Iraq Blog VI

Nothing Spared to Save Our Soldiers

Baghdad is still a tough place. Though there were apparently a couple of IED episodes in Baghdad while I was there, I was not aware of when they happened. However, a visit to the Combat Support Hospital (CSH) inside the Green Zone had a powerful impact on my understanding of the reality of war.

I met the doctors and nurses on duty that day. They walked me through their sobering business as if I was a patient arriving by helicopter, as most of their patients do.

I noticed a flag had been hung on the ceiling of the doorway through which wounded soldiers would be wheeled. I was told, “We want the American flag to be the first thing they see here. We want them to know they have come to a place where no effort will be spared to give them what they need. We want them to know once they get here, there is a 98-percent chance they will survive.”

In general, the staff observed that, thankfully, trauma treatment for combat-related injuries had slowed dramatically. We walked into the trauma center. During my visit, it lay quiet, but, on some days, as many as 40 soldiers will lay on those tables, victims of explosions, bullets or other combat injuries. The chief nurse who briefed me said, “Sometimes all three of these tables will be full, the floor will be covered with blood, and there will be a line of gurneys waiting, but the most remarkable thing to observe is the calm professional way in which this team provides care. Nothing is spared.”

After a wounded soldier has been stabilized, and the extent of injuries determined, most must go to the operating area. We walked the pathway along which so many had been rolled. I found myself imagining what would go through their minds as they deal with the pain and uncertainty of their circumstances.

Secretary Leavitt and Chief of Staff, Rich McKeown on a tour of the CSH.

We entered the operating area. At the moment we were there, only two of the several operating theaters were in use.

I looked through the window of the dual swinging doors, and could see the body of what was obviously an Iraqi man, lying naked on the operating table, with a team of four working over him. He had lost a hand, had a serious wound to his head, and the team had his chest open working to remove a piece of metal.

The chief nurse explained to me he was Iraqi, and appeared to have been setting an explosive device of some type when it had blown up prematurely. He had received the blow he had intended for one of our soldiers.

What interested me is that the United States provides him the same care we would one of our soldiers. Something tells me that isn’t true of the insurgents and the terrorists.

In the second operating theater was another Iraqi, wounded in combat. It was another scene where the nature of his injuries made the seriousness of war graphically apparent. I won’t go into detail, except to say they were extreme. The surgeon, a youngish looking guy who was on his second tour, conceded to me that the first time around it was somewhat shocking, but this time, he knew what to expect. The emergency surgeries are, he said, “a professional challenge like none other I have ever faced.”

It is not unusual to have a wounded American soldier arrive at the CSH, get stabilized and be on an airplane to Germany on the same day.

On my way out the door, I saw a little Iraqi boy who was being treated for a poisonous snake bite. His father was at his side. A significant part of our military medical resources in Iraq go to provide treatment to local citizens. One thing I know is that their view of America and Americans will never be the same.

As Prime Minister Maliki told me, “Health care is one of the best messengers of peace between nations.”

Iraq Blog V

Meeting Prime Minister Maliki

On my second day in Iraq I had a 30-minute meeting with His Excellency Nouri Kamel al-Maliki, Prime Minister of the Republic of Iraq. I had not met him before.

His office is inside the protected Green Zone, in a rather remarkable building I understood to be the home of one of Saddam’s sons at one time. I’m not sure of that, but, by any account, it was ornate and tastefully done. I was joined in the meeting by the Ambassador from the United States, Ryan Crocker, with whom I had met the previous day, and the senior members of my delegation. Minister of Health Salih also attended, sitting on Prime Minister Maliki’s left.

Prime Minister Maliki went into exile in 1980, after Saddam Hussein’s regime sentenced him to death for his leadership role in an opposing party. He spent his time away in Iran and Syria. He was elected as Prime Minister in May of 2006.

Visits with a Head of State or Prime Minister have a rhythm about them. There is a formal greeting, and a few pictures. Generally, one sits on the right of the host. The media is invited in for a picture; when the media is cleared out, a more formal part of the conversation can begin.

Typically, the Head of State speaks first, and offers a greeting, maybe laying out some things he or she is interested in talking about. Then the visitor responds with similar expressions.

I told the Prime Minister why I was there by relating the experience I had in talking with the American health community about receiving Iraqi physicians for short-term exposure to current medical practice. I referenced the unqualified generosity and willingness uniformly expressed by everyone I spoke with.

Secretary Leavitt (left); interpreter (middle); Prime Minister of the Republic of Iraq, Nouri Kamel al-Maliki (right)

I expressed the view that our Governments were developing working relationships, but it was important, in my view, that we begin concentrating on connecting the American and Iraqi people. I referenced the historic quality and regional leadership of the Iraqi health-care community, and acknowledged the damage it had sustained during the previous 30 years of neglect. I told him we wanted to support the goal of returning Iraq to its previous stature as a center of excellence for medicine in the Middle East.

