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Health Diplomacy

Iraq Blog VI

Nothing Spared to Save Our Soldiers

Baghdad is still a tough place. Though there were apparently a couple of IED episodes in Baghdad while I was there, I was not aware of when they happened. However, a visit to the Combat Support Hospital (CSH) inside the Green Zone had a powerful impact on my understanding of the reality of war.

I met the doctors and nurses on duty that day. They walked me through their sobering business as if I was a patient arriving by helicopter, as most of their patients do.

I noticed a flag had been hung on the ceiling of the doorway through which wounded soldiers would be wheeled. I was told, “We want the American flag to be the first thing they see here. We want them to know they have come to a place where no effort will be spared to give them what they need. We want them to know once they get here, there is a 98-percent chance they will survive.”

In general, the staff observed that, thankfully, trauma treatment for combat-related injuries had slowed dramatically. We walked into the trauma center. During my visit, it lay quiet, but, on some days, as many as 40 soldiers will lay on those tables, victims of explosions, bullets or other combat injuries. The chief nurse who briefed me said, “Sometimes all three of these tables will be full, the floor will be covered with blood, and there will be a line of gurneys waiting, but the most remarkable thing to observe is the calm professional way in which this team provides care. Nothing is spared.”

After a wounded soldier has been stabilized, and the extent of injuries determined, most must go to the operating area. We walked the pathway along which so many had been rolled. I found myself imagining what would go through their minds as they deal with the pain and uncertainty of their circumstances.

Secretary Leavitt and Chief of Staff, Rich McKeown on a tour of the CSH.
Secretary Leavitt and Chief of Staff, Rich McKeown on a tour of the CSH.

We entered the operating area. At the moment we were there, only two of the several operating theaters were in use.

I looked through the window of the dual swinging doors, and could see the body of what was obviously an Iraqi man, lying naked on the operating table, with a team of four working over him. He had lost a hand, had a serious wound to his head, and the team had his chest open working to remove a piece of metal.

The chief nurse explained to me he was Iraqi, and appeared to have been setting an explosive device of some type when it had blown up prematurely. He had received the blow he had intended for one of our soldiers.

What interested me is that the United States provides him the same care we would one of our soldiers. Something tells me that isn’t true of the insurgents and the terrorists.

In the second operating theater was another Iraqi, wounded in combat. It was another scene where the nature of his injuries made the seriousness of war graphically apparent. I won’t go into detail, except to say they were extreme. The surgeon, a youngish looking guy who was on his second tour, conceded to me that the first time around it was somewhat shocking, but this time, he knew what to expect. The emergency surgeries are, he said, “a professional challenge like none other I have ever faced.”

It is not unusual to have a wounded American soldier arrive at the CSH, get stabilized and be on an airplane to Germany on the same day.

On my way out the door, I saw a little Iraqi boy who was being treated for a poisonous snake bite. His father was at his side. A significant part of our military medical resources in Iraq go to provide treatment to local citizens. One thing I know is that their view of America and Americans will never be the same.

As Prime Minister Maliki told me, “Health care is one of the best messengers of peace between nations.”

Iraq Blog V

Meeting Prime Minister Maliki

On my second day in Iraq I had a 30-minute meeting with His Excellency Nouri Kamel al-Maliki, Prime Minister of the Republic of Iraq. I had not met him before.

His office is inside the protected Green Zone, in a rather remarkable building I understood to be the home of one of Saddam’s sons at one time. I’m not sure of that, but, by any account, it was ornate and tastefully done. I was joined in the meeting by the Ambassador from the United States, Ryan Crocker, with whom I had met the previous day, and the senior members of my delegation. Minister of Health Salih also attended, sitting on Prime Minister Maliki’s left.

Prime Minister Maliki went into exile in 1980, after Saddam Hussein’s regime sentenced him to death for his leadership role in an opposing party. He spent his time away in Iran and Syria. He was elected as Prime Minister in May of 2006.

Visits with a Head of State or Prime Minister have a rhythm about them. There is a formal greeting, and a few pictures. Generally, one sits on the right of the host. The media is invited in for a picture; when the media is cleared out, a more formal part of the conversation can begin.

Typically, the Head of State speaks first, and offers a greeting, maybe laying out some things he or she is interested in talking about. Then the visitor responds with similar expressions.

I told the Prime Minister why I was there by relating the experience I had in talking with the American health community about receiving Iraqi physicians for short-term exposure to current medical practice. I referenced the unqualified generosity and willingness uniformly expressed by everyone I spoke with.

Secretary Leavitt (left); interpreter (middle); Prime Minister of the Republic of Iraq, Nouri Kamel al-Maliki (right)
Secretary Leavitt (left); interpreter (middle); Prime Minister of the Republic of Iraq, Nouri Kamel al-Maliki (right)

I expressed the view that our Governments were developing working relationships, but it was important, in my view, that we begin concentrating on connecting the American and Iraqi people. I referenced the historic quality and regional leadership of the Iraqi health-care community, and acknowledged the damage it had sustained during the previous 30 years of neglect. I told him we wanted to support the goal of returning Iraq to its previous stature as a center of excellence for medicine in the Middle East.

The Prime Minister said he was not surprised to hear of the positive way people had responded to my request. “This matches what we have come to know about the American people and their desire to help others,” he said.

He went on to say, “We need to build bridges based on love and appreciation. Health care is one of the best messengers of peace between nations.”

We had a fairly lengthy conversation about the dual agreements currently being negotiated between our nations. A blog is not a place to be talking about the specifics of that kind of conversation. It was candid and productive.

I will say that he had some fascinating observations about the challenges of governing people who have freedom thrust upon themselves for the first time. I saw some of that play out, first-hand, later in the day, as I traveled outside the Green Zone to a major teaching hospital in the Medical City complex in Baghdad. (I wrote about that in my previous blog.)

Iraq Blog IV

Iraqi Health Outside The Green Zone

I wanted to see health-care facilities, patient care, and to talk with doctors and health-care workers outside the Green Zone. It was suggested I visit Medical City in central Baghdad.

Medical City is the largest medical complex in Iraq, and includes six hospitals and the Baghdad University College of Medicine. It has almost 3,000 beds, and is the leading provider of tertiary services for the entire country.

During the 1990s, the complex’s infrastructure aged, and the hospitals have suffered rapid degradation. As Prime Minister al-Maliki told me, “Medical City has exceeded its expiration date.”

The tap water in many of the hospitals is not safe to drink, equipment is not sterilized and doctors cannot find water or disinfectant to wash their hands. The availability of medicines and medical supplies is a major problem.

Getting there was rather instructive on the challenges that remain. While I acknowledge my profile as a target likely warranted some special precautions, there are obvious risks anytime an American ventures outside the Green Zone, and serious security operations have to accompany any such move. The people executing the moves are well-trained and operationally proficient.

For security reasons, I won’t go into details, but, suffice it to say, the move involved a coordination of multiple operating units on the ground, and in the air. We wore heavy protective gear on our persons, and moved fast, minimizing any opportunity for a negative incident. I feel appreciative toward those who planned and executed my travel around Iraq so safely and efficiently.

Once at Medical City, it became clear health care in Iraq is different from that in many countries. Iraqi health-care facilities rely less on nurses and technicians. It is not uncommon for families to take up residence in the hospital to care for family members. In fact, I was shown facilities set aside to house some of them. I was told in some facilities they will even cook in the hallways, but I didn’t see that during my visit.

While I did tour a pediatric unit, where I mostly saw premature babies, most of whom had been born in other regions of Iraq, I was not able to tour many of the patient areas because of security concerns.

Much of my time was spent talking with students, faculty and staff. I began to experience what the Prime Minister had referenced in our conversation about what happens when freedom is given to people who have been oppressed for a time. There is a profound impatience for improvement.

Secretary Leavitt talking with Doctors
Secretary Leavitt talking with Doctors

Students would talk about the inadequacy of their training. Using the Internet, they know what is available in the rest of the world, but they see little of it.

In a meeting I held with students who were bused in from Baghdad University, I ended up playing referee for a fascinating exchange between a student and the Dean of the university’s medical school.

The student, in his final year of his six-year course, had made the point he and his peers were not being exposed to new imaging technology. The Dean stood up to say the medical school did have some new imaging equipment, and that the students’ training included exposure to it.

The student responded, “With all due respect, sir, we don’t have access to it. I just finished my radiology section, and we only got to see the CAT scanner through the glass of a locked door. Nobody knows how to use it.”

That exchange was symbolic of what I heard over and over again.

At the conclusion of my meetings with a fairly large sample of Iraqi medical people, I came away resolved that in the short time I have left at HHS, I would find a way to facilitate more direct contact between practitioners in Iraq and American doctors. Even if it is just e-mail, calls over cell phones and an occasional video conference, both sides of the equation will benefit, and our relationship with the people of Iraq will grow.

We have a strong and complex relationship with the Government of Iraq. Our relations now need more contact between our people.

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.

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.

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.

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.

August in Africa- Blog V

Written August 12, 2008

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

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

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

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

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

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

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

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

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

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

August in Africa- Blog IV

Written August 12, 2008

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

August in Africa- Blog III

Written August 11, 2008

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

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

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

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

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

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

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

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

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

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

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

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HHS Secretary Mike Leavitt and Prime Minister Meles

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

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

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

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

August in Africa- Blog II

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

August in Africa- Blog I

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

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

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

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

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

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

Nicaragua

Written June 30, 2008

This was my third trip to Nicaragua. The place has started to be quite familiar to me, and I am beginning to develop what feels like a good relationship with many of the people there, including President Daniel Ortega and his wife Rosario.

President Ortega has perspectives different than those of many people in the United States, but I have always appreciated the fact that he treats me personally with dignity, and in a friendly, open way. We have developed the capacity to talk privately about our differences, and in the health field, we have common interests and aspirations for the people of Nicaragua.

This trip was actually fulfilling a commitment I had made to President Ortega when I saw him in January this year, at the inauguration of President Colom of Guatemala. During that conversation, we discussed the connection between clean water and air and general health. I committed to bring some people from the Environmental Protection Agency and the HHS Centers for Disease Control and Prevention to consult with the Nicaraguan Government on how to deal with the challenges they face with Lake Nicaragua, a large lake near the city of Granada.

People in the United States might reasonably ask why the United States Secretary of Health and Human Services spends time in Nicaragua worrying about the water. There are several reasons. My primary purpose for being in the region was the safety of products (especially food) imported into the United States. We are changing our strategy to make sure quality is built into the food we consume and a significant amount of our fresh fruit and vegetables is produced in Central America. One of the most significant components of food safety is the quality of water. If we want to have Central American fruit during the winter months, it is important the water they use in Nicaragua and elsewhere in the region to grow the fruit is clean.

Another reason is the success of Nicaragua as an emerging democracy. Our nation cares about the people of Nicaragua, and sees delivering on health and basic social services as important for elected governments to succeed, which further supports the stability of that region.

In the evening, President Ortega and I spent about an hour and a half talking together about the lake and ways we could work together to improve it. The lake has a fascinating history. President Ortega invited some knowledgeable local experts who are working hard to save the lake. I had invited Ben Grumbles, the Assistant Administrator for Water at EPA, to accompany me, and Captain Craig Shepherd from HHS/CDC, the Chief Environmental-Health Officer of the U.S. Public Health Service. We agreed to spend some time the next day actually on the lake to help us devise ways of working together.

Following our meeting, President Ortega drove me in his car to a local hospital, where we talked to patients, doctors and families about the quality of care they were getting and what needed to be done to improve their health system. There are a lot of needs in Nicaraguan hospitals.

Thursday morning we spent time on the lake itself, aboard a steamship. After the tour of the lake, the President and I drove around an island, and then settled into a meeting to outline a process for the U.S. Government to help Nicaragua, technically, in their clean-up. The Nicaraguans are aware of the progress we have made in the United States with our Great Lakes. When I was Administrator of the EPA, I organized the Great Lakes Collaboration, which has developed a master plan to further improve the lakes. We talked some about that process, and agreed to send a technical team to Nicaragua at the end of July.

President Ortega brought Secretary Leavitt and Captain Craig Shepherd on a boat tour of Lake Nicaragua to work on a plan to analyze the condition of Lake Nicaragua
President Ortega brought Secretary Leavitt and Captain Craig Shepherd on a boat tour of Lake Nicaragua to work on a plan to analyze the condition of Lake Nicaragua.

I met with several other groups while I was in Nicaragua, including people from the business community and a large group of students at the medical school of the National Autonomous University. I enjoy my encounters in other countries with students. They have straightforward questions, and I’ve found they appreciate straightforward answers.

Regional Health-Care Training School

About two years ago, while attending a meeting of the Health Ministers in Central America, I listened to a discussion related to a common need they have for skilled medical workers. The Minister of Health of Panamá at the time was Camillo Alleyne. He proposed at the meeting the creation of a regional center where the countries could jointly train workers.

