Atul Gawande, a renowned surgeon, writer, and public health leader visited Ho Chi Minh City from November 17 to 18 to strengthen the partnership between the United States Agency for International Development (USAID) — where he works as an assistant administrator for global health since January 2022 — and Vietnam in promoting global health security.

A Tien Phong (Youth) newspaper reporter joined him in a meeting with Ho Chi Minh City youths where Gawande shared how his one commitment has landed him three of his dream jobs.

Can you tell us about your journey from a surgeon to a writer and global health leader? 

My parents were Indian immigrants to New York City. My mother was trained as a young paediatric student and my father was trained to be a surgeon there. They met and I was the first result. So part of this journey was that I developed an anaphylactic reaction to the smallpox vaccine and my parents had to abandon their planned return to India. 

They ended up settling in Athens County, which is the poorest county in the state of Ohio, where they practice rural medicine. When I grew up, in some ways, I felt like an outsider as an Asian kid in an almost all white Appalachian town. In another way, we clearly had advantages. We had two doctors in the family and I knew my life prospects were going to be different. Half of my class did not go to college and I ultimately graduated from Harvard Medical School.

The second part of the journey was that I came to live by a preset that I labeled: Say yes to everything before you’re 40. By that, what I meant was I didn’t know what I was going to be good at or able to do. As the child of two Indian doctors, they wanted me to be a doctor. And I did become one. But I was willing to try almost anything I could. I had a band in college, I worked at the college radio station. I took classes in political science and biology. I was good at science so the medical path was opened to me. I was very interested in public affairs and I’m not actually any good at writing — that didn’t seem to be covered. But I kept saying ‘yes’ to different things and paid attention to things that actually energized me and stopped doing things that didn’t energize me.

By the time I was in my late 20s, I had worked in politics for three years and ultimately worked in health policy. I had completed medical school and found unexpectedly that I liked surgery. I found I was very attracted to public health. And then a weird thing happened, a friend of mine started an Internet magazine, and asked if I would write for it. In the spirit of ‘yes,’ I said ‘yes.’ I ended up writing 30 pieces in one and a half years and it led to an unexpected writing career. So I tried to figure out how to put practicing surgery, public health and writing — the three things I was energized by — together. Weird enough, that all came together.

I love surgery because of the ability to save people’s lives, but at the same time, it is the opportunity to save only one (life) at a time. With global health and public health, you can save lives by the millions. My work all along the way has been about one commitment, which is understanding how we make it possible for all the world to get the advantage of what we have achieved for many of the wealthiest countries in the world, which is the ability to now have an average 80+-year life expectancy in a state of health. However, no country on Earth, including the United States, has achieved it for their entire population, let alone bringing it to the entire world. Even in the U.S., we have a 15-year gap between the richest one percent and the poorest one percent. I see it as a generational challenge that will take us our lifetime to be able to learn how to make it possible to bring this capability to everybody.

What is your advice for Vietnam to maximize the life expectancy of its people?

Vietnam is incredibly fascinating for me. Vietnam has generally been able to produce higher life expectancy for its given income levels than in other countries at the same level. For example, right now, the life expectancy of Vietnam is more than 75 years. The U.S. at the moment is 76 years, with six times the income per capita that Vietnam has. There are things I think we can learn from you, almost more than the other way around. 

In order to go from 75 years to 80+ years, the usual gap is in how you manage chronic illnesses, vaccinations for infectious diseases, early childhood illnesses, maternal mortality issues, HIV and more. But I think at this point, Vietnam is transitioning to the place where the big killers are cardiovascular disease and cancer and the burden of mental health. Those are challenges that we have known approaches. You want to have an effective primary health system that has well trained people to do outreach — reach out to everyone, rather than wait for people to show up. You want to make sure people are able to be recognized for their illnesses and supported to stay on the medication.

In HIV, Vietnam is one of a few countries that are on their way to fully pass the 90-90-90 milestone. That is, 90 percent of people living with HIV know their status, 90 percent of people living with HIV who know their status using antiretroviral therapy, and 90 percent of people living with HIV on antiretroviral therapy achieving viral suppression. Those are hard goals to achieve. You can only achieve them with a strong system of outreach, community-based connection, and care and regular support. That’s true with any other chronic illnesses like blood pressure, diabetes, and others.

What is your view about the right to die of people who have terminal illnesses and assisted death?

I have learned that people have goals in their life besides just surviving or living longer. Those goals are priorities in their life, vary from person to person, and change over time. The most effective way to find out what people’s priorities are is to ask them. And usually we don’t ask or we don’t know how to ask appropriately. The result is that when people undergo care for a life-threatening condition or chronic illness, they are suffering, because the treatment is often not in line with what their priorities are. 

I began learning how to ask about those priorities with questions like: What’s your understanding of where you are with your illness? What are you willing to endure or not willing to endure for the sake of having more time? What’s the minimum quality of life you find acceptable? And I found people gave really, incredibly valuable answers. I don’t think of it as being about the right to die. I think about it as being about the right to live all the way to the very end, to have a life worth living all the way to the very end. We have people getting to live longer than ever in history but half of a person’s life is spent living and dealing with chronic illnesses, heart disease, high blood pressure, diabetes, kidney conditions, and more. I am not a proponent of euthanasia and I have observed a few things.

Many of the reasons why people want to die is because of poor care while they face problems like pain, anguish, and loss of control of their life. Those are treatable. But there are many dimensions in which we all, across the world and societies, fail people who are very elderly or are very debilitated from illness and are not able to support them. The country that has the longest experience with assisted death is the Netherlands where approximately four percent of people come to the end of life with assistance. And it disturbs me that the majority are elderly women who report their number-one reason is they don’t want to be a burden on their family. I feel that we have not done a good job in enabling basic palliative care and medical care-oriented for people’s needs. We are failing people at that first level and resort to the solution rather than address their pain which will put them out of misery by assisting death.

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