Atul Gawande, the head of the U.S. Agency for International Development’s global health office, is trying to figure out how to tackle one of the world’s biggest crises in decades as governments struggle to fund the effort.
After two years of the Covid-19 pandemic, the world recorded a 20 percent increase in the overall death rate and the first decline in global life expectancy in a century. The virus has killed millions across the globe — and shut economies, ravaged health systems and slashed the health care workforce. Low-income countries remain highly unvaccinated and the war in Ukraine is leading to food shortages, worsening the conditions for people living through droughts in parts of Africa. Now, monkeypox infections are causing some countries to scramble for vaccines. Combined, global officials confront health emergencies that are increasingly dire — and deadly — as nations wrestle with putting up money to curb their growth.
For Gawande, the past two years have shown exactly how a pandemic can leave the world with far fewer resources to ensure safety and it has underscored how governments and the global health community need to commit significantly more money to reverse the downward trend of life expectancy — to ensure the sick don’t get sicker.
But that might not be possible right now — a reality that is concerning officials like Gawande whose job it is to help protect the vulnerable and save lives overseas. In just the past few months, despite Covid cases continuing to circulate and vaccinations moving slowly in low-income countries, wealthy western countries have slashed global Covid budgets by millions.
“It is a mistake of epic proportions,” Gawande said in a recent interview. “Covid is not over. It is a continuing recurrent illness that we will be living with, at least for the next few years to come. And being prepared for a health system, whether it’s in the United States or abroad, that is going to have more hospital visits, more needs hitting primary health care offices … We need to make sure that the health systems at home and around the world have the basic tools to respond.”
Gawande spoke with POLITICO in a wide-ranging interview about the future of the global health office at USAID and how it plans to deliver key services to low-income countries and vulnerable populations at a time when the world faces multiple crises at once.
The question Gawande and his team must answer in the coming months is whether and how the U.S. — traditionally a massive player in global health and humanitarian aid — will try to help the world reverse course. And whether the U.S. will commit more resources to that fight. Congress this spring failed to sign off on new funding for USAID to continue its global Covid work. And with the U.S. economy weakened, agency officials worry about Congress approving the proposals put forward in President Joe Biden’s budget for global health efforts.
That puts Gawande’s office on an uneasy footing as it tries to both wrap the Covid projects it is working on with low-income countries and to envision a strategy that will, over the next several years, tackle infectious disease outbreaks, food insecurity and other public health crises. During the pandemic, some of those public health challenges intensified as more resources were shifted toward prioritizing the fight against Covid.
Gawande joined USAID in January 2022 just as Covid vaccines were beginning to arrive in bulk to low-income countries. He stepped into the lead position in the global health office and joined forces with Jeremy Konyndk, the executive director of the Covid-19 task force and senior adviser to the USAID administrator, to help renew efforts to get shots into arms across the world. But just as soon as USAID announced and formally launched its new Covid vaccine program — dubbed Global Vax — lawmakers on Capitol Hill were in the throes of negotiating whether to approve new funding the agency would need to continue its global Covid work for the rest of the year.
The talks among lawmakers lasted for months as Democrats battled competing priorities — approving new funding for the war in Ukraine but failing to come to a compromise on both domestic and international Covid aid. The entire saga has left top officials at USAID angry — rattled, even — as they try to rejigger the agency’s priorities. With dwindling funding, some staff have left the Covid team.
“When I took the job, I felt like Covid had unleashed both a terrible crisis and an opportunity to make investments in the part of public health that matters the most. Building it around our ability to make a sound, primary health care scaffolding that can enable these capabilities is the single most important thing I hope I can accomplish in this role,” Gawande said.
Since the beginning of the year, Gawande’s office has focused on its Global Vax programs in low-income countries — helping governments hire health care workers to increase vaccination rates. Some of those countries have improved their overall immunization levels. Others are still struggling. But almost all are still dealing with the indirect impact of Covid — the strain on the health care system.
Gawande said his office will prioritize helping to rebuild and retrain the health care workforce across the world, particularly in countries still struggling. In other words, Gawande said, USAID will work with countries to strengthen their health care systems so that if there is another large infectious disease outbreak, they can withstand the strain. Gawande also wants to bolster those systems so they can improve their basic public health work — helping countries provide medicines for HIV and malaria, and treatment for other chronic conditions, such as diabetes.
Gawande flew back recently from Ghana, where he talked with officials and health workers about how to approach both efforts simultaneously — continuing to fight Covid while also working to bring the country’s health care system up to baseline. Ghana has received significant funding this year from the Biden administration to establish a Global Vax program. And it has historically defined itself as a leader in public health in sub-Saharan Africa. Despite substantial outside funding for scaling the country’s workforce, Ghana’s hospitals and local health compounds are grappling with limited resources.
Still, some regions in Ghana are making strides. For areas that are seeing big vaccination spikes, health care workers there who normally work on other public health projects also worked on Covid vaccinations, and that has helped build trust in the community when trying to convince people to get the jab.
“What I think is critical to understand is the scaffolding that ultimately saves lives and provides the flexibility to address a outbreak of a pandemic situation like Covid, to be able to address food insecurity, address malaria, take care of child delivery in a safe way — that scaffolding is the primary health system,” Gawande said. “In Ghana, they have been a standout in building a system that has community health workers who are trained [and] integrated into primary health centers … that are able to have medical supervision and a referral base for the more complex cases.”
Other countries in sub-Saharan Africa do not have the same kind of health workforce — they lack the number of nurses and doctors to treat patients and they lack the facilities to provide medical service. Providing resources to low-income countries to help will require USAID to think more nimbly about how it approaches its work in the coming months, Gawande said, especially as countries prepare for a possible recession and turn their focus to domestic issues.
“Part of my approach to it is to break it down and try to identify where your single most important simple leverage point is. That is making sure there are health workers who are salaried, they’re paid on time, they’re supported with training … and they’re plugged into clinics that can support [them],” Gawande said.
The only hurdle Gawande and his team face is convincing not only politicians in Washington that the work is important and deserves support, but also reimagining the way the world’s governments view health funding.
“Public health lives in a boom-bust cycle where when the disease is at its worst is when people are willing to make an investment. And then when the tide has gone out, people … decide, ‘Now I don’t have to worry about it.’ But the tide is coming back,” Gawande said. “We have left a health system that is battered at home and abroad. It is not the time to abandon support at this point.”