U.S. Senator Mike Enzi, Ranking Member on the Senate Health, Education, Labor and Pensions (HELP) Committee, traveled with a Senate colleague to Cote d'Ivoire, Botswana, South Africa, Malawi, and Zambia the first week of May 2012. When Enzi travels on official trips, he keeps an informal journal. The main focus of the trip was to see how American HIV/AIDS funding was being spent. Enzi met with American aid workers, diplomats, country leaders, Peace Corps volunteers and people from many different countries who care about their fellow human beings. Below are some excerpts/highlights from Enzi's journal.
President Bush, in 2003, shocked both sides of the aisle in his State of the Union Speech by suggesting a staggering sum of money that should be spent on stemming the AIDS pandemic in other countries. I got involved in the issues and wound up helping draft the bill ---- which passed both houses of Congress unanimously!!! Shortly after that, August 2003, several of us were sent to Africa to see what the problem was and how close we came to helping. I always wanted to visit all the continents and knew that meant going to Africa. Instead of picturing the jungles of Tarzan, I thought more of Egypt - riding a camel and climbing a pyramid. I have now been to Africa seven times - and have yet to see Egypt or the jungle.
Africa would be a shock to most any American. I often say we would be better as a country if every American young person had to visit a country in Africa - any country. They would see a level of poverty unknown to us. They would see a giving people who have nothing monetary to give. This trip was much improved from the 2003 trip Diana and I took. At that time HIV/AIDS was rampant in many African countries and continuing to spread in the United States. We knew relatively little about the disease. What we found was a disease spread from infected mother to newborn infant who, without treatment would live a sickly, painful life to no more than five years old. We saw villages having daily funerals. Caskets were made of paper mache and were reused. We saw and discovered entire teen generations wiped out. Grandparents were taking care of grandchildren from several of their own "children" because the "children", the parents, had died of AIDS. A single surviving grandparent might be responsible for 10 to 15 grandchildren from infants to teens. (For more detail see my report, Trip - Africa 2003)
We went from Côte d'Ivoire to Botswana to South Africa to Malawi to Zambia. We visited HIV testing centers, a transfusion center, circumcision clinics, maternity clinics, tuberculosis testing and treatment centers, malaria treatment and testing facilities, a cervical cancer testing, treatment and surgery center and villages to see their basic facilities and their form of "banking". We saw pharmacies, military facilities for soldier HIV/AIDS prevention and treatment, hospitals, orphanages, and some small business economic development. We met with parliamentarians, traditional leaders and even members of the faith community - all playing a major role in the life of the countries. I even got to speak to and swear in 36 new Peace Corps Volunteers.
Political tribulation in Malawi
We were in Malawi at a critical time. The President died in office on April 6. He had thrown the vice-president out of the party, but hadn't gotten her out of office yet which threw succession into a turmoil. Our U.S. Ambassador to the country, Jeanine Jackson was a tremendous help to the Vice-President, assuring the smooth constitutional transition by letting people know a rough transition could mean a problem for aid money coming in from the U.S.
When the President died, we were told that our trip would have to be cancelled. I suggested it was more important than ever as the U.S. could have a bipartisan delegation - one Republican and one Democrat, with some Senate longevity - supporting the new government on behalf of the United States. As it turned out, the visit was even more critical. The new President and members of the Parliament found that the previous administration had gone off the deep end in under-the-table- deals and the country was bankrupt. Rapid inflation made it possible for "insiders with access" to get dollars from the treasury and sell them on the black market for an instant 100% profit. The only solution is to let the value of the money float on the free market which amounts to a devaluation of the money instantly making everything more expensive for everyone - not a very popular political move. Senator Conrad proved to be an expert in this area and was able to emphasize to those in power the need to do the devaluation quickly to stop the bleeding. The catch is that the country would have to have money reserves to survive. Ambassador Jackson was already holding meetings with representative of the World Bank, IMF and donor countries regarding assistance. Our two-person delegation was in the right place at the right time to be able to help our very efficient ambassador meet some of these challenges while we still were able to see the level of HIV/AIDS work and improvement in that country.
I can't emphasize enough the capability and experience of our ambassador, Jeanine Jackson, who is career foreign service officer. She has had incredible assignments around the world to prepare her for this particular change. This is a case where we sent the best at exactly the right time. She is extremely efficient and her military career has given her a sense of organization and urgency. She is a list maker and a list completer. She and Mark, her husband, have taken assignments where they usually could be together. That often meant going to difficult places others did not want. So he too brings some sound counsel to the ambassador.
