Preet Bharara:

From CAFE and the Vox Media Podcast Network, welcome to Stay Tuned. I’m Preet Bharara.

Atul Gawande:

People had recognized there might be a vulnerability to pancreatic cancer. The company generated a drug that doubled lifespan in its trial for pancreatic cancer patients. Now, it had been survival of less than a year and now it’s more than a year. It’s not a cure, but it’s a significant increase in survival for the first time from a pancreatic cancer therapeutic.

Preet Bharara:

My guest this week is Atul Gawande. He’s a surgeon, a bestselling author, and a longtime contributor to The New Yorker. He also served as the assistant administrator for global health at USAID under President Biden. This week we talk about breakthroughs against the fight against cancer and the crisis of faith in our healthcare establishment. That’s coming up, stay tuned.

Atul Gawande, welcome back to the show.

Atul Gawande:

It’s great to be here. How are you?

Preet Bharara:

I’m good. I’m good. I’m also well. I’m not sure which is the correct, but two Indian immigrants here, I think people will make do with good or well. So we have a lot of lawyers on this show. My dad will be pleased that we’re having a doctor on again for various reasons, but there has been so much news in medicine. I’m hoping you’re going to break down some of this for us and help us understand not just the good news. There’s some bad news also that we need to talk about that I mentioned before we hit the record button, but also how public policy can affect these things, how it’s going under RFK at HHS. But can we start first with something that is important to a lot of people and important for various reasons to my family and millions of families? And that is the recent news about cancer treatment.

Cancer is that terrible word that begins with a C, that has devastated so many families, so many lives in the United States and around the world, and there are certain cancers that we have done a very good job on treating, curing. Not a lot of headway until recent news that I’m aware of about prevention in the form of a treatment that you can get. Could you just give us a state of play? Because there are a lot of different streams of stories. I’m not sure everyone has… I certainly don’t have it straight in my head. How are we doing on the fight against cancer?

Atul Gawande:

Well, the thing that’s made a lot of news recently is having a breakthrough on pancreatic cancer, which has been really resistant to finding breakthrough treatments. I shouldn’t say cures yet. So in that particular space, pancreatic cancer, there is now a targeted drug that has been designed successfully to attack a part of pancreatic cancers that hadn’t been able to be hit before. People had recognized there might be a vulnerability to pancreatic cancer and Revolution Medicines, a company generated a drug that doubled lifespan in its trial for pancreatic cancer patients. Now, it had been survival of less than a year and now it’s more than a year. It’s not a cure, but it’s a significant increase in survival for the first time from a pancreatic cancer therapeutic. And it opens the door because it had put in play a mechanism of cancer treatments for pancreatic cancer that hadn’t been there before. So there is a lot of hope that further follow-on treatments will come.

To put it in a larger context in the 1960s, more than 70% of people who had a cancer diagnosed would die from that cancer. Today, it’s more than 70% will live from their cancer. And even among the remaining 30%, many can have extended periods of life with treatments. And the recent decade has given us cancer treatments that are not the kind of scorched earth cancer treatments that wipe out in an undifferentiated way, lots of cells in your body, but capture cancer cells because they’re growing the fastest. Instead are able to have targeted therapies that are specifically targeting mutations in those cancers. And that’s been the revolution of the last decade or so. So we have preventative approaches that end up either detecting cancers earlier, whether that’s mammograms or other kinds of tests.

And that has helped a good deal, but the major driver of gains in survival have been coming from two things. One is we have vaccines now that stop cancers, right? Hepatitis B vaccine, HPV vaccines around the world, that is the virus to… So hepatitis B causes liver cancers. The human papillomavirus causes cervical cancers. We’re seeing countries like the US that are now past 80% of girls getting the vaccination and seeing plummeting rates of cervical cancers, which are among the biggest killers in the world of women in populations where you’re exposed to HPV and that’s lots and lots of people in the world. So long story short, there’s a lot of gains on a lot of fronts. It’s steady chipping away at cancer and this is another addition to the arsenal.

Preet Bharara:

So a lot of what we do on this podcast, because I’m a lawyer, is assigned blame. It’s nice for a change to assign credit. And with respect in particular to the pancreatic cancer treatments and approaches that you’ve described, was it money and investment? Was it a certain kind of science? Was it public policy? Was it a different kind of ingenuity on the part of researchers or combination of all those things? To what do you attribute the recent success on pancreatic research?

Atul Gawande:

It’s really a whole ecosystem that the United States has played a huge role in creating over the last century. And that ecosystem starts with basic science funded by the NIH and other and National Science Foundation, but those are the two core ones. This work has represented decades of investment in learning how the mechanisms of cancer, understanding the specific mechanisms that pancreatic cancer has. And that all came out of publicly funded National Institutes of Health research going to major universities by and large to carry out that work. And then we have a biotech industrial capacity that puts capital into taking those novel findings and turning them into drugs that can be tested. You can figure out the right dose and you can figure out if it’s toxic and then run trials that get it funded and brought to large scale.

And then you also get credit because Medicare in general covers every FDA-approved drug and that prompts the private insurers also to do the same and that makes these things widely available to people in the United States. Now we don’t have universal coverage and that’s a whole nother matter, but it’s the combination of all of that. And the fact that you get costly medicines covered early tends to mean we get the breakthroughs faster than just about anywhere else because the drug companies can make a lot of money on breakthroughs like that.

