The Future for The Agency for Healthcare Research and Quality

Research matters. An agency that I fought to save many years ago is at risk again, and Congress must make a move to save it.

I had just been sworn into the U.S. Senate in 1995, when I first found out that the The Agency for Healthcare Research and Quality (AHRQ) – then known as the Agency for HealthCare Policy and Research (AHCPR) – was on the chopping block. I was still unpacking boxes and learning my way around the Senate halls when my good friend and teacher Uwe Reinhardt of Princeton came to me with an urgent request. He reported the federal agency responsible for funding and conducting health services research was in danger of being eliminated in the 1996 Congressional budget. The AHCPR, which had been renamed and reorganized just six years prior with strong bipartisan support and a revised mission, had fallen out of favor with several influential members of the House Budget Committee.

More at Forbes.

Call for a Conversation: Alzheimer’s in Tonight’s Debate

Tonight, when Republican candidates, vying for the White House, debate one another at the presidential library and final resting place of President Ronald Reagan, they should honor his memory and address the illness that claimed his life and the lives of 700,000 Americans annually: Alzheimer’s disease, the sixth-leading cause of death in our nation.

Reagan was a true patriot. He led this country with boldness and tremendous strength. His optimism helped fuel our country’s continued ascent to greatness, even during difficult times. Just five years after leaving the White House, on Nov. 5, 1994, Reagan issued a letter to the American public announcing, “I have recently been told that I am one of the millions of Americans who will be afflicted with Alzheimer’s disease.”

That was more than 20 years ago, and this frightening disease is only becoming more prevalent. As baby boomers (now 51 to 69 years old) age, more Americans are at risk of developing the disease than ever before. None of us will be untouched.

Read more at US News and World Report.

Nashville’s Role in the Healthcare Landscape

I love Nashville and I’m so proud of the work being done  here. Healthcare is the heart of this town and the solutions being developed here are helping patients all over the world. I’m particularly proud of the Nashville Healthcare Council’s Fellows program, and was thrilled to introduce it to a broader audience.

I am constantly inspired by the sheer volume of creativity in Nashville, much of which is channeled toward shaping a smarter, more efficient health care system for our nation.

I was only 16 when my father and brother co-founded HCA in 1968, an innovative venture that grew into the largest hospital management company in the world and reshaped the delivery of care throughout the country. HCA’s founding helped set the stage for Nashville to become the epicenter of the American health care industry, today home to 400 health care companies.

I advise a number of cutting-edge organizations, and I consistently see tomorrow’s successful, shareable care-delivery models being built in Nashville. Future generations of patients across the world stand to benefit.

Read more at Modern Healthcare.

The Virus Wars: Vaccines that Work and Why We Aren’t Using Them

Researchers around the world are scrambling to find an Ebola virus vaccine. Rightfully so. The virus infected nearly 28,000 people and killed over 10,000 in Africa since last year’s outbreak began. But there are other viruses with even more staggering numbers: HPV–human papillomavirus–killed 230,000 women last year. 170,000 more were diagnosed with cancer, but survived.

And yet, we have a vaccine for HPV. Current versions can kill 70% of HPV strains. But in the United States our vaccine rate for HPV is abysmal. A proven-safe vaccine can snuff out a virus that we know causes deadly cancer. Yet only 35% of the recommended population gets the vaccine.

The time for excuses is over.

More at Forbes

Hector Frank and a New Opportunity for Cultural Unity

Last October, Tracy and I visited Cuba and got an up close view of the country, the people, and their challenges. I’ve written about my impressions of their healthcare structure–in many ways woefully lacking, but with some surprising lessons for us in America. What I didn’t write quite as much about was the art. We found the art and the artists in Cuba inspiring, bold, and visionary. I loved what they were doing and how their work was crossing borders and boundaries, even against great odds.

I’m sure you know that I believe health is a powerful tool for diplomacy. But art can be just as unifying–recognizing and communicating our common hopes and struggles like little else can. The creation and sharing of art among peoples around the world evokes cultural understanding and shared unifying dreams.

For that reason, Tracy and I are thrilled to launch today the Mountain Artist in Residence (Mountain AIR) initiative, and introduce the first artist in residence–the man whose work inspired this project–Hector Frank from Havana, Cuba. We will welcome Frank with an exhibit today–Cuban Summer 2015, benefitting Hope Through Healing Hands and SCORE. In the fall, Frank and his wife Teresa take up their residency. We are excited to see what happens next!


About Hector Frank

Hector Frank was born in Havana, Cuba in 1961. Hector continues to be influenced by Cuban and the Caribbean artists working with strong forms and lines.  He incorporates impasto techniques along with various mixed media and collage to build his images up off of the surface and bring them to life.

From the start of Frank’s art career, he preferred to paint abstractly, and continues to be influenced by Cuban and Caribbean artists working with strong forms, and lines. Through drawing, he began expressing figurative forms in a variety of media including wood, handmade paper, and assemblage.  He incorporates impasto techniques along with various mixed media and collage to build his images up off the surface and bring them to life.  He works with mixed media and creates highly sought works on re-claimed wood with found objects. By changing his style often, he keeps in the forefront of the ever changing Cuban art scene.

Frank’s work has been shown in France, Mexico, Panama and the United States,and is featured in prominent private and public collections worldwide.

During his Mountain AIR residency, Frank will draw upon the natural environment and Appalachian setting to create a series of pieces in paint and in a materiel medium.  Abundantly available to him are natural materials, including reclaimed wood, wire, wood, copper, leather and glass that have accumulated on the property for the past hundred years.  His objective is to marry his traditional Cuban culture with the American Appalachian life in an interpretive fashion.

About Mountain AIR

Twice each year, an artist will be selected to spend two weeks living on a beautiful and inspiring 480-acre cattle and horse farm in Sinking Creek, Virginia, deep in the Appalachian Mountains with complete creative freedom. Our hope is to provide an environment encouraging to the individual’s creative and artistic sensibilities.  This majestic rural mountain setting amidst a working farm that includes grassfed cattle, sheep, horses, goats, and chickens provides an inspiring sense of time and place.

The artists will work out of a naturally lit, second floor loft above a working livestock barn with breathtaking, panoramic views of the flowing valleys and stream below and the mountains around. Artists have complete access to the farm including all the land, beaver streams, livestock, farmhands, and materials that have accumulated on the land over the years, as well as the Appalachian Trail and Jefferson National Forest. Artists are encouraged as they wish to actively engage in the farm life that so genuinely defines who we are as Americans.  They will have opportunities to interact with and introduce their art form to local K-12 children as well as writers-in-residence from regional higher educational institutions over two to three days.

Making Dementia Friendly Communities The New Normal (Forbes)

FORBES | Alzheimer’s may be one of the most frightening health challenges today. Over five million Americans—one in eight age 65 and older and one in three age 85 and older—are living with dementia and we don’t yet have a treatment that can prevent or cure the disease. But these men and women are not alone. They are supported by 15.5 million family members and friends, and there are things we can all do to ease their burden.

In 2015, Alzheimer’s and other dementias will cost the nation $226 billion, with half of the costs borne by Medicare. Last year caregivers provided 17.9 billion hours of unpaid care, averaging 22 hours per week and valued at $217.7 billion annually; $34 billion annually is lost in revenue/productivity due to caregiving responsibilities. Unless something is done, in 2050, Alzheimer’s is projected to cost up to $1.1 trillion (in 2015 dollars). This is both financially and socially unsustainable.

In May, I challenged the new Presidential candidates to make a War on Alzheimer’s a top health care priority, and I know that researchers are hard at work developing new drugs to treat, prevent, and slow the disease. We need increased federal and private sector funding to enable innovation in the field of cognitive disorders, and new initiatives in Washington are moving forward.

Read more at Forbes:

Podcast: Medicare and Medicaid at 50

Fifty years after Medicare and Medicaid were created, healthcare in America is still rapidly evolving. Carefully observing where we’ve been will help inform where we are going, so in today’s special issue of the Journal of the American Medical Association (JAMA) Kaiser Family Foundation President and CEO Drew Altman and I look at the Perspectives of Beneficiaries, Health Care Professionals and Institutions, and Policy Makers over the past half decade. The full text of the JAMA article is available by subscription only, but Drew and I also discussed the piece and our findings with Dr. Preeti Malani, Associate Editor, The JAMA Network in a freely available podcast.