As I listened to the discussion, I could see the vision of the school was smart, and it represented a way the United States could help the entire Central American region at the same time. I began to help them with their proposal, and now, less than two years later, we have a functioning school with a terrific facility, offering training to students all over the region.

There is a long story here that I hope to write at some point, but I just want to say that Friday while in Central America, I visited the school and attended the first meeting of its Board of Directors. I was able to visit a class of forty students from four countries who couldn’t have been more excited about what they were learning and the relationships they were making.

Students from Costa Rica, El Salvador, Honduras, Guatemala and Panama listen to Secretary Mike Leavitt at the Regional Health Care Training Center in Panama.
Students from Costa Rica, El Salvador, Honduras, Guatemala and Panama listen to Secretary Mike Leavitt at the Regional Health Care Training Center in Panama.

This school is going to be a major source of good in the region and I couldn’t be more proud about the United States’ prominent role.

Later in the day, President Torrijos invited me to the Presidential palace for a meeting. He has been supportive of the center. We spoke for about 40 minutes about a wide range of subjects.

Central America Blog II

Written June 26, 2008

Wednesday morning, we drove two hours from San Salvador to Acajutla, a community in El Salvador of about 75,000 people on the Pacific coast where the USS Boxer had visited to care for patients as part of the mission, “Continuing Promise,” in May of this year. The Health Minister of El Salvador met us there to tour a public clinic. While the USNS Comfort had visited a different part of the coast last year, some of the health care professionals around Acajutla have also participated in trainings offered by the Comfort crew.

Like public clinics I have seen in other countries, including our own, people with various needs lined up early in the morning to see one of the doctors or nurses. They are served on a first-come, first-served basis, advancing along a series of benches. There is no air conditioning, the temperature is hot and muggy and patients are served with a wholesale mentality but seem grateful for the help. This is the way health care delivery happens in their world.

There are 369 such clinics like this in El Salvador, the Minister told me, plus another 171 smaller rural health posts. In this particular clinic, there were 25 doctors and a similar number of nurses. There are about 5.4 million people in the nation, about 439,000 of whom live in the department, or province, in which Acajutla is located.

In addition to the clinics, El Salvador has a system of referral hospitals and other public health functions. One of them is a network of health promoters in the neighborhoods who teach healthy practices, encouraging those needing care to get it. For example, women of childbearing years are asked to report the date of their last period so the health promoter can get them into prenatal care if they prove to be pregnant. They know every child under five, watch for signs of communicable disease and generally “promote healthy practices."

I spent an hour talking to some of the doctors, nurses and health promoters, trying to understand what motivates them and their general outlook. The main reason I chose to visit Acajutla was to get a reading on the impact of the USNS Comfort and the USS Boxer a few months after their visits.

What a powerful testimony I heard from these people about the value of these efforts by the U.S. Government. They could not find adequate words to cover the sense of gratitude and professional fulfillment they felt. It was simply inspiring to hear them talk about all they had learned from the doctors on the ships, and the appreciation they felt for the dignity and care with which they felt our crews treated their patients, friends and neighbors.

As moving as I found the meeting with the doctors, the most significant experience of the day was meeting with about 10 patients who wanted to tell me about their cataract surgery, hernia operation or the care given to their children on board the Boxer. Each story related a changed life with a renewed sense of purpose and self-worth.

One woman told me how her blurry eyesight, which was now cured, no longer caused her to fall. She threw her arms around me saying, “Thanks be to God for the United States.”

Another woman told me about reading to her grandchildren for the first time. Another older woman, who was caring for three small, abandoned grandchildren, talked about the difference the visit had made to the little girl with cerebral palsy and her able-bodied brothers.

A man in his late thirties pulled up his shirt to show me the scar of his repaired hernias, and then demonstrated how his mobility and strength had returned, which allowed him to work again.

One after another, they used different words to talk about how the Boxer had restored the productivity of their lives. Those who had cataract surgery particularly moved me. Cuba has aggressively provided this rather simple surgery for tens of thousands all over Central America. The Cubans call the campaign "Operation Miracle," and it has built a reputation for Cuba in the arena of health diplomacy.

Secretary Leavitt and a Salvadoran boy share a laugh at a clinic in Acajutla, El Salvador
Secretary Leavitt and a Salvadoran boy share a laugh at a clinic in Acajutla, El Salvador.

Our hospital ships will return to the region this summer. Doctors and patients of El Salvador are anticipating these visits. This is a powerful tool for our nation, and we need to do more of it.

Central America

Written June 25, 2008

Yesterday, we held an all day session on product safety with representatives of the Central American countries and the Dominican Republic. We had Health Ministers from several of the countries and representatives of Agriculture and Commerce Ministries as well. I met with President Antonio Saca of El Salvador for about 30 minutes in advance of the meeting. He formally opened the meeting.

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Secretary Mike Leavitt (2nd from left of those seated) listens as President Antonio Saca of El Salvador addresses attendees at the Product Safety Forum.

Our purpose was to begin a conversation with the participating nations on changing our collective strategy related to the safety of food. Central America and the Dominican Republic have become a major factor in U.S. food production. Collectively, these countries rank just behind Mexico and Canada in importation of food into the United States. A trip to the grocery store fruit and vegetable section will confirm that.

These countries properly fear any kind of import quality problem because it is seriously disruptive to their economy. The U.S. is 80% of their market. A situation like the melon problem we had in Honduras or the tomato situation in Mexico also damages their national brand.

In previous blogs, I have discussed our nation's strategic change. Our efforts are focused on preventing problems before they happen. Our best tactic to accomplish that is the establishment of quality standards and the continual monitoring of them through independent certification. I explain in my blog on the Red Pepper Principle, how implementing new practices can make crops attractive because of higher quality.

We had five panel discussions, all of which went well. Just before lunch, I asked the participants to consider an idea that I wanted to discuss during the afternoon. The idea was to create a U.S./ Central America/ Dominican Republic Memorandum of Understanding (MOU) on food and drug safety. Under this MOU, we would engage in regional capacity-building, joint standards-development, development of accreditation arrangements for certifiers and training at the Regional health-care Training center we have developed in Panama. I suggested that we identify a couple of product categories to start with. After lunch, the panel discussions began to center around the MOU idea. By the end of the session, we had devised a strategy to move the idea forward, with a goal of completing the MOU this fall. The meeting was a big success from my point of view. We didn’t conclude anything, but we were able to start a serious process. I still have a significant amount of work to do in making contact with other important players.

Dinner last night was terrific. Ambassador Charles Glazer and Mrs. Glazer invited a local mayor and two prominent business executives over. It was a chance for me to learn more about El Salvador. We talked about the challenges of local government and the upcoming national elections.

Mexico City Meetings

Written June 23, 2008

I’m writing from Mexico City tonight. I participated in a bi-lateral meeting with José Cordova, Secretary of Health, and members of his staff. We then had a working dinner that added Alberto Cardenas, Secretary of Agriculture, and Eduardo Sojo, the Secretary of Economy, and representatives of other Mexican national government agencies.

Secretary Cordova and I have a long list of things we are working on together. Most of them related to joint projects we are doing along the border.

Secretary Mike Leavitt and Secretary of Health for the United Mexican States Jose Angel Cordova.
Secretary Mike Leavitt and Secretary of Health for the United Mexican States Jose Angel Cordova.

Secretary Cardenas and I have known each other since 2003. Previously, he was Secretary of Environment and I headed the U.S. Environmental Protection Agency (EPA). It was the first time I met Secretary Sojo. Speaking of environmental issues, the air here is much better than I remember it. I joked with Secretary Cardenas that it was the result of the joint projects we had done on clean fuel while I was at EPA. I suspect the air isn’t always as good, but it is good to see some progress.

The evening meeting was devoted to a discussion of product safety. I won’t discuss the content of the meeting except to say it was focused on ways we can work together to assure safety of food and drug products that are produced in Mexico. I am going to Central America tomorrow for discussions with five governments on the same subject.

An obvious topic of conversation was the current situation with tomatoes. Tomatoes are Mexico’s biggest agricultural export to the U.S. Fresh fruit and vegetable exports to America accounted for $4.4 billion last year. As always, an incident in that sector of their economy has serious ramifications, and we are working with them to minimize impact, while putting safety first.

Secretary Leavitt speaking to Secretary Cordova during a bi-lateral meeting between U.S. and Mexican health officials.
Secretary Leavitt speaking to Secretary Cordova during a bi-lateral meeting between U.S. and Mexican health officials.

FDA is working non-stop to find the source of the salmonella outbreak that many states are experiencing right now. FDA has completed the trace-back for some of the tomatoes associated with the outbreak. The investigation has led them to certain farms in Mexico and Florida.

We have deployed a team to Mexico. They will conduct joint inspections with regulators in Mexico and Florida at the farms and other distribution points. Meanwhile, the FDA will continue to collect samples of tomatoes and conduct trace-back activities.

FDA is keeping a list of the areas that have not been associated with the outbreak. We added a long list of states within the United States and Mexico. It is on the FDA website.

Tomorrow, I’ll meet with U.S. businesses in Mexico City, tour a food processing plant, and give a diplomacy speech. One thing making this trip a little extra special is that my 18 year old son is accompanying me (at my expense). He is about ready to leave home for college and this is a way for us to have a little adventure together.

China - Blog IV

Thursday night I was scheduled to have dinner with my friend Gao Qiang, who until last year was China’s Minister of Health. He no longer has day-to-day management responsibility but continues to have significant involvement in health policy. He called to say he had meetings related to the earthquake so he needed to cancel our plans. I completely understood.

We were able to get together for a brief visit on Friday morning. He had only had two hours sleep the previous three nights. He said the entire government was focused on the rescue effort.

I was also able to spend time with Wan Gang, Minister of Science and Technology. We had met at the Third Strategic Economic Dialog last December but this was our first opportunity to spend time getting acquainted. We reviewed the existing relationship between HHS and the Ministry and laid out some areas where we have additional common interests.

During the middle of the day, I took a short break to attend a program at an International School on Internet Safety for Children. My wife Jackie volunteers full time for the ikeepsafe Foundation. The foundation has developed a book about internet safety using an Olympic Game theme and the book launch was held at the school. One of their sponsors has arranged to place several thousand copies of the book in schools.

The afternoon was spent in more meetings with government officials. I spent a productive hour with Minister Li and his Deputy Minister Wei. They reviewed with me plans they have to ensure food safety for the Olympics. It was rather extraordinarily detailed and well coordinated. The essence of the plan is if you touch any food during the Olympics as a restaurant, supplier, or processor, or transporter then you have to register and agree to certain standards. They have developed a tracking system that is the most elaborate thing I have ever seen. I can’t recount every component of the system but it includes GPS tracking of every truck carrying food, traceability of ingredients and an incident reporting system. I told Minister Li that if he could pull half of it off, his organization should be given a gold medal in food safety.

We also spoke at length about the progress on the implementation of our Memorandum of Agreement on food safety. We are making steady progress.

After our meeting, my good friend Vice Minister Wei arranged for us to see the Olympic park. What a treat that was. We went to a building where they display scale models of each venue. It was well presented. We then drove to several parts of the park so we could see the venues from close range. They are spectacular. The visit rekindled many of my Olympic feelings from 2002 when my home state of Utah hosted the Winter Olympic Games.

China will be stretched to manage the final preparations for the games and the earthquake recovery at the same time. It brought back memories of our Olympic preparations. The Olympics were only a few months after 9/11 hit. Suddenly the nature of the 2001 games changed. We would become the first major world gathering after the attack. Many were concerned that terrorists would use the Olympics as a target. We beefed up our security arrangements considerably during the final three months.

I rushed back to the Embassy to do a news conference. Regrettably, I was caught in Beijing traffic, which is simply unbelievable. I was about a half an hour late and that always makes me uncomfortable. The journalists were patient and seemed to understand the traffic problem. Most of their questions focused on import safety issues. There were 18 reporters there.

My final meeting of the day was dinner at Ambassador Sandy Randt’s home for members of my delegation. It was a terrific evening. Ambassador Randt has lived in the region for much of his professional career. He and his wife Sarah have been in China several times, starting in the 1970s. He also lived in Hong Kong for many years, speaks the language and is a terrific relationship builder. He is remarkably able and likeable; all good qualities for an Ambassador.

Our dinner conversation focused on China’s place in the next quarter century and a comparison of the unique challenges our respective countries face to maintain our economic momentum. We talked about the challenge of entitlement spending in the United States and the various disparities China will need to manage. It was an interesting conversation.

The best part of the evening was a conversation we had about music that we grew up with. Each of us named songs that took us emotionally back to our adolescence and the associated memories. My song was Strawberry Fields Forever, by the Beatles. It reminded me of sitting at a small drive-in on the outskirts of Loa, Utah where our ranch is located. I would go there on summer evenings to order food and play songs from the Juke box.

We all shared great memories. It was a terrific way to get to know each other.

Shanghai, China - Blog III

Traditional Chinese Medicine

I had planned to be with Minister Chen at a medical college where they teach Traditional Chinese Medicine (TCM). I have written before about my interest in this subject. I brought Dr. Josephine Briggs, who heads the Center for Complimentary and Alternative Medicine at the National Institutes of Health. Our purpose is to stimulate some scientific cooperation on how Western medicine can be informed by TCM.

