China Olympic Visit

A sub-theme of my service as Governor of Utah between 1993 and 2003 was the Olympics. Prior to my service as Governor, Utah unsuccessfully bid for the games of 1998, and so the bid process for the 2002 Winter Olympic Games occurred during my service. We were awarded the games, and then suffered through a wrenching period when allegations were made involving the bid process.

As Governor I supported the bid completely, and later became deeply involved in working through the problems I referenced and spent nearly seven years getting ready for the games. It was a pressure-packed experience with high highs and low lows. When the games had been successfully completed, I could not help but consider the sum total as one of the great experiences of my life.

Through it all, I became well-acquainted with the Olympic organization, rituals, personalities and politics. I came to know its power for good. I also became intimately aware of how people all over the world wish to hook their cause to the power of those five rings. Nothing better illustrates the appeal of the Olympic brand.

I assume the combination of those factors, and my current portfolio at HHS, is the reason the President assigned me to the United States Delegation for the closing ceremonies. I was delighted, of course, and greatly honored.

Originally, I was to be part of a delegation lead by Secretary of State, Condi Rice. However, when the Russia/Georgia conflict broke out, she was required to pass her responsibilities to Secretary Elaine Chao, the Secretary of Labor and a person of Chinese descent. In addition to Secretary Chao and me, the delegation included the American Ambassador to China, Clark Randt; former Undersecretary of State, Karen Hughes; Olympic figure skater, Michelle Kwan; and Secretary Chao’s Father, Dr. James Chao.

Most Americans had a great seat for the Olympics because of the excellent television coverage. I came to understand that, in many ways, the Olympics are a made-for-television event with a live studio audience. Consequently, I won’t provide any commentary on the events. The truth is, I saw few of the competitions.

However, I do want to comment on the significance of the Olympics as a unique unifying force in the world, the importance of our country’s support to China, and what it means in the context of our current relationship.

Sport is one of the few causes that can bring the world together in peace. There are others. Each year I attend the World Health Assembly, where delegations from nearly 200 nations seek to work out and find solutions to common problems. But none of the other causes attract teams of participants who compete in events with common rules, all in pursuit of victory with high ideals.

The sessions of other diplomatic meetings are not shared simultaneously with more than three billion people around the planet all celebrating in a common interest and passion. It happens only at the Olympic Games.

President Bush made the right decision by going to the opening games himself. It was enormously important to the leadership of the Chinese government. In a meeting we had with Primer Wen Jiabao, he expressed his appreciation and made clear how important the President’s attendance was to the Chinese people.

At a small luncheon Secretary Chao and I attended with President Hu Jintao, he made a point of telling me how much he valued the President’s attendance. At China’s shining hour, it simply would not have been right for our President not to have been there. It would have been a slight felt for decades by China.

The games were not flawless; they never are. However, by my observation, they were excellent. Things worked. The venues were excellent. The athletes seemed pleased, and their performances showed it with lots of new world records, etc.

I think China served notice to the world that they will take sport seriously in the future. They have invested heavily in finding and building potential. It is an investment that will pay dividends for many years. Doing well in the Olympic Games adds prestige to a nation. In the same way people think Universities with winning football or basketball teams must be great educational institutions, in a world where few pay attention to geo politics, medal count often registers high on the scale of global prestige. Nowhere is that more important than at home in China. It builds national pride and support for the government and their system.

I had two other meetings I thought were important. One was with my friend Minister Li, who heads the Administration for Quality Supervision Inspection and Quarantine. We have worked together for the last year and a half on food safety. We had lunch and traded Olympic torches. I had a couple left from my time as Governor. We discussed the opening of our FDA offices in China during October.

Finally, I met with Liu Qi, the President of the Olympic Organizing Committee. He is the former mayor of Beijing and a member of Political Bureau of the 17th Communist Party of China (CPC) Central Committee. I wanted to congratulate him. We have known each other since 2002, when he visited me in Utah for our games.

We had a good laugh when I said to him, “One thing you won’t miss is endless calls seeking credentials.” Anyone who has been involved in the games knows that problem. He seemed like a man savoring a great victory, and well he should. The entire nation of China should. They still have many challenges, but the Olympic experience will have made them better as a country.

Gustav- Blog IV

Resettling after a storm

One of the major lessons learned during Katrina was that when people got displaced and could not return to their homes, the recovery was long and complex.

Every family has a different situation, and therefore, our help to get them back on their feet needs to be customized. We need individual case management.

During Katrina, I proposed using our Office of Refugee Resettlement (ORR) to help. The idea was not adopted, but I felt so strongly about it that I put a team together to develop a pilot, similar to the programs in ORR, to try at a future disaster. Today, for the first time, we will begin using it. I honestly think it will make a major difference in getting people back on their feet faster.

ORR is a little known part of the Administration for Children and Families (ACF) of HHS. Each year, through contracts with a large group of non-governmental organizations, volunteers help people who are immigrating to the United States get settled. It is in our interest to assure it is done in an orderly fashion. Not only is it the humane thing to do, it pays financial dividends quickly to have people become self-sufficient as soon as possible.

When a person is assigned to ORR, a case worker helps them navigate various government programs, and, more importantly, the officer helps the refugees develop a plan for self-sufficiency, then stays with the client until the plan is working. It has been a great success.

Today, we activated a contract through ACF's Human Services Preparedness and Response Office to help Americans in need of similar services due to Hurricane Gustav. The contract will be fulfilled by Catholic Charities, who will coordinate the activities of other organizations, who also do casework for immigrants.

With many families still displaced after Katrina, I’m looking forward to seeing the difference in this more managed approach.

Gustav Blog III

Written September 3, 2008

After spending Tuesday in Texas looking at shelters, the weather and air space cleared sufficiently so that I was able to join the President in Louisiana to review the progress in dealing with Hurricane Gustav. 

Rather than attempt to detail the entire trip or various meetings I want to write a series of observations I made during the day.

First, we are getting much better at emergency response. One example is the fact that in the 72 hours before the storm hit, the largest medical evacuation in our nation’s history took place.  We relocated more than 10,000 people from nursing homes, hospitals and situations requiring special needs.  We did it in an orderly, safe and well planned way.  Was it perfect? No, but it was done extremely well. 

I’m hoping the real story of our nation’s response will not be missed. The media reports on the activities of the federal, state and local government to establish organization and facilities.  However, the big story is the hundreds of thousands of Americans who previously didn’t know what to do this time ended up in shelters across the country.  During Katrina there were more than 600,000 people in shelters.  During this storm we had about 80,000 despite similar numbers being displaced overall. (On Wednesday there were only about 60,000 in shelters.)

There were hundreds of thousands of people who developed individual and family evacuation plans and executed them. Families went to Aunt Mabel’s, friends, motels or camp grounds. Preparedness isn’t just government’s work; it is the reaction of the ordinary citizen.  The aggregate of each prepared citizen played starring roles in the drama.  This is very good news because government simply cannot respond to everyone, we have to create facilities for the exception, the special need, the anomaly.

I report this not as way to be solicitously upbeat. The big story is that positive citizen action is key to successful execution. There were 1.5 million people who were evacuated in less than 12 hours. (During Katrina it took 25 hours for that many) Most of them took care of themselves this time allowing government to do a much better job with those that couldn’t. 

The big problem right now in Baton Rouge is electricity.  There are 1.4 million people without power. The lack of electricity requires constant transfers out of hospitals.  Just before I left, I visited Baton Rouge General.  There was a line of ambulances loading patients for transfer.  As I walked up and down the hall, the conditions were extremely difficult.  There was no air conditioning and few lights.    They had backup generators, but they were proving inadequate for the demand.

A walk through a hospital during a time period like this is an important reminder of two things: how dedicated the staff is to continue working and just how sick many of those people are which makes moving them complicated.

The big commodities at this point in an emergency are water, ice, MREs (meals ready to eat—military prepackage meals) and tarps. 

Secretary Leavitt meets members of the Disaster Medical Assistance Team in Baton Rouge.

This was the President Bush’s 27th trip to a disaster area during his time as President.  The presence of a President is an important symbol. It reassures people and also serves as a deadline for people to get things done. 

We met at the emergency management operation in Baton Rouge.  The governors, mayor, senior emergency officials from the federal, state and local government were there.  Also some elected officials.  One by one, reports were given regarding the progress that had been made and priorities remaining.   

The President reflected the experience of a man who has been through a lot of emergencies. At one point he said, “By my observation is that there are three phases to natural disasters.  There’s the ‘glad to be alive phase;’ Then the ‘why didn’t you come sooner phase,’ and finally ‘I’m really mad phase.’ People are going to feel those things and our job is to just keep moving forward to solve the problems.”  That matches my experience as well.

It should be noted that the levee system held.  There is a lot of deserved satisfaction among the engineers about that. 

We are obviously not out of the woods on storms this year.  There is a virtual conga line of storms lining up off the gulf coast.  Hopefully, they will dissipate and not throw us into the soup again soon.  If it happens, we’ll be ready.      

Hurricane Gustav – Blog II

I met Jenny in a medical shelter in Tyler, Texas.  She lives in Beaumont Texas where she had just undergone back surgery.  She was at home beginning her recovery when Hurricane Gustuv, approached the gulf coast.  Like thousands of others Jenny called 211, a telephone service offered in her area, registering for help in case evacuation was necessary. 

For days before the authorities monitored Gustav, and 120 hours from the time the storm was anticipated to hit the shore they opened an emergency “playbook” developed to respond to severe storms.  Nobody knew at that point what the intensity of the storm would be, but with the lapse of each hour decisions needed to be made to avoid allowing time to become the enemy.   

There is a hierarchy of evacuation needs. People like Jenny with complicated medical needs are high on the priority list and require emergency managers to start early.  Somewhere between 48 and 72 hours from land fall, officials made the decision to begin evacuation.

I landed in Texas Monday night just hours after Gustav’s dissipated Category two force winds crossed Louisiana and Texas coast lines. Early Tuesday morning we flew from  Dallas to Tyler Texas.  I wanted to see deployment of our Disaster Medical Assistance Teams and Federal Medical shelters first hand.  That’s when Jenny and I met. 

As Jenny sat in a special chair that held her back in proper position to heal, she told me how rescue workers picked her up and took her to a bus.  The three hour bus ride out of the storm’s reach was uncomfortable she said, but it probably saved her life. 

Secretary Leavitt and Jenny at the medical shelter in Tyler, Texas.

I saw hundreds of patients all of whom had a story to tell.  Many seriously ill before the storm and still struggling but for the most part, deeply grateful for a bed, food and medical attention offered at the two federal medical shelters set up by the state of Texas, operated by local health workers and supplemented by federal equipment, supplies, emergency teams and, of course, money. 

Disaster preparedness is a local and state responsibility and the state of  Texas is good at it.  In Tyler, Dr. Lakey, the head of the State Health Department met me. As the storm approached, state emergency planners determined where the demands were most likely going to be felt.  That’s done by simply asking the question, “If you live in an evacuation area, where are you most likely to go?”  Most of the people I met on Tuesday where from Beaumont, Texas and some from western Louisiana.

Given the nature of this storm, the state chooses to establish medical facilities in Tyler at a county-run community center and a few miles away at Eastern Texas Baptist College. Both the local government and the college responded with great generosity providing facilities and people. 

When the state feels they will not have sufficient capacity to staff and meet the demands of both the local population and the in flowing evacuees, they ask the federal government for help, specifically FEMA.  My Department of Health and Human Services (HHS) is then tasked by FEMA to deploy assets we have.  Those activities are managed through the Office of Assistant Secretary for Preparedness and Response and they have become very good at it.

HHS provided two types of assets in this case.  The first is a federal medical shelter.  This is essentially a hospital in a box, more appropriately, a whole bunch of boxes. The federal medical shelter is deployed from one of our national stockpile sites and can be in place within 12 hours.  We also send a component of medical workers to staff the facility. 

The second asset we deploy is a Disaster Medical Assistance Team (DMAT).  Most states have at least one DMAT.  These are remarkable people who have volunteered to be deployed with only a few hours notice anywhere they are needed.  These are groups of medical professionals as well as others trained in different aspects of emergency medical needs.  On Monday I saw teams from New York, Florida, New Mexico and Oregon in action.  Within a few hours they establish a facility to treat the most acute patient needs.  It is rather remarkable to watch. 

Nobody likes disaster but I must say, I am always inspired by the generosity and competence people willingly bring.  They work unthinkably hard hours in beastly conditions.  However, there is something about the human spirit that when people are engaged in emergency assistance they are happy and upbeat.  I think there are few things more rewarding than the satisfaction that comes by providing assistance for a person in need.  My mother once said to me, “Mike, we get our self esteem from the people we serve.”  I believe that more than ever. 

Africa- Blog IX

Timbuktu
Written August 16, 2008

After I arrived in Mali and met with the Minister of Health, toured several facilities, and completed diplomacy speeches and media interviews in the capital city of Bamako, I wanted to get into the Northern portion of the country. Specifically, I was interested in the remote Northern region which has long been viewed as a safe harbor for Al Qaeda.

The only significantly populated area of this region is Timbuktu. Yes, it does exist. In fact, Timbuktu, at one time, was a cultural capital in the same league as Rome, Athens, Jerusalem, and Mecca. In the thirteenth century, it was a thriving trade center in Africa and remained such for nearly two centuries. Timbuktu began to fade because of geopolitical and trade shifts.

Two characteristics make the area surrounding Timbuktu attractive to terrorists: remoteness and lack of government resources to provide any significant presence. Our government has been attempting to help the Mali government in that regard. It is obviously in our mutual interests.

We flew about two hours on a United Nations aircraft and were met at the Timbuktu airport by a long line of community leaders. The length of the line appears to be an expression of the importance they place on the visit. It was a nice expression of their admiration for the United States. Each of the community leaders spoke appreciation for the way our country helps them. The welcoming party ceremoniously wrapped our heads in desert turbans, which I will say felt good as we walked around in the unbelievable heat.

The leader of the welcoming delegation was the new Governor of Timbuktu, Mamadou Mangara. Governor Mangara is a Colonel in the Mali military and former aid to President Amadou Toumani Toure. He has received extensive military training in the United States, speaks reasonably good English and has big ambitions to build the region.

Governor Magara and I toured a health center facility called Centre de Sante Coommunautaire, in Kabara, Timbuktu, just a few miles from a major city. The people were proud of the center and appreciated its presence in their community. They had obviously worked hard to qualify for it. The center reminded me of one of our Indian Health Service clinics in Alaska, only substantially less well equipped. They didn’t have electricity, let alone medical equipment. The only device I saw was a kerosene-powered refrigerator to keep vaccines.

The center had a medical technician who was trained to follow diagnosis charts that hung in his office. There was a nurse midwife, who last year delivered 160 babies among the population of nearly 4,000 they provide care for. The center also had health workers who proactively do out-reach, but I was not able to talk with them. Malaria is the biggest challenge they deal with, the technician told me.

After touring the clinic, I had the equivalent of a town meeting under a tent, attended by several hundred people. This is probably a good time to mention the most memorable physical characteristics of the area: heat and sand. This is the desert. It is blisteringly hot. The day we were there was cool- only 110 degrees. When my team arrived in advance to prepare for my visit, it was 126 degrees. Everything is made of, and surrounded by, sand. The homes and buildings are made of sand bricks, and the roads are compacted sand.

A woman speaking at town meeting in Timbuktu.

At the town meeting, we talked about the aspirations people have for their community. The main two are electricity for the clinic and a water system. A woman stood and made a passionate speech about the worries she had about the water. The more she spoke, the more the crowd of her fellow villages responded. By the time she had finished, she had worked the group to a pitch. It was interesting to see, and it helped me understand local dynamics.

One of the more important meetings I held in Timbuktu was with four members of an Army Special Forces unit that had been deployed into the area. They showed me a map of their 1,200 mile route through the sand, moving from small settlement to settlement. They described how desperately the people needed and wanted health care and the warmth with which they had been received. We talked candidly about the influence of various terrorist organizations, including Al Qaeda, who seek cover in the area. These organizations provide money, equipment and other needed assets in exchange for locals leaving them alone while they train and organize.

We are not alone in recognizing the need to be paying attention to these remote areas of the world. I discovered that while we send Special Forces units into the area twice a year, there are two teams of Cuban doctors and medical personnel working the desert year round.

In areas of Africa like Timbuktu, the people are essentially without government. They don’t have the resources to provide services, and the people have far more confidence in other institutions, like the church. I met with the leader of the church, The Grand Imam Abderrahmane Ben Essayouti, for about an hour. He is a very pleasant man who is clearly the most influential person in that part of Mali. We talked about the importance of the church teaching good health hygiene, like the use of bed nets for malaria prevention.

We had a good laugh together. The Grand Imam said, “most Americans don’t think this place really exists.” I showed him a text-message exchange I had with my mother about 15 minutes earlier, when I had greeted her from Timbuktu. She wrote back, “the real Timbuktu?”

At the conclusion of our meeting, the Grand Imam and I walked through neighborhoods of Timbuktu to the Djingery Ber Mosque, where he leads the community in prayer five times a day. The mosque was built in 1327. He walked our group through the mosque and then showed us a small library the United States had donated, which houses important Islamic documents. It was clear how much it meant to them that we had made the preservation possible.

One of my favorite parts of the day was walking through the neighborhoods on my way to and from the Grand Imam’s home. It was a chance to see up-close what the lives of the people looked like. We passed mothers caring for their children, men working to repair their sand brick homes, children playing games and curiously watching these strange visitors. Despite the scorching temperatures, the blowing winds, and the remoteness; it was home to them.

Africa- Blog VIII

Peer counseling in a unique setting
Written August 15, 2008

While in Bouake, in northern Cote d’Ivoire, I visited Reseau des Ecoles Madrassas, a faith-based, non-governmental organization that promotes abstinence and fidelity to prevent the spread of HIV/AIDS in the community.

I witnessed how they used a dramatization and peer counseling to deal with a very sensitive issue within the Islamic community. There is a practice in the Islamic culture (at least in that part of the world) that the younger brother of a man who dies, is bound to take the wife of the deceased as his wife. (In the Islamic world multiple wives are common.)

After I was greeted by the leaders of the Madrassas, and typical rituals were performed, a group who acts as peer counselors did a short one-act play to set up a conversation with the following scenario:

• After the death of his older brother, a man is informed by his family that he must marry the widow of his brother as dictated by tradition.
• After hearing the news, a friend of the current wife goes to inform her. The current wife is furious that her husband must marry a second wife.
• The man who is obliged to marry his brother’s widow goes with a friend to inform his current wife of the plan. They hesitate, then tell her, and she explodes (because she already knows).
• After discussion, the current wife submits to the wishes of the parents, but asks to put a condition on the marriage: that the widow must get tested for HIV/AIDS beforehand.
• Her husband agrees that the widow must be tested for HIV/AIDS before he will marry her.

