Mozambique- Written Wednesday, August 22, 2007

I walked down a dirt pathway dividing crude houses made of sticks and mud bricks in Quilemane, Mozambique this afternoon. I had just looked at the site of a prospective Millennium Challenge Corporation funded water project that will eliminate standing water and the malaria carrying mosquitoes that come with it. We were 30 minutes ahead of schedule so I decided to take an unplanned walk through the middle of an African hamlet.

My attention was drawn to a vacant chair sitting among a group of woman in front of a small closet-like store. I asked if I could sit down; they signaled their approval. Before I could speak, one of the women said through my interpreter, “We’re mourning the loss of my daughter — she died on Saturday.” Our conversation revealed she had died in child birth. I provided what comfort I could and moved deeper into the neighborhood.

A dozen children scampered around me as I walked, excited about these mostly white strangers. Adults looked up from whatever they were doing, startled and curious. One of them was a pretty woman standing next to a little boy about three years old. I asked to meet her little boy.

“His Father died a few months ago,”she said.

I offered my second condolence in 100 feet and asked if this was her only child?

“No, I have five.” I was surprised. She didn’t seem old enough. As we talked, it seemed evident her husband had died of AIDS, leaving her alone to carry the heavy cost of this pandemic. I didn’t ask, but wondered if she, like so many others I’ve seen on this trip, had been infected by a spouse, compounding the tragedy. I moved on.

Around a small bend in the path, I encountered a man leaning against a house. I noticed he had lost his right eye. It didn’t impact his smile. We shook hands, chatted about his nine children, and I moved a few feet toward a woman who told me she had three children. I asked her if Malaria had been a problem in her home. “Oh yes,” she said, “we’ve all had it many times.”

The mayor, who was walking with me said, “There isn’t a family in this area that doesn’t have somebody in their family sick with Malaria, all the time.”

It’s a dry season right now in Quilemane. The stream bed our water project will fill is dry, full of garbage and debris. However, in wetter months, the whole area is swampy and Malaria vectoring mosquitoes breed in swarms. They carry Mozambique’s biggest killer. It is particularly harsh on children under five years old.

I sensed a crowd gathering behind me. Dr. Julie Gerberding, the Director of the Center for Disease Control and Prevention, had noticed a boy, around twelve, who had an arm badly disfigured by an infection. It had gone on for months, he said, and was getting worse. Oddly, the arm was not just swollen badly, it seemed several inches longer than normal. She explained what she thought his condition was and made some suggestions.

Despite the level of sickness and potential for sadness, the children seemed simply joyful. I stopped as we worked our way back to the car to join a large group of children who had gathered around a circle drawn in the sand to compete in with marbles. They jabbered wildly in their version of Portuguese, expressing the same “thrill of victory and agony of defeat” any boy of that age gets from competitive sports. I tried to resurrect my marble playing skills but a half-century of neglect created a good laugh for all of us.

For thirty minutes I was able to feel part of Africa.

This (Mozambique) is a poor but improving nation. The $400 per person annual income earned is a significant improvement over years past.

I was startled by a figure in my briefing materials.

Only $12 per person is spent on health care each year in Mozambique. (For perspective, in the United States it is nearly $6,000 a year.) Not surprising, 40% have no access to care at all.

Minister of Health

Early yesterday I met with the Minister of Health, Paulo Garrido, M.D. He is a calm, elegant, distinguished looking man. He was trained in the former Soviet Union, as most of his contemporaries in government were. The Minister of Health told me there are places in this country where woman walk 100 kilometers (60+ miles) to get medical attention when they are pregnant. They have formed waiting houses and ask woman to walk that distance when they are 8 months pregnant so they are near help if things go badly.

It is a lack of properly trained people at every level that most vexes the health care system. They are prevented from increasing the velocity of AIDS treatment by a lack of trained people. Our meeting included discussions of ways the United States might be helpful in solving the problem.

Hospital Visit:

I noticed that people are genuinely grateful for medical attention, no matter how basic. That seemed true at Jose McCamo Hospital in the nation’s capital city of Maputo when I visited. The hospital is a single story concrete building. There is no carpet; no landscaping; no art. There are just wooden benches and concrete to accommodate hundreds of women and their children who flood the building every day, waiting in line for their HIV treatments.