Telemedicine and the Tools of Care

At the Spotlight Health event at the Aspen Ideas Festival last month I had the privledge of speaking on a panel moderated by Steve Clemons. We focused on the Supreme Court’s decision on the Affordable Care Act and costs of healthcare in America. It prompted some thoughts about my dad’s medical practice many  years ago. Dad had a DeSoto, and that car took him to many house calls over the years. Of course a DeSoto isn’t the practice of medicine. It was simply a tool Dad used to meet his patients where they were. I think telemedicine is the same kind of tool, one that makes care infinitely better for patients.

More at the Health Affairs Blog

Three Challenges Impacting The Future Of Obamacare (Forbes)

FORBES | Last week’s Supreme Court decision puts the Affordable Care Act firmly and securely into institutional and cultural permanence.  It still bears flaws due to its imperfect construction and divisive passage, but after five years, the new certainty for insurance markets will permit a maturity of risk pools, and the more direct and predictable provider reimbursement moves toward eliminating much of the inefficient cost shifting that obscures pricing and value transparency.

The ACA will need to clear a number of hurdles before it can achieve long-term success.  Legislative action will likely be needed to fix some of these shortcomings.  The reality is that the new President, Republican or Democrat, will be charged to do what President Obama has failed to do: actively bring the parties to the same table to fix what is broken in the law in order to bring affordable care to those in need.

Read more at Forbes:

Compensating for End of Life Conversations Is Important First Step

The Obama Administration is soon scheduled to release the proposed 2016 Medicare Physician Fee Schedule, which determines what and how much providers can bill for health care services. The administration can choose to compensate providers for offering voluntary counseling services to patients and families about end-of-life care options, and I strongly urge it to do so. It is an important first step.

As a heart surgeon, I have seen countless instances where patients near the end of life undergo aggressive medical interventions in order to prolong the inevitable. Yet most people, when asked, say they would want to spend their final days at home, without pain, comfortable with family and friends, and not hooked up to multiple machines in the hospital. We simply must do better and help ensure that a patient receives the health care that they want near the end of their life.

Americans are living longer than ever, and children are increasingly helping aging parents and grandparents manage multiple chronic conditions. This new reality has more and more people thinking about new models of end of life care, and has sparked a national conversation about how we can all live well, until the very end.

I’m encouraged to see that this important issue has reached the halls of Congress, where legislators in both the House and Senate are pursuing bipartisan ways to improve the care patients receive near the end of life. One policy option being considered is reimbursing providers for discussing treatment options and care preferences with patients and their families. I wholeheartedly support this idea, and there is an immediate opportunity to make it happen.

Read more at Forbes.


Advancing transparency in healthcare: A call to action (The Hill)

THE HILL | “How much does health care cost?” It isn’t an easy question to answer. Your yearly check-up, a colonoscopy, or trip to the emergency room doesn’t typically come with an obvious price tag. And it isn’t just finding out the price of a service or product that’s difficult; it’s also difficult to determine the quality of the care provided. In fact, Princeton Economics professor Uwe Reinhardt has likened “shopping” for healthcare to trying to find a purple sweater in a department store while blindfolded.

Greater transparency and access to information about the prices and quality of health care would be beneficial to consumers, providers, policymakers, and stakeholders alike. To achieve the Triple Aim of better population health, an improved health care system, and a lower rate of cost and spending growth, we must take the blindfold off.

Read more in The Hill:

Cuba’s Most Valuable Export

If you had to guess, would you guess sugar? Cigars? What about doctors and nurses?

The Cuban government reportedly earns $8 billion a year in revenues from professional services carried out by its doctors and nurses, with some 37,000 Cuban nationals currently working in 77 countries. The socialist regime allows the government to collect a portion of the incomes earned by Cuban workers abroad.

For example, in 2013 Cuba inked a deal with the Brazilian Health Ministry to send 4,000 Cuban doctors to underserved regions of Brazil by the end of the year – worth as much as $270 million a year to the Castro government. By the end of 2014, Brazil’s Mais Medicos program, meaning “More Doctors,” had brought in 14,462 health professionals – 11,429 of which came from Cuba.

Over the past 50 years, Cuba consistently used the export of its doctors as a powerful and far-reaching tool of health diplomacy. The island nation has built good will and improved its global standing with emerging countries around the world during its years of isolation. It sent its first doctors overseas as far back as 1963, and to date has sent physicians to over 100 countries.

More today at Forbes.


The Worst Kept Secret in Healthcare

For many of our health problems, the solutions are not a secret: eat well, move, make healthy choices. Of course sometimes that is easier said than done. Our physical and social environments–where we live, what kind of emotional support we have, our access to fresh food and healthcare–determine more of our healthcare than what our doctors prescribe. If we want to be serious about improving wellness, we must get serious about preventing health problems before they start.

The Bipartisan Policy Center launched a report last week looking at the best ways to incorporate prevention into our lives. Alice Rivlin and I announced the study:

In order to refocus on wellness, over the past year, the Bipartisan Policy Center convened a Prevention Task Force to determine how to change our nation’s health conversation so we are taking actions to promote wellness rather than focusing solely on providing reactive medical treatment after a person gets sick.

Today, the task force is releasing recommendations for achieving this goal, which include better connecting clinical providers and community organizations, and creating incentives to make preventive care a priority. As senior advisers to the task force, we strongly endorse the two-part framework today’s report outlines to more fully integrate prevention into the nation’s approach to health and health care.

Read more at US News and World Report.

A Charge to Press Forward on Alzheimer’s Research

Heart transplantation revolutionized healthcare in a way that’s hard to comprehend. What was once a death sentence–sometimes without warning–became surmountable. People got their lives back. We need the same revolution in Alzheimer’s research. The answer will be different; transplant can’t solve this problem. But just because the way forward is unclear, we can’t stop pushing forward. I challenge the 2016 Presidential hopefuls to keep Alzheimer’s disease at the forefront of research. We have so much to lose.

One in five Americans are obese. One in four has a risk of dying from cancer in their lifetime. But one in three that live beyond 65 will die with Alzheimer’s or another type of dementia. All these ailments have significant health impacts. The difference? We have solutions to treat obesity and can cure some cancers.

Alzheimer’s is the only disease among the top 10 causes of death in America that cannot be prevented, cured, or even slowed.

Read more at Forbes.

Why Texas is missing out on the future of medicine

If you’ve read much of anything here, you know that I am a big fan of health technologies to improve care and create a sustainable healthcare system. I think it’s essential that we choose the right technologies that will serve patients, and I firmly believe telemedicine is one of those solutions (so much so that I joined the board of advisors for Teledoc, a telemedicine company).

But across the country, thousands of people are desperate for accessible and affordable healthcare. For far too many of them, their only option—even for non-emergency care—is a $1,500 visit to the emergency room.

For example, 200 counties in Texas are considered medically underserved with 16 counties having just one primary care doctor and 27 counties having none. These citizens have nowhere to turn.

The good news is that a solution exists. It is called telehealth and has been increasing in use across the country over the last decade. However, a decision last month by the Texas State Medical Board will sharply restrict access for Texans by requiring in-person visits before you are allowed to use telemedicine. Previously, the board required doctors to establish a relationship with patients before giving a diagnosis or prescribing drugs, but its April 10 decision narrowed rules to state that “questions and answers exchanged through email, electronic text, or chat or telephonic evaluation or consultation with a patient” are not enough to establish a doctor-patient relationship.

Read more at Fortune Magazine.

Killing the superbug: A call for Congressional action

When Alexander Flemming accepted his Nobel Prize for the discovery of penicillin, he issued a warning to future generations: his miracle drug—responsible for saving millions of lives—could one day be useless.

“It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them,” Flemming said. “There is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

Seventy years later, Flemming’s nightmare scenario is coming true.

The U.S. Centers for Disease Control and Prevention (CDC) reports drug-resistant bacteria infect more than 2 million people nationwide, killing 23,000 annually. In addition to lives lost, infections cost $20 billion in additional direct healthcare costs, up to $35 billion in lost worker productivity, and $8 billion in extra hospital days. Given the knowledge and resources available to us, this is unacceptable. ​

We need a multi-pronged strategy to attack antibiotic resistance.

Read more at The Hill.