Great work by the Peace Corps
When I spoke to the Peace Corps Volunteers in Malawi I told of how special Africa is. I mentioned how Diana and I always wanted to visit all the continents but was honest in admitting that I pictured my trip to Africa as Egypt. But when President Bush told us of the amount of money he thought should be spent on AIDS primarily in Africa I wound up involved, helping that pass unanimously and then being sent to Africa to learn more about the problem. I said we have been to Africa seven times and have never made it to Egypt. But we have gotten to see many of the countries and left a little of our heart in each.
I told of our first trip to Africa where we met a retired nurse who emphasized the importance of gaining confidence wherever Peace Corps work is being done. She established health lectures that simultaneously trained the interpreters as lecturers. She saw a need to educate, particularly on sexually transmitted diseases. She knew of the stigma. She organized a series of eight lectures that started with handling headaches, later to backaches, eventually getting to tuberculosis and malaria in the seventh lecture. The eighth lecture, after she has gotten the confidence of the people gets to HIV and AIDS. Because of languages and dialects the interpreters are essential. The advantage is that as the interpreters followed her from village to village doing the same series of lectures, they learned the lectures and can carry on even when she is gone. She made a very astute observation of a need and filled it by slowly gaining the confidence of those she was working with. I also paraphrased the words of President John F. Kennedy, "Ask not what the village can do for you, instead, ask what you can do for the village." If members of the Peace Corps are successful in changing the people to look outward for opportunities instead of inward for personal needs, they will make a big difference. And no one in the Peace Corps has ever had to ask if they made a difference. They always knew they did.
No ordinary orphanage
The highlight of the trip had to be the visit to The Kasisi Children's Home in Zambia - home to 250 orphans at a time. This is a Catholic orphanage run by Polish and Zambian Sisters. The Mother Superior may be the most likable person I've ever met. Volunteers paint the walls of the different rooms with caricatures. Sister Mariola pointed to a purple hippopotamus and said that was her. You have never seen such love and management capability in one small package! Once every three years a Sister gets to return home for 20 days. She delayed her trip a week to take us through her orphanage. She has been there 28 years and seen over 3,000 orphans come through. Some are now doctors and nurses in other places. One got married in the orphanage chapel and Sister Mariola got to give her away. The Sister has one building for very sick kids. We met the young man who is "chief" of that wing. He looked like he was about 9, but short. When we left the room the Sister let us know he is 17 years old. We visited the different buildings and met lots of the delightful kids. All of them seemed very happy. Senator Conrad asked what counseling was done for those who lost their parents at about age five. She explained that they mostly love them a lot. They do have a counselor. But the best therapy seems to let them talk through it many times. Several women live and work there too. They mostly do the 24 hour care needed particularly with infants and being room mothers in the rooms of slightly older children. There is no age at which the children have to leave. It's their home and even when they get an education and a job they come back on weekends or holidays because they are family.
At the house with the older boys (jr. high on up) they introduced themselves. I was surprised at the number of biblical names until it occurred to me that many of them were probably named by the Sisters. They help with the upkeep and painting as well. She runs the orphanage on $220,000 a year. By my calculation high school tuition for the 18 boys and 19 girls has to be $50,000 of that a year. They also have to buy shoes, uniforms and books for elementary students. They have to buy formula for the infants. That runs about $10 a tin for 18 tins a day.
The preschoolers have two classrooms so they can "go to school" when the older kids go. Each of the preschoolers had to shake hands. One little girl in pink alternated between the classroom and the bathroom. In one nursery we got to meet some of the newest additions. One little girl was three months old and couldn't yet weigh four pounds. Another infant girl was three days old. She was brought by her mother who then passed away. Beside the pharmacy we saw the "Place of Rest", a table under a crying Mary, Mother of God, where ones who have died are laid until they can be attended. Much of what they are able to provide in medicine and facilities was provided through PEPFAR that I helped get started. Before the antiretroviral drugs, Sister Mariola said they buried about 18 children a month. That has gone down to one a month. Each child had their own bed, towel, clothes, and a pair of shoes for play and a pair of shoes for special days. There is mass every day. The Jesuits take turns coming. Senator Conrad and I were each given a painting by the student who painted it. We in turn gave them supplies; paint, sidewalk chalk, color crayons and soccer balls. We were greeted with singing and clapping. They sang us out to the bus when we left. While we were having some refreshment we were thanked for those who gave up a meal to give them HIV/AIDS drugs. If you visited there you too would want to give up a few more meals.
Less money should mean more focus
At meetings, in every country, when U.S. agencies made the plea for more U.S. money, we explained our financial situation as well as explained that the effort was to find some solutions to the mass deaths and to make a case for what their country could do to save the lives of their people. We told them they would have do more as we are forced to do less.
