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August 2008

August in Africa- Blog V

Written August 12, 2008

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

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

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

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

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

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

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

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

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

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

August in Africa- Blog IV

Written August 12, 2008

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Physician Conscience Blog III

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

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

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

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

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

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

August in Africa- Blog III

Written August 11, 2008

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

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

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

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

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

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

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

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

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

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

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

Photo3pmethiopia_3
HHS Secretary Mike Leavitt and Prime Minister Meles

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

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

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

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

August in Africa- Blog II

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

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

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

Addisababaethiopia_6
(L-R) Rich McKeown, HHS Chief of Staff; Julie Gerberding, M.D., Director of the Centers for Disease Control and Prevention; Secretary Michael Leavitt; Bishop Abune Samuel of the Addis Ababa Diocese Ato Bedellu Ethiopian Orthodox Church Administrator; and Solomon Zewdu, M.D., Country Director of Technical Support for Ethiopian HIV/AIDS Initiative and Disease Prevention and Control Program, Department of International Health, Johns Hopkins University.

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

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

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

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

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

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

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

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

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

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

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

August in Africa- Blog I

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

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

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

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

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

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

Physician Conscience Blog II

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

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

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

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

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

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

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

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

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

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

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

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

Physician Conscience

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

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

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

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

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

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

Alaska Blog V- Kwethluk and Questions I Learned There

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

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

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

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

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

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

Herman Evans and Secretary Leavitt in Kwethluk, Alaska
Herman Evans and Secretary Leavitt in Kwethluk, Alaska

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

A previous meeting and traveling had put us behind.

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

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

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

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

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

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

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

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

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

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

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

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

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

Home is where the heart is.

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

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

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

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

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

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

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

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

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

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

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

Alaska Blog III- Mental Health Treatment in Remote Alaska

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

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

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

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

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

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

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