Archives for category: Musk, Elon

Thom Hartmann sees the pattern on the rug. Trump and Musk are stifling democratic institutions and rushing headlong towards the tyranny they both admire. Trump thinks that he can make himself dictator for life, Like his buddies in Russia and North Korea. Will the public defend the Constitution?

He wrote:

When Harvard, one of America’s oldest and most revered institutions of higher learning, stands defiant as the federal government freezes billions in funding simply because it refuses to knuckle under to authoritarian demands — like gutting DEI programs and turning faculty into immigration informants — we’re no longer playing the usual game of politics.


This is the open throttling of academic freedom, part of a larger, deliberate campaign to silence dissent, centralize power, and erase democratic norms.


We’ve seen this playbook before in other countries — but now it’s being run right here, in the land that once proudly called itself the world’s beacon of liberty.


Democracy doesn’t die in darkness, as the saying goes; it suffocates in broad daylight.


Americans are witnessing an unprecedented assault on the very foundations of our democratic experiment, orchestrated with a precision that would make authoritarian strongmen worldwide nod in approval.


Senator Chris Murphy has raised alarm bells about what he describes as a methodical attack on American institutions that are supposed to keep government accountable to its citizens. By his account, the strategy isn’t dramatic coups or burning parliaments; that’s not how modern democracies perish. Instead, they’re slowly dismantled through the calculated erosion of accountability mechanisms.


History provides a disturbing playbook, and we’re watching it unfold right now here in America. Putin, Orbán, and Erdoğan didn’t need tanks in the streets. They understood that the process is multi-part but straightforward:


— Legitimize political violence,
— Capture the media,
— Intimidate lawyers,
— Install corrupt leaders within regulatory and police agencies,
— Disappear first minorities and later opposition leaders,
— Silence universities, and
— Starve opposition movements by denying their nonprofit status and funding.


Consider what we’re seeing unfold. The recent January 6 pardons sent an unmistakable message about the acceptability of political violence. When legislators openly express fears of “retaliation” — as Senator Lisa Murkowski just did — we’re already several steps down a dangerous path.


Meanwhile, the concentration of media power in the hands of billionaires who increasingly bend to political pressure isn’t accidental. Whether through ownership, lawsuits, or regulatory threats, the ability to speak truth to power is being systematically constrained.


Universities, traditionally bastions of free thought and youth activism, face unprecedented pressure to conform or lose federal support.

Legal professionals, our front-line defenders of constitutional rights, are being asked to choose between principles and practice.


The economic dimension of this strategy can’t be ignored. Targeted tariffs and funding cuts effectively create a corporate compliance regime where business survival depends on political loyalty. When small-dollar online giving platforms become targets, it’s clear this is about drying up resources for political opposition.


Senator Murphy’s warning carries particular weight: “I still believe we can stop it,” he says. His prescription includes institutional solidarity, mass mobilization, and political courage. These steps aren’t just wishful thinking: history shows they work when deployed with determination.


The challenges are clear, but so is the path forward. Democrats and defenders of democracy must recognize this isn’t politics as usual. The systematic undermining of accountability mechanisms isn’t merely partisan: it’s anti-democratic in the most fundamental sense.


It’s the first stages of outright tyranny, the first American dictatorship.


If conventional resistance proves insufficient, Murphy suggests civil disobedience may become necessary. That’s not a suggestion to be taken lightly, especially from a sitting US senator.

The coming months will test America’s democratic resolve. The institutions being targeted aren’t merely political; they’re the scaffolding of self-governance itself. As Murphy warns, “We still have the power, but we probably have less time than most think.”


For those wondering where the line exists between alarmism and appropriate warning, consider this: When elected officials speak openly about fear of retaliation, when media owners preemptively capitulate, when universities face unprecedented political pressure, and when legal professionals must toe ideological lines, we’re no longer discussing hypotheticals.


The American experiment has faced threats before, but, outside of the Confederacy, rarely have they been so comprehensively designed or so methodically executed.


Recognition of this reality isn’t partisan, it’s patriotic. The future of American democracy depends on understanding what’s at stake and acting accordingly.


The assault on Harvard is just one chapter in a larger story — one where the villains aren’t hiding in shadows, but are operating in full view with chilling precision.


The question isn’t whether this is happening. It’s whether enough Americans will recognize the danger in time to stop it.

Before Trump was elected, Elon Musk was being investigated by multiple federal agencies. After Trump’s election, Musk persuaded Trump to put him in charge of a cost-cutting operation called “Department of Government Efficiency,” which was tasked with cutting the budgets or shuttering multiple federal agencies.

Musk and his team of hackers were ruthless in closing agencies that did not like. They shut down USAID, which provided food and medicine to the world’s neediest families and children.They terminated scientific research on a large number of university campuses and in the NIH, which sponsors critical research into cures for deadly diseases. They defunded large and small.

But there is one kind of project they not defund: anything that pays federal funds to Elon Musk.

More than that, Musk had a very lucky break. His good friend Trump, to whom he gave nearly $300 million for the 2024 election, is unlikely to prosecute his pal Elon.

Lawrence Darmiento of the Los Angeles Times had the story:

Elon Musk and his companies faced at least $2.37 billion in potential federal fines and penalties the day President Trump took office, according to a congressional report released Monday that highlights the possible conflicts of interest posed by the billionaire’s cost-cutting work in government.

The 43-page memo by the minority staff of the Senate’s Permanent Subcommittee on Investigations, led by Sen. Richard Blumenthal (D-Conn.), is the most exhaustive attempt yet to detail Musk’s alleged conflicts as an advisor to Trump and chief promoter of his team called the Department of Government Efficiency, or DOGE.
Based on publicly available documents, media reports and the committee’s own calculations, the memo found that as of Jan. 20, Musk and his companies were “subject to at least 65 actual or potential actions by 11 different federal agencies” and that 40 of those created $2.37 billion in potential liabilities.

“Mr. Musk has taken a chainsaw to the federal government with no apparent regard for the law or for the people who depend on the programs and agencies he so blithely destroys,” the memo stated. “The through line connecting many of Mr. Musk’s decisions appears to be self-enrichment and avoiding what he perceives as obstacles to advancing his interests.”

The memo notes that Musk’s companies have received more than $38 billion in government contracts, loans, subsidies and tax credits going back more than 20 years. And it notes that SpaceX, as of Friday, had $10.1 billion in federal contracts.

“President Trump could not have chosen a person more prone to conflicts of interest,” states the memo, which calls on the president, executive departments and regulatory agencies to “take coordinated action to address Elon Musk’s threat to the integrity of federal governance.”

To no one’s surprise, the white Hohse press office indignantly insisted that Musk had no conflicts of interest.

The committee found that Tesla created most of the potential penalties for Musk — a cumulative $1.89 billion — due to investigations, lawsuits and other issues involving eight agencies.

The largest single liability was a potential $1.19-billion fine due to a reported criminal investigation opened by the Department of Justice into allegedly false or misleading statements made by Musk and the company about its Autopilot and Full-Self Driving Features since as early as 2016.

The Times previously reported the National Highway Traffic Safety Administration is probing the Full-Self Driving technology after reports of four collisions in low-visibility conditions, including one in which a pedestrian was killed.

However, doubts have been raised about the Justice Department’s commitment to any prosecution. The memo notes that in February the department dismissed a lawsuit it filed against SpaceX for allegedly discouraging asylum seekers and refugees from applying for jobs or hiring them because of their citizenship status. It calculated the lawsuit could have exposed SpaceX to $46.1 million in liabilities.

The second single largest liability of $462 million facing Musk also involved Tesla. It arose out of a 2023 lawsuit filed by the Equal Employment Opportunity Commission for the company’s alleged toleration of widespread racial harassment of Black employees at its Fremont, Calif., factory. Tesla has denied the allegations. In January, Trump fired two Democratic commissioners and the agency’s general counsel.

How likely is it that any of these charges will go to trial?

In an investigative report, The New York Times demonstrated that Elon Musk failed to deliver on his claim that he could cut $2 trillion from the federal budget. Not only did he fall short, but his efforts were so reckless that they might cost money instead of saving it.

Having launched his so-called “Department of Government Efficiency” (which is not a department at all and was never authorized by Congress), Musk and his then-partner Vivek Ramaswamy promised to cut $2 trillion. Their goal dropped to $1 trillion, and Vivek left the team to run for Governor in Ohio.

Some of DOGE’s claims turned out be be inflated (one alleged saving of $8 billion turned out to be a saving of only $8 million.

Musk eventually reduced his saving claim to only $150 billion.

