Atul Gawande on why American healthcare desperately needs innovation (Transcript)

[00:00:00] Steven Johnson:
Welcome to the TED Interview. I'm your host, Steven Johnson. If you've listened to the last few episodes of the show, you'll have noticed a recurring theme that's come up in those conversations on health: the dismal trends in life expectancy in the United States. In August, the government announced the latest health statistics for the past year, and the numbers were staggering.

Americans have, on average, lost three years of life since 2019. Before the pandemic, average life expectancy across the country was 79, still years behind many other comparably wealthy countries. Today it is 76. When you compare that number to other countries’ health data—UK life expectancy is 81, Australia is 83, Japan's is almost 85—it’s clear that the United States has a problem in that most basic measure of social success: keeping people alive. That's one of the reasons we were so eager to talk to today's guest, Atul Gawande, who has been thinking and writing about and working to improve how we can do better at keeping people alive for more than two decades now.

And thanks to his blockbuster 2014 book, Being Mortal, he's also become one of the most compassionate and influential voices on the question of how to best help people who are at the end of life. Here at the TED Interview, we have a sweet spot for polymaths who have had eclectic career paths and who happen to be great explainers of complicated ideas, and that's Atul Gawande in a nutshell.

He began his career as a surgeon and has served as a professor of medicine and public health at Harvard. He was a staff writer at The New Yorker and has written multiple best-selling books, including Complications, Better, and The Checklist Manifesto. He served as a member of the Biden transition COVID-19 advisory board, and he's now overseeing global health initiatives for the United States Agency for International Development.

Thoughts on how we can all live healthier and longer lives and face death with dignity at the end from one of the great science writers of our time. That's next on the TED interview.

[BREAK]

[00:02:27] Steven Johnson:
Atul Gawande, welcome to the TED interview.

[00:02:30] Atul Gawande:
It's so great to be here, Steven.

[00:02:32] Steven Johnson:
Tell us about this new role. You know, how did it come about and, and what has your primary focus been?

[00:02:39] Atul Gawande:
You know, I, I got sworn into the role leading global health at USAID, which is the Agency for International Development, uh, in January, but, the, the impetus for it was that during the pandemic, I ended up being quite involved in trying to address the problem of how do we make testing access more available in the United States. You might remember that, um, in the first few months of COVID there were a few dominant corporate, um, lab testing companies that provided the majority of American testing, and people had seven-day waits, and there wasn't enough capacity, and you couldn't find places that could do it. And I'd set up a public benefit corporation that ended up expanding access to, uh, to testing by tapping into large, uh, non-profit and academic labs that didn't have the logistics of companies like Quest and, uh, BioReference Labs and LabCorp to pick up swabs and deliver them and get people enrolled online and, and do all that kind of stuff.

COVID was the first time when we said, you know, “It's not good enough just to have the breakthrough innovations that can save people's lives. We need to also have the follow through to make sure that those breakthroughs get to everybody who needs them.” And not just in the United States, but everywhere was the kind of thing I'd been writing about and doing a lot of research on and, and running a lot of projects on.

And so COVID opened the door on everybody's expectations. And then when Biden was elected president, um, I was offered the chance to come in and co-chair the global COVID response and lead our global health work at USAID. And that it was too good an opportunity, um, to take this crisis and see if we could extend those expectations beyond just this one disease.

[00:04:47] Steven Johnson:
Yeah, it's amazing. Were you surprised in the, in the kind of heights of COVID at the public health backlash that there, that we saw in the United States from part of the country, um, having spent so much of your life in that world?

[00:05:02] Atul Gawande:
Yes. As one local public health professional who had written about in The New Yorker, uh, she was in a town in North Dakota. She said, “I have had public health training on everything crisis management for a pandemic coming to town, except for the idea that people wouldn't believe that there is the actual crisis in the first place.” And um, there are lots of ways in which I actually think we're not as divided as it has felt. Um, but it has been still that sense of political, um, divide has been very damaging to public health.

[00:05:44] Steven Johnson:
Do, do you agree with me that part of the problem here is that we don't in, in times of relative stability and and health, when we're not in the middle of a pandemic, we don't spend enough time celebrating the achievements of, of, of public health?

