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.

 

Day 5 in India (Written Jan. 11)

I remember worrying about polio as a child. Victims were put in an iron lung machine to preserve their lives. Many of those who lived had crippling disabilities.

My mother took me to a school where we stood in a long line to be immunized. It was part of a national immunization campaign. The vaccine was delivered by putting drops in a sugar cube.

Now, 50 years later, the polio virus is gone from the United States because of aggressive public health efforts to eradicate it. However, it has continued to ravage other nations. If it is present anywhere, it is a danger everywhere, so our government, in combination with others, has committed to eradicate it from the earth. Only four countries: Nigeria, Pakistan, Afghanistan and India continue to see cases. India is critical because it has the largest number of cases. As of December, 452 cases were reported in India, which represents 55% of the total 832 cases worldwide.

The primary strategy for eradicating polio is the immunization of every child, but it is a lot more complicated in India than it was my hometown 50 years ago. They have to reach 175 million children, multiple times.

I spent a portion of a day in India learning about the strategy and organization of the effort. It is a daunting challenge. Organizers have developed 1.2 million teams of people who go into every nook and cranny of India, searching house-by-house with the objective of reaching every child.

Neighborhoods are charted with hand-drawn maps. Trained volunteers then wade into broken-down, sometimes scary housing areas. They explain immunization to parents. Many are untrusting and wary. Women seem to be more effective as volunteers because they can enter the homes, which is not culturally appropriate for a man.

Two drops are put in the mouth of each child. A check mark is put on the hand-drawn map and the results are recorded in chalk above the doorway.

Drops are squeezed into the mouths of 25 children from the same bottle. It values efficiency and reach over perfection by accepting some risks as inherent when balanced against the greater good. This is raw public health.

I joined the volunteers in a slum area of New Delhi. The homes are made of homemade bricks, sticks, cardboard, sheet metal or any other material they could get. Most had no doors, just drapes. When the drape was pulled back, enough light would flood into the room to reveal a hut-like atmosphere with mats for beds and crudely made furniture. In some cases, the rooms were three or four feet wide and six feet long. Raw sewage ran in a small ditch that weaved a path through the area.

Children ran about, made curious by these unusual visitors. Mothers wore a quiet dignity that I observed as nearly universal among Indian woman. Nearly all of the women wear long flowing saris that provide a sense of elegance even in poverty. They are such attractive people.

Most of the older children understand what is happening and cooperate. However, the smaller ones have to be held with their head back and their mouth opened by pinching their cheeks together. Understandably, they cry and squirm.

As I held those children in my arms, I was a close witness to the filth they live in. Some had puffy eyes and a smell that follows poverty. They were, however, simply beautiful and I felt gratitude for being able to hold them and deliver a potentially life-preserving gift.

During my time at HHS, I have learned a profound appreciation for those who choose to serve the down-trodden of our nation and the world. Many of them work for the Centers for Disease Control and Prevention, the Indian Health Service or National Institutes of Health. They serve with an easily recognized spirit of goodness. They live significant periods of their lives in conditions far below what they could, while accepting risks and personal hardships. God bless them.

Day 4 in India (Written Jan. 10)

It seems as if each day of my India trip has taken on a  theme.  The first day, Monday, was spent  understanding our efforts on HIV/AIDS in India.  Tuesday was a tutorial on the generic drug  and vaccine industry in India  and the role they play in providing products for the United States. I also spent time  with non-profits we support in a push against human trafficking.  Wednesday was devoted to a similar study of  the food industry and its connection to the United States. 

Thursday was devoted to meeting with government officials  and doing diplomacy events at a university.   In total, I held meetings with the Ministers of Health, Commerce,  Agriculture, Science and Technology.  In  each of the meetings we discussed our countries’ new strategy on import safety  and the impact it could have on Indian businesses. 

I also met with Dr. Samlee Pilianbangchang, the Regional  Director of the World Health Organization.   We discussed a long list of subjects ranging from HIV/AIDS, Indonesia’s  unwillingness to share samples of influenza cases and intellectual property  disputes.    

Whenever I visit another country, I like to do a diplomacy  event at a university where I can interact with students.  I think university students are a good gauge  of how the United States  is viewed and more importantly the direction of their thinking.  I also hope it is helpful for them to have  interacted directly with a senior official of our government — to find out we  are just people with lives driven by circumstances not completely different  from their own. 

