U.S. Department of Health and Human Services.  HHS.gov  Secretary Mike Leavitt's Blog

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September 2008

Pakistan- Blog II

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

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

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

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

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

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

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

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

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

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

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

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

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

Pakistan- Blog I

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

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

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

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

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

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

Neither of her points surprised me.

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

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

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

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

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

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

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

Weekends of Hurricanes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

China Olympic Visit

A sub-theme of my service as Governor of Utah between 1993 and 2003 was the Olympics. Prior to my service as Governor, Utah unsuccessfully bid for the games of 1998, and so the bid process for the 2002 Winter Olympic Games occurred during my service. We were awarded the games, and then suffered through a wrenching period when allegations were made involving the bid process.

As Governor I supported the bid completely, and later became deeply involved in working through the problems I referenced and spent nearly seven years getting ready for the games. It was a pressure-packed experience with high highs and low lows. When the games had been successfully completed, I could not help but consider the sum total as one of the great experiences of my life.

Through it all, I became well-acquainted with the Olympic organization, rituals, personalities and politics. I came to know its power for good. I also became intimately aware of how people all over the world wish to hook their cause to the power of those five rings. Nothing better illustrates the appeal of the Olympic brand.

I assume the combination of those factors, and my current portfolio at HHS, is the reason the President assigned me to the United States Delegation for the closing ceremonies. I was delighted, of course, and greatly honored.

Originally, I was to be part of a delegation lead by Secretary of State, Condi Rice. However, when the Russia/Georgia conflict broke out, she was required to pass her responsibilities to Secretary Elaine Chao, the Secretary of Labor and a person of Chinese descent. In addition to Secretary Chao and me, the delegation included the American Ambassador to China, Clark Randt; former Undersecretary of State, Karen Hughes; Olympic figure skater, Michelle Kwan; and Secretary Chao’s Father, Dr. James Chao.

Most Americans had a great seat for the Olympics because of the excellent television coverage. I came to understand that, in many ways, the Olympics are a made-for-television event with a live studio audience. Consequently, I won’t provide any commentary on the events. The truth is, I saw few of the competitions.

However, I do want to comment on the significance of the Olympics as a unique unifying force in the world, the importance of our country’s support to China, and what it means in the context of our current relationship.

Sport is one of the few causes that can bring the world together in peace. There are others. Each year I attend the World Health Assembly, where delegations from nearly 200 nations seek to work out and find solutions to common problems. But none of the other causes attract teams of participants who compete in events with common rules, all in pursuit of victory with high ideals.

The sessions of other diplomatic meetings are not shared simultaneously with more than three billion people around the planet all celebrating in a common interest and passion. It happens only at the Olympic Games.

President Bush made the right decision by going to the opening games himself. It was enormously important to the leadership of the Chinese government. In a meeting we had with Primer Wen Jiabao, he expressed his appreciation and made clear how important the President’s attendance was to the Chinese people.

At a small luncheon Secretary Chao and I attended with President Hu Jintao, he made a point of telling me how much he valued the President’s attendance. At China’s shining hour, it simply would not have been right for our President not to have been there. It would have been a slight felt for decades by China.

The games were not flawless; they never are. However, by my observation, they were excellent. Things worked. The venues were excellent. The athletes seemed pleased, and their performances showed it with lots of new world records, etc.

I think China served notice to the world that they will take sport seriously in the future. They have invested heavily in finding and building potential. It is an investment that will pay dividends for many years. Doing well in the Olympic Games adds prestige to a nation. In the same way people think Universities with winning football or basketball teams must be great educational institutions, in a world where few pay attention to geo politics, medal count often registers high on the scale of global prestige. Nowhere is that more important than at home in China. It builds national pride and support for the government and their system.

I had two other meetings I thought were important. One was with my friend Minister Li, who heads the Administration for Quality Supervision Inspection and Quarantine. We have worked together for the last year and a half on food safety. We had lunch and traded Olympic torches. I had a couple left from my time as Governor. We discussed the opening of our FDA offices in China during October.

Finally, I met with Liu Qi, the President of the Olympic Organizing Committee. He is the former mayor of Beijing and a member of Political Bureau of the 17th Communist Party of China (CPC) Central Committee. I wanted to congratulate him. We have known each other since 2002, when he visited me in Utah for our games.