[00:05:59] Atul Gawande:
I don't think it's as simple as that. Um, my thought that it's just that we haven't told the story enough is, is a, is I think partly not to understand human nature, right?

I wrote an article about this problem, um, that looked at two major discoveries in the 19th century that changed my field of surgery: the discovery of anesthesia and the discovery of antisepsis. They both were published in major journals, one in The Lancet, one in what would become the New England Journal of Medicine. And one spread around the world in weeks, and that was the discovery of anesthesia. Nine cases published where this gas could make you insensible to pain and able to tolerate getting your tooth pulled and getting surgery and things like that. And that spread. I mean, you know, this was, we had no internet. You had to send news by ship across the ocean, and you know, came out in November. By January, every capital in Europe was already using ether anesthesia.

And uh, and by contrast, Lister published in The Lancet in the mid-19th century, this solution that would cut the biggest cut killer in surgery, um, uh, which, infections using a simple disinfectant solution that you washed your hands with, and you sprayed down all of the bedding and, and the, the gauze dressings you used and the, and the, the suture material and the instruments, et cetera.

And a generation later, we still didn't have people willing to, uh, apply it and use it in their daily work. And the story here, um, and I'm giving away the, the story, uh, about what I called slow ideas. Some ideas are viral, and what makes it viral, what what made anesthesia viral was, first of all, it was a solution that had a visible and immediate effect. Made the pain go away, and you could see it instantly. And second of all, it was not just good for the patient. It was good for the implementer: the doctor.

Surgeons hated, it turned out, holding people down with three orderlies to do operations where they could do at most 60 seconds to 120 seconds, do an amputation or to take out a cataract or that kind of thing. And now had this gas that would allow them to operate meticulously, take their time, go deeper into people. They discovered appendicitis and could take the appendix out and all of those kinds of things, right?

Now, think about the antisepsis. It was a solution to an invisible and delayed problem. Germs that don't kill you for a week to two weeks after surgery, and it required literally pain now for gain later. The solution that, that Lister trying to sell was, um, dilute carbolic acid that you had to wash up with, and it, you know, literally, he would try to sell like “The burn is how, you know, it works.” It's how we still try to sell Listerine today. Like the, ah, you're supposed to like that burn in your mouth, right?

And, uh, and, and so now go to this question of making vaccines something that are, that are, that are gonna be viral, uh, no pun intended.

[00:09:09] Steven Johnson:
Yeah.

[00:09:10] Atul Gawande:
Um, the antiviral properties are a problem of solving, and, and it's a solution to an invisible and delayed problem. And, uh, and one that, you know, you can build up all kinds of uncertainties, myths, disinformation, about what happens in between.

And it is, again, pain now for the sake of gain later. We know how to work uphill, how to, uh, follow through and address those issues. But when political identities come into play, um, and, and some of that is about the choices people make, leaders make to exploit that gap. Someone could have politicized, uh, you know, antisepsis at that time and said, you know, I won't even use the words that people use, but you know, “Some radical crazies coming in to try to foist this thing on you. It's just the effort of those crazy public health types to take command of your life.”

[00:10:13] Steven Johnson:
Don’t, don't start something. It could still happen. Yeah.

[00:10:15] Atul Gawande:
We could make the campaign. We, we can make it happen now, right?

[00:10:19] Steven Johnson:
We don't, we have enough trouble as it is. Um, but you know, that reminds me of something, and I think maybe you wrote about this in that same New Yorker article, I can't remember, but, um, something we've both written, which is in this shared idea of kind of simple solutions that take too long to take off, which is, uh, the tremendous success of oral rehydration therapy, uh, as a treatment for cholera and other diseases like that.

I'm curious from your perch now at USAID: are there equivalently simple, elegant, um, interventions that can scale up, uh, that are out there that could, could have the same impact that something like ORT had?