The Prime Minister said he was not surprised to hear of the positive way people had responded to my request. “This matches what we have come to know about the American people and their desire to help others,” he said.

He went on to say, “We need to build bridges based on love and appreciation. Health care is one of the best messengers of peace between nations.”

We had a fairly lengthy conversation about the dual agreements currently being negotiated between our nations. A blog is not a place to be talking about the specifics of that kind of conversation. It was candid and productive.

I will say that he had some fascinating observations about the challenges of governing people who have freedom thrust upon themselves for the first time. I saw some of that play out, first-hand, later in the day, as I traveled outside the Green Zone to a major teaching hospital in the Medical City complex in Baghdad. (I wrote about that in my previous blog.)

Iraq Blog IV

Iraqi Health Outside The Green Zone

I wanted to see health-care facilities, patient care, and to talk with doctors and health-care workers outside the Green Zone. It was suggested I visit Medical City in central Baghdad.

Medical City is the largest medical complex in Iraq, and includes six hospitals and the Baghdad University College of Medicine. It has almost 3,000 beds, and is the leading provider of tertiary services for the entire country.

During the 1990s, the complex’s infrastructure aged, and the hospitals have suffered rapid degradation. As Prime Minister al-Maliki told me, “Medical City has exceeded its expiration date.”

The tap water in many of the hospitals is not safe to drink, equipment is not sterilized and doctors cannot find water or disinfectant to wash their hands. The availability of medicines and medical supplies is a major problem.

Getting there was rather instructive on the challenges that remain. While I acknowledge my profile as a target likely warranted some special precautions, there are obvious risks anytime an American ventures outside the Green Zone, and serious security operations have to accompany any such move. The people executing the moves are well-trained and operationally proficient.

For security reasons, I won’t go into details, but, suffice it to say, the move involved a coordination of multiple operating units on the ground, and in the air. We wore heavy protective gear on our persons, and moved fast, minimizing any opportunity for a negative incident. I feel appreciative toward those who planned and executed my travel around Iraq so safely and efficiently.

Once at Medical City, it became clear health care in Iraq is different from that in many countries. Iraqi health-care facilities rely less on nurses and technicians. It is not uncommon for families to take up residence in the hospital to care for family members. In fact, I was shown facilities set aside to house some of them. I was told in some facilities they will even cook in the hallways, but I didn’t see that during my visit.

While I did tour a pediatric unit, where I mostly saw premature babies, most of whom had been born in other regions of Iraq, I was not able to tour many of the patient areas because of security concerns.

Much of my time was spent talking with students, faculty and staff. I began to experience what the Prime Minister had referenced in our conversation about what happens when freedom is given to people who have been oppressed for a time. There is a profound impatience for improvement.

Secretary Leavitt talking with Doctors

Students would talk about the inadequacy of their training. Using the Internet, they know what is available in the rest of the world, but they see little of it.

In a meeting I held with students who were bused in from Baghdad University, I ended up playing referee for a fascinating exchange between a student and the Dean of the university’s medical school.

The student, in his final year of his six-year course, had made the point he and his peers were not being exposed to new imaging technology. The Dean stood up to say the medical school did have some new imaging equipment, and that the students’ training included exposure to it.

The student responded, “With all due respect, sir, we don’t have access to it. I just finished my radiology section, and we only got to see the CAT scanner through the glass of a locked door. Nobody knows how to use it.”

That exchange was symbolic of what I heard over and over again.

At the conclusion of my meetings with a fairly large sample of Iraqi medical people, I came away resolved that in the short time I have left at HHS, I would find a way to facilitate more direct contact between practitioners in Iraq and American doctors. Even if it is just e-mail, calls over cell phones and an occasional video conference, both sides of the equation will benefit, and our relationship with the people of Iraq will grow.

We have a strong and complex relationship with the Government of Iraq. Our relations now need more contact between our people.

Iraq Blog III

An Iraqi Agenda for Health-System Improvement

Yesterday, I related how terrorist and sectarian forces in Iraq have used tactics right out of the insurrectionist’s handbook to target and disrupt health care. They have done this knowing that few things discredit the legitimacy of a struggling democracy better than the discontent surrounding a lack of health care.

Today, I will tell about some of the things the United States is doing to help the new Minister of Health to re-establish health care in his country. Victory here is essential to allowing the people of Iraq to feel confidence in their new Government. Health is so personal it transcends nearly every other service in this way.

