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I N T E R V I E W
T H O M P S O N  &  I G L E H A R T
W E B  E X C L U S I V E   

4 May 2004  
  

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

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.

Medicare Drug Discount Cards

Iglehart: Let’s turn now to Medicare. Drug discount cards are coming along. Obviously, they are going to take effect here before long. What’s your sense, Mr. Secretary, at this point, of where the likely greatest impact will be with those cards? Will it be on the discounts that are offered to beneficiaries, or will it be some crossover in terms of the price information that is released, to improve the comparisons that not only Medicare beneficiaries, but the entire population, can make?

Thompson: Both. This will represent an opportunity, as you’ve indicated, for cost comparisons. We have never had such a source before—prices for 209 categories with a minimum of three drugs in each category. This information is going to be available not only to the drug card holders. It’s going to be available to you, as a reporter. It’s going to be available to every business leader in America, to every member of the House of Representatives, to every member of this department. We’re going to update it every week, and we’re going to be looking at those comparisons. This is going to drive prices down. You can take that to the bank; you got it right here from me. I keep saying this, but people don’t write about it.

The price comparisons will definitely be affected by the demographics of the elderly; that’s a market the drug companies will not want to lose. So if you are one of the companies that manufacture one of the big-selling statins—Lipitor, Zocor, and so on—you’re going to be watching those cost comparisons. If one company starts reducing its prices, the others are going to be forced to do the same. That is going to have a huge impact. That’s number one.

Number two, if they are charging lower prices to one of those discount cards—and there will be at least thirty-nine national programs and thirty-three regional ones—you’re going to be looking at those and saying, Wow, why can’t my company get the same prices? And then, the HMOs and hospitals are going to say, Why are they selling that drug cheaper to that card company than they are to me? It’s going to have an accelerating effect, to make drugs more price-competitive. We’ll be much more knowledgeable about drug pricing. We will be much better shoppers and better able to pick and choose. When you factor in the effect of generics, that amounts to the ability to really compare prices between patented and generic drugs in more than half of the 209 drug categories. This is going to be a real eye-opener and will have a great impact on pricing in America. At the same time, it’s going to give our seniors a chance to compare costs. They’re the best price shoppers in the world. This is all going to come to fruition here under my watch at the department, and I’m really excited about it.

Advance Of Technology

Iglehart: You mentioned earlier your interest in the electronic medical record. What’s your sense, at this point, of the major obstacles that are preventing physicians from adopting that technology more aggressively than they have to date?

Thompson: As you know, I’m a lawyer, so I look at medicine trying to find a practical way to improve it. Look at going into a grocery store. Grocery stores are more technologically advanced than hospitals and clinics. You go into a grocery store and you check out groceries, and you have an individual there who may be a freshman, sophomore, or junior in high school—maybe a C student or a D student—but he or she never makes a mistake. The computer does it all.

Compare that to a hospital, where you still have doctors writing down prescriptions—and doctors’ handwriting has not improved at all. Then nurses have to try to figure out what the doctor wrote. Just one letter change on some of these patented drug names can give you a different drug. After the nurse deciphers the prescription, he or she has to go down to the medicine cabinet, unlock it, find the right drug, and wheel it back to the patient. In the meantime, the nurse could be stopped three or four times, and the drug might not be delivered to the right person, or the right amount given at the right time, causing a lot of mistakes and too many deaths in our health care system. If a computer handled these drug orders, it would drive down mistakes, improve quality, and therefore improve the cost ratio a great deal.

You asked why this isn’t already being done? Well, it’s because the standards aren’t uniform. Number one, at the conference I mentioned earlier, we’re going to roll out the first five standards we’ve developed. I think we’re going to adopt somewhere between seventeen and twenty-four standards in all, so that there will be uniform standards for software across America. Number two, we are going to roll out what we call SNOMED [Systematized Nomenclature of Medicine] Clinical Terms. We have licensed the technology on a uniform lexicon of therapies and treatments for all diseases and illnesses, and we’re going to give that out, free of charge, to doctors and clinics and hospitals across America, starting sometime in May.

Number three, we’re going to start instituting a uniform patient record, which we don’t have in America. This would mean that we can have the same patient record here in Washington, D.C., and then in our home state of Wisconsin, John, and in California, and anywhere in between.

If I can get the Department of Veterans Affairs, the Department of Defense, and this department to adopt these three tools, the rest of the country is going to have to follow suit. Together, using these three tools, we can transform the practice of medicine in America. We are on the verge of this, and it’s what my conference is going to be about when we roll it out. I really think this will have a huge impact.

Nobody can quantify how many dollars will be saved. But just think about the lives that could be saved, and just think about reducing the paperwork. My ultimate vision is to move to a paperless system, in which everyone carries a card with their whole medical record on it, so that it could be downloaded in any clinic in America.

The Uninsured

Iglehart: I have many more questions than I’m sure there’s time for.

Thompson: I’ve talked too much, but you can tell I love this stuff.