In New Delhi I went to Jamia Millia   Islamia University.  It was a new experience for me.  I had not been on an Islamic campus  before.  The university has about 10,000  students.  About 450 attended mostly science  and medical students and faculty. 

The program started with a reading from the Koran, the  singing of the school song and opening remarks by the Vice Chancellor.  It is my practice to use a hand-held  microphone and stand on the front of the stage so there is nothing between the  students and me. 

I told them I wanted to divide our time together into three  parts.  First, I wanted them to know who  I am and to feel as if they know something about me as a person.  Second, I wanted to make one point that could  stimulate some discussion and give them an opportunity to better understand my  view of the world.  Last, I wanted to  reserve the majority of time for them to ask me questions. 

For 10 minutes or so, I told them about my life.  It included discussion about my parents,  brothers and home in Utah.  I told them about my wife of 34 years and our  five children and three grandchildren.  I  talked about my professional career and how I got into public service.  I went into some detail on the nature of my job  in the United States  government. 

The second part of my presentation was devoted to describing  how I see the world beginning to organize itself into networks.  I used product safety as an example. 

For the final section I invited them to ask me whatever they  wanted. I had been briefed by the embassy that I would likely get some  questions about matters related to Pakistan, Iraq and Afghanistan, so as an  introduction to the Q&A portion I told them there are some subjects on  which I will comment, but I want you to know I am neither an expert nor a  spokesman for the United States on those matters. 

The students interacted with me in a respectful way.  The questions were mostly focused on the  scientific relationships between the U.S.  and India.  Why aren’t Indian doctors recognized in the  U.S?  The price of drugs and intellectual  property protection were raised.   Students asked about the number of people who are uninsured in the United States  as well as matters related to mental health and stem cell research.   

There was one student who  read a statement critical of the United States  and our positions on the war in Iraq.   I told them the war in Iraq was one of those issues that  does not fall into my expertise but I did want them to know what is in the  heart of Americans and specifically President Bush.  I told them war is always awful and that for  centuries afterwards the motives of those involved are questioned and examined  by historians.  This war will be no  different.  However, in my private  conversations with President Bush it has become clear to me that he is most  devoted to the principle that every human being deserves to have liberty and  that no nation can provide another with a better gift than freedom.  Freedom is our goal and we will continue to  pursue that until the people of Iraq  and Afghanistan  can govern themselves in a sustainable democracy. 

In a previous blog I referenced a dinner the Ambassador  hosted at his residence. Two additional comments:  I enjoyed the way the dinner was organized.  There was only one table and it was  round.  So often one goes to dinners like  that and the group is divided into small groups sitting at different  tables.  It means you don’t have any  exposure to many of the people who attend.   As dinner proceeded, the Ambassador asked me to tee up a conversation  with some opening comments.  I recounted  the purpose of my India  trip and posed a series of questions at the end.  The dinner guests then weighed in and we had  a stimulating conversation that nearly everyone participated in. 

The second thing of interest was the embassy.  The United States Embassy in India is large,  spacious and beautifully designed.  The  Ambassador’s home is an image of the Kennedy  Center in Washington, D.C.  It turns out, the embassy was built before  the Kennedy Center and that they were designed by  the same architect.  Jackie Kennedy had  been at the embassy and asked that the same architect do the Kennedy Center  for the Arts.  The Kennedy Center  is the copy, not the other way around.

Day 3 in India (Written Jan. 9)

The Cochin region of India has been the center of the world’s spice trade for millennia. Apparently the soils and climate are perfect and the culture has been defined by the customs and moment and organization it brings.

The port of Cochin is where most of the spices are shipped. Early Wednesday morning our delegation met with port officials and inspected the operation from a boat. It looked like other ports I have seen. They have recently entered into an agreement with Dubai Ports to build a major expansion of the Cochin port. Much of the investment being made to build up India’s infrastructure is coming from private investment referred to as direct foreign investment (DFI). For example they desperately need airports so they have allowed 30 or so private airports to be built. The owners charge leases and landing fees to those using the airports. It generates jobs, and tax revenue but they are not required to use their cash or capital. In the United States we are able to have public construction with bonds.

The balance of the day was devoted to learning about the spice business. I visited Synthite Industrial Chemicals. Many of the businesses are family companies. I’ve found that to be true of many food-related businesses within the United States as well.