Preet Bharara:

Yeah. I want to ask more about money. So a few questions. Let me start with this. So we keep hearing these stories about certain kinds of funding being cut off. Where do we stand today on public funding? Are we good? Are we not good? Can we always use more? What’s going on with the Trump administration and the money to fund the research that you described a minute ago to fight cancer?

Atul Gawande:

It’s very concerning to me on multiple fronts. And so let me try to unpack that a little bit. First of all, the National Institutes of Health had its budget slashed, well, frozen. Payments simply stopped going out the door for many kinds of cancer. Last year there was a dramatic drop in the number of approved awards that the NIH gave out, including in cancer. That was one of the hardest hit areas. Among the very hardest hit were ones like HIV, which is affected by some of the policies around whether you can have targeted efforts to diseases that hit diverse populations, the gay community in that particular case, sex workers and so on. So one thing is that there was a round of freezing and terminating a lot of awards and payments. Some of that was dialed back when the courts in October blocked NIH from the large scale cuts and they restored some of the funding, went from blanket cuts to terminating a variety of studies.

But the big picture is at the end of a year where NIH was hammered, National Science Foundation was cut even more deeply. Courts have somewhat restored some of the funding. We are still down at a historic level of cuts. The Congress, both Republicans and Democrats, passed a budget for 2026 that gave NIH full funding. And however, the administration is doing a variety of things, starting with number one, still not issuing the level of awards that they were giving. Number two, just in the last week, the Office of Management and Budget has come forward with a set of regulatory proposals that would enable political review of each award in order to determine whether it is, quote, unquote, “consistent with the president’s policies,” that would allow non-scientific considerations to enter into the decisions of who gets those awards. And it sets it up for doing what’s been happening in the first year but started to be held up by the courts applying political criteria to who gets funded and whether the funds go out the door at all.

The biggest hit has been that young people who are in science want to get their start. You’re seeing the training grants that are the foundation of creating new talent. Those have been slashed and there’s been targeting of very specific institutions. You mentioned where I am at Harvard University and the medical school and the School of Public Health have been hit extremely hard with a result that many of those schools like ours have slashed the number of positions that are open to PhD applicants. So between political interference cuts, effects on immigration and getting access to talent from around the world to do work in laboratories, this has been a grim time.

Just this week, people who were distributing at the American Diabetes Association national meeting papers that were outlining the effects of these cuts on diabetes patients and their research were escorted out of the conference by police and not allowed to continue in the diabetes meeting. So there’s some real concerns about where we are with research. We’re doing better than in the first three months, but that’s still not saying we’re anywhere near where we used to be.

Preet Bharara:

So I continue to have this very dumb question, Atul. What is the justification for the cuts? How is there political support for the cuts and how is there not tremendous overwhelming political cost to these cuts? I mean, is there an ideological or partisan dimension to this? Is something else going on? Because I’m a fairly informed person. I’m glad I have you here. Can you explain how this is happening and why?

Atul Gawande:

It’s a confluence of multiple forces that you already are aware of. One is Russell Vought and the Office of Management and Budget having a shrink the government view that aside from military and a few limited areas, this is not the business the government should be in. And so that is one. Second, the other force is anti-independent expertise and anti-independent agencies. So agencies in health, whether it’s NIH, CDC, FDA, in global health, USAID, that have independent expert capacity and authorities are having that attacked and curtailed in the name of needing to have, quote, unquote, “political oversight.” Third, you have a desire to push funds away from blue states and towards red states and that turns up in saying that a criteria for consideration of scientific applications should be geography, that places like Massachusetts and California have too many scientific awards and that they need to go to other states. Now there’s an ecosystem.

In Massachusetts, there’s 250,000 scientists and medical research people that has become an ecosystem that has drawn the talent from around the country. There’s lots of reason to want to see more places like that. You have research triangle in North Carolina and others around the world, in Texas. But nonetheless, there’s a very high rate that goes to a few centers around the country and that is under attack as well. And so you have all of these things conspiring and there’s just a general view that it doesn’t matter. The interest in investing now in things that require sacrifice and investment for the long run are easily sacrificed in this current, what’s in it for me now attitude about our public spending.

Preet Bharara:

Part of the problem politically and in terms of attributing blame on certain kinds of things that are not immediate, like the fixing of a pothole on your street that a mayor is responsible for doing. Is that the costs and the crises that arise from the cutting and funding will not be felt for a long time. And it’ll be a future debate if I’m still doing this in 11 years, I’ll tell you you’ll be on and I’ll say, “Well, where are we on the fight against cancer?” And you’ll say, “Well, here we are.” And we’ll have been certainly breakthroughs in discoveries and treatments and vaccines. And you’ll have to speculate and say, “Well, but we could have been much further along if we hadn’t had this four years and maybe longer than that period of indiscriminate cuts based on not any good thoughtful reasoning.” And so the blame is in the future and it’s diffused. Does that play a role in how people get away with these merciless cuts?

