Atul Gawande on shifting from good health and survival to general well-being

Through a series of tweets, he lambasted the medical professionals involved in torturing terror suspects. "The worst for me," he wrote, "is to see the details of how doctors, psychologists, and others sworn to aid human beings made the torture possible."
This isn't the first time Gawande has openly voiced his concerns about the medical establishment and healthcare as a whole. Through his four bestselling books, the public health researcher, The New Yorker staff writer and professor at Harvard Medical school and Harvard School of Public Health has highlighted human errors in medicine — but more importantly, how such errors can be fixed.

On the occasion of the launch of his latest book, Being Mortal: Medicine and What Matters in the End at Literature Live! Evenings, Atul Gawande talks about why we need to shift our focus from just good health and survival to general well-being. Edited excerpts:

In Being Mortal, you talk about how important it is for medical professionals to focus on minimising suffering during our last days rather than just extending life. How vital is this approach for geriatric care?
I think the goal is bigger than alleviating suffering – it's about helping people achieve their potential. Many believe that potential is all about the young, that it has nothing to do with the old or the sick. We have a hard time imagining that someone with just six months to live can have potential, priorities and goals – things that are worth living for, even fighting for during that time. We have this very narrow, weak understanding of life.
Although my father became very Americanised when he came to the US, he had difficulty abiding by the way we took care of our elderly, putting them in hospitals or nursing homes, shuttling them back and forth, and then ending their days in the hands of strangers.
In the last century, we've added 30 years to human life. India's experienced this too. At the time of independence, the average Indian only lived till his/her mid-40s or 50s. But by the mid-1990s, the average Indian lived past 65 years of age. And now you can fully expect to live until your 70s and beyond. This extended lifespan has forced us to think about what it means to have a life after 70. There's more to life than longevity. What is it that we want to be alive for? What is it that we want to accomplish?
Another thing I came across during the course of the book were interesting studies on the differences between the young and old. The goals of the young are more geared towards having larger social networks, acquisition and recognition. For older folks, acquisition doesn't matter so much. These are people interested in deeper, more intimate relationships. They want to make a difference and don't necessarily want recognition anymore. They want satisfaction and contentment. And most of the time, these are things we don't feed.
Many elderly parents would rather have an independent life, especially if they have economic security. The trouble is when you have declining strength, memory problems and trouble managing finances. As it gets worse, we approach retirement complexes – a booming industry now. What strikes me about these places is that people are really miserable. They're miserable because they're shorn of a sense of purpose and their abilities aren't recognised anymore.

You've also had interesting things to say about assisted suicide in your Reith lectures for the BBC…
Assisted death is a complex subject. The trouble being when people say their goal is a good death. The goal should not be a good death. The goal should be a good life all the way to the very end. But if such a life is no longer possible – if there's misery, it feels inhumane not to allow a way out.
What troubles me particularly in India is that the biggest source of misery when people approach the end of their life is pain. In India, narcotic pain medications like Morphine, which can be very effective in controlling pain, is unavailable or hard to get.
My father had brain cancer going into his spinal cord, which caused tremendous pain even when he moved his neck. But he had strong pain medications like Morphine that worked right till the end. In India, the laws allow Morphine to be prescribed, and it's the states that dispense and make drugs available. But they've not put the systems and controls in place. The result is that people at home with severe cancer or a broken hip are trying to manage their pain with Paracetamol, and they're miserable. They end up in the hospital, and that's where they spend the rest of their days. The hospital lines up all the expenses, and it's a never-ending cycle.
So I worry about assisted death in India before certain pain medications are made available. That's the step we should start with: start with the pain meds.

Since we're talking about medications – what are your views on the tussle between India and US on generic vs. patented drugs?
I believe patents have to be strong on true innovations to give people reason to innovate and benefit from it. But the concept of secondary patents – where you take an innovation and tweak it a bit or change the dosing to renew the patent for another 17 years – is keeping basic medications for asthma, diabetes and blood pressure out of the hands of the general community that desperately needs it. My position is that secondary patents are preventing – not helping – medical innovation.