We had a good laugh when I said to him, “One thing you won’t miss is endless calls seeking credentials.” Anyone who has been involved in the games knows that problem. He seemed like a man savoring a great victory, and well he should. The entire nation of China should. They still have many challenges, but the Olympic experience will have made them better as a country.

Gustav- Blog IV

Resettling after a storm

One of the major lessons learned during Katrina was that when people got displaced and could not return to their homes, the recovery was long and complex.

Every family has a different situation, and therefore, our help to get them back on their feet needs to be customized. We need individual case management.

During Katrina, I proposed using our Office of Refugee Resettlement (ORR) to help. The idea was not adopted, but I felt so strongly about it that I put a team together to develop a pilot, similar to the programs in ORR, to try at a future disaster. Today, for the first time, we will begin using it. I honestly think it will make a major difference in getting people back on their feet faster.

ORR is a little known part of the Administration for Children and Families (ACF) of HHS. Each year, through contracts with a large group of non-governmental organizations, volunteers help people who are immigrating to the United States get settled. It is in our interest to assure it is done in an orderly fashion. Not only is it the humane thing to do, it pays financial dividends quickly to have people become self-sufficient as soon as possible.

When a person is assigned to ORR, a case worker helps them navigate various government programs, and, more importantly, the officer helps the refugees develop a plan for self-sufficiency, then stays with the client until the plan is working. It has been a great success.

Today, we activated a contract through ACF's Human Services Preparedness and Response Office to help Americans in need of similar services due to Hurricane Gustav. The contract will be fulfilled by Catholic Charities, who will coordinate the activities of other organizations, who also do casework for immigrants.

With many families still displaced after Katrina, I’m looking forward to seeing the difference in this more managed approach.

Gustav Blog III

Written September 3, 2008

After spending Tuesday in Texas looking at shelters, the weather and air space cleared sufficiently so that I was able to join the President in Louisiana to review the progress in dealing with Hurricane Gustav. 

Rather than attempt to detail the entire trip or various meetings I want to write a series of observations I made during the day.

First, we are getting much better at emergency response. One example is the fact that in the 72 hours before the storm hit, the largest medical evacuation in our nation’s history took place.  We relocated more than 10,000 people from nursing homes, hospitals and situations requiring special needs.  We did it in an orderly, safe and well planned way.  Was it perfect? No, but it was done extremely well. 

I’m hoping the real story of our nation’s response will not be missed. The media reports on the activities of the federal, state and local government to establish organization and facilities.  However, the big story is the hundreds of thousands of Americans who previously didn’t know what to do this time ended up in shelters across the country.  During Katrina there were more than 600,000 people in shelters.  During this storm we had about 80,000 despite similar numbers being displaced overall. (On Wednesday there were only about 60,000 in shelters.)

There were hundreds of thousands of people who developed individual and family evacuation plans and executed them. Families went to Aunt Mabel’s, friends, motels or camp grounds. Preparedness isn’t just government’s work; it is the reaction of the ordinary citizen.  The aggregate of each prepared citizen played starring roles in the drama.  This is very good news because government simply cannot respond to everyone, we have to create facilities for the exception, the special need, the anomaly.

I report this not as way to be solicitously upbeat. The big story is that positive citizen action is key to successful execution. There were 1.5 million people who were evacuated in less than 12 hours. (During Katrina it took 25 hours for that many) Most of them took care of themselves this time allowing government to do a much better job with those that couldn’t. 

The big problem right now in Baton Rouge is electricity.  There are 1.4 million people without power. The lack of electricity requires constant transfers out of hospitals.  Just before I left, I visited Baton Rouge General.  There was a line of ambulances loading patients for transfer.  As I walked up and down the hall, the conditions were extremely difficult.  There was no air conditioning and few lights.    They had backup generators, but they were proving inadequate for the demand.

A walk through a hospital during a time period like this is an important reminder of two things: how dedicated the staff is to continue working and just how sick many of those people are which makes moving them complicated.

The big commodities at this point in an emergency are water, ice, MREs (meals ready to eat—military prepackage meals) and tarps. 

Secretary Leavitt with the Disaster Medical Assistance Team

Secretary Leavitt meets members of the Disaster Medical Assistance Team in Baton Rouge.

This was the President Bush’s 27th trip to a disaster area during his time as President.  The presence of a President is an important symbol. It reassures people and also serves as a deadline for people to get things done. 

We met at the emergency management operation in Baton Rouge.  The governors, mayor, senior emergency officials from the federal, state and local government were there.  Also some elected officials.  One by one, reports were given regarding the progress that had been made and priorities remaining.   

