Viet Nam – Blog IV

Today, I’ll finish the ten observations about Viet Nam I promised.

Observation Seven: The Viet Nam government appears to have taken the threat of Avian Influenza seriously. They seem to be doing what they can. Inherent in that observation is the acknowledgement that they don’t have the capacity to do much. However, I have now been in two small village areas in Viet Nam during different visits. The first was where a family of five contracted the virus. The second visit was in an area where H5N1 was in the poultry population. In both cases, I was impressed by the response.

On this trip I met Mr. Chien, who I’m guessing by the fact that he started in the chicken raising business 18 years ago, is in his late thirties. He appears to be a natural entrepreneur. He started with 200 chickens in 1991 and now has over 11,000.

We walked through his operation while he showed me how he vaccinates his chickens. He told me about the morning he found 100 out of 200 breeder hens dead. He didn’t know what it was, but he called a vet from the Province who determined it was avian influenza.

Vaccinating a chicken

We went back to his house where a group of his friends from the area had gathered to talk. I asked about how the village reacted when they understood what they were dealing with. Mr. Chein said, “Our children were afraid, and we were afraid for them.”

There is no question if the H5N1 virus begins to spread efficiently, person to person, all of southeast Asia is highly vulnerable including Viet Nam. However, we have a much better chance of catching it quickly there, than in other countries in the region.

Observation eight: There are promising signs that Viet Nam may have acted fast enough to avert a major spike in HIV/AIDS cases. Viet Nam is one of the 15 countries in the President’s Emergency Plan for Aids Relief. I’m told the decision was made to invest aggressively in Viet Nam because it looked like HIV/AIDS was just about ready to spike dramatically. Over the past four years, our investment has increased from $17 million to $88 million a year.

I was pleased to learn we are spending much of that amount on building infrastructure and people. The reports I received were quite positive.

I visited a clinic in a section of Ho Chi Min City where they are starting a program to focus on intravenous drug users. A high percentage of the HIV/AIDs in Viet Nam comes from the use of dirty needles. The approach is to help people stop drug use, hence having fewer risks generally. They use a system of peer educators; kids that have had a drug problem but overcame it. I spent about an hour talking with them. I saw the use of this technique in Africa. They have teams of people who are HIV positive trying to convince others to “know their status and get tested.” It seems very effective.

When I met with the Health Minister, we discussed the fact that rapid response HIV/AIDs tests are not being used in Viet Nam. I hope we made some progress in persuading them.

Observation Nine: The rapid increase in the price of food is becoming a big problem in Viet Nam. I mentioned in my blog entry on Indonesia what a problem the rising price of food has become. I simply hadn’t focused on this as an issue until this trip. Rice is now more than $700 a ton, more than three times the rate of five years ago.

Apparently there are many contributing reasons for the price going up. There is a growing problem with various pests and viruses that adversely affects the crops. Also, there has been a series of weather-related matters, which have been part of the problem too. This could become a major issue worldwide if it continues to develop.

Observation Ten: Viet Nam is a young country and I saw a disproportionate number of women emerging in leadership roles within the bureaucracy. I don’t know if that is true within the Communist party however.

More than 60 percent of the population is under 30 years old. As one moves around Viet Nam, it is highly evident. If they can find a way to educate this group and provide an economic system where they can succeed, the youth of their population is a huge asset because they are hungry to succeed.

I gave a lecture and answered questions at the Hanoi School for Public Health. It was a delightful hour. The students were more than willing to engage. Apparently attendance at the school is highly competitive with many applications for each slot. Again, it interested me that the group I spoke to was nearly three quarters female.

Viet Nam – Blog III

Following on yesterday’s blog, here are some additional observations about my recent trip to Viet Nam.

Observation two: While they maintain a communist structure of government, Viet Nam is obviously devoted to being part of the global market economy. As people vote with their dollars, markets are highly democratic. It seems clear they have found a way to reconcile the ideology. They have attained status in the World Trade Organization and seem highly motivated to come into conformance on global economic standards.

When I visited with a group of shrimp farmers, we discussed market conditions, world prices and the demands of entrepreneurship. Clearly, the government plays a different role in their business than it does in a democracy. These were small businessmen, looking to find niches in a market where they could optimize their opportunity.

Dinner with Shrimp Farmers

Observation Three: The Vietnamese government seems to understand the importance of protecting the made in Viet Nam brand. They are proud of the fact that it is beginning to show up more places. We discussed openly how quickly a brand that is not known well can be damaged by adverse quality events. We agreed during our talks to develop a working group to develop MOUs, similar to what we have done with China, which will allow our regulatory agencies to work interoperability, even though we have different systems of government.

Viet Nam is drafting new framework laws for food and drug safety so this is an opportune time to work with them. We agreed to move on aggressive time frames.

Observation Four: The business environment has a frontier quality to it. There appears to be opportunity everywhere, but you would have to have a high tolerance for the type of bureaucratic and political uniqueness that accompanies a country in transition. I had lunch with members of the American Chamber of Commerce. I sat next to Tony Foster, a Chicago based businessman who is building several businesses in Viet Nam. He is actually married to a Vietnamese physician who now lives in Chicago.

One of his businesses is a company providing international telephone services, and from his short description, he appears to have taken advantage of a need Viet Nam had for telephone capacity. As part of his willingness to invest in telephone infrastructure, his company was granted status that, for a time, gave him a comparative advantage in the market.

At the Port of Saigon, the Port executive told me they had contracted with a Seattle company to build a new Port. I know little about it, but presumably the company will invest money and bring expertise, earning a return from Port fees and securing an early position in a growing enterprise. I observed a similar arrangement in southern India.

As we boarded the plane to Ho Chi Min City, our Ambassador, Michael Michalak, introduced me to a private equity fund manager specializing in Viet Nam investments who was also boarding. There are obviously unique challenges investing right now, but with a populations growing rapidly in number and prosperity, Viet Nam is an intriguing marketplace.

Viet Nam still has state control of most of the key industry groups, and they have been slow to give up control. State owned enterprises make up 37% of their GDP. The government owns and controls industries like banking, energy, air travel, and health care.

Observation Five: Reduction of poverty is a primary social goal of the government and they seem to be succeeding to some extent. In 1993 58 percent of the nation’s population was in poverty. Today it is only 15 percent.

They will have to do substantially better in basic areas like education, health care system, etc. However, they seem to know where the problems are.

The Vietnamese government has a goal to be a country with middle income. They also aspire to be considered an industrialized country by 2020. It feels like, to me, that the Vietnamese and Chinese have similar approaches to planning. They also have the ability to compel things done that democracies require more time to finesse.

Observation six: Personal freedom is still mixed. Freedom of religion has dramatically improved the past few years and the churches are full.

However, freedom of speech is not as good. The embassy told me there are many situations in recent years where people have been imprisoned for speaking out against the government.

Viet Nam - Blog II

This is a continuation of my discussion on Viet Nam. I just returned from a trip there. Today, I’m going to list the first of several observations about Viet Nam coming from my trip.

Observation One: The Vietnamese government and people have put war behind them, and we need to as well.

I was a teenager during the war in Viet Nam. To eliminate the uncertainty of the draft, I joined the National Guard and went through basic training and advanced artillery training side by side those regular Army soldiers, most of who anticipated the skills we were learning would be used in Viet Nam. Many people I knew fought there. I lived through the political, social and cultural turmoil that accompanied the war during the late 1960s and early 1970s. The war in Viet Nam was a big part of all our lives.

The first time I flew into Viet Nam, I had a hard time not linking everything I looked at to my war time perceptions of what the country was like. I did not feel animosity, but my curiosity of what things were like then was not easy to suppress. My perceptions came from news reports and pictures of places and situations 40 years ago, but they are stored in that part of the brain teenagers put things that shape them.

In October of 2005 when I was there, I asked several Vietnamese people about how they felt toward Americans. After several questions, one of them said to me: “We have put the war behind us.”

I saw evidence that there are still remnants of the war in Vietnamese society, but they seem to be biases which faintly endure between North and South Viet Nam. However, those seem to have been worn down over time as well. In fact, everything I have experienced in Viet Nam leads me to conclude Americans are well liked generally. And, speaking as one American, I really like Vietnamese people.

I had two experiences on this trip worth relating along these lines. The first happened before we left. I had a conversation with Ashleigh, a young woman HHS colleague of mine, assigned to do advance work on the Hanoi portion of our trip. She related the reaction of joy her Father had to learn of her assignment. He had fought in Viet Nam. She said, he told her how it thrilled him that things had changed in a generation so his daughter was able to return in peace to a place he had fought in war.

Secretary Leavitt and Ashleigh

The second experience took place at a remarkable dinner we had in Hanoi put on by my new friend and colleague, the Minister of Health from Viet Nam. His name is Nguyen Quoc Trieu. Minister Trieu was a soldier, fighting for the North. He was wounded during intense fighting. Also at the dinner was a doctor who works with our U.S. Centers for Disease Control and Prevention and is assigned in Viet Nam. Over dinner they concluded they had fought during the same period in roughly the same region. They toasted, hugged and celebrated their friendship of our nations.

Viet Nam - Blog I

An Overview

The final three days of my trip to Southeast Asia were spent in Viet Nam. This was a follow up trip to my October 2005 visit. I focused on three issue areas: HIV/AIDS, Avian Influenza and the safety of imports. Meeting the new health minister was a priority as well.

As a general overview, I arrived in Hanoi on Tuesday night, the 15th of April. I spent Wednesday the 16th of April there working. On Thursday, I flew to Ho Chi Min City, where I spent the day working, and then on Friday, I was able to go out into the countryside, which always turns out to be a highlight.

In Hanoi, I visited the Ministries of Health and Agriculture; spoke to the American Chamber of Commerce; spent an hour interacting with students and faculty at the Hanoi School of Public health; and then met with Prime Minister Nguyen Tan Dung. In the evening, my new friend, Nguyen Quoc Trieu, the Minister of Health, held a banquet that none of our delegation will ever forget. This was not your routine diplomatic gathering. It was a party, full of personalities, music and bonding.

On Thursday I did media interviews, traveled to Ho Chi Min City, and toured the seaport in the same way I have many American ports; working to understand their role in the safety of imported products. I then visited a clinic our HIV/AIDS money supports, which is setting up the nation’s first methadone clinic as a way of assisting in the prevention of HIV/AIDS, and then met with the party leaders of the city.

Friday morning early, we drove into the countryside about three hours. Seafood is one of the biggest trade items between the U.S. and Viet Nam. I wanted to get a sense of the processes and sophistication levels in that industry, in a similar way as I was able to in India. The three hour drive by itself was worth the effort of going. I saw many different kinds of communities along our route in varying degrees of change.

I visited a large seafood processor and had a two hour discussion over lunch with a group of shrimp growers, a regulator and fellow who appears to have a job similar to an extension agent. I then went to meet with a group of chicken growers in a rural residential area along with public health people. We talked avian influenza.

At fish farm in Viet Nam

In the evening, we had a reception at our hotel and picked up the midnight flight for a connection in Tokyo for D.C. These trips are non-stop events. By the time I get to the end of the week, I’m usually feeling exhausted, but greatly enriched. This was a successful mission, but I’m ready to get back into a normal routine. With the time zone changes, different beds most nights, and fifteen hour days, the last seven days feels like one continuous day.

I was able to keep better control of my diet and exercise routines this trip. Both usually take a hit on these forced marches. I think I got exercise all but two mornings and with only one major banquet, didn’t do any serious caloric damage. It’s a small victory in my long fight to stay healthy.

Having provided this overview of the trip, over the next few days I’ll post a series of observations I have as a result of the trip.

Singapore: More Observations

I mentioned yesterday my short visit to Singapore. I thought I’d add some additional observations.

Singapore spends only 4% of its gross domestic product on health care(Singaporean Health Minister’s estimate). Just a reminder, in the United States we spend 16% of ours — nearly four times as much. What are we getting for that? The life expectancy of a male in Singapore is 79.29 and 84.68 years for a female. Again, just a reminder, in the United States the life expectancy of a male is 75.29 years; a female can expect to live to 81.13 years.¹ Hmmm.

What are the differences? I obviously haven’t had enough time to explore that question fully, but I’m going to now. There are a couple of obvious ones. In their system, everybody pays part of the cost. If you are poor, the percentage is very low, and if you simply can’t pay, the debt is written off, but there is a personal responsibility and it undoubtedly causes patients to engage.

Our system has an ailment I refer to as the “Chronic More Disorder.” Most patients in our country have very little reason to care what the cost is. Doctors have an adverse incentive to do more procedures, make more money. In a market, there have to be countervailing incentives to keep things in check. It doesn’t happen in our country. (An old theme for me, right?)

So, what about the quality you say? Aside from the statistics on life expectancy already cited, let me suggest we think about this. The Government of Singapore estimates that, in 2008, over 600,000 people, including many Americans, will engage in medical tourism. They will fly to Singapore to get their care at a fraction of the price. The Singaporean Government believes by 2012 the number will exceed a 1,000,000 people a year. In order to attract these people, they are transparent with both cost and quality outcomes. Patients have more information about care in Singapore than about care they would get from their local hospital. Hmmmm.

Here’s another thing I learned. When the government was formed in the 1950s, the British had set up a system of Central Provident Fund (CPF) which requires the Sing people to set aside 35% of their earnings. They allow the savings to be tax free. Does that sound like Social Security? Well, there is an important difference. Each citizen’s account is segregated. They cannot use it until it is time for retirement, but they do have influence on how it is invested. It is not like our Social Security System where each generation of workers pays for the retirement of their parents.

If you were simply looking at these two different systems as an investment opportunity and doing steely-eyed analysis on the likelihood of their prosperity in the future, which would you invest in?

• Investment 1: Spending 4% of their total receipts on health care with no future liability.
• Investment 2: Spending 16% of their receipts on healthcare with a $24 trillion legal and moral liability in the future.
• We should also toss in that number 2 above will have half as many workers per retiree in 20 years and that both get similar big picture results.

The global market is now weighing this question. I will have much more to say about this soon.

¹ Singapore statistics: The CIA factbook accessed on 4/21/2008 at https://www.cia.gov/library/publications/the-world-factbook/geos/sn.html 

US statistics: The CIA factbook accessed on 4/21/2008 at https://www.cia.gov/library/publications/the-world-factbook/geos/us.html

Some Lessons in Singapore

I stopped in Singapore while transitioning between Indonesia and Viet Nam. There were a couple of HHS investments I needed to see.

First of all, Singapore took me by surprise. It is beautiful. You would think you were in southern California—climate, quality of infrastructure, construction, etc. It is well run and on a roll of success. I’ve heard this for years, but seeing was believing, for me.

A conversation I had with the Health Minister Khaw Boon Wan had several interesting aspects to it. In some ways Minister Khaw is typical of the policies that have made Singapore a success. He grew up in Malaysia but accepted a grant from the Singaporean Government to study in Australia. The grant had what he described as an 8 year bond. It was an obligation to work in Singapore for that period after they paid for his education. Singapore became his home.

Health Minister Khaw Boon Wan of Singapore

Because the country is so small and has few natural resources, they have mined talent internationally. The Minister is an example of their investments paying off.

I want to mention three topics we discussed that I will be thinking more about. The first is the importance of a population continuing to grow.

The Singaporean Government identified many years ago that their population growth rates were beginning to fall. Intuitively they understand that if a nation’s population growth falls below replacement, it will, under normal circumstances, create serious problems in the future. They have been working to increase their birth rate now for nearly 20 years, with little success.

I asked the Minister what Singapore had learned from the millions they have spent researching and trying different policies. He said they had done mountains of demographic research and tried many different incentives including direct tax subsidies amounting to as much as $20,000 for couples producing a child. They have produced disappointing results. Direct financial subsidies he said are, “like pushing a string.”

Interestingly enough, many other nations provide the subsidies but the results seem to have far more to do with other factors. Australia pays $2,500 (his estimate) and has seen a resurgence in birth rate. He thinks there is simply a different attitude among nations with lots of space. He pointed to super cities like Hong Kong and Tokyo and that they have low birth rates.

The Singaporeans have concluded a series of sociologic changes have clearly contributed to their dilemma. Woman desiring careers, couples deferring the age of marriage, and a de-emphasis on marriage were other points he raised. Our conversation came on a day I had just received a brief on a CDC report indicating that in 2006, 38.5% of all births in the United States were to unmarried mothers. The Minister’s main point was that married couples have more children and foster them more successfully than unmarried parents.

Singapore is pursuing policies that work to develop three things: supportive employers, supporting families, and Government policies that are family-friendly. I took that to mean encouraging marriage. They are also working to increase the percentage of births from successful in vitro fertilization. They have found some European countries, such as Denmark, have as many as 6-7% of births from this method. Singapore has only 1% of their births from successful in vitro fertilization. Even science can play a role, he pointed out.

When I was Governor, I started a Marriage Commission to encourage the practice of marriage and to strengthen existing marriages. It was the first in the country and it was criticized by some. Others have since followed and it has become more common for governments to recognize what a hugely important issue this is.

I have spent time looking at the long-term problems faced by cultures that have limited family size. Japan is deeply worried about its population trend. China has also begun to deal with the impact of their “one child” policy.

In the United States, our population figures are just slightly over replacement. Frankly, if it weren’t for the increase of immigrants, we would be in the same spot as many European countries, facing negative growth.

If you think that sounds like a positive thing, I would recommend two things. First read Will and Arial Durant’s book, The Lessons of History. After studying every major civilization in a 5000 year period they concluded societies that fail to grow, fail to survive. The second thing I would recommend is looking at the Medicare program to which our nation is obligated. Today there are four workers to pay the health care benefits of each senior. In 20 years, because of lower birth rates, there will be two workers for every person on Medicare. Add social security to that mix and a declining birthrate becomes a rather serious problem.

Demographics are destiny.

Indonesia II

Written April 15, 2008

Following the meetings I wrote about yesterday, I met with President Susilo Bambang Yudhoyono (or "SBY," as everyone calls him) at his office in Jakarta. We met previously in October of 2005, on my last trip to Jakarta.

