In May, Senator Frist co-led a conference at CSIS entitled U.S.-Russian Global Health Collaboration. Given the outcome of discussion at the conference, the Senator produced this Op-Ed recently published in Foreign Policy.

What the Doctor Orders

The United States and Russia face strikingly similar health-care challenges -- providing a rare opportunity to strengthen their bilateral relationship.


On Wednesday night, U.S. President Barack Obama made a historic address to a joint session of Congress on the issue of health-care coverage and affordability. It is the banner issue of his first year in office, and Washington's top domestic priority. At the same time, nearly 5,000 miles away, in Moscow, legislators are undergoing a strikingly similar process to reform their health-care delivery system. Given the importance of the U.S.-Russia relationship and the similarity of the challenges confronting us, our two countries have a historic opportunity to expand our health collaboration and, in so doing, improve our diplomatic ties.

Thankfully, this process is already underway. At a summit in early July, Obama and Russian President Dmitry Medvedev announced a memorandum of understanding to expand cooperation on public health and medical sciences. The meeting also produced an agreement for Secretary of State Hillary Clinton and her Russian counterpart, Foreign Minister Sergei Lavrov, to co-chair a forthcoming bilateral commission on health collaborations.

But both countries can and should continue to do more. In May, Dr. Nikolai Gerasimenko -- vice chair of the Duma's Committee on Health Protection -- and I hosted a daylong discussion on the topic at the Center for Strategic and International Studies. Our objective was to generate a blueprint for a future strategic collaboration on health. The conference revealed a strong desire to build genuine partnerships around health on the basis of two key challenges.

The first is national demographics. Both Russia and the United States grapple with rapidly aging populations, with all that implies for the provision of health care and social services. Russia's problems are compounded by alarmingly high middle-aged male mortality and birthrates that are too low to sustain the current size of the population. Demographic regression, the Russian delegates emphasized, is the top health-policy priority. In each of our societies, efforts to encourage healthier lifestyles -- in diet, and alcohol and tobacco use -- will reduce chronic disorders, extend lives, and make for a healthier next generation.

The second challenge is the pressing need for health-care reform. Both of our countries struggle to balance the competing imperatives of high quality, equity in access and affordability, and containment of health-care costs. We are each in the midst of a historic effort to reform our health systems, bring about greater efficiencies in complex federal systems, and produce better health outcomes as a return on substantial investments.

Our dialogue also identified five choice opportunities that I hope will inform the next steps by the United States and Russia in building health cooperation.

First, there is much to be learned from each other with respect to lowering health risks associated with tobacco and alcohol use, especially among young people, including through public-education strategies and community engagement.

Second, in the face of the H1N1 pandemic flu threat, there is much we can do to improve surveillance and data use to bring about better global detection and response to emerging infectious disease threats. Even at the height of the Cold War, the Soviet Union and the United States worked together to create vaccines. Our countries could certainly benefit from such collaboration today.

Third, we should launch an annual U.S.-Russia forum on the reform of national health systems, with a special focus on financing, cost controls, and evaluation. Comparative effectiveness research across national boundaries is a vitally important undertaking. In particular, a U.S.-Russian initiative could include joint exploration of innovative approaches such as e-health and electronic medical records.

Fourth, we should engage in a discussion on how to best leverage our mutual efforts to support global health programs in those countries most affected by infectious diseases such as HIV, tuberculosis, and malaria. The Obama administration recently committed to billions in donations in this area, and Russia is emerging as a significant global health donor as well. Thus, the time is right for our two countries to more closely collaborate.

Lastly, substantial ongoing joint research, institutional twinning and professional exchanges could be expanded. This includes research and research training in alcohol abuse and related disorders, cardiovascular disease, cancer, and tuberculosis. These efforts could be broadened to encompass chronic-disease prevention and management and national health-care reform as well.

Health collaboration is a surprisingly powerful foreign-policy tool and one where U.S. and Russian interests converge. Expanded communication and cooperation will build on a history of collaboration that survived periods of acute strain. There is active interest in both our societies -- among universities, medical schools, research institutions, and private businesses, as well as key government agencies -- in joining such an enterprise.