The President reflected the experience of a man who has been through a lot of emergencies. At one point he said, “By my observation is that there are three phases to natural disasters.  There’s the ‘glad to be alive phase;’ Then the ‘why didn’t you come sooner phase,’ and finally ‘I’m really mad phase.’ People are going to feel those things and our job is to just keep moving forward to solve the problems.”  That matches my experience as well.

It should be noted that the levee system held.  There is a lot of deserved satisfaction among the engineers about that. 

We are obviously not out of the woods on storms this year.  There is a virtual conga line of storms lining up off the gulf coast.  Hopefully, they will dissipate and not throw us into the soup again soon.  If it happens, we’ll be ready.      

Hurricane Gustav – Blog II

I met Jenny in a medical shelter in Tyler, Texas.  She lives in Beaumont Texas where she had just undergone back surgery.  She was at home beginning her recovery when Hurricane Gustuv, approached the gulf coast.  Like thousands of others Jenny called 211, a telephone service offered in her area, registering for help in case evacuation was necessary. 

For days before the authorities monitored Gustav, and 120 hours from the time the storm was anticipated to hit the shore they opened an emergency “playbook” developed to respond to severe storms.  Nobody knew at that point what the intensity of the storm would be, but with the lapse of each hour decisions needed to be made to avoid allowing time to become the enemy.   

There is a hierarchy of evacuation needs. People like Jenny with complicated medical needs are high on the priority list and require emergency managers to start early.  Somewhere between 48 and 72 hours from land fall, officials made the decision to begin evacuation.

I landed in Texas Monday night just hours after Gustav’s dissipated Category two force winds crossed Louisiana and Texas coast lines. Early Tuesday morning we flew from  Dallas to Tyler Texas.  I wanted to see deployment of our Disaster Medical Assistance Teams and Federal Medical shelters first hand.  That’s when Jenny and I met. 

As Jenny sat in a special chair that held her back in proper position to heal, she told me how rescue workers picked her up and took her to a bus.  The three hour bus ride out of the storm’s reach was uncomfortable she said, but it probably saved her life. 

Secretary Leavitt with a patient and medical workers at the shelter.
Secretary Leavitt and Jenny at the medical shelter in Tyler, Texas.

I saw hundreds of patients all of whom had a story to tell.  Many seriously ill before the storm and still struggling but for the most part, deeply grateful for a bed, food and medical attention offered at the two federal medical shelters set up by the state of Texas, operated by local health workers and supplemented by federal equipment, supplies, emergency teams and, of course, money. 

Disaster preparedness is a local and state responsibility and the state of  Texas is good at it.  In Tyler, Dr. Lakey, the head of the State Health Department met me. As the storm approached, state emergency planners determined where the demands were most likely going to be felt.  That’s done by simply asking the question, “If you live in an evacuation area, where are you most likely to go?”  Most of the people I met on Tuesday where from Beaumont, Texas and some from western Louisiana.

Given the nature of this storm, the state chooses to establish medical facilities in Tyler at a county-run community center and a few miles away at Eastern Texas Baptist College. Both the local government and the college responded with great generosity providing facilities and people. 

When the state feels they will not have sufficient capacity to staff and meet the demands of both the local population and the in flowing evacuees, they ask the federal government for help, specifically FEMA.  My Department of Health and Human Services (HHS) is then tasked by FEMA to deploy assets we have.  Those activities are managed through the Office of Assistant Secretary for Preparedness and Response and they have become very good at it.

HHS provided two types of assets in this case.  The first is a federal medical shelter.  This is essentially a hospital in a box, more appropriately, a whole bunch of boxes. The federal medical shelter is deployed from one of our national stockpile sites and can be in place within 12 hours.  We also send a component of medical workers to staff the facility. 

The second asset we deploy is a Disaster Medical Assistance Team (DMAT).  Most states have at least one DMAT.  These are remarkable people who have volunteered to be deployed with only a few hours notice anywhere they are needed.  These are groups of medical professionals as well as others trained in different aspects of emergency medical needs.  On Monday I saw teams from New York, Florida, New Mexico and Oregon in action.  Within a few hours they establish a facility to treat the most acute patient needs.  It is rather remarkable to watch. 