I reported in yesterday’s blog that thousands of Iraqi doctors have fled the country. Dr. Salih’s first priority has been to persuade them to return. The most obvious thing that had to happen for that to occur was for the security situation to improve. The progress in this area has been widely reported in the media. I saw evidence of that mainly in the discussions I had with health providers. They feel it is safer now.

Once doctors feel their physical safety can be assured, the next step is to tackle some very difficult compensation issues. Officials at the Ministry of Health told me doctors within their public health-care system were being paid as little as $3.00 a day. The result is corruption. They can’t live on that amount, so they are forced to resort to other means.

Like almost every socialized system in the world that promises health care for all, two systems end up operating. Doctors work in the public system in the morning, and in the afternoon they practice for themselves on the side. Doctors will then try to steer patients to their private practice where they can accept payment for services and medication. In some cases the doctor may have lifted the medication from the public supply.

Incidentally, this is the big lie of socialized medicine. The waiting lines created by rationed, “free” care end up overflowing into a private system where people have to pay to actually get care. (A subject for another day.)

Minister Salih has succeeded in increasing salaries for doctors by $2,000 to $3,000 a month over what they were previously paid. He is increasing training programs for doctors and support staff. That is having an impact.

No new hospitals have been built in Iraq for the past thirty years. Hospitals suffer from bad infrastructure, and from defective water systems, inadequate electricity, unsafe sewage systems and other problems. The buildings are old and worn, and need lots of repair work.

The World Bank (to which our country is the largest contributor) will soon execute a grant to build six to seven new teaching hospitals. The United States has been helping directly to develop better facilities. So far, the U.S. Agency for International Development has paid to build more than 136 primary-care clinics and small hospitals around the country. We’re also helping them build a big children’s hospital in Basrah.

The reality of the staffing problem confronted me when I found out that, because of staffing shortages, several of the new clinics are not open yet to the public. They are equipped and ready, but there are no people yet to man them.

Fortunately, there is some good news to report there. In the last year, more than 800 of the doctors who left have returned to Iraq. There are thousands more that are still away.

As a result of this trip, we at HHS are instituting a number of additional measures that I hope will help. I will detail those in a future blog.

The bottom line for me was that Dr. Salih, despite working with impossibly difficult conditions, is making progress. He is one of many heroic figures I have encountered who risk their lives to do this service.

There are thousands of Americans doing the same thing. One American I would like to acknowledge in this category is my Health Attaché in Iraq, Dr. Terry Cline. He follows three others who have served in the same position, CDR Bruno Himmler, Dr. Jon Bowersox and RADM Craig Vanderwagen.

The Health Attaché represents the Department at the U.S. Embassy in Baghdad. Their job is coordinating all our activities in the country. He is our player-coach on the field.

Secretary Michael Leavitt, Health Attaché Terry Cline, and Chief of Staff Rich McKeown

It was clear to me that Terry has built great relationships of trust, with the Health Ministry and others within our Embassy. He is making a serious impact.

Dr. Cline was the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) at HHS. He volunteered to do the job, and, while it was hard to lose him in that job, it was clear to me he felt a passion for going to Iraq.

Spending time with him in Iraq reminded me of the sacrifice our soldiers and diplomats make, voluntarily, and how fortunate we are that they are willing to do so.

One last observation about my first day in Baghdad; it was Sunday, and I had hoped I could find a church service to attend. In the evening, somebody told me about a Spanish-language congregation that held a late meeting. I found myself in Baghdad, Iraq, worshipping alongside Spanish-speaking soldiers and contractors, mostly from Perú. An interesting way to finish the day.

Iraq Blog II

A Health Life-line from the American People
Written October 17, 2008

Upon arrival inside the Baghdad Green Zone, I was given a situational overview by a group of U.S. Embassy personnel, and then proceeded to a series of meetings with the Health Minister and different groups of doctors. Those meetings were held at the al-Rasheed Hotel, a famous landmark in Baghdad. During the 1991 war with Iraq, CNN broadcast live from one of the upper floors of the hotel.

Mid-afternoon, I left the hotel for a thirty-minute meeting with U.S. Ambassador Ryan Crocker and General Raymond T. Odierno, the Commanding General of Multi-National Force- Iraq. Both of them are impressive and highly experienced men dealing with enormously difficult tasks.

Most of our discussion related to the Status of Forces Agreement (SOFA) and the Strategic Framework Agreement, currently being negotiated between the United States and the Iraqi Governments. These are complex agreements that will define the nature of our interaction after December 31, 2008, which is when the United Nations Resolutions expire.

Secretary Leavitt meeting with U.S. Ambassador Ryan Crocker and General Raymond T. Odierno.