There are small portrait scenes playing out everywhere. Each patient has a story; some known, most not.

As I sat listening to a presentation about an American funded program to provide psychological support to women who have lost spouses, have children and are HIV positive, I spotted a boy about 7 years old coming out of the building by himself. He was holding a package of AIDS medicine. He sat down and carefully put the medicine into a cloth bag hanging around his neck.

The truth is, I don’t know anything about this little boy but my mind constructed a scenario that he is being treated with ARTs (Anti Retroviral Therapies). He either doesn’t have a mother or he has learned to navigate the clinic on his own at that young age.

I meet an unforgettable woman that morning. She is in her mid 30’s, with an “out there” personality. She wore a black tee shirt with the words printed in large bold letters, “I am HIV Positive.”

Her mission in life now is to give other women courage to face the world without stigma. She contracted HIV from her husband, who is now dead. She helps organize “positive teas” for the woman in this group. They get together, sing and talk, bolstering each other for the hardships of the week.

There are several more experiences in Mozambique I would like to blog about. I’ll need to write later about my meeting with President Gaybuza, visits I made to two medical schools, a fascinating conversation with the nation’s religious leaders and an effort our country is supporting to contact millions of people door-to-door about being tested. However, it’s late.

I need to get some sleep. I’m now in Tanzania. I have an aggressive schedule starting early in the morning. I think I’ll post and go to bed.

I appreciate the comments and thoughtful suggestions on how to improve my blogs. Note: I’ve tried to break them up a little. Not enough yet, but it was a good suggestion one of you made.

Comments

Mr. Secretary,

From what you post it is evident that true joy is not dependent upon circumstance and even in, what we consider to be, the most dire of circumstances hope and joy can be found. "Despite the level of sickness and potential for sadness, the children seemed simply joyful." Children demonstrate to us, no matter what culture we find ourselves a part of, or what trouble we have to endure in this life, that we have broader shoulders than we give ourselves credit for having. It is only as we get older, and a bit more brittle in our thinking, that we have trouble adjusting to what life has in store for us.
(A robust spiritual life can restore that ability).

"...I spotted a boy about 7 years old coming out of the building by himself. He was holding a package of AIDS medicine. He sat down and carefully put the medicine into a cloth bag hanging around his neck." We also can learn to cope. I long to give this child everything that he does not have.

Then, when I think deeply about this issue, I realize that we in the west are the ones without strength. We have lived pampered lives. These are incredibly strong and capable people that you have introduced to us. We must empathize with their struggles and help lift their burdens but certainly pity is not what is needed or probably even desired.

Most of us truly have no clue what it takes to live in the conditions that most of the world endures every single day. Who would fare better if our carefully constructed society failed us? Measure for measure, who are the weak ones? And yet, what a way to become strong.

In the west our definition of success has become so skewed. The children that you characterized for us, what courage! They have faced obstacles and have maintained their dignity, hope and even joy.

The woman that is "in her mid 30’s, with an 'out there' personality. She wore a black tee shirt with the words printed in large bold letters, 'I am HIV Positive.' Her mission in life now is to give other women courage to face the world without stigma" has seen beyond her own circumstances. What a heart for others. Rather than focusing on her inner struggles, she has moved beyond them. It is truly the strongest among us who can be an overcomer, and truly she is doing this.

These are amazing people and you have been truly blessed to be welcomed into their communities.

Posted by: standingfirm | August 24, 2007 at 10:47 AM

Dear Secretary Leavitt,

Thank you for your posts from Africa. You are doing the very best sort of travel writing in recording your impressions here and sharing what amounts to a first draft of history. Indeed, you are on the very leading edge of a new trend: Public officials who use blogs to report directly to citizens. Historians may not be kind to the Bush administration as a whole, but because of you it will be remembered for one good thing: the advent of cabinet-level blogging.

This sort of thing is happening at all levels of government. Right now, a councilman from Sun Valley, Idaho, is basically live blogging a major forest fire that's happening outside his community. His posts are packed with personal observations, photos, and reassuring reports - much like yours. Here's the link:

http://nilsribi.wordpress.com/

I thank you for your reports and I wish you safe travels!

