USAID health chief warns that primary care has been decimated by COVID

You don’t have to die from COVID-19 anymore. That’s the message from Dr. Atul Gawande, assistant administrator of global health for USAID. At the same time, people are dying from a whole host of diseases as primary care took a back seat to COVID-19, which spurred the largest reduction in global life expectancy since World War II. Turning the coronavirus into “a manageable, endemic respiratory illness requires recognizing that at this moment, we are not yet in the aftermath of the pandemic, but we are in the aftermath of the pandemic emergency,” Gawande told Devex Editor-in-Chief Raj Kumar during a discussion last week at the Meridian International Center in Washington, D.C. Gawande, who practiced general and endocrine surgery at Brigham and Women's Hospital in Boston, said a number of steps must be taken before COVID-19 can be considered a routine medical condition. That includes integrating the virus into primary health care so that when you go to your doctor’s office with a cough, you’re tested and treated for COVID-19. Boosters also remain key. “In the low- and middle-income world, we’re north of 60% of the elderly populations, health care workers now being vaccinated, which is an extraordinary accomplishment,” Gawande said, cautioning that this success is predicated on maintaining that protection years from now. The pandemic showed the importance of local health workers in vaccinating millions of people. But primary care, underappreciated and underfunded even before the pandemic, has been battered not just by three years of COVID-19, but also by economic crises and inflationary pressures. Now, it needs time, and resources, to recover, Gawande argued. That entails replenishing anemic health budgets and burned-out front-line health care workers — all while prepping for the next pandemic. “Getting primary care on the map” is among Gawande’s top priorities at USAID, “because we have shown over the last 20 years, you can invest in individual diseases, or outbreak management … but every one of those programs lean on the foundation of primary health care workers at the front line,” he said. Primary purpose In a New York Times op-ed earlier this month, Gawande wrote that this workforce doesn’t get the credit it deserves. “A doubling of human life span in less than a century, one of the greatest accomplishments in history, was achieved through worldwide cooperation on sustained efforts to address many individual causes of death and sickness — polio, H.I.V./AIDS, diarrheal illness, malaria and childbirth risks, to name just a few.” That feat, he wrote, was undergirded by primary health care workers. But the pandemic-fueled erosion of primary care has led to a stunning reversal in human development, as the coronavirus sidelined a litany of other lethal diseases and hampered immunizations “for just about everything,” Gawande said at the Washington event, pointing out that tuberculosis deaths are up while maternal mortality rates have flatlined. He cited the example of Malawi, where there was a drastic drop in childhood immunizations, along with falling investments in water and sanitation. “So what do we have now? A return to polio, with the first case on the African continent in five years turning up in Malawi. You have measles outbreaks. We are now back up north of 100,000 measles deaths for children globally,” he said, adding that Malawi has also been hit with the worst cholera outbreak in its history. Promising gains have also been stunted by COVID-19. “The best way I can put it is we have succeeded in reducing the percentage of deaths among women under 50 and children under 5 from 60% to 40% in Africa — but it’s still 40%,” he said. “So we’ve lost ground on that front. I don’t know what the numbers are for the last couple of years, but our projection at USAID is that they’ve gotten worse. We have to regain that territory.” The congressional equation That territory is what Gawande’s staff is trying to traverse, “with 2,500 people deployed across 63 countries, touching another 100 countries,” working on HIV, tuberculosis, malaria, child nutrition, maternal survival, and global health security, he said. But USAID can only do so much without money from the U.S. Congress — a dicey prospect, especially with the House of Representatives controlled by aid spending-wary Republicans. Last year, for example, lawmakers rejected the Global Health Worker Initiative designed to bolster front line workers in Africa, which shoulders a quarter of the global disease burden yet holds only 4% of the global health workforce, according to USAID. Gawande said his agency will reintroduce the initiative in this year’s budget. He also expressed optimism that USAID’s global health programs won’t face the dreaded chopping block despite the heated partisan landscape, noting that the large cuts proposed by the Trump administration weren’t enacted because global health enjoys bipartisan support. But to the surprise of many, the Biden administration — not Republicans — is cutting $25 million from the U.S. President’s Emergency Plan for AIDS Relief for fiscal year 2024 despite PEPFAR’s proven track record. Gawande disputed the notion that there’s been a rollback in the administration’s HIV/AIDS efforts, noting that antiretroviral treatments have become more effective and efficient, meaning you can get more bang for your buck. He also noted that countries like India and South Africa are now folding PEPFAR’s work into their own national health care systems. “The aim ultimately is transition,” Gawande said. “It’s a 20-year program that has saved tens of millions of lives, and it needs to be there for the next generation to come, and this is how we do it.”