Tanzania- Written Sunday, August 26, 2007

A doctor who had moved to Tanzania in 2002 told me that during the first couple of years she was in Africa, the burden of doing clinical work was nearly unbearable. She said: “I dreaded going to work every day because patients were constantly testing positive (for HIV) and there was nothing we could do for them.” It was like a death sentence.

I have concluded the core business of the United States in Africa is hope. Fear is the enemy of hope. Millions feel fear that keeps them from acting. Once they feel hope, even without certainty, they begin to slowly move toward action.

Conversations with dozens of patients and health workers, and people who work for non governmental organizations, have begun to give me a sense of the despair that gripped this continent during the past decade.

I encountered a lot of gratitude. The situation is still dire, but for those willing to do their part, there truly is hope. I wish more people could experience the spirit of appreciation I have heard.

There are problems, lots of them; but there is also evident progress. The most profound evidence is our own statistics. In 2003 there were only 50,000 people on ART (Anti Retroviral Therapy). Today there are over a million and the number is steadily growing.

The Tanzanian health Minister echoed what others have said about human capital and infrastructure being the rate limiting factor. It is far better, in my opinion, for the United States to invest in solving those problems and allow the host countries to concentrate on buying the actual ART drugs.

Opportunities: Capacity and Quality

In the two days I was in Tanzania, I saw several good examples of ways we can expand capacity with investments. The first was a care and treatment center called Mwananyamia Hospital that we opened on Friday in Dar es Salaam, Tanzania. This is a project PEPFAR (President's Emergency Plan for AIDS Relief) paid for in conjunction with Harvard University.

Before the ceremony, we walked through the old center which is still in use. I’ve now been in enough African hospitals and clinics now to anticipate the model of care. Most of them are similar. People, mostly woman, line up with their children early in the morning, sitting on a wooden bench in a room packed with people. Typically there are two or three intake workers dispatching the patients to small rooms where they are examined by a nurse, or somebody with less training. There may be one doctor or a part timer who comes once a week to see patients who have to return and wait again.

Most of these clinics/hospitals have a pharmacy which is actually a couple of cupboards with a few bulk products. Medical records often are intake logs, not focused on the individual patient but the flow of patients through a particular process. I’ve seen a few basic labs with a single piece of equipment.

The new treatment center is bigger, better organized, better equipped, and feels so much more optimistic. It will increase the volume, sustainability and quality of the offerings. There is a sense of hopefulness just in the contrast of old to new.

Another significant investment is a building that will house laboratories and various public health facilities. Several U.S. organizations contributed to its building. It will allow U.S. scientists and doctors to work side by side with their Tanzanian counterparts. I’ve mentioned this before but it’s worth repeating. Having research at the epicenter is a powerful way to leverage our talent

On Saturday, I attended the opening of a Blood Center in Zanzibar. CDC has consulted heavily on these and has an ongoing relationship to assure they are operated properly. This is an interesting and important investment. Until we started working with the Tanzanians, there were no blood banks. So when a person needed blood, they called on their relatives to donate. With so many untested people giving blood, thousands of people each year where given HIV through a transfusion made, with every good intention, from a relative. We have now built blood centers so the blood can come from a tested source. It will protect innocent victims for generations to come.

Signing the certificate turning over the Zonal Blood Center to the people of Zanzibar, Aug. 25, 2007.

Opportunities: Expand Human Capital

Also in Dar es Salaam, I visited two programs that deal with the severe shortage of trained people. The first was a session with the heads of nursing schools from several regions of the country. The United States through HHS is training nurse trainers on best practices dealing with HIV/AIDS.

I was told of a program we finance that organizes volunteers in a neighborhood to help find and treat HIV positive people. It’s called Pathfinder.

I visited the home of a woman and talked with her about the experience. The volunteer who helped her through it was there also. She told me an all too familiar story of her husband becoming sick with TB. He also had AIDS, but didn’t tell his wife. The husband died and several months later she began to feel symptomatic.