It is interesting that they view themselves as a chemical company and not a spice business. The processes they use to produce oils and extracts are similar to those used in large food operations and food processors. For example, they can produce a mustard oil that flavors other materials. French’s Mustard is a composite of materials that spread well, including a plant that is processed to provide the brilliant yellow color and a little dab of their mustard oil. They also create the chemicals used as coloring and fragrances.

They are a huge producer of black pepper. It strikes one when you see the size of their facility and realize it is producing 24 hours a day, just how many people there must be in the world to consume that much black pepper. It takes a lot of shakes and turns of the pepper grinder to use it all. Actually, with pepper they are finding ways to use an oil pepper to produce the same flavor. They just blend it in.

This is an interesting part of the world I knew nothing about. The customers for Synthite and others like them are “flavor houses”-- businesses that engineer the ingredients and processes of making food.

At lunch I met with a group of business owners known as the Spice Board. This is an entity organized by the government to facilitate and promote Indian spices. My sense was, they really get it. They can see the need to get ahead of product safety as a matter of brand protection and market enhancement. They have created a certification process that assures any spice leaving India in a few categories has been certified to a standard. It is a template for how many different industries and countries will handle product safety. If the United States, for example, can become comfortable that the certification of the Spice Board is to be relied upon, then we would treat any product holding their seal in a favorable way in matters related to customs and entry by allowing them easy and fast access into American markets.

The Red Pepper Principle

Our afternoon was occupied by a visit to another spice operation; this one, AVT/McCormick. The factory is surrounded by homes of the most basic form. The winding road into the plant is narrow but paved and so close to many of the homes that it provided an intimate view of the people who lived there. As we drove I was able to see inside yards and homes, even make eye contract with people. I enjoyed the drive.

McCormick has a big market share in the American spice business. They bought into this plant about 10 years ago. The processing is interesting, but I found the relationships between McCormick’s growers and customers the most interesting part of the visit.

Upon arriving I noticed some large burlap bags of red chili peppers. Sewn to each of the bags were yellow cloth tags with messages written on them. I was told the farmers were required to put their names, location the chili peppers came from and the date they were picked on the tag. The McCormick people told me this was a system they had implemented during the previous year as a result of a traceability requirement their customers were making.

The farmers who provide peppers and other crops to McCormick are people with only an acre or two of land. Most are unsophisticated but they are also part of a powerful political constituency in India. Unlike many parts of the world, poor people vote in India and the political officials are extremely sensitive to their desires.

It is highly unlikely that a requirement of traceability would have ever been imposed on the small farmer by the government. However, when customers made it a condition of doing business, the farmers accepted it or started doing business someplace else. Since McCormick is the most reliable partner in the market, almost all adapted. Let’s call it the Red Pepper Principle of Product Safety: Markets, not mandates, will drive improvement in quality.

The small farmer is a unique aspect of India’s economic and social challenge going forward. Like so many emerging economies, significant disparities are developing between urban and rural. While in Vietnam a couple years ago I saw a nation subdivided into plots of less than an acre. Forty-three million farmers worked the land by hand growing their own food and a little extra, which they sold. I asked their Agriculture Minister why more mechanization was not introduced. I understood how the social stability of their nation was linked to the system when he said, “What would those forty three million people do if they didn’t farm.” In India, the government wrestles with the same question except the number is more like 700,000,000.

At Ambassador Mulford’s home my second night in New Delhi, I had dinner with 10 people he had selected for a round-table discussion. Part of the group was a well-respected economist whose clear thinking I immediately admired. In response to a government official’s defense of protectionist policies to preserve the small farmer she said, “What you’re leaving out is they can change.”

Indeed they will change, but likely not because of government policy changes. People will avoid change intuitively and democracies follow. Over time, things will begin to change because of the only democratic force stronger than a self-interested constituency: an efficient market. A global market will require change for survival, and over time some will adapt. The McCormick red pepper farmers are a prime example.

This kind of change takes years. Many small farmers will resist adaptation, living out their lives raising food for themselves and selling the balance for subsistence. Others will be of a nature to accept change and seek greater prosperity. They will begin to join with others so they achieve economies of scale. They will implement new practices that make their crops attractive at higher prices because they are higher quality.