Following my meeting at the Ambassador’s office, we drove back to the al-Rasheed to continue a succession of meetings and conversations with the leadership of the Health Ministry and doctors from around Iraq.

The Minister of Health, Dr. Salih Al-Hasnawi, is a psychiatrist by training. He has a steady, calm demeanor that engenders trust. He speaks English well enough that we can communicate without problems. Most of all, he seems genuinely committed to improving the health of the Iraqi people.

Dr. Salih works in a very difficult and somewhat dangerous atmosphere. Previous Ministers have been subject to assassination attempts. He must have massive amounts of security for that reason.

Dr Salih’s security concerns are emblematic of the primary reason the health-care system in Iraq is so desperately in need of help. Insurgents have strategically and systematically targeted doctors, hospitals, and health workers. They have kidnapped or wounded thousands of them, murdered hundreds, and threatened their families. This follows 25 years of deprivation and abusive practices under Saddam Hussein.

Throughout the day, I sat with doctor after doctor who related stories of being shot, kidnapped, threatened and tormented by the thought that they or their families could be next. One told me privately of e-mails, notes and phone calls in the night threatening him and his family because he treats members of the Iraqi Army.

Others described how hard it is to get staff to come to work when health clinics are bombed. They feel intimidated and scared. One person described the health community as suffering wounds upon wounds, never fully able to recover.

These are tactics right out of the insurrectionist’s handbook. If you disrupt the capacity of the government to provide essential services, it discredits the government, and creates a fertile ground to foment terrorist ideology.

There is nothing essentially more personal than health care. That is the reason insurgents and terrorists focus so intensely on it. Not just in Iraq, but all over the world. The pattern is the same.

Regrettably, the tactic has worked in Iraq. Out of 34,000 doctors registered in Iraq in 1990, at least 20,000 have left the country. Since 2003, 8,000 doctors have stopped practicing medicine; more than 2,200 Iraqi doctors and nurses have been killed, and over 250 kidnapped. The doctor’s flight further crippled health institutions in Iraq, because without them corruption and mismanagement became the rule. Iraq probably needs around 100,000 doctors to meet the needs of its population, but has at present only 15,000.

The doctors who remain spoke to me of the hunger they have for professional improvement. They have had no capacity to interact with doctors in other countries who can teach them updated techniques.

In one of my meetings, I sat with a group of mental-health practitioners who had just returned from the United States on a program sponsored by my Department. We arranged for about thirty of them to spend time with their counterparts in the United States. These people were energized and appreciative. Every one of them reported continued conversations by phone and e-mail with mental-health professionals in the United States who have become friends, confidants and mentors. One can only imagine the mental-health toll the last thirty years have created in Iraq.

Tomorrow, I will talk about Minister Salih’s plans to begin rebuilding the health-care system in Iraq.

Iraq Blog I

Sleeping at Saddam’s Palace
Written October 17, 2008

In the spring of this year I was visited by Dr. Salih Al-Hasnawi, the Iraqi Minister of Health and the Iraqi Ambassador to the United States, Samir Sumaidaie. They came with a specific request; help in providing re-training for doctors in Iraq.

Thirty years ago, Iraq was considered a center of health care excellence within the Middle East. Deliberate under-funding by Saddam Hussein and five years of focused kidnappings of doctors, bombings of clinics and ruthless killings of health workers by insurgents has resulted in thousands of doctors leaving the country. Those who stayed have fallen behind, deprived of an exposure to professional enhancement or even contact with others within their area of specialty.

The Minister’s request was that we organize opportunities for Iraqi doctors to shadow American doctors who practice in their specialty for a period of a few weeks. Doing so, he reasoned was the most efficient way to update them on the current practice of medicine. It would also establish relationships, allowing Iraqi practitioners to continue contact after they return home.

I found the Minister’s request compelling, and committed to explore the possibilities. The idea seemed feasible, especially because the Minister committed to pay all the costs of the traveling physicians.

Following our meeting, I did two things to test-drive the project’s viability. I organized a working group at HHS and assigned them to study the barriers to such an effort. In addition, as I traveled around the United States over the next couple of weeks awarding Chartered Value Exchange charters, I asked to meet with leaders of medical associations to explore their enthusiasm for undertaking such a project.

I was gratified to find American medical communities energized by the thought. Many had suggestions and helped flesh out the challenges we would need to overcome to make it work.

Ultimately, I formed an HHS team, called the Minister of Health and committed we would generate a pilot group before the end of the year. I hoped, in executing the plan, we could get the program organized and operating before I vacated the Office of Secretary. Looking back, I have to admit, I underestimated the amount of bureaucratic challenges, diplomatic obstacles and legal entanglements necessary to do what seemed like a fairly simple task.

