Hope as Plan: On Words, Health Policy, and Making Ideas Matter
It was 2010, I was perusing The New Yorker online as my keen seventeen-year-old self occasionally did, and I stumbled upon a piece innocuously entitled ‘Letting Go’. On its face, it was an article about health policy and palliative care. But what I found upon reading it was a powerful and visceral exploration of human mortality, about what it means to be confronted with the end of one’s own life. I was floored by it.
That was also the first time I read the name Atul Gawande.
Fast forward to the present and I’m standing in Rhodes House, Oxford University introducing the fated author (Ohio & Balliol 1987). Trained in a smattering of disciplines spanning surgery, philosophy, public health, political science, biology, and economics, you can tell immediately he’s an interdisciplinary mind. Gawande’s speeches weave a multi-faceted narrative, one that reflects a keen appreciation of how to make things work – the duality of a science- and evidence-based policy that works in concert with local anthropological contexts and systems. Like its predecessors, this speech doesn’t disappoint.
We learned about an awkward young Gawande’s attempts at romance (with a wry smile and embarrassed laugh, he quips about the object of his affections “so, I married her.”) We learned about his days playing electric guitar for a local band (he left out the name – it was ‘Thousands of Breaded Shrimp’). We learned about his creeping feelings of inadequacy as friends pursued successful careers. We learned that for Gawande, being young was the time to unabashedly say yes to opportunities, wherever they might lead. We also learned that saying no was the inescapable next step.
After the speech, many scholars commented that one of the most resonant parts was Gawande’s ruminations on approaching the uncertainty of the future and of one’s career. He stresses the contradictions at the heart of his early life: PPE and a stint as a political advisor as anathema to an immigrant-doctor family; a passion for writing belied only by his own mediocrity. He called a spade a spade – rebellion followed by acquiescence followed by vindication. It’s a story that hit home for me, and for the other first-generation immigrants in the room. It’s hard not to admire his honesty.
Words are still what motivate him. The doctor writes in ‘Letting Go’ that “arriving at an acceptance of one’s mortality and a clear understanding of the limits and the possibilities of medicine is a process, not an epiphany.” This repudiation of ‘eureka!’ moments is classic Gawande – his commitment to incrementalism, methodical reporting, and sober cost evaluation shows a penchant for process, an understanding that systems are what drive change and that reforming them takes time, knowledge, and concerted effort.
In planting his flag there, Gawande strikes at a challenge right at the heart of health policy – many actors are committed to new innovations and to new policies, but rarely focus enough on bringing these innovations and policies to scale. This is a useful framing, especially when every order of magnitude in scaling has a host of different challenges and approaches.
Next, he advances his big idea, still under development. It’s a model for achieving transformational systems change – for making ideas matter, as it were. Gawande suggests that leadership, incentives, and tools comprise the three main components of change-making, and that certain organisations and community groups are best suited for tackling each of these problems. Moreover, he adds that in order for a chain of processes or innovations to succeed, a coherent and unified priority must be agreed upon, the right people must be mobilised to achieve it, and – somewhat presciently given the incoherent Ebola response marshalled by the international community – they must all pull together.
In September 2006, Atul Gawande was bestowed a MacArthur ‘Genius’ Fellowship. In December 2014, he delivered the BBC’s Reith Lecture to millions around the world. And just last week, he opened the Skoll World Forum. It is clear that his is an essential voice in an increasingly noisy pastoral. It’s the acuity with words, the crisp writing, the willingness to challenge the status quo that underpins his success.
Take his reflections on 21st century healthcare. Gawande is unafraid to land a sobering indictment of our system as an exercise in suspended belief, in hoping desperately for the statistically improbable escape from mortality. He writes, “the trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win.” It goes without saying that this endears him to few. But that’s the point.
He concludes, “hope is not a plan, but hope is our plan.” Let us hope then, that Dr. Gawande plans on writing for many years to come. The world needs his words.
Kaleem Hawa (Ontario & Lincoln 2016) is a Canadian Rhodes Scholar from Toronto currently working on his PhD at Oxford University’s Big Data Institute. Follow Kaleem on Twitter @kaleemhawa