I have an agricultural heritage. My family bought the farm of my grandfather and as his generation died away, we bought their land to achieve the efficiency of scale necessary for survival. Today the collection of land that supported 21 families 50 years ago is farmed by fewer than three full-time workers. However, during the same time other things changed. The next generation of children sought education and earned their living differently than their forefathers. How to navigate such change in a nation with four times the population and one third the land? That is the question facing India in the next half-century.

Day 2 in India (Written Jan. 8)

Tuesday in India, I concentrated on drug safety by traveling to Hyderabad, about an hour flight from Chennai.  My first event was a visit to Dr. Reddy’s, a significant manufacturer of generic drugs for the American market.  I’m told there are nearly 100 facilities in India producing generics.  It is a major industry here and the United States is their primary market. 

The Chairman is Dr. Anji Reddy who 22 years ago began manufacturing active ingredients for other drug companies.  Four years ago, they decided to manufacture generic drugs of their own.  They are also working to get some original molecules approved by FDA.  They built a state-of-the-art plant that has been inspected many times by FDA.  They choose to do the manufacturing in India because the cost structure is so favorable.  They employ nearly a thousand scientists who are paid much less than American scientists. An HHS scientist working with me estimated the average Indian scientist would be paid around $2,000 a month, which puts them in the top social economic range. A comparable American scientist would demand six figures. 

The company feels the combination of circumstances creates a 25 percent or greater cost advantage.  The generic market is by nature a commodity, price-driven market.  I was impressed by the quality of the facility and some of the innovations I saw. This begins a clear pattern of Americans innovating and the Indians producing.  That will change over time, however, because it won’t be long until there is a steady stream of Indian molecular innovations in the FDA pipeline. 

I drove to a village called Thumkunta to talk with a group of non-profits who work with victims of human trafficking.  Nearly all travel is on narrow two-lane roads just overrun by traffic.  Pedestrians, motorbikes, small three-wheel taxis, cows, and large trucks all jockey for position.  There are few rules that seem to define navigation.  Most of the motorbikes have loads of three or more people, rarely with helmets.  Little children routinely sit atop the gas tank or sit on the lap of their mother who sits sidesaddle on the back.  They pass inches (no exaggeration) from the car as our motorcade picks its way through.

Commerce is everywhere.  Small store fronts, garages, small real estate offices, and some unusual ones.  A store front sign with a picture of an arm in a sling stands out.  The sign says: bone setting.

Evidence of emerging economic conditions can be seen.  We passed walled developments being built with small units organized like condominiums.  There were signs advertising home-ownership opportunities.  The eight to 10 percent economic growth of India is real but not uniform.

Once at the meeting with the non-profit leaders working on human trafficking, some discouraging realities set in.  Human beings can be so brutal and cultures so willing to turn their heads to it.  Trafficking in persons takes many forms.  People target young women who are either in serious poverty or being abused at home—or both.  They offer them employment in a glamorous setting and when they get them away, the arrangement turns into a horrifying situation where they are forced into prostitution, begging or other kinds of labor.  It can also be children who are sold by family members into labor.  The stories are simply awful and frightfully common.

Our nation has taken a strong position on trafficking in persons.  We are holding nations accountable for their actions related to it.  We condition much of our foreign assistance, for example, on a nation’s enactment and enforcement of laws prohibiting trafficking.  India needs to do a better job of it.  Much of it is based on long-held cultural values and practices that diminish the role of women generally. As discouraging as it is, I must say how grateful I am that there are people like the non-profit workers I met here and other places around the world who are willing to devote their lives to helping them. 

In the afternoon, we visited Bharat Biotech, a small vaccine manufacturer built by Dr. Krishan Ella and his wife Suchitra.  Krishan is an India scientist who spent many years in the United States. His facilities have been built to American standards and are regularly inspected by FDA.

It’s a great entrepreneurial story of people who sold their home, persuaded a couple of friends to believe in them and developed an industry in India.   While the cost structure here is clearly a major part of their success, it appears to me that their success has also been the ability to solve some problems others didn’t. That has been the foundation of their rise.

Interestingly, his business has another side story.  The first two vaccines he produced were given to him by the U.S. government.  They were available to anybody but no one had seen a way to make a market.  He used his engineering background and a group of Indian scientists who he hired to invent new processes to solve problems that otherwise would have required massive investment. 

It is remarkable how many of the people involved in these sectors have spent careers in the United States.  Most of them were educated in our country and spent a decade or more working in the U.S.

After a courtesy visit with the Chief Minister (equivalent of Governor) of the state Hyderabad is in, we talked about their challenge to implement a health insurance program and the problems of import safety. 