Iglehart: OK. There are something like forty-three million uninsured Americans, as you well know. How do you characterize the government’s obligation to encourage the expansion of coverage through public channels, or at least more publicly supported channels, such as community health centers and the National Health Service Corps, through tax credits, through Medicaid, SCHIP [the State Children’s Health Insurance Program], and so forth. What do you feel most strongly about as the way forward to get as many people insured as possible?

Thompson: I don’t think there’s a silver bullet out there, because you’re dealing with so many different classifications of people that are uninsured. Some individuals are making over $50,000 a year and have good jobs and are single and healthy, and just don’t want to be covered—they don’t want to spend the money because they feel that they’re so healthy, they’ll never need the insurance. Others don’t believe in health insurance. Some people just can’t afford it. So I think you have to address the uninsured with a whole plethora of different ways, and you mentioned them all.

I think, first, that we should take the tax credits and put them into a pool, and require the states to pass a law putting all uninsured people into a purchasing pool, and then set up a commission to negotiate the terms. This should be a fairly good, insurable risk pool, because a good share of those who are uninsured are very good insurable risks. Some will be more difficult, but overall it should be a good, insurable risk pool.

If you do this pooling at the state level, and the federal government puts up the tax credits, the state of Wisconsin, for example, let’s say gets 2 percent of the tax credits, out of a hypothetical $7 billion. That’s a nice chunk of money. The state or the individual could add to that, but you would have a very good, insurable product. Also, people would know where they can go to get insurance and could use the tax credits in a much more systematic fashion.

Second, expansion of SCHIP is probably the most exciting way to do anything. We did that in Wisconsin, and we were the first state to do so, when I was governor of that state. It’s a very cost-effective way to expand coverage. I think it’s entirely possible that this could be accomplished nationwide.

Third, Medicaid law needs to be rewritten, just like the Medicare law. I had hoped to be able to sit down with the governors this year and do just that. For some reason—I think because it is an election year—so far this has not come to fruition. I feel bad about that, because I would like to have been able to modernize the Medicaid law before I leave the job of secretary.

The fourth thing we do is through waivers. I have issued more waivers to states than the eighteen other secretaries of this department combined—3,800 waivers and state plan amendments. And I do this because I believe states need the opportunity to try new things.

If you put all those things together, you’d have a very good package to drive down the number of uninsured people. I think it’s the responsibility of government to do so, and I wish I could get more support for it.

Views On Federal-State Relations

Iglehart: Federal-state conflicts have happened to all HHS secretaries for one reason or another—very understandable conflicts dealing with resources and so forth. My question, though, is whether you’ve been at all surprised; as they say, where you stand is usually determined by where you sit. You were in Madison for many years, fighting the monster in Washington. During your years here, the role has been somewhat reversed. Has anything surprised you about this?

Thompson: Oh, yeah. You know, I always tell this little humorous story, but I think it’s very true of the different operations. When I was governor, I could think of an idea early in the morning. I get some of my best ideas at three o’clock in the morning, strange as it may seem, and I jot them down and start working on them. At the state level I could do that. Somebody could start working on one of those ideas and actually have made progress by that afternoon. That’s the power of the governor. In Washington it’s “mañana,” big time. Here in Washington I still have great ideas, some of which I’ve already talked about. Others may question those ideas, but I think that they would move the practice of medicine to the better for a long time. But here, ideas have to get vetted through this huge department. Then, if you do get any kind of consensus, it goes over to the god of OMB [Office of Management and Budget]. I didn’t know we had a supergod in our society, but I found out soon after I got here that OMB is a supergod. OMB turns you down nine times out of ten, just to show you who’s boss. Then, if an idea does get by the OMB supergod, it goes to the intelligentsia: the White House staff, who think that nothing original or intelligent can come out of any department. If you do get your idea past them, then it goes on to a president who is very receptive to good ideas, I find. Then, if the president agrees with it, it goes on to Congress; by the time Congress takes it up and passes it, it’s time to retire. It’s just the difference between the two systems, but I think it explains my frustrations.

Leaving A Legacy

Iglehart: When you depart HHS, what do you hope to leave as your greatest mark—your legacy?

Thompson: First off, I think this department is going to be run extremely well. It’s going to be integrated, which it hasn’t been before. And all of CDC and NIH and FDA and HRSA and CMS and AOA and all the other various operating divisions are actually going to be operating as one integrated department. Number two, America’s going to have a much better understanding of medical costs, and how they can prevent high medical costs by practicing good diet and exercise and improving that. And, number three, we’re going to have a much more international focus on health than we’ve ever had before. Finally, I think our work to modernize Medicare by adding a drug benefit and preventive services will be a great legacy of this department and administration. All four of those, I think, are huge gains for the American taxpayer, and for the ability to promote good public health—not only in this country, but throughout the world.

Iglehart: Thank you.

Tommy Thompson was named secretary of the Department of Health and Human Services by incoming President George W. Bush in 2001. He was previously the governor of Wisconsin. John Iglehart is the founding editor of Health Affairs.

DOI: 10.1377/hlthaff.W4.262
©2004 Project HOPE–The People-to-People Health Foundation, Inc.