There is also a "branding" fight going on between U.S. agencies. Each wants their logo on projects they have a part in. Sometimes all partners are U.S. agencies. They need to understand they work for the United States and that the only branding needs to be Our Flag prominently displayed.
I heard a presentation by one USAID director about all the things they were involved in that needed more money to continue. I may have interrupted her by saying, "Don't you think you could be more effective if you focused MORE on LESS missions? Shouldn't you prioritize what you are most effective at and what makes the most difference?"
At one luncheon we were bombarded by every project person in the embassy about the need to continue funding. I did my litany about debt and the shortage of money.
Clinics and their African staff are familiar with doing more with less. At many of the clinics there is "duty shifting". That means shifting what is done, down one skill level so there are providers. In other words, what is usually done by doctors is done by nurses and so on down the line. For instance we saw one health care worker who does an examination for cervical cancer and performs a freezing technique to cure early stage cancer. This worker uses vinegar and a digital camera to make a determination about the presence of cancer. If she is in doubt, the pictures she has taken can be looked at on the internet by a doctor. The testing is promoted at community centers and HIV testing places and at circumcision clinics. A high number of the women with HIV/AIDS have cervical cancer.
Circumcision by men is sold as a successful reduction in their odds of contracting AIDS. Circumcision reduces the chance of getting HIV/AIDS by 60 percent and is the most effective prevention found so far. Of course, it also reduces the chances of the woman getting cancer of the cervix by a large percentage but that is not a big selling point to many men.
I learned that the way we coped with South African health officials who hated the United States in 2003 and put out the word that our medicines were to kill off Africans, was to go to the military who were losing trained soldiers. Like the civilian population four would have to be trained for each job because three would die before the training ended. So we were able to help the military and prove that the medicine extended life and improved the quality of life. Today's Minister of health knows the benefits of the U.S. PEPFAR program and is appreciative.
They've come a long way, but still have a long way to go
The big hospital in Soweto, South Africa that we visited that first trip has been greatly improved with accommodations for the interns and accommodations for the nurses. The city around the hospital has been dramatically upgraded to a town with real houses (although many of them allow a hovel or two in their small yard as rentals). It was built as a series of barracks, each with beds separated by hanging sheets sometimes. They were built ranch style because elevators were seldom operable, making it impossible to get patients from one floor to another. We visited a number of different kinds of wards, the most difficult being the infant pneumonia ward. Pneumonia is a very common seasonal ailment in South Africa. Many children can't breathe and die. The treatment is oxygen and antibiotics. But many clinics do not have access to oxygen or antibiotics. The oxygen alone makes a difference. I was thinking of how common for seniors the oxygen concentrator is that many have in their own home. I have trouble believing that a caring world couldn't find used ones for at least one at each clinic. We did hear of an organization that takes old medical equipment, repairs and revitalizes it and then ships it to where is most needed. That includes a wide variety including laboratory equipment.
We saw a Botswana clinic that has the first certified lab in their country. The shocking part is that all records are kept on paper in notebooks. The storage requirements alone are staggering, let alone the ability to find a person's record on a return visit.
In Malawi at a clinic we got to see a computer system they designed for keeping those medical records. More importantly, the touch-screen had yes, no and quantity entries only, so it was simple enough to be used even by their less skilled staff.
We were also surprised by how little privacy patients received when we were visiting. We went into rooms where patients were being treated. The waiting lines would also appall most Americans. Huge rooms were filled with benches closely spaced. Every bench was filled with people waiting and constantly moving down the bench to another bench and eventually being seen only to be helped and then directed to another line just as long to wait their first procedure. Often women were even sitting, closely packed, in aisles. On benches people sat close enough that a shoulder had to be in front of the next person to make more room.
At a maternity delivery facility in Malawi, most of the deliveries were by midwives. In the whole country about 73 percent of the women get an assisted birth. About 43 percent of the assisted births are in that facility. They sometimes come by whatever conveyance or walking will get them there and some come a month before their due date to be sure they will be there. The hospital does have barracks and food for them.
We met with the religious leaders of Malawi, some of whom had to drive four or five hours to get to the meeting. One was Seventh Day Adventist, another Catholic, a Lutheran, several Presbyterians from the various Synods, and a Muslim woman leader. It was amazing to hear what their churches were doing and able to do. Their biggest complaint was that the government wasn't reimbursing their private hospitals as promised. I was able to raise that issue when we met with the President.