Since DOGE began, thousands of federal employees have been fired. Some have been rehired after courts decided their firing was illegal. Some have been fired, rehired, and fired again. Some career employees have taken buyout offers. Tens of thousands of federal employees have been laid off, without regard to their experience. There was no time for DOGE workers to evaluate each person they ousted, nor did DOGE have the competence to judge its victims.

The New York Times concluded that DOGE’s activities may actually save nothing at all. Firing workers is expensive when you do it the wrong way, the DOGE way.

Elizabeth Williamson of The New York Times wrote:

President Trump and Elon Musk promised taxpayers big savings, maybe even a “DOGE dividend” check in their mailboxes, when the Department of Government Efficiency was let loose on the federal government. Now, as he prepares to step back from his presidential assignment to cut bureaucratic fat, Mr. Musk has said without providing details that DOGE is likely to save taxpayers only $150 billion.

That is about 15 percent of the $1 trillion he pledged to save, less than 8 percent of the $2 trillion in savings he had originally promised and a fraction of the nearly $7 trillion the federal government spent in the 2024 fiscal year.

The Partnership for Public Service, a nonprofit organization that studies the federal work force, has used budget figures to produce a rough estimate that firings, re-hirings, lost productivity and paid leave of thousands of workers will cost upward of $135 billion this fiscal year. At the Internal Revenue Service, a DOGE-driven exodus of 22,000 employees would cost about $8.5 billion in revenue in 2026 alone, according to figures from the Budget Lab at Yale University. The total number of departures is expected to be as many as 32,000.

Neither of these estimates includes the cost to taxpayers of defending DOGE’s moves in court. Of about 200 lawsuits and appeals related to Mr. Trump’s agenda, at least 30 implicate the department.

The errors and obfuscations underlying DOGE’s claims of savings are well documented. Less known are the costs Mr. Musk incurred by taking what Mr. Trump called a “hatchet” to government and the resulting firings, agency lockouts and building seizures that mostly wound up in court.

“Not only is Musk vastly overinflating the money he has saved, he is not accounting for the exponentially larger waste that he is creating,” said Max Stier, the chief executive of the Partnership for Public Service. “He’s inflicted these costs on the American people, who will pay them for many years to come.”

Mr. Stier and other experts on the federal work force said it did not have to be this way. Federal law and previous government shutdowns offered Mr. Musk a legal playbook for reducing the federal work force, a goal that most Americans support. But Mr. Musk chose similar lightning-speed, blunt-force methods he used to drastically cut Twitter’s work force after he acquired the company in 2022.

“The law is clear,” said Jeri Buchholz, who over three decades in public service handled hiring and firing at seven federal agencies, including NASA and the Defense Intelligence Agency. “They can do all the things they are currently doing, but they can’t do them the way they’re doing them. They can either start over and do it right, or they can be in court for forever.”

Since Trump invited Elon Musk and his DOGE team to cut the federal budget, the federal government has been subject to a bloodbath of firings, layoffs, and closed agencies. Some of the most shocking budget cuts have focused on scientific research. Reckless cuts have been imposed on the National Science Foundation and on every part of the Department of Health and Human Services, where the Secretary–conspiracy theorist Robert F. Kennedy Jr.–is crushing genuine research and prioritizing his obsession with vaccines as the cause of autism, which has been debunked.

Trump has blocked the payment of millions of dollars to universities that fund basic science research. He is using those blocks to force universities to stop DEI programs.

We can understand why Kennedy wants to destroy science: it has an annoying tendency to undercut his pet conspiracy theories. No matter what science says, he will continue to warn the public that vaccines are dangerous, that fluoridating water is dangerous, and anything that contradicts his ideology is fake, regardless of how many scientists disagree. WHO you gonna believe? The addled RFK Jr. or the world’s top scientists? Or Ghostbusters?

But we do not know why Trump put the nation’s public health agencies into the hands of a man who does not respect science.

Why does Trump want more children to die of measles? Why does he allow Elon Musk to shut down agencies like USAID that have saved millions of lives? Why he is cancelling grants to universities for basic scientific research? Why does he want to stop the work of scientists who are seeking cures for cancer, tuberculosis, AIDS, and other lethal diseases? I don’t know.

Frankly, the cuts are coming so fast that I can’t keep track of them all. I hope soon to find a comprehensive summary of the destruction of federally-funded scientific research.

In the meanwhile, this is the best overview I have seen.

Alan Burdick of the New York Times wrote this story about Trump’s rampage against scientific research:

Late yesterday, Sethuraman Panchanathan, whom President Trump hired to run the National Science Foundation five years ago, quit. He didn’t say why, but it was clear enough: Last weekend, Trump cut more than 400 active research awards from the N.S.F., and he is pressing Congress to halve the agency’s $9 billion budget.

The Trump administration has targeted the American scientific enterprise, an engine of research and innovation that has thrummed for decades. It has slashed or frozen budgets at the National Institutes of Health, the National Science Foundation, the Centers for Disease Control and Prevention and NASA. It has fired or defunded thousands of researchers.

The chaos is confusing: Isn’t science a force for good? Hasn’t it contained disease? Won’t it help us in the competition with China? Doesn’t it attract the kind of immigrants the president says he wants? In this edition of the newsletter, we break out our macroscope to make sense of the turmoil.

American research thrives under a patronage system that funnels congressionally approved dollars to universities, national labs and institutes. This knowledge factory employs tens of thousands of researchers, draws talent from around the world and generates scientific breakthroughs and Nobel Prizes.

It’s a slow-moving system, because science moves slowly. Discoveries are often indirect and iterative, involving collaboration among researchers who need years of subsidized education to become expert. Startups and corporations, which need quick returns on their investment, typically can’t wait as long or risk as much money.

Science is capital. By some measures, every dollar spent on research returns at least $5 to the economy.

President Trump is less patient. He has defunded university studies on AIDS, pediatric cancer and solar physics. (Two prominent researchers are compiling lists of lost N.I.H. grants and N.S.F. awards.) The administration has also laid off thousands of federal scientists, including meteorologists at the National Weather Service; pandemic-preparedness experts at the C.D.C.; black-lung researchers at the National Institute for Occupational Safety and Health. A next-generation space observatory, already built with $3.5 billion over a decade, awaits a launch that now may never happen.

Administration officials offer various reasons for the crackdown: cost-cutting, government efficiency, “defending women from gender ideology extremism.” Many grants were eliminated because they contain words, including climate, diversity, disability, trans or women. Some drew the administration’s ire because the applications included D.E.I. statements required by the previous administration.

It doesn’t take a telescope to see where this leads. American leaders have historically seen science as an investment in the future. Will this administration foreclose it? One-third of America’s Nobel Prize winners have been foreign-born, but an immigration crackdown has swept up scientists like Kseniia Petrova, a Russian who studied aging at Harvard and now sits in a Louisiana detention center. Australian academics have stopped attending conferences in the U.S. for fear of being detained, The Guardian has reported.

Now some American scientists are looking for the exits. France, Canada and other countries are courting our researchers. In a recent poll by the journal Nature, more than 1,200 American scientists said they were considering working abroad. The journal’s job-search platform saw 32 percent more applications for positions overseas between January and March 2025 than during the same period a year earlier.

These are mechanical threats to science — who gets money, what they work on. But there is a more existential worry. The Trump administration is trying to change what counts as science.

One effort aims at what science should show — and at achieving results agreeable to the administration. The health secretary, Robert F. Kennedy Jr., wants to reopen research into a long-debunked link between vaccines and autism. He doesn’t want to study vaccine hesitancy. The National Science Foundation says it will no longer fund “research with the goal of combating ‘misinformation,’ ‘disinformation,’ and ‘malinformation’ that could be used to infringe on the constitutionally protected speech rights of American citizens.” A Justice Department official has accused prominent medical journals of political bias for not airing “competing viewpoints.”

Another gambit is to suppress or avoid politically off-message results, even if the message isn’t yet clear. The government has expunged public data sets on air quality, earthquake intensity and seabed geology. Why cut the budget by erasing records? Perhaps the data would point toward efforts (pollution reduction? seabed mining limits?) that officials might one day need to undertake. We pursue knowledge in order to act: to prevent things, to improve things. But action is expensive, at a moment when the Trump administration wants the government to do as little as possible. Perhaps it’s best to not even know.

One sure way to shut down knowledge is to question who can gather it. The administration is painting scientists with the same liberal brush it has applied to academics more broadly — what Project 2025 describes as “the ‘enlightened,’ highly educated managerial elite.” The N.I.H. is controlled by “a small group of highly paid and unaccountable insiders,” the Project 2025 authors write. The regulatory work of the Environmental Protection Agency “should embrace so-called citizen science” and be left “for the public to identify scientific flaws and research misconduct.”