Atul Gawande:

100%. I’ll give you one very clear example. The US has given up our mRNA vaccine industry. We were leaders of the revolution that has brought the capacity to generate vaccines based on mRNA technology that are safe, highly effective, and can be made in a matter of days when you’re up against the pandemic. We have targeted and punished the companies that were involved in that work. They have largely walked away from it, even though for example, in pancreatic cancer, one of the new directions has been a vaccine against pancreatic cancer that has shown early very successful results. Again, building on the knowledge of what we now know can be a target in pancreatic cancers. And that kind of work is no longer receiving public funding and backing.

Now, we went from a place where the United States was an undisputed leader in generating the next technologies. There was a TB vaccine in the making, an HIV vaccine in the making and others. Some of that has not stopped, but instead the majority of now new mRNA vaccine candidates that are in testing are made by China now. And so we will be depending on importing from China the cures that we might need in the future. And that will be something that we’ll say, “Well, that might not have needed to happen.” But you can say right now it’s going to have major consequences for US leadership.

Preet Bharara:

And you would think that that would be a bad consequence in a foreseeable adverse event even for people in this administration and why they don’t see that I still don’t fully understand. Can I ask you a question about COVID while we’re talking about mRNA? Obviously devastating experience for the United States. Two questions. One, what is our preparedness if such a thing should happen again in the near term? And two, on a more hopeful note, how much, if at all, was medical science advanced by the drill that our medical profession, hospitals, and doctors, and researchers had to engage in to ameliorate the effects of COVID?

Atul Gawande:

As contentious and awful an experience as COVID was, it dramatically improved our capacity in the country to respond and be ready for the next pandemic. I’d say on a cultural level, the biggest thing was you got public health people and departments working much more closely with hospitals and health systems. And hospitals and health systems discovering their public health departments and how they could aid them as well. In the beginning, you couldn’t name places were running out of ventilators. Where can we get ventilators? You were trying to keep track of laboratory results through fax machine. And there were a set of investments about upgrading and innovating in those areas where we developed wastewater monitoring of viruses where we developed direct electronic connections between clinical institutions and public health departments and things like that.

Where are we today with taking advantage of these capabilities and being able to be wired for detect… Now we can detect disease faster, recognize when you have an unusual microbe design vaccines against it and build scale and deploy them. Much of that system has been systematically broken, whether it is the White House level infrastructure for monitoring and responding to threats. The pandemic office has been shut down. The National Security Council doesn’t manage these issues anymore.

Bird flu, we had candidate vaccines for making sure we had a vaccine within 100 days. If we have a bird flu outbreak that crosses over to human beings, we can have it. We were on path to have a vaccine probably within 25 days. That contract was terminated, that relationship, because it depended on mRNA vaccine technology was canceled and we’re not prepared for that. And then the funding sources from CDC to state and local health departments to have upgraded information technology and to sustain the infrastructure that had come out of COVID, that has also been clawed back and removed as well. So we still have some of the components of what we learned and developed in COVID, but we’ve dismantled significant parts of the capability.

Preet Bharara:

I’ll be right back with Atul Gawande after this.

What about the level of public trust? A lot of people, I think, still have a bad taste in their mouths or stronger language than that. You talked about coordination between government and hospitals and things along those lines. I think a lot of people believe there was not appropriate coordination or policy decision making or communication as between the government, medical professionals and schools or workplaces. And every jurisdiction had a different idea and sometimes in certain jurisdictions like where we live, one day they said it’s going to be all remote, then the next day they say it’s going to be hybrid and there’s a lot of debate about that. What is the residual effect of public trust in people in your profession, public health professionals in the wake of COVID? Is that stagnating at low? Does it depend on if you’re a red state or a blue state? How do you look at that?

Atul Gawande:

Well, I think that number one, there were clear lessons that we needed to have lifted the closures of schools faster and earlier and face down resistance from teachers to do that. Number two, the vaccines worked and there continues to be data that now HHS is not releasing showing that even today COVID vaccination has benefited in reduced hospitalizations for what still produce a significant number of deaths from COVID in at-risk populations. Trust in a pandemic has constantly taken a hit. The major issue is that you have an invisible microbe that needs action now for harm it’s going to cause later. Those sacrifices when you take those risks and get them and are even slightly wrong, can undermine confidence.

That said, let’s look at where we are now. We have a Secretary of HHS in RFK Jr., who has attempted to really attack the basic principles of some of the public health remedies we have, such as measles vaccination and access to other routine childhood vaccines. And it has not been popular at all. South Carolina had an outbreak that ended up reaching more than 1,000 children with measles, hospitalizing large numbers. And the pockets in South Carolina where you had very low rates of vaccination, South Carolina has been able to lift them enough to get now up above 90% to 92%, 93% vaccination, getting over 95% is kind of where you need to completely stop outbreaks. And more than… We have continued confidence of 90% of the country that they believe that vaccines are safe, effective, and necessary for the children, believe that having requirements in order to attend schools are necessary.