At the urging of her neighbor, (the woman who volunteers with Pathfinder) she was tested. The result was positive; in fact, she was rather ill with a CD4 count, reflecting the strength of her immune system, of 140. (The CD4 count in an non-HIV infected adult can range from 500 to 1,500 and the CDC considers persons with CD4 counts below 200 to have AIDS.) She told me, as others have, of their despair at that moment.

She began getting treatment and has regained both health and hope. She has now become a volunteer doing the same for other people.

Seeing people in their neighborhood environment is such an important part of this experience. You can hear these stories, but until you see the two rooms this family of 3 lives in -- with a concrete floor, sheet metal roof, and no power or water -- one doesn’t have the picture.

Incidentally, her neighbors don’t know of her HIV positive status so we had to be somewhat careful in the way we approached her home. I also found it interesting to talk with her about her two children, one of whom is 17 years old. I asked if she talks to her son about this. She does, but doesn’t know if he’s following her advice. Some things are universal across cultures.

Comments

Mr Secretary,

Pardon me. As a foreigner I'm a little slow to catch on certain things, in addition to sometimes finding certain attitudes/beliefs mystifying, so please bear with me.

I just realized that you've written some 6-7 blogs and no less than 6000 words on HIV/AIDS and not once have you mentioned the C word - condoms. Why is that?

I don't think it has to do with prudery because you seem to have no difficulty mentioning sex. You also seem to acknowledge the connection between sex, behavior, and transmission of HIV/AIDS.

I know you are too busy to respond to individual questions, but I wonder if you can tell me how many of the US-sponsored programs on HIV/AIDS that you are visiting teach safe sex ie the use of condoms?

I wonder whether you can tell me what are the scientific and public health rationale for not promoting the use of condoms in HIV/AIDS education programs, if indeed that is the case here?

The analogy that comes to mind is seat-belts. Seat-belts save lives, period. Now that their use is mandatory in most developed countries, I don't believe there are figures showing the use of seat-belts have ENCOURAGED more reckless driving. Indeed, the opposite appears to be the case, that reckless drivers are more likely to not use seat-belts even when available.

And if, as your posts suggest, that HIV/AIDS programs are overwhelmingly attended by women not men, and given the status of women in such societies, what would you say is the chance of stamping out HIV/AIDS for the next generation if the only recourse available to women is to 'just say No'?

Posted by: SusanC | August 28, 2007 at 08:34 AM

Dr. Leavitt,

Human capitol. Not just hearts and hands but minds to carry out what must be done with positive mental attitude. The doctor from Tanzania going to work each day believing they are helping even though they do not see the progress yet.

Infrastructure and people. Hmmm. I am biased because I see people who want to learn. People actually pay to learn CPR, first aide, etc with no compensation.

I guess Africa is the same. People want to learn they just do not have teachers. I am biased to think that working with trained people is better than working with untrained, un-skilled folks.

Infrastructure needs supplies and people. Listening to those who fought in Vietnam talk about supply lines run by a bike, a bamboo stick and one man. Turns out you can put 500 pounds of supplies on a bike and with a bamboo stick tied to the front handle bars you can steer the bike down a bombed out road unfit for trucks. Such is the tale of the Ho Chi Minh trail. People can make due with simple supplies a few ideas, some ingenuity and the belief that they can.

Of course - may we also get trained here at home. Today Las Vegas is flooded. Tomorrow is the second anniversary of Hurricane Katrina. Four days ago was anniversary of Hurricane Andrew hitting Florida. Disasters happen. Best to be prepared.

As for Africa, HIV is one disaster. Other natural disasters will occur on time even with HIV causing so much pain.

As for the HIV positive woman and 17 year old son - yes some things are common across cultures and countries. We use the same brain with many of the same fears, hopes and feelings. If not, why learn from other cultures? Why do movies play in other countries just by changing the dialog?

Regards,
Allen
"No problem can be solved by the thinking that created it " A. Einstein.