President Yudhoyono is a former soldier. He did a significant part of his training in the United States, including an MBA from Webster University, in Missouri. He is tall, with a strong military bearing. Generally speaking, he struck me as a gracious man, with a good grasp of the complicated problems of governing a nation like Indonesia, and a good understanding of regional and global problems.

Coordinating Minister Bakrie and I opened the meeting by recapping the nature of our meetings earlier in the day. The Foreign Minister, Health Minister and the President's Foreign-Policy Advisor were also there.

The President stated clearly Indonesia wants to be a cooperative part of the world health community, and stressed a desire to get both the NAMRU issue and virus-sharing problems behind us. Minister Bakrie reported his two-month timeframe. I re-stated our strong, philosophic objection to linking virus-sharing with compensation.

What I wanted to write about today, however, is an interesting conversation we had about the challenge of governing a developing nation. This was a continuation of a set of themes that interested me from my conversation with the Indonesian Foreign Minister earlier in the day.

The President reminded me that Indonesia has only been a democracy for 10 years. He made the point that for democracy to succeed, it must prove to people it can deliver them a better life. In essence, he said, it’s likely the vote of a person who lives on a remote island in Indonesia who earns $1.60 a day will decide if democracy is working, less by ideology and more by the cost of what fills his rice bowl.

I spent time earlier in the day discussing the economics of rice with Indonesian Minister of Agriculture, Anton Apriyantono. Rice is the most significant dietary staple for Indonesians. At times, the Indonesian Government goes into the world market to supplement its domestically grown supply. For a variety of reasons, the price of food, specifically rice, has increased sharply over the past year. Ambassador Hume had told me earlier in the day that a ten-percent increase in the price of rice in Indonesia pushes two million people into poverty. So, the price of food has serious political and sociological ramifications.

Energy also fits into the category of priorities for President SBY for the same reasons as food. The Indonesian Government heavily subsidizes fuel. It occurred to me, as bio-fuels become more prominent, and more grain goes for that purpose, it could bring two of the most important needs of the world's poor into conflict with each other.

The President indicated health was obviously another priority, but confessed he was not able to budget what he aspires to provide. He remembered our discussion in 2005 about the dangers of the H5N1 strain of avian influenza, and made an interesting observation: Places like Indonesia have many unique health challenges, so a problem like influenza has trouble penetrating the public agenda. Coordinating Minister Bakrie told me tuberculosis kills 400 people a day in Indonesia. Put next to that statistic, the 107 people who have died in that country from infection with the H5N1 flu virus is such a small number that it is hard to get the Indonesian public or government too worked up.

Of course, it is the potential that the H5N1 strain of influenza could spark a worldwide human pandemic that demands a response. However, countries with limited resources are often more concerned with the snake biting at their ankle than to worry about the one hiding in the bush.

I remember the Health Minister of Cambodia telling me in 2005 that 12,000 people a year there die from rabies. Consequently, it is hard to get farmers worried about a few sick chickens. It put a lot of things in perspective for me.

Indonesia

Written April 14, 2008

I’m in the Jakarta Airport, having just finished a day of meetings with Indonesian Government officials. I met with President Susilo Bambang Yudhoyono, Coordinating Minister for Family Welfare Aburizal Bakrie, Foreign Minister Noer Hassan Wirajuda, Agriculture Minister Anton Apriyantono, and Health Minister Siti Fadilah Supari. The meetings involved discussions on a group of issues, among them the control of H5N1 avian influenza, the U.S. Naval Advanced Research Laboratory (NAMRU-2) in Jakarta, and Indonesia’s departure from international expectations on sharing samples of influenza viruses.

I was here in October 2005 as we were scaling up our own pandemic preparedness in the United States. Being here is an important reminder of how different the problem looks from different perspectives. Indonesia has 245 million people, who live in a space about the size of New York State. About 60 percent of the country's area is water, since the nation is really thousands of islands. It appears to me that most of those people must have highly localized lives, and developing a national strategy on anything would be difficult.

The next presidential election in Indonesia will take place in 2009. Just like in the United States, the upcoming election has begun to affect the formulation of policy. The night before I arrived, local elections took place in the largest Province, West Java, and, in what appears to have been a surprise, an Islamist party took power. It would be similar to having a populist movement win a statewide election in California. The election in West Java is an event that will clearly begin to factor into everyone’s political calculus in Indonesia.

I didn’t have any political discussions about this with Indonesian officials. These are observations I am picking up from reading the local papers, and from talking with people at the U.S. Embassy. I’ve always found it important to understand the political context in which foreign government officials are operating- it helps you understand the filter through which they are seeing the world.

My first meeting was with Foreign Minister Noer Hasson Wirajuda. He is a sophisticated and well-educated man who spent five years doing legal studies in the United States. We talked at length about a group of themes related to the challenges of governing an undeveloped country. Later in the afternoon, our discussion continued. I think rather than discuss those in this entry, I will do a separate piece tomorrow.

Next, I visited the office of the Coordinating Minister for People’s Welfare, Aburizal Bakrie. A Coordinating Minister oversees several Ministries or areas of the Indonesian Government, and has the responsibility to coordinate their work. The meeting included the Ministers of Agriculture and Health.

Minister Bakrie is a noted businessperson. His family holdings are extensive, and their reputation looms large within the region. He speaks excellent English, and deals confidently with people. His business background is evident in his willingness to engage directly on problems.

Minister of Agriculture Apriyontono was invited because of the animal-health connection in avian Influenza. I met him in 2005 as well. Likewise, I have met multiple times with Health Minister Supari. She has become a controversial figure within the health world, because she has stopped sharing with the World Health Organization (WHO) any samples of influenza viruses that are circulating in Indonesia. She asserts that if a nation provides a virus from which a manufacturer makes a vaccine, that country is entitled to monetary compensation of some form. This is a dangerous course that threatens to undermine a worldwide agreement honored by nations for nearly 60 years. I wrote previously about this subject.

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

NAMRU-2 is an important public-health asset in Indonesia. The lab is a WHO reference lab, which means the level of expertise there is high enough that the world accepts its work. If a communicable disease breaks out in South East Asia, any country can send samples of the virus there to have them identified. The laboratory has been in Indonesia for decades, and exists under a Memorandum of Understanding (MOU) between our Governments, which is up for renewal.

The MOU that governs the status of NAMRU-2 expired two years ago, and both sides have been trying to renew it. When I was in Indonesia in 2005, the lab was a major topic of conversation in my discussions with various Ministers, and with the President. At that time, I received absolute assurances the Indonesian Government would approve the MOU shortly.

Minister Supari recently issued orders to prohibit Indonesian institutions from providing tissue samples to NAMRU-2, under the justification that such sharing is not legal in the absence of an active MOU and a Material-Transfer Agreement. Her action is obviously linked to her global initiative to seek specific benefits for sharing samples.

To add more drama to this picture, Minister Supari, recently published a book in which she asserts the U.S. military is using influenza samples to create biological weapons. Secretary of Defense Gates was asked about the Minister's accusation when he was in Indonesia this past February; he replied, “That’s the nuttiest thing I’ve ever heard.”

All this background created great media interest in my visit. The morning of my discussion with Minister Supari, an article appeared in the English-language Jakarta Post that said I might refuse to meet with her. The truth is, I came all the way to Jakarta quite specifically to see her. Anyway, all this added up to a minor drama.

We met privately in Coordinating Minister Bakrie’s office for a while, and then joined the rest of our delegation and Indonesian Government staff who had gathered. The conversation was refreshingly straight-forward, an outcome I attribute to the style of the Coordinating Minister. While we talked about a number of other issues, such as HIV/AIDS, most of our time focused on the NAMRU-2 and sample-sharing. After a time, the Agriculture and Coordinating Ministers left, but Health Minister Supari and I continued our conversation.

It is important to remember that, while the NAMRU-2 issue is between the United States and Indonesia, the influenza-sample issue is between Indonesia and the other 192 Member States of the World Health Organization. The United States has been part of a group that has been trying to resolve the problem for the past two years. They have held numerous meetings, and various other types of negotiations. These have yielded a short list of things the parties believe the WHO Secretariat could do to improve its influenza program. The Minister mentioned this several times as "progress."

However, I could see little real progress in the key question whether contributing countries should receive direct, monetary benefits as compensation for sharing samples. The Minister’s main point is that what she wants should not be considered "royalties" or "compensation." What she says she wants is for the contributing countries to be eligible for some share of the value commercial companies create out of the influenza samples they provide. Or, as she expressed it in a hand-delivered letter to me later in the afternoon, “Allow me to reiterate that when I raised the term ‘monetary benefits,' I was not referring to any type of royalty, nor any type of quid-pro-quo arrangement, but rather to a method that leads to the allocation of values derived by commercial interests into one commonly defined system, which will provide benefits to those that have made contributions.”

I told the Health Minister two things. First, I understand her desire to assure people in her country have access to medicines and vaccines. This is a problem in developing countries all over the world. It is a complicated issue, but we need to address it, while preserving the incentives for innovation. I pointed out that technology is improving and might well hold solutions we don’t currently have. I used as an example the billon-dollar investment our nation has made in cell-based vaccine technology. Once we are using cell-based methods of making vaccines, the capacity and cost of making vaccines will dramatically drop, which will change the entire equation. The world is working on solutions.

However, linking sample-sharing to payment in any form will immediately begin to erode our ability to make vaccines at all, because once the practice of free and open sharing of viruses stops, the slope is slippery, and there will be no end to the demands.

The issues of the availability of vaccines and the sharing of samples are both legitimate ones, and we must deal with them both, but we should not link. World health should not be the subject of barter.

The second thing I told her is that I find it impossible to distinguish a difference between what she is seeking and royalties. The bottom line in both is this: share samples, get paid.

I would summarize the conclusion of my meetings this way: We celebrated the small list of consensus recommendations that are emerging from the multi-lateral discussion at the WHO on this matter, and committed to keep looking for solutions. The Coordinating Minister suggested we could find a solution within two months. He later reported that to his President in our meeting with him.

I have instructed my representative on this matter, Bill Steiger, to work with Ambassador John Lange, Secretary Rice's Special Representative for Avian and Pandemic Influenza, to continue our discussions with the Indonesians and others for the next two months. However, we cannot be party to an arrangement that will un-do 60 years of one of the world’s great public-health successes.

There are some situations that, despite our best efforts, we cannot resolve. In those cases, we just live with the added risk. The cost of Indonesia's refusal to share influenza samples is incrementally small. However, the damage done by accepting Indonesia’s view is profound, and simply unacceptable.

We will work on this for the next 60 days. If we haven’t been successful in resolving the matter, I think it will be time for the world to just accept Indonesia’s unwillingness to participate in the WHO influenza system, and move on to other ways of making the world safer. Perhaps when circumstances change, Indonesia will rejoin the mainstream on this issue.

Dennis Smith: Competence and Dignity

During the mid 1990s, I met Dennis Smith. He was working for Senator (William) Roth of Delaware, who at the time was Chairman of the Finance Committee. He was quiet and thoughtful, always considerate despite the considerable stature he had as a senior Congressional staff leader.

I was among a small group of Governors from both parties who were deeply involved in welfare and Medicaid reform. Dennis often represented Senator Roth and worked with our staff to actually draft the legislation. We succeeded with welfare reform; it has been a wild success. We didn’t get to the finish line on Medicaid reform however.

In 2001-2002, I was still Governor and still working on Medicaid reform. I had an idea that we could extend a basic policy of health insurance to more people if we modified the benefits for certain Medicaid populations to look more like regular insurance policies. Secretary Tommy Thompson brought Dennis Smith to the table. It has worked just as we thought it would. Tens of thousands more Utahns have had health insurance as a result. Governors all over America could report similar stories.

Roll forward to 2005; I was asked by President Bush to become Secretary of Health and Human Services. To my delight, Dennis Smith was willing to stay on as the head of Medicaid. For the last three and a half years we have worked together and accomplished a great deal; among other things, finally succeeding in the reforms we started working on together ten years earlier.

Dennis told me last week it was time for him to conclude public service and move to another chapter in his life. There is a much longer and more elaborate list of things Dennis Smith has accomplished in public service. I list what I did, mostly to credential myself as being in a position to say the following.

In more than a decade of working together, I know few who equal Dennis Smith’s competence. I know even fewer who match his dignity. I have never once witnessed Dennis lose his patience or his temper. I never once observed Dennis treat anyone—regardless of whether he agreed with his or her political philosophy or not—with anything other than respect and dignity. And truly unique in Washington, I have never seen him seek the limelight for his numerous accomplishments. He is a noble and dedicated public servant.

Dennis Smith, HHS photo by Chris Smith

Two Simple Leadership Tools

The last nearly sixteen years, my life has revolved in four year terms. I have learned that four years is not long when one is working on big complex problems that have existed for decades.

I was elected three times as Governor of Utah. Some of the things I consider accomplishments were initiated in my first term, but fully matured in my third. Likewise, the fruit of some initiatives started in the 3rd term are only now beginning to flower.

Living in four year cycles has taught me to choose priorities and to impose urgency from the beginning. At HHS, two of the tools I use to keep us focused are quite simple. The first is a 5,000 day vision with a 500 day plan.

The 5,000 day vision is an expression of what we aspire for the world to look like, a decade or so from now, in the areas HHS influences. The 500 day plan is a more granular listing of the things we can do in the short run to bring that vision about. It is a rolling 500 day plan. Every 250 days, I review the vision and recalibrate the 500 day plan.

The second tool is a small countdown clock I gave to each of my leadership team. I call it our urgency meter. All our major projects have timelines which align with the time remaining. Time passes so quickly.

We are just a little more than a month away from the 250 day point in the administration. A lot needs to happen during that period. There is nothing like a last minute deadline to make things happen.

Naturally, I have begun to narrow my focus to those matters on the 500 day plan not yet complete. Because this is the last 250 day period, I have to take a steely eyed view of what can and can’t be finished, so we can make best use of the time.

Many different considerations go into what moves up the list and what goes down. For example, legislative opportunities are rare at this point in the cycle, though those that remain are critical.

One of the personal objectives I have is to write a series of papers/speeches that will frame up the 5,000 vision that has evolved; the steps we have taken toward it and what I think should be done in the future to follow on our work. As those develop, I will, of course, post them here.

Dennis Quaid Meeting

Many across the country watched “60 Minutes” a couple of weeks ago when Dennis Quaid told the horrifying story of his twin daughters and family bearing the burden of a life-threatening medical mistake. (“60 Minutes” story)

Thankfully his twins have recovered, but the experience clearly triggered a passion in Dennis Quaid to do all he can to draw attention and seek solutions to a problem —medical mistakes.

I share Dennis Quaid’s passion. I find his willingness to step forward as enormously helpful. Medical mistakes needlessly end tens of thousands of lives each year.

Dennis Quaid and I spoke to a common group this week. Our path crossing provided an opportunity to visit for a while.

Our meeting was a private one; therefore I’m not going to recount the discussion. I just want to say he’s not only likeable in a down-to-earth kind of way; he was open about what he didn’t know and hungry to learn. It is clear he’s taking this very seriously, and systematically doing his homework. This is not a casual or superficial effort. I found the whole thing rather noble, frankly.

I hope to be of help to him and all those working to reduce medical errors, in any way I can.

New Portrait of Tommy Thompson

There is a new portrait hanging in the Great Hall of HHS Headquarters in Washington, D.C. It is of former Secretary Tommy Thompson, who I followed as Secretary here at HHS. Governor Thompson’s portrait joins a collection of the other 18 Secretaries who have served since HHS became a Department.

I have a long friendship and association with Tommy Thompson. We served together as Governors and worked together often. Ironically, much of our work together was on issues at the heart of the HHS mission. We were among a small team of Governors who consulted Congress on welfare and Medicaid reform in the mid-1990s.

I followed Tommy as Chairman of the Republican Governors Association and the National Governors Association. We served on the Cabinet together when I ran the EPA and then I followed him at HHS.

Tommy Thompson is a good leader with the capacity to get his ideas implemented. I see the evidence of his work and legacy often as I travel the country and world.

In addition, he’s just a terrific guy. At the portrait unveiling ceremony, many of his former colleagues had gathered. In his animated way, Tommy told stories, joked and reminisced.

A couple of my children were in town and I invited them to stay for the ceremony. Later that night, they commented on how much they enjoyed his jovial Irish way. I’m with them. Tommy Thompson is my friend and it has been a privilege to work with him for these many years.

Portrait of Tommy Thompson.

Hospital Compare

Over the past few months I have repeatedly said we need to make health care more value-driven. Of course, what I mean is that patients need information that helps them make better health care decisions. Specifically, comparative cost and quality of the care they purchase.

Friday (March 28) I unveiled a new Hospital Compare Web site. It will make it easier for consumers and their families to get accurate, practical information when they need to evaluate their local hospitals.

Take a look that it. I would appreciate getting your reaction. (Hospital Compare Web site)

The site assembles basic quality information collected from 2,500 hospitals and compares a series of quality measures, not only indicators of quality, but also price.

Look up hospitals in your area. Some of the data won’t surprise you much, other parts will. In your comments, I’d appreciate hearing if you were surprised in any way about the comparative quality of hospitals in your area.

This is a significant step forward, but my aspirations are higher in terms of the quantity, quality and accessibility of data. During the press conference announcing the release, I said if this were a video game it would resemble the first game I ever played, Pong, more than state-of-the art software like Nintendo’s Wii game. However, we’re making progress fast.

It is my expectation that hospitals all over America will be looking at how they compare and plotting strategies for improvement. People want to provide quality, but they need to know how they compare as a measure. The release of this data and its continual improvement will spur improvement.

So, tell me what you think.

Honduras Cantaloupe

FDA recently placed an Import Alert on cantaloupe coming into the United    States from Agropecuaria Montelibano, a  major Honduran grower and packer. This action was taken after the Centers for  Disease Control and Prevention (CDC) determined fruit from the company was  associated with outbreaks of Salmonella Litchfield in 16 states. 