Nobody likes disaster but I must say, I am always inspired by the generosity and competence people willingly bring.  They work unthinkably hard hours in beastly conditions.  However, there is something about the human spirit that when people are engaged in emergency assistance they are happy and upbeat.  I think there are few things more rewarding than the satisfaction that comes by providing assistance for a person in need.  My mother once said to me, “Mike, we get our self esteem from the people we serve.”  I believe that more than ever. 

Africa- Blog IX

Timbuktu
Written August 16, 2008

After I arrived in Mali and met with the Minister of Health, toured several facilities, and completed diplomacy speeches and media interviews in the capital city of Bamako, I wanted to get into the Northern portion of the country. Specifically, I was interested in the remote Northern region which has long been viewed as a safe harbor for Al Qaeda.

The only significantly populated area of this region is Timbuktu. Yes, it does exist. In fact, Timbuktu, at one time, was a cultural capital in the same league as Rome, Athens, Jerusalem, and Mecca. In the thirteenth century, it was a thriving trade center in Africa and remained such for nearly two centuries. Timbuktu began to fade because of geopolitical and trade shifts.

Two characteristics make the area surrounding Timbuktu attractive to terrorists: remoteness and lack of government resources to provide any significant presence. Our government has been attempting to help the Mali government in that regard. It is obviously in our mutual interests.

We flew about two hours on a United Nations aircraft and were met at the Timbuktu airport by a long line of community leaders. The length of the line appears to be an expression of the importance they place on the visit. It was a nice expression of their admiration for the United States. Each of the community leaders spoke appreciation for the way our country helps them. The welcoming party ceremoniously wrapped our heads in desert turbans, which I will say felt good as we walked around in the unbelievable heat.

The leader of the welcoming delegation was the new Governor of Timbuktu, Mamadou Mangara. Governor Mangara is a Colonel in the Mali military and former aid to President Amadou Toumani Toure. He has received extensive military training in the United States, speaks reasonably good English and has big ambitions to build the region.

Governor Magara and I toured a health center facility called Centre de Sante Coommunautaire, in Kabara, Timbuktu, just a few miles from a major city. The people were proud of the center and appreciated its presence in their community. They had obviously worked hard to qualify for it. The center reminded me of one of our Indian Health Service clinics in Alaska, only substantially less well equipped. They didn’t have electricity, let alone medical equipment. The only device I saw was a kerosene-powered refrigerator to keep vaccines.

The center had a medical technician who was trained to follow diagnosis charts that hung in his office. There was a nurse midwife, who last year delivered 160 babies among the population of nearly 4,000 they provide care for. The center also had health workers who proactively do out-reach, but I was not able to talk with them. Malaria is the biggest challenge they deal with, the technician told me.

After touring the clinic, I had the equivalent of a town meeting under a tent, attended by several hundred people. This is probably a good time to mention the most memorable physical characteristics of the area: heat and sand. This is the desert. It is blisteringly hot. The day we were there was cool- only 110 degrees. When my team arrived in advance to prepare for my visit, it was 126 degrees. Everything is made of, and surrounded by, sand. The homes and buildings are made of sand bricks, and the roads are compacted sand.

A woman speaking at town meeting in Timbuktu.  HHS Photo by Holly Babin
A woman speaking at town meeting in Timbuktu.

At the town meeting, we talked about the aspirations people have for their community. The main two are electricity for the clinic and a water system. A woman stood and made a passionate speech about the worries she had about the water. The more she spoke, the more the crowd of her fellow villages responded. By the time she had finished, she had worked the group to a pitch. It was interesting to see, and it helped me understand local dynamics.

One of the more important meetings I held in Timbuktu was with four members of an Army Special Forces unit that had been deployed into the area. They showed me a map of their 1,200 mile route through the sand, moving from small settlement to settlement. They described how desperately the people needed and wanted health care and the warmth with which they had been received. We talked candidly about the influence of various terrorist organizations, including Al Qaeda, who seek cover in the area. These organizations provide money, equipment and other needed assets in exchange for locals leaving them alone while they train and organize.

We are not alone in recognizing the need to be paying attention to these remote areas of the world. I discovered that while we send Special Forces units into the area twice a year, there are two teams of Cuban doctors and medical personnel working the desert year round.

In areas of Africa like Timbuktu, the people are essentially without government. They don’t have the resources to provide services, and the people have far more confidence in other institutions, like the church. I met with the leader of the church, The Grand Imam Abderrahmane Ben Essayouti, for about an hour. He is a very pleasant man who is clearly the most influential person in that part of Mali. We talked about the importance of the church teaching good health hygiene, like the use of bed nets for malaria prevention.