The Promises and Challenges of Precision Medicine

Only 15% of our health is determined by the healthcare we receive, the rest are the social determinants of health: environment, economic stability, access to care, education and community resources. Paying attention to that 85% is imperative, and precision medicine aims to take targeted genetic and molecular information and consider it in tandem with data about our environmental exposures and lifestyle choices. Integration of the smallest building blocks with the macro environment is exactly the direction in which medicine should be moving, and President Obama’s Precision Medicine Initiative is a needed step forward. But getting there will take some new habits, a new funding model and new technologies.

Read more at Morning Consult.

MCC: Foreign aid in action

Most people are surprised when they learn how little we actually spend on foreign aid. But as we know, global health issues know no boundaries. That’s why it is so very important that spend our foreign aid  money wisely. I’m at The Hill today discussing a model that I think does a great job.

Most Americans agree foreign aid helps improve our nation’s image globally and protects Americans’ health by preventing the spread of diseases.

In fact, it does more than that. Our comparatively small investment in foreign aid enhances national security by stabilizing weak states and helping to fight the causes of terrorism. It encourages economic development, opening new global markets for American business. And it supports our humanitarian goals and values, advancing peace and democracy.

Considering the benefits, the surprising truth is that the U.S. spends less than 1 percent of our budget on foreign aid, and that amount has been dwindling due to sequestration. At a time when we are faced with global unrest and budget cuts, we must make strategic investments in foreign aid programs that have a record of success.

The Millennium Challenge Corporation (MCC) is a prime example.

Read more at The Hill

A Conversation on Haiti

Last week, Hope Through Healing Hands and I had the honor of welcoming the former Prime Minister of Haiti, Laurent Lamothe, to Nashville. I’ve been to Haiti many times, and was thrilled to hear the latest updates on the quantifiable successes in Haiti over the last few years, namely in providing housing for those displaced by the earthquake and putting children back in school.

Jenny Eaton Dyer, Hope Through Healings Hands’ Executive Director, has all the details about the event on the HTHH blog.


It’s National Health Care Decisions Day: Who will you designate?

End-of-life planning is an important part of healthcare. It’s a refrain I’ve been repeating. I’ve called for changes in care models, payment schemes, and physician education. But all of the needed changes aren’t at the system level. There are steps that every individual must take as well.

Along with Gary Dodd, a palliative care nurse with years of experience, I’m at Fox News this morning talking about a conversation you can have to take to take control of your end-of-life care.

We know that at least 90% percent of Americans have heard of a living will, but still only about one third have one. Even among nursing home residents, only 65% have some type of Advanced Care planning documentation. This is not news in the health care community, but if we want to change these numbers we have to ask “why?”

Read more at Fox News.



Where Health And Environment Converge

An area of healthcare that has recently become very important to me is community transformation projects focusing on the social determinants of health: environment, economic stability, access to care, education, and community resources. Only 15% of our health is determined by the healthcare we receive, so looking at the other 85% is not only imperative, it is just good math.

At Forbes, I look at where health and environment converge, not just in our own backyards, but globally as well.

This past March, I met Luis Giuria at the Building a Healthier Future for America Summit.  He was smiling ear to ear when he and his beautiful family took the stage to talk about what an impact his environment has had on his life.

Luis was born in the South Bronx, and grew up eating inexpensive junk food because it was the easy, affordable option.  His hometown lacked safe playgrounds and he never learned the importance of exercise.  By age 27, he weighed nearly 400 pounds, had trouble sleeping, finding clothes that fit, and was prone to injury.  To be a good father and husband, and good to himself, he knew he needed a major life change.  That’s when he discovered Arbor House, an innovative low-income housing project in the Bronx that was designed to encourage physical activity.  Arbor House boasts indoor-outdoor gyms, play areas for children, a rooftop farm that provides fresh produce and clean air, and abnormally slow elevators that encourage residents to take the stairs.  Luis and his family moved into Arbor House, and it’s helped the whole family embrace healthy living. Luis has lost 200 pounds thanks to his new environment and other healthy lifestyle choices.

His experience shows where health and environment converge. Most people would still list exercise, diet, or access to affordable healthcare as the key determinant of health—and those are all important. But the most important factor is one that influences everything else: your zip code.

Read more at Forbes:

The Mother & Child Project

I am thrilled to announce that a huge project of ours has finally come to fruition. Thanks to the team at my global health nonprofit, Hope Through Healing Hands, The Mother & Child Project is now available!


The Mother & Child Project was compiled by Hope Through Healing Hands’ Faith-based Coalition for Healthy Mothers and Children Worldwide. In this important book, Melinda Gates, Kay Warren, Christine Caine, Kimberly Williams Paisley, Michael W. Smith, Natalie Grant, Jennifer Nettles, Jennie Allen, Amy Grant, and many other inspirational leaders, cultural icons, political experts, academics, and service providers tackle the important topic of maternal and child health in developing countries. Through personal narrative and compelling research, this book educates and inspires people of faith to join us in empowering mothers and children worldwide.

I’ve written a bit about the powerful role of maternal health in influencing communities for good, and I’m so proud of what this book accomplishes: an insider’s look into the way this most fundamental goal shapes cultures.

I hope you’ll read it, and see for yourself what power we wield when we speak out for mothers and their children.

Read Publishers Weekly review

A Vaccine For Future Health Crises: A Coordinated Communications Strategy Will Be The Difference (Forbes)

FORBES | During the Ebola epidemic this fall, I was reminded of the chaos and fear we felt in the Senate in 2001.  When the first anthrax letter was opened in the office of Majority Leader Tom Daschle, no one really even understood what anthrax was, much less how it was contracted, transmitted, or the disease’s natural history. As a result, it was days before a plan for evacuation, testing, and treating exposures was implemented. We had no mechanism for a coordinated and controlled response to a major health emergency.

Thirteen years later, I am afraid we were just as unprepared.  News that the first Ebola-infected doctor was returning home for treatment resulted in outrage about the potential threat, and calls for a West Africa travel ban.  Given the rarity of Ebola, the public lacked general knowledge of the disease. Relevant governmental agencies failed to adequately disseminate information, and hospitals and healthcare workers didn’t know how to contain and treat infected patients.  Soon, two Texas nurses became infected. It wasn’t until eighteen days after the first case of Ebola was diagnosed in the U.S., that the Obama administration appointed an “Ebola Czar.”

Read more at Forbes:


Ebola Doctor and Survivor Ian Crozier Advocates Global Awareness and Treatment (Hope Through Healing Hands)

HOPE THROUGH HEALING HANDS BLOG | On Tuesday, March 31, Hope Through Healing Hands had the honor of hosting Dr. Ian Crozier, an Ebola physician and survivor at an event with Siloam Family Health Center. I had the privilege of talking with Ian as he shared his experiences with the packed auditorium. His message is one that deserves a wide audience.

Ian Crozier trained as a physician at Vanderbilt, specializing in infectious diseases. He was living in Uganda treating HIV patients when he was deployed by the World Health Organization to serve in an Ebola Treatment Unit (ETU) at Kenema General Hospital in Sierra Leone. His time there was brief; he worked just a few weeks before he contracted Ebola and was evacuated to Emory University in Atlanta. But his firsthand experiences are rich with lessons for infectious disease research, global health, and each one of us.

Ian’s story has been chronicled by the New York Times, and although I’m tempted to retell it—because it is so powerful—I want to focus on the challenges he laid out for us.

His is a dual citizenship, Dr. Crozier said: both Ebola physician and Ebola patient, caregiver and sufferer, crusader and survivor. His mission, now, is to raise awareness about the ongoing epidemic and the state of global health in Africa and beyond.

Read more at the Hope Through Healing Hands Blog:

Tackling Administrative Waste: The Promises Of Data Science For The FDA

Our healthcare system needs an overhaul in lots of areas and the FDA is not exempt. It’s slow, expensive, and cumbersome. Modernizing the FDA is now the focus of several initiatives including ones from Congress and the Bipartisan Policy Center. One of the top priorities: using data to speed the drug approval process without sacrificing safety.

In looking at the $2.8 trillion a year—20% of our Gross Domestic Product—that our nation spends on healthcare, we see that about $900 billion of that is waste and $248 billion can be attributed to administrative complexity. This costly complexity stems from the ACA, insurance regulations, and regulatory agencies in the U.S., including the Food and Drug Administration (FDA). The FDA in particular is a needed and valued part of healthcare in this nation – it just needs a serious overhaul.