I urge Secretary Clinton and Foreign Minister Lavrov to commission in the coming months a joint organizing committee charged with prioritizing issues, laying down a timetable, and agreeing upon some early concrete products. It could prove a vital platform for the health of our countries and the health of our bilateral relationship.

William H. Frist, M.D., is a former two-term U.S. senator from Tennessee and was the U.S. Senate majority leader from 2003 to 2007. He is a member of the Center for Strategic and International Studies' board of trustees.

Healthier beginnings

What the world can learn from Pittsburgh

Monday, September 14, 2009

By Bill Frist

When world leaders chart a course toward a more prosperous future at next week's G-20 summit, Pittsburgh can inspire in more ways than one.

The city built on steel has renewed its shine as a center for research and technology and become a model for economic comeback. When this recession recedes, Pittsburgh is poised to jump far ahead of cities where "rust belt" still rings true.

But progress is not measured solely in economic terms. Presidents and prime ministers should note a different kind of progress that Pittsburgh pursued and achieved in the years it was still building its first boom. This kind of progress has yet to reach many parts of the planet, but, in the interests of all, must.

Sustainable recovery and long-term economic growth depend on improving the well-being of the world's most vulnerable people and ensuring they, too, participate in recovery. To that end, improving the health of children and mothers is fundamental.

In 1920, Pittsburgh had the worst recorded infant mortality rate of any large U.S. city. Some of the oldest residents of Pittsburgh today started life with the same odds of reaching their first birthday as newborns in Somalia do now. One in nine babies died.

Several other cities also had dismal records, but Pittsburgh's last-place ranking prompted the federal government to make a case study of the city. After World War I, the United States had recognized that resilience and continued growth depended on healthy babies who would grow into strong, productive adults.

In "Infant Mortality in Pittsburgh," the Children's Bureau of the U.S. Department of Labor recorded diarrhea and pneumonia as the most-common infections killing babies in Pittsburgh. Remarkably, despite decades of medical advances and low-cost, easy-to-administer treatments, this still holds true in the developing world.

The study also noted that nearly half of Pittsburgh's infant deaths occurred in the first month of life from prenatal or birth-related causes. Today, this remains by far the most dangerous month of life in poor countries. Nearly 4 million newborns die every year, half on the day they're born.

In analyzing Pittsburgh nearly 90 years ago, the Children's Bureau wrote that most newborn deaths had already been "clearly demonstrated" to be "largely preventable." Yet, the kind of basic health services and practices that Pittsburgh subsequently embraced are still lacking in many countries today.


Krista Ford, Princeton University

September 9, 2009

The Beginning of Ramadan

The end of August has brought with it an amplified reminder of the cultural divide between America and Tanzania. The sighting of the first crescent of the new moon signified the beginning of Ramadan and because Tanzania has a sizable Muslim population the effects are quite noticeable. Ramadan is a Muslim holy month meant to cleanse the soul and express repentance for all the sins committed during the rest of the year. Muslims must, amongst other things, fast from dawn to dusk everyday for the duration of the holy month. The goal is to be pure in thought and deed, which means Muslims give up behaviors that are thought to be sinful, negative, or distracting from spiritual introspection and closeness to God. Less orthodox Muslims who usually don't are now wearing traditional Muslim clothing and in many parts of the city where there are concentrated Muslim populations you will find restaurants closed during the day and open late into the night. In Zanzibar, where something like 98% of the population is Muslim you can be fined if caught eating publicly during daylight. The most orthodox Muslims are so strict about fasting that they spit on the ground all day to avoid consuming their own saliva.

In my office this translates into about 1/3 of my co-workers skipping lunch while the rest gather together in the staff kitchen eating traditional foods and inquiring after one another's families. Personally, I'm amazed by the determination of Mariam, the office lunch lady. Because she is Muslim, she is also fasting but she still shows up everyday like clockwork to cook lunch for the office. Even though I eat breakfast every morning, my stomach always rumbles around 2 o'clock when the smell of fried fish, ugali (a stiff porridge) and pilau (a spice rice dish featuring potatoes, meat, and a tomato salad on the side) wafts its way up to my office. I ask myself daily how someone who hasn't eaten since before dawn can stir a pot of delicious smelling food at 2 p.m. and not partake.