Watching these things unfold is fascinating. Each situation is like a mystery being solved by investigators at FDA and CDC. The investigators are often referred to as disease detectives because their techniques are a blend of scientific skill and detective shoe leather. 

The investigators piece together extensive interviews with affected people until they can find a common thread tying them together. When there are cases across 16 states that can be difficult. Once they find what is  causing it, they have to track the product back through an intricate system of  distributors, import brokers and suppliers. When the product comes from outside the United States, it is even more complicated.

An Import Alert has cascading consequences. Not only does it  affect consumers, but it immediately changes the livelihood of thousands of farm workers, processors and shippers and in many cases the viability of  companies and the way an entire nation’s products are perceived. As a result we  have to take these things very seriously. 

The cantaloupe problem is complicated further by the fact that Honduras  is in the middle of their season. There is fruit in process and still on the  vine. 

I spoke twice with Honduran President Manuel Zelaya Rosales who asked that I meet with his Agriculture, Health and Commerce Ministers the  next day in Washington.  Of course, I agreed. The envoys flew all night; their plane touched down at 5:30 a.m. for an 8:30 a.m. meeting with me and FDA Commissioner Andy Von  Eschenbach.   

The three Ministers were most cooperative and understanding  of the situation. They pledged their full cooperation, asking only that we move  with all speed to find the solutions. Knowing what is at stake both in terms of human health, economics and our friendship with Honduras, I committed we would  have a team on the ground by the next day.   

The next morning a team of people from FDA and CDC left for Honduras.  As I write this over the weekend they are in the fields where we suspect the contaminated fruit originated.  We agreed at the meetings  with the Ministers that our team would work side by side with their  regulators to get at the bottom of this as quickly as possible. We have put FDA labs on notice that we want to make this a priority. Hopefully, we can get to the bottom of this quickly and help the producing company remedy any problem.

Social Security Trustee Meetings

I wrote yesterday in anticipation of going to the Spring Trustee meeting of the Social Security System. I promised a little more commentary today, after the meeting.

We met in the Secretary of Treasury’s conference room. The meeting did not include the public trustees, because the appointments expired and none have been confirmed yet.

Once again, we listened to reports from the actuaries and administrators of the Social Security Trust Funds. I will link to the materials that were released.

The bottom line is that the system is not sustainable and has the potential to become an increasingly large (prosperity altering) problem for our country. The Medicare Trust Fund is broke in the first few weeks of 2019. That is almost a year sooner than last year’s forecast.

I will confess to frustration over the fact that the repeated warnings and Trustee reports seem to have no impact on Congress. I agree with so many others who have said this is the biggest long term threat to our national prosperity. I am disappointed entitlement solvency has not become a matter of discussion in the Presidential campaign.

I decided while sitting at the table that I want my strongest and clearest expressions of concern to be recorded for history. I formally asked the Chairman to leave the record of the meeting open so I can prepare a piece containing my thoughts and recommendations. It will take a couple of months to complete, but I’ll put it on my blog upon sending it to the Secretary of Treasury as part of the record of the meeting.

Aging

While serving in the President’s Cabinet, I reside in Washington D.C. area. However, I still consider Utah my home, and we gathered there over the weekend for a wedding celebration.

Before returning to D.C., my wife and I attended church at the congregation where we have attended since our late twenties. We have attended there for more than twenty five years.

As you might imagine, in the four years we have been gone, there are lots of new people. The place was bustling with new families. However, it was a chance to greet a number of people I haven’t seen for a while, including a charming collection of people who are now in their eighties and nineties whose lives are affected, nearly every day, by the programs of HHS.

One of them is Lowell, whom I met nearly 30 years ago just after he retired as a high school music teacher. He is now 94 years old and still hauls his vibraphone (electric xylophone) around in the back of his pick-up truck so he can play for audiences at senior centers and nursing homes. He told me he always asks his audience, “anybody here older than me?” There are fewer and fewer who can answer yes. Lowell still plays the piano in church and routinely jazzes the hymns with a little spontaneous riff that makes even the most somber worshipper grin.

Another favorite of mine is Lee, a retired business man who went to the office until just a few years ago. He just turned 95. He and his wife lived in our neighborhood for more than 65 years. Once he told me he paid $6,500 for his charming little cul-de-sac home. That was another era. His wife is gone now and I sense things are hard. I said, “Lee, it’s good to see you.” He smiled and said, “Well, I can’t see who you are; my eyes are about gone.” Later, he told me he has a machine that allows him to magnify the newspaper and mail so he can see it on his television. He called it “a life saver.”

There is a wonderful couple who live right across the street from us. He was a respected high school counselor and community leader until he retired. I don’t recall her career, but in post retirement they did missionary work in Mongolia and then volunteer work for many years. They are now walking the lonely and hard path of Alzheimer’s disease. She is the heroic caregiver along with a daughter. He still smiles at me, but I know our friendship is stored in a part of his brain that is no longer accessible. He relies on others to guide his steps. What great people; what a devastating disease.

It was good to see Renee and LoVinia sitting together; they often do. Both lost their husbands many years ago. Lovenia is a stylish woman and a long time teacher, similar in age to Renee. I won’t speculate on their exact age but I will confide that Renee complained to me that the Senior Games she enters each year no longer has a tennis bracket for her, and she has to play with the younger 85 year-old’s group.

Renee said, “but I still win.”

I appreciate that we live in a nation committed to see that people who struggle with the ravages and riggers of age have the health care they need. They have spent their lives contributing and now deserve to be treated in respectful and dignified ways.

As I talked with my friends, it occurred to me that when I first got to know each of them, they were in their sixties or seventies. Twenty five years passed so quickly.

During those years, things have changed for my wife and me too. Twenty five years ago our children were toddlers. Now they are adults with children of their own. In a similar amount of time, I’ll be dealing with the difficulties of age that challenge my friends and my children’s generation will be running Medicare.

What will Medicare be like then? Can my generation count on it to be there for us?

Today I will be attending a meeting of the Medicare Trust Fund. Reading the briefing papers causes me to worry. When the meeting is over, I’ll write more of my thoughts.

Pandemic Exercise with Bloggers

We routinely hold readiness exercises at HHS on various emergency scenarios. Typically, people from various parts of the emergency management community sit around a square table, and a moderator paints a picture of a disaster unfolding. It is like a reader’s theater. As events are described, each actor assumes their part, describing what they are thinking and doing to respond.

Slowly, the moderator heightens the stakes and intensifies the nature of the problems, throwing out more complicated circumstances, and challenging the reasoning various players use. It is an excellent way to learn and refine emergency protocols.

Monday, we had another exercise on pandemic influenza. Included in the exercise was a group of journalists, including bloggers. Not amateur bloggers like me. Real pros, people who have built reputations with their readers for innovation and speed.

We invite journalists to participate in our exercises because managing their needs for information is a part of crisis management. We need to learn more about how bloggers would react and interact.

Television reporter Forrest Sawyer was the moderator. He has done several of our exercises and he’s very good. He laid out a set of facts that represent routine health news from around the world and laced it with a few interesting tidbits that could attract the interest of people following the flu world.

Turning to public health officials at the table, Mr. Sawyer asked if they found any of the news that day interesting or concerning. He did the same with the journalists, asking what they would do to get more information and how big a story they thought it was. As the facts became more concerning, several observations came to me.

I found it reassuring how important accuracy was to those that attended our session. They were willing to report rumors but made a point of distinguishing them as such. Many of them said they had separate sections of the page for rumors.

The blogs represented at our session tended to be rather specialized and the bloggers knew a lot about the subject matter. It made them better at challenging the facts they were given. I suspect in a major emergency we would be dealing with a broader range of understanding than in our exercise. These people knew their stuff.

I was surprised how much interaction there is between online communities. They seem to share information, monitoring one another’s sites.

More than one of the blogs talked about the way they use traditional news sources but provide added value. One example is translating foreign news articles into English.

I enjoyed watching the interaction between traditional media and blogs. It’s clear television, major radio and newspapers are monitoring blogs all the time. It is also evident most of them are starting to use blogs to supplement their own reporting. The unlimited supply of space and time is appealing to traditional journalists.

The exercise went most of the day. I was only able to stay until noon, but it was a morning full of learning.

The bottom line for me: Government needs to understand the blog world better, and factor it into the way we interact with people. A growing part of the world relies on bloggers for unvarnished information; something they are not sure they always get from us in government.

More on Medicare

Not long ago, a reader commented, “don’t you have more important things to do than write a blog.”

I have much to do, but I enjoy writing and appreciate the comments you make. However, the person raising questions about my blog time may feel better because I haven’t posted for a while. My absence was not intentional but last week was a whirlwind. Hopefully this week will be better. I’m actually traveling for a couple of days. I’ll be in Georgia, Kansas, Utah and Nevada. Nights in hotels seem to be good for my blogging regularity.

I want to stay with a Medicare theme today. In my last posting, I mentioned a “trigger” contained in the Medicare Modernization Act of 2003 which requires Medicare Trustees to notify Congress and the President if more than 45% of the Trust Fund comes from general revenues, two years in a row. That happened last year.

The warning “triggers” provisions of law that call for the President to send Congress legislation to bring the percentage back under 45%. Last week, the President delegated that responsibility to me and I sent actual legislation to Congress, which has a duty to act within a short time.

I’m pleased the provision is there. We need to respond. While I have little optimism the Congress will act, it is important to keep the discipline of a warning voice and the expedited procedure should at least generate some debate.

The proposal is solid. I’m simply going to link you to information about it (letter transmitting legislation to speaker of the House; summary of legislation). Remember there are two problems we’re dealing with. The big one is Medicare going broke in 2019. Frankly, responding to the trigger does little about that.

The second problem is the one the trigger is focused on. The problem is we are using more and more regular tax dollars, those usually used on other parts of the budget, to pay for Medicare. So, if you worry about education, you should worry about Medicare. Because, Medicare will get its money before education does. Likewise, if you want good roads, you should worry about Medicare. If you think medical research is an important priority, you should be worried about Medicare. Health care costs paid by the federal government are eroding our capacity in other important areas.

Claims Data from Medicare

The proposal I made last week is also relevant in another way. A couple of commenters asked about a lawsuit involving the use of Medicare claims data by people outside of government.

Brian Klepper said: “On Friday the Memphis Business Journal reported you saying that we ought to have ‘a Travelocity for health care’ that would ‘give a quality grade for doctors and show how much they charge for services.’ I'm wholeheartedly with you on this. But how do you square this proposal with the fact that, though you're the nation's largest payor, you acquiesced to the AMA's interests and then refused to release physician data?

Can you please explain these discrepancies?”

Michael Millenson of Highland Park, IL agreed with Brian. He said, “It's past time for HHS to be an aggressive, whole-hearted mover towards release of more information and more timely information. Meanwhile, one easy, no-cost step would be for Secretary Leavitt to use his bully pulpit to call for states to collect ‘all payer’ data. It sounds like a technical issue, but what it will do is allow valid national comparisons of quality of care, as well as enable better state efforts. A local/nation win-win.”

I want to use Medicare claims data for this purpose. And I have been advocating the states provide their data for this purpose. However, I have a problem. A federal court in Florida, some years ago, prohibited HHS from publicly disclosing certain Medicare claims data. Specifically, HHS was prohibited from disclosing annual Medicare reimbursement rates for individually identifiable physicians.

A few months ago, another federal court — this time in D.C., ruled the opposite — that I must provide the data to a specific party. This leaves me sandwiched between two differing courts.

We are working to develop a solution. However, the real fix will need to be legislative.

In the Medicare trigger legislation I sent to Congress, I have included language that would allow HHS in a thoughtful, consistent way to enhance quality improvement efforts in our Chartered Value Exchanges with physician performance measurement results. This needs to happen. I think there is a potential for bipartisan action on at least this part of the legislation I sent up.

Michael and Brian, take a look at the legislation linked above and tell me what you think.

Dealing With Medicare

I suppose the compulsion I feel to get people’s attention on the plight of the Medicare Trust Fund can be attributed to my current close association with it. Medicare is part of HHS and I’m also a Trustee.

This week, I released our budget proposal for the next five years. Medicare makes up 56 percent of the $737 billion we spend. I said at a news conference our proposal should be viewed as a stark warning. Medicare, on its current course, is just 11 years from going broke.

Eleven years is going to fly by. Here’s a perspective builder. The Fourth of July last year seems like yesterday. In 20 times that time, left on autopilot, Medicare will be broke.

Systems as big and complex as Medicare don’t turn on a dime. We need to start dealing with this.

I’m certainly not the first person to warn of this. Part of the problem is that the entire country has been desensitized, numbed actually, by a repeated cycle of alarms and inaction.

Dire warnings on Medicare insolvency have become a seasonal occurrence in Washington. It is like the cherry blossoms blooming in April, part of life’s natural rhythm. People briefly take note, remember it’s that time of year and continue on their way.

The budget we announced Monday is admittedly aggressive. It is another type of warning. I wanted to make sure people could see with specificity the hard decisions policy makers, no matter their party, will face every year until we change the current course.

Medicare is a centrally planned, government regulated system of price fixing. Price fixing systems adjust by having government regulators decide the priorities. The tools we use are blunt and inexact.

Government makes a few thousand decisions that determine who gets treated, how much they get treated, and how much value it has. It is an inefficient way and it contributes substantially to the dilemma we face. We can’t fix Medicare without changing the way health care works in the United States.

What if, rather than government making a few thousand regulatory decisions that affect everybody, consumers made millions of personal decisions informed by transparent information about the cost and quality of various providers? What if doctors and hospitals were rewarded by having high-value care rather than high-volume care?

My view: quality will improve and costs will diminish. That is what happens when consumers are allowed to make decisions armed with reliable information.

The invisible hand of the marketplace is better at rooting out waste and finding optimal value than government regulators.

USS Theodore Roosevelt

Part of being in the President’s Cabinet is becoming acquainted with the broader mission of the government. I accepted an invitation to spend part of the weekend with the Navy aboard the USS Theodore Roosevelt, a nuclear-class aircraft carrier, as it conducted training off the eastern seaboard of the United States.

I spent time with the ship’s commanding officer as well as the Commander of the Second Fleet and the battle group of which the TR is a part. An aggressive schedule allowed me to get a first-hand look at each of the sub-divisions of the ship and its operation. I came away with a much better understanding of the Navy’s mission and the way it integrates into the armed forces of the United States.

The ship was conducting flight qualification for pilots of various squadrons attached to the Second Fleet. Before pilots can be deployed, they have to demonstrate competency in landing on and taking off from an aircraft carrier. On display was world-class science, engineering, logistics, and management.

Hour after hour, planes took off and then landed on the deck of the ship. To take off, an aircraft is hooked to a catapult which uses steam pressure and hydraulics to sling the plane into the air. In less than two seconds, it reaches 150 miles an hour. The pilot has the engines at full throttle so the engines take over where the catapult leaves off.

Most people have seen pictures on television or movies of this procedure but what is not evident is the electrifying energy and thundering sounds surrounding the operation. Standing a few feet away, I could feel my body vibrate on the inside. It is the kind of force so overpowering that a feeling of smallness overtakes you. However, the reality of all that steel and the flaming explosiveness of the jet fuel somehow blends with the controlled and methodical motion of the crews. They move with robotic precision over and over.

The landings are even more remarkable to me. Standing on the deck about 50 feet from their touch point, I could see the aircraft approaching. The closer they came, the more evident their speed became. They are flying at about 150 miles an hour when they cross the trailing deck of the ship. The planes wiggle back and forth as the pilots struggle to position them at exactly the right altitude and angle.

I watched dozens of landings, and every single one gave me the same feeling one gets when they see an accident about to happen. There is an explosive sound of the jet engines at full bore, and then the collision of sixty thousand pounds of steel hitting the deck of a ship. For a split second you wonder: is it going to stop? Then the plane snaps to a halt, even rolling backwards a few yards. And then suddenly, quiet, as the plane calmly follows the directions of the crew to a parking spot.

All of this was dramatic in the daylight, but when night came, the impact racketed up several notches. Then add driving rain and the full specter of our Navy’s competency came to view; they just continued to work through it all.

Speaking of competency; I admire how competency-oriented the military is. The amount of time you spend in flight school is not the final determinant of your ability to fly. It is the demonstrated ability to land and take off in all kinds of situations. Nobody is considered combat-ready until they are proven as such. Every landing is graded, every move evaluated. If you don’t prove it today, go back and get better and try again later. Our schools should be more like that.

Many of those we watched being tested had never landed on a carrier before. Most of the pilots I talked with agreed, it was adventurous in the daylight but far closer to frightening at night.

I had my own experience with both landing and taking off. We were flown to the carrier on a C2. It is a plane built to be adaptable for passengers or cargo. We were strapped into our seats facing backwards on the landing. I would describe the landing as violent, jarring and frankly a little nauseating, but everything other than the nausea was over in less than two seconds. The catapult off the ship was far closer to a great amusement ride, but still only lasting about 2 seconds.

They refer to the USS Theodore Roosevelt as the Big Stick, referencing Teddy’s slogan, “speak softly and carry a big stick.” Much of the 27 hours I was there was spent climbing steep stairway ladders that connect nine layers of the ship where people live and work. The ship is a small industrial city with a population of 5,500. The place is permeated with uniquely Navy culture where everybody knows their job and goes about doing it.

Like any city, there is a post office, a hospital, places to shop, and eat. There are recreation opportunities, residential areas, offices and highly industrialized sections. Every part of the ship is defined by the equivalent of an address; otherwise, one would get hopelessly lost in the maze of tunnel like halls, hatches and ladder stairs.

The food was good; the sailors polite; the quarters were suitable, though the constant roar of jet engines and ship-rattling thud of jets landing on the deck took some getting use to. They say sailors learn to ignore it. Fortunately, they quit flying about midnight and I slept quite well on the lower level of a three-man bunk with 15 inches of clearance between my nose and the next one up.

Though all the machinery was marvelous, I was told it would be the people that impressed me the most and it was. All the senior officers I met were remarkable. I’ve concluded if a person survives 25 or more years in the “up or out” system of the United States Navy, you are an exceptional person. That is certainly true of Captain Ladd Wheeler and his Executive Officer, Greg Fenton. Captain Fenton told me over dinner he had 800 take-offs and landings on aircraft carriers.