[00:10:59] Atul Gawande:
Yes. I mean, can I tell this story with you? I mean, like, this is such a great story, oral rehydration therapy, and also the fact, again, why it is what I've called a slow idea, why it is not viral and self-spreading. Um, so oral rehydration therapies you wrote about in, uh, in, in your book, which I just loved. I love Ghost Map, and, um, when I think about it, the way I approach it in these terms… Cholera: terrible killer. Um, it is a deadly bacteria with a toxin that, uh, that when you get this bacteria from contaminated water, the toxin triggers your intestine to just pour out water, right? And you wrote about this, and very vividly.

[00:11:45] Steven Johnson:
Some would say too vividly. And some would say water too vividly.

[00:11:46] Atul Gawande:
So… right. So fast that a child with cholera can lose a third of all of the water in their body in 24 hours. Vomiting and diarrhea. Uh, and that's what makes it fatal. That's why it killed millions of people across the 19th century.

And your book was critically about the fact that simple sewage systems rescued the world from cholera for the most part. But a large part of the world still is subject to, uh, childhood diarrhea illnesses like cholera, and, um, oral rehydration therapy was discovered in the 1960s, and it really is one of the great medical advances of the 20th century. Um, and it's so simple. It's that, you know, the basic solution to how people treated cholera was to give intravenous fluids, but children lost—or just people lose—so much fluids that you would have to give them 3, 4, 5 gallons of IV fluids in order to replace all the losses. And in poor countries, which are precisely the settings where contaminated water and lack of um, uh, sanitation and clean water systems, uh, are, are where these problems take off. And they don't have enough workers to place IVs and keep those bags of fluid going. Don't have the supplies for all of those bags, and so they just chronically run out when you suddenly have thousands of people who are hit by a mass cholera epidemic and, um, and so you'd just have terrible rates of death.

Oral rehydration therapy was the discovery that a, um, a simple, uh, solution of water, the right amount of salts, and the right amount of sugar would be sufficient to, um, replace the losses that they've had from the cholera and get through the period of time needed to get rid of the bacteria. It cut the death rate down to, you know, 3%, 4%, uh, for, uh, for, for in cholera epidemics.

And so the, what, what what's not recognized is, is there is an equal need for innovation in how you get, not just the discovery that this kind of thing works, but then in delivering it and seeing it drive to scale. So today, more than 50 years after its discovery, we still don't have half the children in the world who have, uh, you know, diarrheal illness is still among the top three killers of children under the age of five. And less than half of them get access to oral rehydration therapy.

And so a place like Bangladesh, which is what I'd written about in that article, had found ways to scale it up, to make it so that, that over 90% of children would end up getting that therapy and they cut their death rates by 80% while many other countries in the world that still hasn't happened.

And the secrets behind that are, I think, what are incredibly interesting in my role. Um, there are lots of those places where we have, uh, high-value critical interventions that can save huge numbers of lives. Um, those range from the, simply, you know, still the basics of antisepsis: washing hands before childbirth, and at each stage of the childbirth along the way. Um, knowing that 10% of babies are born, uh, with difficulty breathing and that there are steps that are required to rescue children from that instance. I could go on down the list. Um, including in the United States. I mean, we have a cure for hepatitis C and we have a vaccine against Hepatitis B, but we have 4 million people a year in the United States who still have chronic, uh, liver disease from, from these infections.

So, you know the story of global health and my job both before I came to USAID, uh, focusing on problems in the US and abroad, and then here focusing on the problems abroad is about the fact that we have made the discoveries that enable people on average to live more than 80 years of life. But even in the United States, we don't make that available to the entire population, let alone around the world.

And I think the job of our generation is to be not only committed but learn how we can deliver these capabilities town by town to every person alive. We have places, uh, that are much less rich than the United States that have, uh, life expectancies far beyond ours. And I don't think this is about money. This is about being committed to systems that enable these discoveries to reach everybody.

[00:16:46] Steven Johnson:
Talking about life expectancy is a great transition to Being Mortal, your book from almost a decade ago, which is just such a powerful combination of these kind of intimate stories drawn from your own family's life connected to this much broader perspective about the reality of an aging society.