Would you term this an ethical problem?
Yes. When we talk about the provision of medications, we talk about a fundamentally moral issue of making them accessible to as many people as possible. It's a complex moral issue because if the drugs don't exist in the first place, you have a problem. Then you need incentives to offer the drugs. But the secondary patent market where you're not truly innovating but are curbing accessibility – that is a fundamental danger.

As far as ethics go, you've also criticised how the Ebola outbreak was handled.
I think that was more of an operational failure. There were successful public health organisations saying, "We're seeing an outbreak that's unlike 24 other outbreaks over the last four decades. It's overwhelming the hospitals." They'd raised the red flag in March, April and May. The WHO kept saying it was being exaggerated. But they were not exaggerating it, they were completely right. It took until September, at which point hundreds were affected and dying – for the international community to act. And it really only acted when the first case of Ebola appeared outside Africa.
The fact that this first case (outside Africa) appeared in the US, rather than, say, India, was a boon. Because at the end of the day, a lot of money got poured into the efforts. Thousands of medical professionals were sent to the frontlines. And the world began to mobilise. Now, I would argue that we still haven't mobilised enough. The disease that affected hundreds in September is still affecting thousands of people now. The passage rate is slowing, but we haven't quite reversed the situation yet.

In The Checklist Manifesto, you highlight the importance of communication within hospital teams, more so in operating theatres. How successful is the checklist in blurring hierarchies between surgeons, technicians, nurses and other team members?
The checklist is a communications checklist more than anything else. Communications like surgeons briefing the team on goals of the operation, how long the case may take, expected blood loss and prepping nurses and anaesthesiologists is a must. Such communication sounds elementary, but the sad truth is that it almost never happens – whether in Delhi or Boston.
The cultural barrier or resistance to my checklist is to the flattening of hierarchy within medical teams. If people aren't allowed to communicate their concerns and say things like, 'I'm worried, the patient isn't looking good', you have a problem on your hands. Surgery is indeed a very hierarchical community, but the strongest improvement comes from bettering communications within teams.
The communications part of the checklist also been the hardest to implement in the low income world, because such hierarchies are stronger in India, China and sub-Saharan Africa, where the surgeon is god, at some level. If I walk into an average Indian operating room today, I think they'd have heard about the checklist. But if I ask, 'Has anyone in the team ever voiced a concern or said 'Stop!' if s/he thought there was a problem somewhere?' – that's another question. When nurses and technicians can openly raise concerns to a surgeon in an operating room – that's when you know the checklist truly works.

You were Bill Clinton's senior health policy advisor before you gave it up to go back to medical school. Is policymaking something you'd consider again?
I had a great experience working on the '92-'93 (Clinton) campaign and then in the White House. But I wanted to have my own independent standing, start as a medical student and work my way up. Now, I'm at a point where the question is: 'Am I going to enjoy taking on an administrative role, or speaking to the public and having a more creative, ideating role?' I like creativity in solving problems, I want that to be part of what I do.
At the same time, I want to have an impact. So it's certainly possible I can be in government again. But I'd be very frustrated if I can't write, reach the public, or if there's no creativity I what I do. I'll find that very frustrating, and I don't see great models of creativity in government (laughs).
I turned down opportunities to look at jobs in the Obama administration, in part because I was worried that all the things I had going, they would collapse. But if there comes an opportunity that offers what I want – I'd consider it.

Checks and balances
Gawande's third bestselling book, The Checklist Manifesto: How to Get Things Right, focused on the use of simple checklists to increase efficiency by medical professionals. His checklist, developed for a WHO program to minimise surgery-related deaths, was so effective that hospitals implementing it witnessed a 47 per cent decrease in surgery-related deaths and a 35 per cent decrease in surgery-related complications.