So the fact that we do have a significant and vocal audience who are against vaccination, but it is still a significant minority. And the biggest driver of distrust has been having a leader in place in our health system, who does not use the scientific method, does not back having independent expert panels. And has been putting his thumb on the scales to remove basic tools that we have. And that has not been popular at all. So in the end, trust comes from demonstrating better results, demonstrating competence and capability, and having to be convinced people that you are benevolent, that you put them first, you put the public and the patient’s needs first over your own. And I think people remain convinced of the competence of people in medicine and public health. They remain convinced of good intent, but not convinced that it has been putting patients in the public first. And the more that we’re able to demonstrate in our local communities that that’s where we are, that that’s what we do every day, the more we rebuild that connection.

Preet Bharara:

Do you think the word vaccine in substantial quarters is a bad word? And does the medical community and do our public officials have to do something to rescue the reputation of the class of thing that we call vaccines for the next pandemic and also for these potential cancer approaches as well?

Atul Gawande:

I do. And I don’t think it’s by abandoning the word vaccine. It means using a small amount of a harmful microbe or disease, an antigen to provoke the immune system to fight it. The fear of vaccines in some quarters, it’s still, again, I want to emphasize it is a minority of the public. But when you need to get to 90% or more vaccination, in some cases, 95% before you control epidemics-

Preet Bharara:

Minority puts a big monkey wrench in it.

Atul Gawande:

In a very divided country, it puts a big monkey wrench in. People want their treatments for pancreatic cancer. They want the treatments for new pandemics and they’re going to be outraged when and if those are not available. I do think we have to keep on producing the results showing that we’re making honest assessments and providing those results and parrying the misinformation and often disinformation that is constantly being thrown at us. I’ll give an example of one harm that’s currently happening. Children when at birth do not have enough vitamin K and vitamin K is necessary to have the clotting factors that you need to prevent bleeding at birth. At about six months, a child’s organ systems generates enough vitamin K, but we have been injecting for years children in the first days of life with vitamin K and that has dramatically reduced a rarer but nonetheless reproducible recurrent form of bleeding in the brain that is either permanently damaging cognitively or causes death.

And refusal rates have risen because of fear that this injection, which is not a vaccine, has occurred. Now, it is still well over 90% of people who accept it, but we’re seeing increased occurrence of bleeding, the increased risk of bleeding in babies’ brains because of this kind of ideological attack. And as we see harms rise, we do see people then recognize, “I really want this for my baby. I really want this for my kids.” And as you saw in South Carolina, families that had said, “I don’t want vaccines,” saw the measles cases and said, “I do want my child vaccinated.”

Preet Bharara:

Can I say something that will sound heartless? Actually, maybe I shouldn’t. I think arguably a reasonable person might be much more concerned. Obviously you care about all life and you care about people making uninformed, unthoughtful decisions, thoughtless decisions for their family. But I think a reasonable citizen should be much more concerned about the measles example because if a certain percentage of the population refuses to do that, that affects their own children. Whereas I don’t believe the vitamin K deficiency issue is contagious, correct?

Atul Gawande:

Correct. No, that’s right. Measles under six months of age, a child is not going to have protection against measles because they’re not old enough to get a measles vaccination and the spread of measles then will affect any child in the country. And so yes, communicable diseases. One of the other lessons of COVID was mandatory vaccination. When that vaccination did not significantly reduce transmission, should have been something that was abandoned once it became evident that the transmission was not being affected.

Preet Bharara:

What should have been abandoned?

Atul Gawande:

The mandate that people had to-

Preet Bharara:

Oh, interesting.

Atul Gawande:

… take the vaccine. There are certain situations where you’d say, “Look, I want my health workers to get them because we couldn’t afford health workers to be knocked down.” So you might say, “I want to require vaccination for health workers because we need them to be healthy enough to continue to keep health systems functioning.” But the idea that you need to give it to people, once we knew it didn’t stop spread of the virus but mostly with saving lives and preventing hospitalizations, then there are classes of people we should have been able to pull back on the mandates.

Preet Bharara:

That’s very interesting because I’m not sure that I’ve heard other people say that, but I may have missed it. My own view as a matter of language is that the term vaccine is ordinarily understood by folks means you don’t get the disease as opposed to it mitigating. That you still can get whatever the infection is, but it has mitigating property. And so people felt lied to when they told this is a vaccine, even though it is a simple matter of mathematics, research and logic, as you’ve been pointing out, that people who took the vaccine had a greater survival rate, lower complications and everything else. I could spend a lot more time talking about both these things, but I do want to talk about another big medical story that everyone is talking about. These are the GLP-1s, Ozempic, Wegovy, Zepbound, and there are like 89 more products on the market every day.

I’m going to ask you to do something unfair, but to begin the ledger with Dr. Gawande making the case against taking a GLP-1.

Atul Gawande:

Well, here you go. I’m seeing a lot of people who do not have a medical indication for a GLP-1. The medical indications, it’s clearly lifesaving if you have diabetes or obesity, dramatic results. And we’re seeing in those populations not only positive results we’re seeing for cardiovascular death, we’re also seeing reduction in risk of dementia potentially. We’re seeing some benefits that may accrue to make it a valuable medication for addiction. What I don’t see-

Preet Bharara:

Addiction of narcotics and alcohol, both.

Atul Gawande:

Correct. Yeah.

Preet Bharara:

Very substantially, am I right?