Um, but one of the stories you tell near the beginning of the book, which really resonated with me, is this story about your grandfather, who back in India, lived to be 110. And which reminded me a little bit of my grandmother who lived, died just before she turned 105. And, and both of them had had very active and kind of mentally sharp, um, periods right up kind of to, to the end of their lives.

In the long view of history, those kinds of lives would've been very unusual, uh, a century ago or two centuries. We know that people are living longer. Um, how common do you think the arc of a life like your grandfather’s or my grandmother’s… Will that become the standard in the coming years?

[00:17:47] Atul Gawande:
Well, we are still striving for the standard to be living past 80.

[00:17:54] Steven Johnson:
Right.

[00:17:54] Atul Gawande:
Given all the discoveries that we've made, but even in wealthy societies that have all of the access and everything put together, it's still an uncommon experience though now, you know, many people have connections to somebody who lived past 100, which is not an experience that people could talk about before.

You know, when I think about my grandfather's, um, long years, people wanna point to nutrition, to all different kinds of things, but then you have to explain, well, on the other hand, my grandmother didn't make it to 30 because she died of malaria. And what you have is both a certain degree of luck, when you've lived more than a century and managed not to have, have war come to your community, not be hit by a car. In fact, he died at 110 falling off a bus, and he hit his head, and had a cerebral hemorrhage. Right? So the, the um, which is insane, right? Uh, what he personally represented was living through a period in which he survived famine, survived major malnutrition episodes in his life, uh, where drought ended up killing off, you know, the only source of food they had when he was 18 years old.

Um, and then, uh, getting through late in his life, in his eighties, a gastric cancer and being able to undergo surgery and come through it to have, uh, the cancer removed and live another 20-plus years. Um, he was very lucky to have his mind quite sharp. He was a kind of self-taught lawyer and would, instead of fighting out disputes in the village, you know, Mafioso style, he would, he would bring them into the courts, and people would sue each other and solve these problems. And, and he would kind of be a, a, the jailhouse lawyer in some sense, and he would enforce contracts against people and, uh, when they didn't pay up for their loans and all of those kinds of things.

And he, and, and he was on that bus still on the way to court. Because he gonna insist on keeping on doing that. The story of India, however, is the, the part of it that struck me was my father, like many young people, left the family to follow his dreams, and the success of the system in India and in every agricultural society, this was also in 19th century United States, of having an extended family taken care of the eldest in the family and have somebody who could look after them, uh, and allow them to be still the, the patriarch or the matriarch of their domain.

Um, he still, all the way up to 110, sat at the head of the table. People still came for business advice and to bless the new marriages and, and play that role, but it was made possible because young people, typically young women, um, were there to be providing that care, the feeding, the changing, the whatever needed to be done. My father, like many young people as societies urbanize, went to follow his dreams, and that happened to take him to America. And in India, where now the population has moved to the cities, that extended family is breaking down.

You have an explosion in growth of nursing homes and communities for the elderly, and breakdowns from neglect, especially of the poor elderly, and demand as we see in every developing economy, as you have people living longer. Demand for pension systems and for, um, you know, social security style programs, and, and, and health coverage, um, to support people living through those years.

We've essentially, as you have eloquently also written about, um, we've more than doubled human life expectancy. You know, you, you've called it giving people a whole extra lifetime, and that is a dramatic, um, reframing not just of the course of life, but it's also forced, I think a, a slower process in healthcare and in medicine and in public health of asking, “So what is our job?”

[00:22:21] Steven Johnson:
Yeah.

[00:22:22] Atul Gawande:
In healthcare, we think that our job is, um, is help people live longer and be independent, but then when independence is no longer possible and life becomes a complicated thing to even define, um, what is our goal? And part of my writing Being Mortal was about asking that question of my own patients as a surgeon who mainly treated cancer patients, um, and as my father navigated a tumor in his brain stem, and, uh, and discovering that the answer to that question is, after about age 50, the vast majority of us are dealing with chronic illnesses that we will not make it go away, and that we will face serious life impairing illnesses, perhaps terminal illnesses, um, at some points in our, at some point in our lives, um, and that the job becomes understanding what matters in your life.

