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

« September 2008 | Main | November 2008 »

October 2008

Iraq Blog III

An Iraqi Agenda for Health-System Improvement

Yesterday, I related how terrorist and sectarian forces in Iraq have used tactics right out of the insurrectionist’s handbook to target and disrupt health care. They have done this knowing that few things discredit the legitimacy of a struggling democracy better than the discontent surrounding a lack of health care.

Today, I will tell about some of the things the United States is doing to help the new Minister of Health to re-establish health care in his country. Victory here is essential to allowing the people of Iraq to feel confidence in their new Government. Health is so personal it transcends nearly every other service in this way.

I reported in yesterday’s blog that thousands of Iraqi doctors have fled the country. Dr. Salih’s first priority has been to persuade them to return. The most obvious thing that had to happen for that to occur was for the security situation to improve. The progress in this area has been widely reported in the media. I saw evidence of that mainly in the discussions I had with health providers. They feel it is safer now.

Once doctors feel their physical safety can be assured, the next step is to tackle some very difficult compensation issues. Officials at the Ministry of Health told me doctors within their public health-care system were being paid as little as $3.00 a day. The result is corruption. They can’t live on that amount, so they are forced to resort to other means.

Like almost every socialized system in the world that promises health care for all, two systems end up operating. Doctors work in the public system in the morning, and in the afternoon they practice for themselves on the side. Doctors will then try to steer patients to their private practice where they can accept payment for services and medication. In some cases the doctor may have lifted the medication from the public supply.

Incidentally, this is the big lie of socialized medicine. The waiting lines created by rationed, “free” care end up overflowing into a private system where people have to pay to actually get care. (A subject for another day.)

Minister Salih has succeeded in increasing salaries for doctors by $2,000 to $3,000 a month over what they were previously paid. He is increasing training programs for doctors and support staff. That is having an impact.

No new hospitals have been built in Iraq for the past thirty years. Hospitals suffer from bad infrastructure, and from defective water systems, inadequate electricity, unsafe sewage systems and other problems. The buildings are old and worn, and need lots of repair work.

The World Bank (to which our country is the largest contributor) will soon execute a grant to build six to seven new teaching hospitals. The United States has been helping directly to develop better facilities. So far, the U.S. Agency for International Development has paid to build more than 136 primary-care clinics and small hospitals around the country. We’re also helping them build a big children’s hospital in Basrah.

The reality of the staffing problem confronted me when I found out that, because of staffing shortages, several of the new clinics are not open yet to the public. They are equipped and ready, but there are no people yet to man them.

Fortunately, there is some good news to report there. In the last year, more than 800 of the doctors who left have returned to Iraq. There are thousands more that are still away.

As a result of this trip, we at HHS are instituting a number of additional measures that I hope will help. I will detail those in a future blog.

The bottom line for me was that Dr. Salih, despite working with impossibly difficult conditions, is making progress. He is one of many heroic figures I have encountered who risk their lives to do this service.

There are thousands of Americans doing the same thing. One American I would like to acknowledge in this category is my Health Attaché in Iraq, Dr. Terry Cline. He follows three others who have served in the same position, CDR Bruno Himmler, Dr. Jon Bowersox and RADM Craig Vanderwagen.

The Health Attaché represents the Department at the U.S. Embassy in Baghdad. Their job is coordinating all our activities in the country. He is our player-coach on the field.

Secretary Michael Leavitt, Health Attaché Terry Cline, and Chief of Staff Rich McKeown
Secretary Michael Leavitt, Health Attaché Terry Cline, and Chief of Staff Rich McKeown

It was clear to me that Terry has built great relationships of trust, with the Health Ministry and others within our Embassy. He is making a serious impact.

Dr. Cline was the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) at HHS. He volunteered to do the job, and, while it was hard to lose him in that job, it was clear to me he felt a passion for going to Iraq.

Spending time with him in Iraq reminded me of the sacrifice our soldiers and diplomats make, voluntarily, and how fortunate we are that they are willing to do so.

One last observation about my first day in Baghdad; it was Sunday, and I had hoped I could find a church service to attend. In the evening, somebody told me about a Spanish-language congregation that held a late meeting. I found myself in Baghdad, Iraq, worshipping alongside Spanish-speaking soldiers and contractors, mostly from Perú. An interesting way to finish the day.

Iraq Blog II

A Health Life-line from the American People
Written October 17, 2008

Upon arrival inside the Baghdad Green Zone, I was given a situational overview by a group of U.S. Embassy personnel, and then proceeded to a series of meetings with the Health Minister and different groups of doctors. Those meetings were held at the al-Rasheed Hotel, a famous landmark in Baghdad. During the 1991 war with Iraq, CNN broadcast live from one of the upper floors of the hotel.

Mid-afternoon, I left the hotel for a thirty-minute meeting with U.S. Ambassador Ryan Crocker and General Raymond T. Odierno, the Commanding General of Multi-National Force- Iraq. Both of them are impressive and highly experienced men dealing with enormously difficult tasks.

