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**sharon sanders** · August 14, 2007, 09:55 AM

Re: Support for Participatory Government

Wading into Blogdom!

A couple of months ago, we had a successful experiment with our pandemic flu blog. It was done in advance of a conference on preparedness we had in Washington D.C. I found myself engaged in reading the comments and learning from them. So, I?ve decided to wade in a little deeper into blogdom by writing one for the next month or so. I?m going to see how I feel after that time period. I may continue; I may not.
The viability of my capacity to do this longer term, will be determined by time management considerations. I want to write my entries personally, rather than relying on staff. If I can do it justice we will continue; if not?we won?t. I likely won?t write everyday, but I commit to check in most days and will read as many of the comments as time allows. I have no idea how many comments there will be. I may try to reply to comments occasionally, but not always.
I expect some of my entries may only be a paragraph or two punched out on my Blackberry while traveling in a car or waiting in an airport. Anybody who uses a similar device understands the efficiency and the limitations (No spell check, for example).
I will have some help monitoring the comments. Our web management folks feel that is important. They have set some rules about how comments will be handled. I?ll leave management of that to them.
Most of my postings will typically be about something I?ve learned or experienced during the day. What I value most about this job is the remarkable opportunities it provides to learn and gain perspective on problems. I hope I can share a small part of it this way. I may also invite some of my colleagues at HHS to share some of their experiences.
There are an unlimited number of things to write about. This is an intensely demanding period. For example, I?ll be traveling the last two weeks of August in Africa to get a better perspective on our nation?s efforts to battle HIV-AIDS and malaria. I am in the midst of a special assignment President Bush has given me to lead a Cabinet level working group on import safety. The reauthorization of SCHIP must occur before the end of September and I?m focused hard on increasing the velocity of health information technology standards development.
Topics won?t be the rate-limiting factor here; time will. But, let?s give this a try and see what happens. I hope you will add to the value with your comments.

**Shannon Bennett** · August 14, 2007, 12:52 PM

Re: Support for Participatory Government

I see this as a wonderful opportunity. Secretary Levitt in an unprecedented move is opening the door for direct communication. He is even willing to use a medium he isn't comfortable with and use tools that may expose spelling and grammatical errors. We may for the first time have access to the highest levels of government in the U.S.. After the frustration of cover-ups and distortions we have witnessed by some foreign nations, I see this as a remarkable move. We will be able to offer advice, solutions, and expose flaws in the frameworks without going through intermediary filters. Let us please use this window in as polite a manner as possible. All of us here would like to move faster but,government doesn't work that way. Personal feelings about the administration need to be put on hold lest the window slam shut. Bravo Secretary Levitt, may this experiment reap positive rewards for you, us, and in turn for every other human being on earth.

**sharon sanders** · August 17, 2007, 05:23 PM

Re: Support for Participatory Government

From Montana: 8/16/07

Thanks to all of you who commented and wished me luck. I quickly reviewed all the comments. It?s clear the pandemic influenza blog is still generating conversation.
Several of you expressed interest in Tamiflu being an over the counter drug. I don?t possess the technical background to detail the challenges presented by that idea, however, I feel certain its status as a serious antiviral is a significant barrier.
I can?t remember if I mentioned on the pandemic blog that we are testing various distribution alternatives, including making available medical home kits with personal supplies of various emergency medications. CDC actually designed the kit and we have placed 5,000 of them in homes. We need to assure that families don?t break them open and use the medications etc. in advance of a true emergency. I?m told the first phases of the test have gone well.
We?ve also tested postal service delivery of medications in emergency situations in two cities with a third test scheduled soon. Those have been extremely instructive.
Tonight I?m sitting in a hotel room in Montana. I?ve got the television on in the background. Ironically, Charlie Rose?s program is about pandemic influenza. He has David Nabarro, Jeff Koplin, Larry Brilliant and a couple of others on. It?s a very thoughtful discussion.
My primary reason for being in Montana was to work with Senator Max Baucus. We visited a Boys and Girls Club in Bozeman.
One of the blog comments I read tonight was from Goju who referred to herself as ?an ordinary mom,? and said she was glad to have her health care concerns heard. The event I did with Senator Baucus was an opportunity he provided to hear from several ?ordinary moms? about SCHIP (State Children?s Health Insurance Program). Their situations were all a little different but all expressed how important it was to them.
They are right; SCHIP needs to be reauthorized before September 30th so no child?s coverage is endangered. There is significant disagreement right now between the Senate, House and Administration on what constitutes a low income child. We need to get reauthorization done and then get on with the question of how we solve the problem for adults and children who aren?t eligible for SCHIP or other programs for those in hardship.
I am a passionate believer that our nation, in a relatively short period of time, could organize a system so that every American could have access to affordable health insurance coverage; a topic for another night.
Friday, I?m headed to Africa. I hope to use this blog to record some of my feelings and experiences.
-Mike Leavitt