The innovation bottleneck at the FDA has a real impact on Americans’ healthcare. One of every $4 spent by consumers each year is on an FDA-approved product, including drugs, devices, food, and tobacco. Expensive development and approval processes drive up those costs with an average drug taking about $1 billion and a decade to make it to market. With increased consumer cost-sharing, expensive drugs and devices are already becoming out of reach for many Americans. And for those facing a disease with potential life-saving treatment in trials, the clock is ticking entirely too slowly.

Thankfully, modernizing the FDA has become a key focus for Congress this year. I am leading an initiative through the Bipartisan Policy Center, a non-profit think tank in Washington, DC, focused on reversing this cost trajectory to improve affordability and availability of healthcare. We are working on strategies to advance medical innovation within the FDA, while reducing the time and cost associated with drug and device development.

One area I think shows significant promise is the use of “big data”.

Read more at Forbes:

Reauthorizing No Child Left Behind matters to Tennessee (The Tennessean)

THE TENNESSEAN | Tennessee teachers, parents and local education leaders know what’s best when it comes to educating our children.

Federal education law has a powerful role to play in ensuring that our nation’s schools equip the next generation of global leaders, but only if the law is carefully crafted so that local expertise can be applied.

I voted for No Child Left Behind, or the Elementary and Secondary Education Act (ESEA), in 2001, and the law has benefited the children of Tennessee and of many states. But much of Tennessee’s success under the law has come because we made innovative decisions at the state level to identify and support great teaching, turn around low-performing schools, and raise academic standards, among other policies.

Read more at The Tennessean:

Notes from the Road: Hong Kong

I’m in Hong Kong right now attending some financial meetings and touring some infrastructure projects. It’s been an eye-opening trip so far. Today in a financial meeting, one of the smartest participants is an historian, a student of thousands of years of Chinese history.

He observed: “The era of a Dynasty always begins with low taxes and full treasuries and ends with high taxes and empty treasuries.”


But it’s not been all meetings. We toured the Central Wan Chai Bypass and Island Eastern Corridor Link, currently under construction by AECOM. The Central Wan Chai Bypass and Island Eastern Corridor Link is 4.5 km in length and has six lanes of traffic. It’s scheduled to be completed by end of 2017. Impressive.


AECOM is a global provider of architecture, design, engineering, and construction services for public and private clients (with a Nashville office!). In Hong Kong, the company early dominated the market for infrastructure architecture and construction; it’s responsible for more than half of the public works projects. Here, AECOM has 4,600 employees and accounts for one out of 800 workers in Hong Kong. Hong Kong has the fourth-largest harbor in the world, and AECOM built 100% of the container terminal. It will be building the new airport terminal, and the sewage water treatment plant.



Telemedicine Is A Game-Changer For Patients, The System

The Affordable Care Act won’t address our physician shortage–a problem expected to grow to as many as 52,000 needed physicians by 2025. And for many, the ACA still isn’t providing actually affordable care. To bridge these gaps, we must find innovative ways facilitate hassle free access to a provider that is more cost-effective. There is a solution.

While 87% of Americans now have health insurance, overwhelming co-pays, high deductibles and a lack of primary care doctors still stand in the way of healthcare for many.

An average GOLD level plan—one of the more expensive, “better” insurance plans—still has a deductible of $2,000 for an individual, which approximately 40% of Americans cannot afford. Thirty-five percent of Americans already struggle with medical debt despite that 70% of those struggling have insurance. And by 2025, the United States faces a potential physician shortage of as many as 52,000.

For many, new health insurance is not providing access to affordable care, and the ACA will not address the physician shortage. To bridge that gap, we must find innovative ways facilitate hassle free access to a provider that is more cost-effective. Telemedicine is a growing model that is a part of the answer.

Read more in Forbes.

Separate Health Care For Veterans Does Not Best Serve Our Vets (Forbes)

FORBES | I had the privilege of speaking at the Concerned Veterans for America Summit last week in Washington, D.C. I’ve written about my concern for veterans’ healthcare before (and I highlighted some of my thoughts immediately before the Summit). Our healthcare system needs a lot of work, and having served as a VA staff surgeon for nine years, the care we offer our veterans is an area of particular concern for me.

In my experience as both a physician and former Senator, I have come to believe a forward thinking, technologically advanced, and efficient 21st Century American Health Care System should be patient-centered, consumer-driven, and provider-friendly.

I developed these conclusions after years of practicing medicine in this country and all over the world, as well as having a front row seat to the evolution of healthcare in our country: from fee-for-service, to managed care, to the current transition to value-based healthcare.

I know that people need to have some skin in the game. We can talk about concepts like moral hazard and healthcare literacy as complicating patient autonomy, but ultimately the most important person in a healthcare decision is the patient.

Read more at Forbes:

Training the Next Generation of Doctors in Palliative Care Is the Key to the New Era of Value-Based Care (Academic Medicine)


I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.


We would like to think Hippocrates made this statement about the field of palliative care. Considering the state of medical practice during Hippocrates’s time, and the definition of palliative care, he probably did.

The World Health Organization defines palliative care as care that

improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.

This should be how all medical care is defined. But unfortunately, it is not. To better understand why palliative care is an important issue in the current debate about health care reform, we first briefly review landmark legal cases in the area of end-of-life care. We then discuss the role of palliative care in conversations in the current health care climate and conclude by emphasizing the importance of integrating palliative care into the standard medical curriculum.

Read more at Academic Medicine:

A bold blueprint for transforming veterans’ health care (The Washington Post)

THE WASHINGTON POST | Imagine how we would meet the service-related health-care needs of military veterans if we had a clean slate and were considering the question for the first time. The answer is obvious. Just as we do with veterans’ educational benefits, we would use the private sector. We would never create something like the Veterans Health Administration(VHA) that exists today.

But we are not writing on a clean slate. The United States owns and operates the highly bureaucratic and inefficient VHA, a legacy institution that badly needs reform. Last year’s legislation expanding health-care choice for select veterans and holding senior VHA executives accountable was a step in the right direction. But some of its key measures are temporary or are not being fully utilized or implemented efficiently.

If endless funding, more personnel or piecemeal reforms were the answer, the VHA wouldn’t be failing. Since 2006, the budget for the Department of Veterans Affairs, which oversees the VHA, has ballooned by a staggering $91 billion, and the VA has added 101,000 employees. This growth has coincided with worsening care for a shrinking veterans population. Bolder reforms are sorely needed to improve the convenience, timeliness and quality of care received by veterans with health needs resulting from their service.

Read more at The Washington Post:

FDA Reform (Morning Consult)

MORNING CONSULT | The FDA’s warning letter Anne Wojcicki received as the CEO of 23andMe in November 2013 came as a shock to the direct-to-consumer product industry dealing in the “peri-medical” device space. The Food and Drug Administration (FDA) had not previously made such a move, and perhaps 23andMe was being used to set an example, but nonetheless, the action was at the time unprecedented.  23andMe could no longer provide consumers with information about potential disease markers in their genome sequence.

The FDA was signaling it would now regulate the burgeoning field of consumer genomics. As Dr. Margaret Hamburg, the FDA Commissioner who stepped down from her role last week, explained, the FDA has “an enormous set of responsibilities that every day get bigger…”  In fact, FDA-regulated products account for about 25 cents of every dollar spent by American consumers each year.  And the agency is continuing to expand its reach by announcing plans to regulate digital medical devices like apps and wearables, as well as Laboratory Diagnostic Tests (LDTs).

Why does this matter?  Today’s drug and device development process costs too much and takes too long.  It now takes a decade or more and well over a billion dollars for the average drug to make it to market—a dramatic jump compared to $300 million in 1987 and $100 million in 1975 (adjusted for inflation). As a result, venture capital investment in medical technology has declined by 42% between 2007 and 2013. A 2011 survey by the National Venture Capital Association found that over 60% of their members cite FDA regulatory challenges as reason for shifting away from biotech & medical device investment.

No one wants the FDA to approve drugs or devices that haven’t been properly vetted or could be dangerous to the public.  But we also must make sure we aren’t stifling innovation and deterring investment in the name of safety.  An inefficient, outdated FDA drives up costs for consumers, delays patient access to lifesaving medications and devices, deters private investment in medical innovation, and encourages companies and investors to move overseas.

What can we do to reverse this trend?  Congress must act.