We visited a large new hospital about an hour outside the Shanghai city center. It had 750 beds and is connected to the Medical School. We visited three departments at the hospital: the pharmacy, a general ward and the acupuncture center. At the acupuncture center, the management of the hospital had very cleverly identified some of the patients with Utah ties, people who had lived there during the time I was Governor. We walked through three small rooms and observed the treatment of a dozen patients for things ranging from knee problems and bells palsy, to infertility.

Afterward, we gathered in a conference room to ask questions of the medical staff. I find it rather easy to grasp the portions of TCM related to medicine. They use naturally grown plants in combination to produce a therapeutic result. The components obviously have active ingredients that have some impact on the human body. Over the years they have developed patterns of what works in various situations. Diagnosis is done through a form of observation and intuition.

TCM deals with concepts that are thousands of years old, and involves assessment of more than physical well being. It strives to find balance within the various systems of the body. I don't understand all of it, but I think it is important to respect that their approach is different than ours, and to acknowledge there may be a lot we can learn. In medicine, it is important to understand why something works. It appears to me in TCM, it is only necessary to believe something works. What I hope we can do more of, is applying scientific methods to understand why Chinese methods work. Blending knowledge from the two should be our goal. We are working on a Memorandum of Understanding to do just that.

I will admit that what I learned about acupuncture-aided surgery went over the top for me. They do major surgery with the patient awake and alert using acupuncture instead of anesthetics. I didn't see an actual surgery, but they had clips of video.

The difference between TCM and Western medicine typifies the challenge of working cooperatively with the Chinese; two different philosophies and two different systems. Neither should attempt to change the other, but rather to make our systems interoperable.

I spent about an hour at a TCM museum, which was helpful in understanding the history and philosophies. I found it helpful to see the development throughout a few thousand years. They also had a group of students who talked about the teaching techniques used in training TCM doctors. It is critical to remember this is a method of treatment hundreds of millions of Chinese prefer. They don't trust Western medical techniques.

Secretary Leavitt tours a Traditional Chinese Medicine Museum in Shanghai
Secretary Leavitt tours a Traditional Chinese Medicine Museum in Shanghai

Diplomacy Speech

The most pleasant part of the day for me was a diplomacy speech I did at the medical school with 300 students. My goal in the hour we had together was to make friends with them. I told them about me and my family. Then I told them about my job. After that, I let them just ask questions about anything. It was great fun. They asked me about TCM in the U.S. We talked about the Olympic Games. I told them stories about when my state hosted the games. We discussed health costs in the U.S. I was very candid about my concerns. They asked me for advice on how to succeed in life. I gave them some thoughts about goal setting.

I concluded my talk with the students by talking about why I meet with students like them. It is to plant seeds of relationship between our countries to help each of them know us better and for us to understand them. The students responded well, and we talked for an hour, but it could have gone much longer.

A Personal Curiosity

On the way back to the hotel, we stopped to see an animal display at the convention center. My interest was stimulated because a friend of mine, Ken Bearing, donated all the taxidermy. It is a spectacular display of African animals including an elephant, a 20 foot man-eating gator, a hippo and many others. It is displayed in a spectacular way. They have had over a million visitors since it opened a year ago.

On to Beijing

Tomorrow, it’s a speech to the American business community and then on to Beijing for meetings with various government officials.

Shanghai, China Blog II

No matter the culture, people get themselves messed up on drugs. Yesterday in Shanghai, I visited a methadone clinic in Xi portion of the city. That apparently means "west side." It's the older part of the city. I've visited similar clinics around the world, so the physical layout and process wasn't a surprise. However, I was able to talk with a couple of the patients at some length.

They are now serving about 175 addicts. Each day, they come to the clinic, check in, (often taking a urine test to demonstrate they have kept their commitments), pay the dollar co-payment they make, and then proceed to a counter where they are given a green liquid drink in an 8 ounce plastic cup. They gulp it down, followed by a water chaser. It appears to be a ritual they follow each morning.

A male patient, who I estimate was 30 years old and whose Chinese name I wasn't able to catch, told me methadone has a bitter taste. However, he welcomes it. A jolt of bitterness appears to be a welcome trade for the angst heroin addicts endure dealing with the drug’s slavish pang. Through our interpreter, he explained he is a factory worker and has a family. He seems like so many other factory workers who live out their lives in Shanghai. I wanted to know more about him, and how he had found his way to this point, but a crowd had gathered and the intimacy of our conversation disappeared.

A woman, whose Chinese name sounded like Julie, (I'm sure it was something else--my ear for Chinese is poor), told me how glad she was to have broken the grip of her addiction. She appeared to be in her early 20's and wore stylish tight fitting jeans and giant pink sun glasses. Her teeth were stained in way that seems common here.

Julie told me she had a job now, working at a clothing store. "I don't have to worry about finding money for my habit any more."

"Do you feel better physically," I asked.

"Yes, and my Father says my face looks good again," was her response.

I asked how she felt when her body craved heroin. She described achiness, nausea and her entire body shaking uncontrollably." What an awful plague heroin is.

She was persuaded to seek help at the clinic by a volunteer who knew she had a problem. Addicts know addicts.

Secretary Leavitt signing a message in a book of patient stories at a methodone clinic in Shanghai
Secretary Leavitt signs a message in a book of patient stories at a methodone clinic in Shanghai

Bi-lateral Meeting and the Earthquake in China

My friend, the Minister of Health for China, Chen Zhu, had to cut short the day we had planned to spend together so he could get to the scene of the earthquake in Chaendu. We had a poignant conversation about this moment of crisis.

The Chinese government is not unfamiliar with, or unprepared for, this kind of disaster. In 1976, a similar earthquake killed 242,000. They have mobilized their army and civil society. Minister Chen was anxious to be on his way. It was gracious of him to host the meeting under those circumstances.

We had a significant list of agenda items, which we moved through in about an hour. Most of the items relate to the agreements we have or are negotiating on a range of issues.

Business takes longer in diplomatic meetings of this type because of language interpretation. I have found it is important to break my thoughts into short bits. Good interpreters have the ability to mimic your expressions and voice inflections, thereby providing insight into attitude as well as content. For that reason, both sides normally supply their own interpreters.

Our meeting was held in the Shanghai convention center, a new facility which appeared to have a set up for such diplomatic meetings. The United States is not as good as many other countries at diplomatic hosting. We don't have budgets for it, and I would like to see us improve our approach.

Over the years, I have come to know the interpreters and staff for the various ministries. Having been with people from the health ministry many times now, there is a good sense of warmth and familiarity.

I also visited a large hospital and attended a museum to learn more about Traditional Chinese Medicine, but I will write more about that in my next post.

Shanghai, China: Product and Food Safety

Written May 12, 2008

Well, this blog entry will break new ground for me. I'm writing it with my Blackberry while striding up and down on a stair stepper in a health club overlooking Shanghai, China. Before you jump to any conclusions about my accuracy with thumbs, be aware I'm going to send this draft to my colleague in Washington and have her clean up my double letters and typos. With the day’s schedule it is likely the best, perhaps only, opportunity I will have.

Yesterday, I gave a speech to about 800 representatives of manufacturing companies from around the world who supply a major retailer in the United States, the Target Corporation. It was a significant chance to once again send the message that if producers desire access to American consumers; they will have to meet American standards.

I spent the afternoon with a local office of the General Administration for Quality Supervision, Inspection, and Quarantine (AQSIQ), a rough equivalent of a Chinese Customs and Border Protection. This is the entity in the Chinese government with specific responsibility for the safety and quality of imported and exported food. The people I met with had spent a significant amount of time in the United States, and understood our processes reasonably well. A half day is long enough to learn some essential facts, but not enough to draw conclusions. Most seaports have a similar feel around the world. Actually, most of the large unloading cranes are made in Shanghai.

HHS Secretary Mike Leavitt joined by Chinese inspectors looks at chicken shipped from the U S  to the Port of Shanghai China's largest port
HHS Secretary Mike Leavitt joined by Chinese inspectors looks at chicken shipped from the U S to the Port of Shanghai China's largest port

Not surprisingly, the Chinese see our concerns about the safety of food imports differently than we do. They repeatedly mentioned they require certificates before goods are shipped out of China, and point out we don't. They also want us to accept AQSIQ certificates as proof of the safety for Chinese food exports to the United States. I won't take that on in a blog, but it does indicate why it is important to understand the perspective of others. One learns a lot being able to talk with people on the ground.

I'm not going to get into a travel log, but there are a couple of observations worth making. This is an amazing city: incredibly vibrant and modern.

The Chinese are serious city-builders. They do infrastructure faster than anybody in the world, I think. They can just throw so many people at projects, and exercise such absolute social control, that they can move in a way that gives them a significant comparative advantage. In making that statement, I do not discount the negative environmental compromises, or the impact on human beings, but they have a clear set of priorities, and when they decide to move, things happen.

For example, they are building 150 miles of subway within the city in the next two years. Compare that to Boston’s Big Dig.

They decided to build a deep-water port about 18 miles off the shore of Shanghai on some islands. In order to get the goods from the port to the mainland, they needed a causeway. It will take them three years to build the causeway. It would take more than three years in the United States just to scope the work.

I was at the port when the earthquake struck. It was felt in the upper floors of our hotel, but not at the port. I visited the area of the earthquake last December. I am checking in at the White House to see if there are ways I can be helpful on behalf of the United States, and when I meet with the Minister of Health later today [Wednesday, May 13], I will express my condolences from all Americans for the loss of life here.

The disasters here and in Burma are frightening examples of how vulnerable we are as human beings.

Today, I'll visit a hospital and school of traditional medicine, and meet with a large group of students. Tomorrow, I'll meet with American businesses in Shanghai to discuss product safety, before I leave for Beijing.

Viet Nam – Blog III

Following on yesterday’s blog, here are some additional observations about my recent trip to Viet Nam.

Observation two: While they maintain a communist structure of government, Viet Nam is obviously devoted to being part of the global market economy. As people vote with their dollars, markets are highly democratic. It seems clear they have found a way to reconcile the ideology. They have attained status in the World Trade Organization and seem highly motivated to come into conformance on global economic standards.

When I visited with a group of shrimp farmers, we discussed market conditions, world prices and the demands of entrepreneurship. Clearly, the government plays a different role in their business than it does in a democracy. These were small businessmen, looking to find niches in a market where they could optimize their opportunity.

Dinner with Shrimp Farmers
Dinner with Shrimp Farmers

Observation Three: The Vietnamese government seems to understand the importance of protecting the made in Viet Nam brand. They are proud of the fact that it is beginning to show up more places. We discussed openly how quickly a brand that is not known well can be damaged by adverse quality events. We agreed during our talks to develop a working group to develop MOUs, similar to what we have done with China, which will allow our regulatory agencies to work interoperability, even though we have different systems of government.

Viet Nam is drafting new framework laws for food and drug safety so this is an opportune time to work with them. We agreed to move on aggressive time frames.

Observation Four: The business environment has a frontier quality to it. There appears to be opportunity everywhere, but you would have to have a high tolerance for the type of bureaucratic and political uniqueness that accompanies a country in transition. I had lunch with members of the American Chamber of Commerce. I sat next to Tony Foster, a Chicago based businessman who is building several businesses in Viet Nam. He is actually married to a Vietnamese physician who now lives in Chicago.

One of his businesses is a company providing international telephone services, and from his short description, he appears to have taken advantage of a need Viet Nam had for telephone capacity. As part of his willingness to invest in telephone infrastructure, his company was granted status that, for a time, gave him a comparative advantage in the market.

At the Port of Saigon, the Port executive told me they had contracted with a Seattle company to build a new Port. I know little about it, but presumably the company will invest money and bring expertise, earning a return from Port fees and securing an early position in a growing enterprise. I observed a similar arrangement in southern India.

As we boarded the plane to Ho Chi Min City, our Ambassador, Michael Michalak, introduced me to a private equity fund manager specializing in Viet Nam investments who was also boarding. There are obviously unique challenges investing right now, but with a populations growing rapidly in number and prosperity, Viet Nam is an intriguing marketplace.

Viet Nam still has state control of most of the key industry groups, and they have been slow to give up control. State owned enterprises make up 37% of their GDP. The government owns and controls industries like banking, energy, air travel, and health care.

Observation Five: Reduction of poverty is a primary social goal of the government and they seem to be succeeding to some extent. In 1993 58 percent of the nation’s population was in poverty. Today it is only 15 percent.

They will have to do substantially better in basic areas like education, health care system, etc. However, they seem to know where the problems are.

The Vietnamese government has a goal to be a country with middle income. They also aspire to be considered an industrialized country by 2020. It feels like, to me, that the Vietnamese and Chinese have similar approaches to planning. They also have the ability to compel things done that democracies require more time to finesse.

