Atul Gawande enters the patio of the Mexican restaurant proffering his arm — clad in professorial lilac elbow patch — instead of his hand. It is my first in-person interview in five months, and I was expecting him to know the right Covid-19 protocol. I am surely one of many looking to him for guidance and solace on living through the pandemic — and recovering afterwards.
The 54-year-old literary surgeon is famous for changing the way people think about the end of life. His Being Mortal (2014) moved many readers to have difficult conversations about a topic we notoriously avoid, prompting patients to examine what makes life worth living and guiding them away from intrusive last-ditch treatments. Beyond his bestselling books, his articles for the New Yorker helped to shape Barack Obama’s healthcare policy. He has also had stints in government and most recently the private sector. He could be exactly who we need at this moment: a practising doctor with a grasp of politics.
So what was he thinking as the world began to grapple with the pandemic? “How do you navigate a path when you’ve got only a sliver of information?” he says, leaning back in his chair, picking at the tortilla chips already on the table. “That felt very much in my toolkit, because as a surgeon, you’re often seeing people and having to make decisions about what you have to do, when there’s a certain amount of evidence but there’s a lot missing and decisions still have to be made.”
Now, he believes the questions facing Americans are moral, rather than technical. He compares this to the kinds of end-of-life conversations he advocates in Being Mortal. But the US is polarised over its priorities, between those arguing in favour of putting the economy first, and those who want to concentrate on saving lives.
“What you have is a debate over values, about whether . . . people’s lives matter more than either the president’s own concerns about things looking
bad for him, or a party’s view about whether those lives matter,” he says. His gentle tone contrasts with the sharpness of his criticism.
He looks back to a brief period at the end of March when Trump appeared to take the coronavirus pandemic seriously. He believes that even those five to seven days bought time — yet laments that it did not last nearly long enough. “In March or April, if he had said, ‘We have to come together around this and there’s some very simple things we can do,’ he not only would have saved a ton of lives, he would be hugely ahead in the polls. He would all but guarantee his re-election,” he says. We met before Trump himself contracted Covid-19, which he might have avoided by taking the simple precautions he eschewed.
Gawande is a regular at Taqueria Mexico, a squat red-brick building squeezed between clapboard houses in the backstreets of his Boston suburb. Hesitating over the drinks menu, he explains that he usually comes in the evening and orders sangria. I assure him that the FT is in favour of a glass of wine at Lunch with the FT — but he decides to try a soft version of the cocktail. He may not have surgery but he still has patients to see this afternoon.
Gawande grew up the son of two doctors, first-generation Indian immigrants who met in New York before moving their family to the small university town of Athens, Ohio. After majoring in biology and political science at Stanford, Gawande spent his twenties juggling roles in politics — serving as an adviser in Bill Clinton’s health department — with his studies at Harvard Medical School. He was later offered positions in Obama’s administration, but felt others could do those jobs just as well.
“My whole approach to writing and policy and having an impact has been that I’ve never believed that politicians lead. They react,” he says. At the New Yorker, he has aimed to produce work that might change leaders’ minds, or provoke a public discussion.
The scale of deaths in the US is still hard to fathom, months after the first peak on the East Coast. I ask Gawande if he has been surprised at how much death people seem able to tolerate. A poll in August found that 57 per cent of Republicans thought the death toll — at the time 165,000 in the US, making it the worst-hit developed country in the world — was “acceptable”. Now that figure is 207,000.
“I’ve talked to many Republican politicians all the time, senators, congressmen, and they care about deaths in their constituency,” he says. “And they genuinely believe that this is a dangerous situation. And that it’s not a winning issue to go up against the president on 200,000 deaths. That is shocking to me.”
He is troubled, too, by the fact that many patients suffered through their final hours alone, with visitors often banned because of the risk of infection or a need to preserve personal protective equipment. “It really disturbs me that there are all these people dying alone, with their families unable to see them,” Gawande says, adding that his hospital — the Brigham and Women’s, part of Harvard Medical School — saved gowns for relatives even when they were in short supply. “The dying have to have access to a family member. Just out of sheer humanity.”
I read Being Mortal on a plane shortly after my grandad died two years ago, and have always remembered the story about the man who only considers life worth living if he can still manage to eat ice cream. Instead of assuming that quantity of life is more important than quality, which can lead doctors to prescribe ever more onerous medical regimes, Gawande thinks they should actually ask their patients what matters to them.
24 Charles Street, Waltham, Greater Boston
Taco de lengua $3
Taco de barbacoa $3.60
Taco de pastor $3
El Presidente $13.95
Rice side $2.50
Fried bean side $2.50
Soft sangria $3.10
Jugo combo $4.45
Total (inc tax and tip) $49.72
He tells me about an elderly relative in a different state who cannot go to a home to have 24/7 care because the rules mean she would not be able to see her husband — potentially ever again. “It’s appropriate in that early period to say, ‘OK, only quantity of life matters and we’re not gonna let this virus spread and kill people,’” he explains. “But we need to bring back what we learnt over the last few years, which is: it’s not just about keeping people safe, it’s also about being able to have meaningful lives and not torture people.”
Gawande’s trio of tacos arrives on a large turquoise plate: one al pastor, another tongue and the third barbacoa, along with side bowls of rice and refried beans. I’ve chosen the Presidente, which includes a chile relleno and an enchilada.