Atul Gawande:

So far, yes. Not in large scale trials that you’d want to see to begin using it. But now I’m seeing more of, I just was visiting a friend in California, told me they’re taking a GLP-1, they’re as thin as I am and have no diabetes.

Preet Bharara:

So what’s wrong with that? What’s the harm?

Atul Gawande:

Yes. So here’s my take on all of these things because there’s people taking metformin also, there are people doing microdosing for their mental health, et cetera. The reason people want to do this is mostly for anti-aging. They want to stop themselves from aging and the goal of it requires you to basically stay on it forever. And in order to do that, to decide you’re going to do that, I would want to see two things. Number one, strong evidence that being on this in the long run is beneficial and not harmful because we don’t know that for people who have low risks of cardiovascular disease compared to the high-risk populations who are benefiting. And I’d want to see a big effect size of being on it. And we don’t know what the level of benefit is. We do know the level of GLP-1 benefit for mortality for people who have the tested indications is very high.

And meanwhile, people are not doing the things that we know has significant benefit in your longevity and in how you age. For example, there’s sleep. There is what you do with a balanced diet. If you have high lipid levels or your hypertension, more than half the country is not having these problems diagnosed and under appropriate management.

Preet Bharara:

I want to talk about something very important before we run out of time.

Atul Gawande:

Yeah.

Preet Bharara:

Can you remind people what your job was in the Biden administration?

Atul Gawande:

So I led global health at USAID

Preet Bharara:

And USAID much in the news because in a way, even it seems like, I think this is a fair statement, more puzzling, more arbitrary and even more devastating than the cuts you talked about to funding NIH and other places in this country. This sort of wanton, capricious, effective shutting down of USAID and the work it does and the health and wellbeing that it funded around the world at fairly low cost on a per capita basis as you have written about in the New Yorker. Can you explain to people what it is that was lost? And I’ll ask you the same question again. What was the thinking there or was it just we need to spend less except on the military?

Atul Gawande:

So what I’ll tell you is in leading global health at USAID, I came into the best job in medicine that I’ve ever had. I led 2,500 people around 65 countries in the world and in DC deploying about half the budget of my hospital system in Boston, $24 per American taxpayer out of the $15,000 a year. It still was a good pile of money. It was $8 billion. With that, instead of reaching, we reached many times more than my health system, hundreds of millions of people and saved lives by the millions. The estimates are in the last two decades, the work of USAID saved over 90 million lives, cut mortality rates in the countries where we worked by more than a third. It also got its roots in the Marshall Plan when after World War II, the US decided we’re not going to pillage and plunder Europe, and Germany, and Italy as the vanquished countries, what many victors of war would do.

We did the completely contrary thing and invested at massive scale. The US had to sacrifice actually continued rationing of certain goods in order to help Europe stand on its feet again and set up for peace and stability in the long run. It saved lives in the short run. It built peace and stability and economic prosperity in the much longer run. And that’s what USAID did. You and I come from… My parents came from, India from a country where it was considered a basket case, a place that could never achieve prosperity. And the US invested in food aid for preventing famine and then in agriculture ending smallpox, reducing child mortality. And the result is that by the 1970s, it became self-sufficient for food. By the 1980s, had become a major trade partner to the United States and by the 1990s a donor for aid rather than a recipient.

And that was all shut down in the first weeks of the Trump administration. At the end of the year, people have documented and estimated three quarters of a million people have lost their lives from the shutdown of… I filmed, did a film called Rovina’s Choice that was an Oscar shortlist that you can see on YouTube released by The New Yorker that just examined the shutdown of malnutrition systems. That enabled the not just food aid, but the treatment of children with severe malnutrition who had a 20% death rate before developing the methods that cut it to less than 1%. And that’s just one of the things going across HIV and so on that was lost.

Preet Bharara:

I know this is hard for you because you have a connection to it in the most direct and dramatic and consequential way, but has there ever been put forth a thoughtful or arguably thoughtful brief in favor of the cuts other than… I suppose the best would be, look, we’re not the world’s policemen in other areas and we’re also not the world’s doctor. We’re not the world’s health clinic. We should focus all our money here at home. Is that the theory?

Atul Gawande:

Yeah. The argument put forward is a few things. Again, it’s a confluence of government needs to reduce its ambit and scope to defense and a narrow set of aims and this is not one of them. Second is the argument that it was bureaucratic and too much money went to the bureaucracy rather than out into the field where it belongs. There’s an argument that it fostered dependency. There are things that USAID needed to do better. There were some of the things I worked on while I was there, none of the shutdown, however. And the discovery afterwards that some of those functions were necessary and now are hastily trying to be rebuilt while having lost the infrastructure. None of that was about fixing the problem and indeed the administration is worsening some of these. And arguably with not just lives saved, the benefit to the United States and economic returns and so on over the long run, it has been the biggest impact per dollar of any agency in the US government.

Preet Bharara:

Yeah. I’ve had the discussion with many guests on this podcast doing the thought experiment if Trump had been the president in the middle of the last century. In no universe would he have approved the Marshall Plan, which events is a shortsightedness that you were seeing the consequences of. What’s the hope for the future on any of these points, whether we’re talking about measles, which you’ve given some hopeful signs about that, but funding for the NIH, USAID. Which of these things can be resuscitated and turned around with a new administration and which cannot?