I usually grab lunch outside the office at one of the local restaurants, but nowadays I feel guilty knowing that my chips (fried potato pieces similar to french fries) and mishikaki (meat skewers of either beef or goat meat) are stirring stomachs and tempting my co-workers from their spirituals paths.  Out of respect for what my co-workers are trying to achieve I've taken to quietly sidling out the door for an eat-in lunch or consuming something non-fragrant at my desk. This is, admittedly, lonely since my usual lunch partner is unavailable because he is fasting.

Ramadan will end on the first day of the next lunar month with Eid-ul-Fitr or The Festival of Breaking Fast. I'm not exactly sure how Tanzania will celebrate Eid. I've heard there'll be everything from gift giving, to visiting neighbors and friends, to money and toys for the kiddies and the widespread buying of new clothes. I'm not sure how much of this will pan out but one thing's for sure-Christians, Muslims, and school kids alike will have the time off because in Tanzania Eid qualifies as a public holiday. Since the Muslim calendar is a lunar one the occurrence of Eid is dictated by the phases of the moon. No one knows yet exactly when Eid will be but its predicted to fall on September 20th and 21st. Everyone is hoping that it'll be on the 21st and 22nd, creating the ever-so-rare four-day weekend.

I'm keeping my fingers crossed for a wonderful Eid celebration bur for now I'm enjoying the heightened visibility of Muslim ladies wrapped in beautiful scarves and men sporting tennis shoes under traditional Muslim dress, as well as the respectful and supportive solidarity showed by their Christian counterparts.

August 28, 2009

Xi'an, China

Terracotta Warriors

It's not all that easy to get to Xi'an, in the heart of China, when you are in Beijing or Shanghai, but since we have a day, we are off to see one of the great wonders of the world - one that man built 2,300 years ago but just discovered during my adult lifetime.

Situated geographically in north central China, Xi'an is ranked among the great historic centers of the world. From its early role in Chinese civilization as the center for the first empire from which "Qin" (I pronounce "chin") gave the West the concept of "China," this gateway to the fabled Silk Road also was the largest and most cosmopolitan city on earth during the golden ages of the Han and the Tang.

My geography of China is pretty basic but the way I think of it on the map is that the borders of China are the silhouette of a rooster - the head to the right and the tail to the left with two feet extending below. The two feet are the islands of Taiwan and Hainan. Beijing is located in the throat of the rooster and Xi'an is the heart. China has had a total of 19 dynasties (I think). Xi'an served as the capital of China for 1,100 years; it has been a city for 3,100 years. The four main dynasties while it was the capital, and probably the most significant four of all since they were so fundamental to establishing Chinese culture was the Zhou (I pronounce "Joe"), the Qin (the ‘chin"), the Han (the "hand") and the Tang (the "tongue") dynasties - sorry but this is the only way I can remember the names and come close to pronouncing them.

We spent the day in Xi'an, the whole purpose of which was to visit the famed terracotta warriors, one of the true wonders of the world. What amazes me is that this stunning archeological find occurred the same year I graduated from college. (What will be found next?). The buried army of Qin Shi Huangdi is one of the largest and most stunning archaeological finds of the 20th century. Discovered in 1974 by a farmer (farmer Young - we actually met one of the other 4 "founding" or "discovering farmers" at the museum), the warriors and horses have earned the distinction of being one of the Wonders of the World, deservedly so. The full-size terracotta army (so far over 1,000 have been excavated - of an estimated 8,000 that are believed to exist at the site) testify to the imagination and ingenuity of man and his commitment to be protected in afterlife. What you see when you visit is three buildings (one the size o fan aircraft hangar) that have been constructed over the sites that are being excavated - you see a stunning display of life-size sculptured warriors and horses. Pretty unbelievable and hard to describe.

The emperor had constructed an army of warriors to protect him in the afterlife. We were told 720,000 people spent 38 years constructing the 8,000 terracotta soldiers and horses. At the end of the project, all of the workers were sacrificed (killed) o that no one would know of the project - mass graves were found later. The terracotta soldiers were left as standing armies in large pits, with a ceiling constructed above them, and then 20 meters of earth placed on the ceiling (all beneath ground level) to hide the entire operation under the farmland That is why it took 2,300 years to find them. These warriors with their horses stand in these pits in battle-ready position, fully armed, battalion after battalion over several acres. At the time of the discovery back in 1974 Newsweek magazine described the eerie and monumental find as "the clay clones of an 8,000 man army."

