Assistant Administrator Atul Gawande on America's Global Health Edge: How USAID Is Redefining The Way To Secure A Healthier World

We're coming to the end of my time at USAID, and I want to use this opportunity to say thank you. I have been constantly reminded of a proverb I heard in Nigeria on my first TDY: "If you want to go fast, go alone. If you want to go far, go together." We have gone together. And because of that we have gone far.

I will miss you and this agency dearly. I tell people who ask what I do, "I have the best health job in government that you've never heard of."

USAID has given me a chance for impact on a scale I never imagined. Our mission is to help low- and middle-income countries address their leading causes of premature death and disability and combat emerging disease threats for the US and the world. And to do so, our bureau has 900 people in D.C., working alongside 1,600 plus staff in over 65 countries, deploying $10 billion a year in foreign assistance for health. I'll remind you of the vision statement we created together: "We are an inclusive, agile, and innovative team, co-investing resources and expertise with communities and countries to advance the equitable delivery of sustainable public health approaches, improving lives everywhere."

When USAID was founded in 1961, that meant priorities like fighting smallpox, a disease that claimed half a billion lives in the prior century, and reducing child mortality - deaths in children under five accounted for half of all deaths in Africa and Asia. By the time of President Biden's inauguration 60 years later, the challenges had evolved. Smallpox had been eradicated. Child deaths were cut 80 percent. Twenty-five years had been added to the average person's life.

But in low income countries, almost two-thirds of deaths still occur before the age of 50. And we now faced a pandemic that had caused the first global drop in life expectancy in 70 years and would claim 15 million lives. Turning COVID-19 into a manageable respiratory illness was, necessarily, our top priority. Working with other U.S. agencies and partners around the world, we distributed nearly 700 million vaccines to 120 plus countries, built global oxygen capacity, and took other critical steps in turning the tide.

New, shape-shifting pathogens are also emerging with increasing frequency. And in our tightly connected world, they can spread anywhere in hours. So we built out a network of 50 plus countries on every continent, developing what I've called the world's immune system - an ever-accelerating capacity to prevent, detect, and more rapidly respond to pandemic threats. Internally, we built a dedicated Global Health Emergency Management System, including an Outbreak Response Team that now tracks thousands of outbreak notifications in human and animal populations. Over the last four years, our teams mobilized critical assistance to contain 21 major outbreaks around the world, including 11 involving deadly viral hemorrhagic fevers and two global mpox emergencies. And we've seen faster and faster results.

Equally vital has been our long-term work to address the leading causes of premature death and disability - such as HIV, TB, malaria, vaccine-preventable diseases like measles and polio, and unsafe childbirth, lack of contraception, and malnutrition. Progress had stalled in many places, even before the pandemic hit. But we saw that nations that invested in robust primary health care systems performed notably better.

For example, Thailand's implementation of universal primary health care in 2002 accelerated its progress on nearly all health indicators and halved its rate of deaths before 50. They've freed themselves from dependency. And their life expectancy has now passed the United States'- all with total health spending of just $305 per person in a year. We found similar outliers on every continent performing far above their income by prioritizing primary care. So that's where we focused.

We launched USAID's Primary Impact initiative, which makes sure our disease-focused programs enable countries' plans for local primary care systems. We created the Community Health Delivery Partnership to coordinate others, including donors, CSOs, and implementing countries, to do the same. We won the support of Congress to invest $10 million in global health workforce development. And we joined the board of the World Bank's Global Financing Facility to drive more domestic and international investment into primary care. It has emerged as a groundbreaking body of effort.

The joy of this work often feels, to my surprise, like the joy I have found in surgery. You face new, life-threatening situations everyday - in surgery, it might be a cancer or a knife wound; in global health it might be a cluster of deaths from an unidentified virus in central Africa, a request to support Ukraine's health system after Russia's attack on Kyiv, or data showing a dangerous fall off in results from a partnership to reduce TB deaths in India. Your knowledge is always imperfect, the risks significant, and yet action is required. You can also see daily evidence of immediate, tangible benefit. Mortality rates in USAID-supported countries drop consistently faster than comparison populations in published research.

Here are specific examples. For children under five in African countries with sustained health sector support since 2000, the benefit translates into six extra years of life versus controls, according to our analyses; women of childbearing age gained four extra years of life. During just the last three years, we helped our partner countries reduce deaths before age 50 - our overall metric for premature mortality - to below pre-pandemic levels, saving 1.2 million lives.

Then add the impact of our leadership and support for global health institutions, such as the World Health Organization, the Global Fund to Fight AIDS, TB, and Malaria, and the global vaccine alliance, Gavi. For example, one of the high points of my experience has been serving on the Gavi board. We've helped position Gavi to accelerate vaccines to half a billion children in the next five years. That alone will save another eight million lives.

We know how meaningful this work is not only from its impact, but also from how it is being targeted by foreign propaganda campaigns. Last month, Administrator Power gave a speech where she discussed scores of examples. For instance, over the past year, Russia's intelligence services have backed a new information agency called African Initiative. This agency runs a website and social media accounts that consistently attack U.S. health programs across the continent of Africa. It repeatedly publishes baseless claims that our programs are covertly carrying out nefarious biological testing on African communities. As Power noted, the propaganda reveals how America's competitors understand the enormous power of our work - how our work increases US standing, strengthens alliances, and strengthens our security in an age when so many of the biggest security threats we face, like emerging pathogens, transcend borders.

Our ultimate test will be the test of time. Sustaining our impact means investing in the slow, steady work of building local leadership and systems - of going far by truly going together. Global Health led the Agency in localizing our funding. During my tenure, we went from putting just 14 percent of our funding through local organizations and governments to reaching 30 percent in 2025. The TB program has exceeded 45 percent. Our HIV program is over 65 percent. Unlike other agencies, we have also focused on developing foreign service nationals as our experts on our teams around the world rather than flying them in. FSNs make up 70 percent of USAID's mission workforce, and we've substantially increased the number in leadership positions.

These ambitions are necessarily long range. We launched our partnership to eliminate poisoning by lead - a neglected neurotoxin affecting 1 in 3 children globally and causing more deaths than any infectious disease. Our target date? 2040. Some of the goals we set are so long-range we will likely not live to see them completed. Like enabling community-based primary care that is as universal and self-sustaining as roads and a high school education. These efforts, nonetheless, are the ones I am proudest of.

There's one more way USAID is redefining how we secure a healthier future. That is in how our teams define our true expertise in health. It is not in how to stop this or that disease or health threat - though we and other US agencies have that expertise. USAID is a development agency. Our essential and unique strength is being experts in how countries and global institutions develop their systems for delivering health solutions in communities.

Health systems can seem abstract. But they are personified by the people who do the work of delivering health care to communities. So our critical expertise is in how countries currently finance, support, and develop their health workforce and in how our and others' investments can most effectively advance countries' plans and abilities for that workforce to deliver and sustain a healthier future. I'm delighted to see the release of our Policy for Global Health Development today, laying out how we build and operationalize that expertise.

There are so many opportunities for leaps forward in our programs and initiatives. But if we remember who we are and how we've redefined the work of global health, nothing will stop this agency's impact.

Let me close by saying, again, thank you - for going together with me these last few years - for going so far.

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