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**sharon sanders** · August 17, 2007, 05:29 PM

Re: Support for Participatory Government

"...I can?t remember if I mentioned on the pandemic blog that we are testing various distribution alternatives, including making available medical home kits with personal supplies of various emergency medications. CDC actually designed the kit and we have placed 5,000 of them in homes. We need to assure that families don?t break them open and use the medications etc. in advance of a true emergency. I?m told the first phases of the test have gone well.

We?ve also tested postal service delivery of medications in emergency situations in two cities with a third test scheduled soon. Those have been extremely instructive...."

This kind of information is extremely informative. Interesting options.

Thank you Mr. Secretary for continuing to participate in this new kind of public health delivery system.

**sharon sanders** · August 21, 2007, 03:02 PM

Re: Support for Participatory Government

(Written Friday, August 17, 2007)

I?m sitting on an airplane, headed to Africa. It?s a 15-hour flight, so I?ll write for a few minutes before trying to sleep.

I just finished reading the first volume of the briefing material. This looks to be an extremely valuable trip. I?ll be in South Africa, Mozambique, Tanzania and Rwanda. I want to see, first hand, HHS and U.S. Government research, programs, staff and partners in action, especially in the President?s Malaria Initiative and our work on HIV-AIDS. I also hope the trip reinforces partnerships with those countries. I?ll be doing some public diplomacy events in each country. I worry not enough people know all the things our government does in health diplomacy. We need to tell the story better. Health is a universal language; people always appreciate it.

The schedule is packed every day so it is unclear to me how often I?ll be able to post thoughts. At very least, I?ll have someone post pictures from time to time. We will be going into some remote areas and I?m not sure what my access will be to the Internet.

Speaking of the Internet?

Today we had an important meeting at HHS related to electronic medical record standards. The development of standards for interoperable health information systems is one of my most significant goals. I believe the standards required to make this electronic medical records system work have to be collaboratively developed among various stakeholders. About two years ago we created the American Health Information Community for that purpose. Rather than try to write much about it I will ask one of my colleagues to insert a link here to the AHIC website:

Access Denied

http://www.hhs.gov/healthit/community/background/

People have been talking about interoperable systems for years but the standards to make them work haven?t materialized. So, those who invest in electronic health records are isolated. Many others put investment off, waiting until the systems mature.

This is an extraordinarily complex problem but the biggest challenges aren?t technological; they?re sociological, i.e. conflicting economic interests and turf. AHIC has successfully created a place and process to sort through them in an orderly way. We are starting to make serious progress which you can read about on the website.

Our plan from the beginning has been to get the standards development process started inside the government and then once it is functioning create a non-profit entity that operates under a highly democratic governance system so the progress can be accelerated and perpetuated. I call the transition moving from AHIC 1.0 to AHIC 2.0.

The government will have to be the biggest participant in the process, but to get these things right, the entire health sector has to be at the table in a meaningful way. The federal government will not only be the biggest participant but we have also committed to use the standards developed there. The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time.

Today we held a meeting with interested people and organizations to invite their help in creating the non-profit entity and its governance.

The last several years I have become rather interested in collaboration as a large scale problem solving tool. I?m persuaded skillful organization of collaborations is a 21st century skill set. It is a close cousin to network theory. In fact, I think collaboration is the sociology of network building.
Our world is intuitively organizing itself into networks. Networks require standards to operate. The skills to navigate the creation and governance of networks constitute the next frontier of human productivity. Organizations and societies that learn to solve complex problems using these skills will begin to out pace their competitors.

The development of AHIC 2.0 is a significant venture. I?m optimistic it can produce a vitally important institution but it will require our best statesmanship to overcome the natural tension of competing economic interests and turf.

If readers have a chance to look through the AHIC website, I?d be interested to hear your thoughts.

One last thing...

My heart has been with my fellow Utahn?s who are suffering through the coal mine disaster near Huntington. As Governor of Utah, I got to know the people of that area well and I went into the mines several times, so I have a picture in my mind of the environment those rescue workers and the trapped workers are working in. I?m grateful for the courageous action of the rescuers; sad for the families and community; mindful of the excruciatingly difficult decisions the mine safety people are faced with.

They are all in my prayers.
-Mike Leavitt

**sharon sanders** · August 21, 2007, 03:08 PM

Re: Support for Participatory Government

(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.

