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

HIV/AIDS

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.

Photo3pmethiopia_3
HHS Secretary Mike Leavitt and Prime Minister Meles

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

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

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

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

August in Africa- Blog II

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

August in Africa- Blog I

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

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

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

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

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

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

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.

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.

Tanzania- Written Sunday, August 26, 2007

A doctor who had moved to Tanzania in 2002 told me that during the first couple of years she was in Africa, the burden of doing clinical work was nearly unbearable. She said: “I dreaded going to work every day because patients were constantly testing positive (for HIV) and there was nothing we could do for them.” It was like a death sentence.

I have concluded the core business of the United States in Africa is hope. Fear is the enemy of hope. Millions feel fear that keeps them from acting. Once they feel hope, even without certainty, they begin to slowly move toward action.

Conversations with dozens of patients and health workers, and people who work for non governmental organizations, have begun to give me a sense of the despair that gripped this continent during the past decade.

I encountered a lot of gratitude. The situation is still dire, but for those willing to do their part, there truly is hope. I wish more people could experience the spirit of appreciation I have heard.

There are problems, lots of them; but there is also evident progress. The most profound evidence is our own statistics. In 2003 there were only 50,000 people on ART (Anti Retroviral Therapy). Today there are over a million and the number is steadily growing.

The Tanzanian health Minister echoed what others have said about human capital and infrastructure being the rate limiting factor. It is far better, in my opinion, for the United States to invest in solving those problems and allow the host countries to concentrate on buying the actual ART drugs.

Opportunities: Capacity and Quality

In the two days I was in Tanzania, I saw several good examples of ways we can expand capacity with investments. The first was a care and treatment center called Mwananyamia Hospital that we opened on Friday in Dar es Salaam, Tanzania. This is a project PEPFAR (President's Emergency Plan for AIDS Relief) paid for in conjunction with Harvard University.

Before the ceremony, we walked through the old center which is still in use. I’ve now been in enough African hospitals and clinics now to anticipate the model of care. Most of them are similar. People, mostly woman, line up with their children early in the morning, sitting on a wooden bench in a room packed with people. Typically there are two or three intake workers dispatching the patients to small rooms where they are examined by a nurse, or somebody with less training. There may be one doctor or a part timer who comes once a week to see patients who have to return and wait again.

Most of these clinics/hospitals have a pharmacy which is actually a couple of cupboards with a few bulk products. Medical records often are intake logs, not focused on the individual patient but the flow of patients through a particular process. I’ve seen a few basic labs with a single piece of equipment.

The new treatment center is bigger, better organized, better equipped, and feels so much more optimistic. It will increase the volume, sustainability and quality of the offerings. There is a sense of hopefulness just in the contrast of old to new.

Another significant investment is a building that will house laboratories and various public health facilities. Several U.S. organizations contributed to its building. It will allow U.S. scientists and doctors to work side by side with their Tanzanian counterparts. I’ve mentioned this before but it’s worth repeating. Having research at the epicenter is a powerful way to leverage our talent

On Saturday, I attended the opening of a Blood Center in Zanzibar. CDC has consulted heavily on these and has an ongoing relationship to assure they are operated properly. This is an interesting and important investment. Until we started working with the Tanzanians, there were no blood banks. So when a person needed blood, they called on their relatives to donate. With so many untested people giving blood, thousands of people each year where given HIV through a transfusion made, with every good intention, from a relative. We have now built blood centers so the blood can come from a tested source. It will protect innocent victims for generations to come.

Signing the certificate turning over the Zonal Blood Center to the people of Zanzibar, Aug. 25, 2007.

Signing the certificate turning over the Zonal Blood Center to the people of Zanzibar, Aug. 25, 2007.

Opportunities: Expand Human Capital

Also in Dar es Salaam, I visited two programs that deal with the severe shortage of trained people. The first was a session with the heads of nursing schools from several regions of the country. The United States through HHS is training nurse trainers on best practices dealing with HIV/AIDS.

I was told of a program we finance that organizes volunteers in a neighborhood to help find and treat HIV positive people. It’s called Pathfinder.

I visited the home of a woman and talked with her about the experience. The volunteer who helped her through it was there also. She told me an all too familiar story of her husband becoming sick with TB. He also had AIDS, but didn’t tell his wife. The husband died and several months later she began to feel symptomatic.

At the urging of her neighbor, (the woman who volunteers with Pathfinder) she was tested. The result was positive; in fact, she was rather ill with a CD4 count, reflecting the strength of her immune system, of 140. (The CD4 count in an non-HIV infected adult can range from 500 to 1,500 and the CDC considers persons with CD4 counts below 200 to have AIDS.) She told me, as others have, of their despair at that moment.

She began getting treatment and has regained both health and hope. She has now become a volunteer doing the same for other people.

Seeing people in their neighborhood environment is such an important part of this experience. You can hear these stories, but until you see the two rooms this family of 3 lives in -- with a concrete floor, sheet metal roof, and no power or water -- one doesn’t have the picture.