Atul Gawande:

Well, I’d say the hopefulness is that chaos, destruction, and denial of reality is recurrently in history, hated and short-lived. It does not make for a better life. And in our much more aware news cycle world, the consequences have come to light much more quickly than would’ve otherwise. And in year one, not just like the NIH, USAID, which doesn’t exist, Congress still funded the foreign aid appropriation for its global health work, its humanitarian work, et cetera, and put the money back in the coffers. And that was Republicans and Democrats continuing to put it forward. You have an Ebola outbreak right now, you have a variety of forces that are showing the places where the investments had needed to be made. We’re already spending more on Ebola than was cut by shutting down USAID. And so the reality of the next couple of years is the consequences are making it so we will have to have these capabilities.

No great power can approach the world simply through use of force and extractive diplomatic deals. It has to be in cooperation around assisting and cooperating with the rest of the world around achieving objectives that may be as wide ranging as stopping an Ebola epidemic and ending polio, to helping a place like Ukraine maintain its energy infrastructure, which USAID was playing a central role in doing. So the hopefulness is that all of these functions are ones that the ideology can say, shut them down. And the reality is we see the consequences fairly quickly that indicate how much is lost and how much more will be lost if we don’t restore functions.

Preet Bharara:

Do we know what level of public support or opposition there is to this? I mean, the other problem in America is our interests don’t often or not as often as they perhaps should extend beyond our borders. So these deaths you’re talking about are unknown to most people and they’re not felt by most people and there are no pictures. I’m not aware of any documentary film work that is making the point. It was a line item that was slashed and there you go.

Atul Gawande:

Well, so yes, it happens abroad and that made it a soft target as they say. Foreign assistance is generally not high on the popularity list, but when USAID was shut down, awareness of its work and the impact of it has been sky high. 25 point jumps in the support for foreign assistance, for humanitarian assistance, for global health and other needs. And so the popularity of these efforts, when you lose them, health is funny that way. Obamacare was highly unpopular when it passed. It cost the Democrats control of Congress in 2010, but since then has been immensely popular. And once you have the benefit of health coverage here at home, seeing control of diseases abroad and just people actually back the moral case that USAID has played a central role in reducing child mortality by 80% over the last half century. And having the US not only withdraw from that, but destroy programs in ways that may give us the first year of increased child mortality since the famine of the Great Leap Forward, the Great Leap Famine in the 1960s in China, that is immensely unpopular in surveys.

Preet Bharara:

Yeah, goodwill brings benefits. So you were the head of global health, right?

Atul Gawande:

Yes.

Preet Bharara:

As this administration was planning to engage in the cuts that it did, did anyone ever come and sit down with you and ask what would be the consequence? Make the case for us not cutting as deeply as we want to cut. Are there alternatives? Are there ways to prepare these various countries around the world for the shock? Is there private money that we can bring in and encourage to be brought in to make up the difference? Are there contacts we should make in those countries and have their governments be persuaded to do other things that did… Ordinarily, you would expect a lot of that. Was there any of that?

Atul Gawande:

Zero. So not only did the prior administration not come to me, perhaps that’s not a surprise, but they actively shut down the civil servants and foreign service officials who were trying to give them an assessment of what the consequences were. Charged them with being insubordinate for supplying that information and attempting to guide Marco Rubio supposedly… Well, signed a order saying there should be waivers for lifesaving assistance so that those programs were not shut down, but then DOGE and others in the administration actively blocked and Rubio showed no intent of actually making that come to life. And people were ultimately fired who were trying to generate the information about what programs would be lifesaving. Among those programs was in fact maintaining the surveillance systems that we had set up in 50 countries for diseases and outbreaks and rapid response such as to the outbreak currently underway in Congo.

And Nick Enrich wrote a book called Into the Wood Chipper about his failure among other things to be able to get these concerns taken seriously. Musk said in the Oval Office in an interview, “Oh, by mistake we shut down Ebola programs, but we’ve turned it back on.” They never turned it back on.

Preet Bharara:

No. Is it your sense that the folks who were responsible for shutting this down knew the consequences and did it anyway or didn’t know the consequences and may have cared or may not have cared? In other words, did they understand the effect of what they were doing or not?

Atul Gawande:

I think there was a group of people, Elon Musk among them, who ideologically believed that shutting it down would make no difference, or if they shut it down and made a difference that they could patch it up. It’s like Twitter, slash and burn, and then we can always fix if something comes along and things will be fine. Well, you can’t do that with people in clinical trials, people on HIV treatment, people receiving food assistance and not have consequences for tens of thousands of what’s now proven to be hundreds of thousands of people. I was in South Sudan just two weeks ago seeing devastating consequences of shutdown of primary health centers for refugees and for people in conflict areas. And I think a large part of it was just indifference and in curiosity about their fate. Marco Rubio put in another category. He knows very well as what was one of the strongest defenders of USAID.

He’s visited the programs. He knows exactly what it was and I can only surmise there’s been a calculation that if he wanted to keep his job and have his shot at his presidential future, that this was his pathway to go along with. And in fact, endorse and sign off on the destruction and dismantling of a basic capacity of the United States for our foreign policy.