Read more at Morning Consult:

Bill Frist and Jenny Eaton Dyer: Americans need to step up on global health issues (Dallas News)

DALLAS NEWS | The Kaiser Family Foundation recently reported that Ebola is still a top-tier global health concern in Americans’ hearts and minds. Although media coverage has slowed, there is still much work to do in West Africa to curb the spread of the virus that has now killed more than 8,500 people. In a promising step forward, the National Institutes of Health just announced that a vaccine trial will soon be available in Liberia.

Sadly, it took the death of Thomas Eric Duncan to prompt real assessments of how prepared local hospitals are to handle a global outbreak. But as a result, our nation is now more aware and more concerned about the tragic loss of life in West Africa and the broader issues of global health.

More than half of Americans believe that the U.S. government offers more than 26 percent of our annual budget in foreign assistance. The reality: Less than 1 percent of our budget goes to global health and development.

As we’ve seen, health issues abroad have a real impact at home. Years of underfunding global health has allowed a virus like Ebola to become a crisis in Africa and reach American soil. If we had spent even one-tenth of our perceived investment, perhaps we wouldn’t be in this position.

We can’t again wait until the crisis is upon us.

Read more at Dallas News:

Save the Children’s Insurance (New York Times)

NEW YORK TIMES | NO child in America should be denied the chance to see a doctor when he or she needs one — but if Congress doesn’t act soon, that’s exactly what might happen.

For the past 18 years, the Children’s Health Insurance Program has provided much-needed coverage to millions of American children. And yet, despite strong bipartisan support, we are concerned that gridlock in Washington and unrelated disputes over the Affordable Care Act could prevent an extension of the program. As parents, grandparents and former legislators, we believe that partisan politics should never stand between our kids and quality health care.

We may be from different political parties, but both of us have dedicated our careers to supporting the health of children and their families. This shared commitment inspired us to work together in the late 1990s to help create CHIP to address the needs of the two million children whose families make too much money to be covered by Medicaid, but cannot afford private insurance.

The resulting program, a compromise between Republicans and Democrats, disburses money to the states but gives them flexibility to tailor how they provide coverage to meet the needs of their own children and families. Some expanded Medicaid; others created separate programs. As a result, the number of uninsured children in America has dropped by half. Children miss less school because of illness or injury, and we’ve seen a significant decline in childhood mortality.

Read more at New York Times:

I’ve Seen A Measles Outbreak; It’s Not Something We Want To Risk By Denigrating Vaccines (Forbes)

FORBES | I last witnessed a measles outbreak in 2011. Thousands were sick with high fevers, dry cough, and a spreading rash. Three quarters of the ill were children under five years old, and the disease was spreading rapidly. Once the outbreak began, immunization response strategies could barely keep up. It took months before even the hospitalized pediatric patients were all vaccinated.

Back then I was in the Dadaab refugee camp, near the border of Kenya and Somalia. I’m horrified to think we are courting a similar outbreak in America.

In the United States, before 1963, there were 400,000 cases of measles per year. One thousand of those children developed measles encephalitis, a serious brain infection, and often subsequent permanent disability. An estimated 400-500 of those children died, and many who lived were plagued with permanent disabilities including deafness.

In 2000, the U.S. had no measles cases. One of the most infectious diseases was eradicated by one of the most effective vaccines we have. The measles vaccine, which is 95% effective after one dose, decreased incidence of the measles in this country by 99%. Thanks to vaccine science, we had achieved a monumental public health milestone.

Read more at Forbes:

New Tennessee telemedicine law grows health care access

I am convinced that telemedicine is a crucial part of the solution for delivery of healthcare in the United States–care that isn’t yet affordable or accessible for all. Tennessee has made important steps toward ensuring telemedicine is an option for our citizens, but there’s more to do.

Telemedicine is in its infancy in Tennessee. Specialists at our university medical centers provide remote consultations and conduct virtual patient examinations. School nurses in rural counties use secure telemedicine links for consults. But it is vastly underused where the need is the highest: in the delivery of primary care.

Telemedicine can prevent an ER visit on a Saturday night and keep a busy Monday morning on track. Patients can avoid travel time, last-minute child care arrangements and a lengthy stay in the waiting room.

Telemedicine does not replace the need for a relationship with a family physician, but it does serve as a convenient, affordable and high-quality alternative to an unnecessary ER visit.

Last year, Tennessee became the 21st state to enact “telemedicine parity” legislation requiring that insurers reimburse licensed health care providers for services delivered remotely just as they would for in-person visits.

The legislation removes the wasteful financial incentive to having patients make a trip to an emergency room when a telemedicine consult would suffice. In both cases, the reimbursement to the provider would be the same. Tennessee’s parity law also includes TennCare, the state’s managed Medicaid program. The law was signed by Gov. Bill Haslam in April and became effective Jan. 1.

It’s a good first step, but Tennessee must go further. We need two additional assurances.

Read more at The Tennessean.

We Must All Play a Role in Ending Childhood Obesity (Robert Wood Johnson Foundation)

ROBERT WOOD JOHNSON FOUNDATION | We all want our kids and grandkids to grow up happier and healthier than we did. Instead, today’s children are the first generation of young Americans to face the prospect of living their entire lives in poorer health and dying younger than previous generations.

The reason is no mystery. Too many of our children – one in three, according to studies – are overweight. We are allowing, and in some ways encouraging, our kids to consume more calories, more sugar, more fat, more sodium. At the same time we’re enabling a more sedentary lifestyle. Running, jumping, skipping, dancing, biking – today’s children simply don’t move as much as they once did, making it that much harder to keep off the pounds.

The childhood obesity epidemic is having a devastating affect on too many families. Obese and overweight children are sick more often. They too often endure prejudice and bullying at school, leaving them embarrassed and depressed. They miss more school. When they grow up, they have more difficulty leading productive work lives. And they are more likely to suffer from chronic illnesses directly linked to obesity, such as diabetes and heart disease.

Read more at Robert Wood Johnson Foundation Culture of Health Blog:

The Physician’s Role and End-of-Life

Over the past several months, I’ve been championing a revolution in end-of-life care. The care models need to change. Reimbursement strategies need to change. The way we think and talk about end-of-life needs to change.

And physician education needs to change. We, as doctors, need a new perspective on our role as healers and what that means when our patients can no longer be healed.

In the March issue of Academic Medicine (preprint available now), I look at the history of end-of life care, and consider how we should incorporate palliative care into our evolving healthcare landscape. As a preview to the academic paper, I’ve written a column at Forbes on some of the challenges.

This is a topic that deserves much thoughtful attention. I’d love your input.

Recent thoughts on end-of-life and palliative care:

Palliative Care: More than just end-of-life planning, Morning Consult, September 2014
Palliative Care: We know we need it, but how will the system pay for it?, National Institute for Health Care Management, September 2014
The Landscape of Long-Term Care, Aspen Ideas Festival session, June 2014
Bipartisan Policy Center Long-Term Care Initiative Launch, April 2014
NIC for Seniors Housing & Care Executives keynote, event preview interview, February 2014
Digitize your own advanced-care plan, The Hill, December 2013
End of life stories give us impetus to learn, Tennessean, December 2013
End-of-life care plan can ensure wishes are respected, Tennessean, November 2013
2013 Health Care Investors Conference report, November 2013
Elderly need options for palliative care, Tennessean, October 2013
We often avoid important conversation, Tennessean, October 2013
It’s never too early to discuss your final wishes, Tennessean, September 2013

Bill Frist supports Haslam’s Insure Tennessee plan (The Tennessean)

THE TENNESSEAN | Medicaid expansion has been a contentious topic since the Supreme Court’s 2012 decision holding mandatory state participation was unduly coercive. And the arguments against expansion are well-founded: Does the federal government really have enough money to fund this? What happens if the money runs out? We have tried this before and it was too expensive!

This last point sounded especially loudly in Tennessee; just ten years ago over 170,000 disenrolled from TennCare.

However, we have seen first hand that healthcare costs are a zero sum game. Removing insurance does not remove disease. Shifting costs away from the state in the form of insurance coverage only moved these expenses to hospital systems, which continue to provide emergency coverage to all Tennesseans regardless of insurance as required by federal law.

As a result, Davidson County alone saw as much as an 18 percent increase in emergency room visits and hospitals saw a 60 percent increase in their uncollectable debt.