We had a good laugh together. The Grand Imam said, “most Americans don’t think this place really exists.” I showed him a text-message exchange I had with my mother about 15 minutes earlier, when I had greeted her from Timbuktu. She wrote back, “the real Timbuktu?”

At the conclusion of our meeting, the Grand Imam and I walked through neighborhoods of Timbuktu to the Djingery Ber Mosque, where he leads the community in prayer five times a day. The mosque was built in 1327. He walked our group through the mosque and then showed us a small library the United States had donated, which houses important Islamic documents. It was clear how much it meant to them that we had made the preservation possible.

One of my favorite parts of the day was walking through the neighborhoods on my way to and from the Grand Imam’s home. It was a chance to see up-close what the lives of the people looked like. We passed mothers caring for their children, men working to repair their sand brick homes, children playing games and curiously watching these strange visitors. Despite the scorching temperatures, the blowing winds, and the remoteness; it was home to them.

Africa- Blog VIII

Peer counseling in a unique setting
Written August 15, 2008

While in Bouake, in northern Cote d’Ivoire, I visited Reseau des Ecoles Madrassas, a faith-based, non-governmental organization that promotes abstinence and fidelity to prevent the spread of HIV/AIDS in the community.

I witnessed how they used a dramatization and peer counseling to deal with a very sensitive issue within the Islamic community. There is a practice in the Islamic culture (at least in that part of the world) that the younger brother of a man who dies, is bound to take the wife of the deceased as his wife. (In the Islamic world multiple wives are common.)

After I was greeted by the leaders of the Madrassas, and typical rituals were performed, a group who acts as peer counselors did a short one-act play to set up a conversation with the following scenario:

  • After the death of his older brother, a man is informed by his family that he must marry the widow of his brother as dictated by tradition.
  • After hearing the news, a friend of the current wife goes to inform her. The current wife is furious that her husband must marry a second wife.
  • The man who is obliged to marry his brother’s widow goes with a friend to inform his current wife of the plan. They hesitate, then tell her, and she explodes (because she already knows).
  • After discussion, the current wife submits to the wishes of the parents, but asks to put a condition on the marriage: that the widow must get tested for HIV/AIDS beforehand.
  • Her husband agrees that the widow must be tested for HIV/AIDS before he will marry her.

Peer counselors using a dramatization to discuss sensitive issues.
Peer counselors using a dramatization to discuss sensitive issues.

The discussion afterward among the crowd that watched was animated and fascinating. In typical style for Islamic communities, the men and women were seated separately and the male moderator moved back and forth between them taking comments. I won’t try to recount the discussion except to say that an underlying theme of the facilitator was that this is not a practice based on the teachings of the Koran, but one of cultural popularity. He said the same is true for the tradition of a woman taking the husband of her deceased sister.

Following the moderated discussion, I was given an opportunity to ask questions of the peer educators. During that session, one of the women boldly challenged the practice of female genital mutilation. She made the point that the practice was not a religious teaching, but a cultural practice. I was surprised, but pleased, she was willing to talk about it.

Every culture around the world has unique challenges and practices. To win the fight against HIV/AIDS, we have to let people mold the education practices to address the issues where they live and to do it in their own unique ways.

Africa- Blog VII

Written August 14, 2008
Bouake, Cote d’Ivoire

We flew about an hour north of Abidjan and then drove to the village of Lomibo. My purpose was to see HIV/AIDS treatment in a remote area of the country. In those areas, the effort has to be home-based, because there often are not clinics. The reality is that, in areas like this, the government is not a significant factor in the lives of the people. The culture is governed through a hierarchy of village elders. Since the 2002 crisis, areas like this have essentially been cut off from all health care.

Lomibo looks just like one would imagine an African village. When I arrived, I was met by the village elders. These are men who appear to be in their late 60s or early 70s. They dress in traditional African raps. The most senior wears head gear that designates him as such.

The Chief Elder of Lomibo
The Chief Elder of Lomibo

Something I’ve found true in meeting men of this nature is the need to let them size you up. If you pause and gain eye contact for just a second or two, their eyes tell a story and a connection can be made. Without that moment, it is hard to establish a rapport. With the difficulties of language interpretation and culture, it is hard for them to know if they trust your words. I saw that play out in Lomibo.