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.

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.

**Niko** · August 21, 2007, 09:54 PM

Re: Support for Participatory Government

I did not post comments during the blog summit period. After being profundly touched by Sec. Leavitt's Aug 20th blog entry, I felt compelled to wirte the following message. (I don't know whether it will appear on his blog)

Dear Secretary,<o:p>
</o:p>
<o:p> </o:p>
As a Mom to three young children, we are struggling to pay for the latest backpacks and fashionable school clothes for the new school year. Gas prices and expensive medications are taking a huge bite out of our budget. <o:p>
<o:p> </o:p>
Your observations of the circumstances in <st1:place w:st="on">S. Africa</st1:place> have hit home. The post was a poignant reminder that we have never gone hungry, needed a comfortable safe shelter, nor faced life threatening illness. My children are growing up with 2 loving parents in the home plus supportive extended family. <o:p>
<o:p> </o:p>
Thanks for the reminder to count our blessings and to share with our fellow man to the extent we are able.
<o:p> </o:p>
Your post also brings to mind a correlation between the overwhelming circumstances currently faced in S. Africa and the potential catastrophe that will be faced by many communities around the world should a high <st1:stockticker w:st="on">CFR</st1:stockticker> pandemic occur. Orphaned children need to be carefully considered in inter-pandemic & post-pandemic planning.
<o:p> </o:p>
Thank you for continuing the dialog. May you be richly blessed in your efforts!

</o:p></o:p>

**sharon sanders** · August 29, 2007, 07:57 PM

Re: Support for Participatory Government

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.

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.

Posted on August 23, 2007 in Africa , HIV/AIDS | Permalink | Comments (4) | TrackBack (0) | Email this post |  
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**sharon sanders** · August 29, 2007, 08:01 PM

Re: Support for Participatory Government

Written Wednesday, August 22, 2007

Mozambique
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.

Posted on August 24, 2007 in Africa , HIV/AIDS | Permalink | Email this post |  
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**sharon sanders** · August 29, 2007, 08:30 PM

Re: Support for Participatory Government

Written Sunday, August 26, 2007

Tanzania
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.
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.

Posted on August 27, 2007 in Africa , HIV/AIDS | Permalink | Comments (2) | TrackBack (0) | Email this post |  
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**sharon sanders** · August 29, 2007, 10:27 PM

Re: Support for Participatory Government

US secretary of health praises South Africa's new AIDS plan

The Associated Press
Sunday, August 19, 2007

JOHANNESBURG, South Africa: The U.S. secretary of health and human services praised South Africa's new national AIDS plan on Sunday, but sidestepped questions on the dismissal of the country's deputy health minister who had been a driving force behind the program.
South Africa "has constructed a good plan," Mike Leavitt said at the start of a visit to South Africa, where nearly 1,000 people die each day of AIDS and an additional 1,400 are infected with the AIDS virus. "Now it must be executed in a way that makes good on the prospects it offers and the hope it can provide."
Leavitt was on a four-nation tour to highlight U.S. health care programs in Africa with a focus on HIV/AIDS and malaria, two of the biggest killers in Africa.
His visit follows President George W. Bush's call to Congress to double the initial US$15 billion (€11 billion) funding of the President's Emergency Plan for AIDS Relief, or PEPFAR.
The program helps provide treatment for 1.1 million people worldwide, with more than a million in Africa, but has been criticized for emphasizing abstinence and fidelity over the use of condoms in its prevention efforts.
The U.S. has this year invested US$600 million (€446 million) in South Africa, where an estimated 5.4 million people are infected with the AIDS virus, the second highest total in the world after India.
South Africa's five-year plan, launched earlier this year, makes reducing the number of new HIV infections one of its main targets, and aims to extend treatment to 80 percent of those with AIDS by 2011.
There is concern that implementation of the plan is under threat after President Thabo Mbeki — who has long been accused of playing down the AIDS epidemic — fired Nozizwe Madlala-Routledge as deputy health minister.
Madlala-Routledge had won widespread praise for her work in drawing up the plan. Her boss, Health Minister Manto Tshabalala-Msimang, has been seen as a destructive force because she has questioned the efficacy of AIDS drugs and instead promoted beets and garlic as a remedy.
Leavitt would not comment on the matter, but warned that "any country that does not aggressively move" to address the epidemic "will bear the unhappy results."
Briefing reporters, he said he would not be meeting with Tshabalala-Msimang as he had been informed she would be out the country, and instead would meet with the minister for social development and officials from the health department.
Kent Hill, assistant administrator of the bureau of global health at USAID, raised concerns about the increasing number of new HIV infections because of multiple partners, and said this was making treatment programs more expensive and unwieldy to implement.
An estimated 1,400 people are newly infected in South Africa each day, and the government has raised concerns about the increasing costs of anti-retroviral drugs.
Leavitt and his team said the United States was also involved in a few programs that encourage male circumcision following research that shows that practice reduces the risk of female-to-male transmission of HIV by around 60 percent.
"As a tool of prevention it is of some benefit," said Dr. Julie Gerberding, director of the Atlanta-based Centers for Disease Control. "But it is not a magic bullet."