In science, as in a democracy, there’s plenty of room for skepticism and debate. That’s what makes it work. But at some point, calls for “further research” become disingenuous efforts to obscure inconvenient facts. It’s an old playbook, exploited in the 1960s by the tobacco industry and more recently by fossil-fuel companies.

Now it’s being weaponized by the government against science generally. Facts are elite, facts are fungible, facts are false. And once nothing is true, anything can be true.

Today is a good day to reflect on hypocrisy. The Trump administration is deeply entwined with two groups: evangelical Christians and Elon Musk’s DOGE team. The White House has frequent prayer meetings, issues proclamations written by evangelical leaders, and even has offices in the Weat Wing for Trump’s spiritual advisors.

Meanwhile, Trump empowered DOGE to ransack every federal agency, fire staff by the tens of thousands, and shutter agencies that were established by Congress. Many fear that Medicaid, Medicare, and Social Security will suffer deep cuts.

The result will be not “efficiency,” but inefficiency. Worse, people will die if they cannot afford to pay for health care and do not get their Social Security because their local or regional office has been closed and they do not have a cell phone or computer.

The prime example of DOGE slaughter of an agency that has saved millions of lives is USAID. Foreign aid has had bipartisan support for decades. It brings food, medicine, and medical clinics to desperately poor people around the globe. American farmers supply the grains that are exported and lose billions of dollars.

But most important, millions of people will die because of the cutoff of drugs and food.

This is rank cruelty. This is obscene. This is a crime.

What do the evangelicals who surround Trump say about this? Clearly they influence his words but not his deeds. Jesus spoke about love, compassion, healing the sick, feeding the hungry, welcoming the stranger. What do they say about withdrawing drugs and food from millions of the needy and poor?

Today is a good day to ask, What would Jesus do?

David Remnick, editor of The New Yorker, interviewed Dr. Atul Gawande about his work at USAID. He was especially interested in learning Dr. Gawande’s views about the likely consequences of the evisceration of USAID.

Remnick writes:

It is hard to calculate all the good that Atul Gawande has done in the world. After training as a surgeon at Harvard, he taught medicine inside the hospital and in the classroom. A contributor to The New Yorker since 1998, he has published widely on issues of public health. His 2007 article in the magazine and the book that emerged from it, “The Checklist Manifesto: How to Get Things Right,” have been sources of clarity and truth in the debate over health-care costs. In 2014, he published “Being Mortal: Medicine and What Matters in the End,” a vivid, poetic, compassionate narrative that presents unforgettable descriptions of the ways the body ages and our end-of-life choices.

Gawande’s work on public health was influential in the Clinton and Obama Administrations, and, starting in November, 2020, he served on President Joe Biden’s covid-19 Advisory Board. In July, 2021, Biden nominated him as the assistant administrator for the Bureau of Global Health at the U.S. Agency for International Development, where he worked to limit disease outbreaks overseas. Gawande, who is fifty-nine, resigned the position on the day of Donald Trump’s return to the Presidency.

When we spoke recently for The New Yorker Radio Hour, Gawande, usually a wry, high-spirited presence, was in a grave mood. There were flashes of anger and despair in his voice. He was, after all, watching Trump and Elon Musk dismantle, gleefully, a global health agency that had only lately been for him a source of devotion and inspiration. As a surgeon, Gawande had long been in a position to save one life at a time. More recently, and all too briefly, he was part of a vast collective responsible for untold good around the world. And now, as he made plain, that collective has been deliberately cast into chaos, even ruins. The cost in human lives is sure to be immense. Our conversation has been edited for clarity and length.

President Biden appointed you as the assistant administrator for global health at U.S.A.I.D., a job that you’ve described as the greatest job in medicine. You stepped down on Trump’s Inauguration Day, and he immediately began targeting U.S.A.I.D. with an executive order that halted all foreign aid. Did you know, or did you intuit, that Trump would act the way he has?

I had no idea. In the previous Trump Administration, they had embraced what they themselves called the “normals.” They had a head of U.S.A.I.D. who was devoted to the idea of development and soft power in the world. They had their own wrinkle on it, which I didn’t disagree with. They called it “the journey to self-reliance,” and they wanted to invest in Africa, in Asia, in Latin America, to enable stronger economies, more capacity—and we weren’t doing enough of that. I actually continued much of the work that had occurred during that time.

Tell me a little bit about what you were in charge of and what good was being done in the world.

I had twenty-five thousand people, between D.C. and sixty-five countries around the world, working on advancing health and protecting Americans from diseases and outbreaks abroad. The aim was to work with countries to build their systems so that we protected global health security and improved global outcomes—from reducing H.I.V./aids and other infectious diseases like malaria and T.B., to strengthening primary health-care systems, so that those countries would move on from depending on aid from donors. In three years, we documented saving more than 1.2 million lives after covid alone.

Let’s pause on that. Your part of U.S.A.I.D. was responsible, demonstrably, for saving 1.2 million lives—from what?

So, covid was the first global reduction in life expectancy in seventy years, and it disrupted the ability across the world to deliver basic health services, which includes H.I.V./aids [medications], but also included childhood immunizations, and managing diarrhea and pneumonia. Part of my target was to reduce the percentage of deaths in any given country that occur before the age of fifty. The teams would focus on the top three to five killers. In some places, that would be H.I.V.; in some places that would be T.B. Safe childbirth was a huge part of the work. And immunizations: forty per cent of the gains in survival for children under five in the past fifty years in the world came from vaccines alone. So vaccines were a big part of the work as well.

What was the case against this kind of work? It just seems like an absolute good.

One case is that it could have been more efficient, right? Americans imagine that huge sums of money go to this work. Polls show that they think that a quarter of our spending goes to foreign aid. In fact, on a budget for our global health work that is less than half the budget of the hospital where I did surgery here in Boston, we reached hundreds of millions of people, with programs that saved lives by the millions. That’s why I describe it as the best job in medicine that people have never heard of. It is at a level of scale I could never imagine experiencing. So the case against it—I woke up one day to find Elon Musk tweeting that this was a criminal enterprise, that this was money laundering, that this was corruption.

Where would he get this idea? Where does this mythology come from?

Well, what’s hard to parse is: What is just willful ignorance? Not just ignorance—it’s lying, right? For example, there’s a statistic that they push that only ten per cent of U.S.A.I.D.’s dollars actually got to recipients in the world. Now, this is a willful distortion of a statistic that says that only ten per cent of U.S.A.I.D.’s funding went to local organizations as opposed to multinational organizations and others. There’s a legitimate criticism to be made that that percentage should be higher, that more local organizations should get the funds. I did a lot of work that raised those numbers considerably, got it to thirty per cent, but that was not the debate they were having. They’re claiming that the money’s not actually reaching people and that corruption is taking it away, when, in fact, the reach—the ability to get to enormous numbers of people—has been a best buy in health and in humanitarian assistance for a long time.

Now the over-all agency, as I understand it, had about ten thousand people working for it. How many are working at U.S.A.I.D. now?

Actually, the number was about thirteen thousand. And the over-all number now—it’s hard to estimate because people are being turned on and off like a light switch—

Turned on and off, meaning their computers are shut down?

Yeah, and they’re being terminated and then getting unterminated—like, “Oops, sorry, we let the Ebola team go.” You heard Elon Musk say something to that effect in the Oval Office. “But we’ve brought them back, don’t worry.” It’s a moving target, but this is what I’d say: more than eighty per cent of the contracts have been terminated, representing the work that is done by U.S.A.I.D. and the for-profit and not-for-profit organizations they work with, like Catholic Relief Services and the like. And more than eighty per cent of the staff has been put on administrative leave, terminated, or dismissed in one way or the other.

So it’s been obliterated.

It has been dismantled. It is dying. I mean, at this point, it’s six weeks in. Twenty million people with H.I.V., for example—including five hundred thousand children—who had received medicines that keep them alive have now been cut off for six weeks.

A lot of people are going to die as a result of this. Am I wrong?

The internal estimates are that more than a hundred and sixty thousand people will die from malaria per year, from the abandonment of these programs, if they’re not restored. We’re talking about twenty million people dependent on H.I.V. medicines—and you have to calculate how many you think will get back on, and how many will die in a year. But you’re talking hundreds of thousands in Year One at a minimum. But then on immunization side, you’re talking about more than a million estimated deaths.

I’m sorry, Atul. I have to stop my cool journalistic questioning and say: This is nothing short of outrageous. How is it possible that this is happening? Obviously, these facts are filtering up to Elon Musk, to Donald Trump, and to the Administration at large. And they don’t care?