Posted by: Julie Fanselow | August 24, 2007 at 09:06 PM

I am reading your blog about your travels to far off lands.

While I find it fascinating, I am disturbed that you are spending your time and our taxpayer dollars focusing on another country's hardship. We have hardship right here in this country. Every dollar you are spending can be spent on a child in need here in the US. I see children in our inner cities and in our struggling heartland who are in desperate need of healthcare and assistance.

I see a huge need right now for Pandemic awareness and planning... here in the US.

I just don't understand Mr. Secretary.

Posted by: Goju | August 24, 2007 at 11:20 PM

"There are several more experiences in Mozambique I would like to blog about....However, it’s late.

I need to get some sleep..... I think I’ll post and go to bed."

LOL. When your blogs are getting so long you have to break them up (which is good, thank you), when there are so many things you want to write about you have to make yourself stop cos it's late, when blogging is the last thing you do before you make yourself go to bed....

Like I said, this thing grows on you.

Good luck with the rest of your trip!

Posted by: SusanC | August 25, 2007 at 01:07 PM

Thanks for sharing this. Such glimpses lend perspective facts and figures cannot.

Posted by: InKy | August 25, 2007 at 05:41 PM

Mr. Secretary,

Thank you for your comments. When you write that people are grateful for any medical attention I am not sure if that is basic care or care with supplies or both?

I ask because there are so many courses here in the US (Frist aide, CPR/AED and wilderness first aide, mountain rescue, EMT) that people do not take advatage of.

Do they need teachers or teachers and supplies?

I hope there is some evidence of sterling engines for pumping water, jakarta(?) oil stoves for cooking and wind up radios. Jakarta oil is made from a local plant so people can cook without fire wood, coal or petrol.

As for us, during a pandemic or katrina like emergency I know that U.S. citizens would not have access to medical care. Perhaps not even full medical supplies.

That it would be good for people to know first aide and if a pandemic comes how to care for people.

HIV requires many drugs. Malaria requires spraying and drainage of standing water but so much can be done with basic first aide. First aid is not a cure all, but then nothing is. I am just not sure what they need.

As standing firm posted joy can be found in all places.
For joy comes "came without ribbons. It came without tags. It came without packages, boxes, or bags." It came from person to person so that all is right in WHO-vill.

Reagards,
Allen
"Joy, Harmony, IQ adn Courage" - more than Kids show charectors - good for what bugs you.

Posted by: Allen | August 25, 2007 at 09:31 PM

Dr. Leavitt, Goju,

Hi. I am glad to see the posts over the weekend made it.

Goju - we rarely disagree. I find Dr. Leavitt's trip both enlightening about Africa as well as what could happen here in America or elsewhere in Britain, Russia, Australia, Guam, Hawaii or Alaska. Yes, Guam Hawaii and Alaska are part of America, it is just harder to do interstate trade and travel with them. Hence they may suffer more than the lower 48 states.

I kinda wish Dr. Leavitt and others would do a whirl wind tour to build some rapport and face time with those in other countries. When disaster strikes it is good to see a familiar face instead of doing ceremonial introductions. Still I look forward to everyone's thoughts.

HHS is about schools, health - like the floods in the Midwest - education about health, pandemic planning as well as terrorist planning.

The only thing I am sad about is that the preparation the flubloggers have talked about, done and posted on could have helped so many of those weather the flood safely. Food, water, flashlights, second place to SIP.

Like so many Pan Flu folks I doubt we are better off without preparations.

I wish CNN had reported more on the hospitals and how they faired. How California has portable emergency hospitals for emergencies. Can't we learn from each other or do we have to wait for the emergency to happen in our state before saying "Wow, it *really* could happen here - we are not immune from nature."

Sorry - stepping off my soap box.

Regards,
Allen
"A smart man learns from his mistakes, a wise man learn the mistakes of others."

Posted by: Allen | August 27, 2007 at 08:35 AM

Goju,

It may not be obvious but Africa's fate is intimately connected with ours. Destitute societies and failed states on the other side of the world are sources of global instability and diseases in more ways than I can count on the fingers of my hands. When governments are not able to govern, whether for lack of competence, political will, institutional structure, or integrity, people in those lands have no Plan B. When developed countries show they care, in words and in action, we gain the chance to advise and influence on matters that will have great import on our domestic wellbeing.