Um, what is important to you besides just living longer that you would not wanna sacrifice along the way? What are your goals? What are your fears? If your health worsens, what are you willing to endure and what are you not willing to endure for the sake of more time? And then making the people who take care of you understand those goals and serve them at every stage along the way, not just at the end of life, but at every stage along the way.

[BREAK]

[00:24:02] Steven Johnson:
Well, thinking about those people who take care of the elderly, one of the things that you write about in Being Mortal is the, what you describe as the kind of crucial field of geriatrics, which is also kind of you, you argue neglected and underfunded. Um, to talk about that a little bit, and I'm also curious if you feel that anything has changed, uh, since you wrote the book on that, on that front.

[00:24:28] Atul Gawande:
The book started out as an article in the New Yorker, and I had decided… There was one floor down from the surgery clinic is the geriatrics clinic. And I'd walk by it, you know, practically every day that I'd go into clinic. And I had no clue what geriatrics even was.

And so, I get to write articles and books. So I asked them to, “Can I come spend a day with you? I'm gonna write about this.” And this was really what started the journey for me was, here are these professionals who are exceptional at what they do, taking care of people in their eighties, nineties, in their hundreds. And uh, and the question became, “How do I get you your best possible day and your best possible days?”

It's not about “How do I make you survive as long as possible? How do I make you thrive as long as possible?” And then they're paying incredible attention. I remember one of the things was that, um, that, that, that, uh, geriatricians spend an inordinate amount of time looking at the, at his patient's feet.

[00:25:29] Steven Johnson:
Right. Yeah.

[00:23:30] Atul Gawande:
And he explained you could learn so much looking at their feet. First of all, are the toenails well-care—someone may be impeccably dressed, but if the toenails may not be cared for, which indicates that they're actually not able to take care of themselves, and they don't have someone who address small matters and notice that their toenails have made it so they can't walk properly.

Um, do they have indications that they're, uh, hobbled or injured? Is the skin breaking down indicating poor blood flow to their feet? And from that, you can understand what are the conditions this person is living under. And those are the questions that turn out to matter the most. The geriatrician’s job arguably needed to enter, I think, the, our, our jobs in all of medicine, these are skills that we all need to have. Um, as far as the condition of the field of geriatrics, it is not doing any better than before. When I wrote a, was writing about this a decade ago, we were having a declining number of geriatricians, and I don't think that has changed much.

Um, at a time when we had a skyrocketing number of, of older people, the field of palliative care, which is focused on, uh, supporting people with serious illness, uh, to, um, optimize their quality of life, that has grown considerably and has become a popular field, not very well paid. It's one of the few fields I know of where you get extra training to be paid less.

But when I wrote that book, it was partly in reaction to, uh, the notion that the, it started to be politicized. The idea that having a converse about your goals for your life, if you had a terminal illness, um, was seen as death panels. The fact that Medicare was gonna pay doctors to do this under Obamacare, the, the ACA, um, and that wanting to push back, but not in a way that was, it was by going around the rivalry to say, “Here's what we want. We want control. We want to know, do, do my choices about what matter in my life get to govern and drive my care that doctors, nurses, personal care, attendance, and others give, or am I at the whims of a system that ignores what matters to me most about my life?”

And, uh, and I, I think we have come a long way in, in the decade and a half since I started writing about this to where I, it’s become normal to have these conversations. What troubles me much more now, we still have people who face a serious illness, come into the hospital, they're getting advanced care, are never asked, “What are your priorities besides just living longer? What are you willing to do? Or what are you not willing to do to endure for the sake of more time? Are we making a treatment plan that is in line with your wishes and goals?” That, um, happens, still, a minority of the time. That minority who gets that care and has those choices? Markedly lower levels of anxiety and depression, markedly improved outcomes in their quality of life. And they, and they live at least as long, and in some studies, notably longer.

[00:28:58] Steven Johnson:
Yeah. There's a quote from Philip Roth in Being Mortal, which I thought was quite striking, which is “Old age is not a battle. Old age is a massacre.” And in some sense, you know, part, part of what this work tries to do is to make it less of a massacre.