The logic is to deny the reality, either because they simply don’t want to believe it—that they’re so steeped in the idea that government officials are corrupt and lazy and unable to deliver anything, and that a group of young twentysomething engineers will fix it all—or they are indifferent. And when Musk waves around the chainsaw—we are seeing what surgery on the U.S. government with a chainsaw looks like at U.S.A.I.D. And it’s just the beginning of the playbook. This was the soft target. This is affecting people abroad—it’s tens of thousands of jobs at home, so there’s harm here; there’s disease that will get here, etc. But this was the easy target. Now it’s being brought to the N.I.H., to the C.D.C., to critical parts of not only the health enterprise but other important functions of government.

So the National Institutes of Health, the Centers for Disease Control and Prevention, and other such bureaucracies that do equal medical good will also get slammed?

Are being slammed. So here’s the playbook: you take the Treasury’s payment system—doge and Musk took over the information system for the Treasury and the payments in the government; you take over the H.R. software, so you can turn people’s badges and computer access on and off at will; you take over the buildings—they cancelled the leases, so you don’t have buildings. U.S.A.I.D.—the headquarters was given to the Customs and Border Protection folks. And then you’ve got it all, right? And then he’s got X, which feeds right into Fox News, and you’ve got control of the media as well. It’s a brilliant playbook.

But from the outside, at least, Atul, and maybe from your vantage point as well: this looks like absolute chaos. I’ve been reading this week that staff posted overseas are stranded, fired without a plane ticket home. From the inside, what does it look like?

One example: U.S.A.I.D. staff in the Congo had to flee for their lives and watch on television as their own home was destroyed and their kids’ belongings attacked. And then when they called for help and backup, they could not get it. I spoke to staff involved in one woman’s case, a pregnant woman in her third trimester, in a conflict zone. They have maternity leave just like everybody else there. But because the contracts had been turned off, they couldn’t get a flight out, and were not guaranteed safe passage, and couldn’t get care for her complications, and ended up having to get cared for locally without the setup to address her needs. One person said to me, as she’s enduring these things, “My government is attacking me. We ought to be ashamed. Our entire system of checks and balances has failed us.”

What’s been the reaction in these countries, in the governments, and among the people? The sense of abandonment must be intense on all sides.

There are broadly three areas. The biggest part of U.S.A.I.D. is the fema for disasters abroad. It’s called the Bureau for Humanitarian Assistance, and they bring earthquake response; wildfire response; response in conflicts, in famines. These are the people who suit up, and get assistance, and stabilize places where things are going wrong.

The Global Health Bureau, which I led, is the second-largest part of the agency, and that does work around diseases and health threats, as well as advancing health systems in low- and middle-income countries around the world. There’s coöperation on solving global problems, like stopping pandemics, and addressing measles outbreaks, and so on.

The third is advancing countries’ economies, freedom, and democracy. John F. Kennedy, when he formed U.S.A.I.D. in 1961, said that it was to counter the adversaries of freedom and to provide compassionate support for the development of the world. U.S.A.I.D. has kept Ukraine’s health system going and gave vital support to keep their energy infrastructure going, as Russia attacked it. In Haiti, this is the response team that has sought to stabilize what’s become a gang-controlled part of the country. Our health teams kept almost half of the primary health-care system for the population going. So around the world: stopping fentanyl flow, bringing in independent media. All of that has been wiped out completely. And in many cases, the people behind that work—most of the people we’re working with, local partners to keep these things going—are now being attacked. Those partners are now being attacked, in country after country.

What you’re describing is both human compassion and, a phrase you used earlier in our conversation, “soft power.” Describe what that is. Why is it so important to the United States and to the world? What will squandering it—what will destroying it—mean?

The tools of foreign policy, as I’ve learned, are defense, diplomacy, and development. And the development part is the soft power. We’re not sending troops into Asia and Africa and Latin America. We’re sending hundreds of thousands of civilians without uniforms, who are there to represent the United States, and to pursue common goals together—whether it’s stemming the tide of fentanyl coming across the border, addressing climate disasters, protecting the world from disease. And that soft power is a reflection of our values, what we stand for—our strong belief in freedom, self-determination, and advancement of people’s economies; bringing more stability and peace to the world. That is the fundamental nature of soft power: that we are not—what Trump is currently trying to create—a world of simply “Might makes right, and you do what we tell you,” because that does not create stability. It creates chaos and destruction.

An immoral universe in which everybody’s on their own.

That’s right. An amoral universe.

Who is standing up, if anyone, in the Administration? What about Secretary of State Marco Rubio, whom you mentioned. What’s his role in all of this? Back in January, he issued a waiver to allow for lifesaving services to continue. That doesn’t seem to have been at all effective.

It hasn’t happened. He has issued a waiver that said that the subset of work that is directly lifesaving—through humanitarian assistance, disaster relief, and so on, and the health work that I used to lead—will continue; we don’t want these lives to be lost. And yet it hasn’t been implemented. It’s clear that he’s not in control of the mechanisms that make these things happen. doge does not approve the payments going out, and has not approved the payments going out, to sustain that work.

The federal courts have ruled that the freeze was likely illegal and unconstitutional, and imposed a temporary restraining order saying that it should not be implemented, that it had to be lifted—the payment freeze. Instead, they doubled down. And Marco Rubio signed on to this, tweeted about it earlier this week—that over eighty per cent of all contracts have now been terminated. And the remaining ones—they have not even made a significant dent in making back payments that are owed for work done even before Trump was inaugurated.

There’s always been skepticism, particularly on the right, about foreign aid. I remember Jesse Helms, of North Carolina, would always rail about the cost of foreign aid and how it was useless, in his view, in many senses. I am sure that in your time in office, you must have dealt with officials who were skeptical of the mission. What kind of complaints were you getting from senators and congressmen and the like, even before the Trump Administration took over in January?

It was a minority. I’ll just start by saying: the support for foreign-aid work has been recognized and supported by Republicans and Democrats for decades. But there’s been a consistent—it was a minority—that had felt that the U.S. shouldn’t be involved abroad. That’s part of an isolationist view, that extending this work is just charity; it’s not in U.S. interests and it’s not necessary for the protection of Americans. The argument is that we should be spending it at home.

They’re partly playing into the populist view that huge portions of the budget are going abroad, when that’s not been the case. But it’s also understandable that when people are suffering at home, when there are significant needs here, it can be hard to make connections to why we need to fight to stop problems abroad before they get here.

And yet we only recently endured the covid epidemic, which by all accounts did not begin at home, and spread all over the world. Why was covid not convincing as a manifestation of how a greater international role could help?

Certainly that didn’t convince anybody that that was able to be controlled abroad—

Because it wasn’t.

Because it wasn’t, right. And covid did drive a significant distrust in the public-health apparatus itself because of the suffering that people endured through that entire emergency. But I would say the larger picture is—every part of government spending has its critics. One of the fascinating things about the foreign-aid budget, which has been the least popular part of the budget, is that U.S.A.I.D. was mostly never heard of. Now it has high name recognition, and has majority support for continuing its programs, whether it’s keeping energy infrastructure alive in Ukraine, stabilizing conflicts—whether it’s Haiti or other parts of the world—to keep refugees from swarming more borders, or the work of purely compassionate humanitarian assistance and health aid that reduces the over-all death rates from diseases that may yet harm us. So it’s been a significant jump in support for this work, out of awareness now of what it is, and how much less it turns out to cost.

So it took this disaster to raise awareness.

That’s human nature, right? Loss aversion. When you lose it is when you realize its value.

Atul, there’s been a measles outbreak in West Texas and New Mexico, and R.F.K., Jr.—who’s now leading the Department of Health and Human Services—has advised some people, at least, to use cod-liver oil. We have this multilayered catastrophe that you’ve been describing. Where could the United States be, in a couple of years, from a health perspective? What worries you the most?

Measles is a good example. There’s actually now been a second death. We hadn’t had a child death from measles in the United States in years. We are now back up, globally, to more than a hundred thousand child deaths. I was on the phone with officials at the World Health Organization—the U.S. had chosen measles as a major area that it wanted to support. It provided eighty per cent of the support in that area, and let other countries take other components of W.H.O.’s work. So now, that money has been pulled from measles programs around the world. And having a Secretary of Health who has done more to undermine confidence in measles vaccines than anybody in the world means that that’s a singular disease that can be breaking out, and we’ll see many more child deaths that result from that.

The over-all picture, the deeper concern I have, is that as a country we’re abandoning the idea that we can come together collectively with other nations to do good in the world. People describe Trump as transactional, but this is a predatory view of the world. It is one in which you not only don’t want to participate in coöperation; you want to destroy the coöperation. There is a deep desire to make the W.H.O. ineffective in working with other nations; to make other U.N. organizations ineffective in doing their work. They already struggled with efficiency and being effective in certain domains, and yet they continue to have been very important in global health emergencies, responding and tracking outbreaks. . . .