That's as well as I can do describing the site. Karyn and Bryan and the rest all loved it. Add it to your bucket list.

Now we are off to Hong Kong.


Commentary: Ted Kennedy's death a loss for mankind

By Bill Frist
Special to CNN

Editor's note: Bill Frist is the former Republican majority leader of the U.S. Senate and a professor of medicine and business at Vanderbilt University.

(CNN) -- The telephone rang in the deep hours of a dark night after a heavy day for our family.

My mother, affectionately known as Dodie, had passed away just a few hours after my father had passed, the two dying of independent causes.

The call -- the first that my wife, Karyn, and I had received from any of our friends or Senate colleagues -- was from Ted and Vicki Kennedy. That is caring and that is love.

Imagine being in Nantucket with your non-sailing sons with Ted, the master of the sea, skippering his beloved wooden sailboat over from Hyannis, asking the boys to jump aboard so he could take them on a harbor cruise and tell them a bit about why his brother John so dearly loved the United States of America.

He focused time and energy on the young and the importance their lives will play in meeting the challenges of today and tomorrow.

You see, in our lives Ted Kennedy was more than the legislative lion of the Senate.

He was the young senator I first met as a college intern in 1972 as he patiently found the time to lay out the fundamentals of universal health care to our summer class.

He was the proud stepdad who with Vicki beat Karyn and me to every afternoon high school baseball game while our sons played side by side.

And he was the masterful legislative colleague who never sacrificed his liberal principles standing for the everyday person as we joined each other on the health committee as respective co-chairmen to write and pass bills on health care disparities among the poor, emerging infectious diseases such as HIV and avian flu, and preparing the nation and the world to fight bioterrorism.

His death is a loss not just for Massachusetts and the Senate, but for all of mankind.

The opinions expressed in this commentary are solely those of Bill Frist.

From Big Kenny Interview: The First Trip -- Impressions of Akon, SUDAN 2007

Love Everybody has helped with the facilitation of the Konyok School for Girls in Akon, Sudan. The school currently has 550+ students enrolled. Love Everybody's goal is to instill hope, strength, and excellence to all students who attend so they can prosper in life. Their motto: "Highlight the good, inspire greatness, and encourage mutual responsibility for the betterment of humankind. -- Love Everybody." Member of the Tennessee Global Health Coalition.

August 26, 2009

So, two years ago; October of 2007, my wife and I and several friends from the organization My Sister's Keeper from Boston and Dr. David Marks and Walt Ratterman from Sun Energy Power decided we were going to get together and go into the country of Sudan.  We went there and visited this village, which is basically a refugee camp right in southern Sudan, about 50 kilometers from the line of demarcation between there and Darfur.  So this is an area that people had fled into that had been pushed off of their land.  Like farmers.  My dad's a farmer, and I guess that's why it hits with me. 

They'd just been pushed off their land that they had fought for over a half a century.  This thing's been going on in Sudan since 1956, a full on by God civil war.  And then in 2005, the south of Sudan and the north entered into what was called the CPA, or the Comprehensive Peace Agreement, which was mentored and led by the U.S.  It's a good thing.  And they've been trying to keep that peace, and that's when the north started trying to push against the west of Sudan and push all the Darfurians out also.

And it's crazy to think that a person that lives over there and a person that lives over here, that there's any difference between them and that they shouldn't respect each other.  And so we decided after seeing this and going and visiting this village that Dr. Gloria Hammond from Boston had originally told me about.  I met her here in Nashville at an event where she was speaking, and she told me about the people in Akon and how we were both in this conundrum: there's a war going on where these people are being tormented and hurt so bad.  But you know, I'm a musician.  I can't go into a war zone.  She's a minister and a "nun", a sister and a doctor and an educator.  You don't put women in a war zone.  But get as close as you can to it and shine as bright of a light as you can possibly shine, and all that other stuff just has to go away, or at least stand on the sidelines and chill out for a while and see what happens when three, four, five, six, seven, eight, 900, 1000 girls are meeting underneath of a tree to get educated, to get an education, because they know that they can rise up and lead their people and lead their country and there can be peace.  And they can be friends with everybody, everywhere, and make music.

