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

Iraq

Iraq Blog VI

Nothing Spared to Save Our Soldiers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Iraq Blog V

Meeting Prime Minister Maliki

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

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

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

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

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

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

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

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

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

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

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

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

Iraq Blog IV

Iraqi Health Outside The Green Zone

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

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

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

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

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

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

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

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

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

Secretary Leavitt talking with Doctors
Secretary Leavitt talking with Doctors

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

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

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

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

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

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

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

Iraq Blog III

An Iraqi Agenda for Health-System Improvement

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Iraq Blog II

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Iraq Blog I

Sleeping at Saddam’s Palace
Written October 17, 2008

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

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

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

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

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

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

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

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

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

Flight_to_iraq
Secretary Leavitt and Air Force crew on flight to Iraq

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

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

Iraq_accomodations
Sleeping accommodations in Saddam Hussein’s palace

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

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