Um, and it, and it connects also to this idea of, of health span versus lifespan, as well. So that we're, we, you know, we index off of how long are people living? Um, what we're less focused on is how long is the span of their life where they are fundamentally healthy? And how, how, how manageable, um, is the, the stretch of the end when they are not fundamentally healthy? Um, and, and how can we make it less of a massacre? That, that seems to be a really worthy goal. And is that, is that something you're dealing with on some level in, in the new role at USAID?

[00:29:48] Atul Gawande:
So in my role at USAID, where my aim is increasing global life expectancy and reducing global burden of disease in the low-income and low and middle-income countries in the world.

I'm still trying to catch the 21st century, up to the 20th century where I want to enable that lifespan of 80-plus years. Um, we're working in countries, I just came, uh, earlier in the summer from Ghana where life expectancy is, uh, is currently at 65 years, which is an improvement from where it was before, which was less than 55 years, uh, when we started our partnership there, but has longer to go given that countries with the same level of GDP per capita achieving 75 years plus.

So when I think of that older population, those are the ones that you see. Countries start to climb in their life expectancy past, past 70 years into 75, even 80 years. You know, you take a country like Costa Rica where they have one-sixth of the income per capita of the United States, but they've committed to having a basic primary health system that's universal. That includes a community health worker who will visit every home across all of the communities in Costa Rica to ensure that people are not falling between the cracks and that the most lifesaving interventions are available to people at every stage of life and plugs everybody into a primary healthcare clinic where they get appropriate needs met.

And the result is that they're at 81 years life expectancy and climbing, while we are at 79 years and dropping, uh, with dramatic gaps, with years lower than that, um, uh, among people in the bottom quarter of the income spectrum, uh, many of whom don't have any relationship with a doctor and a primary care system.

So, those gaps are the ones that I, I focus on in this work, but those needs end up being served across the lifespan because as Costa Rica went from addressing their maternal and child death rates in the 1970s and then addressing high blood pressure and diabetes in the 1990s and 2000s, they now have a large number of geriatricians because they recognize that the, “I'm making sure we have systems that are designed to address the most common problems at each stage of life”, which is a very different approach than to health systems normally take.

[00:32:27] Steven Johnson:
One of the other conversations we've had this season in some of these health-themed episodes we've been doing was with Linda Villarosa, the wonderful writer for the New York Times Magazine, has written about health inequality. And we were talking about the importance of, of community health workers in, in communities who are, who are there as kind of a bridge between the official health system and the doctors and the community, who were kind of translators and explainers, um, and that there are a lot of countries outside the United States, folks who are in that kind of role and they have a lot of kind of names for that particular position, um, are really an essential part of it. And we don't have enough of that in the United States. In a way, it’s one place where we probably could learn from the rest of the world. Does that, does that connect with your own vision of these things?

[00:33:10] Atul Gawande:
100%. Yeah. Uh, we, we'd probably demonize these folks, but yeah. You know, having, uh, having people come to your house, uh, sent by health insurers and the government, but, but in fact, we recognize more and more the value of having someone who's a connector in the system. The system is so complicated—

[00:33:29] Steven Johnson:
Yeah.

[00:33:29] Atul Gawande:
—that people, uh, don't have a front door in. I'll, I'll tell you this one study I've written about before. Um, in Sweden for a time they, they had a lottery for medical students. They decided the way they'd handle their surge of applications of medical schools… Once you had a score above a certain bar, then they did a lottery and then they followed the families of people who had a doctor in the family, and it was like a randomized trial of what's the effect of having a doctor in your family? And then they subsequently validated this for nurses, which is having someone who has a healthcare background in your family increased the likelihood you would reach age 80. And what that implied to me was that, um, people who had a connection to medical knowledge and the medical system, um, were much more likely to get the things that they needed, whether it was vaccinations or acute care for sudden needs, and it turns up in lots of ways.

Your speed to getting the right care is often through people who encourage you to go in when that stomachache starts, not when it's terrible. When you have access to a system where the finances aren't a barrier to getting in the door. All of those things that dissuade you from going until it's too late.