Peer counselors using a dramatization to discuss sensitive issues.

The discussion afterward among the crowd that watched was animated and fascinating. In typical style for Islamic communities, the men and women were seated separately and the male moderator moved back and forth between them taking comments. I won’t try to recount the discussion except to say that an underlying theme of the facilitator was that this is not a practice based on the teachings of the Koran, but one of cultural popularity. He said the same is true for the tradition of a woman taking the husband of her deceased sister.

Following the moderated discussion, I was given an opportunity to ask questions of the peer educators. During that session, one of the women boldly challenged the practice of female genital mutilation. She made the point that the practice was not a religious teaching, but a cultural practice. I was surprised, but pleased, she was willing to talk about it.

Every culture around the world has unique challenges and practices. To win the fight against HIV/AIDS, we have to let people mold the education practices to address the issues where they live and to do it in their own unique ways.

Africa- Blog VII

Written August 14, 2008
Bouake, Cote d’Ivoire

We flew about an hour north of Abidjan and then drove to the village of Lomibo. My purpose was to see HIV/AIDS treatment in a remote area of the country. In those areas, the effort has to be home-based, because there often are not clinics. The reality is that, in areas like this, the government is not a significant factor in the lives of the people. The culture is governed through a hierarchy of village elders. Since the 2002 crisis, areas like this have essentially been cut off from all health care.

Lomibo looks just like one would imagine an African village. When I arrived, I was met by the village elders. These are men who appear to be in their late 60s or early 70s. They dress in traditional African raps. The most senior wears head gear that designates him as such.

The Chief Elder of Lomibo

Something I’ve found true in meeting men of this nature is the need to let them size you up. If you pause and gain eye contact for just a second or two, their eyes tell a story and a connection can be made. Without that moment, it is hard to establish a rapport. With the difficulties of language interpretation and culture, it is hard for them to know if they trust your words. I saw that play out in Lomibo.

After a series of introductory activities were conducted, I was asked to speak. I put my remarks into the context of their 2002 crisis. I told them I had come to understand how heavily it had weighed on them. I linked to HIV/AIDS by saying that, to prosper again, they need to be healthy. HIV/AIDS is stealing the health of many of their young people. It is not just killing them, it will hurt the village and its ability to recover as well. I expressed my belief that God has given us bodies, and we are expected to take care of them. “Every person needs to be tested for HIV/AIDS. If you test positive, you need treatment, and you can live a positive and productive life. If you don’t get tested, you can’t be treated.”

My remarks where being interpreted, but I could tell the elders were getting it because they would nod their heads in affirmation. After I was finished, I walked over to a chair sitting at a small table in front of them and had a medical technician prick my finger and squeeze a tiny drop of blood onto the HIV quick-test strip.

When I had finished being tested, volunteers from the audience were invited to be tested. To my great pleasure and to everyone’s surprise, the Chief Elder stood and walked to the table for testing. There was an audible stir in the crowd of people who had come from three different villages. When he was finished, the second most senior person did the same thing.

The U.N. health people said they had been doing these village education sessions for a decade and hadn’t seen a village elder do that. Tim Ziemer, the National Malaria Coordinator, leaned over to me and whispered, “that’s real leadership.”

When the testing had been concluded, the elders said they had a gift for me. They brought out a very colorful robe and ceremoniously rapped me in it. They then placed a colorful cap on my head similar to the one the village elder had worn. They told me I was being made an honorary village chief. They designated me with the name: Nanan Kouakoo the First. I was later told that Nanan means King. Kouakoo is roughly “crowned on Thursday.”

While being provided such an honor feels a little conspicuous, I could tell it was a serious gesture for them and I want to treat their expression with the dignity and appreciation it deserves. (However, I will likely stick with the simple title of Secretary for now.)

Secretary Leavitt wearing traditional robe and cap.

After the ceremony, all the women in the village began to chant and dance. We all got into the spirit of it and had quite a moment. Many of the women wanted to dance with Nanan Kouakoo the First, and I was more than willing to accommodate. It was an experience I will not ever forget.

Africa- Blog VI

Abidjan, Cote d’Ivoire
Written August 13, 2008

Cote d’Ivoire is better known as Ivory Coast. However, the government insists it is called by its French name, which is odd, given the French are currently persona non-grata in Cote d’Ivoire for reasons I will explain.

Things have been extremely complicated in Cote d’Ivoire since the fall of 2002 when civil war broke out between the North of the country and the South. People in the North believed they were being discriminated against politically and economically. I suppose there was a long history of tension, and what appears to have triggered it was a policy that eliminated many in the North as voters. Forces in the North, lead by a group of lower ranking military officials, attacked three cities in the South. They were turned back fairly quickly.

The government responded with an aggressive security operation, searching and burning shantytowns where the poor lived. The actions of the government caused the situation to explode throughout the country. It is often referenced as the Crisis of 2002.

Ultimately, the United Nations established a “Zone of Confidence” which separated the North and South and then, through the French government, a deal was brokered. Before the arrangement could begin to function, another incendiary event happened. A government aircraft bombed a French military installation in Bouake and killed nine French soldiers and one American civilian. The French retaliated by essentially destroying the entire Cote d’Ivoire Air Force. The country broke into violence again.

Things remained unstable until March of last year (2007) when President Gbagbo (the current President) and Guillaume Soro, then the leader of the Northern opposition, announced they had agreed to a peace agreement. The deal essentially provided for President Gbagbo, who is from the South, to remain as President, and Soro, who is from the North, to be Prime Minister.

As Prime Minister, Soro named a new Cabinet, consisting mostly of the Ministers from the previous Cabinet. The agreement called for the U.N. to eliminate the Zone of Confidence. The government called elections for November 30, 2008. Whether those elections will actually take place is hard to say. Apparently, there have been promises before that elections would be held, but they have been cancelled.

To his credit, Soro and his New Forces party have indicated they will not be contending for the Presidency this time around. However, with the two top leaders of the country representing different interests, it is safe to say progress is hard.

Cote d’Ivoire is one of the fifteen countries in the President’s Emergency Plan for AIDS Relief (PEPFAR). We spend about $120 million a year there. We represent nearly 70 percent of all money being spent on the problem there. I had three primary purposes to go there: First, to get a picture of how the money is being spent; second, to maintain our relationship with the leadership of Cote d’Ivoire; and lastly, to remind the citizens of their country of our nation’s contribution and interest in them.

I spent my first day in the capital of Abidjan and, as I typically do, met with the U.S. Embassy staff to be briefed on the current situation. I also met with HHS employees. We held a small celebration to commemorate twenty years of a CDC project on HIV/AIDS in Cote d’Ivoire.

I visited a clinic supported by PEPFAR funds where I met with HIV positive patients. Following a tour, I did a media event where I was publicly tested for HIV/AIDS. Getting tested always captures the media’s attention and, therefore, allows me to both emphasize U.S. involvement and also discuss the importance of being tested. The message is: Everybody needs to be tested. Know your status. HIV is not a death sentence if you seek treatment.

Secretary Leavitt getting tested for HIV/AIDS

Following the media event, I met with a group of HIV positive patients. It is not hard to imagine their gratitude. It is openly expressed and heart felt. Literally, nearly two million people being treated would die without the treatment. The chance of them being treated without PEPFAR is remote.

Each one told me how devastated they felt upon hearing the news of their positive test and then how, slowly, their hope returned as they learned about treatment options and got to know other people who were struggling like they were.

At the conclusion of my meeting with patients, I met a woman I would judge to be in her late twenties or early thirties. I could tell she was terrified to speak, but did anyway. She explained that even though the PEPFAR made the drugs available, the price was high enough that it was making it difficult for her to buy food.

I know nothing about her situation and therefore can’t make a judgment about the truth of her statement, but the conversation was important, because it called to my attention that the government had adopted a policy of charging for the drugs we give them. Upon inquiry later, I found that the government was not being transparent on what the money was being used for. I committed to address it with the Prime Minister later in the day.

Prime Minister Soro is a young man. I’m guessing late thirties or early forties. He was part of the rebel movement in the North and then was invited into the government. He was in and out of government as the tensions ebbed and flowed, but ultimately was the organizing force around which the deal was made with President Gbagbo. I would guess Soro will emerge as a candidate for President in a future election.

Our meeting consisted of an agenda of diplomatic expressions with the exception of my pressing him on the issue of charging for HIV/AIDS drugs that the U.S. provides for free. I don’t think he was aware of it. Cote d’ Ivoire has both a Minister of Health and a Minister for HIV/AIDs. It seems like a rather unusual arrangement. They were both in the room and I hope the conversation resonated with them. It is something that needs to change before we do allocations for the next round of PEPFAR.

Hurricane Gustav

The weekend has been dominated by preparation for Hurricane Gustav. Though I am now in Dallas preparing to enter the storm’s footprint with my senior team, I was working from Utah over the weekend.

Assistant Secretary for Preparedness and Response, Admiral Craig Vanderwagen, operated out of our emergency management center at headquarters. He conducted briefings every few hours. The difference in the work atmosphere, by comparison to Katrina, in our department and in our interaction with other departments and states, has made the hard work of the last three years evident.

I'm typing this blog on my Blackberry and therefore a more detailed description of the differences will need to wait for another day. I will simply generalize that all the lessons learned, all the exercises, all the meetings and conferences, and investments have paid off. People knew what to do and when to do it. We followed a play book that had been rehearsed over and over. Were there surprises and departures from the script? Of course, but for the most part, we carried out the plan.

Assets were moved into place, the medically compromised were evacuated (more than 9000 of them), and shelters and field hospitals were erected. HHS had more than 1,500 people deployed to the region. It has been a moment of great satisfaction to see how ably our team has functioned. Admiral Vanderwagen calmly and professionally guided the process from headquarters. Craig was our field commander during Katrina and is intimately familiar with the situation. I'm extremely proud of him and his team.

This effort revealed weaknesses. They were worked around this time, but they need to become the focus of our improvement. The weakening of the storm is a blessing we are all grateful for. However, there is a virtual conga line of storms queuing up in the Atlantic. We are by no means out of harms way.

There are thousands who need help from the devastation they experienced from this storm. We should never view a Category II hurricane as anything but a deadly storm. I will spend the next two days in Texas and Louisiana to see the outcome of our preparation and assessing what must be done now. I will periodically provide updates. However, I will be communicating them by Blackberry, so they will, by necessity, be short.

www.HHS.gov/hurricane

August in Africa- Blog V

Written August 12, 2008

I am sitting in the Addis Sheraton feeling a bit disoriented by the contrast of my comfortable room with what I experienced today. I just returned to Addis Ababa, the capital city of Ethiopia, after having traveled to some of the country’s remote areas. How can the comfort of this hotel be on the same planet, not to mention the same country?

I’m trying to assimilate all I have seen, learned and felt. One cannot help but feel an omelet of emotions: gratitude, inadequacy and confusion by the inequalities mortal circumstances provide. I’ve seen it many times before, in different places around the world, and I am always affected the same way.

One of the areas I visited was Lalibela, about an hour’s flight from Addis Ababa. As we began to descend, I could see thousands of small circles grouped in configurations ranging from a half dozen to hundreds. I recognized them as shelters with thatched roofs. From the vantage point of ten thousand feet one could see that they existed over wide expanses of territory, usually with one to three miles between settlements. The groupings were not connected by roads or power lines that typically connect communities. They were isolated and independent from each other.

I picture the young female health extension workers, who work in the area carrying their clinic-in-a-bag. They must walk great distances between each small grouping.

We were met at the airport by Ato Abadi Zemo, the Vice President of the regional government, and representatives of the health ministry within the regional government. As we drove toward the village of Lalibela, a picture of just how remote this area is began to emerge. The acreage that stretched for miles on either side of the road was being cultivated in small plots of about a half acre.

Hundreds of farmers and their families worked the fields. Men walked behind yoked cattle pulling a plow device that consisted of a wood stick (fashioned from the staved branch of a tree) attached to a metal plow shear. Women and children weeded the field typically arranged in a straight line, elbow-to-elbow in a squat that seasoned field workers seem to maintain for hours, with only their feet touching the ground. Periodically herds of goats, cattle and small mules grazed in groups, almost always watched by a child, often five or six years old.

Lalibela is notable within Ethiopia, because, in the 12th Century, Saint Gebre Mesqel Lalibela attempted to build New Jerusalem by chiseling 13 churches out of a solid mountain. It is an awesome feat and is considered one of the wonders of the world. (http://en.wikipedia.org/wiki/Lalibela)

By virtue of the concentration of churches, Lalibela is still a hub of the Ethiopian Orthodox Church. It was my purpose to meet with Memeher Aba Gebereyesus Mekonen, head of Saint Lalibela Churches, and a group of clergyman who work under his leadership to understand the impact the church has at the ground level. I met with Memeher Aba Gebereyesus Mekonen, who had assembled about a hundred clergyman so we could talk. I was honored that they gathered. Apparently my visit came on a day of fasting and they rescheduled their worship services to accommodate the meeting.

Our conversation made clear that the church plays a profound role in the community. Each of the clergy had been trained to counsel their members on the importance of being tested. We talked candidly about the nature of the threat HIV/AIDS presents to their members, their church and the viability of the community. What I witnessed in our meeting confirmed a view I have held for many years. People will respond to requests from those to whom they pay their tithes and offerings, long before they heed the advice of those to whom they pay their taxes. In reality, in this region of Ethiopia, the church is the framework that defines society, not government.

I was struck by how happy the people seemed with their simple life. It seems like such a hard life to me and I am grateful to be sleeping tonight at the Sheraton.

August in Africa- Blog IV

Written August 12, 2008

Today I will write about a remarkable young woman I met in a remote area of Africa. However, I will first describe the context of our meeting.

I asked my friend Tewodrose Adhanom Ghebreyesus, Minister of Health for Ethiopia, to show me the system of Health Extension Workers (HEWs). Our government, through our HIV/AIDS, Malaria and USAID funds, has helped build the system. We need to ensure our money is building capacity for ultimate sustainability and not just creating an endless dependency.

To understand the design of this effort, one must first remember the starting place. This is a nation estimated to have 80 million people. Statistics don’t do the level of poverty justice, but the average annual income is $700, although the majority of people earn less than $100 a year. The entire gross domestic product of the nation is about 80% of the non-entitlement budget of HHS. Vast numbers of the people live in villages where the word remote is inadequate. The average life expectancy of a male is less than 46 years old.

The Prime Minister and Minister Twedorose properly concluded that improved health was a pre-requisite to improved economic vitality. They also concluded that with the resources they had available to them, improving health through normal methods was impossible. They had to build something unique, and they had to start basic. They concluded the first objective was to build a primary health system that was within the reach of every Ethiopian citizen. They created a construct that calls for training 30,000 public health workers known as health extension workers.

HEWs are almost all woman and typically young, generally 18 to 25 years old. The Ethiopian government sought to identify high school educated woman from every area of the country and set up a training course that lasted one year, during which the women were taught to provide a surprising and impressive array of services, and a limited number of medical treatments.

By design, HEWs live in their communities, work in pairs, and cover 1,000 households. Their job is to know the people in their community on a personal enough basis that they are able to teach, persuade and enable the adoption of improved personal health practices in a way that will attack the problem of poor health at the root.

The Ethiopian government has undertaken (again with help from HIV/AIDS money from the United States) to build a series of health centers; one for every 250,000 people. These health centers have the capacity to provide basic curative service and have around 15 beds capable of managing a patient for up to 48 hours. These are typically managed by the equivalent of what we know as physician assistants. When needs go beyond what the health center can manage, they aspire to get patients into a system of larger hospitals.

The Ethiopian government reports considerable progress on fulfilling this vision. They will have recruited and trained 24,000 of the needed 30,000 health workers, for example. They admit to being a little behind on opening new health centers, but the reality is all systems like this have weak spots and break downs, and the goals of starting with prevention and focusing on the basics seem logical and admirable.

The Minister accompanied my delegation, which included Dr. Julie Gerberding and Tim Ziemer, the Coordinator of the President’s Malaria Initiative, to Axum, Ethiopia, a small city on the northern border. Our purpose was to accompany a HEW into homes and watch her work.

In that setting, I met Abrehet Tarekegne, an attractive and smart 20-year-old woman, who has been working since she was 18 years old as a HEW. Together, we visited a family that lived in a dwelling that appeared to be typical to the area. It was made of a collection of materials including mud, stone and straw. The family had seven children ranging in age from late teens to three years old (my estimate). They cultivated the land around them with some corn and wheat. They had some chickens and three cows, which they yoke and use to plow and cultivate their fields. They told me proudly about bees they raise. It is the one crop they have that generates cash. They get the equivalent of $50 per hive. Last year they generated eight hives.

Abrehet told me privately about the conditions in which the family was living when she first visited them two years earlier. There was no separation between themselves and their animals. They had no latrine system, no malaria nets and little idea of personal hygiene. My visit revealed they had rearranged their living quarters to separate the animals, though not as completely as she hoped. The living quarters were small, maybe 14 feet by 14 feet. There were two beds, both with bed nets. They had a latrine system built so that the waste was kept away from the house. She insisted I go inside the latrine to show me the way it worked. It was slightly more information than I wanted, but it demonstrated to me how committed these health workers are. She had a list of over 250 homes she was working with.

I asked how many visits she is able to make. She told me her goal is to spend considerable time with 10 families a week. She said, “I like to spend enough time with each one so that I can make real progress. Sometimes I have to help them do things.”

Two important things to put into context here: First, she walks everywhere she goes and the families often live a long ways apart. Second, all this is on top of the routine other work she does as she moves about. I asked her if she keeps records on her work. She reached into a black bag she carries with her and produced a paper summarizing her work during the past year. During the past 12 months, working on her own, Abrehet has:

• Tested 1,100 people for HIV/AIDS
• Counseled the 9 people who tested positive
• She is currently tracking 105 pregnant woman
• She delivered 7 babies herself
• Trained 152 mothers on breast feeding
• She follows 152 woman with family planning
• Distributed 1,001 vitamin A capsules
• Vaccinated 219 children against tuberculosis
• Distributed more than 3,000 condoms

This was done by a 20-year-old woman walking from home-to-home with a canvas bag as her office.

I asked if the family had been resistant to change. She said, “Almost everybody is, but if you just keep coming back and explaining why it is important, they ultimately begin to change.”