We have a flu vaccine because there are parts of the world where flu breaks out, like China, that don’t share data with us. But they share it with the W.H.O., and the result is that we have a flu vaccine that’s tuned to the diseases coming our way by the fall. I don’t know how we’ll get a flu vaccine this fall. Either we’ll get it because people are, under the table, communicating with the W.H.O. to get the information, and the W.H.O is going to share it, even though the U.S. is no longer paying, or we’re going to work with other countries and be dependent on them for our flu vaccine. This is not a good answer.

I must ask you this, more generally: You’re watching a President of the United States begin to side with Russia over Ukraine. You’re watching the dismantlement of our foreign-aid budget, and both its compassion and its effectiveness. Just the other day, we saw a Columbia University graduate—you may agree with him, disagree with him on his politics, but who has a green card—and ice officers went to his apartment and arrested him, and presumably will deport him. It’s an assault on the First Amendment. You’re seeing universities being defunded—starting with Columbia, but it’ll hardly be the last, etc. What in your view motivates Donald Trump to behave in this way? What’s the vision that pulls this all together?

What I see happening on the health side is reflective of everything you just said. There is a fundamental desire to remove and destroy independent sources of knowledge, of power, of decision-making. So not only is U.S.A.I.D. dismantled but there’s thousands of people fired—from the National Institutes of Health, the C.D.C., the Food and Drug Administration—and a fundamental restructuring of decision-making so that political judgment drives decision-making over N.I.H. grants, which have been centralized and pulled away from the individual institutes. So the discoveries that lead to innovations in the world—that work has a political layer now. F.D.A. approvals—now wanting a political review. C.D.C. guidance—now wanting a political review. These organizations were all created by Congress to be shielded from that, so that we could have a professional, science-driven set of decisions, and not the political flavor of the moment.

Donald Trump’s preference, which he’s expressed in those actions and many others, is that his whims, just like King Henry VIII’s, should count. King Henry VIII remade an entire religion around who he wanted to marry. And this is the kind of world that Trump is wanting to create—one of loyalty trumping any other considerations. So the inspectors general who do audits over the corruption that they seem to be so upset about—they’ve been removed. Any independent judgment in society that would trump the political whims of the leader. . . . The challenge is—and I think is the source of hope for me—that a desire for chaos, for acceding to destruction, for accepting subjugation, is not a stable equilibrium. It’s not successful in delivering the goods for people, under any line of thinking.

In the end, professionally organized bureaucracies—that need to have political oversight, need to have some controls in place, but a balance that allows decision-making to happen—those have been a key engine of the prosperity of the country. Their destruction will have repercussions that I think will make the Administration very unpopular, and likely cause a backlash that balances things out. I hope we get beyond getting to the status quo ante of a stalemate between these two lines of thinking—one that advances the world through incremental collective action that’s driven around checks and balances as we advance the world ever forward, and one in which a strongman can have his way and simply look for who he can dominate.

Right now, Robert F. Kennedy, Jr., is the head of H.H.S. His targets include not only vaccine manufacturers but the pharma industry writ large. But he’s talked a lot, too, about unhealthy food in the American diet—to some extent, he’s not wrong. Do you see any upside in his role in pushing this so-called Make America Healthy Again idea?

Of course there is good. I mean, we as a country have chronic illness that is importantly tied to our nutritional habits, our exercise, and so on. But for all our unhealthiness, we’ve also had an engine of health that has enabled the top one per cent in America to have a ninety-year life expectancy today. Our job is to enable that capacity for public health and health-care delivery to get to everybody alive, I would argue, and certainly to get it to all Americans.

What’s ignored is that half the country can’t afford having a primary-care doctor and don’t have adequate public health in their communities. If R.F.K., Jr., were taking that on, more power to him. Every indication from his history is that this is an effort to highlight some important things. But how much of it’s going to actually be evidence-driven? He’s had some crazy theories about what’s going to advance chronic illness and address health.

I’d say the second thing is the utter incompetence in running things and making things work. They’ve utterly destabilized the National Institutes of Health, the Centers for Disease Control, the F.D.A.

Explain that destabilization—what it looks like from inside and what effects it’ll have.

One small example: doge has declared that all kinds of buildings are not necessary anymore. That includes the headquarters of the Department of Health and Human Services. They’re saying, “Oh, everybody has to show up for work now, but you won’t have a building to work in anymore.”

No. 2 on the list is F.D.A. specialized centers around the country. There’s a laboratory in St. Louis where they have specialized equipment for testing food and drugs for safety. And so that whole capability—to insure that your foods and your medications are able to be tested for whether they have contaminants, whether they are counterfeit—that’s a basic part of good nutrition, good medicine, that could be pulled away.

Whether it’s maintaining the building infrastructure, maintaining the staff who are being purged sort of randomly left and right, or treating them not like they’re slaves but actually bringing good work out of everybody, by good management—that is what’s not happening.

I have the feeling that you, even in a short time, loved being in the federal government. What I hear in our conversation is a sense of tragedy that is not only public but that is felt very intimately by you.

I did not expect that going into government would be as meaningful to me as it was. I went into government because it was the covid crisis and I was offered an opportunity to lead the international component of the response. We got seven hundred million vaccines out to the world. But what I found was a group of people who could achieve scale like I’d never seen. It is mission-driven. None of these people went into it for the money; it’s not like they’ve had any power—

I assume all of them could have made more money elsewhere.

Absolutely. And many of them spent their lives as Foreign Service officers living in difficult places in the world. I remember that Kyiv was under attack about eight weeks after I was sworn in. I thought I was going to be working on covid, but this thing was erupting. First of all, our health team, along with the rest of the mission and Embassy in Kyiv, had to flee for safety. But within a week they were already saying, “We have T.B. breaking out, we have potential polio cases. How are we going to respond?” And my critical role was to say, “What’s going to kill people the most? Right now, Russia has shut down the medical supply chain, and so nearly a hundred per cent of the pharmacies just closed. Two hundred and fifty thousand H.I.V. patients can’t get their meds. A million heart patients can’t get their meds. Let’s get the pharmacies open.” And, by the way, they’ve attacked the oxygen factories and put the hospitals under cyberattack and their electronic systems aren’t functioning.

And this team, in four weeks, moved the entire hospital record system to the cloud, allowing protection against cyberattacks; got oxygen systems back online; and was able to get fifty per cent of the pharmacies open in about a month, and ultimately got eighty per cent of the pharmacies open. That is just incredible.

Yes, are there some people that I had to deal with who were overly bureaucratic? Did I have to address some people who were not performing? Absolutely. Did I have to drive efficiency?

As in any work . . .

In every place you have to do that. But this was America at its best, and I was so proud to be part of that. And what frustrated me, in that job, was that I had to speak for the U.S. government. I couldn’t write for you during that time.

Believe me, I know!

I couldn’t tell the story. I’ve got a book I’m working on now in which I hope to be able to unpack all of this. It is, I think, a sad part of my leadership, that I didn’t also get to communicate what we do—partly because U.S.A.I.D. is restricted, in certain ways, from telling its story within the U.S. borders.

If you had the opportunity to tell Elon Musk and Donald Trump what you’ve been telling me for the past hour, or if they read a long report from you about lives saved, good works done, the benefits of soft power to the United States and to the world and so on—do you think it would have any effect at all?

Zero. There’s a different world view at play here. It is that power is what matters, not impact; not the over-all maximum good that you can do. And having power—wielding it in ways that can dominate the weak and partner with your friends—is the mode of existence. (When I say “partner with friends,” I mean partner with people like Putin who think the same way that you do.) It’s two entirely different world views.

But this is not just an event. This is not just something that happened. This is a process, and its absence will make things worse and worse and have repercussions, including the loss of many, many, maybe countless, lives. Is it irreparable? Is this damage done and done forever?

This damage has created effects that will be forever. Let’s say they turned everything back on again, and said, “Whoops, I’m sorry.” I had a discussion with a minister of health just today, and he said, “I’ve never been treated so much like a second-class human being.” He was so grateful for what America did. “And for decades, America was there. I never imagined America could be indifferent, could simply abandon people in the midst of treatments, in the midst of clinical trials, in the midst of partnership—and not even talk to me, not even have a discussion so that we could plan together: O.K., you are going to have big cuts to make. We will work together and figure out how to solve it.”

That’s not what happened. He will never trust the U.S. again. We are entering a different state of relations. We are seeing lots of other countries stand up around the world—our friends, Canada, Mexico. But African countries, too, Europe. Everybody’s taking on the lesson that America cannot be trusted. That has enormous costs.