I had breakfast with Command Master Chief Chris Engles. He pointed out to me, several times during the visit, that most of those doing the work on board were young, many 18 and 19 years old. They are the products of a system of discipline, training and leadership that demands and gets competency and performance from young inexperienced people, many of whom are away from home for the first time. As we ate breakfast and talked, it became clear to me he cares a great deal about them because that is exactly where he came from.

Engles was born in a row-house neighborhood of central Baltimore as the second child in an Irish-Catholic family of seven. His mother was a 4-foot 10-inch, red-haired, stay-at-home mother. His father is a large gentle Irishman who worked at the shipyards.

A few minutes of conversation with Chris reveal a natively smart man. He speaks with a clipped rapid cadence of the tough neighborhood he grew up in. Talking together I could visualize a 17-year-old who dropped out of high school because he was bored and started working for a buck an hour moving furniture. By his own description, Chris was wasting himself and said he needed something better.

His father had been in the Navy. It had always been a source of pride for his family. In fact, they kept his father’s Navy neckerchief tied to the mirror of the car as a reminder of those days. One afternoon Chris saw a recruiting office and within a few months he was a sailor.

A year or two later he had married the daughter of one of his Naval superiors whom he had met at the christening of a ship he later served on. They have now been married 25 years and have two children, one of whom is in the Air Force.

Chris Engles appears to have been made for the Navy. Smart, disciplined and knows how to talk to everyone. He’s now one of the highest ranking non-commissioned people in the Navy. The Navy has given him education, opportunity and leadership. He has given the Navy his devotion, energy, and lots of sacrifice. He’s a great example for those 18 and 19-year-olds who shoulder so much responsibility and he’s undoubtedly one of the reasons the system works so well.

It also makes one remarkably proud of the armed forces of the United States.

Thoughts On Your Comments

I’m sitting at my desk with a  bowl of soup for lunch.  I have 30  minutes and I’m thinking this might be a good time to respond to a few comments  you have sent. 

First, let me say, I do read the  comments. I just have a hard time finding the time to respond and make new  postings too.  So, I tend to concentrate  on new postings.

Comment on Guatemala  Inauguration
On January 18,  Science Teacher wrote:
Can you tell us whether the topic of H5N1 came up  with any of the representatives of Latin American countries? Is there concern?

Response:
I was  in Central America about a year ago working on  Pandemic issues with the health Ministers.   We have helped them build lab capacity and actually trained more than  200 people from Central America on pandemic  related issues.  It is not a top of mind  issue there, and they still have a ways to go on public health infrastructure.  Gratefully, we haven’t seen any H5N1 positive birds in that part of the world.

Comment on Guatemala  Inauguration
On  January 22, David A. Haley wrote:
Instead of talking about "safe" topics such as India or Guatemala, why don't you address  meaningful topics to the American people, such as what efforts you and the  Administration are undertaking to fix our healthcare system? Hello. Is anyone  home in Washington?

Response:
David, you are right in saying my writings have been fairly  heavily oriented to international work lately. I think if you look back in past  postings I have written about many different topics that fit the criteria you  lay out.  The concentration of recent  writings on international work reflects the fact that I traveled fairly heavily  while Congress was out of session.   International work is an important part of my work and it has a direct  reflection on the health of the Americas.  The safety  of imports is an example. Most of my time in India was focused on products  Americans consume. 

I should also confess that I use this blog as a way to keep track  of what I learn on these trips as a journal of sorts. 

I encourage you to keep reading as there will be lots of meaty  issues to discuss.

Comment on Day 5 in India
On January 17m Robins Tomar wrote:
It would be great if you could write one more post about your  overall experience, changes in feelings before and after your visit and some  recommendations from your experience.

This is just a request if you get time from your busy schedule.  Anyway I will be following your blog to know your opinions about what is  happening around us.

Response:
I would say one of the most of the most important changes in my  feelings were the kind of things that come when one actually sees a place  rather than reflecting what you have heard or read.

Here are just a couple of examples:

• It is hard to adequately explain the challenges of population as large as India’s and how it impacts every public policy issue.         
• I’m attracted to the people of India.  I have lots of friends in the U.S. of Indian heritage and seeing India created a new context for our relationship.
  In Utah there  is a community of people with roots in India.  They have become prominent in academic and  financial circles.  As governor, I was  often invited to attend their celebrations and events.  I always admired the way they worked to  preserve their connection to an ancestral home even though many of them have  become major successes in the U.S.  Now that I have seen that home, it is easier for me to understand their view of America and India.   
• I found particularly helpful the understanding I gained of the small farmers in India and their political influence.  I wrote some about this in one of my postings.
• The number and size of the drug and vaccine manufacturing facilities in India requiring FDA attention was an important actualization.
• The intellectual connection between the U.S. and India came as a pleasant surprise.  I knew it       existed but didn’t have a sense of scale.

I could go on and on, but this will give you a small sense of what the trip did for me.

Comment on Electronic Medical  Records and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
The US  government/we the people already own an excellent EHR - the VA's VistA system. It is fast, simple to use, incredibly  stable and a large portion of the work needed to make it viable in private  practice is already done. Two organizations have taken it,  "de-veteranized" it and gotten it CCHIT certified. With a small  fraction of that cost, the system could be fully upgraded and modified to meet  all of the needs of the commercial market-place and fully implement the quality  measures and disease registries necessary to adopt pay for performance and  improve the quality and lower the cost of healthcare

Response:
I am a big admirer of VISTA and  the Veterans Administration.  In fact, I  borrowed the National Coordinator of HIT from the VA, Dr. Rob Kolodner.  The problem comes in creating compatibility  between other systems and the VA because most patients, even in the VA system, deal  with multiple providers outside their system.   We need to achieve interoperability.   As you point out, there are some providers who are using the VA system  as a foundation to develop smaller systems and we welcome that.  This answer is short but in the press of  time, I’ll leave it at that.

Comment on Electronic Medical  Records and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
It is very easy for the Sec of HHS to say that Electronic records  are the answer to rising Medicare costs. It is very short-sighted to ignore the  reality that the numbers of the Medicare-eligible are increasing every month.  Besides, with increased litigiousness of society, has the HHS conducted an  objective study of what percentage of procedures physicians carry out are just  to protect themselves against frivolous law suits?

Response:
There are a number of studies that document the practice of defensive  medicine.  I would support reforms that would  minimize the practice or perceived need.   Many believe that the development of best practice quality measures will  provide some protection.

Comment on Electronic Medical Records  and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
While agreeing that the current formula is an utter failure, I  would like to point out that Physicians are now working at 2005 reimbursement  levels (far from keeping pace with inflation). The moral of this horror story  is that if professionals are paid their legitimate dues, they will not abuse  the system. It is useful to remember that neither the gas nor electricity  prices; employee salaries nor office rent; neither liability premiums nor cost  of EMRs have stayed at 2005 levels - unlike Medicare payments under this  convoluted SGR formula. I have yet to see any effort by Medicare or any other payee  to actually interact with practices that have had extensive experience with EMRs  to identify real world solutions to real world problems. Until that happens, it  will be unreasonable for Mr. Leavitt to expect physician practices to  voluntarily adopt Electronic records. So if HHS would like to push this idea,  let there be a level playing field and objectivity in assessment of its impact.

Response:
I stand by my belief that the system doesn’t work well.  You would be amazed at the amount of work  Medicare does to estimate what things cost for doctors and therefore what the  reimbursements should be.  The truth is, command  and control regulator systems rarely get it right.  A well informed marketplace where consumers  have information on quality and price will both make the relationship between  doctor cost and charges far fairer.

In a previous entry, I talked about walking through a grocery  warehouse with 50,000 items and asked the manager what would happen if the  government started setting prices on every item.  His answer was right, in my view: “fewer  products, higher cost, and continual arguments.”  I told him, he had just described Medicare  reimbursement.

Well, the soup is gone and my time is up so I’ll conclude and post.

 

Health Information Technology (Written January 22, 2008)

Most readers of this blog won’t get all goose-pimply when I report Tuesday as an important day in the world of health information technology. However, what happened in the 19th meeting of the American Health Information Community (AHIC) will ultimately affect the way all of us interact with medical providers.

At the AHIC meeting a series of significant steps were recommended that will advance the interoperability of health information systems. We moved a step closer to delivering the promise of health information technology -- lower costs, better quality and more convenience for patients.

For those who follow this subject, and other readers willing to learn some about it, I’m going to link this entry to three things:

• First, a short speech I gave at AHIC putting the day’s events into to perspective.

• Second, a press release discussing HHS awarding a contract to design the permanent successor organization to AHIC and a Web site were you can find more information about this.

• Lastly, another press release which tells of AHIC’s acceptance of new standard recommendations on interoperability.

Notes on Martin Luther King Jr. (Written January 21, 2008)

I’m a James Taylor fan. His music speaks to me musically and  emotionally.  The first verse of a song  he wrote, Shed a Little Light, has  been on my mind today.

Let us turn our thoughts today
  To Martin Luther King
  And recognize that there are ties between us
  All men and women
  Living on the earth
  Ties of hope and love
  Sister and brotherhood
  That we are bound together
  In our desire to see the world become
  A place in which our children
  Can grow free and strong
  We are bound together
  By the task that stands before us
  And the road that lies ahead
  We are bound and we are bound

So, on this Martin Luther King Jr. Day, I want to do just  that: “...turn (my) thoughts to Martin Luther King...”  I have had several experiences that have  caused me to hold a deep sense of reverence for him.

In the late 1990s, while Governor of Utah; I was seated next to Coretta Scott King, Dr. King’s widow, at a dinner in Washington D.C. Our  conversation evolved from casual dinner chat to a rather long and searching  philosophic discussion about Dr. King’s life and the mission it thrust upon  her.  It was a uniquely personal conversation and rather than divulge the details, I wish to only recount the  gift I felt she gave me that night.  I felt like I had seen a little bit of her soul and it was moving to me. 

A few days later she sent me a book about Dr. King.  Reading it in the aftermath of our  conversation was a delightful experience that left me feeling a real admiration for both of them. 

In late 2005 and early 2006, I traveled extensively, meeting  with community organizations that were helping to enroll seniors in the new  prescription drug program.  On three occasions, I visited the Ebenezer Baptist Church  in Atlanta, Georgia, where Martin Luther King Jr. spent much of his life.  I met leaders of  the church and community in the basement of the old church and later was invited to speak at the Sunday services.  The experience heightened the impact of my conversation with Mrs. King  and the reading of Dr. King’s book. 

That year I had another experience which added to the  picture I hold of Dr. King’s life.  I met  Dr. Samuel “Billy” Kyles, a respected Pastor in Memphis who was with Dr. King when the civil  rights leader was assassinated.  They  were going to Dr. Kyle’s home for dinner.

I’m sure Dr. Kyles has told the story hundreds of times since then.  However, when I heard the details  in such a personal and direct way, it left no uncertain impact.  It was a tragic turn of events, but like other martyrs who sealed their mission with blood, Dr. Martin Luther King Jr.’s  death punctuated and assured that the message of his life will never be forgotten.  (Here’s a link to a speech  Dr. Kyles gave telling the story – it’s worth reading:  http://www.explorefaith.org/LentenHomily04.03.00.html 

The second verse of the James Taylor song continues:

There is a feeling like the clenching of a fist
  There is a hunger in the center of the chest
  There is a passage through the darkness and the mist
  And though the body sleeps the heart will never rest
 
  Oh, let us turn our thoughts today
  To Martin Luther King
  And recognize that there are ties between us
  All men and women
  Living on the earth
  Ties of hope and love
  Sister and brotherhood

Guatemala Inauguration (Written January 15, 2008)

The inauguration  of a new president is a major historical milestone for any nation. Inaugurations  have attributes that resemble a wedding. 

The steps  leading up to the inaugural are similar.   There has been a courting period and proposal from competing suitors, a  decision, and then an engagement period or transition as we call it in  government. Finally, the ceremony where oaths are said finalizing long-contemplated  promises with legal authority used to seal them.

The ceremony and  ritual of a wedding or inauguration underscores the importance and seriousness  of the commitments being made.  Friends  gather to show support and respect for what is occurring. There are social dynamics  to both.  Who participates, who gets invited,  and where they sit is closely watched. Care is taken to assure that the second  spouse of a divorced parent is seated in a place that avoids tension. There are  parties held in celebration.

Monday, January  14, Alavaro Colom was inaugurated as the President of Guatemala.  President Bush assigned me to lead a  delegation to attend the festivities as a demonstration of the value our nation  places on our friendship with Guatemala.  The other members of our delegation included:

James M. Derham
  Ambassador to Guatemala

Rob Mosbacher
  President of the  Overseas Private Investment Corporation

Sara Martinez  Tucker
  Under Secretary  of the Department of Education

Christopher A.  Padilla
  Under Secretary  of the Department of Commerce

In Latin America, inaugurations are major convenings for heads  of state.  Presidents of more than a  dozen nations, mostly from the region attended.   That makes the day of the inauguration an opportunity for a lot of  business to be conducted in an efficient way. 

After my arrival  the night before, I carried the greeting of our President to outgoing President  Berger. We met at La Casa Presidential, the equivalent of our White House. 

This is the  second occasion I have represented the United States at an  inauguration.  A year ago I lead a  delegation to Nicaragua  when Daniel Ortega took office.  I have  found these meetings with outgoing Presidents fascinating.  It is a period of great reflection for them.  President Berger and his Vice President and  Foreign Minister were there.  We spoke of  lessons he has learned, things he is proud of.

Prominent on  President Berger’s list of important accomplishments is a democracy able to  transition in a fair and democratic fashion.   Twenty years ago Guatemala  was in crisis. He is right — it is a significant accomplishment.   

Early Tuesday  morning, our delegation met for an hour and 15 minutes with President-elect  Colom, Vice President-elect Rafael Espanda, and the new Ministers of Health and  Foreign Affairs, and Economy.  We got  better acquainted and spoke in specific terms about a number of common  interests. 

The significance  was not lost that the President would spend that much time with representatives  of the United States  on such a significant day. 

The new Vice  President of Guatemala is Refael Espada.   He has been a surgeon in Houston for the  last 30 years but each month he has returned to Guatemala to do surgery.  A year ago, he moved back to participate in  the election. He is not a politically experienced man, but has an enormous  amount to offer his country. 

The balance of  the morning was spent meeting with other heads of state.  I had 30-minute meetings with the Presidents  of Panama, El Salvador, Honduras,  and Nicaragua.  The meetings were each a little different mix  of issues.  I have spent a lot of time in  Central America the past couple of years and  have developed good working relationships with each of them. 

Late in the  morning I had a good meeting with the Mexican Minister of Health. We have an  ongoing series of issues we work together on:  border issues, product safety, disease  surveillance, etc.  We reviewed our  shared portfolio, setting some follow-up meetings for February and March, 2008.

Lunch was at the  Ambassador’s residence where we met with the other Ministers of the new  Guatemalan government.  We then traveled  to the swearing in ceremony at Centro Cultural Miguel Angel Asturias, a large  hall in Guatemala City. 

The heads of  state were seated on the front row.   Because the U.S.  delegation was headed by a non-head of state, my place was right behind the  various Presidents.  It was a great spot  to watch the interaction between various people.  Care had been taken to seat Hugo Chavez a  fair distance from a couple of people with whom he had well-published dust ups.  He was next to Daniel Ortega.

The President of  Taiwan was there with a delegation of nearly 100 people.  They flew in on over a hundred people in a  747 owned by China Airlines.  Guatemala is one of a small group of countries  which recognize Taiwan  as a nation. 

The ceremony to  transition power was conducted in a rather dignified way, I thought.  In Central America  the primary emblem of power is a colorful sash draped over the right shoulder  of the President.  The outgoing President  removes the sash and gives it ceremoniously to the Speaker of their legislative  body.  The Speaker then announces the  results of the election and calls the incoming President forward to take the  oath.  Once the oath has been sworn, the  sash is draped on the right shoulder of the new President. A similar thing is  done with a pin worn by the Vice President. 

The oath of  office, taken both in Nicaragua  and Guatemala,  were similar and interesting. The oath in the U.S. is an affirmative set of statements  related to supporting, defending and obeying the constitution.  The Latin American countries include a stern  warning that if the leader doesn’t meet the expectations of the people, they  will be held accountable by history and the people.

The President’s  speech was 45 minutes long.  He appeared  to put aside his formal speech and spoke without notes.  He passionately laid out his  aspirations.  It will be great if only a  faction of it could be accomplished in four years. I found interesting how openly  he referenced God and made other religious references. 

There were small  nuances worth observing.  Things like who  didn’t stand up to applaud. You could see the political coalition playing out  among the members of Congress sitting behind him.  A two-man band of indigenous Indians played a  squawking sort of tune with a reed instrument and drum as the transition of  power was occurring. It was a symbol of support for indigenous people.  The interaction between various heads of  state was intriguing to watch.  A lot of  Latin American politics was playing out in front of me.

In the evening, inauguration  parties and rallies were held throughout the capital city.  We dropped by a reception at the same  building where I met President Berger the night before.   

Just outside the  building, a crowd of 20,000 or more people waited for the event to start. We  could hear them, but couldn’t see them.   There were some doors which appeared to open toward the crowd, so  Ambassador Derham and I opened them up to see if we could watch the  festivities. The doors lead onto a balcony overlooking the gathering. 

As we walked on  to the balcony, the crowd apparently thought we were the official party walking  out to greet them.  A great collective  shout went up and the crowd began to cheer.   We realized we had unintentionally triggered a response and quietly  withdrew, closing the door behind us.   For just a second, however, I felt like Juan Peron.
 

Day 5 in India (Written Jan. 11)

I remember worrying about polio as a child. Victims were put in an iron lung machine to preserve their lives. Many of those who lived had crippling disabilities.