I asked the husband about his reaction to this young woman asking him to change the way he and his family lived. He confessed to the resistance but said, “We knew her for a long time, and also believed it was the right thing.”

Minister Tewodrose told me that choosing the HEWs from the local village is a critical part of the formula. They have relationships they can build on. It was clear to me that Abrehet has begun to develop a fair amount of trust and stature by virtue of the personal service she provides. “What are your aspirations for the future?” I asked her.

“I want to get more education, maybe become a nurse or doctor,” she said. She told me she rarely takes a day off, because the needs are so abundant, but also made clear how satisfying she finds her work.

Abrehet Tarekegne, a Health Extension Worker, demonstrating how she uses one of her tools to listen to Secretary Leavitt’s heartbeat.

The Minister of Health told me they expect HEWs will provide an ongoing source of motivated medical students. He said, “We have told them, if they produce results, we will help them get an education.”

Perhaps one of the most interesting parts of our time together, was when I asked her to open her black bag and show me what was inside. It was a mini clinic. She had vaccines, malaria medication, vitamins, etc.

Abrehet Tarekegne showing Secretary Leavitt supplies she carries on her visits to families.

I have seen public health systems used like this in many other places around the developing world. El Salvador is one recent example (blog on Health Promoters). I find this system to be such a practical and efficient formula to make progress in this incredibly difficult situation.

The health system of the United States deals with a much different set of problems than a developing nation like Ethiopia, and nobody would trade our outcomes for theirs. However, there are things we can and should learn from these systems. One is that basic health care, provided by trained care extenders, in spartan facilities, is vastly superior to nothing and will produce substantial benefit to people.

Physician Conscience Blog III

I have on two previous occasions written in my blog about the principle of health care provider conscience. Federal law is explicit and unwavering in protecting federally funded medical practitioners from being coerced into providing treatments they find morally objectionable. This became a topical matter when the American College of Obstetricians and Gynecologists (ACOG) issued guidelines that could shape board certification requirements and necessitate a doctor to perform abortions to be considered competent.

Physician certification is a powerful instrument. Without it, a doctor cannot practice the specialty. Putting doctors (or any one who assists them) in a position where they are forced to violate their consciences in order to meet a standard of competence violates more than federal law. It violates decency and the core value of personal liberty. Freedom of expression and action are unfit barter for admission to medical employment or training.

As Secretary of Health and Human Services, I called on the organization that oversees Ob-Gyn board certification to alter its guidelines to assert that refusal to violate conscience will not be used to block board certification. Their answer was dodgy and unsatisfying.

Today, HHS will file a rule in the Federal Register aimed at increasing compliance with existing federal laws protecting provider conscience. The proposed rule clarifies that non-discrimination rules apply to institutional health care providers as well as to individual employees working for recipients of certain funds from HHS. It requires recipients of certain HHS funds to certify their compliance with laws protecting provider conscience rights. The HHS Office for Civil Rights is designated as the entity to receive complaints of discrimination addressed by the statute or the proposed regulation.

The proposed rule also charges HHS officials to work with any state or local government or entity that may be violating the law or the proposed rule to encourage voluntary steps to remedy the problem. If they fail to fix the problem, it empowers HHS officials to consider a range of sanctions including termination of funding and the return of funds paid out while they were in violation. The proposed rule is open for comment in the Federal Register for 30 days.

Our nation was built on a foundation of free speech. The first principle of free speech is protected conscience. This proposed rule is a fundamental protection for medical providers to follow theirs.

August in Africa- Blog III

Written August 11, 2008

Today, I had interaction with two fascinating personalities, who likely provide the most important influences on Ethiopia right now. The first was His Holiness Abune Paulos, Patriarch of the Ethiopian Orthodox Tewahedo Church. The second was the Prime Minister Meles Zenawi.

Over the course of my visit, and as I prepared for it, a picture of the influence of religion on the Ethiopian culture has begun to emerge. Since there hasn’t been a census done for many years, I don’t think anybody knows for sure the statistical breakdown, but my sense is the population is nearly evenly divided between Muslim and Christian. The religious breakdown clearly varies from region to region. In Addis Ababa (the capital), for example, one can see evidence of both religions constantly. Life in the city is conducted with a constant back drop of Muslim call to pray and, at the same time, one sees Christian churches everywhere.

What would not be disputed is that the most prominent Christian church is the Ethiopian Orthodox church, and it has roots in Judaism. Apparently, in the 4th century A.D., it was a tradition for Jews to travel to Jerusalem to worship. A certain Jewish eunuch, while there, was converted to Christianity, and upon his return began to convert others. The result was a blend of the two religions. The Ethiopian Orthodox church remains heavily influenced, in its practices and doctrines, from this background. Today, the Ethiopian Orthodox church claims to have a membership in excess of 40 million. It has 30,000 churches and nearly 500,000 clergy.

The Patriarch, His Holiness Abune Paulos, is a man in his early seventies who has studied as an undergraduate at Yale and got his PhD at Princeton. He speaks fluent English and has a sophisticated view of the world. During a period of political turmoil in Ethiopia, he was imprisoned. When I asked him about the impact that period had on him, he acknowledged it was “a hard time,” and then said, “It was a hard time for everyone in our country.” He also referenced how much the experience refined him. He was officially elected as Patriarch in 1992. It is interesting to me how many African leaders have been confined by their opponents at one time or another.

As a Pope-like figure in his church, the Patriarch receives visitors in a fashion that is full of religious dignity. Though he received us warmly by standing and shaking hands with non-members of his church, those who recognize him as their religious leader do not shake hands with him, but rather kiss a crucifix the Patriarch carries. He sits in a courtly setting at the head of the room. He was dressed in flowing white clerical robes, on his head was a prominent white covering. The dialog started off rather formal, but within a few minutes it evolved into a conversation about the future of Ethiopia and an array of subjects.

HHS Secretary Mike Leavitt and His Holiness Abune Paulos, Patriarch of the Ethiopian Orthodox Church

His Holiness spoke of his gratitude for the assistance of the United States. He discussed the role of the church in supporting primary health service delivery and lamented his inability to get resources to all the dioceses of the church at the same time.

I thanked the Patriarch for his support of our HIV/AIDs work and his assistance in reconciling the dilemma people felt between the use of holy water (see previous blog) and antiretroviral treatment. He explained his belief that everything comes from God, including those who have knowledge to make medications. We discussed the need for collaborative problem-solving. He said, “People with good hearts see the poor and sick, and naturally want to do something to help. Those who don’t feel a desire to help are sick themselves.”

We discussed the power that 500,000 clergy, who teach their parishioners to avoid risky behaviors, will have on the future of Ethiopia. He said, “We want to help.” “We are willing to do everything we can.” I saw the power of that commitment played out as I traveled into remote areas of Ethiopia the next day. I’ll talk more about that in tomorrow’s blog.

Following our discussion, we traveled to a hospital run by a church that the U.S. supports with funds from the President’s Emergency Plan for AIDS Relief (PEPFAR). It specializes in tuberculosis patients. More than half of the patients are HIV/AIDS positive. I spent time talking with four patients and hearing about their experiences and the hardships of their disease. The patients expressed appreciation for the drugs they were receiving, acknowledging they owe their continued lives to those drugs.

Like the Patriarch, Prime Minister Meles Zenawi’s life-course was also defined during the political hardship of the 70s. Prime Minister Meles was a student with aspirations to become a doctor. The turmoil became so acute that he had to leave school. He and other university students became persuaded that the military junta that was ruling Ethiopia had to be replaced. They began seeking training from supporters outside the country and planning to force change.

HHS Secretary Mike Leavitt and Prime Minister Meles

After the Prime Minister and I had dispensed with a list of business and diplomatic items on our agenda, like HIV/AIDS; Malaria; the food shortages; and regional politics, I got him talking about the early days of the Tigrai People’s Liberation Front, of which he was a part. It was fascinating. The Prime Minister was 19 years old when all of the turmoil began to unfold. One poignant story he told me was how he was in hiding and his father sought him out to express how deeply worried his parents were about him. “My father said he was sorry I had chosen to engage in activity that would likely end in my death. He asked me to write a letter to my mother expressing my feelings to her.”

I asked him if his mother had lived to see him become Prime Minister. He indicated she had. I inquired about the letter, wondering if she had saved it. What a treasure that would be. He said he doubted she had, because they were routinely harassed by their oppressors, and, if it had been found, such a document would have brought additional hardship.

Over the years I was Governor of Utah, I received numerous diplomatic visitors (mostly ambassadors) from emerging democracies in Africa. I came to admire the sacrifices they had made in the name of freedom. These were the George Washingtons of their countries. They risked their lives leading courageous campaigns against tyrants, despots and dictators, often living for years in jungles and other hiding places, while the course of political change was accomplished. My conversation with the Prime Minister reminded me of those discussions.

I did two other important events during the day. One was a visit to a community garden system that the U.S. supports where HIV/AIDS families are able to raise food and get other help. I also did a diplomatic speech at the Addis Ababa University School of Medicine. This kind of speech is one of my favorite experiences while traveling internationally. I attempt to let the students get acquainted with me personally and to show complete openness with the hope that it will give them a different view of the United States than they are sometimes provided through international media.

August in Africa- Blog II

Today, I met Solomon Zewdu M.D., who is the Country Director of Technical Support for Ethiopian HIV/AIDS initiatives. He is actually on assignment as an employee of Johns Hopkins University.

Mr. Zewdu grew up in Ethiopia, moving to the United States when he was sixteen years old. He went to high school and college in the United States and then qualified for medical school. He joined the military as a doctor and was ultimately drawn to work on HIV/AIDS prevention with responsibility for Asia and South East Asia, at the Department of Defense.

His wife, an accountant by training, is half Ethiopian. The Zewdu’s concluded it was time in their lives to explore how they could use their training and experience in helping the people of Ethiopia. He joined Johns Hopkins University, and the Zewdu’s (along with their son) moved here to devote their efforts to the fight against HIV/AIDS.

(L-R) Rich McKeown, HHS Chief of Staff; Julie Gerberding, M.D., Director of the Centers for Disease Control and Prevention; Secretary Michael Leavitt; Bishop Abune Samuel of the Addis Ababa Diocese Ato Bedellu Ethiopian Orthodox Church Administrator; and Solomon Zewdu, M.D., Country Director of Technical Support for Ethiopian HIV/AIDS Initiative and Disease Prevention and Control Program, Department of International Health, Johns Hopkins University.

Once here, Dr. Zewdu recognized that an alarming percentage of those who started antiretroviral treatment abandon it a short time later. He set out to find out why.

As a young boy in Ethiopia, Dr Zewdu was part of a devoted religious family. He had attended church every Sunday morning with his mother. He understood intuitively the impact that a person’s faith can have on patterns of behavior. He was not surprised to find that religion was having a major impact on the problem of people abandoning treatment.

The Ethiopian Orthodoxy has more than 30 million followers in Ethiopia proper. It has 30,000 monasteries and churches and 400,000 clerics who perform various religious services. It has its own rituals, customs and calendar. One of these rituals and beliefs involves “tsebel,” or holy water, to heal the sick and cast out demons. There are some 80 sites where this water can be obtained. One of the most prominent is Entoto, near Addis Ababa, the capital of Ethiopia.

The water, which comes from a spring on the mountain, is poured onto the patients or drunk as a healing tonic. The region around the spring has become a safe haven for the sick and those looking for spiritual help. Thousands have actually moved to the region, including a large population of people with HIV/AIDS.

Dr. Zewdu discovered that a perception existed by the local population that holy water, a spiritual remedy, and antiretroviral medication, was not compatible. The result was that many patients were told by their clergy that it was wrong to take the medication and they quit. Dr. Zewdu was determined to deal directly with this problem. He made an appointment with the Patriarch Abune Paulos, the head of the Ethiopian Orthodox Church.

Dr. Zewdu’s discussions with the Patriarch resulted in an opportunity to meet with leaders of the church from throughout the country, and he was given a lengthy period of time to teach them about HIV/AIDS. The result, in May of 2007, the Patriarch declared that both remedies were gifts of God, and “they neither contradict nor resist each other” encouraging HIV/AIDS patients to swallow their drugs with the holy water.

The result of that declaration has turned a serious barrier to people having the benefit of antiretroviral treatment into a significant partnership. Every day, thousands of people go to holy water sites seeking their healing powers. Now, with the introduction of clergy, HIV/AIDS workers like Dr. Zewdu are able to address them in mass, educating them to the importance of the medication. Clinics have also been built close-by to take advantage of the powerful draw of these waters.

I visited the Entoto site to help me understand the nature of this arrangement. Dr. Zewdu and I walked together down a path made muddy and slick by the seasonal rains in Ethiopia right now. We met the clergyman who had originated the site and oversees the activities. I viewed the area where the water is drawn from. Adherents carried a liter of the holy water away in small plastic bottles. Others undressed and were showered with the water.

Dr. Zewdu and his family typify a group of devoted human beings who leave the comfort of the United States, live in difficult conditions, and endure significant hardship to improve the lives of people who desperately need help. They have to learn the local conditions and find ways to integrate western medical advantages with local customs.

The key in this situation was to not force a conclusion whether it was faith people have in the holy water, or the antiretroviral medication that produced positive health improvement, but to engage with religious leaders in a way which caused them to cooperate. In this way, both faith and health are enhanced.

Nearly a million people in Ethiopia are HIV positive. Three years ago, only 900 people were being treated with public money. Today it is more than 150,000. I will talk more tomorrow about the general health conditions in Ethiopia.

August in Africa- Blog I

I will be spending the next several days in Africa, visiting Ethiopia, Mali and Cote d’Ivoire. My primary purpose of the trip is to look, first hand, at the way our HIV/AIDS money is being spent. I will also be giving some diplomacy speeches and meeting with officials of the government and civil society in each country. I am joined on the trip by Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, and Admiral Tim Ziemer, who heads the President’s Malaria Initiative.

Our travel plan included a stop overnight in the Azores. These are nine small islands populated by about 250,000 people and located about 900 miles off the coast of Portugal. It is a charming place. During our approach to land at Lajes Field, a base operated jointly by the United States and Portugal, you could see miles of stone hedges separating fields. The hedges are built as a practical means of subdividing the land, and are also a way to use the rocks gathered from the fields, making the fields easier to cultivate. Hedge-building must be an art-form passed from generation to generation. The hedges are remarkably sturdy, yet built without mortar.

The visit to the Azores turned out to be an unexpected bonus to the trip. It is always gratifying to see the U.S. military at work. Colonel Jack Briggs is the Wing commander and senior U.S. officer. There are about 1,000 U.S. personnel and the same number from Portugal who operate the facility.

The base has four primary purposes: facilitating equipment that is being shipped to and from the United States and various theaters (the base is a giant gas station for planes), maintaining the global communications gear necessary to communicate while in the region, training and readiness of troops, and finally enhancing the relationship with Portugal.

We were hosted for dinner by Colonel Briggs’ team and the two most senior Portuguese officers on the base. The dinner illustrated the unique nature of the working relationship between our two nations on the base. In the small world category, the Vice Commander on the U.S. side, Colonel Paul Suarez, was the brother of a former colleague of mine at the Environmental Protection Agency.

After dinner, we drove to a town just a few miles away and walked through a festival that reminded me a lot of a county fair in the United States, except everybody spoke Portuguese. Aside from the somewhat isolated nature of the Azores, it seemed like a peaceful and graceful place to live.

Physician Conscience Blog II

I’m delighted to announce that with the help of Planned Parenthood, my blog -- for the first time -- received more visits than my teenage son’s MySpace page. Perhaps I’ll address the subject of physician conscience one more time.

Having served as Governor for 11 years and now in my fifth year as a member of the President’s Cabinet, the debate over abortion is not a new one to me. I was not surprised by the more than 850 comments. Consistent with the comment policy, we will post all but about 25 which violated our rules because they contained what the reviewers described to me as “profane language or personal attacks on your body parts, religion or family.” This is part of an ongoing debate in our country and there isn’t much new.

One thing I did find helpful was the clear explanation of the ideological basis of opposition to physician conscience. Mary Jane Gallagher, President of the National Family planning and Reproductive Health Association, was quoted in Congressional Quarterly’s HealthBeat saying,

“Family planning providers work to provide family planning services. So it’s really not acceptable to the people I represent that this administration is considering allowing doctors and nurses and pharmacists that have received their education to provide services to now be able to not provide those services if they don’t want to.”

“Who’s going to provide access to contraceptives services if the administration provides this large loophole to deny services?"

CQ reported Ms. Gallagher continued: “Providers are ‘given an oath—now they get to pick and choose what they want to do' if a regulation is issued, she said.”

So, according to Ms. Gallagher’s ideology, if a person goes to medical school they lose their right of conscience. Freedom of expression and action is surrendered with the issuance of a medical degree.

There is something I’d like to point out to Ms Gallagher and the people she represents. It is currently a violation of three separate federal laws to compel medical practitioners to perform a procedure that violates their conscience.

Obviously, some disagree with the federal law and would have it otherwise, so they have begun using the accreditation standards of physician professional organizations to define the exercise of conscience unprofessional and thereby make doctors choose between their capacity to practice in good standing and their right of conscience. In my view, that is simply unfair and a clear effort to subvert the law in favor of their ideology.

This is not a discussion about the rights of a woman to get an abortion. The courts have long ago identified that right and continue to define its limits. This regulation would not be aimed at changing or redefining any of that. This is about the right of a doctor to not participate if he or she chooses for reasons they consider a matter of conscience. Does the National Family Planning and Reproductive Health Association believe we can protect by Constitution, statute and practice rights of free speech, race, religion, and abortion—but not conscience?

Is the fear here that so many doctors will refuse that it will somehow make it difficult for a woman to get an abortion? That hasn’t happened, but what if it did? Wouldn’t that be an important and legitimate social statement?

I want to reiterate. If the Department of Health and Human Services issues a regulation on this matter, it will aim at one thing, protecting the right of conscience of those who practice medicine. From what I’ve read the last few days, there’s a serious need for it.

Physician Conscience

Several months ago, I became aware that certain medical specialty certification groups were adopting requirements which potentially violate a physician's right to choose whether he or she performs abortion. I wrote to the organizations in question, protesting their actions.  Frankly, I found their response to be dodgy and unsatisfying. I sent another letter, more of the same.

Not only are there clear provisions in three separate laws protecting federally-funded health care providers' right of conscience, but doing otherwise undermines the most fundamental moral underpinning of freedom of expression and action. I asked that regulations be drafted which would enforce these long-standing laws protecting a medical practitioner's conscience rights.