In addition to organizing the effort, I committed to visit Iraq myself to show U.S. support for the Ministry of Health. This was important to the Minister, because he was struggling to convince the thousands of Iraqi doctors who had fled the country to return. Having the Secretary of Health from the United States visit and announce such an effort would add needed credibility to his message.

On October 17, 2008, I flew from Washington D.C. to Amman, Jordan, stayed the night, and then took an Air Force C-130 from Amman to Baghdad. While Iraq is a safer place than it was six months ago, the heavy, armored vests and steel helmets we wore everywhere we went served as a reminder of the fact we were flying into a war zone.

Secretary Leavitt and Air Force crew on flight to Iraq

Once inside the Green Zone, we were taken to our billets for the two nights I spent there. I slept in a building just off the swimming pool at one of Saddam Hussein’s palaces. The palace is now used as offices for various components of our government’s operation there. It is teeming with people, all walking with a notable briskness. The exterior is surrounded by a maze of concrete “t-walls,” used to protect people from explosions. The compound is dotted with duck-and-cover shelters that serve as protection from mortars lobbed across the walls from outside.

Despite the gold door knobs and marble floors, the sleeping accommodations were spartan and basic. My room had two, inexpensive twin beds, a small desk and a 16-inch television. We ate our meals with the soldiers and contractors.

Sleeping accommodations in Saddam Hussein’s palace

In many ways, the current use camouflages the remarkable opulence of the gold trim, ornate carvings and egotistical murals and self-tributes in the massive rooms of the palace. One could not walk the halls without thinking of the evil conducted there in years past.

The pool was big, beautiful and well-used by soldiers looking for a place to relax and exercise. It was surrounded by traditional amenities soldiers use: A ping-pong table, billiards and a popcorn machine. None of it covered up the soberness of the task, or the time.

Pakistan- blog III

Note: August 19 and 20 I spent in Pakistan and wrote three postings about the experience on my way back from the region. Regrettably, in the interim, terrorists bombed the Marriott Hotel in Islamabad killing 53 people. I want to acknowledge that tragedy, express my condolences to the Pakistani people, and put my writings into proper time context.

As described in my first posting on the Pakistan trip, I traveled there at the invitation of Minister of Health Sherry Ruhman, who had visited my office weeks earlier. Our conversations convinced me I could accomplish multiple things with a trip to Pakistan. I had a couple of days between my trip to Africa and an assignment to represent the President at the closing ceremonies of the Olympic games, and Pakistan was generally on the way, so I decided to go. I had two objectives principally:

• Learn more about how terrorist organizations use health care as means of nurturing support among local communities
• Reinforce, by being there, the ongoing friendship of the United States with Pakistan’s leaders.

Terrorists sometimes hide in the most remote regions of the world or hide in plain sight within communities. In either case, having support, or at least acceptance among locals, is necessary to cover their existence. From what I’ve read, this is well illustrated in Iraq, where locals appear to be turning against terror organizations and assisting security forces in rooting them out.

The region along the Pakistan/Afghanistan border is notorious as a haven for al-Qaeda. Many speculate it is the hiding place of Osama Bin Laden. Periodically, the United States conducts military activities in that region to root them out.

In order to cultivate support among the local people of that region, terrorist groups work through non-governmental organizations friendly to their cause to undermine the credibility of the government in providing basic services like health care. They then set up clinics and actually provide services to the people themselves. Terrorist organizations have discovered the power of health as a tool in securing the loyalty of local people.

This happens all over the world. I spoke with Special Forces Teams who conducted health missions in Northern Mali, another place where al-Qaeda finds isolation. In Northern Mali, Cuban health teams provide medical services. In Lebanon, the government’s health role has been almost entirely taken over by Hezbollah, an Iranian supported political party.

In Pakistan, the national government is able to deliver very little health care and it is unsafe for any U.S. support to attempt delivery. In the border region, the best role for our government is to provide assistance to the Pakistani government. It is their duty and they need to be the face of health. We have a significant stake in their success, however. To the degree that people believe their government cannot deliver, terrorists are enabled.

Throughout the rest of Pakistan, the situation is different. I sense our biggest problem is that ordinary Pakistani citizens don’t have any idea how much we do for their country. When combined with their complicated politics, the United States is not currently held in high regard by the Pakistani people.

One region where the United States is greatly appreciated is in the area of Northern Pakistan that was struck by an earthquake in late 2005. I flew by helicopter over the area. Even two years later, the size and magnitude of the earthquake was evident.

The United States sent massive aid to help. The most important assets at the time were large helicopters with the words, “United States of America” written on the side. People knew the United States was there.