Posted by: Allen | August 28, 2007 at 08:36 AM

Dr. Leavitt,

When you write that "Having research at the epicenter is a powerful way to leverage our talent" it seems to be a great way to train our talent as well.

Getting people to talk about their problems is hard when there are repercussions or judgements made. What is the old line "I have a friend who has a friend with this problem......?" Yet it is so easy to fix a problem before it starts or when it is just beginning. There the internet has allowed people to be, to explore to talk without using their real names. There are web sites that allow folks with a common aliment to find each other for both support and comfort.

Erasing the stigma of AIDS is not easy nor the only solution. Education, supplies, allowing people to have the freedom to speak openly and if need be find each other. The internet is not required - un-signed stories posted for all to see educate the sick and the well. The stories can let people know they are not alone. Might be AIDS, might be some other birth defect or sickness.

The hard part is letting a society keep and promote their morels, traditions and beliefs without posting hate messages.

Hope the work is an educational adventure for all the participants. That once the blood center is open the local government will fund, run and keep it up to date.

The lessons learned here could help with H5N1 and other problems. One can only isolate and work on the virus they know of.

Regards,
Allen

Posted by: | August 30, 2007 at 08:38 AM

With the resignation of Attorney General Alberto Gonzalez, and the persistent rumor that Utah Senator Orrin Hatch will be appointed to replace him, comes the question of who might be selected to finished the Senator's term if that does in fact come about. Obviously, your name tops the list of many of us in your home state. Would you be willing to accept such an appointment if it materialized?

Posted by: Alienated Wannabe | August 30, 2007 at 03:26 PM

I was moved by your description of the Zanzibar blood banks and transfusion infections, because of severe shortage of trained people. [After] "testing positive (for HIV) and there was nothing we could do for them.” It was like a death sentence. As a part of the United Republic of Tanzania, it has 1 physician per 50,000 population. Your quote is life imitating art. This reminded me of the plot of a movie. Imagine a time, back two generations, before the nuclear age, moon walks, internet, cable, cell phones. Sit yourself in a movie house. A talkie comes on with high tech drama, for then, and romance. The film is contemporary for depression years just before World War Two. It’s 1939 and Jimmy Stewart, a young Wall Street lawyer, marries Carole Lombard the same day he meets her. Let’s call it Made for Each Other, and watch, and listen, as the newly weds manage their New York apartment, his career, and her insecurities. Throw in a Mother in law who is aghast at her impetuous son’s selection. Since it is years into the depression, the young father’s requests for raises, at his Wall Street law firm, are not only rebuffed, but, he takes a cut and is glad to even have a job at all. They make room for a baby, and then suspense. After a New Year’s winter holiday party, the parents return home to find the baby burning with fever. The doctor makes his house call and rushes the baby to the hospital. Pneumonia. Might as well be a death sentence. Only a new wonder drug, discovered a decade before, and recently commercialized and available, will save the child. The drug is called penicillin. Very high tech. Brand new. Very expensive. Outside a snow storm rages. Inside the doctor is phoning for the drug. More high tech, as the telephone system has wired a nation only in the same generation as the parents’ lives. No penicillin is to be had in Manhattan. Call Boston. Philadelphia, Baltimore, Washington D.C. No hospital on the east coast can spare even one dose for a baby, wheezing, crying, dying. The fever is high. The pulse is slow. The infection can’t be stopped. What good is the magic bullet if you can’t get it in time? Then good news. Doses are available in Salt Lake City. But the train will take 3 days, and some mountain passes over the Rockies are snowed in. A train will never make it in time, the Doctor laments. The father is frantic crazy for his boy. What about an airplane? More high tech. It has only been 4 years since the Civil Air Board was formed. And yes, yes, a pilot and plane will hazard the trip over the Rockies, and across the country. But its dangerous. Even deadly. The price for a special air delivery is five thousand dollars, half paid in advance, the other half upon delivery. In 1939, an ante bellum house and lot in New Canaan Connecticut could be purchased for about five thousand dollars, which antique house would sell for more than a million, maybe two, 66 years later. The father, unable to get a raise, barely able to hang onto his junior associate position, doesn’t care about his job. He rushes over to the only person he knows with that kind of cash, his boss. After screams, and sobs, and threats, and pleas, the Wall Street “name” lawyer understands the risk, need, and desperation, and guarantees the money. Even writes out the check. The airport in Utah is notified, and the pilot starts out. The whole continent is a cloud cover. There is no air traffic control. Before radar. Just a radio, lights, and compass. The plane gets iced up, and the pilot reaches outside of the plane, with his glove, to scrape ice off to see. See what? It’s night. The baby is dying. The pilot has the precious penicillin wrapped in a container and strapped inside his coat. The wind blows. The propellers strain. The pilot checks his compass as the only means of navigation. Counting the hours, estimating his fuel, nursing the engine, the plane covers mountains and plains, rivers and cities. The pilot has no rest, no place for a break. No place to land and refuel. The radio goes out, and no one has communication. Might as well have been combat. The family is helpless, and so is the doctor. The plane begins to lose altitude, but can’t land without a runway or airport. The pilot knows the plane won’t last, and finally the engine catches fire. The pilot bails out over who knew what or where. Salvation. It was New York, and a farmer family, hearing the plane engine over head, go to inspect the noise, even the crash, and find the pilot and parachute. The pilot is taken to the farm house, and inside his coat is the package, worth an estate in New Canaan, with instructions to rush it to the Doctor at the Mercy hospital in New York City. The farm family calls the hospital, arrangements are made with the police for an escort, and the medicine arrives, and the baby starts pulling through. The recovery is complete, the family saved, and a happy ending for all.

