The good doctor's mission: Atul Gawande sets out to reform US healthcare

It was a not-so-small matter of a smallpox vaccine that altered the course of Atul Gawande’s life. The trajectory of the Indian-origin America-born surgeon, author and public health researcher, who was recently appointed to US President-elect Joe Biden’s Covid-19 advisory board, would have been radically different had it not been for a severe reaction to the initial smallpox vaccine he had as an infant in 1965 in New York.

That sealed the fate of his parents who, instead of returning to Nagpur in Maharashtra, moved to Athens, Ohio with a newborn they could not risk bringing back to India. It was only in his late teens that Gawande finally visited the country of his parents’ birth -- after smallpox was eradicated in 1979-80.  

The irony of his destiny and the fact that vaccines can open, or shut, so many possibilities is not lost on either of us. Gawande and I are on a Zoom call – he's logging in from Boston, with his morning coffee, and I'm in Dehradun – on December 18, a day after the United States recorded a spike in new cases and deaths in the country crossed 300,000. The possibility of a vaccine rollout to tame this demon seemed like the only glimmer of hope in a very dark tunnel.

In the small Republican university town with startlingly low median income where Gawande grew up, his was one of perhaps five Indian families. While he and his sister faced no outright racism, they remained oddities in a fairly conservative rural county unused to outsiders of any kind, let alone affluent Indian immigrants. Although expectations from the siblings were high, the path paved by his parents and their preoccupation with “giving back” at all times made his life easier. His parents both became presidents of the local Rotaries, worked on a visit President Jimmy Carter made to their county and were deeply engaged in public service, while retaining their culture, traditions and building a warm circle of community around their growing children.

The young Gawande immersed himself deeply in life in Ohio, forming several niche peer groups -- creative, scientific, nerdy – and lifelong relationships through the myriad activities he was absorbed in: Debating, science clubs, chess, sports. With liberal thinking, public spirited parents – his father even raised money in his poor county to help fund a college in India – the fundamental values of community engagement and service were ingrained in his fabric early. From the warm glow in his eyes, I can glean that he had a happier childhood than most immigrants, bereft of the stereotypical anxieties on roots or identity.

At college in Stanford, Gawande got his first taste of the sheer breadth of choices on offer, and possibly childhood influences led him to volunteer with Senator Gary Hart’s presidential campaign, opening his eyes to the highs and lows of political fortunes. After earning the Rhodes scholarship that took him to Oxford for a PPE (philosophy, politics and economics) degree in the mid-1980s, he quickly realised that while public engagement was all very well, he had little to contribute by way of “original” thinking to political philosophy. It was through this “circuitous route” that he finally “accepted” what his immigrant doctor parents took as a given: A career in medicine. But for personal reasons, he chose to defer his admission to medical school and instead took a job for a while as a legislative aide to a Congressman in Washington.

Eventually, at 25, he joined medical school but had completed just a year when he was asked to head healthcare policy reforms as part of Bill Clinton’s presidential campaign – an opportunity that catapulted him into a heady mix of White House politics and power. He subsequently joined the Clinton administration as senior advisor to the secretary of health, giving him a deeper insight into the inner workings of government.

When the reforms failed to take off as envisaged, it dawned on him that it would be a while before the reforms he was passionate about would stage a comeback –he didn’t think it would be as long as 19 years! And he felt he needed to get a career going that was less dependent on the vagaries of politics. He decided to take charge of his own life trajectory. So, from running Roosevelt Room briefings, Gawande returned to being a nobody at medical school, burying his nose in books and attending classes.

Post his medical studies, Gawande hit his full stride, so to speak. He started his surgical practice, became a staff writer at the New Yorker and plunged deeper into the policy space. “I am energised when I feel I can solve a problem,” he says, and that’s precisely what he did three times over: Surgery, which is very “gratifying” as one can solve a problem in two or three hours; writing impactful pieces for the New Yorker that took around 3-6 months to research and offered quick results when published; and burying himself in more vexing or ambitious assignments – how to control burgeoning healthcare costs in the country or setting up a new research institution at Harvard – whose impact would be gleaned several years down the line. Donning – and excelling in – three diverse hats enabled him to find his “perfect cadence”.

I change tacks and ask him about one of the primary triggers behind this article. A famous New Yorker piece of his comparing healthcare costs in two American towns had got the attention of then president Barack Obama himself and had been identified as the problem the country needed to fix. Who better than him to advise India on how not to hurtle down the same slippery slope? Private hospitals in India have for some years now begun to resemble five-star hotels and healthcare costs have gone through the roof.

The way he sees this problem is that every country in the world is navigating the reality of a century in which the lifespan of human beings doubles. This doubling is happening through the creation of public health institutions that improve the quality of life, the capacity of what humans can achieve and their longevity. But this means having to marry the entire lifespan of each individual to these institutions.

“If you have access to regular, affordable care and treatment from a team that knows you, you can live on average more than 80 years,” he points out. The problem is that we have not – neither rich nor poor countries – figured out how to enable that equally for all. He says he is fascinated by the example of South Korea that made a public commitment in the 1970s -- when it was far poorer than it is today -- to universal coverage, a tax-based private system with insurance reimbursement for all, something a rich nation like the United States has failed to do so far. The big US mistake – and one that India needs to avoid -- was to tie insurance cover to one’s employment. Once the US built around that, it could not accommodate the fact that people get laid off, leave their jobs or are unemployed for long periods and have no coverage.

To my delight, he assures me India is already on the right journey, one he describes as largely “political”, with Rashtriya Swasthya Bima Yojana and now Ayushman Bharat, and has come a long way, both in terms of the quality and access (the latter he’s witnessed closely with his own family in Yavatmal, Maharashtra).

So if a few rich Indians want to pay more for private facilities, they can go ahead as long as the public commitment to fund those who cannot afford it -- the working class -- remains intact at private or public hospitals. “As India develops and gets richer, the willingness to fund this -- at the national or state level -- remains crucial,” he argues, adding that countries like India or the US have the challenge that they are multi-ethnic, multi-religion and large democracies with far less homogenous societies. So making the commitment that all lives are of equal worth is that much harder.

This “working class” approach -- which a majority of the population can rely on -- has not been guaranteed in the United States despite it being much richer. But it will, if he can help it. His mission is to set right the wrongs of the American healthcare system, a publicly stated personal commitment. His work with Haven and now with the Biden administration will be focused on this.

Obamacare, he argues, has already provided a good starting point that can now be taken forward full-throttle with the new administration, and he fully intends to play his part as required.

On my question about his ties with India, he spends a few minutes listing all his commitments and efforts in India’s public health system. As I listen and try to absorb everything he says, I am convinced that some human beings are blessed with a 36-hour day and several more months in each year. How else can one possibly achieve everything he casually mentions? I have recently finished his fourth book, “Being Mortal”, a poignant exploration of the crux when poised at the end of one’s life, a book that ought to be essential reading for anyone over 50 and doctors globally.

As we reach the end of our conversation, we invariably return to the reality staring us all in the face. Since the pandemic tightened its grip, human beings the world over have yo-yoed between hope and despair. Isn’t it that much harder for someone who is also a medical practitioner, I ask.

Short of witnessing the Earth hurtling into the Sun, he jokes, he is not prone to despair. “Anger, yes. Frustration, definitely. But not despair,” he says. He ends by citing the example of Mahatma Gandhi who never despaired and displayed relentless faith when up against 200 years of British oppression and rule. A pandemic that will likely end sooner than later pales in comparison.