Observation six: Personal freedom is still mixed. Freedom of religion has dramatically improved the past few years and the churches are full.

However, freedom of speech is not as good. The embassy told me there are many situations in recent years where people have been imprisoned for speaking out against the government.

Viet Nam - Blog II

This is a continuation of my discussion on Viet Nam. I just returned from a trip there. Today, I’m going to list the first of several observations about Viet Nam coming from my trip.

Observation One: The Vietnamese government and people have put war behind them, and we need to as well.

I was a teenager during the war in Viet Nam. To eliminate the uncertainty of the draft, I joined the National Guard and went through basic training and advanced artillery training side by side those regular Army soldiers, most of who anticipated the skills we were learning would be used in Viet Nam. Many people I knew fought there. I lived through the political, social and cultural turmoil that accompanied the war during the late 1960s and early 1970s. The war in Viet Nam was a big part of all our lives.

The first time I flew into Viet Nam, I had a hard time not linking everything I looked at to my war time perceptions of what the country was like. I did not feel animosity, but my curiosity of what things were like then was not easy to suppress. My perceptions came from news reports and pictures of places and situations 40 years ago, but they are stored in that part of the brain teenagers put things that shape them.

In October of 2005 when I was there, I asked several Vietnamese people about how they felt toward Americans. After several questions, one of them said to me: “We have put the war behind us.”

I saw evidence that there are still remnants of the war in Vietnamese society, but they seem to be biases which faintly endure between North and South Viet Nam. However, those seem to have been worn down over time as well. In fact, everything I have experienced in Viet Nam leads me to conclude Americans are well liked generally. And, speaking as one American, I really like Vietnamese people.

I had two experiences on this trip worth relating along these lines. The first happened before we left. I had a conversation with Ashleigh, a young woman HHS colleague of mine, assigned to do advance work on the Hanoi portion of our trip. She related the reaction of joy her Father had to learn of her assignment. He had fought in Viet Nam. She said, he told her how it thrilled him that things had changed in a generation so his daughter was able to return in peace to a place he had fought in war.

Secretary Leavitt and Ashleigh
Secretary Leavitt and Ashleigh

The second experience took place at a remarkable dinner we had in Hanoi put on by my new friend and colleague, the Minister of Health from Viet Nam. His name is Nguyen Quoc Trieu. Minister Trieu was a soldier, fighting for the North. He was wounded during intense fighting. Also at the dinner was a doctor who works with our U.S. Centers for Disease Control and Prevention and is assigned in Viet Nam. Over dinner they concluded they had fought during the same period in roughly the same region. They toasted, hugged and celebrated their friendship of our nations.

Viet Nam - Blog I

An Overview

The final three days of my trip to Southeast Asia were spent in Viet Nam. This was a follow up trip to my October 2005 visit. I focused on three issue areas: HIV/AIDS, Avian Influenza and the safety of imports. Meeting the new health minister was a priority as well.

As a general overview, I arrived in Hanoi on Tuesday night, the 15th of April. I spent Wednesday the 16th of April there working. On Thursday, I flew to Ho Chi Min City, where I spent the day working, and then on Friday, I was able to go out into the countryside, which always turns out to be a highlight.

In Hanoi, I visited the Ministries of Health and Agriculture; spoke to the American Chamber of Commerce; spent an hour interacting with students and faculty at the Hanoi School of Public health; and then met with Prime Minister Nguyen Tan Dung. In the evening, my new friend, Nguyen Quoc Trieu, the Minister of Health, held a banquet that none of our delegation will ever forget. This was not your routine diplomatic gathering. It was a party, full of personalities, music and bonding.

On Thursday I did media interviews, traveled to Ho Chi Min City, and toured the seaport in the same way I have many American ports; working to understand their role in the safety of imported products. I then visited a clinic our HIV/AIDS money supports, which is setting up the nation’s first methadone clinic as a way of assisting in the prevention of HIV/AIDS, and then met with the party leaders of the city.

Friday morning early, we drove into the countryside about three hours. Seafood is one of the biggest trade items between the U.S. and Viet Nam. I wanted to get a sense of the processes and sophistication levels in that industry, in a similar way as I was able to in India. The three hour drive by itself was worth the effort of going. I saw many different kinds of communities along our route in varying degrees of change.

I visited a large seafood processor and had a two hour discussion over lunch with a group of shrimp growers, a regulator and fellow who appears to have a job similar to an extension agent. I then went to meet with a group of chicken growers in a rural residential area along with public health people. We talked avian influenza.

Mike Leavitt at fish farm in Viet Nam

At fish farm in Viet Nam

In the evening, we had a reception at our hotel and picked up the midnight flight for a connection in Tokyo for D.C. These trips are non-stop events. By the time I get to the end of the week, I’m usually feeling exhausted, but greatly enriched. This was a successful mission, but I’m ready to get back into a normal routine. With the time zone changes, different beds most nights, and fifteen hour days, the last seven days feels like one continuous day.

I was able to keep better control of my diet and exercise routines this trip. Both usually take a hit on these forced marches. I think I got exercise all but two mornings and with only one major banquet, didn’t do any serious caloric damage. It’s a small victory in my long fight to stay healthy.

Having provided this overview of the trip, over the next few days I’ll post a series of observations I have as a result of the trip.

Singapore: More Observations

I mentioned yesterday my short visit to Singapore. I thought I’d add some additional observations.

Singapore spends only 4% of its gross domestic product on health care(Singaporean Health Minister’s estimate). Just a reminder, in the United States we spend 16% of ours — nearly four times as much. What are we getting for that? The life expectancy of a male in Singapore is 79.29 and 84.68 years for a female. Again, just a reminder, in the United States the life expectancy of a male is 75.29 years; a female can expect to live to 81.13 years.1 Hmmm.

What are the differences? I obviously haven’t had enough time to explore that question fully, but I’m going to now. There are a couple of obvious ones. In their system, everybody pays part of the cost. If you are poor, the percentage is very low, and if you simply can’t pay, the debt is written off, but there is a personal responsibility and it undoubtedly causes patients to engage.

Our system has an ailment I refer to as the “Chronic More Disorder.” Most patients in our country have very little reason to care what the cost is. Doctors have an adverse incentive to do more procedures, make more money. In a market, there have to be countervailing incentives to keep things in check. It doesn’t happen in our country. (An old theme for me, right?)

So, what about the quality you say? Aside from the statistics on life expectancy already cited, let me suggest we think about this. The Government of Singapore estimates that, in 2008, over 600,000 people, including many Americans, will engage in medical tourism. They will fly to Singapore to get their care at a fraction of the price. The Singaporean Government believes by 2012 the number will exceed a 1,000,000 people a year. In order to attract these people, they are transparent with both cost and quality outcomes. Patients have more information about care in Singapore than about care they would get from their local hospital. Hmmmm.

Here’s another thing I learned. When the government was formed in the 1950s, the British had set up a system of Central Provident Fund (CPF) which requires the Sing people to set aside 35% of their earnings. They allow the savings to be tax free. Does that sound like Social Security? Well, there is an important difference. Each citizen’s account is segregated. They cannot use it until it is time for retirement, but they do have influence on how it is invested. It is not like our Social Security System where each generation of workers pays for the retirement of their parents.

If you were simply looking at these two different systems as an investment opportunity and doing steely-eyed analysis on the likelihood of their prosperity in the future, which would you invest in?

  • Investment 1: Spending 4% of their total receipts on health care with no future liability.
  • Investment 2: Spending 16% of their receipts on healthcare with a $24 trillion legal and moral liability in the future.
  • We should also toss in that number 2 above will have half as many workers per retiree in 20 years and that both get similar big picture results.

The global market is now weighing this question. I will have much more to say about this soon.

1 Singapore statistics: The CIA factbook accessed on 4/21/2008 at https://www.cia.gov/library/publications/the-world-factbook/geos/sn.html 

US statistics: The CIA factbook accessed on 4/21/2008 at https://www.cia.gov/library/publications/the-world-factbook/geos/us.html

Some Lessons in Singapore

I stopped in Singapore while transitioning between Indonesia and Viet Nam. There were a couple of HHS investments I needed to see.

First of all, Singapore took me by surprise. It is beautiful. You would think you were in southern California—climate, quality of infrastructure, construction, etc. It is well run and on a roll of success. I’ve heard this for years, but seeing was believing, for me.

A conversation I had with the Health Minister Khaw Boon Wan had several interesting aspects to it. In some ways Minister Khaw is typical of the policies that have made Singapore a success. He grew up in Malaysia but accepted a grant from the Singaporean Government to study in Australia. The grant had what he described as an 8 year bond. It was an obligation to work in Singapore for that period after they paid for his education. Singapore became his home.

Health Minister Khaw Boon Wan of Singapore

Health Minister Khaw Boon Wan of Singapore

Because the country is so small and has few natural resources, they have mined talent internationally. The Minister is an example of their investments paying off.

I want to mention three topics we discussed that I will be thinking more about. The first is the importance of a population continuing to grow.

The Singaporean Government identified many years ago that their population growth rates were beginning to fall. Intuitively they understand that if a nation’s population growth falls below replacement, it will, under normal circumstances, create serious problems in the future. They have been working to increase their birth rate now for nearly 20 years, with little success.

I asked the Minister what Singapore had learned from the millions they have spent researching and trying different policies. He said they had done mountains of demographic research and tried many different incentives including direct tax subsidies amounting to as much as $20,000 for couples producing a child. They have produced disappointing results. Direct financial subsidies he said are, “like pushing a string.”

Interestingly enough, many other nations provide the subsidies but the results seem to have far more to do with other factors. Australia pays $2,500 (his estimate) and has seen a resurgence in birth rate. He thinks there is simply a different attitude among nations with lots of space. He pointed to super cities like Hong Kong and Tokyo and that they have low birth rates.

The Singaporeans have concluded a series of sociologic changes have clearly contributed to their dilemma. Woman desiring careers, couples deferring the age of marriage, and a de-emphasis on marriage were other points he raised. Our conversation came on a day I had just received a brief on a CDC report indicating that in 2006, 38.5% of all births in the United States were to unmarried mothers. The Minister’s main point was that married couples have more children and foster them more successfully than unmarried parents.

Singapore is pursuing policies that work to develop three things: supportive employers, supporting families, and Government policies that are family-friendly. I took that to mean encouraging marriage. They are also working to increase the percentage of births from successful in vitro fertilization. They have found some European countries, such as Denmark, have as many as 6-7% of births from this method. Singapore has only 1% of their births from successful in vitro fertilization. Even science can play a role, he pointed out.

When I was Governor, I started a Marriage Commission to encourage the practice of marriage and to strengthen existing marriages. It was the first in the country and it was criticized by some. Others have since followed and it has become more common for governments to recognize what a hugely important issue this is.

I have spent time looking at the long-term problems faced by cultures that have limited family size. Japan is deeply worried about its population trend. China has also begun to deal with the impact of their “one child” policy.

In the United States, our population figures are just slightly over replacement. Frankly, if it weren’t for the increase of immigrants, we would be in the same spot as many European countries, facing negative growth.

If you think that sounds like a positive thing, I would recommend two things. First read Will and Arial Durant’s book, The Lessons of History. After studying every major civilization in a 5000 year period they concluded societies that fail to grow, fail to survive. The second thing I would recommend is looking at the Medicare program to which our nation is obligated. Today there are four workers to pay the health care benefits of each senior. In 20 years, because of lower birth rates, there will be two workers for every person on Medicare. Add social security to that mix and a declining birthrate becomes a rather serious problem.

Demographics are destiny.

Indonesia II

Written April 15, 2008

Following the meetings I wrote about yesterday, I met with President Susilo Bambang Yudhoyono (or "SBY," as everyone calls him) at his office in Jakarta. We met previously in October of 2005, on my last trip to Jakarta.

President Yudhoyono is a former soldier. He did a significant part of his training in the United States, including an MBA from Webster University, in Missouri. He is tall, with a strong military bearing. Generally speaking, he struck me as a gracious man, with a good grasp of the complicated problems of governing a nation like Indonesia, and a good understanding of regional and global problems.

Coordinating Minister Bakrie and I opened the meeting by recapping the nature of our meetings earlier in the day. The Foreign Minister, Health Minister and the President's Foreign-Policy Advisor were also there.

The President stated clearly Indonesia wants to be a cooperative part of the world health community, and stressed a desire to get both the NAMRU issue and virus-sharing problems behind us. Minister Bakrie reported his two-month timeframe. I re-stated our strong, philosophic objection to linking virus-sharing with compensation.

What I wanted to write about today, however, is an interesting conversation we had about the challenge of governing a developing nation. This was a continuation of a set of themes that interested me from my conversation with the Indonesian Foreign Minister earlier in the day.

The President reminded me that Indonesia has only been a democracy for 10 years. He made the point that for democracy to succeed, it must prove to people it can deliver them a better life. In essence, he said, it’s likely the vote of a person who lives on a remote island in Indonesia who earns $1.60 a day will decide if democracy is working, less by ideology and more by the cost of what fills his rice bowl.