Can we conceive of a time before there was amoxicllin or penicillin, with sufficient doses, and doctors available for round the clock treatment? Before the Salk or Sabine shot for polio? Before small pox was erased? There will not be a word about health insurance in the entire story. Money could buy a plane and pilot who would risk his all, but only after the diagnosis was made, and the medicine was found. Sir Alexander Fleming had discovered the penicillin cure about 1929; but even a decade later it’s manufacture was so limited, only a few doses would be distributed around the largest cities in the country, and none in the rural areas. Now, I agree that the World Health Organization listings of physicians does not entirely take into account education, skills, experience, and a host of infrastructure Americans are used to when receiving health care. But all the great hospital buildings, and insurance policies, and medical devices and insurance policies, and wonder drugs and insurance policies, still won’t help until the patient can be seen, examined, diagnosed, treated, reexamined, and cured. At one physician to 50,000 population in Zanzibar, that is 9,000 more than the 41,000 seats in the $611 million DC baseball stadium.
Everything that is said for physicians, could be said for nurses, dentists, pharmacists, etc. The health care professional to population ratios are high (that’s bad), the professionals are immigrating from their native countries (that’s bad for their native countries), their patients then want to immigrate here to follow their professionals (that’s bad), and so it goes.
Recalling Jimmy Stewart’s anguished cries in his movie, consider the plot that one child is diagnosed with pneumonia on New Year’s day, and there is not a single dose to spare anywhere east of the Rocky Mountains, and to get it in time will require the risk of pilot and plane, and the cost of a house. Weren’t there other children with pneumonia among the ten millions in New York, and the millions in Boston, Philadelphia, Baltimore, Washington, Chicago, Pittsburgh, Cleveland, St. Louis, Atlanta, etc? Yes, there were, and presumably they died. Too bad. Not a feel good ending to a movie that is billed as a comedy. Such a result just wasn't stated.

Source:
http://www.who.int/globalatlas/dataQuery/reportData.asp?rptType=1
Global Atlas of the Health Workforce
Category: Human Resources for Health, Topic Aggregated data 2006, density per 1000, physicians total, world

http://www.jdland.com/dc/stadium.cfm

Posted by: J.I.M.C. | January 28, 2008 at 05:17 PM