And, uh, and you know, one solution is everybody have a, a doctor, a nurse in the family or have a community health worker who knocks on your door, who you get to know by name, who not only knocks on your door and, and makes sure, “Hey, if there's a pregnant woman in the house, then we made sure they're connected into the right care system.” Because in countries all over the world, 20, 30% become disconnected from the system. And this is a way to connect them in, but also make sure that, um, critical vaccinations are met or other basic public health needs are met.

And then that person is your portal where you can call them up or access them. They live in your community. They live down the street, and you can, you, you feel safe going to them saying, “I think this thing is going on. What do you think I should do? Let me, let me get you into the clinic here, and let's get a look at you.” It makes a difference everywhere it happens.

[00:35:44] Steven Johnson:
Thinking about the, the role of government interventions, one of the things that struck me rereading Being Mortal the last couple of days is, is that I think, I think we forget as a society how strongly correlated being old used to be with being poor.

Uh, I mean, there's a study you talk about from about a century ago in Greenwich Village where they do this survey of, of elderly people in the neighborhood, and, like, a hundred percent of them are living in poverty. Um, and that's, that's something that has really dramatically changed in, at least in the United States. Um, what's your take on that?

[00:36:19] Atul Gawande:
Well, it makes logical sense. Once you stop earning income, how are you supposed to survive? And if not for basic inventions like our social security system, our system of, um, giving you medical coverage after the age of 65… You know, you became uninsurable after age 65 in a system that allowed people to be excluded on the base of preexisting conditions.

And so just, you know, Medicare itself was an anti-poverty program along with having social security because, you know, medical needs are so high as you get older, it's still a major source of health bankruptcy given the holes that we have in our system. And, um, and so that reality of poverty being along with age is common.

It's universal, and in advanced countries, that’s part of what they reverse by making it so that the working population subsidizes, helps pay for themselves when they get older. And for children who are vulnerable and you know, uh, being a child and being elderly is a source of poverty, except in societies that decide to address that.

[00:37:40] Steven Johnson:
I really like that you called social security an invention. I mean, I, ‘cause I, I think that that it is an invention on some level. It's an innovation that, you know, changed people's lives, and there, there are all sorts of things like that, that don't take the form of a specific, you know, object. You know, a vaccine, for instance, that, that make a huge difference, like the invention of drug regulation or testing drugs for efficacy and, you know, potential harm and things like that.
Somebody had to invent the set of processes. But we tend to not champion those innovations the way that we champion, you know, a new smartphone. Um, but in terms of our actual day-to-day lives, they're in many ways, they're more important.

[00:38:20] Atul Gawande:
This has been my mantra now for many years now, which is that, um, it's not just about the breakthrough innovations, it's about the follow-through innovations, right? It's not just the grand idea or the grand tech solution, it's how you actually make it get to everybody that makes a difference. And you think about some of the greatest things that have made the United States prosper and be so effective. High on that list, I would put universal high school education.

19th century was a time when we were as poor as India is today, um, poorer than India today. India's now a middle-income country, and we decided we were going to set up buildings and have to put people in those building in every single community in the country in order to convey basic skills to people.

You know, we'd consider it unimplementable. Uh, anesthesia I've described, right? Uh, earlier, in order to give ether anesthesia appropriately without killing people, we discovered you had to double the number of people in the operating room in order to implement it. Today, we’d say, “Oh, impossible. Can't be done.”

And like, well, we, they just did it. And, and then we did the same thing around schools, like, “How are we gonna pay for it? It's unaffordable, it's crazy, it's insane. How could you possibly do that?” And we said, “Well, we're just gonna.” You know, we put libraries in every community, we put schools in everywhere. And we put teachers in those schools and we paid for them. And we did it with taxes. And you know, it's communism, but, but it made the United States one of the powerhouse countries in the world when it started out as this sleepy agricultural country. And I think that we lose track of how the most powerful and scalable innovations are these herculean feats. Um, that, and that's, that's part of what excites me about this role. I get 2,500 people I oversee here who are in a hundred-plus countries around the world and we take on problems that require enormous scale.