At the same time, you know, we got do what I call "due diligence."  I went in to make sure that the people that I had met and had organized with on the ground were really doing what they told me they were doing cause I didn't want to go; you know, I've worked real hard to get what I had, and I didn't want to blow it, you know, and end up being in some corrupt system somewhere where people are just pulling off the top. To me, it's easy enough to grow food and provide for your family.  You know, when you're going to step outside of that to try to take care of some other things, that's when it can get real tough.  But you know, if you use your noggin a little bit, go check it out, do your due diligence. 

Well, that's what we did.  We went in there, checked it out, and did our due diligence. So then, I mean, just so many amazing things happened.  The first plane we flew on, the cowling came off the left engine, and it was pulling that plane hard left.  Fortunately, we'd only been up in the air about 15 minutes, so we were able to circle back around, and there was another runway just outside of Nairobi at Wilson Airport.  We landed there, and ended up the only plane that we could get was a bigger plane, and they had to give it to us for the same price.  So we were able to carry in all the crates and all the people that we were carrying then, plus we picked up 300 refugee survival kits.  These are people who have been burned out of their homes, and this is enough to keep them alive for a little while until they can get somewhere or get to a village and get their feet back under them.

We flew to Akon. Dr. Marks saw about 300 patients in two days.  About a third of the people had malaria at that point, so he was just delving out all these pharmaceuticals that we had brought over with us in 21 cases that we carried through airports. 

So we move forward a couple years.  We go back there this year, right where I saw people take those refugee kits and start to establish themselves. Here's a doctor's clinic over here.  Here's a runway right here.  Something's got to keep happening here.  And kind of right in between them there's now a little village that exists, when there was nothing when we went there the first time.

At least I've got you up to now now.

More to come...

Wednesday, August 26, 2009

11 am


             Met this morning with the Minister of Health. The last time I was at the ministry we met just down the hall from the minister's office.  That was in 2003, and SARS had struck just the month before.  Allegedly the Chinese government has hidden the problem from its people and the world, but as the outbreak grew, the news exploded, and no longer could the government contain the news.  I was openly critical that day in our public meeting, representing the U.S. and world opinion.  Though my remarks had nothing directly to do with what was about to occur, the minister just hours later was summarily fired, a sign of recognition that China would officially change its secretive policy of minimizing the ongoing impact of SARS.  And the epidemic rapidly spread throughout China, Asia, and Canada, paralyzing travel and tourism, killing hundreds, and greatly diminishing economic growth for the next year of Asia and Canada.

             That was just 6 years ago.  Wow, things have changed.  Today, the Minister met with me, my son Bryan, brother Tom and Chuck Elcan and Henry Zhou.  Though one of the main purposes of the meeting was to discuss how we as a government and we in the U.S. private sector could work with the Chinese government and their private sector to address the health challenges the Chinese people are experiencing today, I in particular wanted to get a full understanding of what China was doing in their major domestic reform efforts announced in April.

             Before outlining what I learned, I should point out that being a doctor in China is not very remunerative.   In a web-poll conducted by, 75 percent of the 2,183 doctors surveyed earned an annual salary of less than 40,000 Yuan ($5,883).  These data and much of the content of the discussion below were gleaned from my conversation with Elizabeth F. Yuan, R.Ph. who is the Health and Human Services attaché to the Embassy.  Her discussion at the U.S. embassy yesterday combined with the discussion today with the Minister of Health are the background for the following summary of health reform in China as it stands today.

             China's blueprint for healthcare reform was released on April 6 and has been heavily promoted by the official Chinese media.  My interviews and interactions over the past two days with health experts in Beijing, visiting infectious disease hospitals and doctors, talking last night to local Chinese businessmen, interviewing our ambassador and health experts a the embassy agave me a tremendous opportunity to leave behind for a few days all of the reform discussions in the U.S. and to see how another emerging country is approaching health care reform on a massive scale.  I wrote this today, but over then next several days of discussions I may well modify these observations.