Most of our discussion related to the Status of Forces Agreement (SOFA) and the Strategic Framework Agreement, currently being negotiated between the United States and the Iraqi Governments. These are complex agreements that will define the nature of our interaction after December 31, 2008, which is when the United Nations Resolutions expire.

Secretary Leavitt meeting with U.S. Ambassador Ryan Crocker and General Raymond T. Odierno
Secretary Leavitt meeting with U.S. Ambassador Ryan Crocker and General Raymond T. Odierno.

Following my meeting at the Ambassador’s office, we drove back to the al-Rasheed to continue a succession of meetings and conversations with the leadership of the Health Ministry and doctors from around Iraq.

The Minister of Health, Dr. Salih Al-Hasnawi, is a psychiatrist by training. He has a steady, calm demeanor that engenders trust. He speaks English well enough that we can communicate without problems. Most of all, he seems genuinely committed to improving the health of the Iraqi people.

Dr. Salih works in a very difficult and somewhat dangerous atmosphere. Previous Ministers have been subject to assassination attempts. He must have massive amounts of security for that reason.

Dr Salih’s security concerns are emblematic of the primary reason the health-care system in Iraq is so desperately in need of help. Insurgents have strategically and systematically targeted doctors, hospitals, and health workers. They have kidnapped or wounded thousands of them, murdered hundreds, and threatened their families. This follows 25 years of deprivation and abusive practices under Saddam Hussein.

Throughout the day, I sat with doctor after doctor who related stories of being shot, kidnapped, threatened and tormented by the thought that they or their families could be next. One told me privately of e-mails, notes and phone calls in the night threatening him and his family because he treats members of the Iraqi Army.

Others described how hard it is to get staff to come to work when health clinics are bombed. They feel intimidated and scared. One person described the health community as suffering wounds upon wounds, never fully able to recover.

These are tactics right out of the insurrectionist’s handbook. If you disrupt the capacity of the government to provide essential services, it discredits the government, and creates a fertile ground to foment terrorist ideology.

There is nothing essentially more personal than health care. That is the reason insurgents and terrorists focus so intensely on it. Not just in Iraq, but all over the world. The pattern is the same.

Regrettably, the tactic has worked in Iraq. Out of 34,000 doctors registered in Iraq in 1990, at least 20,000 have left the country. Since 2003, 8,000 doctors have stopped practicing medicine; more than 2,200 Iraqi doctors and nurses have been killed, and over 250 kidnapped. The doctor’s flight further crippled health institutions in Iraq, because without them corruption and mismanagement became the rule. Iraq probably needs around 100,000 doctors to meet the needs of its population, but has at present only 15,000.

The doctors who remain spoke to me of the hunger they have for professional improvement. They have had no capacity to interact with doctors in other countries who can teach them updated techniques.

In one of my meetings, I sat with a group of mental-health practitioners who had just returned from the United States on a program sponsored by my Department. We arranged for about thirty of them to spend time with their counterparts in the United States. These people were energized and appreciative. Every one of them reported continued conversations by phone and e-mail with mental-health professionals in the United States who have become friends, confidants and mentors. One can only imagine the mental-health toll the last thirty years have created in Iraq.

Tomorrow, I will talk about Minister Salih’s plans to begin rebuilding the health-care system in Iraq.

Iraq Blog I

Sleeping at Saddam’s Palace
Written October 17, 2008

In the spring of this year I was visited by Dr. Salih Al-Hasnawi, the Iraqi Minister of Health and the Iraqi Ambassador to the United States, Samir Sumaidaie. They came with a specific request; help in providing re-training for doctors in Iraq.

Thirty years ago, Iraq was considered a center of health care excellence within the Middle East. Deliberate under-funding by Saddam Hussein and five years of focused kidnappings of doctors, bombings of clinics and ruthless killings of health workers by insurgents has resulted in thousands of doctors leaving the country. Those who stayed have fallen behind, deprived of an exposure to professional enhancement or even contact with others within their area of specialty.

The Minister’s request was that we organize opportunities for Iraqi doctors to shadow American doctors who practice in their specialty for a period of a few weeks. Doing so, he reasoned was the most efficient way to update them on the current practice of medicine. It would also establish relationships, allowing Iraqi practitioners to continue contact after they return home.

I found the Minister’s request compelling, and committed to explore the possibilities. The idea seemed feasible, especially because the Minister committed to pay all the costs of the traveling physicians.

Following our meeting, I did two things to test-drive the project’s viability. I organized a working group at HHS and assigned them to study the barriers to such an effort. In addition, as I traveled around the United States over the next couple of weeks awarding Chartered Value Exchange charters, I asked to meet with leaders of medical associations to explore their enthusiasm for undertaking such a project.

I was gratified to find American medical communities energized by the thought. Many had suggestions and helped flesh out the challenges we would need to overcome to make it work.

Ultimately, I formed an HHS team, called the Minister of Health and committed we would generate a pilot group before the end of the year. I hoped, in executing the plan, we could get the program organized and operating before I vacated the Office of Secretary. Looking back, I have to admit, I underestimated the amount of bureaucratic challenges, diplomatic obstacles and legal entanglements necessary to do what seemed like a fairly simple task.