Preet Bharara:

Sir, I could talk to you for many more hours. There are various things in the books that you’ve written, quality of life, but we have to end this so you can go. Save people and get back to your practice. Dr. Atul Gawande, thank you so much for your time. Please come back much more quickly this time.

Atul Gawande:

Glad to talk to you, Preet. Be well.

Preet Bharara:

Our conversation with Atul Gawande continues for members of the Insider community. In the exclusive bonus content, Atul and I discuss affordability and the original sin of our healthcare system.

Atul Gawande:

Our affordability crisis is fundamentally about being able to afford the things that save your life and that starts with primary care.

Preet Bharara:

To try out the membership, head to cafe.com/insider. Again, that’s cafe.com/insider. After the break, I’ll answer your questions about whether Trump’s DOJ anti-weaponization fund is really dead and we’ll also perhaps talk about Hunter Biden’s newly revived X account.

Now let’s get to your questions. This question comes from Wendy in our Stay Tuned Substack chat. “How can Trump appoint a Director of National Intelligence who does not meet the specific minimum qualifications of the statute authorizing the position?” Wendy, that is a wonderful question and lots of people are asking it. So for background, let me just mention a few things. The Director of National Intelligence or the DNI is one of the most sensitive national security positions in the whole government. And interestingly, it’s a relatively recent job. It was created after 9/11 because the intelligence community, it was thought, had a serious structural weakness that became painfully clear in the aftermath of those attacks. So you may recall at the time the US had many intelligence agencies such as the CIA, the NSA, military intelligence, but no single official was in charge of sort of coordinating them all.

While investigating the 9/11 attacks and the causes and our lack of preparedness, the 9/11 Commission found that intelligence agencies failed to share critical information. They found that they operated in silos and didn’t connect the dots, that in hindsight might have helped disrupt the plot. So in 2004, Congress passed the Intelligence Reform and Terrorism Prevention Act, which did a lot of things and one of those things was to create the position of Director of National Intelligence. And so the DNI now supervises and coordinates the 18 or so agencies that make up to US intelligence community and serves as the president’s principal intelligence advisor. But the role was perceived to be so central to national security and Congress was so focused on the need to have someone of great talent and experience in the position that they did something sort of unusual. Congress put a qualification requirement directly into the statute as you mentioned in your question and the requirement reads, quote, “Any individual nominated for appointment as Director of National Intelligence shall have extensive national security expertise,” end quote.

Shall have. As lawyers know, that’s a mandatory requirement. Now the statute doesn’t define extensive, but presumably extensive means I would think more than zero. Now, just to reiterate again, it’s quite rare for Congress to write minimum qualifications into statutes for positions like this. For example, the attorney general has no statutory minimum qualifications, neither do US attorneys, secretary of state, or even the FBI director. So you can be the attorney general without being a lawyer, you can be the chair of the Senate Judiciary Committee without being a lawyer. You can even be a Supreme Court Justice as a matter of law without being a lawyer. But you can’t be the DNI according to the statute unless you have extensive national security experience. So who did Donald Trump tap? A person by the name of Bill Pulte? Mr. Pulte is a 38-year-old former housing businessman who is now being called upon to serve as acting Director of National Intelligence.

Pulte appears to have zero national security experience. So I think by any measure, he clearly fails to meet the statute’s requirement of extensive national security experience. As you may know, he’s currently serving as director of the Federal Housing Finance Agency and before that he worked in private equity. Equally, if not more importantly, Bill Pulte has shown himself to be completely willing and able to use his government position for what? To pursue spurious allegations against Trump’s political opponents. As director of the FHFA, he’s used his office to initiate criminal referrals against several of Trump’s political enemies. Mortgage fraud, for example, by people such as New York Attorney General Letitia James, Senator Adam Schiff, Federal Reserve Governor Lisa Cook, and former Representative Eric Swalwell. And he’s done it publicly and he’s done it by social media and he has a lot of critics both on the left and the right.

Now, imagine he has access to the country’s most sensitive intelligence. Senator Mark Warner on the Democratic side, who happens to be the top Democrat on the Senate Intelligence Committee, criticized the appointment saying this, quote, “The president has chosen an official who has demonstrated not just willingness, but eagerness to use the authorities of government to pursue political retribution.” And here you have a Republican, Senator John Cornyn from Texas, who also sits on the Intelligence Committee who told reporters, quote, “I don’t see any evidence of his qualifications for that job,” end quote. That’s because there isn’t any. So how can this happen if the statute requires what I’ve said? Well, that requirement isn’t really enforced by the courts. These kinds of things are in practice enforced politically through the Senate’s advise and consent power under the Constitution.

And senators can quite easily, if Bill Pulte is nominated for the permanent position, quite easily assert themselves, assert the prerogatives of the Senate and make sure that a duly qualified person is in the job. Will they do that? I don’t know. So the law has real force only if the Senate decides to enforce it and that decision will have serious consequences for national security. By the way, as an interesting and not particularly scientific side note, Jake Tapper of CNN recently asked X’s AI chatbot, Groq, “If one made a list of the one million most qualified people to be Director of National Intelligence, would Bill Pulte be on the list?” Groq’s response? No.