Tennessee needs a solution that can address these questions of cost while considering the specific needs of Tennesseans. What Governor Haslam has negotiated with Insure Tennessee is just that. What he is proposing is not the cookie cutter Medicaid Expansion offered under the Affordable Care Act. It is a Tennessee-specific solution to close the coverage gap left between subsidies offered under the ACA and Tennessee’s current Medicaid coverage.

Read more at The Tennessean:

Real Conversations: You and Me

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here, the overview of you and me here, and the conclusion. Then join the conversation on Twitter and Facebook: #Conversation2015

At the end of the day, everything on our list comes down to a simple question that we all have to ask ourselves: Do we care enough about each other – the health of our nation and our world – to commit to making a difference? Do we believe that compassion for those less fortunate is, or is not, a fundamental part of who we are as a people?

It can be argued that compassion once defined who we are as Americans. You can, if you wish, define it in terms of religious faith. You can call it social justice. Or you can simply describe it as true patriotism. But no matter how you define it, let’s start with a return to a fundamental and basic principle—that we care. We care enough about each other to not let children die because they can’t have access to a basic medication. That women and girls anywhere should not be put at risk simply to find safe drinking water. That we care enough to not allow our fellow citizens to die young because they are poor. That we care enough to make a commitment to protect our environment as the future home of our children and their children—even if it means less economic benefit can be derived from it.

I’m looking forward to 2015 as we dig deeper into these issues. Merry Christmas!

Real Conversation on Democracy

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of the right to vote here. Then join the conversation on Twitter and Facebook: #Conversation2015

Hand in hand with freedom of the press is the right to vote. We learn about each other by expressing our opinions and allowing both small and the large voices to be heard. Many of our most pressing problems are problems of the majority, but the majority often needs to spend its day performing sustenance activities, instead of advocating for its needs. The right to be heard has never been more imperative.

Today, only about one third of the world’s population lives in countries with full and free democracies. The majority of countries in Africa and Asia—the very parts of the world facing some of most pressing challenges to human health and welfare—are not included in this list.

Those of us with “the vote” must recognize that the process of voting is only a small part of the democratic process. But it is emblematic of personal freedom and should be the instigator of our conversations about these very real issues.

We must protect and exercise our own right to vote, and become champions for that same right for people living around the world.

Water for the World

Back in 2003 I was traveling in Mozambique with a delegation of Senate colleagues to take a closer look at U.S. policy on HIV/AIDS.  We found an HIV emergency, but we also identified a health need even more fundamental: access to clean water.

That was the trip that prompted PEPFAR, President George Bush’s unprecedented commitment to address the HIV crisis. But it was also the trip that spurred advocacy for the dire need for safe drinking water, sanitation and hygiene (WASH).

At Forbes on Thursday I wrote a bit about the history of U.S. water legislation.

On Friday, the President signed into law the  the “Senator Paul Simon Water for the World Act of 2014”. It’s been a long time coming: the result of the work we started in 2003 as well as the tireless advocacy of so many other lawmakers and champions since that trip.

I’m thrilled to see the hard work of so many people come to fruition!


Real Conversation on Creative Freedoms

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of creative freedoms here. Then join the conversation on Twitter and Facebook: #Conversation2015

Creativity and freedom of expression are essential to dialogue and truth, and these are essential to democracy. The ability to express your ideas, critiques and concerns should be a basic right, but even in 2013, 70 journalists were killed and over 200 were in jail—murdered or imprisoned because their free thought represented a threat to those in power. Over the past five years, over 400 journalists worldwide were forced into exile.

Fear of expressing an opinion—for whatever reason—threatens the very fabric of our world.

Real Conversations on Population

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of population here. Then join the conversation on Twitter and Facebook: #Conversation2015

Almost all of the problems of the world today either stem from, or are worsened by, overcrowding. In October, 2011, the world’s population passed the 7 billion mark. And this has happened quickly. There are twice as many people on the earth today since the end of the Baby Boom.

We value life and want to prolong and enhance it, but given the issues previously discussed, the reality of population growth is something we cannot continue to ignore. A scientific and compassionate approach to education around and provision of acceptable birth control methods has never been a greater imperative. We need to move past the political barriers in the area to do what needs to be done.

Real Conversation on Children

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of children here. Then join the conversation on Twitter and Facebook: #Conversation2015

Over six million children die per year before they reach their fifth birthday, which is over 750 children per hour. And half of these deaths are preventable – and cheaply preventable. They include pneumonia, for which we need generic antibiotics, diarrhea due to unclean water, malaria preventable by mosquito nets, and measles for which we have a vaccination that costs $1.

Half of the over six million children who die every year are dying not because they have diseases that can’t be cured or prevented, but because they have diseases that we are not curing and preventing.

Then consider statistics on maternal and newborn health. Hope Through Healing Hands is leading an awareness and advocacy initiative to promote education and action for maternal and child health, with a special emphasis on healthy timing and spacing of pregnancies.

Healthy timing and spacing of pregnancies saves lives. We know that if young women in developing countries delay their first pregnancy until they are 20-24 years old, they are 10-14 times more likely to survive than those who have babies when they are younger.

If these women are able to space their children every three years, their newborns are twice as likely to survive their first year.


I recently got together with a couple of friends, entertainer WK “Big Kenny” Alphin and Dr. Randy Wykoff to talk about American compassion and to make a list: a list of things we should really care about. We wish to start a national conversation to identify and address some of the greatest threats to our global community. We are too privileged and have the advantage of too many lessons from history to continue to ignore our current trajectory – to continue to let another Ebola epidemic unfold as it did.

For my part, I frame the conversation in terms of changing health. American rhetoric regarding our national pride and values has taken many forms over the years, and until recently, health has not been a part of that conversation. But a focus on the social determinants of health, the basic tenants of our societal infrastructure, is imperative if we ever hope to build a society that can deftly and efficiently respond to and survive crisis.

This month, Big Kenny, Randy and I launched a conversation for caring, for change, for action. #Conversation2015 will focus on twelve issues for the next year. Picking twelve items was a daunting task, but we looked for opportunities where a little progress aided by a lot of compassion could make a big difference. To do that, let’s focus the dialogue on identifying those challenges threatening people’s health around the world, and how we can work together to address them. Join the conversation. Research these issues yourself and learn as much as you can and share what you learn with us.

Are you ready to take your place? Are you ready to care?

Read  my introduction in the Morning Consult

#Conversation2015 Issues (Links will update as we move through the list)

Safe Food and Water
Environmental Damage
Poverty and Inequality
Natural and Man-Made Disasters
Epidemic Diseases
The U.S. Criminal Justice System
Creativity and Freedom of the Press
The Right to Vote and the Democratic Process
You and Me


Real Conversation on Disaster

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of natural disasters here. Then join the conversation on Twitter and Facebook: #Conversation2015

Natural disasters are a threat in and of themselves, and my friends and I have all witnessed first hand the destruction caused by hurricanes, earthquakes with tsunamis, and famine. As a society we are good at reactionary assistance – sending in the dollars and aid workers after the disaster strikes.

But many disasters are slow to occur and all disasters in an unprepared community – one with the issues of clean water and poverty to begin with – will wreak infinitely more havoc than they would on a well established community.

When an earthquake hits Haiti, when flooding overruns Bangladesh, or when famine starves the Horn of Africa, the impact is often magnified because of the challenging conditions in which the people were living before the disaster struck.

Lack of food, lack of economic opportunity, lack of education—all contribute to a much worse impact from any natural or man-made disaster. These are the “slow motion” disasters—just as devastating, but taking place over a longer period of time.

Can we as a society respond to both the “fast” and “slow” disasters with the same level of compassion and commitment?


Real Conversation on Poverty

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of poverty here. Then join the conversation on Twitter and Facebook: #Conversation2015

Poverty is inextricably tied to poor health. The world’s least healthy people often live in the poorest countries. Even in the U.S., a person in the lowest income bracket is about three times more likely to die before the age of sixty-five than someone in the wealthiest bracket. Poorer Americans are more likely to suffer from asthma, diabetes, high blood pressure, obesity, and heart disease and cancer.

But in the four decades since the war on poverty began, the gap between the richest Americans and the poorest Americans has actually grown. This is detrimental to the fate of our society because of its impact on children. Children born into poverty often remain there. Breaking the cycle of poverty by creating real opportunities is necessary to allow these children to become contributing members of our national family.