An early draft of the regulations found its way into public circulation before it had reached my review. It contained words that lead some to conclude my intent is to deal with the subject of contraceptives, somehow defining them as abortion. Not true.

The Bush Administration has consistently supported the unborn. However, the issue I asked to be addressed in this regulation is not abortion or contraceptives, but the legal right medical practitioners have to practice according to their conscience and patients should be able to choose a doctor who has beliefs like his or hers.

The Department is still contemplating if it will issue a regulation or not. If it does, it will be directly focused on the protection of practitioner conscience.

Many have provided comments on this subject and they will all be included under this posting.

Alaska Blog V- Kwethluk and Questions I Learned There

I had flown about an hour by jet from Anchorage to Bethel, Alaska. From there, I rode in a boat for about 30 minutes to the village of Kwethluk, population 900. In the summer, boat is the only way to get there, other than using the dirt landing strip that exists at many remote villages. In the winter, the river is frozen enough that a road is plowed on the ice for cars to drive on.

At the bank of the river, Herman Evan met me. He is the 55 year-old Tribal Administrator. He grew up in Kwethluk and lived nearly 20 years in the lower 48 states, working at what he said to be low paying menial jobs in Kansas and Oklahoma. He had a family, and they are still in the lower 48 states. The way he referenced them made clear there’s an interesting story there, but it seemed too personal for the first time two people meet. I left it alone, registering the information as part of the puzzle I was working to assemble, so I could get to know Herman.

Herman is an intuitive, smart man. While he was in the lower 48 states, he observed a lot of things. One was the transformation a few Tribal nations made with the economic base that gambling and other pursuits have provided. Another observation was the power of education. Again, I don’t know the story, but somehow Herman got a Bachelors Degree. The education shows up in Herman’s vocabulary and the sophisticated thoughts he has about trying to build a community out of this tiny, desperately poor island on a river in Alaska.

“Why did you come back, Herman,” I asked?

“It’s home,” he said. “I wanted to make the place better.”

The village can afford to pay him only half-time, but he works all day. “Some people probably think I’m an oddball,” Herman said, as he described his habit of getting up before six o’clock in the morning to walk around town.

Herman Evans and Secretary Leavitt in Kwethluk, Alaska

Herman led me to a wood building they assembled from scrap lumber. I was met by members of the council. A woman, whose name I didn’t catch, but who I instantly liked, said to me, “We’ve been waiting nearly an hour for you, and my butt is sore.”

A previous meeting and traveling had put us behind.

To ease the tension she had intentionally created, I joked with her. “We did, and I am sorry. I can do better on being late, but there isn’t much I can do for that sore backside.” As we walked into the building, I continued and jokingly said, “Probably not much you’d want me to do.” A reporter from the Tundra Drums heard me and included it in his story. It was a reminder to me that you’re always on the record.

The building appeared to be the community building. It doubled as the bingo parlor. A couple of single bulb lights provided light in the place, but a fully electric bingo board hung on the back wall.

Our conversation was unusually direct. Several of the Council members had assembled. Herman diplomatically asked each one to talk.

The head of the Tribal government’s social services talked about how difficult it is to protect children from abuse in homes that are isolated. They have limited resources.

The village manager talked about the need for a sewer system. I was about to get a more graphic view of the subject later in my visit. He said, “We are citizens of the United States and residents of Alaska. We deserve to have running water and sewer that is up to par with other citizens.”

The head of law enforcement talked about how hard it is to respond to those who need help, especially in the winter when there are no roads.

The woman who had greeted me at the door said, “Important people come here, they take notes, and then leave; nothing happens to change things.” She was frustrated and spoke plainly about it.

After listening to each of the community leaders, I wanted to make sure they had proper expectations. I told them I did not come with a checkbook to solve all these problems. I had come to learn, so that when budget decisions about Alaska and Tribal health are made, my views are populated by ground truth. They seemed to appreciate my candor in the same way I had valued theirs.

If I was looking for “ground truth,” I got it as Herman and I left the community building for a walking tour of Kwethluk. Americans would be surprised to know there are citizens of the United States living in that kind of poverty. I saw a well-equipped health clinic, a new Head Start building, a Post Office and a new law enforcement building. However, everything else was consistent with the desperate poverty that engulfs that area.

As we walked among the houses, I saw a metal canister at each home that families use to pour their sewage in. Periodically, the “honey buckets” are picked up and carried to a “sewage lagoon,” which is really no lagoon at all, but more of a hole filled with human waste, sitting in the open. It was simply unbelievable.

The problem: It would cost nearly $30 million to complete a sewer system. Even if state or federal dollars were used, a community of 900 people who are desperately poor cannot support its operation and maintenance.

The day left me confronted by so many questions to think about. For example: does citizenship entitle one to have sewer and water no matter what the cost; or is there a point where people have to choose to live without these centralized services or move somewhere they are provided? What are the respective roles of the state government and federal government?

There were other less institutional questions: what is it that causes people to stay there? Why did Herman Evans come back? Herman partially answered that one for me. He said, “I am happiest when I’m doing things to make life better for people. Perhaps, I’m an oddball (one of his favorite phrases) but I think we can make this a better place to live.”

Home is where the heart is.

Alaska Blog IV- Bethel and the McCann Inhalant Abuse Treatment Center

About an hour flight west from Anchorage is the community of Bethel. It has a population of around 5,000 people and serves as a transportation and communication hub of the Yukon-Kuskowim river delta area. It is also the headquarters of Yukon Kuskokwim-Health Corporation (YKHC), another Alaska Native tribal health organization. It is similar in character and mission to the SEARHC, which I have previously described. It is perhaps twice the size of SEARHC and provides a broader array of health-related services. For example, they provide assistance to communities on water and sewer problems. Their CEO, Gene Peltola, is an impressive executive. Spending a day with him makes clear that he sees his mission as building communities, not just a medical organization.

I visited with Gene and several other community leaders at a YKHC facility on the outskirts of Bethel called the McCann Treatment Center. The building houses a truly unique program for boys and girls that have become addicted to inhaling substances. This program responds to what is truly a terrible problem. In many remote parts of Alaska, people, desperate to escape their lives, seek intoxication by inhaling gasoline, glue, aerosols or any number of other household products with ingredients capable of producing such an effect. These toxic products are used as a substitute for alcohol or other drugs, which are both expensive and not as readily available to youth in remote Alaska.

The existence of this problem is symptomatic of an epidemic of suicide in Alaska. In the Yukon-Kuskokwim delta, 13% of all deaths are from suicide. This is over four times the national average.

This little Center serves the entire state of Alaska and is perhaps unique countrywide. The population of patients is boys and girls under 18 years old. By my observation, the average age is much lower than 18. The director said that the population of residents continues to represent more and more severe problems coming at younger and younger ages.

I briefly attended two classes where I had a chance to meet the students. I want to be very careful not to compromise anybody’s privacy in the way I describe this, so I will just say it broke my heart. Seeing 14 to 16 year-old boys (there were not girls enrolled during my visit) who have clearly affected their long-term cognitive outlook was painful. Although I know they are getting help to move forward in a better way, the damage is already significant and there are many more who are not being served.

In a direct way, the scene paints a picture so many children in remote Alaska face. Alcoholism is everywhere. I’m told incest and other forms of abuse are prevalent. Children looking for an escape inhale toxic substances for relief and become hopelessly addicted.

One of the workers told me of a conversation she had with a young boy who said he couldn’t stay away from inhalants. His words, as she reported them, were poignant. “When I think about it,” he said, “I am like metal to a magnet.”

The Center is named the McCann Treatment Center after a man who stood in a town meeting with then Senator Frank Murkowski and, in desperation, pleaded for help with his grandson. The Senator knew there were thousands more like him and sought money to build the Center. It serves the few well, but the many continue in their quiet desperation, too many of them ending up as part of the 13% suicide rate.

Once the brain has been damaged by inhalation it is permanent. However, they can prevent further damage and prevent premature deaths. The students are provided with a small-class-size environment, and taught skills consistent with the subsistence lifestyle they live in their villages. For example, they have a fishing camp where they are taught to catch, process and dry fish.

I asked Jamie, the director of the Center, if the boys have trouble at that age being away from home for that long (the program can be as long as two years). He said that some of them struggle at first, but over time they begin to trust and open up. “They begin talking about the issues that motivated their destructive behavior in the first place. Watching them go through it is hard, but I love every one of these boys and I’m committed to helping them as best we can.”

Alaska Blog III- Mental Health Treatment in Remote Alaska

Imagine you are a woman with two small children living in a remote Alaskan village of 300 people. Winters are harsh, long and dark. You love your husband, but he is often abusive physically and psychologically.

The combination of hardships and some personal tendencies have caused you to turn to alcohol. You are beginning to suffer bouts of depression. Talking with others about the feelings of suicide has become frequent in your head, but you dare not say anything to those around you. Where do you turn? Getting to a doctor requires an hour by plane or eight hours by ferry.

While I was in Juneau, Alaska this week, I took a short walk from the offices of Southeast Alaska Regional Health Consortium (SEARHC) to a small mental health annex for a private conversation with a patient whose personal circumstances were not identical to what I just posed, but close enough. We talked alone for 20 minutes. She was candid about her situation, and I will honor her privacy by not changing the facts and not mentioning anything about where she lives.

Our conversation took place over a new videoconferencing system that is being extended into villages across Alaska. I have used videoconferencing equipment many times before. This was arranged in a way that made the interaction seem quite natural. The video was close up and we could see one another’s eyes and facial expressions. I finished the encounter feeling like I knew her personally. Granted, it is less than ideal but it is a huge step forward.

SEARHC behavioral health providers Rand West, Clinic II Director, and Carolyn Lemmon, Acting Director of Community Family Services Program, talk with Secretary Leavitt over a videoconferencing system.

This patient told me one thing that I think is particularly significant. She said, “In a small village like where I live, it is impossible to talk with anybody without others knowing your problems. Being able to do that this way, gives me the comfort I need to feel safe.”

The mental health problems of remote communities are unique and intense. The videoconferencing system is a great tool. We can find ways of using this technology to provide assistance in underserved areas.

Alaska Blog II- Yakutat Tingit Clinic

The sign on the outside of the airport building said, “Food, Shelter and Booze.” Before leaving to visit the Yakutat Tingit Tribe’s clinic, I told the pilots of our plane I would be gone a few hours and suggested they step inside for two of the three featured amenities.

It was a drizzly afternoon, but life in Alaska just carries on. This was July and the weather was good, during which not an hour can be spared as they get ready for winter. Twenty hours of daylight helps, but knowing winter comes soon keeps people moving.

Yakutat is has a population of about 900 right now. A few years ago it was over a thousand. Victoria Demmert, President of the Yakutat Tlingit Tribe, explained as she drove us on their only oiled road, that when the timber industry went flat, some were forced to leave.

Yakutut is considered a larger village by comparison to most in Alaska. I’m guessing they are one of the villages that are better off. I drove past a fish plant where locals are able to bring their fish for processing before the fish are flown to Seattle on Alaska Airlines, which stops regularly. Still, government jobs are the biggest source of employment.

At the clinic, I met Leslie Jones, the Director of the Clinic. She introduced me to Dr. John Bacicocco, who actually lives in Sitka, Alaska but travels as an Itinerant doctor, visiting Yakutat about one week every three months to do face-to-face patient visits. The rest of the time, health care in Yakutat is provided through two Community Health Aides, Mina Adams and Becky Nickles. Each has completed a four-part training and certification process and they essentially operate as extensions of Dr. Baccicocco.

Mina and Becky operate using a book of medical protocols called the Community Health Aide Manual. It is a brilliantly constructed instruction manual that provides diagnosis and treatment algorithms, and tells them when to call the doctor for further instructions. They have the equipment to provide Dr. Bacicocco with information he needs to treat the more serious cases. They are his hands, eyes and ears. It’s less than ideal, but when your doctor is an hour away by air, living in a village of less than a thousand, it’s the best you’re going to get and much better than most of the remote world gets.

The big news in Yakutut health care for the coming year is the extension of basic dental services in the clinic. I met 21 year old Sheena Nelson, who is finishing a two-year dental training in Anchorage. In a few months she will return to her village as a dental health therapist. She will occupy a small dental operatory inside the clinic. Like Becky and Mina, the health aides, she will work as an extension of a dentist who resides in Sitka. She is being trained to provide oral health education and prevention, fill teeth and perform basic dental repairs. Once a procedure gets to a level of sophistication requiring a dentist, her job will be to stabilize the patient until the additional treatment can be arranged, often weeks later.

Sheena Nelson talks with Secretary Leavitt about her training to become a dental health therapist.

Sheena’s story appears to be fairly typical. She was considered one of the more serious and able students at her high school in Yakatut, but wanted to stay in the area and took employment as a waitress. When the Yakatut clinic was provided a slot for a dental health therapist, she was nominated and, after a series of interviews, selected. She will now return with a job that will dramatically enhance the quality of life in Yakatut, and she has a job that will pay $18 an hour.

Understandably, this program has been enormously controversial among the dental community in Alaska and elsewhere around the country. On more than one occasion, dental professionals have come to express genuine concern about people with only two years of training filling teeth and performing other non-reversible procedures. This visit confirmed my instinct and previous expressions to the dentists. The Professionals aren’t willing to live there and this is giant step ahead from no care at all.

While I was in Central America visiting with health ministers from that region, they expressed a desperate need for this kind of help. The alternative there is a family member using a pair of needle-nosed pliers to provide relief.

After my visit at the clinic, I was treated to a delightful community gathering where villagers, both young and old performed, in colorful native regalia. The dances they perform preserve the stories of their culture and history.

Yakutat villagers dancing in native regalia.

It was a valuable insight into the importance of family and community in surviving the brutal conditions of remote Alaska. Not only do they survive, most find happiness there.

Alaska Blog 1- Gumboot Determination

Along streambeds in Alaska, the Gumboot, a small black snail like creature, attaches itself to rocks and clings with the might of superglue. To Alaska Natives, Gumboot is a delicacy worth the considerable effort it takes to pry it off the rocks. The Gumboot hangs on with determination.

When Ethel Lund, a woman of small stature in Juneau and a group of other tribal leaders (mostly women), decided the region needed better health care they knew it would require tenacity. The tiny Gumboot became their inspiration.

For thirty years, they stuck to the task with Gumboot determination. The result of their efforts is the Southeast Alaska Regional Health Consortium (SEARHC), an Alaska Native health organization which now has 700 employees and provides care to thousands of Alaska residents who belong to 18 different tribes.

I met Ethel Lund and several others when I visited them in Juneau to learn about the unique challenge of getting health care to the tens of thousands, mostly tribal members, who live in hundreds of villages throughout Alaska. They have written the history of SEARHC in a volume appropriately titled Gumboot Determination.

The history tells of SEARHC’s formation in 1975 as a non-profit tribal health consortium of 18 Native communities throughout Southeast Alaska. It was one of the first organized under the Indian Self-Determination and Education Assistance Act, which allows the Indian Health Service to turn programs and facilities over to tribal management.

I have come to admire community health organizations. Each has a story. Rarely were they formed by government. Typically, like SEARHC it was a group of people getting together to help others. Nearly all of them have something in common. Developed by dedicated people who didn’t know what they were getting themselves into when they started but through Gumboot determination, they got it done.

SEARHC operates under a board selected by tribal leaders in each of the communities served. They appear to be moving aggressively into use of technology. Roald Helgesen, the President and CEO, told me they were at the early stage of implementing a comprehensive electronic medical record system. This makes a lot of sense given their treatment model. They are treating through Community Health Aides/Practitioners, people in many different parts of the region. (I plan to write about this model tomorrow.)

Leadership team for SEARHC with Secretary Leavitt
CLOCKWISE FROM TOP: Mark Gorman, Vice President, Community Health Services, SEARHC; Andy Jimmie, Chairman, Alaska Native Health Board; Bill Martin, President, Central Council Tlingit Haida Indian Tribes; Roald Helgesen, President/CEO, SEARHC; Norman Sarabia, Vice President, Douglas Indian Association; Jan Hill, Chairperson of the Board, SEARHC; Ethel Lund, President Emeritus, SEARHC (with red jacket and white blouse); Doloresa Cadiente, President, Tlingit and Haida Indians of Juneau; MOL; Chris Mandregan, Acting Deputy Director, Indian Health Service, DHHS; Ken Truitt, General Counsel, SEARHC.
CENTER: Janis Sheufelt, Medical Director, Ethel Lund Medical Center, SEARHC.

I also learned about their deployment of a remote pharmacy program. Using a device that resembles a large soft drink vending machine, prescription drugs can be dispensed in remote areas. The drugs are pre-packaged. The patient punches prescription number and other information. The information is vetted three times before it is released by a licensed pharmacist remotely, who talks to the patient on the phone. There were other innovations I will write about later in the week many of which, I think could/should be used to make health care delivery more efficient in less remote medical settings.

Safety at the Speed of Life- Blog 7

Last week, I began a blog series on the importance of building safety into our global trade processes. I discussed the scope of our trading in the global markets, our response to the need for new tools and strategies and the importance of collaboration in implementing these new strategies. I would like to close this series by sharing one more story about safety, speed, and Olympic athletes. This one is a tale of devotion to the safety of our country and sheer speed on ice. It is about a true hero of the 2002 Olympic Winter Games — Derek Parra, a Mexican-American speed skater from San Bernardino, California.

Prior to the Games, Derek was an employee at Home Depot working in the flooring and electrical department. He is a regular guy who at the time would eat Fig Newtons the night before each race.

This regular guy represented our country during the 2002 Games in two monumental ways. In the opening ceremony, Parra was chosen as one of eight U.S. athletes who carried in the tattered flag that flew over the World Trade Center. In his book, Reflections on Ice, he wrote about this experience. Let me include an excerpt:

When it came time to begin the procession I touched the flag for the first time and felt a physical sensation unlike anything I had ever experienced. If it is possible to feel your soul being touched that is what I felt. As we carried the flag out before the capacity crowd and worldwide television audience the silence was deafening. I’ve never before heard such stillness. I was some place emotionally I had never been before; some place spiritually I didn’t know existed. While in this instance that flag represented so much death, it seemed also to stand for life, love and the hope of a nation.

I was there and he is right.

Powerful words about the safety of our homeland from a great Olympian.

A few days later, Parra fulfilled the hope of a nation by demonstrating that nice guys do finish first. He had a breathtaking and world-record-setting performance in the 1,500-meter race. In a stunning time of 1 minute 43.95 seconds, he bested the favorite skater from the Netherlands and captured gold for the United States.