I spent time earlier in the day discussing the economics of rice with Indonesian Minister of Agriculture, Anton Apriyantono. Rice is the most significant dietary staple for Indonesians. At times, the Indonesian Government goes into the world market to supplement its domestically grown supply. For a variety of reasons, the price of food, specifically rice, has increased sharply over the past year. Ambassador Hume had told me earlier in the day that a ten-percent increase in the price of rice in Indonesia pushes two million people into poverty. So, the price of food has serious political and sociological ramifications.

Energy also fits into the category of priorities for President SBY for the same reasons as food. The Indonesian Government heavily subsidizes fuel. It occurred to me, as bio-fuels become more prominent, and more grain goes for that purpose, it could bring two of the most important needs of the world's poor into conflict with each other.

The President indicated health was obviously another priority, but confessed he was not able to budget what he aspires to provide. He remembered our discussion in 2005 about the dangers of the H5N1 strain of avian influenza, and made an interesting observation: Places like Indonesia have many unique health challenges, so a problem like influenza has trouble penetrating the public agenda. Coordinating Minister Bakrie told me tuberculosis kills 400 people a day in Indonesia. Put next to that statistic, the 107 people who have died in that country from infection with the H5N1 flu virus is such a small number that it is hard to get the Indonesian public or government too worked up.

Of course, it is the potential that the H5N1 strain of influenza could spark a worldwide human pandemic that demands a response. However, countries with limited resources are often more concerned with the snake biting at their ankle than to worry about the one hiding in the bush.

I remember the Health Minister of Cambodia telling me in 2005 that 12,000 people a year there die from rabies. Consequently, it is hard to get farmers worried about a few sick chickens. It put a lot of things in perspective for me.

Indonesia

Written April 14, 2008

I’m in the Jakarta Airport, having just finished a day of meetings with Indonesian Government officials. I met with President Susilo Bambang Yudhoyono, Coordinating Minister for Family Welfare Aburizal Bakrie, Foreign Minister Noer Hassan Wirajuda, Agriculture Minister Anton Apriyantono, and Health Minister Siti Fadilah Supari. The meetings involved discussions on a group of issues, among them the control of H5N1 avian influenza, the U.S. Naval Advanced Research Laboratory (NAMRU-2) in Jakarta, and Indonesia’s departure from international expectations on sharing samples of influenza viruses.

I was here in October 2005 as we were scaling up our own pandemic preparedness in the United States. Being here is an important reminder of how different the problem looks from different perspectives. Indonesia has 245 million people, who live in a space about the size of New York State. About 60 percent of the country's area is water, since the nation is really thousands of islands. It appears to me that most of those people must have highly localized lives, and developing a national strategy on anything would be difficult.

The next presidential election in Indonesia will take place in 2009. Just like in the United States, the upcoming election has begun to affect the formulation of policy. The night before I arrived, local elections took place in the largest Province, West Java, and, in what appears to have been a surprise, an Islamist party took power. It would be similar to having a populist movement win a statewide election in California. The election in West Java is an event that will clearly begin to factor into everyone’s political calculus in Indonesia.

I didn’t have any political discussions about this with Indonesian officials. These are observations I am picking up from reading the local papers, and from talking with people at the U.S. Embassy. I’ve always found it important to understand the political context in which foreign government officials are operating- it helps you understand the filter through which they are seeing the world.

My first meeting was with Foreign Minister Noer Hasson Wirajuda. He is a sophisticated and well-educated man who spent five years doing legal studies in the United States. We talked at length about a group of themes related to the challenges of governing an undeveloped country. Later in the afternoon, our discussion continued. I think rather than discuss those in this entry, I will do a separate piece tomorrow.

Next, I visited the office of the Coordinating Minister for People’s Welfare, Aburizal Bakrie. A Coordinating Minister oversees several Ministries or areas of the Indonesian Government, and has the responsibility to coordinate their work. The meeting included the Ministers of Agriculture and Health.

Minister Bakrie is a noted businessperson. His family holdings are extensive, and their reputation looms large within the region. He speaks excellent English, and deals confidently with people. His business background is evident in his willingness to engage directly on problems.

Minister of Agriculture Apriyontono was invited because of the animal-health connection in avian Influenza. I met him in 2005 as well. Likewise, I have met multiple times with Health Minister Supari. She has become a controversial figure within the health world, because she has stopped sharing with the World Health Organization (WHO) any samples of influenza viruses that are circulating in Indonesia. She asserts that if a nation provides a virus from which a manufacturer makes a vaccine, that country is entitled to monetary compensation of some form. This is a dangerous course that threatens to undermine a worldwide agreement honored by nations for nearly 60 years. I wrote previously about this subject.

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

NAMRU-2 is an important public-health asset in Indonesia. The lab is a WHO reference lab, which means the level of expertise there is high enough that the world accepts its work. If a communicable disease breaks out in South East Asia, any country can send samples of the virus there to have them identified. The laboratory has been in Indonesia for decades, and exists under a Memorandum of Understanding (MOU) between our Governments, which is up for renewal.

The MOU that governs the status of NAMRU-2 expired two years ago, and both sides have been trying to renew it. When I was in Indonesia in 2005, the lab was a major topic of conversation in my discussions with various Ministers, and with the President. At that time, I received absolute assurances the Indonesian Government would approve the MOU shortly.

Minister Supari recently issued orders to prohibit Indonesian institutions from providing tissue samples to NAMRU-2, under the justification that such sharing is not legal in the absence of an active MOU and a Material-Transfer Agreement. Her action is obviously linked to her global initiative to seek specific benefits for sharing samples.

To add more drama to this picture, Minister Supari, recently published a book in which she asserts the U.S. military is using influenza samples to create biological weapons. Secretary of Defense Gates was asked about the Minister's accusation when he was in Indonesia this past February; he replied, “That’s the nuttiest thing I’ve ever heard.”

All this background created great media interest in my visit. The morning of my discussion with Minister Supari, an article appeared in the English-language Jakarta Post that said I might refuse to meet with her. The truth is, I came all the way to Jakarta quite specifically to see her. Anyway, all this added up to a minor drama.

We met privately in Coordinating Minister Bakrie’s office for a while, and then joined the rest of our delegation and Indonesian Government staff who had gathered. The conversation was refreshingly straight-forward, an outcome I attribute to the style of the Coordinating Minister. While we talked about a number of other issues, such as HIV/AIDS, most of our time focused on the NAMRU-2 and sample-sharing. After a time, the Agriculture and Coordinating Ministers left, but Health Minister Supari and I continued our conversation.

It is important to remember that, while the NAMRU-2 issue is between the United States and Indonesia, the influenza-sample issue is between Indonesia and the other 192 Member States of the World Health Organization. The United States has been part of a group that has been trying to resolve the problem for the past two years. They have held numerous meetings, and various other types of negotiations. These have yielded a short list of things the parties believe the WHO Secretariat could do to improve its influenza program. The Minister mentioned this several times as "progress."

However, I could see little real progress in the key question whether contributing countries should receive direct, monetary benefits as compensation for sharing samples. The Minister’s main point is that what she wants should not be considered "royalties" or "compensation." What she says she wants is for the contributing countries to be eligible for some share of the value commercial companies create out of the influenza samples they provide. Or, as she expressed it in a hand-delivered letter to me later in the afternoon, “Allow me to reiterate that when I raised the term ‘monetary benefits,' I was not referring to any type of royalty, nor any type of quid-pro-quo arrangement, but rather to a method that leads to the allocation of values derived by commercial interests into one commonly defined system, which will provide benefits to those that have made contributions.”

I told the Health Minister two things. First, I understand her desire to assure people in her country have access to medicines and vaccines. This is a problem in developing countries all over the world. It is a complicated issue, but we need to address it, while preserving the incentives for innovation. I pointed out that technology is improving and might well hold solutions we don’t currently have. I used as an example the billon-dollar investment our nation has made in cell-based vaccine technology. Once we are using cell-based methods of making vaccines, the capacity and cost of making vaccines will dramatically drop, which will change the entire equation. The world is working on solutions.

However, linking sample-sharing to payment in any form will immediately begin to erode our ability to make vaccines at all, because once the practice of free and open sharing of viruses stops, the slope is slippery, and there will be no end to the demands.

The issues of the availability of vaccines and the sharing of samples are both legitimate ones, and we must deal with them both, but we should not link. World health should not be the subject of barter.

The second thing I told her is that I find it impossible to distinguish a difference between what she is seeking and royalties. The bottom line in both is this: share samples, get paid.

I would summarize the conclusion of my meetings this way: We celebrated the small list of consensus recommendations that are emerging from the multi-lateral discussion at the WHO on this matter, and committed to keep looking for solutions. The Coordinating Minister suggested we could find a solution within two months. He later reported that to his President in our meeting with him.

I have instructed my representative on this matter, Bill Steiger, to work with Ambassador John Lange, Secretary Rice's Special Representative for Avian and Pandemic Influenza, to continue our discussions with the Indonesians and others for the next two months. However, we cannot be party to an arrangement that will un-do 60 years of one of the world’s great public-health successes.

There are some situations that, despite our best efforts, we cannot resolve. In those cases, we just live with the added risk. The cost of Indonesia's refusal to share influenza samples is incrementally small. However, the damage done by accepting Indonesia’s view is profound, and simply unacceptable.

We will work on this for the next 60 days. If we haven’t been successful in resolving the matter, I think it will be time for the world to just accept Indonesia’s unwillingness to participate in the WHO influenza system, and move on to other ways of making the world safer. Perhaps when circumstances change, Indonesia will rejoin the mainstream on this issue.

Thoughts On Your Comments

I’m sitting at my desk with a  bowl of soup for lunch.  I have 30  minutes and I’m thinking this might be a good time to respond to a few comments  you have sent. 

First, let me say, I do read the  comments. I just have a hard time finding the time to respond and make new  postings too.  So, I tend to concentrate  on new postings.

Comment on Guatemala  Inauguration
On January 18,  Science Teacher wrote:
Can you tell us whether the topic of H5N1 came up  with any of the representatives of Latin American countries? Is there concern?

Response:
I was  in Central America about a year ago working on  Pandemic issues with the health Ministers.   We have helped them build lab capacity and actually trained more than  200 people from Central America on pandemic  related issues.  It is not a top of mind  issue there, and they still have a ways to go on public health infrastructure.  Gratefully, we haven’t seen any H5N1 positive birds in that part of the world.

Comment on Guatemala  Inauguration
On  January 22, David A. Haley wrote:
Instead of talking about "safe" topics such as India or Guatemala, why don't you address  meaningful topics to the American people, such as what efforts you and the  Administration are undertaking to fix our healthcare system? Hello. Is anyone  home in Washington?

Response:
David, you are right in saying my writings have been fairly  heavily oriented to international work lately. I think if you look back in past  postings I have written about many different topics that fit the criteria you  lay out.  The concentration of recent  writings on international work reflects the fact that I traveled fairly heavily  while Congress was out of session.   International work is an important part of my work and it has a direct  reflection on the health of the Americas.  The safety  of imports is an example. Most of my time in India was focused on products  Americans consume. 

I should also confess that I use this blog as a way to keep track  of what I learn on these trips as a journal of sorts. 

I encourage you to keep reading as there will be lots of meaty  issues to discuss.

Comment on Day 5 in India
On January 17m Robins Tomar wrote:
It would be great if you could write one more post about your  overall experience, changes in feelings before and after your visit and some  recommendations from your experience.

This is just a request if you get time from your busy schedule.  Anyway I will be following your blog to know your opinions about what is  happening around us.

Response:
I would say one of the most of the most important changes in my  feelings were the kind of things that come when one actually sees a place  rather than reflecting what you have heard or read.

Here are just a couple of examples:

  • It is hard to adequately explain the challenges of population as large as India’s and how it impacts every public policy issue.         
  • I’m attracted to the people of India.  I have lots of friends in the U.S. of Indian heritage and seeing India created a new context for our relationship.
    In Utah there  is a community of people with roots in India.  They have become prominent in academic and  financial circles.  As governor, I was  often invited to attend their celebrations and events.  I always admired the way they worked to  preserve their connection to an ancestral home even though many of them have  become major successes in the U.S.  Now that I have seen that home, it is easier for me to understand their view of America and India.   
  • I found particularly helpful the understanding I gained of the small farmers in India and their political influence.  I wrote some about this in one of my postings.
  • The number and size of the drug and vaccine manufacturing facilities in India requiring FDA attention was an important actualization.
  • The intellectual connection between the U.S. and India came as a pleasant surprise.  I knew it       existed but didn’t have a sense of scale.

I could go on and on, but this will give you a small sense of what the trip did for me.