My mother took me to a school where we stood in a long line to be immunized. It was part of a national immunization campaign. The vaccine was delivered by putting drops in a sugar cube.

Now, 50 years later, the polio virus is gone from the United States because of aggressive public health efforts to eradicate it. However, it has continued to ravage other nations. If it is present anywhere, it is a danger everywhere, so our government, in combination with others, has committed to eradicate it from the earth. Only four countries: Nigeria, Pakistan, Afghanistan and India continue to see cases. India is critical because it has the largest number of cases. As of December, 452 cases were reported in India, which represents 55% of the total 832 cases worldwide.

The primary strategy for eradicating polio is the immunization of every child, but it is a lot more complicated in India than it was my hometown 50 years ago. They have to reach 175 million children, multiple times.

I spent a portion of a day in India learning about the strategy and organization of the effort. It is a daunting challenge. Organizers have developed 1.2 million teams of people who go into every nook and cranny of India, searching house-by-house with the objective of reaching every child.

Neighborhoods are charted with hand-drawn maps. Trained volunteers then wade into broken-down, sometimes scary housing areas. They explain immunization to parents. Many are untrusting and wary. Women seem to be more effective as volunteers because they can enter the homes, which is not culturally appropriate for a man.

Two drops are put in the mouth of each child. A check mark is put on the hand-drawn map and the results are recorded in chalk above the doorway.

Drops are squeezed into the mouths of 25 children from the same bottle. It values efficiency and reach over perfection by accepting some risks as inherent when balanced against the greater good. This is raw public health.

I joined the volunteers in a slum area of New Delhi. The homes are made of homemade bricks, sticks, cardboard, sheet metal or any other material they could get. Most had no doors, just drapes. When the drape was pulled back, enough light would flood into the room to reveal a hut-like atmosphere with mats for beds and crudely made furniture. In some cases, the rooms were three or four feet wide and six feet long. Raw sewage ran in a small ditch that weaved a path through the area.

Children ran about, made curious by these unusual visitors. Mothers wore a quiet dignity that I observed as nearly universal among Indian woman. Nearly all of the women wear long flowing saris that provide a sense of elegance even in poverty. They are such attractive people.

Most of the older children understand what is happening and cooperate. However, the smaller ones have to be held with their head back and their mouth opened by pinching their cheeks together. Understandably, they cry and squirm.

As I held those children in my arms, I was a close witness to the filth they live in. Some had puffy eyes and a smell that follows poverty. They were, however, simply beautiful and I felt gratitude for being able to hold them and deliver a potentially life-preserving gift.

During my time at HHS, I have learned a profound appreciation for those who choose to serve the down-trodden of our nation and the world. Many of them work for the Centers for Disease Control and Prevention, the Indian Health Service or National Institutes of Health. They serve with an easily recognized spirit of goodness. They live significant periods of their lives in conditions far below what they could, while accepting risks and personal hardships. God bless them.

Day 4 in India (Written Jan. 10)

It seems as if each day of my India trip has taken on a  theme.  The first day, Monday, was spent  understanding our efforts on HIV/AIDS in India.  Tuesday was a tutorial on the generic drug  and vaccine industry in India  and the role they play in providing products for the United States. I also spent time  with non-profits we support in a push against human trafficking.  Wednesday was devoted to a similar study of  the food industry and its connection to the United States. 

Thursday was devoted to meeting with government officials  and doing diplomacy events at a university.   In total, I held meetings with the Ministers of Health, Commerce,  Agriculture, Science and Technology.  In  each of the meetings we discussed our countries’ new strategy on import safety  and the impact it could have on Indian businesses. 

I also met with Dr. Samlee Pilianbangchang, the Regional  Director of the World Health Organization.   We discussed a long list of subjects ranging from HIV/AIDS, Indonesia’s  unwillingness to share samples of influenza cases and intellectual property  disputes.    

Whenever I visit another country, I like to do a diplomacy  event at a university where I can interact with students.  I think university students are a good gauge  of how the United States  is viewed and more importantly the direction of their thinking.  I also hope it is helpful for them to have  interacted directly with a senior official of our government — to find out we  are just people with lives driven by circumstances not completely different  from their own. 

In New Delhi I went to Jamia Millia   Islamia University.  It was a new experience for me.  I had not been on an Islamic campus  before.  The university has about 10,000  students.  About 450 attended mostly science  and medical students and faculty. 

The program started with a reading from the Koran, the  singing of the school song and opening remarks by the Vice Chancellor.  It is my practice to use a hand-held  microphone and stand on the front of the stage so there is nothing between the  students and me. 

I told them I wanted to divide our time together into three  parts.  First, I wanted them to know who  I am and to feel as if they know something about me as a person.  Second, I wanted to make one point that could  stimulate some discussion and give them an opportunity to better understand my  view of the world.  Last, I wanted to  reserve the majority of time for them to ask me questions. 

For 10 minutes or so, I told them about my life.  It included discussion about my parents,  brothers and home in Utah.  I told them about my wife of 34 years and our  five children and three grandchildren.  I  talked about my professional career and how I got into public service.  I went into some detail on the nature of my job  in the United States  government. 

The second part of my presentation was devoted to describing  how I see the world beginning to organize itself into networks.  I used product safety as an example. 

For the final section I invited them to ask me whatever they  wanted. I had been briefed by the embassy that I would likely get some  questions about matters related to Pakistan, Iraq and Afghanistan, so as an  introduction to the Q&A portion I told them there are some subjects on  which I will comment, but I want you to know I am neither an expert nor a  spokesman for the United States on those matters. 

The students interacted with me in a respectful way.  The questions were mostly focused on the  scientific relationships between the U.S.  and India.  Why aren’t Indian doctors recognized in the  U.S?  The price of drugs and intellectual  property protection were raised.   Students asked about the number of people who are uninsured in the United States  as well as matters related to mental health and stem cell research.   

There was one student who  read a statement critical of the United States  and our positions on the war in Iraq.   I told them the war in Iraq was one of those issues that  does not fall into my expertise but I did want them to know what is in the  heart of Americans and specifically President Bush.  I told them war is always awful and that for  centuries afterwards the motives of those involved are questioned and examined  by historians.  This war will be no  different.  However, in my private  conversations with President Bush it has become clear to me that he is most  devoted to the principle that every human being deserves to have liberty and  that no nation can provide another with a better gift than freedom.  Freedom is our goal and we will continue to  pursue that until the people of Iraq  and Afghanistan  can govern themselves in a sustainable democracy. 

In a previous blog I referenced a dinner the Ambassador  hosted at his residence. Two additional comments:  I enjoyed the way the dinner was organized.  There was only one table and it was  round.  So often one goes to dinners like  that and the group is divided into small groups sitting at different  tables.  It means you don’t have any  exposure to many of the people who attend.   As dinner proceeded, the Ambassador asked me to tee up a conversation  with some opening comments.  I recounted  the purpose of my India  trip and posed a series of questions at the end.  The dinner guests then weighed in and we had  a stimulating conversation that nearly everyone participated in. 

The second thing of interest was the embassy.  The United States Embassy in India is large,  spacious and beautifully designed.  The  Ambassador’s home is an image of the Kennedy  Center in Washington, D.C.  It turns out, the embassy was built before  the Kennedy Center and that they were designed by  the same architect.  Jackie Kennedy had  been at the embassy and asked that the same architect do the Kennedy Center  for the Arts.  The Kennedy Center  is the copy, not the other way around.

Day 3 in India (Written Jan. 9)

The Cochin region of India has been the center of the world’s spice trade for millennia. Apparently the soils and climate are perfect and the culture has been defined by the customs and moment and organization it brings.

The port of Cochin is where most of the spices are shipped. Early Wednesday morning our delegation met with port officials and inspected the operation from a boat. It looked like other ports I have seen. They have recently entered into an agreement with Dubai Ports to build a major expansion of the Cochin port. Much of the investment being made to build up India’s infrastructure is coming from private investment referred to as direct foreign investment (DFI). For example they desperately need airports so they have allowed 30 or so private airports to be built. The owners charge leases and landing fees to those using the airports. It generates jobs, and tax revenue but they are not required to use their cash or capital. In the United States we are able to have public construction with bonds.

The balance of the day was devoted to learning about the spice business. I visited Synthite Industrial Chemicals. Many of the businesses are family companies. I’ve found that to be true of many food-related businesses within the United States as well.

It is interesting that they view themselves as a chemical company and not a spice business. The processes they use to produce oils and extracts are similar to those used in large food operations and food processors. For example, they can produce a mustard oil that flavors other materials. French’s Mustard is a composite of materials that spread well, including a plant that is processed to provide the brilliant yellow color and a little dab of their mustard oil. They also create the chemicals used as coloring and fragrances.

They are a huge producer of black pepper. It strikes one when you see the size of their facility and realize it is producing 24 hours a day, just how many people there must be in the world to consume that much black pepper. It takes a lot of shakes and turns of the pepper grinder to use it all. Actually, with pepper they are finding ways to use an oil pepper to produce the same flavor. They just blend it in.

This is an interesting part of the world I knew nothing about. The customers for Synthite and others like them are “flavor houses”-- businesses that engineer the ingredients and processes of making food.

At lunch I met with a group of business owners known as the Spice Board. This is an entity organized by the government to facilitate and promote Indian spices. My sense was, they really get it. They can see the need to get ahead of product safety as a matter of brand protection and market enhancement. They have created a certification process that assures any spice leaving India in a few categories has been certified to a standard. It is a template for how many different industries and countries will handle product safety. If the United States, for example, can become comfortable that the certification of the Spice Board is to be relied upon, then we would treat any product holding their seal in a favorable way in matters related to customs and entry by allowing them easy and fast access into American markets.

The Red Pepper Principle

Our afternoon was occupied by a visit to another spice operation; this one, AVT/McCormick. The factory is surrounded by homes of the most basic form. The winding road into the plant is narrow but paved and so close to many of the homes that it provided an intimate view of the people who lived there. As we drove I was able to see inside yards and homes, even make eye contract with people. I enjoyed the drive.

McCormick has a big market share in the American spice business. They bought into this plant about 10 years ago. The processing is interesting, but I found the relationships between McCormick’s growers and customers the most interesting part of the visit.

Upon arriving I noticed some large burlap bags of red chili peppers. Sewn to each of the bags were yellow cloth tags with messages written on them. I was told the farmers were required to put their names, location the chili peppers came from and the date they were picked on the tag. The McCormick people told me this was a system they had implemented during the previous year as a result of a traceability requirement their customers were making.

The farmers who provide peppers and other crops to McCormick are people with only an acre or two of land. Most are unsophisticated but they are also part of a powerful political constituency in India. Unlike many parts of the world, poor people vote in India and the political officials are extremely sensitive to their desires.

It is highly unlikely that a requirement of traceability would have ever been imposed on the small farmer by the government. However, when customers made it a condition of doing business, the farmers accepted it or started doing business someplace else. Since McCormick is the most reliable partner in the market, almost all adapted. Let’s call it the Red Pepper Principle of Product Safety: Markets, not mandates, will drive improvement in quality.

The small farmer is a unique aspect of India’s economic and social challenge going forward. Like so many emerging economies, significant disparities are developing between urban and rural. While in Vietnam a couple years ago I saw a nation subdivided into plots of less than an acre. Forty-three million farmers worked the land by hand growing their own food and a little extra, which they sold. I asked their Agriculture Minister why more mechanization was not introduced. I understood how the social stability of their nation was linked to the system when he said, “What would those forty three million people do if they didn’t farm.” In India, the government wrestles with the same question except the number is more like 700,000,000.

At Ambassador Mulford’s home my second night in New Delhi, I had dinner with 10 people he had selected for a round-table discussion. Part of the group was a well-respected economist whose clear thinking I immediately admired. In response to a government official’s defense of protectionist policies to preserve the small farmer she said, “What you’re leaving out is they can change.”

Indeed they will change, but likely not because of government policy changes. People will avoid change intuitively and democracies follow. Over time, things will begin to change because of the only democratic force stronger than a self-interested constituency: an efficient market. A global market will require change for survival, and over time some will adapt. The McCormick red pepper farmers are a prime example.

This kind of change takes years. Many small farmers will resist adaptation, living out their lives raising food for themselves and selling the balance for subsistence. Others will be of a nature to accept change and seek greater prosperity. They will begin to join with others so they achieve economies of scale. They will implement new practices that make their crops attractive at higher prices because they are higher quality.

I have an agricultural heritage. My family bought the farm of my grandfather and as his generation died away, we bought their land to achieve the efficiency of scale necessary for survival. Today the collection of land that supported 21 families 50 years ago is farmed by fewer than three full-time workers. However, during the same time other things changed. The next generation of children sought education and earned their living differently than their forefathers. How to navigate such change in a nation with four times the population and one third the land? That is the question facing India in the next half-century.

Day 2 in India (Written Jan. 8)

Tuesday in India, I concentrated on drug safety by traveling to Hyderabad, about an hour flight from Chennai.  My first event was a visit to Dr. Reddy’s, a significant manufacturer of generic drugs for the American market.  I’m told there are nearly 100 facilities in India producing generics.  It is a major industry here and the United States is their primary market. 

The Chairman is Dr. Anji Reddy who 22 years ago began manufacturing active ingredients for other drug companies.  Four years ago, they decided to manufacture generic drugs of their own.  They are also working to get some original molecules approved by FDA.  They built a state-of-the-art plant that has been inspected many times by FDA.  They choose to do the manufacturing in India because the cost structure is so favorable.  They employ nearly a thousand scientists who are paid much less than American scientists. An HHS scientist working with me estimated the average Indian scientist would be paid around $2,000 a month, which puts them in the top social economic range. A comparable American scientist would demand six figures. 

The company feels the combination of circumstances creates a 25 percent or greater cost advantage.  The generic market is by nature a commodity, price-driven market.  I was impressed by the quality of the facility and some of the innovations I saw. This begins a clear pattern of Americans innovating and the Indians producing.  That will change over time, however, because it won’t be long until there is a steady stream of Indian molecular innovations in the FDA pipeline. 

I drove to a village called Thumkunta to talk with a group of non-profits who work with victims of human trafficking.  Nearly all travel is on narrow two-lane roads just overrun by traffic.  Pedestrians, motorbikes, small three-wheel taxis, cows, and large trucks all jockey for position.  There are few rules that seem to define navigation.  Most of the motorbikes have loads of three or more people, rarely with helmets.  Little children routinely sit atop the gas tank or sit on the lap of their mother who sits sidesaddle on the back.  They pass inches (no exaggeration) from the car as our motorcade picks its way through.

Commerce is everywhere.  Small store fronts, garages, small real estate offices, and some unusual ones.  A store front sign with a picture of an arm in a sling stands out.  The sign says: bone setting.

Evidence of emerging economic conditions can be seen.  We passed walled developments being built with small units organized like condominiums.  There were signs advertising home-ownership opportunities.  The eight to 10 percent economic growth of India is real but not uniform.

Once at the meeting with the non-profit leaders working on human trafficking, some discouraging realities set in.  Human beings can be so brutal and cultures so willing to turn their heads to it.  Trafficking in persons takes many forms.  People target young women who are either in serious poverty or being abused at home—or both.  They offer them employment in a glamorous setting and when they get them away, the arrangement turns into a horrifying situation where they are forced into prostitution, begging or other kinds of labor.  It can also be children who are sold by family members into labor.  The stories are simply awful and frightfully common.

Our nation has taken a strong position on trafficking in persons.  We are holding nations accountable for their actions related to it.  We condition much of our foreign assistance, for example, on a nation’s enactment and enforcement of laws prohibiting trafficking.  India needs to do a better job of it.  Much of it is based on long-held cultural values and practices that diminish the role of women generally. As discouraging as it is, I must say how grateful I am that there are people like the non-profit workers I met here and other places around the world who are willing to devote their lives to helping them. 

In the afternoon, we visited Bharat Biotech, a small vaccine manufacturer built by Dr. Krishan Ella and his wife Suchitra.  Krishan is an India scientist who spent many years in the United States. His facilities have been built to American standards and are regularly inspected by FDA.

It’s a great entrepreneurial story of people who sold their home, persuaded a couple of friends to believe in them and developed an industry in India.   While the cost structure here is clearly a major part of their success, it appears to me that their success has also been the ability to solve some problems others didn’t. That has been the foundation of their rise.

Interestingly, his business has another side story.  The first two vaccines he produced were given to him by the U.S. government.  They were available to anybody but no one had seen a way to make a market.  He used his engineering background and a group of Indian scientists who he hired to invent new processes to solve problems that otherwise would have required massive investment. 

It is remarkable how many of the people involved in these sectors have spent careers in the United States.  Most of them were educated in our country and spent a decade or more working in the U.S.

After a courtesy visit with the Chief Minister (equivalent of Governor) of the state Hyderabad is in, we talked about their challenge to implement a health insurance program and the problems of import safety. 

After a two hour flight to Cochen we bedded down for the night.

Chennai, India (Written Jan. 7)

I am in India for the week. My primary mission is to discuss import safety with the leaders of the Indian Government. While I’m here, I will also review our investments in HIV/AIDS, tuberculosis and pandemic preparedness.

Today I’m in Chennai, a city of seven million in India’s south region. This is my first visit to India. The complexity of the place was captured well by the Ambassador to the United States from India, whom I consulted with before I left. He jokingly said, “If you have heard anything about India, it is likely true—someplace.” He referred to the many different cultures. For example, there are 18 official languages spoken. Like China, there are stark differences between urban and rural parts of the country.

The most evident characteristic of India is the density of population. India is about one-third the size of the United States and has four times the population. Put another way, 15 percent of the world’s population lives in India on 2.4 percent of the land mass. Almost a third of the population is under 15 years old, and 70 percent live in one of 550,000 villages. This is one crowded place.

I spent the morning at Tambaram Sanatorium, attached to the Government Hospital of Thoracic Medicine in Chennai. Both CDC and NIH within my department have long-term relationships here. It is a major treatment center for HIV/AIDS. The hospital sees 1,500 patients a day, 33,000 a month and more than 400,000 a year. Being in a HIV/AIDS treatment center is always a moving experience for me.