Derek Parra carrying United States flag.

After winning the race Parra said, “You give up so much, hoping for a moment like this, and it happens.”

He skated the perfect race. He embraced safety, mastered the ice, and skated at the speed of life. His fleet power made him at that moment the best in the world … ever.

In the next 12 to 24 months something far more significant than an Olympic gold medal is at stake. It is the future of product safety in the United States. There are two competing and divergent philosophies ready for battle. This battle is not entirely about safety; it is a surrogate battle about U.S. philosophy on trade.

I believe that opening world markets has brought enormous benefits to consumers — lower prices, greater variety, and more choice. We will achieve safety and speed by harnessing the power of consumers who rapidly and harshly punish those who produce poor products. The game plan is to develop high, science-based standards, demand absolute transparency, reward independent certification, and rigorously enforce high-risk products.

Others would have government inspect everything. They want to stop products at the border and increase point-of-entry government inspection. Not only does such a course mean higher costs and taxes, it means consumers would be denied timely access to an abundance of safe products at lower prices. Frankly, underneath their government-centric view lurks the spirit of protectionism and the illusion that they can use the inspection process to slow or reverse global trade.

If you care about the future of the United States in the global market, you have to weigh in here. Now is the time. This is the medal round.

In a global market there are three ways to approach change: You can fight it and fail; you can accept it and survive; or you can lead it and prosper.

We are the United States of America; let us lead.

Safety at the Speed of Life- Blog 6

I mentioned at the end of my previous post in this series on import safety that FDA’s role in global trade will be changing. FDA’s work is often underappreciated in this country. Nations around the world recognize FDA as the “gold standard” when it comes to food and drug safety. Under Commissioner Andrew C. von Eschenbach’s leadership, FDA is building on that “gold standard” by reaching out to new frontiers and globalizing the FDA.

FDA is opening an office in China with staff in three cities: Beijing, Shanghai, and Guangzhou. We are currently negotiating to do the same in India, with plans for additional FDA offices in multiple areas of Latin American, Europe, and the Middle East.

And we are changing how we do business. The traditional role of FDA as approver stands strong. How and where we do that is undergoing change.

The origin of all product standards, certification and inspection of goods does not need to start with FDA; it can start with the industry and in other countries as it did with shrimp.

This is a fundamental shift in government’s role. The 21st century role of FDA is as convener and arbiter as well as verifier and enforcer.

Will FDA be an aggressive enforcement entity? Yes. In fact, FDA’s enforcement resources will be better funded and more focused on the producers who have not demonstrated trustworthiness.

Will FDA be adopting safety standards as a regulator? Yes. But we will encourage industry to collaboratively develop standards for FDA to review. If they don’t meet the scientific rigor, we won’t accept them until they do.

While the United States is the largest economic player in the food and drug market, there are other nations with excellent systems in which we have great confidence. In the past, each nation has conducted separate inspections. The result is great redundancy as several countries inspect the same plant — for essentially the same things, while too much time lapses between visits.

We are going to change that.

I announced recently a policy initiative where FDA will work more closely with foreign regulators who have systems of inspection and regulation we trust. The principle will be collaborative information gathering, individual decision making.

As part of that effort, FDA has initiated a pilot project with our colleagues in the European Union and Australia to jointly plan, allocate, and conduct international pharmaceutical inspections. This will begin with inspections of active pharmaceutical ingredient manufacturing. These are the “starting products” of many of the medicines we all use.

Through this new collaboration, FDA and these trusted colleagues can spread our inspection net wider by leveraging our respective resources. We will be inspecting some, the Australians others, the European Union still others. We will then share information. This just makes good sense. Facilities will be inspected more often and we can all focus more resources on those products that present higher risk.

This is a very exciting vision: common standards, common certification, and shared inspections. Safer products. Lower costs.

Finally, we need the private sector to step up big-time to initiate, lead, and participate in the development of consensus-based standards and independent certification. You have a responsibility to your consumers and to the integrity of your industry.

I will conclude this series in my next entry, sharing my final thoughts on how, together, we have a unique opportunity to influence the future of product safety.

Safety at the Speed of Life- Blog 5

In my previous post in the series I began last week on the safety of imported products, I brought up the importance of collaborative skills in solving complex problems and working on global issues. In my 16 years of public service, every significant step of meaningful progress has come as a result of collaboration.

Collaboration does not eliminate tensions, but it minimizes them.

Collaboration does not take away hard choices, but it improves the acceptance of the decisions made.

Collaboration does not create instant success, but it has accelerated progress.

In the context of product safety, collaboration will not only be necessary for developing product standards, but in implementing many other parts of the plan as well.

Governments must collaborate with governments. Departments within governments — law enforcement, trade, border security and health agencies, for example — must collaborate with each other. Even competitors must cooperate in some circumstances.

And, in my judgment, a collaborative spirit, skill set, and commitment is a pre-requisite for leadership and success in the 21st century global marketplace.

When we presented our import safety plan to the President, I told him it would require additional money. The President committed to seeking additional funding. Congress has made a down payment that will support crucial steps, including expanding FDA’s international presence and improving its scientific and information technology infrastructure. But it will require sustained investment over the next several years to achieve long-term import safety.

Legislative action is also needed.

We need Congress to provide the FDA with authority to mandate third-party certification in certain high-risk categories when voluntary measures aren’t working.

Having laid out a long-term vision and strategy, I want to acknowledge that changes of this magnitude take time. Solutions take time to implement. But we have to keep steady pressure on the change pedal.

In the limited time left in this Administration, there are several things I plan to complete.

In the United States, our biggest trading partners are now Canada, China, and Mexico, in that order. Chinese products made up about one-sixth of all U.S. imports. Recognizing that, we have signed and begun to implement two landmark Memoranda of Agreement with the Chinese government: one concerning food and feed, and the other, drugs and medical devices.

These strong, action-oriented documents call for specific steps and set clear deadlines for achieving them. Once implemented, they will enhance the safety of scores of items the American people consume on a daily basis.

We recently signed a Memorandum of Understanding with the Vietnamese government. We are working with Indian authorities to support their pharmaceutical regulatory priorities. We have committed to share information and collaborate with our Mexican and Canadian partners on food and drug recalls. And we are developing an agreement with Central American governments that will improve product safety for consumers in the U.S. and abroad.

The role of FDA will change in regard to the issue of import safety. I will explain my vision for this role in more detail in my next entry.

Safety at the Speed of Life- Blog 4

As a continuation of my blog series on the safety of our product imports, I want to illustrate the change in our basic strategy by talking about the shrimp business. I was in Vietnam and Central America recently— both are big producers and exporters of shrimp. I met with representatives of the shrimp industry in both places.

We talked about the impact on their product when a shipment gets detained at our border. Delays create huge costs and often disrupt or even close affected businesses.

Members of the shrimp industry independently decided that they needed to develop a set of quality and safety standards, and a way to verify compliance with those standards. They did this because their consumers needed to know that their products were safe and of high quality. They developed a formal, voluntary collaboration that produced a set of industry standards and certification process.

A centerpiece of our new strategy is to encourage, leverage, and build upon such voluntary third-party efforts. We are not inventing a new concept. It already exists. And it works.

We observed independent certification being used in many sectors of the import world. Until now, we have not integrated this capacity for improvement into our regulatory responsibility. This needs to be a government-wide strategy; ultimately, it should apply to all product lines.

Since FDA has responsibility for the safety of a significant share of our imports, I would like to outline the way we are transforming the Food and Drug Administration to harness the power of this new vision.

In the future, products from those firms that have standards and certification processes that we trust will be given expedited entry and access to U.S. consumers. The FDA will be freed to focus its enforcement resources on those suppliers that don’t have certified products. FDA is establishing a pilot with the shrimp industry to help learn how to evaluate third-party certification programs, and implement them in the field.

So we are saying clearly: “We want you to have access to American consumer markets — we want to have access to yours. To do so, you need to meet American standards of quality and safety. If you can demonstrate through a process we trust, that your products meet the safety standards that we have mutually agreed upon, we’ll be your partners in speed.”

Can you see the linkage that connects speed and safety?

Speed is accomplished when trust has been established. Trust happens only with complete transparency. Transparency requires standards, and standards require collaboration.

This is a key point — a change born of the global market — collaboration is the new frontier of human productivity. I believe learning better collaborative skills is a requirement for success in this century. It is a proven method of solving complex problems, and it’s hard work. I want to write more about the importance of collaboration with other governments around safety in a global market, and I will pick up here in my next entry.

Safety at the Speed of Life- Blog 3

I ended my last post in this series by introducing the need to develop new tools and strategies to ensure the safety of the products we import for American consumers.

A year ago, President Bush directed a working group of his Cabinet to conduct a comprehensive review of our import safety practices. He appointed me Chair. Our review involved teams from throughout the federal government, with extensive help from the private sector. We conducted the most complete policy review ever on this subject by our government.

In my role as Chair, I visited ports and post offices, freight hubs and fruit stands, supermarkets and seaports. I listened, probed, toured, and took in the totality of America’s import system.

I met with leaders from India, Vietnam, People’s Republic of China, Australia, Mexico, Canada, El Salvador, Costa Rica, Panama, Nicaragua, Guatemala, Honduras, Singapore, the largest economies of the European Union and the European Commission to discuss import safety.

The scale and complexity of global commerce amazed me. So did the need for change. We provided a comprehensive report to the President; the most important thing we said was this:

Mr. President,

We have a good system of product safety today, but it is not adequate for the future and we need a fundamental change in our strategy.

In the past we have stood at our borders attempting to apprehend products that don’t meet our expectations.

We cannot inspect our way to product safety without bringing trade to a standstill. Our new strategy must be to extend our borders and ensure that quality and safety are built into the products we import.

We will do this by rewarding producers that have products certified to meet our standards. Their goods will receive expedited entry into our country.

We will make clear to those who don’t that they can expect enhanced scrutiny.

You can read the report and the 50 specific recommendations we made at importsafety.gov. They are important, but the real transformation comes from the change in our basic strategy. I will share an example in my next entry of how a change in strategy can improve safety.

Safety at the Speed of Life- Blog 2

Yesterday, I began a blog series on the need to ensure the safety of imported products as global commerce expands the volume of imported products Americans enjoy.

This opening of world markets has brought enormous benefits to consumers: lower prices, greater variety, and more choice. Nowhere is this more evident than in the produce industry.

I met a produce manager named Dan in Detroit. I can remember his name because he told me he was “Dan the produce man.” He has been in the grocery business for three decades.

I asked him what has been the most significant change he has seen. He immediately responded with four words, “It’s what consumers want.”

It used to be a big deal each year when fresh peaches arrived. They would put up signs and place ads in the local paper. Not anymore.

Now he sells peaches almost every month of the year. During the winter, plums, nectarines, and grapes pour into this country from Latin America. We eat big, bright red strawberries in January without a second thought.

Americans walk into almost any produce department in the country and purchase what used to be seasonal items, at a reasonable price, any time of the year. It is the speed of life — our lives, our demands on an ever-growing global market.

It’s anything, anywhere, anytime.

My point is that as long as Americans want to enjoy fresh produce from around the world, buy needed medicines, wear low-cost clothing, drive foreign-made cars, use electronic products designed and built off our shores, purchase affordable furniture, and otherwise participate in the bounties of a global economy, our import system will become increasingly complex.

This is the value of global trade. The challenges we face are the result of a global market beginning to mature. Last year, the United States imported more than $2 trillion worth of products, an amount that exceeds the entire gross domestic product of France. This is approximately $6,500 for every man, woman, and child in the U.S.

These products were brought into the United States by more than 800,000 importers, through over 300 ports-of-entry. All projections indicate that this volume will continue to skyrocket over the coming years.

Just as the volume of trade has changed, so must the strategies to regulate safety. Simply scaling up our current inspection strategy will not work. This is not a problem unique to the United States. It is a fundamental challenge for all nations. We need to develop new tools and strategies equal to the new challenges we face. In my next post, I will share what we have done over the past year to assess and improve our strategy to ensure import safety.

Safety at the Speed of Life- Blog 1

Next month, the world will gather for the 29th Olympiad in Beijing, China. Those who participate and watch these games will be a part of the largest, most extraordinary collaboration of nationhood and humanity that exists in our world today.

Three out of every five people on the planet will watch as athletes from 200 countries join in this peaceful celebration of sport and personal achievement. It is a marvelous moment for mankind and a force for good in our world.

During my service as Governor of Utah, I witnessed, in a powerful way, the effort, strength, sheer talent, beauty, and grace of Olympic athletes. The setting was the 2002 Olympic Winter Games in Salt Lake City. It was the first major world gathering after September 11th.

The Olympic motto is three Latin words — “Citius, Altius, Fortius” — which mean “Faster, Higher, Stronger.” These words capture the spirit of the Olympic movement, a movement that dares people to break records and to achieve their personal best.

The first of the words in the Olympic motto has particular importance to the topic of my remarks on import safety. That word is citius. It means faster, swifter, quicker. It is the Olympic aspiration of speed. Speed is a value that is engrained in many Olympic athletes, but victory requires another virtue — safety.

Apolo Anton Ohno is arguably the finest short-track speed skater who has ever lived. Short-track speed skating is one of my favorite Olympic sports, a cross between ballet and roller derby. Short-track racers sprint around an oval track wearing helmets and skintight suits. The grace and swiftness of their movement is counterbalanced by some quite spectacular crashes that occur at high speeds.

During the 2002 Games, I watched the 1000-meter, medal-round race where five skaters participated, including Apolo Ohno and a very colorful Australian named Steven Bradbury. What Ohno and Bradbury had in common were colorful personalities. Ohno sported a signature goatee, and Bradbury displayed spiky blonde hair.

I spent time with both of them, and they are terrific guys. Ohno was the most likely to win, Bradbury the least. In fact, Bradbury’s presence in the medal round involved luck. He advanced from the first trial round because of a disqualification. He got through the second round because three skaters crashed. The skaters took their marks. The starter gun sounded. The skaters sprinted through the first straightaway and then fell into a ballet-like glide for eight laps, leaning in unison around each curve.

Going into the last turn of the final lap, Ohno and another skater were stride for stride. The crowd was on its feet. Suddenly, skates bumped, legs flared, and a domino collision left four skaters sprawled on the ice, each banging into the sideboards, just feet from the finish line.

Apolo Ohno crashing with two other speed skaters.

All but Steven Bradbury, who up to that point, was a distant fifth. He skated by the wreckage to victory as the first Australian to ever win a gold medal at the Winter Games.

As a side note, I spoke with Steven the next day in the athletes’ village. I wished him good luck in his next race, to which he replied, “You know mate, I think I’ve used all of my lucky charms.” We later joked that he was “slow enough to win the gold.”

This illustrates an important lesson. In the Olympics, athletes will take extraordinary steps to achieve maximum speed, sometimes sacrificing safety. This produces both heroic results of victory and dramatic crashes.  Great sport, but dramatic crashes — when you are dealing with people’s health — are not an option — we must combine both speed and safety. 

An executive of a large American retail firm told me that one of its core values is represented by the phrase, “Speed is life.”  This connotes the need to be nimble, innovative, and responsive to the need for change in both business operations and consumer preferences.

Too frequently we see product safety problems resulting in unnecessary expense, sickness, injury, and even the loss of life. To the consumer the result is harmful, even tragic. To countries, companies and categories of products, the impact on a reputation can be devastating. In global commerce, as in the Olympics, things happen fast, they have to — but speed without safety carries great risk.

The unsettling stream of product safety problems we are experiencing are a reflection of the most profound changes in commercial patterns in human history — the globalization of trade. This week, I am beginning a blog series on the safety of product imports in a global market that demands speed. I will continue the series in my next post and discuss the impact of global commerce on the need to ensure the safety of imported products.

Medicare Bill

I was disappointed by Congress’s vote to override the President’s veto of the Medicare bill. Congress has shown an unwillingness to change the program’s path and take on the important task of entitlement reform. I wrote more about this in the following op-ed, which ran in The Washington Times:

Yesterday, the president vetoed a Medicare bill that columnist Paul Krugman calls "enormously encouraging for advocates of universal health care." The battle lines could not be clearer. Any member of Congress who believes in the free market or who takes seriously the need for entitlement reform should vote to sustain the president's veto.

The primary objective of the bill is to prevent a scheduled 10.6 percent reduction in physician payments under Medicare. No one objects to fixing this problem. We support fully reimbursing physicians at pre-reduction levels and fixing the fee schedule formula. Doing so is sensible and unobjectionable — we only wish that it didn't have to be done year in and year out.

What is not sensible or unobjectionable is the rest of the bill, which hurts both taxpayers and Medicare beneficiaries. Driven by election-year politics and a strong ideological preference for government-run health care, Democrats in Congress have loaded this bill with provisions that undermine consumer choice and, worse, pave the way to still more government control of Americans' personal health-care decisions.

First, the bill undermines the very successful Medicare Part D prescription-drug benefit. Part D works when seniors have plenty of choices so that drug plans and companies must compete for their business. Over 85 percent of Part D enrollees say they are pleased with their plans. Average monthly premiums have come in below expectations for three years running, and overall costs have been $150 billion less than originally estimated.

But the Democrats' bill would require the secretary of Health and Human Services to force Part D drug plans to cover all drugs within certain "protected classes" of drugs — for example, all statins used to control cholesterol. This would mean that drug plans could no longer use the threat of exclusion from the formulary to negotiate the lowest possible price for drugs like Lipitor and Zocor. The provision is a windfall for certain drug makers, but a hard pill to swallow for beneficiaries and taxpayers.

The provision would also give drug makers and other special interests a powerful incentive to lobby to have their drugs included in protected classes. Part D would become politicized, and government bureaucrats would begin deciding which drugs will be covered, instead of allowing the free and informed choices of American seniors and the competition of the free market to decide the matter.

Second, the bill lays the ax to the popular Medicare Advantage program, which gives seniors the option of receiving their care through private health plans. Medicare Advantage offers more choices and better care than government-run Medicare, often including preventive screenings that can save them money and help them avoid serious health problems later. It is especially popular with low-income beneficiaries. In fact, 49 percent of Medicare Advantage beneficiaries earn less than $20,000 per year, and many live in rural areas where doctors accepting Medicare patients are hard to come by.

The bill, however, would eliminate many of the options that make Medicare Advantage so popular and would force about 2.3 million Americans from their preferred private plans to the standard government-run Medicare, according to the Congressional Budget Office.