Comment on Electronic Medical  Records and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
The US  government/we the people already own an excellent EHR - the VA's VistA system. It is fast, simple to use, incredibly  stable and a large portion of the work needed to make it viable in private  practice is already done. Two organizations have taken it,  "de-veteranized" it and gotten it CCHIT certified. With a small  fraction of that cost, the system could be fully upgraded and modified to meet  all of the needs of the commercial market-place and fully implement the quality  measures and disease registries necessary to adopt pay for performance and  improve the quality and lower the cost of healthcare

Response:
I am a big admirer of VISTA and  the Veterans Administration.  In fact, I  borrowed the National Coordinator of HIT from the VA, Dr. Rob Kolodner.  The problem comes in creating compatibility  between other systems and the VA because most patients, even in the VA system, deal  with multiple providers outside their system.   We need to achieve interoperability.   As you point out, there are some providers who are using the VA system  as a foundation to develop smaller systems and we welcome that.  This answer is short but in the press of  time, I’ll leave it at that.

Comment on Electronic Medical  Records and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
It is very easy for the Sec of HHS to say that Electronic records  are the answer to rising Medicare costs. It is very short-sighted to ignore the  reality that the numbers of the Medicare-eligible are increasing every month.  Besides, with increased litigiousness of society, has the HHS conducted an  objective study of what percentage of procedures physicians carry out are just  to protect themselves against frivolous law suits?

Response:
There are a number of studies that document the practice of defensive  medicine.  I would support reforms that would  minimize the practice or perceived need.   Many believe that the development of best practice quality measures will  provide some protection.

Comment on Electronic Medical Records  and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
While agreeing that the current formula is an utter failure, I  would like to point out that Physicians are now working at 2005 reimbursement  levels (far from keeping pace with inflation). The moral of this horror story  is that if professionals are paid their legitimate dues, they will not abuse  the system. It is useful to remember that neither the gas nor electricity  prices; employee salaries nor office rent; neither liability premiums nor cost  of EMRs have stayed at 2005 levels - unlike Medicare payments under this  convoluted SGR formula. I have yet to see any effort by Medicare or any other payee  to actually interact with practices that have had extensive experience with EMRs  to identify real world solutions to real world problems. Until that happens, it  will be unreasonable for Mr. Leavitt to expect physician practices to  voluntarily adopt Electronic records. So if HHS would like to push this idea,  let there be a level playing field and objectivity in assessment of its impact.

Response:
I stand by my belief that the system doesn’t work well.  You would be amazed at the amount of work  Medicare does to estimate what things cost for doctors and therefore what the  reimbursements should be.  The truth is, command  and control regulator systems rarely get it right.  A well informed marketplace where consumers  have information on quality and price will both make the relationship between  doctor cost and charges far fairer.

In a previous entry, I talked about walking through a grocery  warehouse with 50,000 items and asked the manager what would happen if the  government started setting prices on every item.  His answer was right, in my view: “fewer  products, higher cost, and continual arguments.”  I told him, he had just described Medicare  reimbursement.


Well, the soup is gone and my time is up so I’ll conclude and post.

 

Guatemala Inauguration (Written January 15, 2008)

The inauguration  of a new president is a major historical milestone for any nation. Inaugurations  have attributes that resemble a wedding. 

The steps  leading up to the inaugural are similar.   There has been a courting period and proposal from competing suitors, a  decision, and then an engagement period or transition as we call it in  government. Finally, the ceremony where oaths are said finalizing long-contemplated  promises with legal authority used to seal them.

The ceremony and  ritual of a wedding or inauguration underscores the importance and seriousness  of the commitments being made.  Friends  gather to show support and respect for what is occurring. There are social dynamics  to both.  Who participates, who gets invited,  and where they sit is closely watched. Care is taken to assure that the second  spouse of a divorced parent is seated in a place that avoids tension. There are  parties held in celebration.

Monday, January  14, Alavaro Colom was inaugurated as the President of Guatemala.  President Bush assigned me to lead a  delegation to attend the festivities as a demonstration of the value our nation  places on our friendship with Guatemala.  The other members of our delegation included:

James M. Derham
  Ambassador to Guatemala

Rob Mosbacher
  President of the  Overseas Private Investment Corporation

Sara Martinez  Tucker
  Under Secretary  of the Department of Education

Christopher A.  Padilla
  Under Secretary  of the Department of Commerce

In Latin America, inaugurations are major convenings for heads  of state.  Presidents of more than a  dozen nations, mostly from the region attended.   That makes the day of the inauguration an opportunity for a lot of  business to be conducted in an efficient way. 

After my arrival  the night before, I carried the greeting of our President to outgoing President  Berger. We met at La Casa Presidential, the equivalent of our White House. 

This is the  second occasion I have represented the United States at an  inauguration.  A year ago I lead a  delegation to Nicaragua  when Daniel Ortega took office.  I have  found these meetings with outgoing Presidents fascinating.  It is a period of great reflection for them.  President Berger and his Vice President and  Foreign Minister were there.  We spoke of  lessons he has learned, things he is proud of.

Prominent on  President Berger’s list of important accomplishments is a democracy able to  transition in a fair and democratic fashion.   Twenty years ago Guatemala  was in crisis. He is right — it is a significant accomplishment.   

Early Tuesday  morning, our delegation met for an hour and 15 minutes with President-elect  Colom, Vice President-elect Rafael Espanda, and the new Ministers of Health and  Foreign Affairs, and Economy.  We got  better acquainted and spoke in specific terms about a number of common  interests. 

The significance  was not lost that the President would spend that much time with representatives  of the United States  on such a significant day. 

The new Vice  President of Guatemala is Refael Espada.   He has been a surgeon in Houston for the  last 30 years but each month he has returned to Guatemala to do surgery.  A year ago, he moved back to participate in  the election. He is not a politically experienced man, but has an enormous  amount to offer his country. 

The balance of  the morning was spent meeting with other heads of state.  I had 30-minute meetings with the Presidents  of Panama, El Salvador, Honduras,  and Nicaragua.  The meetings were each a little different mix  of issues.  I have spent a lot of time in  Central America the past couple of years and  have developed good working relationships with each of them. 

Late in the  morning I had a good meeting with the Mexican Minister of Health. We have an  ongoing series of issues we work together on:  border issues, product safety, disease  surveillance, etc.  We reviewed our  shared portfolio, setting some follow-up meetings for February and March, 2008.

Lunch was at the  Ambassador’s residence where we met with the other Ministers of the new  Guatemalan government.  We then traveled  to the swearing in ceremony at Centro Cultural Miguel Angel Asturias, a large  hall in Guatemala City. 

The heads of  state were seated on the front row.   Because the U.S.  delegation was headed by a non-head of state, my place was right behind the  various Presidents.  It was a great spot  to watch the interaction between various people.  Care had been taken to seat Hugo Chavez a  fair distance from a couple of people with whom he had well-published dust ups.  He was next to Daniel Ortega.

The President of  Taiwan was there with a delegation of nearly 100 people.  They flew in on over a hundred people in a  747 owned by China Airlines.  Guatemala is one of a small group of countries  which recognize Taiwan  as a nation. 

The ceremony to  transition power was conducted in a rather dignified way, I thought.  In Central America  the primary emblem of power is a colorful sash draped over the right shoulder  of the President.  The outgoing President  removes the sash and gives it ceremoniously to the Speaker of their legislative  body.  The Speaker then announces the  results of the election and calls the incoming President forward to take the  oath.  Once the oath has been sworn, the  sash is draped on the right shoulder of the new President. A similar thing is  done with a pin worn by the Vice President. 

The oath of  office, taken both in Nicaragua  and Guatemala,  were similar and interesting. The oath in the U.S. is an affirmative set of statements  related to supporting, defending and obeying the constitution.  The Latin American countries include a stern  warning that if the leader doesn’t meet the expectations of the people, they  will be held accountable by history and the people.

The President’s  speech was 45 minutes long.  He appeared  to put aside his formal speech and spoke without notes.  He passionately laid out his  aspirations.  It will be great if only a  faction of it could be accomplished in four years. I found interesting how openly  he referenced God and made other religious references. 

There were small  nuances worth observing.  Things like who  didn’t stand up to applaud. You could see the political coalition playing out  among the members of Congress sitting behind him.  A two-man band of indigenous Indians played a  squawking sort of tune with a reed instrument and drum as the transition of  power was occurring. It was a symbol of support for indigenous people.  The interaction between various heads of  state was intriguing to watch.  A lot of  Latin American politics was playing out in front of me.

In the evening, inauguration  parties and rallies were held throughout the capital city.  We dropped by a reception at the same  building where I met President Berger the night before.   

Just outside the  building, a crowd of 20,000 or more people waited for the event to start. We  could hear them, but couldn’t see them.   There were some doors which appeared to open toward the crowd, so  Ambassador Derham and I opened them up to see if we could watch the  festivities. The doors lead onto a balcony overlooking the gathering. 

As we walked on  to the balcony, the crowd apparently thought we were the official party walking  out to greet them.  A great collective  shout went up and the crowd began to cheer.   We realized we had unintentionally triggered a response and quietly  withdrew, closing the door behind us.   For just a second, however, I felt like Juan Peron.
 

Gates Malaria Forum

This week in Seattle, the Bill and Melinda Gates Foundation invited health leaders from around the world to attend a Malaria Forum. The discussions centered on better coordination between nations, NGOs, multi-national organizations, scientists and individuals on our common goals related to malaria. I left the gathering feeling optimistic that a worldwide collaboration can save millions of lives currently lost in a needless way.

I wrote several blog entries about my experiences related to malaria in Africa in August. This was a good follow up. Many of the health ministers I visited in Africa were in attendance. The formula for progress, in my view, requires coordinated activity over a lengthy period of time, but it is achievable.

I left the conference with a sense of satisfaction that the people of the United States would be proud if they paused to learn what we are collectively doing. The President’s Malaria Initiative (PMI) has become a powerful catalyst worldwide. Our money and leadership are making a big difference. Tim Ziemer, who leads PMI, is outstanding.

A word about Bill and Melinda Gates: I was among a small group invited to their home for dinner.

Yes, their home is spectacular. Unfortunately, I am not good with remembering decorating details. I routinely fail in satisfying my wife’s requests for specifics on design, fabrics and art. I do remember the trampoline room and original documents of Napoleon in the library.

What I will report, with clarity, is an insight into Bill and Melinda personally. I’ve been with them a number of times in social and professional settings, but this was the first time I have had an opportunity to interact with them in their home. I watched as they skillfully listened, questioned, and learned from ministers of health from Africa. People of their economic stature aren’t always good at that. They are gracious and hospitable people. Life’s circumstance has provided the two of them with a remarkable opportunity and the heavy burden that accompanies it.

The stewardship of wealth is weighty. They carry it well.

Pan American Health Organization Meeting

The Pan American Health Organization had its annual Washington meeting last week. We used the occasion to sign the Memorandum of Understanding on the regional training center the United States is helping with in Panama. The need for skilled medical workers is acute all over the world. The health ministers from Panama, Honduras, Costa Rica, and Guatemala joined in signing with the United States. Nicaragua is also participating but will sign the MOU later.

Camilo Alleyne resigned as Health Minister of Panama a couple of weeks ago. However, he was honored at PAHO and I had a chance to see him. It should be acknowledged that the regional training center vision was originally advanced by him. I quickly saw its value and pledged U.S. support as have all the health ministers and Presidents in Central America.

I met with Minister Turner, the new Minister of Health in Panama. She has pledged her continued support and signed the MOU on behalf of Panama.

Regional training of skilled workers has great potential in other areas of the world. We are exploring a joint effort with the Brazilians in Africa.

Dr. Margaret Chan the Director General of the World Health Organization was in town for PAHO. We had a couple of meetings during which most of our time was spent discussing HIV/AIDS, malaria and pandemic influenza. Her natural and comfortable candor makes her an effective leader of WHO. That job requires a person who can be straight with people in a calm and even-handed way. Margaret Chan is good natured, but very direct. We have been friends for a couple of years now. We visited five countries in South East Asia together when she was leading WHO efforts on pandemic influenza (H5N1).

To learn more about Region Health Care Training Centers, visit www.globalhealth.gov

USNS Comfort in Haiti

Last Friday I went to Haiti to observe the remarkable health diplomacy being done by the USNS Comfort, a Navy Hospital Ship President Bush deployed into Latin America. As we flew into Port-au-Prince, the capital city, the Comfort’s white glistening paint stood out beautifully against the coral blue water.

USNS Ccomfort in Haiti

The city looked about as it did the last time I was there, in the early 1980s. The poverty of Haiti is well documented. It was rewarding to see doctors, dentists, nurses and technicians ministering to the lines of thousands who waited.

I met with the Minister of Health in Haiti. He is an OBGYN. Much of our conversation revolved around a challenge I observe in every country I visit — the shortage of health workers. He pointed out that most of the medical professionals in Haiti have left the country; hospitals close as a result and most people go without health care. There is a special place in heaven for those who stay behind and do their best to take care of people.

So far during the Comfort’s 5 days in Haiti, I was told over 9,000 people have been treated, some in several different ways. I watched people being given used glasses American’s have donated. I saw dental work being done in portable chairs.

Mothers brought their children, some of whom where taken immediately to the ship for surgery. I’ll post a few pictures that tell the story better than I can.