We have not left either. I met with community leaders at the site of one of many health centers our government is building. We are also paying to train medical workers. I stopped at a training meeting of traditional birth attendants who were learning how to deal with a particular complication.

Secretary Mike Leavitt attends the opening of a training course for local doctors and nurses in an area affected by the Kashmir, Pakistan earthquake of 2005. The course, sponsored by USAID, is for local doctors and nurses and is key to reducing traditionally high rates of maternal mortality.

Most impressive was the difference in how our reception felt in that region. People compensate health diplomacy with their loyalty. Terrorists know that, and we need to use health diplomacy as a tool against terrorism.

Pakistan- Blog II

Note: August 19 and 20 I spent in Pakistan and wrote three postings about the experience on my way back from the region. Regrettably, in the interim, terrorists bombed the Marriott Hotel in Islamabad killing 53 people. I want to acknowledge that tragedy, express my condolences to the Pakistani people, and put my writings into proper time context.

The difference in security level for my visit to Pakistan and most other countries I visit was evident immediately. I arrived in Islamabad late in the evening. We were taken immediately to the Embassy where Ambassador Anne Woods Patterson invited me to stay. It felt good to sleep in a Marine guarded place.

Early the next morning, I met with the Ambassador Anne W. Patterson and the U.S. Embassy's Deputy Chief of Mission, Peter Bodde, for a country briefing. They confirmed what I already knew. Pakistan was at an historic juncture with President Musharraf having resigned the afternoon before.

My meeting with Minister of Health Sherry Rehman was surrounded by an atmosphere of political excitement and some intrigue. Minister Rehman is a significant player in the Pakistan Peoples Party (PPP). As I mentioned in my last blog, she had been deeply involved in events leading up to the resignation of President Musharraf. In addition to her role as Minster of Health, she is also the Communications Minister and hence a frequent public spokesperson for the party’s interests.

Minister Rehman was moving in and out of meetings involving the difficult task of holding together a governing coalition after the resignation of President Musharraf. She provided me with a certain amount of commentary on their progress as we moved throughout the day. I won’t repeat any of the specifics, because they were private conversations, but it was clearly not going to be easy.

I had similar conversations with Prime Minister Raza Gilani, whom I met with during the afternoon. Then in the evening, I had dinner with a group of leaders from throughout the government. Obviously, the President’s resignation the day before was the primary topic of conversation, and it was hard to resist focusing on their speculation. The buzz was the same; the coalition was going to be difficult to hold.

As it turns out, the governing coalition was not able to stay united. Ultimately, because the party of Nawaz Sharif, (whom Mr. Musharraf had ousted as Prime Minister in a 1999 coup), and the PPP was divided on a question related to reinstatement of some judges who had been fired by the former President. The worry was that failure of the coalition could send the country into early elections.

The PPP was able to engage another small party that allowed them to claim a coalition and win the election of President Asif Ali Zardari in the electoral college, which consists of the Pakistani Senate, National Assembly, and the Provincial Assemblies.

My timing was fortunate. Standing on the periphery, as an event of historic importance took place in a foreign government, is not likely going to happen to me again.

When events put control of a government into play, security concerns go up. Pakistan is a nation where rival parties routinely attack each other with bombs and other means of destruction. Islamabad is not as pronounced as Karachi that way. The security arrangements for my visit reflected the risk.

During my visit in Pakistan, a number of terrorist bombings occurred killing almost 200 people, and I read in the news about an unsuccessful attack on an American diplomat in one of our Consulate cities. Driving through Karachi on Wednesday of that week, the Consul General at Karachi, Kay Anske, who has spent many years in Pakistan on various assignments, began to tell me about the level of violence that routinely occurs there. Often, rival political factions battle each other. So, the violence is not always targeted at foreign governments.

As the Consult General and I drove thru Karachi, things just seem so normal here. It is hard to imagine a car bomb just exploding on an ordinary street on a regular day. I wondered out loud, about how much the threat of such violence inhibits the normal life of people?

My impression is that it doesn’t inhibit life much. In every society, there is a definition of normal. People just learn to live with the risks. I would not enjoy life in such a risky place, but the people of Pakistan (and our courageous diplomats) for the most part, don’t have a choice, and they just live with it.

Pakistan- Blog I

Note: August 19 and 20 I spent in Pakistan and wrote three postings about the experience on my way back from the region. Regrettably, in the interim, terrorists bombed the Marriott Hotel in Islamabad killing 53 people. I want to acknowledge that tragedy, express my condolences to the Pakistani people, and put my writings into proper time context.

Several weeks ago, I had a visit at HHS from the Health Minister of Pakistan, an impressive woman named Sherry Rehman. She is also the Information Minister, which, by her own assessment, fits her background better than the health portfolio. She was a well respected journalist in Pakistan as a magazine editor. However, the Prime Minister had asked her to wear both hats in the government, and she seems to have developed a real passion on several of the health issues.