In addition to organizing the effort, I committed to visit Iraq myself to show U.S. support for the Ministry of Health. This was important to the Minister, because he was struggling to convince the thousands of Iraqi doctors who had fled the country to return. Having the Secretary of Health from the United States visit and announce such an effort would add needed credibility to his message.

On October 17, 2008, I flew from Washington D.C. to Amman, Jordan, stayed the night, and then took an Air Force C-130 from Amman to Baghdad. While Iraq is a safer place than it was six months ago, the heavy, armored vests and steel helmets we wore everywhere we went served as a reminder of the fact we were flying into a war zone.

Flight_to_iraq
Secretary Leavitt and Air Force crew on flight to Iraq

Once inside the Green Zone, we were taken to our billets for the two nights I spent there. I slept in a building just off the swimming pool at one of Saddam Hussein’s palaces. The palace is now used as offices for various components of our government’s operation there. It is teeming with people, all walking with a notable briskness. The exterior is surrounded by a maze of concrete “t-walls,” used to protect people from explosions. The compound is dotted with duck-and-cover shelters that serve as protection from mortars lobbed across the walls from outside.

Despite the gold door knobs and marble floors, the sleeping accommodations were spartan and basic. My room had two, inexpensive twin beds, a small desk and a 16-inch television. We ate our meals with the soldiers and contractors.

Iraq_accomodations
Sleeping accommodations in Saddam Hussein’s palace

In many ways, the current use camouflages the remarkable opulence of the gold trim, ornate carvings and egotistical murals and self-tributes in the massive rooms of the palace. One could not walk the halls without thinking of the evil conducted there in years past.

The pool was big, beautiful and well-used by soldiers looking for a place to relax and exercise. It was surrounded by traditional amenities soldiers use: A ping-pong table, billiards and a popcorn machine. None of it covered up the soberness of the task, or the time.

Pakistan- blog III

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.

As described in my first posting on the Pakistan trip, I traveled there at the invitation of Minister of Health Sherry Ruhman, who had visited my office weeks earlier. Our conversations convinced me I could accomplish multiple things with a trip to Pakistan. I had a couple of days between my trip to Africa and an assignment to represent the President at the closing ceremonies of the Olympic games, and Pakistan was generally on the way, so I decided to go. I had two objectives principally:

  • Learn more about how terrorist organizations use health care as means of nurturing support among local communities
  • Reinforce, by being there, the ongoing friendship of the United States with Pakistan’s leaders.

Terrorists sometimes hide in the most remote regions of the world or hide in plain sight within communities. In either case, having support, or at least acceptance among locals, is necessary to cover their existence. From what I’ve read, this is well illustrated in Iraq, where locals appear to be turning against terror organizations and assisting security forces in rooting them out.

The region along the Pakistan/Afghanistan border is notorious as a haven for al-Qaeda. Many speculate it is the hiding place of Osama Bin Laden. Periodically, the United States conducts military activities in that region to root them out.

In order to cultivate support among the local people of that region, terrorist groups work through non-governmental organizations friendly to their cause to undermine the credibility of the government in providing basic services like health care. They then set up clinics and actually provide services to the people themselves. Terrorist organizations have discovered the power of health as a tool in securing the loyalty of local people.

This happens all over the world. I spoke with Special Forces Teams who conducted health missions in Northern Mali, another place where al-Qaeda finds isolation. In Northern Mali, Cuban health teams provide medical services. In Lebanon, the government’s health role has been almost entirely taken over by Hezbollah, an Iranian supported political party.

In Pakistan, the national government is able to deliver very little health care and it is unsafe for any U.S. support to attempt delivery. In the border region, the best role for our government is to provide assistance to the Pakistani government. It is their duty and they need to be the face of health. We have a significant stake in their success, however. To the degree that people believe their government cannot deliver, terrorists are enabled.

Throughout the rest of Pakistan, the situation is different. I sense our biggest problem is that ordinary Pakistani citizens don’t have any idea how much we do for their country. When combined with their complicated politics, the United States is not currently held in high regard by the Pakistani people.

One region where the United States is greatly appreciated is in the area of Northern Pakistan that was struck by an earthquake in late 2005. I flew by helicopter over the area. Even two years later, the size and magnitude of the earthquake was evident.

The United States sent massive aid to help. The most important assets at the time were large helicopters with the words, “United States of America” written on the side. People knew the United States was there.

We have not left either. I met with community leaders at the site of one of many health centers our government is building. We are also paying to train medical workers. I stopped at a training meeting of traditional birth attendants who were learning how to deal with a particular complication.

HHS Photo by Allyson Bell
Secretary Mike Leavitt attends the opening of a training course for local doctors and nurses in an area affected by the Kashmir, Pakistan earthquake of 2005. The course, sponsored by USAID, is for local doctors and nurses and is key to reducing traditionally high rates of maternal mortality.

Most impressive was the difference in how our reception felt in that region. People compensate health diplomacy with their loyalty. Terrorists know that, and we need to use health diplomacy as a tool against terrorism.