Mike Leavitt speaking to man in Haiti

Haiti is one of 12 countries the Comfort will have visited. In the past three months more than 72,000 people have been treated. More than 800 surgeries ranging from minor to major procedures. All kinds of procedures and other services are rendered; Medical equipment in local hospitals get repaired, water systems in communities are rebuilt, and veterinarians train locals on how to avoid diseases.

The presence of the ship and the excitement it brings to the ports it enters changes the lives of thousands of individual people and their families. The ship also serves as a reminder of our nation’s compassion and partnership. Health is the universal language. Health diplomacy is a powerful and important tool in our foreign policy as a nation.

www.globalhealth.gov

Malaria Clinic in a Box- Written Thursday, August 30, 2007

Malaria is a terrible disease that takes the lives of millions needlessly; most of them children under five years old. I heard Vice Admiral Tim Ziemer who heads the President’s Malaria initiative say:”We know where it is; we know what causes it; we know how to prevent it.”

The President and Mrs. Bush have serious passion for this. Vice Admiral Ziemer is in charge but the initiative is a collaborative effort that includes CDC, NIH, USAID, the DOD and many non-profits. After seeing what has occurred in quite a short time, they are doing what I think is a remarkable job of attacking the problem.

Monday morning in Kigali I saw a system of treatment sponsored and paid for, in large part, by the Malaria money. I found it extraordinarily interesting because it may be a great model of care to use in many areas of the world who lack health infrastructure — which is most places in the world.

Before I describe what I saw, let me observe that looking at health care delivery throughout the world has taught me that while people often receive little, they are always grateful for whatever care they can get. The corollary to that principal is “if you or your loved one is sick, having something is almost always better than having nothing and the aesthetics are secondary.

In Rwanda, like most African and underdeveloped countries people get sick with all the symptoms of malaria and they have nowhere to go or it’s a day’s walk to a clinic. Too many, especially the children, needlessly die for lack of medicine we know works in most cases.

Twubakane Project

The government has subdivided the population into provinces, districts, sectors and in most cases a sub part of a sector. In 12 of the districts, the Health Minister (through some non-profit partners supported by the United States) developed the Twubakane project. It is a system of lay medicine distributors who are trained to recognize the basic symptoms and administer the medicine to children under five years old. Two people, one male and one female are chosen for each area which consists of about 150 households.

The two medicine distributors in each area are given a wooden box about 15x18x6 inches containing medicine packets with pictorial instructions that illustrate how to use the medicine. The distributors are also taught to watch for certain symptoms and to seek higher skilled help in certain circumstances.

In addition to administering medicine to those who appear to have malaria, the volunteer also has the job of identifying women who are pregnant. In research done by NIH, it has been determined giving woman three preemptive doses of anti malaria medication, dramatically cuts down incidents of mothers getting sick and babies being impaired.

As I visited with the lay workers and in the homes of those in their area I asked, “how were the people chosen to have the medicine box?” They were elected by the people in their area. They told me they choose people they trusted.

This is a fascinating idea to me. People in an area democratically electing a neighbor they have confidence in to keep a health treasure they can access if they get sick.

“Does everybody know who has the box?” I asked. They told me they have regular meetings in their community and now everybody knows who has the medication box. It appears to have become a matter of some status.

Because those who have the wooden boxes also must keep basic records, the information forms the basis of good research. Results are collected, graphed and studied. There are notable and encouraging results so far. Incidents of serious complications have dropped dramatically.

Another important outcome relates to success in getting woman to take the three doses while pregnant. The lay medical distributors also encourage the husband and father of the child to go with the mother to the clinic. In fact, they are required the first time. While there, both mother and father are counseled about AIDS testing.

On my way back to the United States, I stopped in Kenya for a few hours. Part of our CDC team met with me at the airport to provide an update. They reported they were working hard at getting woman to take the anti-malaria medication during pregnancy, but so far they had not been successful to get more than 30% to return for more than one treatment. The results in the Rwandan districts have been well over 50%.

This is one way we could potentially build infrastructure inexpensively while we distribute treatment.

Understanding Rwanda- Written Wednesday, August 29, 2007

“To understand Rwanda, you have to understand genocide,” Michael Arietti, our Ambassador told me as we left the airport.  “I want you to see the Kigali Genocide Memorial first.  It will give your entire visit context.”

He was right.

Scenes of genocide are not new to me.  I have been to sights of the Holocaust and to the killing chambers of the Khmer Rouge in Cambodia.  These are dark places that left my spirit sober and cold.

Once again, I found myself without words to describe the horror and a clear sense that I am insufficient to feel the magnitude of sorrow brought on by what happened in Rwanda during a hundred days of 1994 when more than 800,000 people died in a manner so grotesque I choose to avoid any attempt at describing. (www.kigalimemorialcentre.org)

There was a difference for me in this visit. It was the faces of survivors who stood with me as I viewed the images.  The Memorial’s director, a quiet man with imperfect but sufficient English lead me from display to display. He had escaped by hiding in western Rwanda. As we viewed a video of a woman describing the unthinkable barbarism her family fell victim to, a young woman who works for CDC in Rwanda pointed to our guide and whispered: “that is his sister.”

We walked into a darkened room where thousand of photos of victims hung in memorial. Everyone intuitively speaks in whispers. I said to our guide, “I’m told your family was directly affected by this; I’m so sorry.”  He acknowledged my condolence by pointing to one of the pictures, “Yes, this is my mother.”

The CDC employee, and the same person who had whispered earlier to me about the memorial guide, was herself an example of how millions of Rwandans’ were affected.  An attractive woman in her mid 30’s now, she works as a receptionist at our office in Kigali.  In 1994 she was in her early twenties and living in a bordering country.  When news of the atrocities came to her, she courageously worked her way back to Kigali only to find both her parents and several siblings had been killed, leaving only the four youngest. Like so many other young people, she became the head of household and nurtured her sisters and a cousin who was orphaned into young adulthood, forfeiting the education she aspired to.

It was not just those two.  Everyone in Rwanda has a story.  It was the Health Minister who was a medical student returning to treat the wounded in northern Rwanda.  It was the two drivers who both lost parents and numerous brothers and sisters.  It was the woman in a market whose story is told by the ugly machete scar across her forehead. It was the bullet holes and bullet marks on the walls of churches and schools where people were killed by the thousands. 

Yes, the Ambassador is right.  While I never expect to understand genocide, knowing more about it gave me context for what I saw in Rwanda -- and for that matter a lot of other things too.

President Kagame

In 2003 Rwanda elected President Paul Kagame.  Within a couple of weeks of his election, I attended a gathering of corporate and government leaders in Aspen, Colorado where he spoke. Though my recollection of the specifics of the speech is incomplete, I remember his remarks as profound in two ways. The first was his call for reconciliation, healing and forgiveness and the second was how his soft spoken and gentle manner gave his speech power. 

In essence on that day, President Kagame said, Rwandans have to live together and rebuild our country and that can’t happen unless a way is found to heal. The President described a process that had been used historically in the Rwandan traditional court system called Gacaca. It is a process of confession, contrition, compensation and forgiveness -- neighbor to neighbor, victim to offender. Since there could potentially be hundreds of thousand of people involved, there is no way the normal court and correctional system could handle it. Besides, something other than an adversarial system was needed. (An article I found on it: http://findarticles.com/p/articles/mi_m1141/is_25_40/ai_n6019514/pg_3)

I remember at the time wondering during President Kagame’s Aspen speech if it could ever work.  Visiting Rwanda four years later I saw evidence it is working. I watched a short video of perpetrators, dressed in pink, confessing to the victim’s families and others what they had done.  Apparently, the tribunal’s judgment is tempered by the completeness of the confession and contriteness of the offender.  Each of the victims is given a penalty which can range from public service to jail time.  Driving around Rwanda, I saw groups of people, dressed in pink working on a mountainside, apparently doing their compensation. I’m sure the system is highly imperfect but the country appears to be pursuing a solution and positioning itself to move forward.   

The second thing that impressed me about President Kagame’s Aspen remarks was his soft spoken and gentle tone. Being in Rwanda gave me the impression this may be a characteristic of the culture there. I found most Rwandan’s I spoke with to be graciously polite, gentle and soft spoken. I have no way of knowing how universal it is or for how long it has been that way and I must confess, I don’t know how to square that with the profound brutality the genocide period produced.

I am left to wonder if the universal hardship and sorrow experienced by the people of this nation has produced a special kind of humility that allows forgiveness and moving forward. Genocide and hardship has nearly eliminated an entire generation.  Forty two percent of the population is under 14 years old.  Less than 3% of the population is over 65 years old.  Is it possible that the new generation and those who survived will have different values and behaviors than before?

Changing government in a nation can be done by a majority vote or revolution. Changing the collective hearts of a nation is harder than both.

Changing Hearts

Actually, the question of how hearts are changed has been on my mind through out this African trip. The entire continent of Africa is being ravaged by another kind of brutality: disease. In all four countries I visited, the HIV-AIDS virus is waging war, systematically and venomously destroying families, communities and ultimately nations.

I’ve been to the front lines and seen the evidence of caring people from all over the world, rallying to help.  I’ve seen researchers who left the comfort of their university lab to live at the epicenter of the epidemic pursuing every lead on how to defeat the heartless killer. I’ve seen health workers organize clinics to administer medicine. I’ve seen caring people struggle to meet the needs millions of orphans left in the wake of this disease.

I see our nation and others with us, sending tens of billions of dollars to fuel this effort. There has never been a more noble humanitarian effort made to stand between mankind and disease -- and yet, we are losing. While we succeed in treating the sick and providing life and hope for millions, new cases are growing faster than our ability to treat them.

Whether it is in the outback of Africa or the streets of American cities, we cannot treat our way out of this epidemic. Prevention is the only way to succeed.  Prevention requires change of behavior.  Changes in behavior happen only when there is change of heart.

Visit with Students

In Kigali, I visited what in the United States would be considered a public high school. Ironically, I learned later, great brutality took place at this school during the Genocide.  I watched a student body assembly where students performed a dramatization teaching abstinence and the importance of being tested to know your status.

The program portrayed in the frankest of terms a situation between a male and female student regarding sex.  They had been dating for some length of time and the male student was pleading with the female to have a sexual relationship with him. The interaction featured an empowered female refusing to subject herself to the risks of AIDS or unwanted pregnancy.  It included candid conversation between teens about the need to be tested.

Outside, after the program, tents had been set up where students could engage in smaller group conversations.  In addition there were medical workers able to test the students and provide counseling for those who needed it. The program officials told me they will ultimately test over 80% of the students.  Only ½ of 1% will test positive. The Minister of Health told me he aspires to have it expanded to all schools.

I went to the Kigali Institute a medical school.  The Minister of Education in introducing me, said, “Mr. Secretary, our goal at this Institute is to be AIDS free.” The students applauded. No one has illusions about how hard this is but AIDS is a vicious indiscriminate killer and it will only be interrupted and defeated by changing the hearts of the people, especially the coming generation.

The condom use part of our ABC policy (Abstinence before marriage; Be faithful in marriage and consistent Condom use in high risk behavior) is important because it recognizes the realities of human behavior but here’s another reality: In a world saturated with AIDS, any society that counts on the C (Condoms) part of ABC to facilitate a continued practice of males routinely having multiple and concurrent sexual partners will be overrun by AIDS and its harsh economic, social and health consequences. 

President Kagame was out of town so I met with Rwanda’s Prime Minister Bernard Makuza.  He made an important observation in our meeting. He feels while many people think of health as a compassion issue, to him it is also an economic issue. (http://allafrica.com/stories/200708280261.html)

He’s got it right in my judgment.  Failure on AIDS will bring about the type of social and economic instability that inspires further human tragedies.

President Bush has proposed Congress double funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) over the next five years to $30 billion.  Throughout Africa, I asked those working with HHS and our partners to provide suggestions how the reauthorization of PEPFAR should be structured to drive prevention.  If five years out, all we have accomplished is the perpetuation of treatment of millions more people but infection rates are outstripping our capacity to provide treatment; we will have done a compassionate thing, but Africa will still be on a pathway to failure.  We need to organize our efforts so they result in a change in behavior.

Rural Rwanda- Written Tuesday, August 28, 2007

To get a real look at developing nation’s challenges one has to leave the population center.  On Tuesday morning we drove for nearly three hours west of Kigali to visit the Rubengara Health Center.

Rwanda is about the size of Maryland. It has around nine million residents. Rwanda is called the land of a thousand hills. It reminds me of West Virginia in that way.  Everything is built on a hill, often a steep one. The roads are full of turns and often slow. Every scrap of ground is farmed, no matter how steep the grade or unyielding the soil.

Along the way I saw hundreds of people working the soil with hoes or picks.  What I didn’t see was farm equipment, not a single piece.  Surprisingly, I didn’t see any large animals either; no horses or cows.  Goats were prevalent.

Most everyone walks.  There are a few bikes. Anything being carried was generally balanced on their head carefully. Most loads appeared to be water, charcoal, sticks or leafy plants.