Incidentally, her neighbors don’t know of her HIV positive status so we had to be somewhat careful in the way we approached her home. I also found it interesting to talk with her about her two children, one of whom is 17 years old. I asked if she talks to her son about this. She does, but doesn’t know if he’s following her advice. Some things are universal across cultures.

Mozambique- Written Wednesday, August 22, 2007

I walked down a dirt pathway dividing crude houses made of sticks and mud bricks in Quilemane, Mozambique this afternoon. I had just looked at the site of a prospective Millennium Challenge Corporation funded water project that will eliminate standing water and the malaria carrying mosquitoes that come with it. We were 30 minutes ahead of schedule so I decided to take an unplanned walk through the middle of an African hamlet.

My attention was drawn to a vacant chair sitting among a group of woman in front of a small closet-like store. I asked if I could sit down; they signaled their approval. Before I could speak, one of the women said through my interpreter, “We’re mourning the loss of my daughter — she died on Saturday.” Our conversation revealed she had died in child birth. I provided what comfort I could and moved deeper into the neighborhood.

A dozen children scampered around me as I walked, excited about these mostly white strangers. Adults looked up from whatever they were doing, startled and curious. One of them was a pretty woman standing next to a little boy about three years old. I asked to meet her little boy.

“His Father died a few months ago,”she said.

I offered my second condolence in 100 feet and asked if this was her only child?

“No, I have five.” I was surprised. She didn’t seem old enough. As we talked, it seemed evident her husband had died of AIDS, leaving her alone to carry the heavy cost of this pandemic. I didn’t ask, but wondered if she, like so many others I’ve seen on this trip, had been infected by a spouse, compounding the tragedy. I moved on.

Around a small bend in the path, I encountered a man leaning against a house. I noticed he had lost his right eye. It didn’t impact his smile. We shook hands, chatted about his nine children, and I moved a few feet toward a woman who told me she had three children. I asked her if Malaria had been a problem in her home. “Oh yes,” she said, “we’ve all had it many times.”

The mayor, who was walking with me said, “There isn’t a family in this area that doesn’t have somebody in their family sick with Malaria, all the time.”

It’s a dry season right now in Quilemane. The stream bed our water project will fill is dry, full of garbage and debris. However, in wetter months, the whole area is swampy and Malaria vectoring mosquitoes breed in swarms. They carry Mozambique’s biggest killer. It is particularly harsh on children under five years old.

I sensed a crowd gathering behind me. Dr. Julie Gerberding, the Director of the Center for Disease Control and Prevention, had noticed a boy, around twelve, who had an arm badly disfigured by an infection. It had gone on for months, he said, and was getting worse. Oddly, the arm was not just swollen badly, it seemed several inches longer than normal. She explained what she thought his condition was and made some suggestions.

Despite the level of sickness and potential for sadness, the children seemed simply joyful. I stopped as we worked our way back to the car to join a large group of children who had gathered around a circle drawn in the sand to compete in with marbles. They jabbered wildly in their version of Portuguese, expressing the same “thrill of victory and agony of defeat” any boy of that age gets from competitive sports. I tried to resurrect my marble playing skills but a half-century of neglect created a good laugh for all of us.

For thirty minutes I was able to feel part of Africa.

This (Mozambique) is a poor but improving nation. The $400 per person annual income earned is a significant improvement over years past.

I was startled by a figure in my briefing materials.

Only $12 per person is spent on health care each year in Mozambique. (For perspective, in the United States it is nearly $6,000 a year.) Not surprising, 40% have no access to care at all.

Minister of Health

Early yesterday I met with the Minister of Health, Paulo Garrido, M.D. He is a calm, elegant, distinguished looking man. He was trained in the former Soviet Union, as most of his contemporaries in government were. The Minister of Health told me there are places in this country where woman walk 100 kilometers (60+ miles) to get medical attention when they are pregnant. They have formed waiting houses and ask woman to walk that distance when they are 8 months pregnant so they are near help if things go badly.

It is a lack of properly trained people at every level that most vexes the health care system. They are prevented from increasing the velocity of AIDS treatment by a lack of trained people. Our meeting included discussions of ways the United States might be helpful in solving the problem.

Hospital Visit:

I noticed that people are genuinely grateful for medical attention, no matter how basic. That seemed true at Jose McCamo Hospital in the nation’s capital city of Maputo when I visited. The hospital is a single story concrete building. There is no carpet; no landscaping; no art. There are just wooden benches and concrete to accommodate hundreds of women and their children who flood the building every day, waiting in line for their HIV treatments.

There are small portrait scenes playing out everywhere. Each patient has a story; some known, most not.

As I sat listening to a presentation about an American funded program to provide psychological support to women who have lost spouses, have children and are HIV positive, I spotted a boy about 7 years old coming out of the building by himself. He was holding a package of AIDS medicine. He sat down and carefully put the medicine into a cloth bag hanging around his neck.

The truth is, I don’t know anything about this little boy but my mind constructed a scenario that he is being treated with ARTs (Anti Retroviral Therapies). He either doesn’t have a mother or he has learned to navigate the clinic on his own at that young age.