              The overall scheme aims for universal healthcare coverage by 2020.  In the initial 2009-2011 phase, China intends to invest $124 billion in five broad reform areas: 1) basic healthcare insurance, 2) a national essential medicines program, 3) improvement of the rural health care service network, 4) elimination of the gap between urban and rural healthcare, 5) and continuation of public hospital pilot projects.

             The 5 areas parallel much of what we have and are attempting to do in the U.S.  We are shooting in the U.S. for universal coverage overnight (and won't get true universal coverage for another 5-10 years, I predict).  We in the U.S. did the national drug program (2) when I was Majority Leader. And in our major health bills like the bill we passed in 2003 and the Obama bill which will pass in November, there will be a number of significant pilot or experimental projects which importantly will allow some determination of what works and what does not before a proposal is adopted nationally (too risky - I am a big believer in these pilot projects!).

             One of the things we are seeing in the U.S. is reform from Washington being dictated at the federal level, but in the end (as feared by many governors) much of the cost of universal care and reform will fall to the states.  Governors ask, where is the money going to come from (for example the potential doubling of Medicaid under the Obama plan is funded more than 50% by the states - but where are they going to get it? - obviously taxes will have to go up on everyone).  Similarly in China about 60% of the proposed reform spending will be paid for by the provinces, though their reform is mandated by the central government and communist party.  How are the poor provinces going to come up with the money?   Thus, will the ambitious reform really ever take place?  The parallels with what is happening in the US with a paternalistic government mandating huge spending at a time of recession and an obvious inability to pay for it are striking.

            The following is only for the policy wonks and much too much detail for the average reader.  But I love this stuff (and it leads to greater understanding of overall health reform globally and domestically):

            The key features of the announced plan include the following:

`           1.   Government support for the construction of 2,000 county-level hospitals and thousands of urban community clinics;

            2.   Training sessions for village and township medical clinics and urban community medical centers. Specifically, China hopes to train 360,000 health care professionals for township health centers (this seems like an impossible goal to me but at least they are shooting for the sky.  And what I am finding on the ground is not an absence of facilities or even pretty good equipment but an absence of trained human healthcare capital (i.e., people).

            3.   160,000 for urban community health institutions in three years;

            4.   Coverage of 90 percent of rural and urban residents with basic medical insurance by 2011.  By 2010, subsidies to the Urban Residents' basic medical insurance (URBMI) and the New Rural Cooperative Medical Scheme (NCRMS) will be increased to RMB 120 (US$17.60) per person per year.  The maximum amount payable by the Urban Employees' Basic Medical Insurance (UEBMI) and URBMI will be increased to six times the annual average salary of local employees and disposable income of urban residents.  The maximum amount of the NRCMS will be increased to over six times per-capita net income of local farmers. (The importance of the expansion of the social insurance program is much more important that what I initially thought.  Why?  Because the Chinese people, today without much in the way of social insurance, keep saving knowing that someday they will need it for health;  this excessive savings means that they don't spend today, which is clearly needed not just in times like today but in all cases of growing economies).

            5.  A list of national essential medicines was released in August 2009.    It consists of 205 chemical and biological drugs and 102 traditional Chinese medicines.  This is a big deal because supposedly the Chinese people will have success to these in the public hospitals (98% of hospitals are public).

            6.  Increasing government regulation of medical services and prescribing practices to avoid over-prescription to fund hospital operations.  ((This was also surprising to me.  About 50% of hospital budgets come from the charges associated with excessive prescribing of medicines.  Hospitals literally operate on the profits they receive from the medicines they prescribe and dispense.  That is all over the country.  My obvious question was, "If you close this source of hospital revenue, what will replace it?  How will these hospitals stay open?)) The Implementation Plan includes wording to increase public disclosure of hospital budget, expenditure, and revenue management information.

            7.  The Government's plan calls for continued pilot projects to reform public hospitals.  In the key area of hospital funding, which underlies the problem of relying on drug sales and expensive diagnostic techniques, the plan calls for gradual changes to service charges, drug sales, and fiscal subsidies.  The goal is to make service charges and fiscal subsidies the primary channels for funding public hospitals.