Those who didn’t walk or ride a bike rode in mini vans generally packed to overcapacity with ten or more people riding on three seats.

We drove on a paved highway the Ambassador said he thought had been built by the Chinese. The roadway is lined with banana trees and appeared well engineered.  Because it was built onto the side of a hill like everything else, a drainage system had been built to cleverly avert erosion of the road.

There was no water collection or distribution system.  Like so many things in remote areas, availability of basic necessities is made more difficult because of distribution problems. So it is with water.

Many of the road walkers carried yellow plastic water containers of various sizes to a series of water holes.  As we passed the filling spot there were always dozens of people standing in line.  It was clear this was both a necessary ritual to sustain life but served as a social event as well.

Small homes are scattered across the landscape.  Almost all of them are constructed of mud bricks made by the owner.  Some are covered with plaster; most have sheet metal roofs.

Rubengara Health Center

We arrived at the Rubengara Health Center which is operated by the Presbyterian Church of Rwanda.  The mayor and Provincial Governor were both there as well.

I had three purposes in my visit.  The first was to meet with representatives of two associations which have been formed by among people in that area who are living with HIV AIDS. Each group has about 120 members. They meet regularly to provide support and information. They each have arrangements where they cooperatively grow food which can be shared. We had an extremely candid conversation about their circumstances, how they got AIDS and emotional needs of the families.  As we talked, several of the people told me about their children, especially those born after they were positive. None of the children were positive.

I also viewed an exciting development called TRACnet.  This is a project the US Government is supporting through Columbia University.  It is an electronic tracking system on patient data.  The data can be input and accessed manually, over the internet or by cell phone.  The data will create a powerful set of management and research tools. It could be the foundation of an electronic medical record. I was pleased to find there is a significant level of collaboration being done on this in Africa so the same standards will be used across the continent and around the world.

Before I left, we presented to the two associations 50 goats that will serve as the foundation of a herd. It will become an important part of their food cooperative. It was a fun and emotionally touching moment as this entire community turned out to express appreciation to the United States of America.

Tomorrow, I will write about my visit to the Kigali Genocide Memorial and the people I met there.

Written Monday, August 20, 2007

This morning I'm driving to a clinic outside Johannesburg which is run by Sisters of Mercy, one of our NGO partners. They are affiliated with Catholic Charities. I'll tap out a few notes on my Blackberry as we drive and then see if I can pull them together into something coherent tonight.

I spent last night doing briefings on Hurricane Dean. At the conclusion, I determined it was appropriate to declare a Health Emergency just in anticipation. Our teams are in place and our assets ready to respond. We have a play book that scripts out our actions in circumstances like this. It has been developed from past experiences and exercises we routinely do as preparation.

It is winter in South Africa. Temperatures are pleasantly cool today.

Our delegation has now arrived: Ambassador Mark Dybul, the head of the President’s Emergency Plan for AIDS Response, Dr. Julie Gerberding of the CDC, Kent Hill from USAID, and several others.

I did several interviews yesterday to brief the regional media, concentrating mostly on building awareness of our U.S. government HIV/AIDS efforts. The United States invested nearly $600 million in South Africa alone this year. We deal directly with nearly 400 NGOs who deliver the care. Our goal is $30 billion over the next 5 years in 15 countries, of which 12 are in Africa.

The US needs to emphasize this kind of effort. I refer to it as health diplomacy. It is an incredible, generous, and aggressive initiative in my judgment, and something a nation as strong as ours ought to be doing.

Whenever a Cabinet Officer travels internationally, the U.S. embassy provides a country briefing: generally about two hours of intensive briefing on the economic, social, and political situation in the country. What a great education this is. As interesting as what is said are the people reporting it. I'm always interested in the Foreign Service people of the United States. Most of them spent the majority of their career outside the United States, rotating every three years. They become remarkably well informed by their experiences. This morning I am with Don Teitelbaum, the Deputy Chief of Mission. The ambassador is out of the country on an August break. Don has been with the State department 22 years and spent most of it in places like the Dominican Republic, Guyana, Kenya, Somalia, Sudan, Lebanon and Uganda. He is married to a UNICEF employee.

We're starting to see some terrain that looks like what I imagined South Africa to be. The freeway infrastructure in this part of South Africa is impressive. I'm sure it’s not all like this everywhere. We’re on a two lane divided highway.

Like so many other places I’ve visited, the division between economic classes is startling. There are two South Africas. I’m beginning to see now the evidence of the poor impoverished South Africa. The system of trash collection seems to be piling it up next to the street and then allowing goats to rummage through it.

There are signs of progress as well. Children in school uniforms walk everywhere. There are large light posts that have giant lights on top which cast a big footprint allowing them to light an entire section of the township with just one pole.

The landscape is barren and brown. No grass or other ground cover makes the garbage and clutter seem more evident. However, there are many yards where its evident people are trying to create a sense of order.

Construction of the homes is done with whatever materials are available. There is a lot of sheet metal and home-made bricks. It is evident there are no water or sewer arrangements.

As we proceeded, I began to learn the history of Winterveldt. When apartheid was practiced, the nation’s laws created segregation of whites and blacks. White people lived in the city and suburbs. The government then passed the Group Areas Act which created specific areas for specific ethnic or tribal groups. Those who didn't fit into any such area were, as Sister Jacobs, the head of Mercy Clinic, put it, "dumped" into areas like Winterveldt.

I saw a map of Winterveldt hanging on the wall in the clinic area. It was divided into housing plots. I’m told at one point there were as many as a million people living there. Apparently it has dwindled down to about 300,000. Unemployment is incredibly high. As many as 50% are believed to be HIV positive; there are no employers and teen pregnancy is high. All of that provides a bad combination.

We first held a brief meeting with those who operate the clinic; the Sisters of Mercy. Sister Jacobs is the leader. There are numerous others, almost all of them woman. The operation surrounds a school. It is unclear to me if the Sisters of Mercy run the clinics and the school too.

We walked first to a primary care clinic. It serves about 120 people a day. Patients apparently start showing up at 6:00 AM; the clinic opens at 8:00 A.M to see nurses. A doctor comes one day a week. The waiting room is jammed full with people sitting and standing in the hall. Lots of mothers with babies held in carriers on their backs.

There is a board with color-coded pins showing where people are being served at home. Red pins for those in home-based care (pick up medicine and take home), blue for home visits (a worker goes to the home and helps), and yellow for child-headed household (homes with no parent).

Behind the primary care clinic sits a small building used as a clinic for Anti-Retroviral treatment. It is called the Hope for Life Program. They have 357 patients currently (92 males and 213 females). It is important to remember how many people need treatment and don’t get it. The clinic is one of the few places in Winterveldt that provides treatment and the area likely has tens of thousands who are not treated.

I sat at a table and talked with some of the patients. Each has a compelling story. There was a woman who had six children; five of them have died from AIDS. She now brings two grandsons ages 10 and 8 to be treated at the clinic. She is their caregiver. She has four granddaughters who are cared for by another grandmother.

A young woman in her mid 30s has two children of her own; her sister and brother-in-law both died of AIDS, so she now cares for their four children in addition to her own. The father of her children is not in the home. It is unclear to me if he died or if she was simply not married.

I asked how she earned money. She explained she gets a small social grant from the government for each child and also does crafts at the center to sell.

The problem of orphaned children is more profound than I ever imagined. My briefing book indicated there are more than 1.5 million children in South Africa under the age of 15 (one in ten) who have lost one or both parents. By 2010, an estimated 2.3 million children (one in six) will be orphaned. More than three quarters of the deaths will come from AIDS. These figures, however, underestimate the magnitude of the problem, as they ignore huge numbers of children living in households with HIV, caring for siblings and chronically ill family members, and living in financially stretched households that take in other orphans, just like the woman I met who is caring for her sister’s children. This is a nightmare.

There’s another woman in her late 40s, I’d guess, whose husband was sick with AIDS, but didn’t disclose it to her. She discovered it when he died. Afterward, she became extremely ill. She is being treated by the clinic and is now functioning again. She was emotional in her expressions of appreciation to our country for her “second life.”

I met one of the few men who is treated at the clinic. He was 36 years old with three children by two women, both of whom have died. The children are being cared for by their grandmothers. Men just don’t seek treatment in nearly the same numbers as woman. I’m left with the impression it’s the cultural stigma that keeps them away. This seems like a huge problem. You drive through the streets knowing that a major portion of the men you see are unemployed, infected, and untreated with lots of time on their hands to spread the virus. Those factors, either as a cause or in combination with the epidemic of rape that exists in South Africa, contribute to the enormity of this social crisis.

Another member of the delegation told me of a 90-year-old great-grandmother who is caring for four children because the parents and grandparents have died. A heavy burden has fallen upon woman of her generation. They had passed the age when high risk behaviors where prevalent when the virus began to spread—and hence protected somewhat from its ravages.

A plot of land sits outside the clinic where patients are allowed to create Door Gardens. They are small plots of land about the size of a door. The Sisters of Mercy provide them with help in learning to produce food. It helps both sustain them and give them the hope and satisfaction one gets from seeing a garden of your own creation grow. Again, it was almost all women doing the work.

I was drawn to four small children who sat on a swing waiting for their mother. She was attending a class on nutrition. Their undernourished state was visually evident. One of the home workers discovered them during a visit.

The United States, through the PEPFAR (President's Emergency Plan for AIDS Relief) program, contributed $465,000 this year to the support of the Mercy Clinic. Any American would be proud of our involvement. This is happening in 15 countries and the people could not be more expressive in their gratitude.

My time at the clinic was cut shorter than I wanted. It’s hard to just touch down in a place like that and then leave. However, I had to because of a meeting with the Minister of Social Development who is responsible for the non-medical response on these problems. I was interested to get a sense of how aggressively they are approaching it.

Minister Sidney Themba Skweyiya is a fascinating person. I’d enjoy having dinner with him some night just to tease out the details of his life story. He was one of the original activists against apartheid as a young man. What little I was able to learn during our meeting leads me to the conclusion he has an interesting story. He became a lawyer so he could fight the legal battles necessary to overcome the oppression.

Much of our discussion focused on the social grants they provide orphaned and poor children. According to him, they lack the infrastructure necessary to do it as well as they aspire to do. Poor children (which he didn’t define) get about 200 Rand a month. That’s under $30 a month. Those who are orphaned get slightly more. It is paid until they are 14 if they are poor. It can go until they are 21 if they are orphaned.

Ambassador Dybul offered to help with some of their training and infrastructure building. They will follow up through the embassy.

I was interested to drill down further on the orphan problem. This is a ticking time bomb. To do so, we drove to a project titled the Heartbeat Program located in Nellmapius Township. This is a story worth telling, a story of some young, ideological people who started it because they sensed a need. A woman named Sunette Pienaar and some others formed it with some friends. She told me they were caught up in the spirit of Nelson Mandela’s election and just wanted to do something to help. She is a PhD Theologian but has a strong entrepreneurial instinct. They focused on the large emerging population of orphan children.

Students enrolled in the Heartbeat after-school support program

Students enrolled in the Heartbeat after-school support program.

In our country, we recruit foster parents to care for orphans with the hope of finding adoptive families. The massive scale of the problem in South Africa makes that impossible. Heartbeat aggressively seeks out children who have lost both parents and then organizes efforts to fill gaps. They have built a couple of modest buildings next to a school so they can partner in providing additional services to orphaned students. It felt like an extremely active school club for orphaned children. There are counselors, activities and expectations for each child. I sat and talked with several of them. Each was a compelling story.

When we arrived, there was a chorus of teenage orphan children who sang and danced with all the enthusiasm puberty provides. They were having fun. Then some poignant moments: I sat next to a little boy of 9 or 10. He was writing and drawing in a book. I asked to see what he had done. About 3 or 4 pages in, I found, written in his handwriting, a note that started out, “I miss my Mother and little brother.” A few pages later, another mention of his Mother: “I wish she was here so she could help with my homework.” I instantly thought of my own grandfather who lost his Mother at age four to sudden sickness. He told me later in his life, “a day never goes by that I don’t think of my Mother.”

A social worker described the painful process of getting the children to first talk about their loss and then deal with it. The mutual support of the others is critical.

At Heartbeat, there was a group of grandmothers who are caring for children who gather on Mondays to sew and talk. It’s about making clothes for the children, but more about the support they need from each other to keep going.

A grandmothers who is learning sewing skills as part of the community support offered by the Heartbeat program

A grandmothers who is learning sewing skills as part of the community support offered by the Heartbeat program.

Among the older children I felt great hope. Resilience had set in and they were looking to the future. One young woman told me, when her Mother died she felt lost. Now, she had found direction. “What do you want to do,” I asked.

“I want to be an auditor,” she replied. A boy about the same age said, he’d decided to study business. The girl next to him will study natural science and wants to be a doctor.

This will be a strong generation or a broken one. I suspect some of both.

In the evening we had a reception at the Ambassador’s home. We’re off to Durban tomorrow morning at six o’clock.