nytimes.com

http://www.iht.com/articles/ap/2007/08/19/africa/AF-GEN-South-Africa-AIDS.php

**sharon sanders** · August 29, 2007, 10:35 PM

PEPFAR Information

PEPFAR is a method by which a U.S. President can request funding for AIDS.

U.S. funding for PEPFAR has risen from $2.3 billion in FY 2004, to $2.7 billion in FY 2005, to $3.3 billion in FY 2006, to $4.6 billion in FY 2007. For FY 2008, the current President has requested $5.4 billion.

Technical Difficulties

http://www.pepfar.gov/press/80064.htm

**JJackson** · August 31, 2007, 07:41 AM

Re: Support for Participatory Government

Response to 8/14 comment
In response to my first posting (Wading Into Blogdom), GSGS asked for an update on the H5N1 situation in Africa. I?d like to pass on a report given to me by Dr. Marina Manger Cats of the CDC, who is based in South Africa.

Dear Sir,

At the reception held in your honor on Monday 20 August in Johannesburg, we spoke very briefly about Avian Influenza Preparedness (my work at CDC South Africa) and you requested an update, to possibly use for your blog.

We were having a regional training on Avian Influenza Rapid Response Training in South Africa this week, from 20-23 August, for countries of the Southern Africa Development Community (SADC). I am giving you an update only now, after completion of this Trainer of Trainers course, to be in a better position to give a more up to date picture.

South Africa ? CDC Avian Influenza (AI) Pandemic Preparedness

Background

South Africa has developed its own Emerging and Re-Emerging Infectious Diseases Epidemic Preparedness and Response Guidelines (2006) and an Influenza Pandemic Preparedness Plan (2006). The National Department of Health (NDOH) is developing country specific guidelines for Highly Pathogenic Avian Influenza (HPAI) Pandemic Preparedness and Response, with the assistance of the National Institute for Communicable Diseases (NICD), based in Johannesburg. A ?roll-out? plan for provincial and district level training in HPAI preparedness and response has been implemented in 3 of the 9 provinces and is supported indirectly by CDC-South Africa (through funding to NICD), together with others.

CDC Areas of AI Activity

Preparedness and Communications
Surveillance and Detection
Laboratory Capacity
Response and Containment
CDC AI Focus:

Sentinel Surveillance
Rapid Response Training
Laboratory Strengthening
Outbreak Response
Infection Control
Communications
Overview

The NICD is part of the National Health Laboratory Services (NHLS), which consists of 3 geographic branches in the country encompassing 250 laboratories. The NICD functions as a reference laboratory for the region and has highly specialized expertise in house. For example: in the recent Marburg outbreak in Angola, NICD served as a GOARN (Global Outbreak Alert and Response Network) partner and reference centre.

With CDC AI funds (CDC?s Coordinating Office of Global Health 2006 and 2007), the NICD is strengthening its diagnostic capacity for HPAI. The Onderstepoort Veterinary Institute (OVI) in South Africa serves as a reference centre for diagnosing types of HPAI (in animals), and provides training of personnel for the Southern and Eastern regions of Africa in early detection and containment of HPAI.

Inadequate financial resources were identified as a major bottleneck to operationalization of national strategic HPAI Preparedness plans. Linkage and improvement of avian and human influenza surveillance, was identified as one of the main areas needing strengthening. The NDOH is interested in strengthening HPAI surveillance through training. The coordination between the veterinary and human health sector for HPAI preparedness, is also an area needing strengthening in South Africa, as it is in many countries.

Budget / Funding:

CDC Avian Flu funds for 2006 and 2007 for South Africa have been earmarked to the amount of USD 1Million for each year.

Training:

With CDC-South Africa and CDC-Kenya (GDD) support, a Rapid Response Training for HPAI Preparedness and Response for participants from 13 countries from the SADC region was held South Africa. This training was hosted by NICD from 20-23 August 2007 in Johannesburg with the assistance of CDC, FAO, WHO, USAID and with the concurrence of the South African National Department of Health. There were 54 participants from SADC countries as well as The Seychelles. The participants were senior human and veterinarian health epidemiologists, as well as laboratorians and health educationists. It was a unique opportunity for these professions to work together through HPAI preparedness and response (paper) exercises. It was also an opportunity to liaise with the NICD, which is a reference laboratory for the region.