It’s tragic and outrageous, no?

That is beautifully put. What I say is—I’m a little stronger. It’s shameful and evil. ♦︎

What is Elon Musk’s agenda? His DOGE teams are wreaking havoc across the federal government. His claims of saving “billions” are making government inefficient. Thousands of researchers, scientists, and essential personnel have been fired. Is he working to destroy our government? Or is he settting up a scenario of failure as a prelude to privatization?

The Washington Post reported on chaos at the Social Security Administratuin:

Retirees and disabled people are facing chronic website outages and other access problems as they attempt to log in to their online Social Security accounts, even as they are being directed to do more of their business with the agency online.

The website has crashed repeatedly in recent weeks, with outages lasting anywhere from 20 minutes to almost a day, according to six current and former officials with knowledge of the issues. Even when the site is back online, many customers have not been able to sign in to their accounts — or have logged in only to find information missing. For others, access to the system has been slow, requiring repeated tries to get in.

The problems come as the Trump administration’s cost-cutting team, led by Elon Musk, has imposed a downsizing that’s led to7,000 job cuts and is preparing to push out thousands more employees at an agency that serves 73 million Americans. The new demands from Musk’s U.S. DOGE Service include a 50 percent cut to the technology division responsible for the website and other electronic access.

Many of the network outages appear to be caused by an expanded fraud check system imposed by the DOGE team, current and former officials said. The technology staff did not test the new software against a high volume of users to see if the servers could handle the rush, these officials said.

The technology issues have been particularly alarming for some of the most vulnerable Social Security customers. For almost two days last week, for example, many of the 7.4 million adults and children receiving monthly benefits under the anti-poverty program known as Supplemental Security Income, or SSI, confronted a jarring message that claimed they were “currently not receiving payments,” agency officials acknowledged in an internal email to staff.

The error messages set off widespread panic until recipients discovered that their monthly checks had still been deposited in their bank accounts. Another breakdown disabled the SSI system for much of the day on Friday, prompting claims staff to cancel appointments because they could not enter new disability claims in the system and blocking some already receiving benefits from gaining access to their accounts.

“Social Security’s response has been, ‘Oops,’” said Darcy Milburn, director of Social Security and health-care policy at the Arc, a national nonprofit that advocates for people with disabilities. The group fielded dozens of calls last week from nervous clients who saw the inaccurate message and assumed their monthly check, usually paid on the first of the month, would not arrive.

“It’s woefully insufficient when we’re talking about a government agency that’s holding someone’s lifeline in their hands,” Milburn said.

The disruptions are occurring as acting commissioner Leland Dudek and the DOGE team move to lay off large swaths of the workforce in a new phase of downsizing. Thousands of employees already have been pushed out — many in customer-facing roles, others with expertise in the agency’s cumbersome technology systems. At least 800 of the 3,000 employees left in the division that manages all of the Social Security databases face layoffs, a senior official said on Friday. The newly named chief information officer, Scott Coulter, a Musk-aligned private equity analyst, has demanded a cut of 50 percent, the official said.

The network outages are one in a cascade of blows to customer service that also have hobbled phone systems and field office operations as the workforce shrinks.

A surge in visitors to the website is overwhelming the computer system as customers — nervous that the rapid changes at the agency will compromise their benefits — download their benefit and earnings statements and attempt to file claims. President Donald Trump has said that his administration will not reduce Social Security benefits.

The chaos could accelerate starting April 14, when new identification measures are set to take effect that will require millions of customers applying for benefits to authenticate their identity online, part of the administration’s campaign to root out allegedly fraudulent claims.

“We’re just spiking like crazy,” said one senior official, who, like others in this article, spoke on the condition of anonymity because they were not authorized to speak publicly about agency operations. “It’s people who are terrified that DOGE is messing with our systems. It’s the sheer massive volume of freaked-out people.”

The Social Security press office said in a statement that officials are “actively investigating the root cause” of the incidents, which they called “brief disruptions” averaging about 20 minutes each with the exception of the SSI error message. But on several occasions, including during an outage last Monday, customers were shut out of the website for hours. The system was back online last Monday after two hours, but lingering issues lasted through the afternoon while all backlogged queries were processed, current and former officials said. And a system upgrade on a Saturday in late March took several hours longer than anticipated and knocked out the network.

Three times in a recent 10-day stretch, the online systems the field office staff rely on to serve the public have crashed, said one employee in an Indiana office.

The downed programs included tools employees use to schedule visits, to see who has booked an appointment and to check who has arrived, the employee said. It is unheard-of for the system to fail this often, and each outage has led to chaos, they said.

Suddenly forced offline as they were taking claims, the staff members scribbled down clients’ information, then had to wait until later to load it into the computer, doubling or tripling the amount of time and work involved, the employee said.

In other instances, managers or security guards improvised a solution after the online scheduling system failed, the employee said. They walked out to the reception area, wrote down numbers on paper slips and started handing them out to people waiting in line.

The network crashes appear to be caused by an expansion initiated by the Trump team of an existing contract with a credit-reporting agency that tracks names, addresses and other personal information to verify customers’ identities. The enhanced fraud checks are now done earlier in the claims process and have resulted in a boost to the volume of customers who must pass the checks.

But the technology staff did not test the software against a high volume of users to see if the servers could handle the rush, current and former officials said. Connectivity issues and bugs with the expanded system have caused the portal that manages log-ins and authentication for many Social Security applications to go down, officials said.

At a weekly operations meeting on March 28 that was made public last week, Wayne Lemon, deputy chief information officer for infrastructure and IT operations, acknowledged the network crashes and said, “While they’ve been brief, we prefer no outages.” He said the outages were under investigation and may involve “challenges we’ve experienced with a number of partners.” Part of the problem may be that the outages have occurred during “high volume use of the network.”

“Is there a spike in demand or something in the environment causing the issues?” Lemon said.

Customers, meanwhile, are growing more frustrated.………..

What readers are saying

The comments express strong concerns about the recent IT staff cuts and website outages at the Social Security Administration, suggesting these actions are deliberate attempts to undermine the system. Many commenters believe this is part of a broader strategy to privatize Social Security.

This important article appeared on the blog called “Inside Medicine,” which appears on Substack. It describes the terrible consequences of Elon Musk’s decision to eliminate USAID. Many of us are still wondering how he got the authority to dismantle an agency authorized and funded by Congress. Many of us wonder why the Republicans in Congress ceded their Constitutional powers to this one man.

Musk said merrily that he was “feeding it to the woodchipper.” He strutted onstage at a Trump rally, waving a bejeweled chainsaw to flaunt his power. What a cruel and callous man he is. How little he cares about human life. He tells us we must procreate (I think he means whites), yet he is completely uncaring about the people who will die because he cut off medical services, medicine, and food to those in need.

Inside Medicine is written by Dr. Jeremy Faust, MD, MS, a practicing emergency physician, a public health researcher, writer, spouse, and girl Dad. He blends his frontline clinical experience with original and incisive analyses of emerging data to help readers make sense of complicated and important issues. Thanks for supporting it!

This past week, Dr. Atul Gawande briefed US Senators on the effects that the destruction of USAID is already having. Here are the facts we need to know. 

Over the last couple of months, the Inside Medicine community has been fortunate to hear and learn about USAID directly from Dr. Atul Gawande. 

Today, I’m sharing the first public release of Dr. Gawande’s latest update provided to members of the United States Senate, remarks that were delivered in person in Washington, D.C. last week. 

This is essential and up-to-date information that we all need to know. When people ask what the human costs of this administration’s brazen actions have been, we must respond with facts. Well, here they are…


First, a quick reminder: Inside Medicine is 100% supported by reader upgrades.

Thank you!👇

(And, as always, if you can’t upgrade due to financial considerations, just email me and it’s all good). 


Do you have any idea where things stand with USAID? With everything else going on, I realized that even I needed an update. So, I again reached out to our friend Dr. Atul Gawande, who, until noon on January 20, 2025, ran global health for USAID.

Here’s where things stand: While the Supreme Court ruled last month that the Trump administration still has to pay its bills for work already completed by USAID contractors, that was not exactly a high bar to clear—and even that decision was a narrow 5-4 ruling. Meanwhile, all of the contract terminations and personnel purges have been permitted to go through while the overall issues are litigated. Therefore, the reality is that even if the courts eventually determine that the complete gutting of USAID was not lawful, it will already be a fait accompli—that is, practically impossible to reverse. 