For example, ill-conceived public health policies in these countries can and do give us such nightmares as drug-resistant TB. Helping communities nurture their orphans to grow up and find aspirations to become doctors and teachers instead of child soldiers reap benefits in buffering them against extremism. I wouldn't presume to speak about what kind of health diplomacy the US government is doing specifically, but I would suggest with respect that helping the most vulnerable in Third World countries in judicious ways is both an obligation and a necessity for a super-power.

Posted by: SusanC | August 27, 2007 at 01:52 PM

SusanC,

How striking is the difference between governments than Kenya and Somalia. Separated by an artificial line of our creation called a border one prospers while the other falters.

Kenya saved its wild animals and now thrives on tourism. Somalia fell apart and now harbors suffering and ship raiders.

Both have great ingenuity that is beyond the scope here to survive but opposite paths.

It is not the land nor its fate nor its riches but the people that set its course - IMHO.

The land can not be changed as much as the people who live on it. "Change their minds and you change the world"

Regards,
Allen

Posted by: Allen | August 28, 2007 at 08:01 AM

Allen,

Yes, I think so too. Change their minds and you change the world.

Engagement is the first step. What you do with that engagement is the next big question.

Posted by: SusanC | August 28, 2007 at 10:27 AM

SusanC,

The rules of engagement sound like war, but they can also be the start of a beautiful long term marriage of people and government. "

"Listen to the people" would be my reply. I never doubt the work of many great minds till it is put to the "real world test" I've heard others say "One test is worth a thousand expert opinions"

Great men have made many plans that look good on paper but failed in the field. Engage the population that they may test the plan and know if it is good. That they may know why they need to prepare. That the government is not dealing with confused people trying to google H5N1 or watch Dr. Phil about death but to have an engaged population with years of experience ready and willing to act.

O fcourse this means informing the people of the problem and the plans. Therein lies the rub! As you said SusanC, "personal accounts mean more that just facts and figures."

I understand the time Dr. Leavitt is spending in Africa is a lot. That is good. What happens here is well documented in blogs, editorials, specialty papers and occasionally on the news. What happens elsewhere is not. Ohh yes the EU posts the news of the world but my newspaper writes little about Brazil, South Africa, the Azores, Spain, Greece, etc unless there is a conflict, fire or flood.

Once the pandemic starts and becomes news I am sure they will document how unprepared people where. Where the communication problems where, how hospitals where over run and supplies ran out. For a country that prepared it self against a horror that never came we can prepare more for the ones that do.

AIDS, like Ebola, SARS and H5N1 is a simple virus against which we have little to no defense. Seeing how a few hundred cases with high mortality was ignored for so long is soo telling about what may come. What works and what does not.

Dr. Leavitt or Dr. Koop could say "Guard against the virus and learn health skills like first aide, CPR and hygiene" but it would be lost as another PSA. To go and see a country devastated by virus where people are great full not for money but a trained health care worker with some supplies. To hear of a little boy navigating the halls of a clinic alone is deep and touching. I find a lot to learn and tell about.

In H.G. Wells book "The War of the Wolds" a great technologically advanced civilization was brought down by a novel virus they did not have a vaccine for.

Disasters happen. Are we better off semi prepared for what can happen or totally unprepared for what will happen.

Dr. Chu, Dr. Leavitt and others, I leave you with Mr. Wells story, my question and some well wishes to you, the bloggers and Dr. Leavitt.

Regards,
Allen
"Knowledge is not centralized - we all have something to share" - corporate slogan of wikianswers.com

Posted by: Allen | August 29, 2007 at 08:40 AM

Mr. Secretary,

I am so glad to hear about your trip to Africa. I hope you and your office will continue to raise awareness of these problems and how Americans, and the rest of the world, can help. Africa is a stunning continent and the people are so full of hope and love despite the horrible things that are happening to them. Please be safe in your travels and thank you for taking the time to write about this issue.