Partners:
Partners for Preparedness and Rapid Response Highly Pathogenic Avian Human Influenza in South Africa:

South African Partners

NHLS (National Health Laboratory Services )/
NICD (National Institute of Communicable Diseases
OVI (Onderstepoort Veterinary Institute)
NDOH (National Departments of Health)
NDOA (National Department of Agriculture)
NOD (National Department of Defense )
NDFA (National Department of Foreign Affairs)
Private sector: SAPA (SA Poultry Ass.)
Other: Wildlife Conservation Society
Other Partners

SADC
AU-IBAR
UN Agency Partners:
OCHA
UNSIC
FAO
WHO
USG Partners:
CDC
USAID
IFRC
Sir, I hope this information covers some of the areas you are interested to know more about.

The support of the HHS through CDC and other USG agencies has helped to support local initiatives for HPAI preparedness. The challenge is to keep the interest and commitment in HPAI preparedness high on the agenda.

We are working on that and we hope that through your assistance, this will be continued.

Sincerely yours,

Marina Manger Cats, MD, MPH
CDC-South Africa Avian Influenza Officer

**sharon sanders** · September 12, 2007, 10:02 PM

Re: Support for Participatory Government

Rural Rwanda- Written Tuesday, August 28, 2007

To get a real look at developing nation?s challenges one has to leave the population center. On Tuesday morning we drove for nearly three hours west of Kigali to visit the Rubengara Health Center.
Rwanda is about the size of Maryland. It has around nine million residents. Rwanda is called the land of a thousand hills. It reminds me of West Virginia in that way. Everything is built on a hill, often a steep one. The roads are full of turns and often slow. Every scrap of ground is farmed, no matter how steep the grade or unyielding the soil.
Along the way I saw hundreds of people working the soil with hoes or picks. What I didn?t see was farm equipment, not a single piece. Surprisingly, I didn?t see any large animals either; no horses or cows. Goats were prevalent.
Most everyone walks. There are a few bikes. Anything being carried was generally balanced on their head carefully. Most loads appeared to be water, charcoal, sticks or leafy plants.
Those who didn?t walk or ride a bike rode in mini vans generally packed to overcapacity with ten or more people riding on three seats.
We drove on a paved highway the Ambassador said he thought had been built by the Chinese. The roadway is lined with banana trees and appeared well engineered. Because it was built onto the side of a hill like everything else, a drainage system had been built to cleverly avert erosion of the road.
There was no water collection or distribution system. Like so many things in remote areas, availability of basic necessities is made more difficult because of distribution problems. So it is with water.
Many of the road walkers carried yellow plastic water containers of various sizes to a series of water holes. As we passed the filling spot there were always dozens of people standing in line. It was clear this was both a necessary ritual to sustain life but served as a social event as well.
Small homes are scattered across the landscape. Almost all of them are constructed of mud bricks made by the owner. Some are covered with plaster; most have sheet metal roofs.
Rubengara Health Center
We arrived at the Rubengara Health Center which is operated by the Presbyterian Church of Rwanda. The mayor and Provincial Governor were both there as well.
I had three purposes in my visit. The first was to meet with representatives of two associations which have been formed by among people in that area who are living with HIV AIDS. Each group has about 120 members. They meet regularly to provide support and information. They each have arrangements where they cooperatively grow food which can be shared. We had an extremely candid conversation about their circumstances, how they got AIDS and emotional needs of the families. As we talked, several of the people told me about their children, especially those born after they were positive. None of the children were positive.
I also viewed an exciting development called TRACnet. This is a project the US Government is supporting through Columbia University. It is an electronic tracking system on patient data. The data can be input and accessed manually, over the internet or by cell phone. The data will create a powerful set of management and research tools. It could be the foundation of an electronic medical record. I was pleased to find there is a significant level of collaboration being done on this in Africa so the same standards will be used across the continent and around the world.
Before I left, we presented to the two associations 50 goats that will serve as the foundation of a herd. It will become an important part of their food cooperative. It was a fun and emotionally touching moment as this entire community turned out to express appreciation to the United States of America.
Tomorrow, I will write about my visit to the Kigali Genocide Memorial and the people I met there.

Posted on August 30, 2007 in Health Diplomacy | Permalink | Comments (1) | TrackBack (0) | Email this post |  
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