So, what of USAID’s crucial work remains, and what has—in Elon Musk’s own words—already been ‘fed to the wood chipper’? In testimony to members of the US Senate this past week, Dr. Gawande summarized what has already been destroyed by callous and brutal DOGE-directed terminations since January. We are only just beginning to be able to estimate the number of deaths these cuts will cause in the coming months and years, but unless something changes, it will surely amount to millions of human lives lost. A particularly depressing aspect is that these are senseless deaths (not to mention other suffering from disease and poverty), without reasonable or accurate justifications, as Dr. Gawande explicitly delineated in his presentation. 

I’m grateful that Atul has provided his remarks for publication here in Inside Medicine. Please read his words and share them. 


Senate Roundtable on The Dangerous Consequences of Funding Cuts to U.S. Global Health Programs.

Tuesday, April 1 from 2:30-3:30PM. U.S. Senate Visitors’ Center, Room 200/201.

Testimony of Atul Gawande, MD, MPH:

I was the Assistant Administrator for Global Health at USAID during the last administration. It was the best job in medicine most people haven’t heard of. I led 800 health staff in headquarters working alongside more than 1600 staff in 65-plus countries. With less than half the budget of my Boston hospital system – about $9 per U.S. household – they saved lives by the millions and contained disease threats everywhere.

Before my departure on January 20, I briefed this committee about several major opportunities ahead for the next few years. Among them were three breakthroughs. The journal Science had just declared one of them the scientific breakthrough of 2024. American scientists had developed a drug called Lenacapavir that could prevent or treat HIV with a single injection that lasted six months and perhaps even a year. Deploying this game-changer in high-risk communities through PEPFAR could finally bring an end to HIV as a devastating public health threat.

Similarly, USAID launched a trial of a four-dose pill that could prevent tuberculosis in exposed individuals and dramatically reduce cases – while three TB vaccines complete testing.

And USAID was just about to scale up a novel, inexpensive package of existing drugs and treatments that was found to reduce severe hemorrhage after childbirth – the leading cause of maternal death – by 60%.

American companies, nonprofits, and scientists played key roles in these breakthroughs, and they were poised to transform global health over the next five to ten years. The next administration had no reason not to pursue these objectives. Congress had already funded them. There was nothing partisan about them at all.

But instead of saving millions of lives, we got surgery with a chainsaw. The new administration not only shuttered this work, they fired the staff of the entire agency, terminated 86% of its programs, and kneecapped the rest – all against Congressional directives. They dismantled the US’s largest civilian force advancing global stability, peace, economic growth, and survival. And they have done it in a way maximized loss of life and mismanagement of taxpayer dollars.

Here are few specific examples of the global health damage:

● Our 50-country network for stronger surveillance to deadly diseases from bird flu to swine fever – gone.

● Our emergency response system that cut response times to global outbreaks from >2 weeks to <48 hours – gone.

● AIDS programs to prevent new cases of HIV in high-risk populations – gone.

● Programs for preventing child and maternal deaths that reached 93 million women and children under 5 in 2023 and added 6 years of life on average – cut 92%.

● Lifesaving tuberculosis programs – cut 56%.

● Lifesaving water and sanitation programs – cut 86%.

● Funding for Gavi, the global vaccine alliance, which was set to vaccinate half a billion children — terminated and, if not restored, will cost 500,000 lives a year and drive higher exposure to measles in the US.

The damage is already devastating. And it is all part of a larger dismantling of America’s world-leading capacity for scientific discovery, health care delivery, and public health that goes well beyond USAID. They are using the same playbook to purge staff and destroy programs in across our entire domestic infrastructure in government, universities, and medical center. And they are inserting political controls on NIH science research, FDA approvals, and CDC guidance.

For the sake of power, they are destroying an enterprise that added more than 30 years to US life expectancy and made America the world leader in medical technology and innovation. We need you in Congress to stop this process. USAID cannot be restored to what it was. But we must salvage what we can of our health, science, and development infrastructure and stop the destruction.

Thank you, Dr. Gawande!

Social Security is called the third rail of American politics. The third rail is the one you never touch because it will electrocute you. millions of retirees will want your scalp. Many have no other income.

But Elon Musk is fearless. He thinks he knows how to “fix” Social Security. Not only is he sure that billions are wasted on dead people but now he thinks the computer code must be rewritten.

Gary Legum of Wonkette explains how Musk is touching the third rail:

Having already fucked up the Social Security Administration six ways from Sunday with staff cuts and new ID requirements and field office closures, the incels of the ironically named Department of Government Efficiency are reportedly plotting one more big step in their rampage: They are planning to rewrite the SSA’s entire computer codebase in a more modern programming language. And they plan to have this project completed in “a few months.”

Oh guess what, it’s Saturday morning (Gary wrote this post Friday afternoon) and the Social Security website is already down.

It has been a long time since we had a database/computer technology-adjacent job, but we know enough to understand that migrating a huge system with a reported 60 million lines of code is not something that happens that quickly. This is a years-long sort of job, one that will take the efforts of hundreds, if not thousands, of people. It’s a delicate undertaking, and the vampires of DOGE have proven themselves anything but delicate.

Of course, they have also proven that they genuinely don’t give a shit if you wind up sleeping under a railroad trestle after their hacky changes leave you listed as “dead” in Social Security’s databases, so there is one more reason to not trust them if you needed one.

So, we hope you current Social Security recipients enjoyed getting your benefit checks or your benefit direct deposits on time! Hell, we hope you enjoyed getting them, period. Because there is an excellent chance all that is about to be deader than Elon Musk’s soul.

Wired reports on the new plan in a frightening new story with the words “System Collapse” prominently displayed in the title. It all reads as stupid as it sounds. The basic gist is that SSA systems still run on COBOL, a common, business-oriented programming language that has been around since the 1950s. COBOL has lasted this long for a variety of reasons, but a big one is that it still works really well. Programmers at the SSA still actively work with it despite the existence of newer, more modern programming languages for a few reasons, one of which is that it is very robust. So robust, in fact, that quite a few federal government systems still run on it.

The federal government tends to lag way behind in modernizing the technology that bureaucrats use to keep the country running. But as the saying goes, if it ain’t broke, don’t fix it.

And DOGE has already proven that it is unfamiliar with COBOL conventions, as Wired already explained in an earlier story about why, contra Musk’s band of Nazi virgins, there were not actually millions of Social Security checks going out to 150-year-olds.

This is one system you do not want to screw up until you are absolutely, positively sure any replacement system is up and chugging along. The computers at Social Security are paying benefits to 65 million Americans every month. For many of them, this is their only source of income. Fuck it up, and people, especially the elderly, can’t pay rent or buy food. Their existence is already precarious enough.

Yet that is likely to be the result when the weasels of DOGE (we very much appreciate the Wired locution referring to it as “the so-called Department of Government Efficiency,” as it is anything but that) get through here.

How enormous an undertaking is it to move the SSA off of COBOL? Let Wired tell you:

In order to migrate all COBOL code into a more modern language within a few months, DOGE would likely need to employ some form of generative artificial intelligence to help translate the millions of lines of code, sources tell WIRED. “DOGE thinks if they can say they got rid of all the COBOL in months then their way is the right way and we all just suck for not breaking shit,” says the SSA technologist.

Lot of problems with that, starting with the fact that even generative AI code still has to be checked for errors. And if it’s wrong, someone still has to manually fix it. What do you think the chances are that DOGE will thoroughly test any changes made by either humans or a technology capable of about the same level of thought as a blender? We’re not talking about Jarvis from the Iron Man movies, we’re talking about Large Language Models of code trained on other code written by humans that likely contains plenty of its own errors. The possibilities for disaster are infinite.

DOGE would also need to develop tests to ensure the new system’s outputs match the previous one. It would be difficult to resolve all of the possible edge cases over the course of several years, let alone months, adds the SSA technologist.

This is just basic quality assurance testing. But if there’s one thing we’ve learned about the sorts of dweebs hired by Elon Musk — and by Donald Trump for that matter, he’s still allegedly the president — is that they simply shrug when something breaks before moving along to the last thing. Careless people smashing things up and then leaving the mess in their wakes for others to clean up, as F. Scott Fitzgerald once memorably said of another generation of arrogant, over-moneyed chucklefucks.

Wags online are suggesting that breaking Social Security is the entire point. Conservatives have long wanted to end the program. But too many people rely on it, so cuts are impossible to get through Congress. It’s the infamous third rail of American politics.

If, on the other hand, Social Security broke because a bunch of nerds broke it, and then nobody could get hold of anyone at the agency to help sort out why their measly $2,000 check hasn’t come through this month because DOGE shut down all phone help lines and closed many field offices that people could otherwise have gone to, well, that’s just an act of God that can’t be helped. Shrug and move on to the next thing, the Silicon Valley ethos.

