Advocating For Medical Diplomacy: A Conversation With Tommy G. Thompson

From: Health Affairs: 05/04/2004

The HHS secretary uses his position to help improve people’s health status around the world and right here at home.By John K. Iglehart

ABSTRACT: Health Affairs founding editor John Iglehart interviews HHS Secretary Tommy Thompson, who calls for closer integration of health policy and foreign policy, with the aim of improving the lives of vulnerable populations and serving the best interests of the United States. Thompson also discusses the indelible impressions of his travels to Afghanistan, Africa, and Iraq; the Medicare drug discount card program; and more.

Sermons From A Bully Pulpit

John Iglehart: In your stewardship at the Department of Health and Human Services, you have wielded the bully pulpit as enthusiastically as any secretary I’ve observed over thirty years or so. I think only Joe Califano approaches your record in this regard. What I’m wondering, Mr. Secretary, is this: Of the subjects you’ve pressed through the bully pulpit, where do you believe you’ve made the most headway in promoting the health interests of society?

Tommy Thompson: Several. First of all, prevention, which is key to really holding down health care costs. I have met monthly with different groups, from the fast-food industry, to restaurant associations, to the food institutes, to soft-drink makers, to many different corporate leaders, as well as with health insurance companies, to drive home the message of prevention, mainly on obesity. I’ve tried to make sure that people are aware of eating properly and exercising, and also have kept up my vendetta against tobacco smoking. I’ve challenged America, and I will continue to do so.The second area, of course, is the big emphasis on fighting HIV/AIDS, not only domestically but internationally. I’ve traveled to Africa twice, and we’re going to go again this November. Each time we go over there, we try to make sure that people understand that this president’s committed, I’m committed, to fighting the scourge on the continent of Africa, and we’ve raised the profile of the fight against the disease immensely. We will continue to do so.I also mention our tremendous effort to change the way medicine is practiced in America—namely, in regard to using more and better technology. In fact, I will be holding a conference on this subject relatively soon. We’re going to try and transform the way we practice medicine by higher and more uniform use of technology.

Iglehart: What have you found to be the most intractable challenge when you use exhortations in the bully pulpit, in terms of positive change?Thompson: The real problems are, of course, that everybody in Washington is fixated on terrorism and the war in Iraq. There’s not much attention paid to what I consider the really important issues facing America: how we’re going to improve the quality of health, how we’re going to improve medicine, how we’re going to improve patient safety, how we’re going to work on prevention. It’s just a sign of the times that everybody is more concerned about terrorism than they are about those things. I find this perplexing but understandable. And I have to find a way to shout above the noise and the rhetoric in order to get my message out there, which I think is a very positive message for America—one I would think America is willing and needs to hear.

Travels Abroad

Iglehart: As you mentioned, you’ve logged many international miles in your role as secretary—more, I suspect, than any other, perhaps than all combined.

Thompson: Probably.

Iglehart: In any event, what experiences have left the most indelible impressions with you?

Thompson: Well, the most indelible impressions, certainly, are the health conditions in Afghanistan and Iraq. We have been through Afghanistan three times. We’re building a maternal and child health teaching clinic at Rabia Balkhi Hospital in Kabul, because poor women and children in Afghanistan have very poor medical care. So we’re trying to highlight the issue but also, at the same time, do something about it: putting money into fixing up the Rabia Balkhi Hospital and sending people over from our department who actually help do the teaching. Many doctors in Afghanistan didn’t have any training whatsoever during the period of time when the Taliban controlled Afghanistan. They destroyed the books in the medical school, as well as the laboratory equipment. Many women were refused the opportunity to practice medicine, and the male culture in Afghanistan denied women the opportunity to be seen by male doctors. As a result of that, care was so bad for women and children that 1.6 percent of women in childbirth die. One out of four children die before age five. Afghanistan has the worst maternal death rates of any country in the world. We’ve teamed up with the Department of Defense and the Department of State, which are giving us some assistance in setting up what we hope will eventually become a first-class teaching hospital for maternal and child health.Second thing, in Iraq. What happened there was one of the most unbelievable things that happened to the medical system of any country in the world. In the early 1960s doctors in Baghdad were actually doing open-heart surgery. They were doing transplants in the 1960s. Bagdhad was a center of medical excellence for that whole region. Then Saddam Hussein came in and systematically destroyed the medical system because he was fearful of doctors. He starved it for money and resources and education, even destroyed the books. In fact, in a hospital I visited, the latest article there from the New England Journal of Medicine was, I believe, from 1998, and it had been duplicated and reduplicated and passed on among all of the doctors in Baghdad. That was the most recent thing they had to read about modern medicine.Saddam Hussein only appropriated $16 million for health in the last year he was in authority. That amount had to cover 1,200 clinics and 240 hospitals. He was paying doctors five dollars a week for medical care, and nurses, one dollar. Hospitals were not allowed to turn on the lights in the evening. Health care workers had to use candles to take care of their patients during the evening. He also would not allow the children’s cancer center to give children chemotherapy, because he wanted children to die so he could use it for public relations against America. He was one of the most maniacal despots that this world has ever known. I have said before, and still do say, that Saddam was the weapon of mass destruction. He destroyed a medical system that was outstanding, so now we have to rebuild it.Fortunately, a doctor who was driven out of Iraq in 1979, Dr. Khudair Abbas, who has been a surgeon for twenty-seven years in the United Kingdom, has come back to run the ministry of health. He’s doing a very good job of starting to rebuild it. People from our department are over there assisting him. The nice thing about all of this is to go over to these countries, Afghanistan and Iraq, and see what they have and see how we, in America, can actually help to improve the health conditions of an entire country.The third area, of course, would be my recent trip in the effort to eradicate polio. It was a great thrill to me, a lawyer, to have the opportunity to give vaccine to children—to actually be able to do the art of medicine. More than that, to be able to see these children who have so little, and be able to give them the opportunity to not be paralyzed because of this insidious disease that we have eradicated here in America but that has not been eradicated worldwide (we’re on the precipice, 784 cases last year in six countries). HHS has provided $139 million this year for funding the polio eradication campaign. My job was to highlight in Pakistan, Afghanistan, and India that we can actually eradicate polio. India had 250 cases last year; it’s down to eight cases this year. To give you an idea of the magnitude of this, they’re going to knock on every door in India, which is incomprehensible to me, and make an inventory of all children under age five to find out if they’re vaccinated against polio. Just think—we’ve only eradicated a disease once before in history, and that was smallpox. To be able to do it now with polio would be a remarkable thing for humankind. My little role is to highlight it and to do what I possibly can to encourage the government leaders of those countries to do what is necessary to bring this to reality.

