Instead of his usual multi-member panel to update viewers on the Covid-19 pandemic, UCSF Grand Rounds moderator Dr. Bob Wachter conversed one-on-one with author Dr. Atul Gawande in a special Grand Rounds dedicated to the 23rd Annual Reza Gandjei Memorial Lecture.
Gawande, a surgeon at Brigham and Women’s Hospital, the founder of Ariadne Labs, author of four books, professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health, began the discussion by noting the “uncanny parallels” he shared with Gandjei. Both were Rhodes scholars, attended Harvard Medical School, and worked at the WHO and in public service, though under different administrations (Gawande worked during the Clinton campaign and Gandjei during the Bush Administration).
After describing both of their passions for politics, philosohy, and service, Gawande connected the “heartbreaking” nature of Gandjei’s suicide in 1997 to the pandemic.
“Given his immense talents and the recognition and opportunities he was able to have in his life, his death, I think speaks to the vulnerability that we all have, especially in this moment, this year of crisis, when we’re all under duress and forced to be aware of the fragility of life by a virus that we witness claiming lives at every age,” Gawande said. “It’s difficult to think of this virus and this pandemic as a gift, but we should.”
“Many people are learning that in this crisis,” Gawande said. “I am seeing it everywhere. People are changing their focus, they’re changing their jobs, they’re changing how they live. There may yet be good to come out of this.”
He related that change to a phenomenon that Dr. Laura Carstensen found in HIV patients. Her earlier research tracking the emotional lives of individuals from ages 18 to 94 over time showed that people’s desires and emotional signatures — the way and individual’s presence makes others feel — change as they age. As we get older, we transition from seeking achievement to seeking intimacy, and feel more at peace. Carstensen found that young men diagnosed with HIV developed emotional signatures to match those in higher age groups as they became more ill, demonstrating that it is not age, but perspective, that changes emotional signatures. As individuals came “face to face” with their fragility, they drew closer to the people in their lives who meant most to them, experiencing lower rates of anxiety and depression. They actually became happier.
That, Gawande said, is reflected in how individuals made changes during the pandemic.
The pandemic has also revealed several other truths, Gawande said. One of those is the importance of communication. Though the United States topped many rankings of pandemic preparedness, Gawande said, it failed to execute on “the single most powerful thing in this pandemic,” the ability of governments and public health officials to unite in one voice around truth.
However, Gawande still feels hopeful. In a recent piece he wrote for the New Yorker, where he has been a staff writer since 1998, Gawande described the struggles of the city council in hard-struck Minot, North Dakota, when deciding to implement covid protection protocols.
As hospital beds filled up and cases rose, there was a battle between what Gawande called “the public health voice” and “the pro-freedom voice.” Gawande asked, “Can a democracy pull together — as frayed as ours — to actually take on a crisis?”
Though the action came late, the council eventually passed a mask mandate that 90 percent of residents abided by, leading to a drop in cases, hospitalizations, and deaths.
“That was a sign to me that as riven as we are, we are capable of coming together around the most important things that matter,” Gawande said.
“Yeah I guess,” Wachter said. “But we didn’t mostly.”
Highlighting political partisanship and the “choose-your-own-adventure” nature of media today, he asked Gawande if there is something fundamentally different about our current environment and how we can “get out of this mess.”
Gawande noted that “this is a uniquely politically fraught virus,” in part because the people spreading the virus tend to be younger, while those dying from the virus are much older. Moreover, the deaths happen several weeks after increased spread.
“You need action now in the face of an invisible thing for the sake of a population that’s much older. And you can have politicians exploit that,” he said, noting that this is taking place in several countries. “That is a vulnerability of this virus and it’s layered on a time when there are deeper, much deeper divisions.”
Gawande contends that these divisions can be seen in the declining rates of life expectancy in the United States, especially those ages 45 to 55.
“What we hear is the anger of the high-school-only educated, middle-aged white American,” he said, but what we see in larger numbers is the despair associated with being part of an economy where the average person is worse off than their parents. “And that experience is driving a big part of what’s going on as well. It turns up as anger, it turns up as exploitation, it turns up as tribalism.”
Gawande was also concerned about the rapid spread of the B117 variant, whose presence is doubling every 10 days in the United States. In Florida, this variant will become the dominant strain within the next month.
“The reality of the strain is that as fast as we can drive vaccination, the supplies won’t be sufficient to stop it,” he said. “The vaccines are effective against the strain, but we need to do a few more things.”
Further actions include upgrading masks (preferably medical-grade); staying away from bars, restaurants, and other social gatherings; and following more aggressive safety measures in the workplace — the biggest site of spread, Gawande said.
He also fears the decline of conversation around health equity and racial justice in the healthcare system. While there has been earlier and more creative dialogue around these topics throughout the pandemic, Gawande noted that we are already seeing an erosion of attention as the attention turns to vaccines.
Wachter and Gawande then dove into Gawande’s writing and public health careers, especially his work in founding the Ariadne Labs, a joint health systems innovation, and Haven, a healthcare startup. Ariadne Labs grew out of a project to create a safe surgery checklist that had excellent trial results, with a 47 percent reduction in deaths. Eventually the project was scaled up for hospital use.
“And that created Ariadne labs—to provide a platform to attract people who want to solve those kinds of problems, generate new solutions, test them in the real world, deploy them.” Today, the center has over 150 associate faculty and 100 staff members, and the safe surgery checklist is used in 90 percent of the high income world and 60 percent of the low income world.
One of Gawande’s more recent ventures was as CEO of Haven, a healthcare startup funded by Amazon, JP Morgan and Berkshire Hathaway, to improve healthcare services and lower costs for the low-income employees of the companies. However, it was shut down this month, just three years after its launch.
Though there were several factors that contributed to its end, Gawande cited difficulty in implementing a single model for the 1.5 million employees at three different companies, as well as ruptures caused by the pandemic.
“If not for the pandemic, I would have continued to power ahead doing many of those things to keep them going. I think the pandemic really changed a lot of the reality of what was going to matter,” Gawande said.
He also critiqued the employer-based health insurance model.
“A job-based system is a broken system in a world where people are moving every couple of years to different roles in many, many kinds of jobs and the pandemic has brought this out in spades,” Gawande said. “The vulnerability we have of tying your health care to your job, that remains a still a big hill to climb, and the government has to solve that.”
Today, Gawande is focused on CIC Health, an organization he founded to run healthcare and mass vaccination sites in Massachusetts.
See our previous Grand Rounds coverage here.
We are approaching the one year anniversary of the lock down of longterm care patients, which had been ongoing in San Francisco despite much evidence that forced isolation from family caregivers is deadly. The inflexibility of our department of public health and those advising it here in San Francisco is legendary to senior advocates state wide. Why no mention of this? Not grand enough for gramd rounds?