We doubt it is one reason more than another. Sure, ending Social Security through the back door would fulfill a long-term goal of the Right. It could also be that the DOGE guys really are so high on themselves that they look at government programmers and think, What a bunch of dinosaurs! Get out of the way, old people, and let us show you how this shit gets done.

Well, we weren’t going to be able to retire for awhile anyway. Now maybe we’ll just work until we drop dead under that railroad trestle where we’ll spend our dotage.

Those of us who have watched the movement to privatize public education over the past 30 years have witnessed a long list of broken promises. Privately-run schools, we were told, would be more effective, more accountable, more transparent, more responsive to students and parents, and would save money!

Now we know that none of those claims were true.

Privatization, in the case of charter schools and vouchers, does not produce better results, except when the privatizers exclude the students with the greatest needs. Privatization does not save money; in fact, it’s more expensive because the business has to turn a profit. Privatization means less accountability and less transparency; lobbyists for the charter chains and voucher entities fight both accountability and transparency. Accountability and testing, it turns out, is only for public schools, not for religious and private schools. Privatization opens the way to graft, corruption, fraud, waste, and abuse.

The Washington Post wrote that the highest goal of Elon Musk’s DOGE plan is privatization of government services.

Mail delivery. Real estate. Foreign aid grants. The Trump administration is moving to privatize a sweeping number of government functions and assets — a long-standing Republican goal that’s being catalyzed by billionaire Elon Musk.

The slash-and-burn approach of Musk’s U.S. DOGE Service is paving the way for a new shift to the private sector, reducing the size and power of the federal bureaucracy in a real-world test of the conservative theory — a version of which is also widely popular in Silicon Valley — that companies are better than government at saving money and responding to people’s needs.

Examples are popping up across Washington and in proposals from President Donald Trump’s allies, though the plans are at various stages of development and, in some cases, have already encountered resistance.

At the DOGE-allied General Services Administration, officials are quietly moving ahead with a push to sell hundreds of publicly owned buildings to private companies — which can then lease them back to the government, theoretically saving maintenance and upkeep costs for taxpayers, according to two people briefed on internal deliberations who spoke on the condition of anonymity because they were not authorized to discuss them publicly.

At the Postal Service, whose leaders have tussled with DOGE representatives, a plan for full privatization appears to have lost steam after facing pushback and legal hurdles. But private firms are preparing for a piecemeal government effort to outsource mail and package handling and long-haul trucking routes, while off-loading leases for unprofitable post offices, according to six industry executives.

At the Interior Department, Secretary Doug Burgum has proposed allowing private developers to build on federal lands across the West. And in his first public address as treasury secretary, former hedge fund manager Scott Bessent vowed to “reprivatize the economy.”
Businesspeople and policymakers close to the administration are stepping up with additional proposals.

A Wall Street investor nominated to run the International Development Finance Corporation, a little-known foreign investment agency that works to align the private sector with U.S. foreign policy goals, has suggested redirecting a large portion of the $40 billion budget of the shuttered U.S. Agency for International Development to investors, start-ups and companies that work in developing countries.

The proposal, which was posted on X by the nominee, Ben Black, and tech investor Joe Lonsdale, is under consideration within the White House, according to a person familiar with it, who also spoke on the condition of anonymity to describe private deliberations. Bloomberg first reported that the initiative was under consideration.

The military contractor Erik Prince has pushed to turn over defense and immigration enforcement functions to private security firms, at one point pitching U.S. officials on a plan to execute operations in Africa, according to three people with knowledge of the idea, who spoke on the condition of anonymity to reflect private conversations. CNN reported that Prince also has floated the use of private military contractors to carry out operations against Houthi rebels in Yemen…

Traditional Republicans have long argued that private companies can do a better job of managing government services than civil servants. But Musk and his Silicon Valley associates want to push the idea much further than the mainstream GOP. At a Morgan Stanley technology conference this month, Musk said the government should privatize “everything we possibly can.”

Government Executive reports that the Secretary Of Health and Human Services Robert F. Kennedy Jr. plans to lay off 10,000 of the Department’s 80,000 employeees. Entire divisions will be eliminated or merged. But no one knows who will be laid off. Decisions about layoffs are being made by Elon Musk’s DOGE. Since no one knows who will be fired or why, everyone is fearful.

Government Executive writes:

The Health and Human Services Department has told its employees that 10,000 of them will soon receive layoff notices, though it has not offered any details on who will be impacted or when they will learn of their fates. 

The uncertainty has dangled over the more than 80,000 HHS employees since Thursday, when the department first announced it was planning to shed around 25% of its workforce and half of those eliminations would come through reductions in force. Leadership at individual components and offices are regularly seeking to update their employees on what is happening, according to seven individuals within HHS, though they have all said they have been fully kept out of the loop and only a small group of political leaders within HHS know the plans.

The Food and Drug Administration is expected to lay off 3,500 employees, the Centers for Disease Control and Prevention 2,400, the National Institutes of Health 1,200 and the Centers for Medicare and Medicaid Services 300, according to an HHS fact sheet. HHS did not respond to an inquiry into why the notices were delayed or when they would go out.

Several employees were told to expect RIF notices to hit inboxes on Friday. When that did not happen, they were told to expect them Friday evening or over the weekend. As of Monday afternoon, the notices have still not gone out. 

“FDA leadership doesn’t know who will be cut,” said an employee briefed on the matter. “They didn’t have any input into these cuts whatsoever.” 

Employees at CDC and NIH expressed similar messages were going out from leadership to the workforce. 

“It’s unnecessarily cruel,” said one CDC employee of the uncertainty and delays. 

A second CDC employee said they spent the entire weekend refreshing their email waiting to see if a RIF notice arrived. The employee was resigned to their fate, but wanted an answer: “Just put me out of my misery,” the staffer said. 

Prior to an “all hands” meeting at one NIH office, employees were encouraged to download their complete personnel files, current position description, pay stubs, tax documents, awards information and contact information for human resources and their supervisor in case they lost access upon being laid off. 

The department will not allow those who are subject to RIFs to be allowed back onto HHS campuses, according to two employees briefed on the matter. Some staff were told to bring their laptops homes each day in case they were laid off and not allowed back into their offices. Unlike other agencies that have gone through RIFs, which have immediately placed impacted staff on administrative leave, at least some HHS employees will be expected to work until their date of separation. 

At FDA, conversations with office directors were taking place to identify U.S. Public Health Service Commission Corps members who could escort laid off employees to their desks to collect their laptops and personal belongings. The uniformed personnel would be available for the RIF-affected staff who need to retrieve items on campus.

The RIFs are expected to take effect May 27, according to the National Treasury Employees Union, which represents much of the HHS workforce. That date could get pushed back given the delay in sending out official RIF letters, however, as agencies typically provide 60 days notice before separations take effect. 

Directors at the highest level of the component agencies have communicated “have no knowledge over what is happening,” one employee said in a sentiment echoed by those throughout the department. 

A senior HHS official said even HR at component agencies have received no information on who is being laid off or when the notices were going out, though the latest expectation was the letters would be delivered Monday. 

“Radio silence,” the official said. “It is madness!” 

Government Executive previously reported that top officials were being left out of the workforce reduction process. At NIH, for example, liaisons from the Department of Government Efficiency dictated staffing targets without input from the agency or anyone else at HHS. 

Some informal notices were beginning to trickle out Monday afternoon. CDC is planning to eliminate its entire Freedom of Information Act office, according to an impacted employee, which could create legal questions as agencies are required to maintain those functions. The official notices had not yet gone out as of Monday afternoon but all of the office’s 40 employees are expected to receive them. 

The reductions will be part of a comprehensive reorganization of HHS. The cuts will save $2 billion annually, department Secretary Robert Kennedy said last week, and HHS will go from 28 divisions throughout the department down to 15. Department-wide functions such as human resources, IT, procurement, external affairs and policy will be centralized into the Administration for Healthy America and regional offices will be slashed in half to just five.

The new AHA will fold into its structure the Substance Abuse and Mental Health Services Administration, Agency for Toxic Substances and Disease Registry and National Institute for Occupational Safety and Health. HHS will divide up the functions of the Administration for Community Living, which provides oversight of those serving older and disabled Americans, into CMS, the Administration for Children and Families and the Assistant Secretary for Planning and Evaluation. ASPE itself will be combined with the Agency for Health Research and Quality into the Office of Strategy.

This hurried reorganization is being imposed by the young engineers and computer geeks who work for Musk, apparently without consulting anyone who has done the work. The changes are rushed, haphazard, and carried out without the participation of those with knowledge and experience.

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