Medical Diplomacy

Iglehart: The subjects you mentioned suggest a knitting of foreign policy and health policy.

Thompson: I call it medical diplomacy. I think we should be doing that.Iglehart: Do you see, going forward, the general need for the various agencies of government and Congress to think in a more integrated way about foreign policy and health policy?Thompson: I think it is the most exciting thing that we could do as a country. To be able to give people hope and a chance to have good health is a primary motivating factor for all of us, whether we come from Egypt, Afghanistan, or America. It’s a driving force. What better way to knock down the hatred, the barriers of ethnic and religious groups that are afraid of America, and hate America, than to offer good medical policy and good health to these countries?I have been talking to several different groups about medical diplomacy. I coined that phrase, and I did it for a reason: because I really think that it’s a way to further America’s causes around the world. Instead of worrying about any types of wars, if we could somehow substitute the integration of health policy with our state policy, I think we could accomplish a lot more.If we could somehow—like we’re doing in Afghanistan—get women and children energized for America about good health, I can’t imagine that they would turn on us and go back to a terrorist kind of operation. That’s why when we opened up Rabia Balkhi a year ago on April 21, it was absolutely remarkable: In the crowd were 750 women and children but just a handful of males.When I went to Africa, as part of our fight against HIV/AIDS, we went to a community called Tororo, outside of Kampala, Uganda, which took us four hours on a bus to reach. We have a clinic run by this department in Tororo. People there get around on motor scooters, small motorcycles—mostly Suzukis. The only thing I was upset about was that they were not Harley-Davidsons from Wisconsin; they were Suzukis. Anyway, the workers still accomplished the objective of going out into the villages where they don’t have roads. The only way to get there is by motorcycle or four-wheel-drive vehicle. Since late 2002, starting under my tenure, we have been giving antiretroviral medicines to people who are HIV-positive. This was the first time that these people had been able to have any kind of opportunity to live, to be able to stave off this insidious disease that has caused so much death and destruction to that continent.Anyhow, this trip had a delegation of a 103 people, and we each went into two homes. The two homes I went to had such a tremendous impact on my life that they actually changed me as a person. The first one belonged to Rosemary. Her husband died in 1994 from HIV/ AIDS, leaving her HIV-positive with four children. Her brother died in 1995 from AIDS, leaving her with three more children. In late 2002 she was on her deathbed, when our department—our wonderful people here—started giving her antiretroviral drugs. She was so far gone that people had started building her coffin. With the antiretroviral drugs, she recovered, and now she lives in a mud hut a little bit bigger than this table. They all sleep on the floor, except for her. She’s got a little rickety bed. She takes care of the seven children, plus her elderly mother, and she raises crops on two acres of land that she rents from her brother-in-law. You would think that a woman with so little and having so much responsibility would be quite beaten down and depressed. Au contraire—she was one of the most uplifting and visionary women I have ever met, without any kind of education. She told me, “I want you to know that I appreciate it, and I want you to thank America for giving me the opportunity to live so I can raise my seven children.” If not for her, these seven children would have joined the legions of orphans in Africa, which number somewhere between twelve and fourteen million because of AIDS. And she said, “You give me hope, you give me an opportunity.” I was so moved by her demeanor that I vowed to redouble my efforts to fight this fight in Africa.Then I went to see the next person, by the name of Sampson. He is a carpenter. Every morning he goes to the swamps and brings up wood, then he dries it and makes little tables and chairs for his living. He has three children: two girls, ages twelve and ten, and a little boy, age six. His wife died in 2001, and he buried her right outside the front door of their little mud hut, as a constant reminder to his children that they have to be careful so that they don’t catch HIV/AIDS. He also is HIV-positive, and he was also on his deathbed, but because of the generosity of this department and of America’s taxpayers, he’s alive.So we sat outside of his house drinking tea. I’ll never forget this. He looked at me, a person who has never seen television, never heard a radio, and cannot read. And he said, “Please thank President George Bush and the American people for giving me the opportunity to live.” I felt so good, John, about being an American, that I vowed to pursue medical diplomacy, from that moment on.I gave a speech to the whole delegation about an hour later. Bill Steiger [special assistant for international affairs] was there. He remembers me saying that. I don’t think there was a dry eye in the whole crowd. Everybody was tearing up as I spoke. I said, “This is what we have to do in America. We have to really start talking about medical diplomacy.” I coined the word on that day. That’s how it came about—as a result of this trip.I’ve been talking too long—you can’t ask questions. But I feel very passionate about all of this.

Iglehart: No—it’s a wonderful story.

Thompson: They’re wonderful because they’re true.