            I can't wait until the business and medicine course I teach at Vanderbilt begins this year because I want them to look at the following argument and see what they think on the relationship among this plan, rural consumption, and rebalancing: In the official media, Chinese academics argue that increased healthcare expenditures under the plan will help reduce precautionary savings, thus increasing domestic consumption, helping to rebalance the economy to rely less on exports and investment.  Official media reports that the plan will help reverse the trend in who bears the burden of medical costs, in which the share of personal spending on medical services has doubled from 21.2 percent in 1980 to 45.2 percent in 2007, while Chinese Government funding has dropped from 36.2 percent in 1980 to 20.3 percent.  (Note: This data is based on official records.  Because many doctors and hospital fees are paid covertly in 'red envelopes' (gratuities) directly by the patient, the proportion of private medical expenditures are likely even greater.  In my discussions with a broad range of people I estimate that private out-of-pocket medical spending is probably 60% of all spending.

             Again, I want to thank Elizabeth F. Yuan at the American Embassy for explaining so much of this to me yesterday after I met with Ambassador Jon Huntsman  Our embassies do a remarkable job.  I also wish to thank the Minster of health in china who so generously gave of his morning today.  I have much more to learn.


August 26,2009

Today Karyn and I feel the deep loss of a personal friend.  In our lives Ted Kennedy was more than the legislative lion of the Senate.  He was the proud sailor who introduced our sons to the spiritual element of sailing on his beloved wooden sailboat in Nantucket, the young senator I first met as a college intern in 1972 as he patiently found the time to lay out the fundamentals of universal health care to our summer class,  the proud step-dad who with Vicki beat Karyn and me to every afternoon high school baseball game while our sons played side by side, and the masterful legislative colleague who never sacrificed his liberal principles standing for the everyday person as we joined  each other on the health committee in writing and passing bills on health care disparities among the poor, emerging infectious diseases like HIV and avian flu, and preparing the nation and the world to fight bioterrorism.    His death is a loss not just for Massachusetts and the Senate, but for all of mankind.   

 --Senator William H. Frist, M.D.

August 25, 2009

Final Reflections

by Glenn Quarles

As much as I hate to say it, my time in South Africa has now come and gone. Calandra Miller and I safely arrived back on American soil at 7:30 AM on August 6, 2009. At the time, I could not say the same for our luggage, which remained (safely) in Johannesburg, South Africa.

The last couple of weeks spent in South Africa were bittersweet, to say the least. I was looking forward to coming home and seeing my family and friends once again, but at the same time I was having to say goodbye to many good friends and, what I consider to be, family back in South Africa. The volunteer girls, Betty, Eva, and Engelinah treated us to some milkshakes as a going away present. This was a distinct honor to me, because what we might take for granted in the United States, they had to budget for weeks in advance. We also spent some time celebrating with Stefan and his family, the Wiids (the family who hosted me in their cottage during my stay in SA), and Pastor Dave Garton and his wife Gail (who run the rehab program that Project HOPE is partnering with). In the midst of our imminent departure, I took some time to reflect on what I was doing and had done since arriving in South Africa.

My purpose for being in South Africa was to assist in the fledgling steps of a promising program targeted towards orphans and other vulnerable children. Calandra and I had the distinct privilege to contribute our work to laying the foundation on which this program could get started. Much of this consisted of doing what many would consider mundane: data collection. Day in and day out we went door to door asking the same questions for our rapid needs assessment. After all was said and done, we had a grand total of 185 caregiver surveys and 266 parenting maps for children. This data has since been used by Project HOPE for grant proposal writing and other fund raising endeavors. All of our labors brings to mind a famous quote from Dr. Irving J. Selikoff, "Statistics are human beings with the tears wiped away." I can now whole-heartedly attest first hand to this, and with nearly every interview was reminded of why I was there.

My translator and I entered into a dimly lit home constructed entirely of sheet metal where we found a frail middle-aged woman crouched down washing the red clay dust off some furniture in her small room. She was obviously ill, and barely had the strength to stand and greet us with the customary handshake. Yet, when asked to take part in our survey she eagerly agreed and carefully sat down on the edge of her bed. Throughout the entire interview the woman provided responses through restrained whimpers and sobs. The questions I asked were simple, non-intrusive, and were not targeted toward specific health conditions. I could only assume it was due to her being overwhelmed with her health and living conditions. At the conclusion of our interview, she pleaded for any help we could give her, but all I could do was offer her a hug and a promise of my prayers, which she gratefully accepted. For many, the only hope they have is their faith in God to deliver them from their squalid conditions.