After a series of introductory activities were conducted, I was asked to speak. I put my remarks into the context of their 2002 crisis. I told them I had come to understand how heavily it had weighed on them. I linked to HIV/AIDS by saying that, to prosper again, they need to be healthy. HIV/AIDS is stealing the health of many of their young people. It is not just killing them, it will hurt the village and its ability to recover as well. I expressed my belief that God has given us bodies, and we are expected to take care of them. “Every person needs to be tested for HIV/AIDS. If you test positive, you need treatment, and you can live a positive and productive life. If you don’t get tested, you can’t be treated.”

My remarks where being interpreted, but I could tell the elders were getting it because they would nod their heads in affirmation. After I was finished, I walked over to a chair sitting at a small table in front of them and had a medical technician prick my finger and squeeze a tiny drop of blood onto the HIV quick-test strip.

When I had finished being tested, volunteers from the audience were invited to be tested. To my great pleasure and to everyone’s surprise, the Chief Elder stood and walked to the table for testing. There was an audible stir in the crowd of people who had come from three different villages. When he was finished, the second most senior person did the same thing.

The U.N. health people said they had been doing these village education sessions for a decade and hadn’t seen a village elder do that. Tim Ziemer, the National Malaria Coordinator, leaned over to me and whispered, “that’s real leadership.”

When the testing had been concluded, the elders said they had a gift for me. They brought out a very colorful robe and ceremoniously rapped me in it. They then placed a colorful cap on my head similar to the one the village elder had worn. They told me I was being made an honorary village chief. They designated me with the name: Nanan Kouakoo the First. I was later told that Nanan means King. Kouakoo is roughly “crowned on Thursday.”

While being provided such an honor feels a little conspicuous, I could tell it was a serious gesture for them and I want to treat their expression with the dignity and appreciation it deserves. (However, I will likely stick with the simple title of Secretary for now.)

Secretary Leavitt wearing traditional robe and cap.
Secretary Leavitt wearing traditional robe and cap.

After the ceremony, all the women in the village began to chant and dance. We all got into the spirit of it and had quite a moment. Many of the women wanted to dance with Nanan Kouakoo the First, and I was more than willing to accommodate. It was an experience I will not ever forget.

Africa- Blog VI

Abidjan, Cote d’Ivoire
Written August 13, 2008

Cote d’Ivoire is better known as Ivory Coast. However, the government insists it is called by its French name, which is odd, given the French are currently persona non-grata in Cote d’Ivoire for reasons I will explain.

Things have been extremely complicated in Cote d’Ivoire since the fall of 2002 when civil war broke out between the North of the country and the South. People in the North believed they were being discriminated against politically and economically. I suppose there was a long history of tension, and what appears to have triggered it was a policy that eliminated many in the North as voters. Forces in the North, lead by a group of lower ranking military officials, attacked three cities in the South. They were turned back fairly quickly.

The government responded with an aggressive security operation, searching and burning shantytowns where the poor lived. The actions of the government caused the situation to explode throughout the country. It is often referenced as the Crisis of 2002.

Ultimately, the United Nations established a “Zone of Confidence” which separated the North and South and then, through the French government, a deal was brokered. Before the arrangement could begin to function, another incendiary event happened. A government aircraft bombed a French military installation in Bouake and killed nine French soldiers and one American civilian. The French retaliated by essentially destroying the entire Cote d’Ivoire Air Force. The country broke into violence again.

Things remained unstable until March of last year (2007) when President Gbagbo (the current President) and Guillaume Soro, then the leader of the Northern opposition, announced they had agreed to a peace agreement. The deal essentially provided for President Gbagbo, who is from the South, to remain as President, and Soro, who is from the North, to be Prime Minister.

As Prime Minister, Soro named a new Cabinet, consisting mostly of the Ministers from the previous Cabinet. The agreement called for the U.N. to eliminate the Zone of Confidence. The government called elections for November 30, 2008. Whether those elections will actually take place is hard to say. Apparently, there have been promises before that elections would be held, but they have been cancelled.

To his credit, Soro and his New Forces party have indicated they will not be contending for the Presidency this time around. However, with the two top leaders of the country representing different interests, it is safe to say progress is hard.

Cote d’Ivoire is one of the fifteen countries in the President’s Emergency Plan for AIDS Relief (PEPFAR). We spend about $120 million a year there. We represent nearly 70 percent of all money being spent on the problem there. I had three primary purposes to go there: First, to get a picture of how the money is being spent; second, to maintain our relationship with the leadership of Cote d’Ivoire; and lastly, to remind the citizens of their country of our nation’s contribution and interest in them.