When the Russian government invaded, you know, the entire country of Ukraine, overnight, their pharmacy system shut down. Their pharmacies closed, medical suppliers stopped coming, and because they're in a state of war, no truck drivers were coming into the country. And, you know, we had to work with the government to reconstruct the nuts and bolts of a medical delivery system that could ensure all the HIV patients kept their meds and the people who have heart disease and, and need to stay on chemotherapy. All of that reconstituted with humanitarian aid organizations and standing up a, you know, Amazon-like, um, uh, delivery infrastructure that pivoted from the old one.

And, and you know, this extraordinary team brought the technical know-how to do that in a matter of weeks. Uh, cyber-attacks, hitting the country’s, trying to shut down the country's health system by trying to, um, infect with, uh, their electronic medical record system. And, and, uh, and, and the team I led got that, helped the country move their electronic health records into the cloud. That to me is just as innovative and inventive, finding those kinds of solutions as what a tech entrepreneur does. Um, and uh, and the impact I get to have in that kind of role is, is extraordinary.

[00:41:54] Steven Johnson:
Last question, kind of a big picture question about our demographic future, um, as a species, really. I mean, it occurs to me that of all the potential issues we're gonna face over the next decades, um, that are gonna be transformative, I think one of the least appreciated ones is the transition to an aging population and declining birth rates, um, and ultimately probably population decline. How do we prepare for this future?

[00:42:27] Atul Gawande:
Well, I'm gonna challenge the notion that, I mean, I'm interested as much in variation as in what happens at that extreme end of the spectrum. And so one of the jobs is to give as many people as possible that opportunity to get to that point in life.

And, and that's part of health equity. But I do think that the second part is, living 80 to 100-year lives is gonna, is the norm of our generation and future generations. And once we've made that available to people, as we make that available to people, we are going to need to understand how to structure society.

So, you know, we, we. we are producing now an extended adolescence, um, that, that people get to have at the start of life and, uh, and adapting to that, um, and have a longer, uh, work span capability in enabling people longer, more productive lives, but making those more manageable.

You know, we have a, a young generation, my, my kids, among them now in their twenties, who feel like they've gotten a raw deal, uh, you know, working in worlds where you're, you're at 60 and 70-hour work lives for, uh, diminishing reward in unstable jobs. No loyalty to you as a, as a worker, and increasingly making choices that allow them to have a more balanced life and expect to try to ride that out for longer. You know, talk to them about retirement, like they don't expect that they'll ever get to retire and instead wanna, wanna have a balance of, you know, uh, one of my kids even says like, “Look, I'm, I'm working to figure out how I make it on 20 to 30 hours a week but do that for 75 years.”

And that kind of thinking I think is going to be part of what we get into. We have to enable health, learning, education all along the way. Many phases of careers and lives and people stepping away for family, stepping away for illness, stepping back into work. Um, and so I think that structure and the way we support people when they become unable to contribute in these ways, but can contribute in other ways, is a, a vital part of what will happen in life and be essential.

[00:45:00] Steven Johnson:
Well, Atul Gawande, you do so many wonderful important things with your careers, uh, in all the various guises. So may you live to 110 like your grandfather so that you can keep doing it, uh, so we can all benefit from your work. We really appreciate spending time with you today.

[00:45:14] Atul Gawande:
It's fantastic to be here, Steven. Thank you for all you do.

[00:45:22] Steven Johnson:
That's it for the show today. The TED interview is part of the TED Audio Collective. This episode was produced by Kira Powell and mixed by Erica Huang. Sammy Case is our story editor, Fact-checking by Meerie Jesuthasan. Farrah Desgranges is our project manager. Wilson Sayre is our managing producer, and Gretta Cohn is our executive producer.

Special thanks to Constanza Gallardo, Dan O'Donnell, Michelle Quint, and Anna Phelan. I'm your host, Steven Johnson. As always, for more info on my other projects, including my latest book on life expectancy Extra Life, you can follow me on Twitter at @stevenbjohnson, or you can sign up for my Substack newsletter: Adjacent Possible.