Generally their patients have been tested some other place, and then come to this hospital to get counseling and a treatment regimen, along with the appropriate drugs. Patients then return about once a month to be checked and get their medicine. The process is similar to what I observed in Africa.

As I walked through the pediatric section, I was surrounded by children and their mothers. I was distributing toys I had brought to cheer them up. Through the crowd, I noticed a woman sitting on a cot. She was thin, dangerously thin, but strikingly beautiful. She must have felt my gaze, because she looked up and engaged me with her eyes. She slowly and deliberately mouthed the words “thank you.” Still surrounded by a press of people, I simply nodded and accepted her expression. We used no words, but communicated deeply. It was not me she addressed, but my country. Her expression sent gratitude to every American. Our compassion had given her hope.

Throughout the day I was with my friend Anbumani Ramadoss, the Indian Minister of Health and Family Welfare. We have known each other for two years now. He is young, charismatic and competent. He is a medical doctor by training, and the son of a prominent regional political party leader. Chennai is his hometown, and he is a popular figure here.

The United States and India have an active agenda of things we already work together on. Vaccines, infectious disease, HIV/AIDS, maternal and child health, vision and medical technology are just a few. Much of our conversation centered on food and drug safety and the Minister’s plans to create an equivalent of the FDA in India. I have offered technical assistance. Dr. Andy Von Eschenbach, Commissioner of the FDA within my department, is with me. Each of us will be putting a team together to work on this, much the same as we did in China. I still need to speak with other Ministers of the Indian Government on this matter.

Our collective teams sat down to review an agenda of items, and then had a formal lunch with about 400 people from the medical community throughout Tamil Nadu state. I directed my remarks mostly to import safety. Actually, I printed off the blog post I wrote on the five lessons I had learned dealing with import safety, and used it as an outline for my speech--an unanticipated side benefit of writing this blog.

The rest of the afternoon was spent visiting Loyola College of Chennai, to observe an HIV/AIDS awareness program called the Red Ribbon Club. They have just launched a curriculum for communicating prevention messages among peer groups of young people. It’s an impressive piece of work. We’re losing the battle when we just treat HIV/AIDS among the infected. We have to be in front of this, and prevent it if we are ever to be hopeful of stopping the epidemic. A lesson from Africa reinforced in India.

I was grateful for a two-and-a-half hour break before dinner with a group of community leaders. The jet lag and a cold I picked up over the holiday were beginning to combine against me. A short nap helped.

I always meet interesting people on these trips. Another I’ll mention today is Dr. Pratap Reddy, M.D. He is a trained cardiologist who worked at the Missouri State Chest Hospital for about 10 years. He returned to India to set up private hospitals. His company, Apollo Hospitals Group, now has 46 hospitals. I want to write more about this later, because one of their hospitals’ trademark characteristics is they make their results public, and post their prices. They have results that rival the best U.S. hospitals, and their costs are a fraction of U.S. prices. Many of their patients are from other countries, part of India’s medical tourism initiative; more on this later.

Import Safety Agreements with the Chinese Government

Under assignment from President Bush, I have devoted considerable time and a lot of HHS resources over the past six months to an Import Safety Working Group. I was chairman of the 12-person group which represented all the relevant parts of the U.S. government.

The working groups concluded that our country has a good system of import safety, but it is inadequate for the future. In September, we laid out a strategic framework for the future. In November, we issued an implementation plan with 50 specific recommendations in 14 different categories.

Throughout the period of our work, Chinese products have been under substantial media scrutiny because of a series of negative incidents involving their pet food, aquaculture products, tooth paste and toys with lead paint. It was evident to both our countries that these events were warning signs that required a policy response.

In the summer of 2007, I began working with Chinese officials to develop binding memorandums of agreement on how we can work together to assure their products meet U.S. standards. I asked Andy von Eschenbach, Commissioner of the FDA, to assemble a technical team. I assigned my Chief of Staff, Rich McKeown, to represent me in the negotiations. Vice Premier Wu Yi of the Chinese government received a similar assignment from President Hu to organize a team.

The work between the Chinese and American negotiating teams spanned six months and involved four different rounds of meetings. They were rigorous and spirited. However, in the end, two agreements were produced. One agreement is on food and animal feed. The second is focused on drugs and medical devices. I believe these two agreements contain a framework which will have a profound impact not just on the importing relationships between the U.S and China, but also on the relationships we have with other nations.

I want to enumerate five of the many important conclusions I have reached during this period.

Lesson 1: The import safety problem is the natural consequence of a maturing of the global marketplace. These issues have been slowly ripening for several years now. It is a direct reflection of the profound growth in the amount of trade between nations. Our systems are not designed for the pressure they are under. We are inventing tools to deal with new problems. Scaling the old way up is an inadequate response.

Lesson 2: Collaboration is necessary within governments as well as between governments. Different countries have different systems of government and different views of import challenges and priorities. Likewise, different parts of governments see import safety with different perspectives. For example, a border protection agent views this as a law enforcement challenge. A public health official sees it as a health problem and, naturally, a trade negotiator wants to know how it will affect commerce.

Lesson 3: Different perspectives, economic systems and regulatory regimes must be bridged by common goals, international standards and interoperable systems. The standardization of cargo containers across the world is a proper metaphor. By adopting standard-sized containers, the shipping community has made it possible for cargo to be handled efficiently in any nation. There is no substitute for the hard, messy work of collaboration in developing them.

Lesson 4: Transparency is trust’s seed. In a global market, speed is life. Anything that slows the flow of goods down, including unnecessary inspections, damages competitiveness. Competitiveness and safety can co-exist only when one knows who to trust. Transparency brings trust; trust brings speed; speed wins in a global market.

Lesson 5: Continuous improvement is necessary. The agreements we signed with the Chinese are frameworks and will require continued work at many layers of government and industry. There is a Chinese saying, “A man who would move a mountain starts by moving small stones.”

Traditional Chinese Medicine

The National Center for Complementary and Alternative Medicine is part of the National Institutes of Health.  Its role is to explore complementary and  alternative healing practices in the context of rigorous science.  While in Beijing last week, I had experiences that  added to my instinct that there is value to be gained in understanding  traditional Chinese medicine (TCM) better.

The first experience was meeting the new Minister of Health for  China, Chen Zhu. He brings a reputation as a world class scientist to his new post. In  addition to our meetings at the Strategic Economic Dialog, Dr. Chen and I had breakfast  on Wednesday. It gave us an opportunity to talk about areas of  cooperation.  It also provided a chance  for me to get to know him on a more personal level. 

I asked Dr. Chen to tell me more about his youth.  He told me that despite having parents who  were both sophisticated physicians in urban areas, during the difficult days of  the Cultural Revolution, Chen Zhu was required by the government to live in  very poor areas of China,  working on the land until his adolescence. Those experiences clearly gave him sensitivity  to the plight of the poor and underserved.  During that time he taught himself English by  comparing the English and Chinese versions of Mao’s Red Book.   He later  became a physician and medical researcher of some renown, becoming a member of  the National Academy of Sciences in France  and China. 

When he was in medical school, Dr. Chen learned western  medicine and traditional Chinese medicine techniques which he had observed as a  boy in the countryside. He described how an insight he gained from traditional  Chinese medicine unlocked a major discovery in developing response for a form  of leukemia.  He had a hunch, based on  what he knew of Chinese medicine, that arsenic could play a productive role in  treatment.  Turns out, he was right.

During a visit at Beijing University of Chinese Medicine, I  visited a museum devoted to recording the history of TCM.  On display are many of the different  botanical, animal and mineral substances used in treatment.  Each of the components in the collection was  displayed in a clear jar with a short description. 

I asked the curator how discoveries had typically been made  and recorded.  She explained that most of  them had come because of the connection between medicine and food.  People were constantly looking for ways to  nourish themselves.  They found that  eating certain things had additional benefits beyond just satisfying their  hunger. 

Walking through the museum, I found myself thinking what a  remarkable earth we live on that can produce so many varieties of  vegetation.  Surely each one of them has  a molecular structure with active ingredients capable of affecting the human  body in different food.  We turn to these  plants for our nourishment; why not for our healing? 

After visiting the museum, I went to a clinic at the medical  school where students were examining patients using TCM methods.  I watched acupuncture therapy being  applied.  I sat in (with the patient's  permission) as a seasoned doctor surrounded by three students interviewed and examined  a patient who had been referred by a local hospital.  He carried with him pictures of the inside of  his stomach taken by a scope of some kind at the hospital.  I watched the convergence of western medical  science and traditional Chinese medicine as the doctor looked at the scoped  photos and then examined his tongue for clues.   His examination was concluded by carefully feeling the patient’s  pulse. 

At the medical school, they teach both western medicine and  TCM.  Apparently it takes many years of  practice before a doctor is able to practice TCM on their own. Much of it is  learned from experience. 

When the examination was complete, the doctor dictated a TCM  prescription which was filled at the pharmacy.   The pharmacist had eight or ten prescriptions being completed at once on  the counter in front of him.  Each one  was the aggregate of several small piles of plant leaves, bark, seeds, flower  pedals and minerals.  The patient takes  them home, and following instructions either boils them, drinking the broth as  the medicine, fries them for eating or grinds them into another form for  ingestion.

I want to be clear here.   I am not advocating a substitution of TCM for the western style  treatment we receive in the United    States.   I would observe that in the United States, a doctor develops  his/her diagnosis based on similar techniques. They take vital signs, ask for a  medical history and seek to understand the nature of the patient's complaint  and its source.  In many cases they would  also offer a prescription which comes in a small plastic bottle containing tablets  of processed elements of the earth, generally in the form of processed chemicals  held together and colored by other chemicals.

Elsewhere on my blog you will find entries about  personalized medicine where patients get treatments customized for their use.  The TCM approach to treatment seems less precise in some ways but the  prescribed medical treatment in many ways is more personalized. 

One more thing; I don’t know exactly, but I’m guessing the  total cost of the elements for any one of the TCM prescriptions would have been  under a dollar.  When I was in western China a year  ago, I came to understand better why that is significant.  If a nation is responsible to provide health  care to 1.3 billion citizens, on an average of $6 to $12 dollars a YEAR, they  probably won’t be able to afford many brand name pharmaceutical products.  It should also be noted that the mortality  and morbidity results in China  and the United States  are not all that different. 

Through the National  Center for Complimentary and  Alternative Medicine at NIH, and a number of other institutions within the United States,  researchers are working to find ways to understand TCM better.  We need to do more of that.  Dr. Andy Von Eschenbach, the Commissioner of  the United States Food and Drug Administration, and  Director of the National Institutes of Health,  Dr. Elias Zerhouni and I have been discussing a trip to China next year to  increase the levels of collaboration.

During our visit at breakfast, Minister Chen and I agreed to  actively explore ways we can work together applying rigorous science to  traditional Chinese medicine.  More  science-based understanding could lead to a convergence of real value. 

Meeting China's 'Netizens'

In a compact Beijing studio on Monday, Li Xing, the International News Editor of China Daily had questions for me. She asked me about meeting a little girl in western China who had contracted the H5N1 avian influenza virus. We then talked about import-safety agreements with the Chinese governments and the availability of health insurance to U.S. citizens. The questions she asked for more than a half-hour were not just her curiosities, but rather questions e-mailed from China Daily’s online readers whom she refer to as netizens.

I like the concept of netizens. I have to admit, I hadn’t thought much about the term until Li Xing used it. We are citizens of nations but also find ourselves members of global communities connected not by geographic boundaries but our collective interests and passions. When I saw a stream of questions filling Li Xing’s computer screen from some of the estimated 10 million China Daily-reading netizens located all over the world, the term was abruptly given more meaning.

As we talked, two studio-quality digital video cameras streamed our conversation over the Web. Our words were simultaneously transcribed into text. The next day China Daily’s print edition published an article summarizing our interview. That is a combination of digital mediums with serious reach and the capacity to interactively engage people.

I’ve become a novice blogger. I started a few months ago. My first effort was a blog related to pandemic flu. The input we received from netizens (though we didn’t refer to them as such) was remarkably good and persuaded me to spend more time exploring different combinations of media as public policy tools.

In the space of an hour, my encounter with Li Xing and her colleagues at China Daily elevated my thinking some. It seems possible I should be embarrassed not to have realized this before. I suspect there are 26-year-old netizens reading this saying, “Where has this guy been?” Well, despite what most would call a pretty good technology pedigree, the term netizen and its sociologic potential just eluded me.

During our conversation I told Li Xing about my blogging adventure. She volunteered to tell China Daily’s netizens about it. I hope she will because I want to continue the discussion I started with Li Xing and her ten million friends. I have a lot to learn about good netizenship.

For those who linked here through China Daily, it might be helpful for me to tell you about my blog.

First, I am committed to write it myself. For better or worse, what you get are my words, not the product of my staff. They manage the blog and occasionally clean up the postings some but I write the content. I also attempt to read the comments. Time simply doesn’t permit me to regularly respond to the comments. However, once in a while I’m inspired or agitated enough to respond. But time is a real issue. I was the first U.S. Cabinet Secretary to use a blog. So far, I’ve enjoyed it and I find it helpful in hearing different points.

I aspire to write a couple times a week. Lately it’s been more like once a week. Most of the posts are written on my laptop while I’m sitting on an airplane or in a hotel room. Tonight, as I write, I’m on an airplane winging my way back from Beijing.

I’m learning about the blog culture as I go. So, occasionally I make errors, but readers have been good-natured in pointing out my mistakes. For example, when I get on a roll and I tend to be too long. A couple of readers pointed out it would be better to break it up some with subheadings or even individual posts. I’m working on that.

My blog also serves as a combination journal and sounding board. However, I confess to being a little bit circumspect at times given the nature of my responsibilities.

I hope you enjoy occasionally reading my thoughts. I’ll look forward to hearing the reaction of my fellow netizens.

Electronic Medical Records and the Medicare Sustainable Growth Rate

[Note: This afternoon, I notified Congress we (the Administration) support a requirement that doctors adopt e-prescribing and electronic medical records in order to get the full Sustainable Growth Rate update (HHS statement). I've written more below about why I think this is important.]

When I was a boy, there was a Tennessee Ernie Ford ballad titled, “Sixteen Tons.” It told the story of a coal miner who bought all of life’s necessities from the company-owned store on credit. 

Apparently, the miner in the song spent more at the company store than he earned, but the company store just kept running his tab up higher and higher, making it more and more difficult for him to ever pay it back. It created a hopelessness reflected in the song.

The chorus of the song was:

"You load sixteen tons, and what do you get;
Another day older and deeper in debt.
Saint Peter don’t you call me cause I can’t go;
I owe my soul to the company store."

This week, the Congress will begin working on the Medicare Sustainable Growth Rate (SGR) or what people call the “doc fix.”  The doc fix is a ritual crisis brought on annually by a terrible system Congress put into place in 1997 to manage the amount Medicare pays doctors for various procedures.   

Here’s how it works: Each year, the Secretary of Health and Human Services is required by law to establish a target for the rate of overall spending on Medicare Part B. (Think of that as the total of all the miners’ wages)

If, collectively, doctors bill Medicare for more than the target, the Secretary of HHS is then required by law to make it up on future updates. (The mining company reduces the future wages to pay off past debts at the company store)

However, the doctors just keep billing more and more procedures to Medicare and spend far more than the target.

This has gone on now for more than 10 years and Medicare has now paid so much more than the target that the formula in the law dictates that doctors receive negative updates, cutting the amount they get paid for each procedure. This year, the SGR hole is so deep the law requires HHS to reduce the future rates we pay doctors by 10%.

So, each year Congress steps in and overrides the system by instructing Medicare not to cut the reimbursement rates.  Consequently, the amount that doctors get paid at least stays the same or is a little more.

Here’s an important point.  When Congress overrides the law, it doesn’t fix the system or pay off the deficit which is now so large it would require nearly $200 billion to pay off the backlog. 

This is a lousy system and it hasn’t reduced Medicare costs.  The total expenditures just keep going up.  Why? When rates per procedure don’t go up, doctors have simply done more procedures.

Moving toward a long term solution

Long term, the solution to this problem is to change the way we pay doctors.  At least some portion of their payment should be based on how successful they are in keeping people healthy, rather that just the volume of procedures they perform.  Sometimes that is called pay for performance or value-based health care. Whatever you call it, we cannot make progress unless doctors adopt a system of electronic medical records. Such a system depends on being able to gather quality data electronically.

Electronic medical records are widely accepted as providing significant long term efficiencies. The technology is maturing but doctors have not adopted them in sufficient numbers to create critical mass. 

Doctors want Congress, in the next couple of weeks, to once again override the Sustainable Growth Rate law.  It will cost taxpayers at least $4 billion. This year it’s a 10% reduction they will be overriding.  Next year it will be 15%.  We just dig a bigger and bigger hole. We need to begin the process of moving toward a longer-term solution.

It is the position of the Administration that any new bill overriding the SGR law should require physicians to implement health information technology that meets department standards for interoperability in order to be eligible for higher payments from Medicare. 

The benefits of utilizing interoperable health information technology for keeping electronic health records, prescribing drugs electronically and other purposes are clear.  This technology will produce a higher quality of care, while reducing medical costs and errors, which affected an estimated 1.5 million Americans last year through prescription drug errors. 

Such a requirement would accelerate adoption of this technology considerably, and help to drive improvements in health care quality as well as reductions in medical costs and errors.  I’m confident that many members of Congress are of a like mind on this issue and I look forward to discussing it with them in the next few days.   

Framingham Study

When I was Governor of Utah I became fascinated by the potential of personalized medicine. Researchers years before had begun developing the Utah Population Database (UPD) which is genealogy records accumulated by the Church of Jesus Christ of Latter Day Saints, combined with medical records, disease registries and other publicly available documents. When combined with genetic information on certain families, the UPD was a powerful tool in finding the genes linked to specific forms of cancer and other diseases.

I wanted to enhance the Utah database by creating capacity to track directly more families. Our strategy was to identify families that had settled in Utah in the mid-19th century and track their descendents. Incidentally, my family fit into that category.