We toured a "township" village with the traditional leaders of that village. These leaders are the ultimate authority in the village so we congratulated them on being pro-active and saving the lives of their people. The village consisted of homes made of mud bricks. Each house must have been eight foot by twelve foot. Apparently the floors were dirt. They had two windows for ventilation. Their property was probably four times the size of the house. An outdoor bathing/laundry area was given some privacy by the hanging laundry. A latrine and a garbage pit were located furthest from the house. Outside the latrine was a hand washing area. A gallon plastic container with the bottom cut out was suspended upside down and filled with water. A dipper of a plastic bottle had a wire handle to dip water out of the bigger container. The dipper could be hung beside the big bottle. A hole in the bottom of the dipper let a small flow of water out to wash your hands in. A bar of soap on a string was there too. Emphasis was on air drying the hands so they didn't touch dirty clothes. That had cut the incidence of diarrhea. Latrines had reduced the deaths from cholera.
The village had a Common Building where hygiene was taught in five lessons. Nutrition and exclusive breast feeding were also taught. (Mothers even with HIV were encouraged to breast feed as the medicine comes through the milk to the baby and prevents transmission of HIV to the baby about 99% of the time.) This is a change from the early days when it was thought the only prevention was to feed the baby formula - and most couldn't afford that nor is it as nutritious as mother's milk.) We also got a demonstration of a slow cooker that has been developed. A pot of porridge is put over a fire for 15 minutes to get it boiling. Then the pot is removed and placed in a bed of banana leaves and covered with a blanket full of banana leaves. The porridge stays hot for up to six hours and frees the woman to do activities other than cook. We got to see the healthy ingredients they used for the porridge. I'm betting few in America would eat it. One ingredient was potato leaves. The women who did the explanations and demonstrations were rightfully very proud. We learned what they were saying through an interpreter.
Community banking on a whole different level
We got to see a meeting of the community bank. Members of the bank assemble and sit on the floor in a circle. The metal box with three locks is brought out. The three women who have a key to one of the three locks go forward and unlocks their padlock. Accounting books for each member are distributed. Deposits are collected by a member stating the amount and giving it to the "teller" who verbally confirms the amount and records it. The individual enters the amount in the personal record book. Then people can purchase up to five "shares" the same way. A share is a portion of ownership in the bank sharing in the profits. Next, loan repayments are received with the same announcements and recording. Then members can make loan requests, giving an explanation of what it will be used for and how they will pay it back. At this point a couple of members related their stories. One lady bought the ingredients to make sweet beer (in other words she brewed a drink and then opened a bar). She was so successful she was able to repay the loan and be able to buy a case of Fanta (orange soda pop in bottles) which she also sold. I think she had the equivalent of a $60 loan for two months. The interest charged is 20% per month which is 1/3 the amount they can borrow from other sources. You also have to remember that the only profit that shareholders get is from that interest paid in. It was neighbors helping neighbors with a safe place to store some money. We asked about defaults. They have a procedure where someone who falls behind is visited by some of the members. If that doesn't work, one of the village leaders talks to them. They have never had a default. We got an abbreviated meeting that went on long after we left.
China's influence everywhere
In Malawi we saw a new Parliament building and stadium built by the Chinese (who always use Chinese laborers). In Zambia two stadiums are being built by the Chinese. Since the Chinese always get something in return, I am curious as to what deals had been made. In both countries there were new administrations. I am concerned about China's quest to obtain ownership of "Rare Earth" minerals all over the world including Malawi. There are very limited sources and the Chinese already own about 50%. Someday those deposits will be worth more than gold or diamonds, especially if China has a monopoly.
Country leaders and wrap up
We not only got to meet extensively with the President of Malawi, but got to meet with the President and First Lady of Côte d'Ivoire. We met with parliament members and leaders in every country. We met with the key new Ministers of Finance, of Agriculture, and of Health in Zambia. In Botswana we even met with the feisty lady who is Speaker of the National Assembly. In Malawi we met with seven Parliamentarians, five of whom were from the different political parties. Having them together for an evening at the Ambassador's invitation to her residence gave them an opportunity to informally work out some questions about succession and those who changed parties. President Banda had been the Minister of Women's Issues. We met the woman the President appointed to that ministerial.
In Côte d'Ivoire we saw a transfusion center where large numbers of people go to donate blood for free to save lives of people they don't even know. The cells in the blood that fight disease get to be so few in an infected person, that the person can only be saved by an infusion of blood. Not only do the centers collect and type the blood, they have to test it for disease as well. One clinic does the tests for all of Cote d'Ivoire amounting to about 2000 a day.
In Botswana a highlight was getting to meet with the Baylor Hospital Teen Club Leaders. Children who have HIV/AIDS from birth transmission from their mother have formed a club that helps kids adjust to having HIV/AIDS.