Third, the bill aborts a major money-saving reform for consumers and taxpayers — by effectively killing a new program for the purchase of durable medical equipment (DME). Since the 1980s, Medicare has been paying for DME according to a government-fixed fee schedule. The reform opens Medicare purchases up to competitive bidding. This program is already underway in 10 areas, and it's already saving Medicare and its beneficiaries 26 percent on average. Annual savings are estimated at $1 billion when fully implemented.

I can't explain why some members of Congress think that is a bad deal, except that some seem to believe it's always better to have government set a price, however high, than for the market to decide the matter. The bill would kill the contracts Medicare has already signed with DME suppliers. Adding insult to injury, it would also require my department to spend Medicare Trust Fund money to pay for any damages resulting from the cancellation of those contracts.

When Congress votes again this week on the deeply flawed bill, what is at stake is far more than whether the president's veto will be upheld. What is at stake is whether our country lives under a system focused on one-size-fits-all coverage and price-fixing, or whether it embraces free-market incentives, competitive bidding, and consumer choice.

If we want a health-care system that promotes value — that promotes the highest quality care at the lowest possible prices — Congress simply must do better.

Nicaragua

Written June 30, 2008

This was my third trip to Nicaragua. The place has started to be quite familiar to me, and I am beginning to develop what feels like a good relationship with many of the people there, including President Daniel Ortega and his wife Rosario.

President Ortega has perspectives different than those of many people in the United States, but I have always appreciated the fact that he treats me personally with dignity, and in a friendly, open way. We have developed the capacity to talk privately about our differences, and in the health field, we have common interests and aspirations for the people of Nicaragua.

This trip was actually fulfilling a commitment I had made to President Ortega when I saw him in January this year, at the inauguration of President Colom of Guatemala. During that conversation, we discussed the connection between clean water and air and general health. I committed to bring some people from the Environmental Protection Agency and the HHS Centers for Disease Control and Prevention to consult with the Nicaraguan Government on how to deal with the challenges they face with Lake Nicaragua, a large lake near the city of Granada.

People in the United States might reasonably ask why the United States Secretary of Health and Human Services spends time in Nicaragua worrying about the water. There are several reasons. My primary purpose for being in the region was the safety of products (especially food) imported into the United States. We are changing our strategy to make sure quality is built into the food we consume and a significant amount of our fresh fruit and vegetables is produced in Central America. One of the most significant components of food safety is the quality of water. If we want to have Central American fruit during the winter months, it is important the water they use in Nicaragua and elsewhere in the region to grow the fruit is clean.

Another reason is the success of Nicaragua as an emerging democracy. Our nation cares about the people of Nicaragua, and sees delivering on health and basic social services as important for elected governments to succeed, which further supports the stability of that region.

In the evening, President Ortega and I spent about an hour and a half talking together about the lake and ways we could work together to improve it. The lake has a fascinating history. President Ortega invited some knowledgeable local experts who are working hard to save the lake. I had invited Ben Grumbles, the Assistant Administrator for Water at EPA, to accompany me, and Captain Craig Shepherd from HHS/CDC, the Chief Environmental-Health Officer of the U.S. Public Health Service. We agreed to spend some time the next day actually on the lake to help us devise ways of working together.

Following our meeting, President Ortega drove me in his car to a local hospital, where we talked to patients, doctors and families about the quality of care they were getting and what needed to be done to improve their health system. There are a lot of needs in Nicaraguan hospitals.

Thursday morning we spent time on the lake itself, aboard a steamship. After the tour of the lake, the President and I drove around an island, and then settled into a meeting to outline a process for the U.S. Government to help Nicaragua, technically, in their clean-up. The Nicaraguans are aware of the progress we have made in the United States with our Great Lakes. When I was Administrator of the EPA, I organized the Great Lakes Collaboration, which has developed a master plan to further improve the lakes. We talked some about that process, and agreed to send a technical team to Nicaragua at the end of July.

President Ortega brought Secretary Leavitt and Captain Craig Shepherd on a boat tour of Lake Nicaragua to work on a plan to analyze the condition of Lake Nicaragua.

I met with several other groups while I was in Nicaragua, including people from the business community and a large group of students at the medical school of the National Autonomous University. I enjoy my encounters in other countries with students. They have straightforward questions, and I’ve found they appreciate straightforward answers.

Regional Health-Care Training School

About two years ago, while attending a meeting of the Health Ministers in Central America, I listened to a discussion related to a common need they have for skilled medical workers. The Minister of Health of Panamá at the time was Camillo Alleyne. He proposed at the meeting the creation of a regional center where the countries could jointly train workers.

As I listened to the discussion, I could see the vision of the school was smart, and it represented a way the United States could help the entire Central American region at the same time. I began to help them with their proposal, and now, less than two years later, we have a functioning school with a terrific facility, offering training to students all over the region.

There is a long story here that I hope to write at some point, but I just want to say that Friday while in Central America, I visited the school and attended the first meeting of its Board of Directors. I was able to visit a class of forty students from four countries who couldn’t have been more excited about what they were learning and the relationships they were making.

Students from Costa Rica, El Salvador, Honduras, Guatemala and Panama listen to Secretary Mike Leavitt at the Regional Health Care Training Center in Panama.

This school is going to be a major source of good in the region and I couldn’t be more proud about the United States’ prominent role.

Later in the day, President Torrijos invited me to the Presidential palace for a meeting. He has been supportive of the center. We spoke for about 40 minutes about a wide range of subjects.

Central America Blog II

Written June 26, 2008

Wednesday morning, we drove two hours from San Salvador to Acajutla, a community in El Salvador of about 75,000 people on the Pacific coast where the USS Boxer had visited to care for patients as part of the mission, “Continuing Promise,” in May of this year. The Health Minister of El Salvador met us there to tour a public clinic. While the USNS Comfort had visited a different part of the coast last year, some of the health care professionals around Acajutla have also participated in trainings offered by the Comfort crew.

Like public clinics I have seen in other countries, including our own, people with various needs lined up early in the morning to see one of the doctors or nurses. They are served on a first-come, first-served basis, advancing along a series of benches. There is no air conditioning, the temperature is hot and muggy and patients are served with a wholesale mentality but seem grateful for the help. This is the way health care delivery happens in their world.

There are 369 such clinics like this in El Salvador, the Minister told me, plus another 171 smaller rural health posts. In this particular clinic, there were 25 doctors and a similar number of nurses. There are about 5.4 million people in the nation, about 439,000 of whom live in the department, or province, in which Acajutla is located.

In addition to the clinics, El Salvador has a system of referral hospitals and other public health functions. One of them is a network of health promoters in the neighborhoods who teach healthy practices, encouraging those needing care to get it. For example, women of childbearing years are asked to report the date of their last period so the health promoter can get them into prenatal care if they prove to be pregnant. They know every child under five, watch for signs of communicable disease and generally “promote healthy practices."

I spent an hour talking to some of the doctors, nurses and health promoters, trying to understand what motivates them and their general outlook. The main reason I chose to visit Acajutla was to get a reading on the impact of the USNS Comfort and the USS Boxer a few months after their visits.

What a powerful testimony I heard from these people about the value of these efforts by the U.S. Government. They could not find adequate words to cover the sense of gratitude and professional fulfillment they felt. It was simply inspiring to hear them talk about all they had learned from the doctors on the ships, and the appreciation they felt for the dignity and care with which they felt our crews treated their patients, friends and neighbors.

As moving as I found the meeting with the doctors, the most significant experience of the day was meeting with about 10 patients who wanted to tell me about their cataract surgery, hernia operation or the care given to their children on board the Boxer. Each story related a changed life with a renewed sense of purpose and self-worth.

One woman told me how her blurry eyesight, which was now cured, no longer caused her to fall. She threw her arms around me saying, “Thanks be to God for the United States.”

Another woman told me about reading to her grandchildren for the first time. Another older woman, who was caring for three small, abandoned grandchildren, talked about the difference the visit had made to the little girl with cerebral palsy and her able-bodied brothers.

A man in his late thirties pulled up his shirt to show me the scar of his repaired hernias, and then demonstrated how his mobility and strength had returned, which allowed him to work again.

One after another, they used different words to talk about how the Boxer had restored the productivity of their lives. Those who had cataract surgery particularly moved me. Cuba has aggressively provided this rather simple surgery for tens of thousands all over Central America. The Cubans call the campaign "Operation Miracle," and it has built a reputation for Cuba in the arena of health diplomacy.

Secretary Leavitt and a Salvadoran boy share a laugh at a clinic in Acajutla, El Salvador.

Our hospital ships will return to the region this summer. Doctors and patients of El Salvador are anticipating these visits. This is a powerful tool for our nation, and we need to do more of it.

Central America

Written June 25, 2008

Yesterday, we held an all day session on product safety with representatives of the Central American countries and the Dominican Republic. We had Health Ministers from several of the countries and representatives of Agriculture and Commerce Ministries as well. I met with President Antonio Saca of El Salvador for about 30 minutes in advance of the meeting. He formally opened the meeting.

Secretary Mike Leavitt (2nd from left of those seated) listens as President Antonio Saca of El Salvador addresses attendees at the Product Safety Forum.

Our purpose was to begin a conversation with the participating nations on changing our collective strategy related to the safety of food. Central America and the Dominican Republic have become a major factor in U.S. food production. Collectively, these countries rank just behind Mexico and Canada in importation of food into the United States. A trip to the grocery store fruit and vegetable section will confirm that.

These countries properly fear any kind of import quality problem because it is seriously disruptive to their economy. The U.S. is 80% of their market. A situation like the melon problem we had in Honduras or the tomato situation in Mexico also damages their national brand.

In previous blogs, I have discussed our nation's strategic change. Our efforts are focused on preventing problems before they happen. Our best tactic to accomplish that is the establishment of quality standards and the continual monitoring of them through independent certification. I explain in my blog on the Red Pepper Principle, how implementing new practices can make crops attractive because of higher quality.

We had five panel discussions, all of which went well. Just before lunch, I asked the participants to consider an idea that I wanted to discuss during the afternoon. The idea was to create a U.S./ Central America/ Dominican Republic Memorandum of Understanding (MOU) on food and drug safety. Under this MOU, we would engage in regional capacity-building, joint standards-development, development of accreditation arrangements for certifiers and training at the Regional health-care Training center we have developed in Panama. I suggested that we identify a couple of product categories to start with. After lunch, the panel discussions began to center around the MOU idea. By the end of the session, we had devised a strategy to move the idea forward, with a goal of completing the MOU this fall. The meeting was a big success from my point of view. We didn’t conclude anything, but we were able to start a serious process. I still have a significant amount of work to do in making contact with other important players.

Dinner last night was terrific. Ambassador Charles Glazer and Mrs. Glazer invited a local mayor and two prominent business executives over. It was a chance for me to learn more about El Salvador. We talked about the challenges of local government and the upcoming national elections.

Mexico City Meetings

Written June 23, 2008

I’m writing from Mexico City tonight. I participated in a bi-lateral meeting with José Cordova, Secretary of Health, and members of his staff. We then had a working dinner that added Alberto Cardenas, Secretary of Agriculture, and Eduardo Sojo, the Secretary of Economy, and representatives of other Mexican national government agencies.

Secretary Cordova and I have a long list of things we are working on together. Most of them related to joint projects we are doing along the border.

Secretary Mike Leavitt and Secretary of Health for the United Mexican States Jose Angel Cordova.

Secretary Cardenas and I have known each other since 2003. Previously, he was Secretary of Environment and I headed the U.S. Environmental Protection Agency (EPA). It was the first time I met Secretary Sojo. Speaking of environmental issues, the air here is much better than I remember it. I joked with Secretary Cardenas that it was the result of the joint projects we had done on clean fuel while I was at EPA. I suspect the air isn’t always as good, but it is good to see some progress.

The evening meeting was devoted to a discussion of product safety. I won’t discuss the content of the meeting except to say it was focused on ways we can work together to assure safety of food and drug products that are produced in Mexico. I am going to Central America tomorrow for discussions with five governments on the same subject.

An obvious topic of conversation was the current situation with tomatoes. Tomatoes are Mexico’s biggest agricultural export to the U.S. Fresh fruit and vegetable exports to America accounted for $4.4 billion last year. As always, an incident in that sector of their economy has serious ramifications, and we are working with them to minimize impact, while putting safety first.

Secretary Leavitt speaking to Secretary Cordova during a bi-lateral meeting between U.S. and Mexican health officials.

FDA is working non-stop to find the source of the salmonella outbreak that many states are experiencing right now. FDA has completed the trace-back for some of the tomatoes associated with the outbreak. The investigation has led them to certain farms in Mexico and Florida.

We have deployed a team to Mexico. They will conduct joint inspections with regulators in Mexico and Florida at the farms and other distribution points. Meanwhile, the FDA will continue to collect samples of tomatoes and conduct trace-back activities.

FDA is keeping a list of the areas that have not been associated with the outbreak. We added a long list of states within the United States and Mexico. It is on the FDA website.

Tomorrow, I’ll meet with U.S. businesses in Mexico City, tour a food processing plant, and give a diplomacy speech. One thing making this trip a little extra special is that my 18 year old son is accompanying me (at my expense). He is about ready to leave home for college and this is a way for us to have a little adventure together.

Medicare Blog 7: Committing to the Course and Paddling Hard -Part 2

This will be my last post in the blog series on my comments to the Medicare Trustee's Meeting, held on March 26, 2008. I have used the metaphor of canoeing whitewater rapids to explain the disaster that lies ahead on our current course and how safety depends on repositioning the boat. Yesterday, I explained how important it is to make "value of care" rather than "volume of care" the most rewarded virtue in health care. Today, I will explain how Medicare Parts A and B can be changed to allow competition to drive change and how change can avoid an intergenerational struggle.

Make Medicare Parts A and B, more like Medicare Part D.

In addition to changing the incentives from volume-rewarding to value-rewarding, the Medicare Part D Prescription Drug Program provides a good example of how better transparency and competition can drive change. It has not only ensured that seniors get the drugs they need, it has also demonstrated that seniors can use an organized marketplace to drive quality up and cost down.

Today, 90 percent of those who are eligible have drug coverage; satisfaction rates are high, and the cost is almost 40 percent below the original estimates. While there are several things that have contributed to the drop, a big one is the power of a competitive marketplace. Prices are determined through competition. The cost of the benefit is transparent to consumers and they can choose the benefits that meet their needs.

If the Medicare Part D structure were applied to Medicare Parts A and B, it would revolutionize the entire system. Imagine a physician practice investing resources to monitor and track patients with chronic conditions. They might if the program provided beneficiaries with information on the quality-of-care and their dollar savings if they used more effective providers. It would drive quality up and cost down.

Each generation needs to do its share.

My father and mother are on Medicare. They worked hard all their lives and have done well. My dad likely earns more than my 30-year-old son I told you about earlier. My son is struggling to buy a home, support his family, save for the children’s college fund, and buy his health insurance. Yet, my son has taxes drawn from each pay check to subsidize my parents’ health insurance.

Medicare can be made more efficient by rewarding value and shifting to a Part-D-like competitive model of delivery. However, what remains the most important obstacle is rebalancing the generational obligation.

This is a classic public policy decision that has to be faced. It is unreasonable to think Medicare can be sustained unless this is changed. If we start now, the change can be made over time and with genuine fairness. We can avoid an intergenerational economic struggle from which both sides suffer. Promises to today’s and future beneficiaries to provide coverage of health care must be kept, but not at the expense of future generations.

Medicare is indeed drifting toward disaster, but we know what to do. Matt Knot’s river advice is the key: “Start positioning your boat well ahead of the danger, commit to a course that averts the problem, and paddle hard.”

Every generation of Americans has overcome challenges to secure our nation’s role as the world’s economic leader. I believe solving the health-care puzzle is this generation’s challenge. It will require change.

In a global market there are three ways to approach change. You can fight it and fail; you can accept it and survive; or you can lead it and prosper.

We are the United States of America; let us lead.

Medicare Blog 6: Committing to the Course and Paddling Hard -Part 1

So far in my blog series, I have talked about the serious imperative our nation has to change the course of Medicare.

I also discussed several parts of a political construct that would allow political action. Now I would like to frame up, at a high level, what a solution should look like from my perspective.

A Medicare System that would be solvent through the 21st Century would have three characteristics. First, value-of-care would replace volume-of-care as Medicare’s best-rewarded virtue. Second, Medicare parts A and B would operate like Part D. Third, each generation would carry its share of the load.

In Medicare, our most expensive patients are those with multiple chronic diseases. The combination of ailments compounds to magnify each other. The same is true with Medicare. Medicare has three chronic ailments that are defeating the system.

The first, I call Silo Syndrome: each medical action is paid for separately. That provides little opportunity or incentive for coordination among providers and it often results in bad referral decisions, sloppy hand-offs, duplications, fraud, and poor quality of care. The result is inappropriate care and unnecessary cost.

Medicare needs to use its power as the nation’s biggest payer to change this. It’s not only wasteful but it encourages unnecessary care and expensive medical mistakes.

The second category is Quality Indifference: doctors, hospitals and other medical providers are paid at the same rates for low-quality or high-quality performance. Physicians who take measures that prevent acute flare-ups of chronic conditions are paid no more than those who don’t. Skilled nursing facilities that prevent unnecessary re-hospitalizations are paid the same as those that don’t.

In fact, poor quality is often rewarded. When patients contract preventable hospital infections, costs skyrocket and in most settings, the hospital profits from it. Not only is our current system quality-indifferent, we reward poor quality!

Patients deserve to know the quality of the care they receive according to standards set by the experts. The information should be transparent, and most of all, we should reward quality.

This leads naturally to the third category of Chronic More: there are no mechanisms or incentives for controlling the volume and intensity of care. Not for the patient or the provider. The entire process rewards volume.

Doctor and hospital incomes rise as more units of service are ordered. If those units are more costly, they generate even more revenue.

It is the same for a patient. Our current payment system provides no means for a patient to know the cost and little reason to care.

These volume incentives need to be treated with strong doses of information transparency and by building incentives for high quality, efficient care directly into our payment structure. A variety of policies would force these changes, and luckily the infrastructure of quality metrics and strategies for rewarding value are available. It just takes Congressional action.

In my next entry, I will explain how changing Medicare Parts A and B to be more like Part D can drive quality up and cost down. I will also elaborate on how each generation can do its share to ensure benefits for future generations.

Medicare Blog 5: Positioning the Boat and Avoiding Disaster

Last night, I posted a brief entry about my conversation with Ted Kennedy, and today I am returning to my series on Medicare. In this series of blog posts, I am using the metaphor of navigating whitewater rapids to describe the dilemma of the Medicare problem facing our nation. I concluded my post yesterday by stating that if we are to avoid the disaster of Medicare insolvency by 2019, we needed to change our course in a way that will affect the entire health care sector.