Periodically, I would invite some of the most respected members of those families to the Governor’s residence for dinner with me and a genetic scientist. Our conversation would lead to an invitation for their family to participate in the project. Accepting meant they would organize what I called a “poke and probe” family reunion. Family members would fill out questionnaires about their history and behavior. Each would be physically examined. Each participant committed to repeat the effort in subsequent years.

One night, after sitting quietly through dinner and the conversation, an older man indicated to me that he had something he wanted to say.

“I don’t understand all the science here, but I do believe there is something to this genetics stuff.” He continued, “This week I was diagnosed with macular degeneration and I’m 70 years old. When my father was 70 years old, he had the same symptoms. When my grandfather was 70 years old, he had them too. If there is something my family can do to prevent a grandson or granddaughter from having to go through this—we’re in.”

A couple of years later, I found myself Secretary of Health and Human Services. I attended a meeting launching another project to pioneer future genetics research. At that meeting it was announced that the gene causing macular degeneration had been isolated.

I doubt my friend from Utah had anything directly to do with the discovery. However, his family’s participation in that project will undoubtedly result in future announcements.

This week I was in Framingham, Massachusetts, a community about 45 minutes out of Boston. It’s a quiet little town and one wouldn’t naturally think of it as a capital of medical research. However, if you use the words Framingham Study to most medical researchers it evokes a responsive recognition.

In 1948, the Public Health Service, working with some local physicians and researchers, persuaded the entire community to be part of a long term study on a wide range of health related behavioral studies. They have been at it now nearly 60 years. More than 14,000 people have participated. The benefits to the average American just keep piling up. (Read op-ed article)

Having detailed medical histories on all these people and their families, when combined with new genetic information and electronic medical record technology, will be profoundly important.

I traveled to Framingham to thank the participants in that study and to encourage them to pass the ethic of consistent involvement to their children. It was a reminder to me of how important it is that ordinary people understand the impact they can have on the health and well-being of future generations.

Health IT

I’m returning from Chicago where we had a meeting of the American Health Information Community. This is the Federal Advisory Committee HHS initiated to advise the Secretary on health information technology standards. I won’t report on the meeting. We Web cast it and it’s available on the HHS Web site if you’re interested (http://www.hhs.gov/healthit/community/meetings/m20071113.html). I do want to reflect on a subject the meeting caused me to begin thinking more about.

We had a discussion about electronic prescribing of medicine. The technology necessary to electronically receive and fill prescriptions exists in most pharmacies in the United States. However, only a small percentage of doctors use it. The benefits are unchallengeable. E-prescribing is not only more efficient and convenient for consumers, but widespread use would eliminate thousands of medication errors every year. At the AHIC meeting, we announced standards that will help to get us there. We are starting with standards for providing medication history and for formularies so that providers have the information they need to write correct prescriptions. These two standards alone could go a long way to eliminating errors.

Most doctors haven’t invested in the necessary technology to do e-prescribing. The reasons are complex and range from a perceived lack of financial incentives to a reluctance to give up the familiar prescription pad. It is not expensive. This change needs to happen and, from my standpoint, sooner rather than later.

The last several years we have been nudging the medical family toward this. This fall, we eliminated the capacity for providers who have an e-prescribing tool to fax prescriptions paid for by Medicare to pharmacies. That has motivated some to use electronic systems. However, we need to do more, I think, including using our power as a payer to motivate the change.

When I was Governor of Utah, I spent time with members of the Highway Patrol. I discovered that after a drunk driver was ticketed it took the patrolman nearly three hours to fill out a stack of forms that was a quarter-inch thick. They then made four copies of the stack and mailed them to various parts of the government for processing.

I ordered laptops installed in patrol cars and had an electronic system developed that allowed users to process documentation in a fraction of the time. The system had undeniable benefits of efficiency and safety because patrolmen could spend more time on the road and less time in the office doing paperwork.

There was a problem I hadn’t considered. Many of the officers didn’t keyboard and frankly some of them were resistant to learning. Ultimately, I had to say, “Look, we are at a point where we can’t afford to have people on the highway patrol who can’t type. If you want to work here, you need to develop the skill to fill your reports out efficiently using a computer. We’ll help you learn, but this is now a requirement of your job.” The patrolmen that didn’t have the skills developed them and the system functions well.

E-prescribing needs faster implementation. We have been through all the public processes necessary to develop standards. The technology is readily available and widely distributed. Electronic prescribing will enhance the safety and convenience for patients. Large health care providers, including Medicare and Medicaid, need to move toward making it a mandatory part of medical practice soon.

Import Safety Report

A good share of my week has been spent in activities related to a report for the President on the safety of imports. Every few days it seems another significant recall is announced.  It has become a matter of real focus for consumers and policy makers.

It is my observation that issues like this slowly ripen because of bigger and more fundamental shifts in economic or social practices. Concern over the safety of imports is not unique to the United States.  Last week I hosted the health ministers of the G7 countries plus Mexico and the European Union.  Every country represented is dealing with import safety concerns. 

What are the underlying economic and social changes causing this sudden concern?  Import safety concerns represent the natural maturing process of a global market.  They represent an early warning that we need to adapt our systems and thinking to accommodate a new set of challenges.  The old ways do not protect us adequately from the new risks. 

I was assigned by the President to chair a government-wide review of our practices related to imports of all kinds.  The working group included 10 other cabinet members and the heads of the Food and Drug Administration and Consumer Product Safety Commission. 

I’ve previously reported on some of my experiences doing this review.  Today, I want to provide you access to the report.  I think it has been well crafted.  It contains 50 specific recommendations in 14 categories, all crafted to fill in detail to the Strategic Framework we provided the President eight weeks ago.

In keeping with my goal of making these postings shorter (and the fact that I’m out of time today) I will provide some additional observations later.  In the meantime I would value your reactions.

Express Lane SCHIP

There’s a website my son showed me called howstuffworks.com. I don’t think what I want to write about today can be found there. However, my thoughts fit into that category. I want to explain how just one provision of the SCHIP bill the President vetoed would have worked and why we insist it is changed.

First, let me make a couple of points. Whoever said “the devil is in the detail,” must have been talking about legislation. This bill was written in consultation with people who knew exactly what their goal was: universal, government-run, taxpayer-financed health care for citizens and non citizens alike in the United States. Second, this bill clearly moved multiple steps toward that end.

The President and I believe every American needs health insurance, but our vision of how to accomplish it is fundamentally different than the Democrats’. We believe government should offer insurance to citizens in hardship, like poor children (Medicaid and SCHIP), and low income adults (Medicaid), like the disabled and elderly (Medicare). However, we believe government can organize the private marketplace so everybody else can choose their own plan, and choose their own doctor and hospital. We believe consumers make better decisions about their health than the government does. We think competition drives quality up and cost down.

Last week, we made clear that we want this program reauthorized and we are willing to assure there is enough money in the budget to cover poor children. What we aren’t willing to do is fund the program with $15 to $18 billion dollars more than is needed. And we don’t believe it is necessary to raise taxes to do it.

Now, back to the devil in the very clever and deliberately hidden details of the vetoed bill. The bill has a basic strategy: Flood the program with money and then build into the language of the bill methods of blowing the doors open for eligibility. In short, use the language of poor children to fill the money bucket up. Then, when taxpayers have committed money, we can expand the population of those who get the benefit to include adults, aliens, and higher income people who have private insurance now.

There are several glaring examples of how this bill was designed to do exactly that. One method used is hidden under the phrase, “express lane” enrollment. This allows states to delegate deciding if people are eligible for SCHIP to others, like schools. It then provides that if the school decides they are eligible for subsidized school lunch they can get Medicaid and SCHIP.

Here’s the really clever part of this camouflage. Schools don’t have any way to enforce eligibility by income or citizenship for subsidized school lunch, let alone SCHIP. If there is any question, they put children into the program. Talk to anybody knowledgeable about school lunch programs and they will tell you, significant numbers of children are deemed eligible for these programs that aren’t.

The school doesn’t even have to have the signature of the family, nor does the family really have to verify income or citizenship status or other important information such as whether the family already has health insurance.

What’s the penalty if a state lets lots of people who aren’t eligible into the program? Virtually none; again, let me explain how the bill would work.

Assume the federal government wanted to check up on a state to assure they are keeping the rules. It is not possible to check every file, so the logical thing would be to pull a scientifically drawn sample of all their enrollees, survey those cases for compliance, drawing conclusions based on the survey for the entire program. If say, a thousand cases are checked, statistically you can predict the compliance of the entire group.

Let’s say, the sample found 200 of the 1000 were falsely allowed in the program, or 20% of the entire program. The law would simply allow the federal government to ask for its money back on the 200 specific cases. But the bill actually prohibits the federal government to make the states accountable for the tens of thousands of cases the sample represents.

In other words, the bill not only makes it easy for ineligible people to get in the program; it also takes away any meaningful penalties for states that put them there. In fact, it creates massive financial incentives for states to do so.

We are all for signing up kids and even signing up kids fast. States can use presumptive eligibility but still maintain the integrity of the program by running a full eligibility determination. States can send eligibility workers with laptops into the schools to take applications, but we should not ask taxpayers to foot the bill for people who are not eligible.

There are many other reasons the President vetoed this bill. I’ll write more later.

MRSA

Monday I had Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, brief me on the MRSA bacteria. This is the drug-resistant strain that has been a worry for several years now, especially in health care settings. My interest was peaked by new research reporting the frequency and severity of the problem.

Dr. Gerberding currently administers one of the true public health treasures of the United States. CDC is seen worldwide as the gold standard of public health agencies. Julie also happens to be a world class scientist and, as it turns out, the MRSA (methicillin-resistant Staphylococus aureus) bacteria was the subject of much of her research.

I asked for the briefing after the Journal of the American Medical Association published a study estimating MRSA caused 94,360 life-threatening infections and 18,650 deaths in 2005 within the United States (Klevens et al., 2007). The human suffering created by this bug is enough to make it a serious matter. The financial impact is also profound.

To say Dr. Gerberding is passionate about this work is a huge understatement. I could well have been listening to the head of the CIA talk about current intelligence on a terrorist cell within the United States. She speaks of the different microbial players and describes their personalities. She uses the word community as she discusses the bacteria’s efforts to undermine its competitors so it can unexpectedly overwhelm its host. Scientists are the intelligence analysts in this struggle; the medical family is the armed forces that work to protect us; and antibiotics are the weapons used to fight.

There are serious challenges in fighting MRSA. Like any microbe it is constantly adapting; “learning new tricks” is Dr. Gerberding’s phrase. Tricks like genetically learning to ignore antibiotic treatments, or the capacity to invade into deep tissues and destroy them with a potent toxin.

Some of those “tricks” MRSA learned in hospitals have been transported to staph that healthy people carry into the community, and now they too are MRSA carriers. Dr. Gerberding said this started happening in the late 1990s then began to run wild outside medical areas. She told me of a situation involving a college football team where 10 players developed MRSA through their turf burns. She mentioned prisons, schools and other populations, like Alaskan Natives, where outbreaks of skin and sometimes deeper infection occur. Once the bacteria have a foothold, they easily move to others in close contact.

Her description of the way MRSA adapts reminds me of a computer code breaker. To break a computer code, hackers try sequences of numbers, letters and symbols at high speed until it stumbles upon the combination. Billions of MRSA microbes are testing the genetic codes to find new ways to exploit weaknesses in their host.

After moving through the community and picking up new “tricks,” MRSA has begun to concentrate on medical facilities again. More than 80% of the incidents occur in hospitals, doctors’ offices, etc. Obviously, people with open wounds and weak resistance make easy prey.

This is a remarkably clever bug. Dr. Gerberding told me it will hang out on a person’s skin and then when an IV is inserted in an arm, it will slide down the needle into the system where it will begin to compromise other microbes.

The best defense against MRSA is prevention. Hospitals, doctor’s offices, and nursing homes need to have aggressive programs to deal with this. Patients deserve to know hospitals, nursing homes and doctors do a good job at prevention. Patients need to know if a hospital has a history of regular MRSA infections.

I have to quit now, but I have more thoughts on this. I want to explain how transparency of incidents is critically important. How electronic medical records play a role here. Also, some about who should pay when a patient gets sick from a hospital born infection.

Klevens RM, Morrison MA, Nadle J, et al. Invasive Methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007;298(15): 1763-1771.

Strategic National Stockpiles

Strategic National Stockpiles have had my focus the last few weeks.  Each year Congress appropriates money (just under $600 million last year) so we can maintain stockpiles of medical supplies that would be needed in a national emergency. We have organized the system with the objective of being able to deliver basic supplies to the scene of an emergency within 12 hours.

The stockpile system became a serious undertaking following September 11, 2001. Our level of sophistication continues to increase. The procedures for prioritizing and executing the purchases are improving.  We have a ways to go in my view.

It is easy to underestimate the challenge of keeping supplies current and ready to deploy. It involves advanced logistics and it is not inexpensive.  In many cases, buying the item is a minor part of the cost. Warehousing has to be paid every year. Another challenge is shelf life.  Most medical products have to be constantly monitored for currency and after an appropriate period they are no longer usable. 

Some items are used and rotated constantly, but others don’t lend themselves to that pattern.  Medical masks for example are not reusable and they just plain take up a lot of space. Medicines for certain emergencies would not be useful for any other purpose.

Another difficult issue is what and how much to stockpile.  We have an interagency working group that makes those decisions.  This group weighs the various categories of natural and man made emergencies that could occur and does its best to anticipate the supplies needed to recover from each.  Careful priorities must be chosen because we can’t buy everything.

Among my biggest concerns related to the stockpile are two obvious ones.  I worry about local and state governments and private entities relying on the federal government instead of preparing themselves.  Our national stockpiles are set up to cover gaps, not to provide everything for everybody. 

My second worry is distribution.  The stockpile organization is able to get medicines, etc. to an airport within 12 hours. State and local governments are depended upon to have plans for distribution.  We coordinate closely with them. The drills we have had in recent months with postal workers delivering medications to homes in Seattle, Philadelphia and Boston are examples.

Gates Malaria Forum

This week in Seattle, the Bill and Melinda Gates Foundation invited health leaders from around the world to attend a Malaria Forum. The discussions centered on better coordination between nations, NGOs, multi-national organizations, scientists and individuals on our common goals related to malaria. I left the gathering feeling optimistic that a worldwide collaboration can save millions of lives currently lost in a needless way.

I wrote several blog entries about my experiences related to malaria in Africa in August. This was a good follow up. Many of the health ministers I visited in Africa were in attendance. The formula for progress, in my view, requires coordinated activity over a lengthy period of time, but it is achievable.

I left the conference with a sense of satisfaction that the people of the United States would be proud if they paused to learn what we are collectively doing. The President’s Malaria Initiative (PMI) has become a powerful catalyst worldwide. Our money and leadership are making a big difference. Tim Ziemer, who leads PMI, is outstanding.

A word about Bill and Melinda Gates: I was among a small group invited to their home for dinner.

Yes, their home is spectacular. Unfortunately, I am not good with remembering decorating details. I routinely fail in satisfying my wife’s requests for specifics on design, fabrics and art. I do remember the trampoline room and original documents of Napoleon in the library.

What I will report, with clarity, is an insight into Bill and Melinda personally. I’ve been with them a number of times in social and professional settings, but this was the first time I have had an opportunity to interact with them in their home. I watched as they skillfully listened, questioned, and learned from ministers of health from Africa. People of their economic stature aren’t always good at that. They are gracious and hospitable people. Life’s circumstance has provided the two of them with a remarkable opportunity and the heavy burden that accompanies it.

The stewardship of wealth is weighty. They carry it well.

SCHIP Response

Last week John E. McDonough responded to my entry on SCHIP by making a couple of statements that are typical of those I’m hearing about SCHIP, so I will respond.

John’s comment: First, though you decry New York State's proposed expansion of SCHIP eligibility to 400%fpl, you and the President ignore the fact that the bipartisan Congressional bill would make it harder for states to expand SCHIP above 300%fpl than it is now.

Answer: Yes, the bill would allow New York to offer SCHIP to families of four making $83,000 or 400% of the FPL, or federal poverty level. We do not think children living in families with that much income qualify as poor. We also believe states should focus on children under 200% of the poverty level before offering coverage to families over 250%. New York for example still has 12% of the children under 200% who don’t have insurance. Yet they now want to expand to cover children at 400%.

As you point out, the vetoed bill does contain a requirement for states to enroll children under 300% equal to the average of the top ten states. We agree there should be a standard of performance before states can expand eligibility. We see the bill's standard as weak. We think it should also measure performance on children below 200% FPL not 300%. I would also point out New York and New Jersey, who have expanded above 300%, are exempted from the requirement.

John’s comment: Second, though you say you care about poor children, you ignore that the vast majority of new funds in the bipartisan Congressional legislation would only help about four million children who are currently eligible for SCHIP and who are not enrolled because state's lack the funding to enroll these children.

Answer: John, of the four million children the sponsors say the bill would help, only 500,000 are currently eligible for SCHIP. Over a million are eligible for Medicaid. In other words, these children are eligible for government insurance and could enroll today. Of the remaining 2.5 million, nearly half already have private insurance (according to the Congressional Budget Office).

Most of the money in this bill isn’t going to pay for newly insured children. The majority of the funding will provide states with better match rates and cover children who are already eligible or have private insurance.

A Great Nobel Story

I enjoyed this Christopher Lee article in the Washington Post on University of Utah Professor Mario Capecchi who shares the Nobel Prize in Medicine this year.

I was Governor of Utah for eleven years and, in that capacity, followed Dr. Capecchi’s work closely. My friend Dr. Steve Prescott who now runs the Oklahoma Research Foundation has told me for years that Dr. Capecchi would be a Noble Prize winner.

The emphasis I have placed on personalized medicine as Secretary of HHS is actually a continuation of interests I have cultivated in Utah as Governor. I was able to visit the labs of genetic pioneers and look at their work in isolating gene markers, growing tissue and splicing genes. It was a remarkable education for a policy maker. I’ve always appreciated the time they took to teach me.