After a two hour flight to Cochen we bedded down for the night.

Chennai, India (Written Jan. 7)

I am in India for the week. My primary mission is to discuss import safety with the leaders of the Indian Government. While I’m here, I will also review our investments in HIV/AIDS, tuberculosis and pandemic preparedness.

Today I’m in Chennai, a city of seven million in India’s south region. This is my first visit to India. The complexity of the place was captured well by the Ambassador to the United States from India, whom I consulted with before I left. He jokingly said, “If you have heard anything about India, it is likely true—someplace.” He referred to the many different cultures. For example, there are 18 official languages spoken. Like China, there are stark differences between urban and rural parts of the country.

The most evident characteristic of India is the density of population. India is about one-third the size of the United States and has four times the population. Put another way, 15 percent of the world’s population lives in India on 2.4 percent of the land mass. Almost a third of the population is under 15 years old, and 70 percent live in one of 550,000 villages. This is one crowded place.

I spent the morning at Tambaram Sanatorium, attached to the Government Hospital of Thoracic Medicine in Chennai. Both CDC and NIH within my department have long-term relationships here. It is a major treatment center for HIV/AIDS. The hospital sees 1,500 patients a day, 33,000 a month and more than 400,000 a year. Being in a HIV/AIDS treatment center is always a moving experience for me.

Generally their patients have been tested some other place, and then come to this hospital to get counseling and a treatment regimen, along with the appropriate drugs. Patients then return about once a month to be checked and get their medicine. The process is similar to what I observed in Africa.

As I walked through the pediatric section, I was surrounded by children and their mothers. I was distributing toys I had brought to cheer them up. Through the crowd, I noticed a woman sitting on a cot. She was thin, dangerously thin, but strikingly beautiful. She must have felt my gaze, because she looked up and engaged me with her eyes. She slowly and deliberately mouthed the words “thank you.” Still surrounded by a press of people, I simply nodded and accepted her expression. We used no words, but communicated deeply. It was not me she addressed, but my country. Her expression sent gratitude to every American. Our compassion had given her hope.

Throughout the day I was with my friend Anbumani Ramadoss, the Indian Minister of Health and Family Welfare. We have known each other for two years now. He is young, charismatic and competent. He is a medical doctor by training, and the son of a prominent regional political party leader. Chennai is his hometown, and he is a popular figure here.

The United States and India have an active agenda of things we already work together on. Vaccines, infectious disease, HIV/AIDS, maternal and child health, vision and medical technology are just a few. Much of our conversation centered on food and drug safety and the Minister’s plans to create an equivalent of the FDA in India. I have offered technical assistance. Dr. Andy Von Eschenbach, Commissioner of the FDA within my department, is with me. Each of us will be putting a team together to work on this, much the same as we did in China. I still need to speak with other Ministers of the Indian Government on this matter.

Our collective teams sat down to review an agenda of items, and then had a formal lunch with about 400 people from the medical community throughout Tamil Nadu state. I directed my remarks mostly to import safety. Actually, I printed off the blog post I wrote on the five lessons I had learned dealing with import safety, and used it as an outline for my speech--an unanticipated side benefit of writing this blog.

The rest of the afternoon was spent visiting Loyola College of Chennai, to observe an HIV/AIDS awareness program called the Red Ribbon Club. They have just launched a curriculum for communicating prevention messages among peer groups of young people. It’s an impressive piece of work. We’re losing the battle when we just treat HIV/AIDS among the infected. We have to be in front of this, and prevent it if we are ever to be hopeful of stopping the epidemic. A lesson from Africa reinforced in India.

I was grateful for a two-and-a-half hour break before dinner with a group of community leaders. The jet lag and a cold I picked up over the holiday were beginning to combine against me. A short nap helped.

I always meet interesting people on these trips. Another I’ll mention today is Dr. Pratap Reddy, M.D. He is a trained cardiologist who worked at the Missouri State Chest Hospital for about 10 years. He returned to India to set up private hospitals. His company, Apollo Hospitals Group, now has 46 hospitals. I want to write more about this later, because one of their hospitals’ trademark characteristics is they make their results public, and post their prices. They have results that rival the best U.S. hospitals, and their costs are a fraction of U.S. prices. Many of their patients are from other countries, part of India’s medical tourism initiative; more on this later.