While walking through the dusty, debris ridden streets of the Zenzele settlement with Betty as my translator, I saw three men sitting on buckets in front of their home singing a song. I didn't think much of it, and continued on to the next person's home to conduct another survey. About 20-30 minutes later, we emerged to these same three men singing the same song. I asked Betty what they were singing out of curiosity. "God have mercy on us," she said.

Unfortunately, many of these people will not find much refuge from the currently overwhelmed healthcare system in South Africa. Residents of these settlements have told us that healthcare providers will often mistreat or even completely overlook them when it is discovered that they are not native South Africans. This is only exacerbated by the physician strikes taking place all around the country due to poor salaries and working conditions.

This is not by any means encouraging for a woman who volunteered for a field test of the Munsieville Survey Calandra and I had designed for Project HOPE. She was 23 years old, and spoke English well enough for me to conduct most of the survey without Betty's help. Within this survey were much more detail oriented and intrusive questions, including those that asked about sexual behavior. After completing the field test, Betty and I struck up a conversation with this woman to discuss the strengths and weaknesses of the survey. When I least expected it, she volunteered to us some extremely sensitive information that she would only entrust to her closest friends and family. She had AIDS. On top of this, she also told us that she had recently been diagnosed with breast cancer in her left breast (which she reported only having pain medications for). Her live-in boyfriend and sole bread winner for the family (making about R800 per month, or around $100 U.S.) also had AIDS. While he was at work, she was responsible for raising their young 2 year old child in the small shack they called home. I was deeply honored by her telling this to us. It was as though she trusted us, as representatives of East Tennessee State University, Project HOPE, and Hope Through Healing Hands, like we were family. She understood that we were there to help and wanted to change the conditions that they lived in for the better.

Even though she was just one year younger than myself, I couldn't help but think about her as a child no more than 10 years ago. There was no one around to teach her safe sexual practices, or to help her get a proper South African identification card. There were no concerted efforts to give her the proper education she needed to become an empowered woman and begin the climb out of poverty's grasp. Then it struck me. This is why Calandra and I are here. This is the spirit of public health, to prevent terrible outcomes like this regardless of where they come from or what gender they are. Though her story was transformed into categorical and continuous variables in a database, her story, in conjunction with many others, will be used in research by Project HOPE and its partnering organizations to help prevent suffering like this for future generations.

I feel honored to have taken part in Project HOPE's endeavors in South Africa. Without Hope Through Healing Hands and the Frist Global Health Leaders Program, it would not have been possible for me to contribute to this great cause. Through this experience, I have gained tremendous into what it is like to operate a health campaign in a foreign country, something that I plan to pursue professionally when I am finished with my formal education. I am forever grateful for having this opportunity, and will carry what I have learned from this experience for the rest of my life.

August 24, 2009


Today, after meeting all day with health reformers in China, it is clear that partnerships with U.S. academic institutions are important to build capacity and institutional support here. 


At Peking University, Dr. Ke Yang, Executive Vice President of Peking University (PKU), enthusiastically described the great results of a Duke-Peking University two-week global health diploma program with the School of Public Health.


By email, my friend and global leader at Duke University’s Global Health Institute, Mike Merson, M.D. also told me of Duke's training program in cardiovascular disease at Peking University Health Sciences Center and their partnership in a new Center of Excellence in Cardiovascular Disease Research led by Yengfeng Wu, M.D., Ph.D. that is based at The Georges Institute in Sydney, Australia.


And at Vanderbilt University’s Institute for Global Health, global health leader Sten Vermund, M.D., Ph.D. tells me Vanderbilt has a twelve year partnership with two sides of the Ministry of Health for training, the Foreign Loan Office and National Center for AIDS.  They have strong research ties in Guangxi, Xinjiang, and Yunnan Provinces (one large ongoing study in the former two provinces). Also, they have a special partnership on rural health management training that Governor Bredesen and Commissioner Matt Kisber have co-initiated and sponsored.  In fact, there are other VU links to China (history, business, education, etc) including the partnerships between Fudan University and VU as "peer partner institutions."


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