She had come to Washington, D.C. to ask for assistance in some specific projects, but our conversation turned a different direction. I asked if she saw evidence that organizations sympathetic to terrorists were using health care as a means of cultivating support among the people, particularly in the Federally Administered Tribal Areas (FATA).

The FATA is a region on the Pakistan/Afghanistan border, where the national government of Pakistan has very little presence and little, if any, control. This is a rugged mountainous region that is simply not controlled by the government. It is the place people believe Osama Bin Laden holds up and, unquestionably, a great deal of terrorist activity is harbored and hatched.

Minister Rehman acknowledged that the combination of the danger and lack of resources means little or no health care is provided by the government. She also indicated there are a number of organizations with terrorist ties who sponsor clinics and other facilities.

I asked the Minister if she thought the people of Pakistan, outside the FATA, had any idea how much help the United States provides now. She made two points in reply. The United States is quite unpopular right now in Pakistan, and people there aren’t aware of the quite-generous assistance we provide in many categories, not just health care.

Neither of her points surprised me.

One exception to that is the help the United States provided after the 2005 earthquake in the Kasmir region. She said that people not only know of the help in that area, but are deeply grateful.

I believe health is a powerful diplomatic tool. I have seen it all over the world. Health is a universal language. When a person or loved one is hurting, whoever helps will be considered a friend. Terrorist organizations like Hezbollah know that. Castro has been using this tactic for a quarter century.

This is a subject to which I have been giving considerable thought. In fact, I am currently writing an article on the subject, based on my experiences over the past four years. I won’t try to frame up my thoughts in this short piece, but I will simply say that I believe health diplomacy should become a significant theme in the fight against terrorism, and that we can do better than we are right now.

Minister Rehman and I had many common thoughts. Our conversation was thought provoking to me. At the conclusion of our discussion, she asked if I would be willing to visit Pakistan. I knew I would be in the region during August and committed to do so.

I did not expect my visit to be at such an intense moment. In the days leading up to my visit to Pakistan, as I monitored the news clips on the political situation, I began to see the name of Minister Rehman quite prominently as a leader of the ruling party’s effort to impeach President Mushariff. As I traveled through Africa, the pressure increased on the President, and on the day I arrived in Islamabad, he resigned.

Needless to say, the two days I was there were exceedingly interesting, both in terms of the understanding of our health diplomacy in the region and the politics of Pakistan. This was my first visit to Pakistan. I don’t pretend to have a sophisticated knowledge of the region, but because I met with many of the major players in the immediate aftermath of the resignation, my observations should at least be written down.

My blog tomorrow will deal with observations after visiting the earthquake zone and the profound improvements in the standing of the United States within that region. The blog following that will recount the experience of watching the government struggle to develop a coalition around a new President.

Weekends of Hurricanes

The past weekends were full of disaster preparation. In previous blogs, I have talked about the competence of the people who manage disaster response in our country and the substantial increase in our readiness in the three years since Katrina. That point of view has only been enhanced watching them manage emergencies in two successive weeks.

As Hurricane Ike moved closer to land fall in the United States, it looked to be a massively treacherous storm. When I woke up Friday morning, the words “may face certain death,” were being used by weather forecasters to describe anybody ignoring the evacuation advice.

Every few hours, I had a conference call among my advisors and emergency managers to update me on the storm. This storm, like Hurricane Rita in 2005, was dancing across the gulf, changing directions at least five times. Each time required responders to begin evacuating a different population. Late in the afternoon, it was evident that it would hit the Galveston and Houston area. The storm was projected to have category 4 winds and ocean surges as high as 25 feet, which would produce widespread disaster— serious disaster.

On the final call of Friday evening, our equipment, supplies and people were in place and all we could do was wait for the storm to pass.

Saturday morning at about five a.m., I got up to watch the early television reports. I was relieved as the morning passed to hear officials say that the massive surges being forecast were not developing. We deferred the call until noon so our command center could gain situational awareness and consider how our preparation needed to be altered.

During the noon call, it became evident there were a number of communities hit hard along the coast. We were well positioned with assets to meet the requests of the states. I got a report on our capacity to respond to the millions who had been evacuated.

By Sunday afternoon, we were discussing when I should visit the area. The decision was made that Monday would be too early, things were still playing out and that I would fly down on Tuesday morning, stay the night in Austin and return Wednesday, visiting four cities during the two days.

Monday morning, we woke to news that problems of another kind had been occurring during the weekend, the collapse of Lehman Brothers and sale of Merrill Lynch, signaling more dramatic fallout from the credit crisis.