There is a very close relationship between Medicare and the balance of the U.S. health sector. Medicare is such a powerful payer; the rest of the sector has based their billing and reimbursement mechanisms on Medicare.

I believe the key to health-care reform in our nation is Medicare reform. Successfully changing Medicare will trigger the rest of the health care sector to follow. That would be better news if changing Medicare were not so politically and bureaucratically complicated.

Since I am speaking in my capacity as a Trustee of the Social Security and Medicare Trust Funds today, it is important to acknowledge that this job is about sounding the alarm. I hope I have made clear to you just how alarmed I am and how alarmed we should all be. There is serious danger here.

It troubles me that this matter is not receiving more attention in the Presidential candidates’ discussions. The next President will have to deal with this in significant part. In fact, if they don’t deal with it, our opportunity to apply Matt Knot’s strategy of repositioning early and paddling hard is lost.

So, given the strong possibility this won’t get fixed in the next 266 days, I would like to add some general advice on the creation of a political construct for action and a general strategy to solve the problem. I want to add, these are not being presented as Administration policies or proposals. I take complete responsibility for them as a Trustee simply laying out my thoughts.

In our country we maintain special facilities called “Level Four Laboratories” for handling lethal biologic agents. It would be unreasonable to expect anyone to handle lethal bio-agents without special protection.

To members of Congress, fixing entitlements like Medicare is lethal. Persuading them to accept the inherent risks will require a system of special political protection. Without it, Congress is unlikely to ever deal directly with Medicare’s problems.

In an era where Election Day marks the beginning of the next campaign season, the degree of bipartisan statesmanship needed to solve the entitlement problem will be hard to come by. It will require what I call a partisan eclipse — a brief moment of time when political planets align to create an opportunity.

Partisan eclipses are often brought on by a crisis or national emergency. They can also happen in the vortex of a political storm. There are moments during certain election cycles when both parties feel mutually at risk of being the minority party.

During the final weeks of the 2006 election for example, it was not clear whether either party would win control of both Houses of Congress. Both parties were competitive but neither had the benefit of certainty. While the situation presented intense partisanship on most issues, it also represented a rare moment of opportunity for leadership.

What if leaders of both parties in Congress had met privately and acknowledged that while they could not agree on how to fix Medicare, they could agree that the approaching Medicare insolvency had to be dealt with. Both would likely be motivated by an understanding that it was in their party’s long-term interest because solving such a problem would be especially costly in political terms to the party in power at the time the dilemma matures.

I grew up in a family of six boys. My mother would often resolve disputes over the remaining portion of a dessert by requiring one brother to cut the pie and the other to choose the first piece. The equilibrium of uncertainty created an elegant self-enforcing fairness.

What if Congressional leaders used this political equilibrium of uncertainty to define a process not for themselves, but for a Congress and President to be elected years in the future? What if that legislative process they agreed on was so scrupulously fair and bi-partisan that either party would be willing to proceed even if they were not in the majority? A partisan eclipse will occur in the future and it should be used to provide political protection and a viable path forward at a future date.

The legislation resulting from the partisan eclipse must incorporate another practical principle: separate commitment-making from pain-taking. The bill should establish measurable trigger points for action. For example, if Medicare currently constitutes 3.2% of GDP, when the government actuary declares Medicare expenditures to it to have exceeded 4% of the GDP, a special decision-making process would be triggered.

The special process could resemble the one Congress has used successfully for military base closure. A special bipartisan committee was established to assemble a proposal. The proposed plan is submitted to the President for review. Within a time certain, the President is required to approve or disapprove the entire plan. Once the President approved a plan, it was submitted to Congress, where they could not amend the proposal, but were forced to vote the proposal up or down within a specific time frame. It worked.

It would be critical that the law enabling this special process also include one other provision. If either the Congress or the President fails to act, a series of default provisions must be triggered which solve the problem. Without A default trigger, Congress will not act. Senators Judd Gregg (R-NH) and Kent Conrad (D-SD) have offered bi-partisan legislation creating a special legislative process.

Finally, there is a group of budget estimating tools referred to as scoring conventions that are used universally across the federal government. Many of the tools Congress will need to reform Medicare will involve significant behavioral changes and require investments that the current scoring conventions would count solely as expenditures. In an age when the power of investment and productivity are the keys to success; the federal scoring conventions overvalue the status quo while undervaluing the investments that could transform it. Many have called for these to be modernized. I add my voice to that chorus.

We are beginning to understand how to reposition Medicare to avoid the dangerous rapids of insolvency, but we must commit to the course and paddle hard if we are to achieve a Medicare System that can be sustained through the 21st Century. Tomorrow, I will conclude this blog series by outlining the characteristics of a system that can be supported through future generations.

A Call with Ted Kennedy

This morning I had a delightful telephone conversation with Ted Kennedy. He called to talk about the health care of others in his state; a subject on which he has expressed passion to me many times before.

He sounded great! We talked briefly about his health. He was forward looking, crisp and as passionate as always. There wasn’t a single hint of negativity or worry. I’m sure he has moments when both creep in, but the call was an unexpected lift to my spirits.

Medicare Blog 4: Learning from the Experience of Others

This week, my blogs are focused on Medicare and the serious crisis we face in coming years. The thoughts in this series will be submitted as part of the minutes of the Medicare Trustee's Meeting. In my last post, I outlined the current course for Medicare as it is drifting toward disaster.

Would it be a stretch to say 20 years hence, we would likely have accumulated a substantially larger national debt than we have now; and that a significant portion of that debt would be in the hands of foreign capital sources? Again, that’s our current course.

What will the impact be of continued trade deficits, and new global competitors who spend a fraction of what we do on health care, yet produce similar or better big picture health results?

We factor continued growth into our scenario like it is certainty. Without continued investment from private and public sources, our prosperity would be taken away.

Other nations, of course, have scouted out the river. I was in Singapore in April 2008. Their health care system consumes four percent of their gross domestic product. Rather than a Medicare-like government system, they require citizens to save. Incidentally, the Singaporean life expectancy is slightly longer than it is in the United States.

I would simply ask this question. If you were considering between an investment in two organizations and one spent four percent on health care with no future liability and the other spent 16 percent and had trillions of dollars of unfunded obligations, which one would you be most interested in?

In the late 1990s, I was Governor of Utah, and went to Argentina to develop trade relationships. I met various Ministers of the Argentine Government who, at the time, were proposing some aggressive and controversial changes. Among these was an attempt to transition their country away from a constitutionally protected pension system, their version of entitlements.

I remember thinking, “These are the most courageous political leaders I’ve ever met.” I soon found it was not just courage. They were compelled.

At the beginning of the 20th Century, Argentina was one of the wealthiest countries in the world — wealthier even than the United States. Over the next 50 years, successive governments constructed, and then expanded an ever-generous system of social benefits, nationalized industries, and created a vast and bloated public administration. Yet protectionist policies and a failure to invest in innovation in agriculture and other key industries meant the world economy began to change while Argentina’s didn’t. Its productivity suffered. But the country kept on spending, content and confident it was better-off than its neighbors.

As it turns out, Argentina had been operating for many years on money borrowed from the financial markets and organizations like the World Bank and the International Monetary Fund. By the 1990’s, the mortgage outstripped the country’s ability to pay. Creditors told Argentina, “no more, unless you fix your entitlements.”

Frankly, Argentina had started down the path of reform late, and once the government started, the political pain was too much—the nation could not sustain it. The government developed a solid monetary policy, but could not change its fiscal or spending practices.

A few years later, Argentina was in political turmoil with a rapid succession of governments, a currency in free-fall, and a rapid spike in unemployment. The country teetered on the verge of civil unrest. Why? Because Argentines had put off hard choices for so long that they were forced to make change too quickly, and they simply didn’t have the political strength to do it.

It seems inconceivable that the United States of America, the strongest economic power in human history, the land of the free and the home of the brave, could ever be in a situation like the one Argentina faced a decade ago. But, is it?

Let’s think on a horizon of 20 years.

Is it hard to conceive of a severe productivity dip in the United States as labor markets become more sophisticated in nations like China, Vietnam, India, and Brazil? They are increasingly competing not only with our manufacturing sectors, but also with our more dynamic knowledge sectors.

Is it really difficult to imagine world credit markets saying to the United States of America—as the world did to Argentina: “Given your lack of action in dealing with your deficit and the entitlements causing the problem, we are beginning to lack confidence in you.”

When we talk about the metaphoric torrent we are navigating, it is much more than just Medicare, of course. The massive burden we are feeling is created by a full 16 percent of our Gross Domestic Product rushing through a single sector of the economy.

We need changes that can affect this entire sector we call health care. Tomorrow, I will share what kind of changes might be possible to reposition Medicare and avoid the whirlpool effect that awaits us.

Medicare Blog 3: Scouting the Rapids - Part 2

I have started a series of blogs on the Medicare problem facing our country, using the metaphor of navigating whitewater rapids. Last week, I began "scouting the river" by discussing the current course and the generational divide, between workers and their parents and grandparents, that awaits us in the future.

I have a son who is 30. He and his wife are just beginning their household. They have one young daughter and another baby on the way. They are in many ways becoming a typical American household. This is a wonderful thing to see as a parent, but I worry about our national economic future; I worry about our growing generational divide.

Let’s consider what their generation’s economic prospects look like over the next two decades. The typical household is going to see its health-care spending basically double in the next twenty years—from 23 percent to 41 percent of total compensation. At the same time, we are going to nearly double the share of federal spending that goes to pay for Medicare, from 13 percent to more than 23 percent. We are going to do this while the number of working people per Medicare beneficiary is sliced nearly in half, from four to two-and-a-half.

That is clearly not a rosy scenario for growing young households like my son’s. These working families will argue, “My generation did not agree to this arrangement. This is happening at a time when my own health care is unaffordable. I have children who need food and clothes. I’m struggling to make ends meet. Seniors need to either have lower benefits or pay more of the cost themselves.”

In fact, they will insist, “We are the ones with the heavy burden. Government needs to help us more so we can continue to work and enjoy the benefits our parents did.”

But their parents and grandparents will have legitimate worries too. They will argue, “I did my time. I paid into the system. I have a legal entitlement for health care, and the government has a moral obligation to provide it. I know the demographics have changed, but that isn’t my problem.”

In fact, seniors will argue, “Health-care costs are so high, my Medicare premiums, co-pays and deductibles are eating up almost half of my Social Security check. You need to help us more, not less.”

The problem is: both will be right. The problems we see today with Medicare have the power to pit these parents and children against each other in an intergenerational economic struggle where each side will suffer.

Frighteningly, we will see that competition for resources play out much like another economic tension we are already experiencing. Our choices about social investment—in infrastructure, education, national defense—are being reduced as mandatory spending crowds out discretionary spending. In the last two decades, we’ve gone from half of our national spending being discretionary to only 38 percent. In four years, it is projected to be down to less than one-third.

We are seeing mandatory health-care expenses crowd out other government spending—just as we are going to see health-care spending crowd out non-health-care spending in American households.

By now the current has grown so much that we are being sucked down into the hydraulic whirlpool again and again, with little surface time for air. The debris is piling up, and we may not have a way out.

We may not have a river guide like Matt Knot to navigate Medicare, but we can anticipate what is forthcoming and make efforts to change our course. In my next entry, I will share what I have learned from other nations that have scouted the river.

Medicare Blog 2: Scouting the Rapids - Part1

Yesterday, I started a series of blogs on Medicare. The thoughts in this series I will be submitting as part of the minutes to the annual Medicare Trustee's Meeting, which was held March 26th. In my last entry, I introduced the metaphor of navigating the dangers of whitewater canoeing and addressing the tenuous future of Medicare.

Disaster is not inevitable. If we act now, we can change the outcome. In health care, the core problem is that costs are rising significantly faster than costs in the economy as a whole.

Health care has done exactly that my entire life. When I was born, it was four percent of the economy. When my son was born, it had doubled to eight percent. When my first Grandson was born two years ago, it had doubled again to 16 percent.

Every piece of evidence shows the trend continuing. The problem is beyond the fact that medical cost growth is faster than that of any other part of the economy. Our problem is also demographic. Our population is aging and as we age, medical expenses grow.

Today, 12 percent of the population is 65 or older. By 2030, nearly 20 percent of us will be seniors. There is nothing we can do to change that.

We have made a decision in our society that the cost of seniors’ health care will be borne primarily by younger people who are still working. When that decision was made, it was assumed there would always be a fresh crop of earners to support the health care of their parents. That is not proving to be true. The demographic reality is there are diminishing numbers of workers per senior. This ratio will decline rapidly once the “baby boom” generation reaches Medicare eligibility age starting in 2011.

Higher and higher costs are being born by fewer and fewer people. Sooner or later, this formula implodes.

The real urgency of this problem starts between now and 2019 when the Medicare Hospital Insurance Trust Fund is projected to become insolvent. There is no backup plan in the law to ensure that hospitals continue to be paid when the Trust Fund is depleted.

Congress will not be able to sit idly by and allow the Medicare program to become insolvent—they will be forced to take action. They will have the old familiar choices of raising taxes, cutting benefits to seniors, or imposing reduced payment rates on health-care providers. Some of these choices represent the ugliest of political dilemmas, pitting a generation of workers against their parents and grandparents.

I will pick up here tomorrow and share the likely perspectives of the generational divide as I continue to scout the river on our current course for Medicare.

Medicare Blog 1: Drifting Toward Disaster

I want to begin a series of blog entries about the promise our nation has made to provide health care to our seniors. I am going to be critical of our current course. I don’t want to see us fail. To keep this commitment requires change.

Time is running out. Medicare is drifting toward disaster.

I am a trustee of the Medicare Trust Fund. On March 26, 2008, I attended what will likely be my last annual spring meeting of the trustees. Our primary business was to issue a report to the people on the condition of the Social Security and Medicare Trust Funds. The report is based on work by government actuaries.

In the Treasury conference room we use, there is a wall clock that has been there since 1873. At one time, the clock was actually hooked to the Western Union telegraph line, which calibrated the exact time on a regular basis.

This year, Rick Foster, the chief Medicare actuary, sat in perfect alignment between me and the clock. As Rick gave his report that the Medicare Hospital Insurance Trust Fund was projected to be insolvent in 2019, I could see time passing with each swing of the clock’s pendulum: tic, toc, tic, toc.

I’m not sure if that caused what I am going to describe to you, but as I listened I felt the weight of this responsibility pressing on me. When the report was finished, the final page of the report was passed around for our signatures.

It felt like the moment required more than just signing my name and moving on to the next appointment. This is serious business involving trillions of dollars and the lives of hundreds of millions of people.

As much as anything, the weight was a blend of responsibility and selfish panic. I realized that when the actuaries’ forecast matures—and it will—somebody is going to say to me, “Weren’t you a Trustee of the system for four years? What did you do to address the problem?” Somehow, the response “I signed the report each year,” just doesn’t feel adequate. Though the truth is, that’s about all the authority the Trustees are given.

Just before the vote to accept the report, I asked the Secretary of the Treasury, Hank Paulson, the managing Trustee, if he would keep the record of the meeting open because there were some things I felt a need to say. He agreed.

I have composed my addition to the minutes. Beginning with the paragraphs below, the contents of my blogs over the next several days will be submitted as part of the minutes for the March 26th meeting.

I have constructed a metaphor in my mind that is useful in describing our dilemma with the Medicare entitlement program, which I will share with you today.

Whitewater canoeing at the championship level is high adventure and comes with serious dangers. My friend, Matt Knot, is an instructor and guide on the Gauley River in West Virginia.

There are treacherous places in whitewater country. Canoers call them hydraulics. They are given descriptive names like “Hungry Mother” or “Lunch Counter” that dramatically communicate danger.

Hydraulics form when water pours over an obstacle such as a rock. Unwary canoeists get sucked into them and can be trapped in one place by the force of the current. They are instantly overwhelmed and dragged under by the whirlpool effect created.

Matt says when you go into a hydraulic, everything gets very dark as you are pulled deeper. Water circulates the boat back to the surface and then drags it down again, over and over. Survival depends on keeping your wits, waiting—and hoping—to be flushed out the bottom.

Some thrill-seeking river runners find the experience of navigating a hydraulic exhilarating. However, the worst hydraulics are known as “keepers.” Boaters become victims when they get sucked down into a hydraulic, and instead of being tossed about and flushed out from the bottom, they get mired in a jungle of debris.

This is an important point to remember: it is not just the hydraulic that brings fatal consequences; it is the combination of the hydraulic and debris beneath the surface.

Matt teaches students to anticipate. He calls it “scouting the river.” Scouting is more than looking ahead. It’s listening for the roar and sensing when the current is pulling you toward a dangerous place.

Here’s the second important point. Safety comes only in foresight and avoidance. Matt says, “You have to start positioning your canoe well ahead of the danger, commit to a course that avoids the dangerous area, and then paddle hard.”

I’m sure it is obvious to you that the river in my metaphor is the growing obligation our nation has to pay for the health care of our senior and disabled citizens. Medicare’s liabilities have grown from a mere trickle 40 years ago into what Matt Knot would call “Class 5 rapids.” As new streamlets merge, it is becoming a raging torrent—more demanding and dangerous with each successive day.

The Medicare Trustees Report does a good job of “scouting the rapids.” But a nation that does not act on the warnings the report contains is no different than a canoeist ignoring evidence of hydraulics in the river ahead.

Over the next several days, I want to draw on this metaphor to describe the dangerous financial realities to which our current course leads. I hope you will take the time to read the entire series.

China - Blog IV

Thursday night I was scheduled to have dinner with my friend Gao Qiang, who until last year was China’s Minister of Health. He no longer has day-to-day management responsibility but continues to have significant involvement in health policy. He called to say he had meetings related to the earthquake so he needed to cancel our plans. I completely understood.

We were able to get together for a brief visit on Friday morning. He had only had two hours sleep the previous three nights. He said the entire government was focused on the rescue effort.

I was also able to spend time with Wan Gang, Minister of Science and Technology. We had met at the Third Strategic Economic Dialog last December but this was our first opportunity to spend time getting acquainted. We reviewed the existing relationship between HHS and the Ministry and laid out some areas where we have additional common interests.

During the middle of the day, I took a short break to attend a program at an International School on Internet Safety for Children. My wife Jackie volunteers full time for the ikeepsafe Foundation. The foundation has developed a book about internet safety using an Olympic Game theme and the book launch was held at the school. One of their sponsors has arranged to place several thousand copies of the book in schools.