I spent my first day in the capital of Abidjan and, as I typically do, met with the U.S. Embassy staff to be briefed on the current situation. I also met with HHS employees. We held a small celebration to commemorate twenty years of a CDC project on HIV/AIDS in Cote d’Ivoire.

I visited a clinic supported by PEPFAR funds where I met with HIV positive patients. Following a tour, I did a media event where I was publicly tested for HIV/AIDS. Getting tested always captures the media’s attention and, therefore, allows me to both emphasize U.S. involvement and also discuss the importance of being tested. The message is: Everybody needs to be tested. Know your status. HIV is not a death sentence if you seek treatment.

Secretary Leavitt getting tested for HIV/AIDS
Secretary Leavitt getting tested for HIV/AIDS

Following the media event, I met with a group of HIV positive patients. It is not hard to imagine their gratitude. It is openly expressed and heart felt. Literally, nearly two million people being treated would die without the treatment. The chance of them being treated without PEPFAR is remote.

Each one told me how devastated they felt upon hearing the news of their positive test and then how, slowly, their hope returned as they learned about treatment options and got to know other people who were struggling like they were.

At the conclusion of my meeting with patients, I met a woman I would judge to be in her late twenties or early thirties. I could tell she was terrified to speak, but did anyway. She explained that even though the PEPFAR made the drugs available, the price was high enough that it was making it difficult for her to buy food.

I know nothing about her situation and therefore can’t make a judgment about the truth of her statement, but the conversation was important, because it called to my attention that the government had adopted a policy of charging for the drugs we give them. Upon inquiry later, I found that the government was not being transparent on what the money was being used for. I committed to address it with the Prime Minister later in the day.

Prime Minister Soro is a young man. I’m guessing late thirties or early forties. He was part of the rebel movement in the North and then was invited into the government. He was in and out of government as the tensions ebbed and flowed, but ultimately was the organizing force around which the deal was made with President Gbagbo. I would guess Soro will emerge as a candidate for President in a future election.

Our meeting consisted of an agenda of diplomatic expressions with the exception of my pressing him on the issue of charging for HIV/AIDS drugs that the U.S. provides for free. I don’t think he was aware of it. Cote d’ Ivoire has both a Minister of Health and a Minister for HIV/AIDs. It seems like a rather unusual arrangement. They were both in the room and I hope the conversation resonated with them. It is something that needs to change before we do allocations for the next round of PEPFAR.

Hurricane Gustav

The weekend has been dominated by preparation for Hurricane Gustav. Though I am now in Dallas preparing to enter the storm’s footprint with my senior team, I was working from Utah over the weekend.

Assistant Secretary for Preparedness and Response, Admiral Craig Vanderwagen, operated out of our emergency management center at headquarters. He conducted briefings every few hours. The difference in the work atmosphere, by comparison to Katrina, in our department and in our interaction with other departments and states, has made the hard work of the last three years evident.

I'm typing this blog on my Blackberry and therefore a more detailed description of the differences will need to wait for another day. I will simply generalize that all the lessons learned, all the exercises, all the meetings and conferences, and investments have paid off. People knew what to do and when to do it. We followed a play book that had been rehearsed over and over. Were there surprises and departures from the script? Of course, but for the most part, we carried out the plan.

Assets were moved into place, the medically compromised were evacuated (more than 9000 of them), and shelters and field hospitals were erected. HHS had more than 1,500 people deployed to the region. It has been a moment of great satisfaction to see how ably our team has functioned. Admiral Vanderwagen calmly and professionally guided the process from headquarters. Craig was our field commander during Katrina and is intimately familiar with the situation. I'm extremely proud of him and his team.

This effort revealed weaknesses. They were worked around this time, but they need to become the focus of our improvement. The weakening of the storm is a blessing we are all grateful for. However, there is a virtual conga line of storms queuing up in the Atlantic. We are by no means out of harms way.

There are thousands who need help from the devastation they experienced from this storm. We should never view a Category II hurricane as anything but a deadly storm. I will spend the next two days in Texas and Louisiana to see the outcome of our preparation and assessing what must be done now. I will periodically provide updates. However, I will be communicating them by Blackberry, so they will, by necessity, be short.

www.HHS.gov/hurricane