're protected from being able to transmit viruses. When
they're protected, th e humans are protected as well.

Margaret Flinter: Dr. O'Neill's team released the genetically modified mosquitoes into a
t argeted area and the results showed a dramati c reduction in human
infections.

Dr. Scott O’Neill: In Northern Australia we deployed the Wolbachia over quite large

Atul Gawande

areas, entire cities, and we've seen ess entially a complete elimination,
96% reduction in deng ue in those cities. We believe if we can scale
this intervention across entire cities, we can completely prevent the
transmission of diseases like dengue, chikungunya, and Zika.

Margaret Flinter: The World Mosquito Program is one of the six finalists in th e
MacArthur Foundation's 100&Change competition, which awards
$100 million grant to innovative public health intervention s.

Dr. Scott O’Neill: We're hoping that over the next five years, we could bring this
technology to protect 75 to even 100 million peop le. We would hope
that within 10 years we could bring this intervention to 500 million
people .

Margaret Flinter: The World Mos quito Program, an effective targeted genetic
engineering approach to eradicating the threat of deadly mosquito
borne pathogens lea ding to a dramatic reduction in harm to public
health. Now, that's a bright idea.

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Mark Masselli: I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and Health.

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Marianne O’Hare : Conversations on Health Care i s recorded in the Knowledge and
Tech nology Center Studio in Middletow n, Connecticut, and is brought
to you by the Community Health Center now celebrating 50 years of
providing quality care to the underserved where health care is a right
not a privilege, www.chc1.com and www.chcradio.com .

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