Posted by: Sarah Lingo | August 29, 2007 at 11:39 AM

I spent two weeks in Mozambique this summer with a group from my church, and we visited the homes of some families who are dealing with AIDS. The ladies of a local church are ministering to them, offering encouragement and prayers and arranging for help from neighbors and family members, if needed. There is no social welfare to speak of - only people of the community taking care of one another.

Secretary Leavitt, I am pleased to hear you spoke with Mozambique's religious leaders, because I believe they play a very important role in the recovery of the country. I know they were instrumental in bringing Frelimo and Renamo together to end the civil war in the 1990s.

Thanks for sharing your experiences in Africa, and travel safe.

Posted by: Kari | August 30, 2007 at 12:20 PM

thank you

Posted by: Sohbet Odalari | September 04, 2007 at 04:37 AM

Thanks for sharing this.

Posted by: Word Hugger | September 08, 2007 at 08:20 PM

Dear Mr. Secretary,

Thank you for your comments and observations on Mozambique. My friend Rob Helten and I were in Mozambique the same time you were.
My wife and I have a small organization - Africans Orphaned by AIDS. Through a number of circumstances we have raised funds and built a small orphan facility in Chokwe, Mozambique. The facility, Vukarhani, currently is the home for 13 children, and will expand to 24. The goal is to love and nurture the children, allow them to become educated and develop life skills and then leave the 'nest' and lead productive lives. We are planning to drill a well and provide water for Vuk and the neighborhood as well as gray-water recycling. Also, we will provide Junior Achievement materials, in Portuguese, and hopefully mosquito nets.
Mozambique is a challenge for many reason, not the least of which is the language issue. Selfishly, I wish our efforts were in an English speaking African country. I believe Mozambique flies below the radar of compassion in the USA for several reasons, making it difficult for a small 501(c)3 like ours to find resources that could mentor us on this work in Mozambique. If you have suggestions on folks that we could bounce ideas off of, we would be grateful to make contact with them.
Thank you for your work and observations.
Gary Worth

Posted by: Gary Worth | October 22, 2007 at 10:38 AM

To the Honorable Secretary, I was impressed by your observation that "Not surprising, 40% have no access to care at all." You noted the Minister of Health lamented the "lack of properly trained people at every level that most vexes the health care system. They are prevented from increasing the velocity of AIDS treatment by a lack of trained people." Please consider the following as “ways the United States might be helpful in solving the problem." Mozambique has 1 physician for 33,333 population. The United States has 750,000 physicians of which a fourth are foreign trained, as compared to 2 million attorneys. Beginning with the Flexner report before World War One, medical school education has been artificially restricted so that we now have fewer medical schools than a century ago, whereas we have six times the number of law schools and 3 times the population. We aren’t even teaching and replacing the physicians we have, and haven’t done so in generations. About the turn of the 20th century, a hundred years ago, America had 160 medical schools. America now has 145 schools. Compare that to the growth in legal education. In 1900 the Association of American Law Schools recorded 32 charter members. Today, there are 180 ranked law schools, plus 18 more accredited in California, and 14 more registered, and 15 institutions offering law study for at least 227 American law schools.