This question comes from David in our Stay Tuned Substack chat. “We’ve heard that the slush fund has been withdrawn, but has it really?” David, good question and one that’s been swirling around like the other questions that we’ve gotten in the last couple of weeks. It happens to be a question that President Trump was recently asked during his interview on Meet the Press. You may have seen it, the one that he walked out on, like a petulant child. The slush fund you were referring to obviously is the 1.776 billion so called anti-weaponization fund. It was created, as you may know, as part of Trump’s settlement with the IRS after he sued the agency for allegedly failing to protect the confidentiality of his tax returns. And under that very unusual unprecedented settlement, the DOJ agreed to establish a fund to compensate people who claim they were victims of government weaponization, meaning in their view, the misuse of the legal system for political purposes.

Perhaps the most controversial aspect of the fund and the one that has caused it to bleed Republican support is who could potentially qualify. Critics argue, and I’m among them, that claimants could very well include people who participated in the January 6th attack on the Capitol. More than 1,200 people were convicted of offenses relating to January 6th and many of them might qualify for payout, including individuals who beat and harmed Capitol police officers. So as we’ve talked about on this podcast and on the Insider podcast, the fund was quickly challenged by multiple lawsuits. As of this moment, a federal judge has issued a temporary injunction blocking the DOJ from transferring money, processing claims, or paying anyone out while the legal challenge proceeds. But DOJ has appeared to take its own preemptive step. After heavy criticism from Republican senators, acting Attorney General Todd Blanche testified before Congress that DOJ would not move forward with the fund, period.

And he used that definitive emphatic word, period. Then in court filings on Friday last week, DOJ lawyers insisted the case was moot because the fund was already not going forward. The judge in the case has yet to respond to those filings, but President Trump doesn’t sound like he’s abandoned the idea. In that Meet the Press interview that I mentioned earlier, he pushed back forcefully when Kristen Welker asked whether he was backing off, Trump said…

Donald Trump:

People have been hurt so badly by radical left lunatics that worked for the Biden administration and Sleepy Joe. People have been badly hurt over a fake weaponization of government. Now let me just ask you-

Kristen Welker:

So are you looking for a way to revive it?

Donald Trump:

Well, look, if it was up to me. I’d pay them the kind of money that they deserve.

Preet Bharara:

If that interview tells us anything about Trump’s intentions, we may be hearing about the anti-weaponization fund again. Now, probably it’s the case that in its current exact form it won’t go forward, but Trump seems bent on compensating people who attack law enforcement and Trump often gets his way. So we’ll see.

This question came as an email from Calvin who writes, “Preet, have you been following Hunter Biden on X? What do you make of what he’s been saying?” So you know, Calvin, I have. I’ve been following him with a good amount of interest. Hunter Biden has been a lot of things to a lot of people, but in his very first tweet in recent memory on his long dormant X account, this was his first post. Quite simple, it read only, “I’m Hunter Biden. You’ve never actually heard from me.” And that’s kind of true.

Since May 19th, he’s been pretty prolific. As one of our listeners pointed out, Hunter Biden signed up to Substack 10 hours ago and already has 7.4,000 subscribers. People seem to like his nothing to lose and no Fs to give attitude combined with his brutally honest take on sobriety. Another listener wrote, “His honesty and authenticity about recovery has been very touching to watch. It has created meaningful conversations, especially for those that are struggling with addiction based on their comments who are reaching out to him for help to tell their stories.” In a similar vein, another listener Susan writes, “I like his honesty about addiction and recovery.” But not everyone is a fan as you might imagine, and that breaks down along political lines mostly. One user on X said, “Congratulations on your sobriety, Hunter Biden. Addiction makes people do dumb things. That’s why true sobriety requires restitution and making amends. Now pay back your Ukraine bribe money.”

While there certainly will be a lot of material it seems as Hunter himself posted on June 4th, quote, “This crackhead has a lot to say, so buckle your seatbelt, my friend,” end quote. I’d like to hear from more of you. What do you think of his feed? What do you think of his Substack? And maybe I’ll have something more to say about it next week.

Well, that’s it for this episode of Stay Tuned. Thanks again to my guest, Dr. Atul Gawande. If you like what we do, rate and review the show on Apple Podcasts or wherever you listen. Every positive review helps new listeners find the show. Send me your questions about news, politics, and justice. You can reach me on Twitter or Bluesky @PreetBharara with the #AskPreet. You can also call and leave me a message at 833-997-7338. That’s 833-99-PREET, or you can send an email to letters@cafe.com.

Stay Tuned is now on Substack. Head to staytuned.substack.com to watch live streams, get updates about new podcast episodes and more. That’s staytuned.substack.com. Stay Tuned is presented by CAFE and the Vox Media Podcast Network. The executive producer is Tamara Sepper. The deputy editor is Celine Rohr. The supervising producer is Jake Kaplan. The lead editorial producer is Jennifer Indig. The associate producer is Claudia Hernández. The audio and video producer is Nat Weiner. The senior audio producer is Matthew Billy and the marketing manager is Liana Greenway. Our music is by Andrew Dost. Special thanks to Torrey Paquette and Adam Harris. I’m your host, Preet Bharara. As always, stay tuned.