I meet an unforgettable woman that morning. She is in her mid 30’s, with an “out there” personality. She wore a black tee shirt with the words printed in large bold letters, “I am HIV Positive.”

Her mission in life now is to give other women courage to face the world without stigma. She contracted HIV from her husband, who is now dead. She helps organize “positive teas” for the woman in this group. They get together, sing and talk, bolstering each other for the hardships of the week.

There are several more experiences in Mozambique I would like to blog about. I’ll need to write later about my meeting with President Gaybuza, visits I made to two medical schools, a fascinating conversation with the nation’s religious leaders and an effort our country is supporting to contact millions of people door-to-door about being tested. However, it’s late.

I need to get some sleep. I’m now in Tanzania. I have an aggressive schedule starting early in the morning. I think I’ll post and go to bed.

I appreciate the comments and thoughtful suggestions on how to improve my blogs. Note: I’ve tried to break them up a little. Not enough yet, but it was a good suggestion one of you made.

Written Tuesday, August 21, 2007

Early this morning our team traveled to Vulindlela, a 90 minute drive outside Durbin, South Africa. I wanted to see first hand Caprisa, a combined treatment and research organization several U.S. organizations contribute to.

It is the epicenter of the HIV/AIDS epidemic. Vulindlela is a community of 400,000 people, but it appears highly rural and extremely poor. Most of the people speak Zulu.

I met Nkosi Sondelani Zondi and Nkosi Nsikayezwe Zondi, two impressive traditional tribal heads who became alarmed by the number of funerals they were attending and concluded that the very survival of their community depended on doing something. They invited researchers, community organizations, community leadership and health service providers to establish a partnership that would combine treatment with research. The result is a unique place where over a thousand people are getting ART (Antiretroviral Therapy) treatment and important research can be conducted.

The feeling the chiefs had about survival being on the line was born out in surveys done by the research staff at Caprisa. HIV prevalence in pregnant women has steadily been increasing. Among pregnant women 32.4% were HIV positive in 2001. By 2005, more than 42% tested positive. The rate fell to 39.4% last year.

Among the entire population age 20 to age 29, more than 46% are HIV positive. In this area, half an entire generation is infected.

What I learned

I’m not going to write a lot about Caprisa; suffice to say, it’s remarkably valuable, run by dedicated brilliant people and constitutes a unique partnership with the community. You can read more detail at the Web site (www.caprisa.org). What I want to focus on is what I learned by talking to the patients, doctors and chiefs.

I had a candid conversation with a fellow I’d say was in his mid-twenties. He tested positive in 2002 but kept it a secret until 2005 when he was, in essence, forced to tell his secret. He had applied to attend medical school in Cuba. His application required testing. In the process he had to reveal the secret he had kept. He described the combination of fear and relief he felt. The revelation felt like the end of not only his dream to be a doctor, but also the end of his life. He described the painful process of overcoming the dark hopelessness he felt. He’s doing better now. “I have more years to live and I want to do good things with them,” he said.

“Why,” I asked, “are men so much less willing to get tested?”

“They are scared,” he said. “Or, they think HIV occurs because of where you live.”

I was quite surprised by the thought that after all this time there are still a lot of men who don’t see HIV tied to behavior. The researchers confirmed many have misconceptions and skepticism that cause them to avoid testing. That adds some light on why women get tested 2.6 times more often than men.

     Secretary Leavitt and others lighting a candle with an AIDS ribbon on the front

The more I learn about the behaviors surrounding this crisis, the more complex it seems. This is  extraordinarily complicated sociology.

Dr. Salim Abdool Karim, the head of CAPRISA, told me women have their share of misconceptions. He told me of a study he had conducted where he asked women if they thought they were vulnerable to being infected; 32% said they were. When asked if they thought their partner was in danger, 78% said yes. There is an implicit admission inherent in those answers. The women surveyed clearly know their partners are having sex with multiple partners but don’t see it as a threat to them.

Salim told me part of the problem can be attributed to the policies of apartheid. The black populations were forced to live in specific areas often far away from their work opportunities. The consequence was that they would rarely see their spouses/partners. In many areas it was common for four or five men to share what they call a “town wife.” While they were away from home, a worker would receive food, company, comfort and sex. In return, he provides a portion of the woman’s support.

It does not take much imagination to construct the algorithmic progress a virus can make in such an arrangement. Especially if a significant number of the women left at home are engaged with multiple partners.

In another interesting project, CAPRISA found 86% of new infections were among people with stable relationships; married or long term relationships. Researchers characterized the actual viruses and found in 25% of the cases, the female got the virus from a male other than her partner.

I asked several of the patients I talked with if they had any sense that women they know were more selective about their partners if they suspected they could be HIV positive? Their responses did not give me confidence it was so.

In all our research, we need to understand better the combination required to help people change their behavior. This work is about changing hearts. The status of a nation is defined by the aggregation of their hearts. When a heart changes, a nation changes in a small way with it.

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.