Utah lists 262 insurers writing Individual Health policies plus about 1500 insurance companies licensed in the state. Utah has one Medical School of 126 accredited, and no osteopathic schools. So it appears there are between 200 health and a thousand insurance companies for every medical school. But have you ever seen an insurance policy deliver a baby, make a diagnosis, give a shot, remove an appendix, set a broken arm? If so, it would make the Guinness book of Weird world events, if there were such. I use Utah as an example as your background is in insurance. But, this comparison applies to all other states, to wit we have hundreds of times more insurance companies than medical schools.
So how many physicians is enough? What level of care do you want? Consider other statistics, the Veterans Administration maintains a ratio of about 60 patients per physician.
Stamford and Greenwich Connecticut have a ratio of about 250 people per physician. There is one physician for every 657 Texans, compared to the U.S. average of one physician for every 454 Americans. Utah’s average of physician to population ratio depends on the source; to wit the American Medical Association gives it at one physician to 531 population, the US Department of Health and Human Services lists it at one physician to 676 population, and the Utah GME gives it at one physician to 290 population. Why is the Veteran’s Administration relevant? It trains one in four physicians by its affiliations with medical and osteopathic schools. If we used one to sixty as a standard, the United States needs five million physicians, plus nurses, dentists, pathologists, pharmacists, etc. Immigration policy encourages intake of doctors, nurses, health professionals from other countries, with a fast track for visas and green cards. Sucking the brains out of the rest of the world, even the third world, is not a sustainable policy when it comes to health care. The availability of physicians determines access to regular checkups for health maintenance, timely intervention, crisis care, expert diagnostics, and specialty care.
How many medical students would it take? How much would it cost? Pick your level of care. If you want the nearly 6 million uninsured Texans treated at a third world level, one physician for Fourteen hundred patients, Texas needs about 4,200 more physicians, or 3 times the number of annual medical school seats. As it takes 8 years, after college, to train the physicians, doubling the seats now would provide the extra 4,200 physicians about the year 2020. If Texas wants to raise its health care standard to those of Greenwich-Stamford Connecticut, it need about 91,000 physicians, or two and a half times the present. If Texas wants a Veterans Administration ratio, it needs 380,000 physicians. That is to meet current population, and does not consider estimates that Dallas Fort Worth plans to add five million population within the next 20 years. Apparently that is what California has done as it offers three times the number of residencies for graduate medical education than the seats it fills from its own medical schools. California’s policy of luring graduate medical students away from medical colleges they attended is economically damaging to the states or nations where the students went to school. If Texas, or Utah, or Connectiut, want to grow, and not expand their medical school seats, they will have to do the same as California.

Since it costs about $100,000 a year to train a physician, open 100 new medical (including pharmacy, dental, nursing schools) each with seats for 100 students to train 10,000 new health-care providers a year. First year cost would be $1 billion. Add another $300 million for overhead, labs, buildings, supplies, travel, advertising, and you have solved the health care problem for, say, Connecticut or Utah. After the fourth year, the costs would top out about $5.2 billion, and 10,000 providers would be graduating every year forever. Once Connecticut, or Utah, had enough health care, they could train the nation’s physicians. If we want 50,000 new providers a year, the cost would top out about $52 billion, which is a fraction of the multi trillion dollar annual expense of health care. That would provide seats for those taking the MCAT each year, and would be comparable to present law school admissions.
Nothing else is going to bring down the ratio of one physician to 33,000 population in Mozambique. Unless you have more trained people, more insurance won’t help. Just where are the priorities? Education is matter of money. Every year, tens of thousands of qualified and capable students are turned away from medical (and other health care) schools because of an artificial shortage of seats.

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

(Table D http://www.insurance.utah.gov/2004GovRpt/MS_2004/MS_IndA&H.pdf) plus 7 HMOs (http://www.insurance.utah.gov/hmo.html)
(http://services.aamc.org/memberlistings/index.cfm?fuseaction=home.search&search_type=MS&wildcard_criteria=&state_criteria=CNT%3AUSA&image=Search)
(http://www.brown.edu/Administration/Dean_of_the_College/hco/downloads/form10_DO_school_list.pdf).
However, when the data from these several sources were compared, they were found to vary over a wide range, as has been found by others making similar comparisons (Ricketts, 2000). The American Medical Association reported 4,190 patient care physicians practicing in Utah in 1998, the U.S. Department of Health and Human Services, Health Resources and Services Administration, reported 3,280 and the Utah Department of Workforce Services reported 7,680 http://ruralhealth.hrsa.gov/pub/UtahGME.asp
Utah Links Federal Funding for Graduate Medical Education to State's Physician Workforce Needs This publication was produced for U.S. Department of Health and Human Services Health Resources & Services Administration Office of Rural Health Policy by Pat Taylor, Ph.D. under Contract # HHSH250200416005P

US Census for Utah 2,550,063 in 2006 estimate. 2,233,169 in 2000.

Posted by: J.I.M.C. | January 28, 2008 at 06:31 PM

Being South African, im often amazed by the inaccuracy of international commentary on Sub-Saharan Africa. Your post is accurate and poignant, well done...

Posted by: Ben Vorster | June 23, 2008 at 11:24 AM