People are more at risk of Covid-19 if they have underlying conditions such as diabetes and hypertension. Is the US as a country more at risk because of the underlying condition of its healthcare system? Gawande rails at the lack of sick pay, which is potentially keeping ill people at work, and the country also has many who might be reluctant to seek care, most notably the 26m uninsured, a number likely to grow as millions lose their jobs.
“I do think that the fundamental disaster of the United States is tying where you get your healthcare to where you work,” says Gawande. It is not just about the huge bills that patients struggle with — it is bad for the economy. “We basically added a $15,000 to $20,000 head tax to every low-income job there is, which means we’re stopping people from being hired and we’re pushing contracting and outsourcing,” he says. “We have an increasingly fluid economy, where people are moving in and out of jobs all the time, and your healthcare should follow you your whole life.”
Gawande is flexible about which country’s model might be better for the US, listing the many different approaches that are better than what it has now. “I’d be game for Medicare for All, if we’re able to agree on the financing,” he says. A rather large caveat.
“I do think that another critical lesson coming out of this is that people feel strongly that coronavirus treatment, and care, and testing, should be paid for universally by the government,” he continues. “That really opens the door to being able to say we should be able to guarantee this with government funding for any kind of illness or condition.” I suspect this is optimistic — the pandemic is yet to inspire a new movement to reform healthcare — but maybe it will take time.
I have demolished my chile relleno, but have piles of creamy refried beans and rice to plough through. The green enchilada sauce exudes a subtle heat, and tastes surprisingly authentic: Boston is not known for its Mexican food. Between talking, Gawande is making less progress, but is enjoying his tacos.
I ask how closely the fight to reform healthcare is linked to the fight for racial justice. “The whole idea that there is a deserving and an undeserving for healthcare, I think is deeply tied to the injustice of unequal treatment based on race,” he says. He describes a revolt in the South when Lyndon Johnson brought in Medicare, the government-backed health-insurance plan for seniors, in the mid-1960s, because it forced the desegregation of wards and blood banks. Gawande’s wife Kathleen Hobson, whom he met as a student at Stanford, is a housing activist, and he credits her with opening his eyes to the consequences of segregation in US communities, particularly in access to care.
But again he finds reason to be hopeful. “I think one of the most important things that has happened with the Black Lives Matter movement, and its suddenly blossoming, is the recognition of how all these things are tied together, and the willingness now to call it out.”
Gawande has spent the past two years trying to tackle the problems of US healthcare at Haven, a secretive joint venture that excited many when it was founded by several of the biggest names in tech and finance: Amazon, JPMorgan and Berkshire Hathaway. The aim was to experiment with their combined one million employees to use technology and data to come up with new, cost-effective ways to deliver healthcare.
From the outside, it does not look as if it has done anything to revolutionise healthcare. Amazon is pursuing health projects outside the venture and some Haven leaders have left. In May, Gawande stepped down as chief executive to become chairman, saying he wanted to focus on the pandemic.
I ask if leaving to spend more time on Covid-19 was like the well-oiled excuse of leaving to spend more time with one’s family? Gawande calmly insists that’s not the case. “Now, with the pandemic hitting, I found myself needing to spend more time getting back on the public stage, and building things to attack the problem we’ve got, and splitting that time with being CEO wasn’t going to be viable.”
I am intrigued to know what he’s working on now, but he cannot tell me yet. Later, he emails with a link to a New Yorker article, where he discusses his work launching the Assurance Testing Alliance, an umbrella organisation working to make it easier to scale Covid-19 testing for schools and employers by using underutilised university labs.
The rain interrupts, pittering on our half-eaten meal. We have a choice: go inside and endure an increased risk of Covid-19, or get wet. Gawande thinks we should avoid going inside and hope the shower will pass.
I ask what the most significant achievement was at Haven. His answer seems to reflect a non-disclosure agreement and I feel as if I’m momentarily in dialogue with the company’s lawyers. “Well, I wish I could talk about it. But I’m afraid I can’t,” he says. “We’ve launched a bunch of experiments and tested different ideas and we’re now gathering some of the information on that, and eventually we’ll be able to talk more publicly about some of it.”
A few minutes damper, we are able to move to a table with an umbrella to shield us. Gawande has finished eating and sips his faux sangria. It comes in a green plastic bottle, dressed up like wine but flavoured like black cherry soda.
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Speaking in late summer, Gawande was worried about coronavirus surges in the autumn, which now seem to be under way in many states. “We’re getting better at treating it, so that the deaths are coming down from over 1,000 a day; we are still tolerating a situation where we now have coronavirus as the number-three killer in the country,” he says, as it joins heart disease and cancer as top causes of death. “And we aren’t doing anything about it.”
I wonder if his intention to step back on to the public stage means going into politics. Gawande seems somewhat scarred by his time in the Clinton administration. “I did not love it in my late twenties, the power politics of people leaking to the press so they could get you kicked out of briefing the president — and they’re on your side,” he says. “On the other hand, I love the impact, in the sense that you get things done.”
But he leaves the possibility open, making me wonder about conversations with Biden. “If I can help an administration in ways where I’m not just duplicating something that someone else could do, then I would consider it,” he says.
His cure for coronavirus seems to start with securing new leadership for the country. “I’d like to think that as we crossed the 200,000 deaths, then the 250,000 mark, and then the 300,000, that at some point the White House decides you have to take a different path,” he says. The man who has written so movingly about death is exasperated at the scale of it.
“In the absence of that . . . we turn him out of office and you have a leader who will take it seriously. Then we’ll take a few months to really start turning things around.”
Hannah Kuchler is the FT’s US pharma and biotech correspondent
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