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

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August 31, 2008 - September 6, 2008

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