My first scheduled event of the day was an arrival ceremony for the President of Ghana on the South Lawn of the White House. Because of HHS’s significant activities in Africa, I had been asked to attend. Following a meeting in the Cabinet room with President Bush and President Kufuor, we briefed President Bush on the storm in the Roosevelt Room.

The storm briefing was lead by David Paulison, the head of the Federal Emergency Management Administration (FEMA), with Sam Bodman, the Secretary of the Department of Energy, who discussed the impact the storm would have on the nation’s energy situation. My part of the report didn’t take long because our assets were in place and services were being provided as planned. At the conclusion of the meeting, Ken Wainstein, the President’s Homeland Security Advisor, asked me to accompany the President on Tuesday morning to the Houston area, so our travel plans changed.

I left the House at 5:50 a.m. for Andrews Air Force Base. As I walked across the tarmac, it was still pre-dawn. It is never that I see Air Force One and I don’t feel a sense of awe. It is such an inspiring symbol of our nation’s stature. It is shaped like any other 747, but there is something special about the remarkable power-blue color and the words United States of America.

Typically, those who accompany the President on these trips get into place about a half-hour before takeoff. It’s actually a very pleasant time. The plane is more like an office building than an airliner. It’s a place of work. There are small offices and a conference room as well as places for the news media to sit and work.

We arrived at an airport near Houston, spent a half-hour being briefed by Texas emergency management officials and then boarded helicopters so we could view the widest possible areas during our visit. One element of the briefing likely hasn’t seen much news coverage. The briefer told the President one significant issue the emergency management officials were having was animal problems. “Cows,” he said, “are running all over the place.” “And,” he continued, “a lion and two tigers on the loose.”

It turns out, some people in remote parts of the island had these wild animals as pets. Somebody wryly said, “Well, that probably takes care of the cow problem.” A good sense of humor in a disaster is always appreciated.

President George W. Bush speaks with state and local officials during a briefing Tuesday, Sept. 16, 2008, at the Galveston emergency operations center.

I rode, along with Governor Rick Perry and David Paulison of FEMA, with President Bush in Marine One (another fine machine and symbol).

I won’t attempt to duplicate news accounts, except to say that seeing damage like that is always more startling in person than on television. The scene I saw was reminiscent of Katrina, but not as universal as some of the areas of Louisiana and Mississippi at that time. I was not able to visit any of the flooding areas.

As they move from survival and rescue into recovery, the Mayor of Galveston, Lyda Ann Thomas, and her team were beginning to wrestle with public health issues. There were no toilets, or places to wash hands. Disease becomes a serious threat. I linked up to talk with David Lakey, the Texas Director of Public Health. I also discussed recovery resources with Governor Perry. The Texas team is a good one.

When I talked with the Governor on the phone earlier in the week, I simply said, “Well, here we go again.” They are battle-proven and confident. However, it was clear to me the Governor was worried that this one could be a monster. Fortunately, it was bad, but not as serious as it could have been overall.

The President had to get back to D.C. to deal with the financial crisis on Wall Street, which was unfolding as we moved. Occasionally, a reporter would shout a question about AIG, which was leading the news. The President reminded them he was dealing with a grieving Galveston right then. He would deal with that in Washington.

One cannot avoid being overwhelmed by the power of nature. Likewise, it is hard to understand why people build homes in some of the places they do. There were stretches of beach in and around Galveston where homes were not only destroyed, but also completely cleared of all debris. There was no sign anything had existed but a concrete pad.

There were some homes standing that had been built with a different code, requiring hurricane-resistant construction.

Once again, I will say the emergency responders were an inspiration. There are always things we can do to get better, and we’re getting better with each disaster. Texas was impressive. The mayors and their teams in Houston and Galveston were both impressive.

Galveston will be a long time recovering. In my view, homes on the beach areas of that region should not be rebuilt unless they are at a standard of construction that can withstand a powerful Hurricane. I also don’t believe the government should be heavily subsidizing property insurance, or offering big payouts after a storm for private structures in areas where they will obviously be blown away again by a hurricane.

HHS has deployed more than 1,600 people into the hurricane theater. The state of Texas is carrying most of the burden. We are now moving from rescue into a recovery mode.

I would also like to say what an effective operator I think David Paulison is. I’ve watched him for many months now. He’s direct and organized; doesn’t over-promise and is willing to solve a problem with a little ingenuity. FEMA is often the target of frustrated critics. Sometimes, FEMA probably deserves it. However, in an organization as complex as the combined national and state government emergency management system and in the middle of a disaster, there is bound to be some confusion and unpleasantness. With Paulison’s leadership it has been minimized.