In addition to great scientists like Mario Capecchi, Utah has a unique genetic resource called the Utah Population Database. It is a database that overlays genetic and medical histories with genealogy records. The database was used extensively in the gene mapping project. In fact, I’m told the gene mapping project was hatched when a bunch of scientists were trapped at Alta Lodge by a snow storm for several days.

Anyway, those of us with interests in genetic research, and common links to Utah, celebrate the honor given to Dr. Capecchi and Sir Martin J. Evans.

Visit the HHS Personalized Health Care Web site.

Pan American Health Organization Meeting

The Pan American Health Organization had its annual Washington meeting last week. We used the occasion to sign the Memorandum of Understanding on the regional training center the United States is helping with in Panama. The need for skilled medical workers is acute all over the world. The health ministers from Panama, Honduras, Costa Rica, and Guatemala joined in signing with the United States. Nicaragua is also participating but will sign the MOU later.

Camilo Alleyne resigned as Health Minister of Panama a couple of weeks ago. However, he was honored at PAHO and I had a chance to see him. It should be acknowledged that the regional training center vision was originally advanced by him. I quickly saw its value and pledged U.S. support as have all the health ministers and Presidents in Central America.

I met with Minister Turner, the new Minister of Health in Panama. She has pledged her continued support and signed the MOU on behalf of Panama.

Regional training of skilled workers has great potential in other areas of the world. We are exploring a joint effort with the Brazilians in Africa.

Dr. Margaret Chan the Director General of the World Health Organization was in town for PAHO. We had a couple of meetings during which most of our time was spent discussing HIV/AIDS, malaria and pandemic influenza. Her natural and comfortable candor makes her an effective leader of WHO. That job requires a person who can be straight with people in a calm and even-handed way. Margaret Chan is good natured, but very direct. We have been friends for a couple of years now. We visited five countries in South East Asia together when she was leading WHO efforts on pandemic influenza (H5N1).

To learn more about Region Health Care Training Centers, visit www.globalhealth.gov

Continuing the SCHIP Debate

I’m falling into a pattern of posting once a week. I have ambitions to do better than that. The reality, however, is if I’m going to keep the commitment I made to write the postings myself, I’m likely to be imperfect in my regularity. I suspect one solution is to write shorter, more frequent postings; something a few readers have properly suggested.

My week has been focused on the reauthorization of SCHIP. This is playing out about the way I expected it would thus far. Some months ago, the Democratic leadership in Congress made clear they were going to send the President an SCHIP bill he would have to veto. Likewise, the President made clear he would veto any bill that didn’t focus on poor children as the primary priority, or that motivated middle income people with private insurance to cancel it to get on a government program. The bill Congress passed violates both principles. So, the President did exactly as he said he would and vetoed it.

Now, the leadership of Congress has decided to put the override vote off for two weeks. During that period we will hear a lot of political rhetoric but in the end the veto will be sustained. When that occurs we can get down to the business of solving this problem. Demagoguery is a politic ritual in situations like this that just has to be endured.

Over the weekend, President Bush made a significant point in his radio address. This isn’t about money; it is about the priorities, accountability and focus of the program. He wants to reauthorize SCHIP with its core mission of helping poor children intact. The Children’s Health Insurance Program isn’t a program for adults; it wasn’t instituted to help children in families with middle or upper incomes.

The policy differences between the two sides are real and more complicated than a duel between two competing budget numbers. President Bush made clear when we can find a solution to our policy differences he is willing to work with Congress in finding additional money, if necessary.

I’m asked regularly, “So what’s the President’s SCHIP budget number; how far is he willing to go?” There isn’t an answer to that question yet, because we aren’t even talking to the other side of the debate. They have chosen to proceed as though the President’s opinion isn’t important. They will likely continue to act that way until after the veto is sustained. This is a dance that occurs whenever controls of the legislative and executive branches of government are held by different parties. Each time there is a shift in the power structure of Washington, the resilience has to be measured. Each time the lesson is the same. It takes both the legislative branch and the executive branch to make a law.

Visit the Every American Insured Web site

Evaluating after More than a Month

Six Week Evaluation: Your thoughts?

Several readers have made helpful suggestions over the six weeks since I opened this blog. Here are my observations so far:

• I have written each entry myself, as promised. I’m fairly sure my colleagues who manage the site clean them up some before posting, but it is punctuation and small editing only.
• Most postings have been written on airplanes or late in hotel rooms during the late evening. Finding the time has been a bigger challenge when I’m in Washington.
• My postings tend to be too long.
• I may invite a few people besides me to post an entry occasionally. It will add variety and perhaps stimulate discussion.
• The comments have been constructive. I think the blog would be better if I could respond to more. It’s simply a time issue.
• Some comments ask factual questions others could respond to. I’m thinking it would be good to have another HHS person respond to those. I think we’ll try that for a while. They should respond in the comment section not as a blog posting.
• Readership has been reasonably good. We continue to pick up new links each week. We’re getting close to a hundred. I have no idea if that’s any good. Maybe some of you more experienced bloggers can give me some perspective. We get thousands of visits every week.
• On a couple of occasions news media have used blog comments to ask questions more appropriately directed through normal channels at HHS. I hope the media will find this interesting enough to read, but if they have questions it would be better to call or email Public Affairs at (202)690-6343.

The bottom line: So far, this has been a positive experience. I will get better at it as we go. I’ve not been as regular as I aspire to be. I’ll keep working on that. I’m still not committing to blog perpetually, but for now I’ll keep writing.

I would invite you to suggest how we could expand readers and improve the blog. Any thoughts?

Round One on SCHIP

This past week, the process of reauthorizing the State Children’s Health Insurance (SCHIP) bill began.  People wonder how there can be disagreement over a program to help poor children.   There is no disagreement about helping poor children.  The ruckus is more about children who are better off, and a question of governments’ proper role. 

SCHIP was intended to cover poor children; those with family incomes under 200% of the poverty level ($42,000 for a family of four).  The bill Congress passed redefines who is considered poor to include some families of four who make up to $83,000.  Incidentally, a fellow jokingly pointed out to me that many families who make $83,000 a year have to pay a special tax on the rich, called the alternative minimum tax.  “Only in Washington can you be rich and poor at the same time,” he said.

The controversy stems from the fact that most of the children in this income category already have private health insurance.  Late last week, the Congressional Budget Office issued a new financial analysis of the SCHIP bill Congress just passed.  They predict over the next five years, 800,000 children who are currently eligible, but not insured, will enroll in SCHIP.  However, 1.1 million children will DROP PRIVATE INSURANCE so they can enroll at taxpayer expense.  SCHIP should help uninsured poor children get private insurance, not motivate insured children with private insurance to cancel it and move to public assistance.

The President has said he will veto this bill.  Congress will then conduct an override vote, first in the House of Representatives.  I read this morning that:  Roy Blunt, a member of the Republican leadership in the House of Representatives, quoted projecting a 100% probability the veto will be sustained. 

The drama around vetoes and overrides are just the way Washington conducts a conversation and debate.  It generally creates an improved work product.  That will certainly be the case here.

In 1995-1996, I was Governor of Utah and deeply involved in welfare reform.  We went through a similar period of time.  Like today, there had been a change of power in Congress and the parties shared power.  My party, the Republicans, who had just assumed control, acted as if they could pass legislation without the Democrats.  President Clinton vetoed the welfare reform bill a couple of times.  Ultimately, everyone came to understand that accomplishing anything in a divided government requires bi-partisan work.  After a few attempts to simply roll over the Democrats, the Republican leadership got serious about finding compromise.  It appears we’re going through the same experience again but now with roles reversed. 

This debate isn’t about who cares for kids most or just about money.  It’s about different philosophies about the role of government.  Clearly, some people want the federal government to run health care.  They think taxpayers should pay to insure everyone.  Many others (the President and I among them) believe government should help people in hardship (the poor, elderly and disabled) and organize a private insurance market that allows people to choose affordable insurance plans that fit their needs.

Am I saying everyone who voted for the reauthorization bill wants the federal government to insure everyone? No.  For many members of Congress this wasn’t about philosophy or high principle; it was a political calculation.  They simply didn’t want to deal with the vocal and well orchestrated wrath of the advocacy groups who clearly do want Washington run health care, and who see SCHIP as the best chance in years to advance their cause.  These groups wrongly and unfairly paint those who favor reauthorization but not expansion to children in better off homes—as hostile to children.

I talked to several who voted for the bill.  Many of them expect competitive elections in 2008 and knew enough other members of Congress would vote to sustain the President’s veto.  This was a way to “have their cake and eat it too.”  Others who voted for the bill told me their reasoning was essentially this: “If we vote for a bad Senate version of the bill, it will save us from a disastrous House version which was truly over the top expansion.” 

That’s the way Washington works, everybody doing their own political calculus.  This kind of situation is exactly why the founding fathers of our nation provided for a veto.  It is a tool to keep unwise things from occurring when dynamics of politics might propel them forward otherwise.  The President’s veto is the right thing to do.  SCHIP will be a better program in the future as a result.  Ultimately, more people will get health insurance as well, because rather than just moving those who have private insurance to government insurance, we will focus on the uninsured and get on to the bigger discussion of getting every American insured. 

To learn more about our Every American Insured priority, visit www.hhs.gov/everyamericaninsured.

Clarifications on HHS Energy Newsletter

Several of you have brought to my attention concerns about a recent newsletter that went out to HHS employees. You are right; we made a mistake. I have asked my Assistant Secretary for Administration and Management, Joe Ellis, whose office issues the Energy Newsletter, to address this issue in a statement below.

Statement from Assistant Secretary Ellis:

HHS is committed to being a responsible steward of taxpayer dollars and natural resources. One of the ways we have been successful in contributing to energy conservation is by periodically writing to our employees about energy efficiency, conservation, and steps they can take to contribute to these efforts.

Our most recent energy newsletter for employees focused on energy efficient vehicles, and the newsletter encouraged employees to consider the benefits of fuel efficient vehicles when shopping for a car. Unfortunately, the newsletter highlighted vehicles not made by American manufacturers, thereby giving the impression that HHS was encouraging employees to buy foreign makes of cars.

Nothing could be further from our intent. Clearly, the newsletter strayed from its purpose of sharing information about energy conservation that is relevant to working for our Department. In sending such a newsletter, we implied that we endorsed the purchase of cars not made by American companies.

I deeply regret that our newsletter offended anyone, especially those Americans working in the automobile industry and the millions of people who make American automobile manufacturers successful.

Joe Ellis
Assistant Secretary for
Administration and Management, HHS

Defining Personalized Medicine

The term personalized health care is often used these days. It is an exciting outgrowth of our better understanding of the human genome. We now know that our genetic makeup impacts the way we respond to certain treatments.

For example, in this month’s issue of Biological Psychiatry, there’s an article (Lee et al. 2007) about a link between a certain genetic variant and the drug Zyban, which helps people quit smoking. It seems that people who have the variant were less likely to have resumed smoking six months after taking Zyban.

There are numerous medicines doctors prescribe now only if a certain genetic condition exists. In other words, treatment is personalized based on genetic history of a patient.

I worry when we use the phrase personalized medicine, for some, it creates a mental picture of a patient having one-of-a-kind pharmacology developed specifically for them, based on their phenotype, environment and genetic make-up.

That model, while appealing, raises doubts. Intuitively, people develop questions about the scalability and sustainability of trying to treat a population of people in that fashion.

The vision we are moving toward, in my mind, is best described as mass personalization. Using a thorough understanding of a person’s genetic and clinical history, a doctor will select a combination from a group of biological and chemical treatment tools.

I sense our vision will be better understood and accepted if we begin to paint a picture more familiar and comfortable to patients, providers and payers. As consumers we have become quite familiar with mass customization in many of the things we purchase.

When I bought my first set of golf clubs, I bought a set the golf professional had on the shelf. After many years, I decided to buy new ones. The technology has improved and there were several aspects of my game that would fall into the category of needing treatment.

This time, I was confronted with a different experience. The golf professional and I measured my height and arm extension (my phenotype) and inventoried my game (genetic and health history) until we knew what the best length and flexibility of the new golf clubs shaft should be, the angle of the housel, the weigh distribution of the club head and grips to fit my touch.

The golf professional said to me, “now that we know how you align your clubs (medication) with your game (ailments), we can fit you properly. We carry ten different models of club with different combinations; the X20 Long has most of the attributes you need.”

I bought a set of clubs, off the shelf that was personalized to me. This company is now engaged in mass customization.

Now, I want to say, tongue in cheek, I have a vision of the golf improvement in the future. It personalized golf. There will emerge a system of electronic golf records. These records will be interoperable between golf courses so no matter where I play, each shot will be tracked. The genetic tendency I seem to have for slicing the ball will be well documented. So, as I need golf clubs in the future, they will be personalized to remedy my ailments.

In fact, because there will be so many golfers like me with electronic golf records, researchers will be able to gather data to invent new tools to cure the common slice and three putt green.

All kidding aside, we do need to begin defining personalized medicine in ways people can understand. We have the technology now to make health care much more personal and much more efficient.

More on this later.

www.hhs.gov/myhealthcare

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Lee A.M., Jepson C., Hoffmann E., Epstein L., Hawk L.W., Lerman C. et al. (2007): CYP2B6 Genotype alters abstinence rates in a Bupropion smoking cessation trial. Biological Psychiatry 62: 635–641.

USNS Comfort in Haiti

Last Friday I went to Haiti to observe the remarkable health diplomacy being done by the USNS Comfort, a Navy Hospital Ship President Bush deployed into Latin America. As we flew into Port-au-Prince, the capital city, the Comfort’s white glistening paint stood out beautifully against the coral blue water.

The city looked about as it did the last time I was there, in the early 1980s. The poverty of Haiti is well documented. It was rewarding to see doctors, dentists, nurses and technicians ministering to the lines of thousands who waited.

I met with the Minister of Health in Haiti. He is an OBGYN. Much of our conversation revolved around a challenge I observe in every country I visit — the shortage of health workers. He pointed out that most of the medical professionals in Haiti have left the country; hospitals close as a result and most people go without health care. There is a special place in heaven for those who stay behind and do their best to take care of people.

So far during the Comfort’s 5 days in Haiti, I was told over 9,000 people have been treated, some in several different ways. I watched people being given used glasses American’s have donated. I saw dental work being done in portable chairs.

Mothers brought their children, some of whom where taken immediately to the ship for surgery. I’ll post a few pictures that tell the story better than I can.

Haiti is one of 12 countries the Comfort will have visited. In the past three months more than 72,000 people have been treated. More than 800 surgeries ranging from minor to major procedures. All kinds of procedures and other services are rendered; Medical equipment in local hospitals get repaired, water systems in communities are rebuilt, and veterinarians train locals on how to avoid diseases.

The presence of the ship and the excitement it brings to the ports it enters changes the lives of thousands of individual people and their families. The ship also serves as a reminder of our nation’s compassion and partnership. Health is the universal language. Health diplomacy is a powerful and important tool in our foreign policy as a nation.

www.globalhealth.gov

Finishing the Import Safety Report- Written Friday, September 7th, 2007

The safety of imported products has been in the news frequently. I’m in the final stages of preparing a report for President Bush on the subject. In July he appointed me Chair of a Cabinet Task Force on Import Safety. He asked us to report back within 60 days. I’ll provide him with a strategic framework this week.

The week after the President signed an executive order creating the Task Force, I organized a team of people from 12 different parts of the federal government and assigned them to analyze current authority and practices. As their work progressed, I hit the road.

Experience has taught me that if I spend enough time talking with people actually doing the work, my understanding of the problems improves rapidly and consistent themes begin to emerge. I’ve been in seaports, post offices, food manufacturers, wholesalers, retailers, at checking stations, freight handlers at border crossings. When the themes raised by those working on the front lines match the conclusions of those doing analysis in Washington, it gives me confidence our work product will be solid. Clearly, that is the case on this task.

Yesterday, (Thursday, September 6th) was spent at a seaport in Charleston, South Carolina. I wanted to see an interagency working group called Project Seahawk. The co-location of various agencies like FDA, USDA and the Customs and Border Protection has produced remarkable improvements in efficiency.

I met up old friend, J.P. Suarez in Orlando Florida, mid day Thursday. We worked together when I headed the EPA. J.P. is now Senior Vice President of Corporate Compliance for Wal-Mart. He brought some of his colleagues who have responsibilities for product safety. We walked through one of their large stores and talked about the challenges with import safety related to all kinds of products. Walmart and other major retailers now require rigorous inspections at every stage of production.

Late in the afternoon I met a terrific couple, Migdale and Clara La Rosa in Miami. Some FDA inspectors introduced me to them as they taught me more about the inspection on seafood.

Both Migdale and Clara come from Cuban emigrant families. They could see an opportunity to live the American dream. They bought a truck and began distributing freight for a single customer. Eleven years later, they run La Rosa Logistics, Inc in Miami. They now have 23 employees and a dozen trucks.

La Rosa Logistics is a freight forwarder. Many of their customers are wholesale fish distributors. Rather than maintaining refrigeration facilities, and delivery trucks, they hire La Rosa to do those things for them. When a shipment of fish comes from Chile or Honduras, La Rosa picks it up at the airport, checks the product freshness and quality, then delivers to the distributor’s customers.

Clara runs the front office. Migdale oversees the operation in the warehouse. Around the office there are pictures of their four children who reflect the combined attractiveness of their parents.

By law, shippers have to inform border officials of their intent to present goods at the border. As the shipment approaches, FDA inspectors decide which packages or containers they need to inspect. If one of those packages is to be processed by La Rosa, FDA notifies them it needs to be held. If FDA doesn’t tag it for inspection, La Rosa still tests the fish in essentially the same way the FDA would. When I asked why they perform tests not required by law they pointed out that delivery of poor product is a failure their customers won’t tolerate. The survival and prosperity of their business depends on product safety.

Inspection is a critical part of keeping imports safe. However, the amount of products is so large we will never inspect it all. We have to create a system of standards and verification so quality is built in.

www.importsafety.gov