If we aren’t addressing poverty, we can’t improve health. If we aren’t thinking about poverty, we aren’t really considering the staggering level of injustice and inequality in the world.


Real Conversation on Environmental Damage

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of environmental damage here. Then join the conversation on Twitter and Facebook: #Conversation2015

Whether we are talking about global warming, strip mining or natural habitat destruction, the tension between economic interests and environmental concerns are becoming more tangibly apparent. We can now see the destructive impact our predecessors have had on the planet. Given this trajectory we know an uninhabitable world will be our fate in only a few more generations.

We can argue about the details, but the facts cannot be ignored. For example, the world is losing forests at a rate of about 120 square miles per day and as many as 3 million people, mostly in poor and developing countries, die each year from outdoor air pollution related to exhaust and emissions. Almost half that many are dying from indoor air pollution.

So it is not a matter of when our environmental destruction will impact our health, it is a question of when will it be a non-compatible threat? When will we reach the tipping point, beyond which we may not be able to return?

I liken our behavior to the smoker who says he will quit next week. At some point that is also the week he is diagnosed with a fatal illness. We have to change our habits before the earth develops its cancer.

Real Conversation on Safe Food and Water

With WK “Big Kenny” Alphin and Dr. Randy Wykoff, I am launching #Conversation2015, a look at the opportunities we have to make dramatic changes through compassion and caring. Read the introduction to the project here and the overview of safe food and water here. Then join the conversation on Twitter and Facebook: #Conversation2015

For many Americans it is a shock to realize there are still more than 2 billion people without access to clean water and 40% of the world population is without access to a toilet. The daily chore of securing clean water – clearly a necessity of life — can take up to eight hours a day and quite frankly be a life threatening endeavor in itself. As a result, over 3 million people a year are believed to die from water-related diseases.

Access to clean water, and the ability to keep it clean by not having it contaminated with human waste, industrial by-products, mining effluents, or other pollutants, is absolutely essential to improving health.

Even in the absence of significant famines, it is estimated that each year over half of all deaths of children under five are associated with malnutrition. This translates into almost 20,000 deaths per day.

As the world’s population grows, there will be a growing tension on the supply of food and water. Furthermore, regional disruptions in the food supply—from hurricanes, fires, earthquakes, or man-made disasters—will impact increasing numbers of people. For locations that are already without a supportive infrastructure, their communities are one natural disaster away from desolation of their community.

My global health organization, Hope Through Healing Hands, works with some excellent organizations addressing these issues. How can we all help?



Time to advance a new oversight framework for health IT

By former Sen. Bill Frist (R-Tenn.), MD

(The Hill; December 11)

Innovations in digital technology have changed the way we live our everyday lives, and we are finally, just now, seeing them change the way that we deliver health care and manage our own health.

Now new technology makes it possible for us to track and improve our health and wellness by logging our personal habits like physical activity, food intake, and sleep, as well as helping us keep track of important health information like medications and blood pressure. Americans are also using social networks for much more than socializing. Through online communities patients and caregivers are sharing their stories and advice, getting emotional support, and even logging and sharing side effects of specific treatments and interventions. In addition, price transparency tools are emerging to help the consumer-patient make better informed decisions about the quality and costs associated with many medical choices.

Given the pace of technology in every other field, it is embarrassing to report that we are just now seeing a significant penetration of online communication between doctors and patients. However, it is imperative to the efficient delivery of modern medical care. In addition to moving medicine into the 21st century with online portals and secure emailing, we are also seeing the rise of telehealth. Telehealth or connected health has been aided by the slow but eventual uptake of electronic health records by the nation’s physicians and hospitals. We can now access patient data and support on best practices at the point of care between physician visits. As we combine this type of health information access with genomic information, we move one step closer to truly personalized medicine.

However, new innovation is always met with the age-old problem of existing regulation. Laws are understandably written with existing technology in mind and without flexibility for an evolving and unforeseeable landscape. What Congress envisioned 40 years ago is simply no longer relevant. To support invention and innovation we need a flexible, risk-based oversight framework that protects patient safety and reduces regulatory duplication.

To address this need the Bipartisan Policy Center has engaged hundreds of stakeholders and experts to develop a set of principles and recommendations for a new oversight framework for digital technologies in health care. The BPC framework—reflecting agreement among leaders across every sector of health care—calls for higher risk health information technology (IT) to be subject to oversight via public-private partnerships promoting adherence to a set of voluntary consensus standards and patient safety reporting. This framework would better support rapid response, learning, and improvement. Advancing and implementing this framework was discussed during an event I kicked off at the Bipartisan Policy Center last week.

The good news is this is on the radar for Congress, the administration, and the private sector alike, with everyone agreeing we need a risk-based framework for health IT.
Just last week during BPC’s event, Representative Marsha Blackburn (R-TN) confirmed that an updated version of the Sensible Oversight for Technology which Advances Regulatory Efficiency (SOFTWARE) Act of 2013, which has 38 co-sponsors on both sides of the aisle, would be part of the 21st Century Cures package scheduled to emerge from the House Energy and Commerce Committee in January. Also last week, Sens. Michael Bennet (D-Colo.) and Orrin Hatch (R-Utah) introduced the Medical Electronic Data Technology Enhancement for Consumers’ Health (MEDTECH) Act, which provides greater certainty regarding regulatory expectations, limiting the Food and Drug Administration’s role related to low risk medical software and mobile apps in alignment with the BPC framework.

And the administration is also onboard with the release in April 2014 of the FDASIA Health IT Report: Proposed Strategies and Recommendations for a Risk-Based Framework, which reflects many of the principles and recommendations outlined in the BPC report.

With growing agreement among and action by Congress, the administration, and the private sector we are on the cusp of evolving a regulatory environment that would reward innovation, protect patient safety, create jobs, and improve health and health care in this country. But we cannot stop now.

We demand online and digital access 24 hours a day to most of the other information in our lives and employ digital technologies and devices to make frictionless our daily business and leisure activities. Why should something as important as our health be any different? Sure there are barriers and privacy considerations, but we can overcome them. We know how right now. So, it is time to move on bringing health information technology up to speed with the rest of our lives. No more excuses.

Frist was senator from Tennessee from 1995 to 2007. He was Senate Majority Leader from 2003 to 2007, and is currently senior fellow at the Bipartisan Policy Center.

This article originally ran online:

Building Companies that Change Medicine

I am a partner at Cressey & Company, a health care focused private investment firm, where I serve as chairman of the company’s Distinguished Executives Council.  Yesterday, we announced the closing on a new fund that totals $615 million. Health care in America is changing so rapidly and I believe health-IT is an essential part of that. That’s why we are building high quality, value-driven companies that are centered on better care of the patient and prevention of disease.

It’s clear that government is not in a position to move as quickly as the market demands, but the innovation I’ve seen in private companies is astounding. Technology will change the face of medicine for the patient, the physician, and the payer, and we specialize in eliminating gaps in health care delivery so the patient sees better access and improved care.

It’s such an exciting time to watch to the health care industry change to deliver better care in better ways than ever before.

Read more about our news at:
Nashville Business Journal

November Update

The fall has been exceptionally busy around here with several international trips and speaking engagements, but I was able to be home for Thanksgiving and got to enjoy some of the beautiful autumn color that Middle Tennessee has to offer.

I hope you all had a happy Thanksgiving holiday. Here’s an update on some of what we’ve been up to.

Hope Through Healing Hands (Global Health)

We are very glad that some of the panic associated with the Ebola outbreak has calmed. Infections in the U.S. have been few and none of those healthcare workers who were infected here have succumbed to the disease.

But in Africa, the problem is still very real. Last month there was a panel at Vanderbilt University on U.S. leadership on Ebola in West Africa and at home. My notes from the event were published at Forbes. Now is the time to think carefully about what we are learning from this outbreak. Not only how do we best help and treat those sick with Ebola, but what can we learn about how our country responds to international health crises? What can this virus tell us about other hospital-acquired infections? What are containment best practices?

We must also remain aware that the countries battling the worst of Ebola are facing many other health challenges as well. The infrastructure questions for these health systems are complex and many. Foreign aid will still be needed after this outbreak is contained.