The afternoon was spent in more meetings with government officials. I spent a productive hour with Minister Li and his Deputy Minister Wei. They reviewed with me plans they have to ensure food safety for the Olympics. It was rather extraordinarily detailed and well coordinated. The essence of the plan is if you touch any food during the Olympics as a restaurant, supplier, or processor, or transporter then you have to register and agree to certain standards. They have developed a tracking system that is the most elaborate thing I have ever seen. I can’t recount every component of the system but it includes GPS tracking of every truck carrying food, traceability of ingredients and an incident reporting system. I told Minister Li that if he could pull half of it off, his organization should be given a gold medal in food safety.

We also spoke at length about the progress on the implementation of our Memorandum of Agreement on food safety. We are making steady progress.

After our meeting, my good friend Vice Minister Wei arranged for us to see the Olympic park. What a treat that was. We went to a building where they display scale models of each venue. It was well presented. We then drove to several parts of the park so we could see the venues from close range. They are spectacular. The visit rekindled many of my Olympic feelings from 2002 when my home state of Utah hosted the Winter Olympic Games.

China will be stretched to manage the final preparations for the games and the earthquake recovery at the same time. It brought back memories of our Olympic preparations. The Olympics were only a few months after 9/11 hit. Suddenly the nature of the 2001 games changed. We would become the first major world gathering after the attack. Many were concerned that terrorists would use the Olympics as a target. We beefed up our security arrangements considerably during the final three months.

I rushed back to the Embassy to do a news conference. Regrettably, I was caught in Beijing traffic, which is simply unbelievable. I was about a half an hour late and that always makes me uncomfortable. The journalists were patient and seemed to understand the traffic problem. Most of their questions focused on import safety issues. There were 18 reporters there.

My final meeting of the day was dinner at Ambassador Sandy Randt’s home for members of my delegation. It was a terrific evening. Ambassador Randt has lived in the region for much of his professional career. He and his wife Sarah have been in China several times, starting in the 1970s. He also lived in Hong Kong for many years, speaks the language and is a terrific relationship builder. He is remarkably able and likeable; all good qualities for an Ambassador.

Our dinner conversation focused on China’s place in the next quarter century and a comparison of the unique challenges our respective countries face to maintain our economic momentum. We talked about the challenge of entitlement spending in the United States and the various disparities China will need to manage. It was an interesting conversation.

The best part of the evening was a conversation we had about music that we grew up with. Each of us named songs that took us emotionally back to our adolescence and the associated memories. My song was Strawberry Fields Forever, by the Beatles. It reminded me of sitting at a small drive-in on the outskirts of Loa, Utah where our ranch is located. I would go there on summer evenings to order food and play songs from the Juke box.

We all shared great memories. It was a terrific way to get to know each other.

Shanghai, China - Blog III

Traditional Chinese Medicine

I had planned to be with Minister Chen at a medical college where they teach Traditional Chinese Medicine (TCM). I have written before about my interest in this subject. I brought Dr. Josephine Briggs, who heads the Center for Complimentary and Alternative Medicine at the National Institutes of Health. Our purpose is to stimulate some scientific cooperation on how Western medicine can be informed by TCM.

We visited a large new hospital about an hour outside the Shanghai city center. It had 750 beds and is connected to the Medical School. We visited three departments at the hospital: the pharmacy, a general ward and the acupuncture center. At the acupuncture center, the management of the hospital had very cleverly identified some of the patients with Utah ties, people who had lived there during the time I was Governor. We walked through three small rooms and observed the treatment of a dozen patients for things ranging from knee problems and bells palsy, to infertility.

Afterward, we gathered in a conference room to ask questions of the medical staff. I find it rather easy to grasp the portions of TCM related to medicine. They use naturally grown plants in combination to produce a therapeutic result. The components obviously have active ingredients that have some impact on the human body. Over the years they have developed patterns of what works in various situations. Diagnosis is done through a form of observation and intuition.

TCM deals with concepts that are thousands of years old, and involves assessment of more than physical well being. It strives to find balance within the various systems of the body. I don't understand all of it, but I think it is important to respect that their approach is different than ours, and to acknowledge there may be a lot we can learn. In medicine, it is important to understand why something works. It appears to me in TCM, it is only necessary to believe something works. What I hope we can do more of, is applying scientific methods to understand why Chinese methods work. Blending knowledge from the two should be our goal. We are working on a Memorandum of Understanding to do just that.

I will admit that what I learned about acupuncture-aided surgery went over the top for me. They do major surgery with the patient awake and alert using acupuncture instead of anesthetics. I didn't see an actual surgery, but they had clips of video.

The difference between TCM and Western medicine typifies the challenge of working cooperatively with the Chinese; two different philosophies and two different systems. Neither should attempt to change the other, but rather to make our systems interoperable.

I spent about an hour at a TCM museum, which was helpful in understanding the history and philosophies. I found it helpful to see the development throughout a few thousand years. They also had a group of students who talked about the teaching techniques used in training TCM doctors. It is critical to remember this is a method of treatment hundreds of millions of Chinese prefer. They don't trust Western medical techniques.

Secretary Leavitt tours a Traditional Chinese Medicine Museum in Shanghai

Diplomacy Speech

The most pleasant part of the day for me was a diplomacy speech I did at the medical school with 300 students. My goal in the hour we had together was to make friends with them. I told them about me and my family. Then I told them about my job. After that, I let them just ask questions about anything. It was great fun. They asked me about TCM in the U.S. We talked about the Olympic Games. I told them stories about when my state hosted the games. We discussed health costs in the U.S. I was very candid about my concerns. They asked me for advice on how to succeed in life. I gave them some thoughts about goal setting.

I concluded my talk with the students by talking about why I meet with students like them. It is to plant seeds of relationship between our countries to help each of them know us better and for us to understand them. The students responded well, and we talked for an hour, but it could have gone much longer.

A Personal Curiosity

On the way back to the hotel, we stopped to see an animal display at the convention center. My interest was stimulated because a friend of mine, Ken Bearing, donated all the taxidermy. It is a spectacular display of African animals including an elephant, a 20 foot man-eating gator, a hippo and many others. It is displayed in a spectacular way. They have had over a million visitors since it opened a year ago.

On to Beijing

Tomorrow, it’s a speech to the American business community and then on to Beijing for meetings with various government officials.

Shanghai, China Blog II

No matter the culture, people get themselves messed up on drugs. Yesterday in Shanghai, I visited a methadone clinic in Xi portion of the city. That apparently means "west side." It's the older part of the city. I've visited similar clinics around the world, so the physical layout and process wasn't a surprise. However, I was able to talk with a couple of the patients at some length.

They are now serving about 175 addicts. Each day, they come to the clinic, check in, (often taking a urine test to demonstrate they have kept their commitments), pay the dollar co-payment they make, and then proceed to a counter where they are given a green liquid drink in an 8 ounce plastic cup. They gulp it down, followed by a water chaser. It appears to be a ritual they follow each morning.

A male patient, who I estimate was 30 years old and whose Chinese name I wasn't able to catch, told me methadone has a bitter taste. However, he welcomes it. A jolt of bitterness appears to be a welcome trade for the angst heroin addicts endure dealing with the drug’s slavish pang. Through our interpreter, he explained he is a factory worker and has a family. He seems like so many other factory workers who live out their lives in Shanghai. I wanted to know more about him, and how he had found his way to this point, but a crowd had gathered and the intimacy of our conversation disappeared.

A woman, whose Chinese name sounded like Julie, (I'm sure it was something else--my ear for Chinese is poor), told me how glad she was to have broken the grip of her addiction. She appeared to be in her early 20's and wore stylish tight fitting jeans and giant pink sun glasses. Her teeth were stained in way that seems common here.

Julie told me she had a job now, working at a clothing store. "I don't have to worry about finding money for my habit any more."

"Do you feel better physically," I asked.

"Yes, and my Father says my face looks good again," was her response.

I asked how she felt when her body craved heroin. She described achiness, nausea and her entire body shaking uncontrollably." What an awful plague heroin is.

She was persuaded to seek help at the clinic by a volunteer who knew she had a problem. Addicts know addicts.

Secretary Leavitt signs a message in a book of patient stories at a methodone clinic in Shanghai

Bi-lateral Meeting and the Earthquake in China

My friend, the Minister of Health for China, Chen Zhu, had to cut short the day we had planned to spend together so he could get to the scene of the earthquake in Chaendu. We had a poignant conversation about this moment of crisis.

The Chinese government is not unfamiliar with, or unprepared for, this kind of disaster. In 1976, a similar earthquake killed 242,000. They have mobilized their army and civil society. Minister Chen was anxious to be on his way. It was gracious of him to host the meeting under those circumstances.

We had a significant list of agenda items, which we moved through in about an hour. Most of the items relate to the agreements we have or are negotiating on a range of issues.

Business takes longer in diplomatic meetings of this type because of language interpretation. I have found it is important to break my thoughts into short bits. Good interpreters have the ability to mimic your expressions and voice inflections, thereby providing insight into attitude as well as content. For that reason, both sides normally supply their own interpreters.

Our meeting was held in the Shanghai convention center, a new facility which appeared to have a set up for such diplomatic meetings. The United States is not as good as many other countries at diplomatic hosting. We don't have budgets for it, and I would like to see us improve our approach.

Over the years, I have come to know the interpreters and staff for the various ministries. Having been with people from the health ministry many times now, there is a good sense of warmth and familiarity.

I also visited a large hospital and attended a museum to learn more about Traditional Chinese Medicine, but I will write more about that in my next post.

Shanghai, China: Product and Food Safety

Written May 12, 2008

Well, this blog entry will break new ground for me. I'm writing it with my Blackberry while striding up and down on a stair stepper in a health club overlooking Shanghai, China. Before you jump to any conclusions about my accuracy with thumbs, be aware I'm going to send this draft to my colleague in Washington and have her clean up my double letters and typos. With the day’s schedule it is likely the best, perhaps only, opportunity I will have.

Yesterday, I gave a speech to about 800 representatives of manufacturing companies from around the world who supply a major retailer in the United States, the Target Corporation. It was a significant chance to once again send the message that if producers desire access to American consumers; they will have to meet American standards.

I spent the afternoon with a local office of the General Administration for Quality Supervision, Inspection, and Quarantine (AQSIQ), a rough equivalent of a Chinese Customs and Border Protection. This is the entity in the Chinese government with specific responsibility for the safety and quality of imported and exported food. The people I met with had spent a significant amount of time in the United States, and understood our processes reasonably well. A half day is long enough to learn some essential facts, but not enough to draw conclusions. Most seaports have a similar feel around the world. Actually, most of the large unloading cranes are made in Shanghai.

HHS Secretary Mike Leavitt joined by Chinese inspectors looks at chicken shipped from the U S to the Port of Shanghai China's largest port

Not surprisingly, the Chinese see our concerns about the safety of food imports differently than we do. They repeatedly mentioned they require certificates before goods are shipped out of China, and point out we don't. They also want us to accept AQSIQ certificates as proof of the safety for Chinese food exports to the United States. I won't take that on in a blog, but it does indicate why it is important to understand the perspective of others. One learns a lot being able to talk with people on the ground.

I'm not going to get into a travel log, but there are a couple of observations worth making. This is an amazing city: incredibly vibrant and modern.

The Chinese are serious city-builders. They do infrastructure faster than anybody in the world, I think. They can just throw so many people at projects, and exercise such absolute social control, that they can move in a way that gives them a significant comparative advantage. In making that statement, I do not discount the negative environmental compromises, or the impact on human beings, but they have a clear set of priorities, and when they decide to move, things happen.

For example, they are building 150 miles of subway within the city in the next two years. Compare that to Boston’s Big Dig.

They decided to build a deep-water port about 18 miles off the shore of Shanghai on some islands. In order to get the goods from the port to the mainland, they needed a causeway. It will take them three years to build the causeway. It would take more than three years in the United States just to scope the work.

I was at the port when the earthquake struck. It was felt in the upper floors of our hotel, but not at the port. I visited the area of the earthquake last December. I am checking in at the White House to see if there are ways I can be helpful on behalf of the United States, and when I meet with the Minister of Health later today [Wednesday, May 13], I will express my condolences from all Americans for the loss of life here.

The disasters here and in Burma are frightening examples of how vulnerable we are as human beings.

Today, I'll visit a hospital and school of traditional medicine, and meet with a large group of students. Tomorrow, I'll meet with American businesses in Shanghai to discuss product safety, before I leave for Beijing.

Value-Driven Health Care Interoperability

I thought you might be interested in a brief report on our progress related to electronic health records (EHR). They are a critical element in making the health care system become value-based.

Just having electronic health records isn’t enough. The systems have to be interoperable. Interoperability means that different computer systems and devices can exchange information.

Three years ago, there were 200 vendors selling electronic health record systems but there was no assurance that the systems would ever be able to share privacy protected data in interoperable formats. Since then, we have made remarkable progress.

An EHR standards process is now in place, and we are marching steadily towards interoperability. We created the CCHIT process to certify products using the national standards and it is functioning well. More than 75% of the products being sold today carry the certification.

In addition, a National Health Information Network will start testing data exchange by the end of the year and go into production with real data transmission the year after.

The number of hospitals and larger physician practices employing electronic medical records has grown. However, we continue to have a serious challenge with small- to medium-sized practices where fewer than 10 percent of these practices currently have health IT systems.

The primary reasons for low adoption rates among small practices are predictable: economics and the burden of change.

We are experimenting with different methods of changing the macro economics of reimbursement so that small practice doctors share the financial benefits.

We are also beginning a pilot program that provides Medicare beneficiaries with personal health records.

Finally, HHS is signaling that in the near future, payers like Medicare cannot reimburse doctors at the highest level unless they can interact at the highest level of efficiency.

A good example of this is e-prescribing. The software exists in nearly all pharmacies and in many doctors’ offices. It saves money and lives. It’s time to fully implement e-prescribing.

I’m hoping Congress will give HHS the ability to establish e-prescribing requirements as part of Medicare legislation in June of this year.

Learn more about Value-Driven Health Care.

Value-Driven Health Care

Over the last three years, I have been visiting different communities where groups have formed to pursue the measurement of quality. Generally, it has been a few curious doctors, convinced if they had a way to measure quality they could improve the outcomes. Other times, it would be a group of large payers looking for metrics that would allow them to negotiate lower prices. The best of these organizations however, are the places where all the stakeholders are working together.

The collective result of all these groups working independently was a large number of measures but not much standardization. Our progress was highly fragmented.

Great effort has been made recently among medical organizations, insurers, government, employers and unions to develop what I will collectively refer to as the “quality enterprise.” I’m referring to organizations like the National Quality Forum, the AMA Physician Consortium, the Ambulatory Quality Alliance and Hospital Quality Alliance and others.

I am a big advocate of this kind of collaborative stakeholder process. I think it is the best way to arrive at national standards. I often restate the commitment of HHS to adopt endorsed measures when they are available and to adapt our activities as they are adopted.

While progress is being made, gaining agreement on a modest number of uniform measures has taken a fair amount of time. Frankly, the process remains complicated and slow. Hopefully, it will gain speed as experience is gained.

However, we need standardized methods for quality measurement and very soon.

As health care’s largest payer, I believe HHS has a duty to push the envelope and I want to tell you about a project we have initiated.

HHS is in the process of doing an inventory of all the quality measures we are currently using someplace in HHS. We intend to harmonize the measures we are using, and then we plan to publish our set so everyone can see our current and planned measurement thinking.

I hope this will have the effect of accelerating the velocity of the quality standards process.

With standardized quality measures laid beside standardized price measures like I wrote about earlier this week, consumers will be in a position to make value the most rewarded virtue in health care.

Learn more about Value Driven Health Care.

Single Price Health Care

I often talk about the need to make “value of care” rather than “volume of care” the best rewarded virtue in health care. I want to elaborate on what I mean in using the word value.

A couple of days ago, I listened to a consumer report on CNN evaluating hybrid cars. The reporter was discussing an independent evaluation someone had conducted to determine the relative merits of several models. They had created criteria to hold each car against as a means of measurement. Then the price of each one was compared. The car that scored the best quality at the lowest cost was determined to be the best buy, or best value.

Given the proper information, consumers should be able to make similar comparisons on health care. Until recently, little information has been available for use by consumers. That is changing. Great effort is now being made to evaluate the quality of services a patient gets in different settings.

It takes both quality and price information to determine value. The problem in determining price is that the billing system is simply insane.

I’ve tried to imagine using the way we bill health care in any other part of the economy. To continue the automobile analogy, let’s just speculate on what would happen if we transformed the automobile industry to adopt the health care pricing structure?

The dealer would say to a customer, “We don’t really know the price and we haven’t got a way for you to compare this car for quality but we know you need it, so come in and we'll give you the car.”

Then about three weeks later, the customer would start getting bills. There would be a bill from the people who made the car’s body. Another bill would arrive from the transmission people. Everyday more bills would arrive from seat makers, the paint people, and the folks making the sound system.

Then when the bill from the dealer comes, there would be a charge for time spent in the show room, a separate charge for the salesman’s office with a $27.90 cent item for the coffee you drank while there.

Gratefully, they don’t sell cars that way. All those costs are packaged and managed by a car company. Consumers get one price they can understand.

Some of my friends in the practice of Medicine will find my analogy troubling, pointing out that health care and a car purchase have significant differences. Okay, the analogy isn’t perfect, but let’s not miss the point.

The way we price health care cannot be understood by a human being of average intelligence and limited patience. And I think it’s also time we began to challenge the assumption that health care is all that different from other things consumers buy.

For many common procedures and conditions, consumers should be able to ask for and receive a firm, single price, and expect providers to stand behind it. Such a system would promote coordination and accountability and allow apples–to-apples comparison.

It can be done. Last year, Medicare paid for 255,000 knee operations. Incidentally, we paid for 95,000 heart bi-pass operations and 95,000 lung cancer treatments. Believe me. When you pay for 255,000 of anything, you know what medical supplies, services, procedures and facilities somebody getting a knee operation is going to use; and so do the medical providers who perform them.

I believe HHS has a responsibility to push the envelope on this. We will soon publish information on top Medicare procedures by cost and volume as part of an efficiency measurement roadmap for the department. Medicare is also developing a demonstration that would establish bundled payments for hospital-based episodes of care.

Participating hospitals would be able to competitively bid for episodes, then savings would be shared with beneficiaries who choose hospitals providing services at below the per episode rate.

This not only holds the potential to improve quality and reduce costs by encouraging physicians and hospitals to work together, but also encourages more informed consumer decision-making.