With foreign health systems at the front of mind, I had the opportunity to twice visit Cuba over the past six weeks. They were powerful trips. Cuba is a fascinating country, rich in culture and art despite severe and widespread poverty. Immediately after returning I got my first impressions down in a blog post. I was struck by some of the strengths of the primary care system—a system that in many ways reminded me of my father’s medical practice. But at the tertiary care level, the system falls apart to the detriment of the Cuban people. As we always find with international travel, Cuba yielded observations that will shape and inform thinking.


Falling between the two trips to Cuba was one of my favorite dates all year: the annual SCORE Prize event. We awarded three $10,000 awards to individual schools and one $25,000 award to a school district for outstanding work with Tennessee’s students.

It is always an honor—and such fun!—to be a part of this night. Congratulations to Dresden Elementary School; Hillsboro Elementary/Middle School; Covington High; and Kingsport City Schools.

Also last month our friend Touch left for new horizons. Touch the Dog was auctioned off to benefit the Old Friends Senior Dog Sanctuary at the beginning of October. His new home is in South Carolina, but he’s sure to keep spreading his message of compassion, healing, and connection.

Domestic Health Reform

We’ve noted over the past several weeks the challenges that still lie before the VA. Congress wisely passed bipartisan legislation in July to bring greater accountability, transparency and patient choice to VA. Additionally, a new VA secretary, Robert McDonald, was appointed who will hopefully implement real change. As a former VA staff surgeon, I’ll be closely watching the progress.

But it’s not only our veterans who are faced with ongoing health challenges. The nation as a whole is struggling to reconcile our health goals and our realities. There have recently been great strides forward for the 86 million adults who have diabetes. The U.S. Preventive Services Task Force last month proposed new screening guidelines aimed at reaching a greater percentage of individuals at risk for diabetes. It’s a step in the right direction.

But really it’s up to all of us to take control of our health for ourselves and our communities. Yesterday we encouraged everyone to take a look at the Robert Wood Johnson Foundation County Health Rankings. You—like me—may be surprised and dismayed by what you learn. It’s time for us all to take action!

Finally, if you’re struggling with how insurance works, can we suggest the YouToons? The Kaiser Family Foundation’s series of animated videos is an amazing resource, and the latest short gets to the heart of the insurance structure. Maybe you’ll even recognize a voice there?

The Way Forward for Ebola

Thankfully—and appropriately—the panic surrounding Ebola in the United States has waned over the past weeks. But the calm doesn’t mean it’s time to move on, though the news cycle may have. All major crises can be teachable moments and now is the time to carefully consider our response to the Ebola outbreak and what we can learn to prevent these types of outbreaks in the future.

Last week I sat on a panel hosted by the Center for Strategic and International Studies (CSIS), the Vanderbilt Institute for Global Health, and Hope Through Healing Hands, the global health nonprofit for which I am founder and chairman.

I shared some notes from the discussion at Forbes.

2014 SCORE Prize Awards

Patricia Stokes, CEO of Urban League of Middle Tennessee; Spencer Beckman, Rise to the Challenge Winner; myself

Patricia Stokes, CEO of Urban League of Middle Tennessee; Spencer Beckman, Rise to the Challenge Winner; myself

Each year in late October I have the privilege of hosting the Annual SCORE Prize celebration. Every year just gets better and last night was no exception! We had a great time with school representatives from across the state and country music artist Dustin Lynch.

The SCORE Prize celebrates success in Tennessee’s schools, and this year we had much to celebrate! We awarded three $10,000 awards to individual schools and one $25,000 award to a school district for outstanding work with Tennessee’s students.

We also rewarded the students themselves. Students were invited to submit videos, essays, and creative writings that documented their experiences in classrooms and schools that have helped prepare them for their future through our Students Rise to the Challenge campaign. Last night we gave $250 college scholarships to three creative students for their entries.

The competition this year was fierce; I’m proud to say I think it gets tougher each year! Choosing the winners is the task of the SCORE Prize Selection Committee. They serve as crucial partners in planning and designing selection criteria for the SCORE Prize, and they give their time examining data and visiting schools and districts across the state. They’ve done great work this year, and we are grateful!

The 2014 winners are:

  • Dresden Elementary School
  • Hillsboro Elementary/Middle School
  • Covington High School
  • Kingsport City Schools (district award)

The Students Rise to the Challenge winners are:

  • Katie Workman, a third-grader at Foothills Elementary School of Maryville City Schools
  • Vincent Gould, a sixth-grader at Robinson Middle School of Kingsport City Schools
  • Spencer Beckman, a 12th-grader at Central Magnet School of the Rutherford County School District

You can get all the details on the 2014 SCORE Prize finalists and winners at the SCORE website, and be sure to look for upcoming case studies of best practices gleaned from these winners.

Congratulations again to SCORE, the winning schools, and all of the educators who are working so hard for excellence in Tennessee schools. I’m so proud of all you’ve accomplished, and I can’t wait to see what you do in this coming year!


Notes From the Road: A Big Picture Impression of Cuba

Two weeks ago, I was in Cuba as part of a healthcare delegation to learn more about the country as a whole and its healthcare system in particular on a “people-to-people” trip.

Cuba is a land of heterogeneity and chaos: an amalgam of cultures, colors, tastes, and textures. Wifi access there is severely limited, so I wasn’t able to blog from Havana. Since I returned, I’ve been focused on Ebola at home and in Africa, but I have had time to reflect a bit more on the trip.

I’ll dig into healthcare more soon, but first here is an overview of the biggest challenges for Cuba.


Increasing social inequity. Twenty percent of Cubans live below the poverty line. It’s inconsistent with socialist values, but that’s the reality today. The socialist program is failing.

To be poor in Cuba is different from being poor in the rest of the world. This really struck me in comparison to what I’ve seen in Ethiopia, Kenya, South Sudan, and Bangladesh. The poor in Cuba don’t starve because everybody receives food rations—beans, rice and chicken—every week. The poor don’t die of curable diseases because the primary care system offers everyone free early treatment and prevention. Children are not forced to work.

But almost everybody works for the State, and their incomes are not high enough to match the free market prices, some of which is driven by the strengthening black market. As money starts to flow in Cuba, it aggravates the inequality and shows failure of the socialist system.

Low political participation. The decision-making process in Cuba is highly-centralized and far removed from the average person. The average Cuban feels like he has no voice in government. The people don’t feel like they can change things. They don’t elect their representatives. They’re just told what to do by the State. There’s declining political participation and people are very passive.

The State is overextended. Published numbers from the 1990s show that 95% of the labor force is employed by the State and 85% of the productive land is owned by the State. In the past, the State could support that burden with foreign money, but now the Soviet Union money has disappeared and the Venezuelan money has disappeared. There isn’t an influx of money with which to support the people. The Cuban government is looking mainly to Brazil to be their economic savior.

Too much bureaucracy. For the past decade, bureaucracy and government by very ineffective administrative control has been increasing. Leaders don’t have management techniques. Small businesses are buckling under bureaucratic regulations, and too many prohibitions stifle innovation.

Corruption. There seems to be corruption everywhere at every level with a general attitude of: “We need it; we take it.” For example, someone works at a restaurant not for pay, which is paltry, but so they can steal food and take it home to their family. Waitresses I talked to explained that salaries were miniscule, and patrons don’t tip. But by working in a restaurant, she can take a bit of food off the stove home to her family.

That kind of corruption is caused by unfilled consumption demands. People want more and there is no way to get it, so they take it. There’s no social contract. The whole concept of taxation is so foreign to them, because the federal government simply gives them everything. When that model begins to fall apart because of a lack of resources, the corruption and the stealing increases.

Media Policy. All media is party media—government media—of poor quality. For most Cubans, the internet does not exist. Access is severely restricted. Wifi is generally available only in big hotels, and then bandwidth is limited.  There’s been an explosion of cell phones in the last two years and people do have computers, but they can only download their news once a week from a memory stick.

Embargo with the United States. As the embargo approaches its 54th anniversary, it continues to have a major impact on nearly all aspects of Cuban life, and makes economic recovery and structural changes difficult. Even though there has been foreign investment, I believe things are not really going to improve in Cuba without a change from the United States.

Helping VA Do Better

(Military Times, October 15, 2014)

By Bill Frist

In his second inaugural address, President Lincoln articulated a clear principle to guide our nation’s commitment to military veterans. The goal, he said, should be “to care for him who shall have borne the battle and for his widow and his orphan.”

That sentiment still resonates a century and a half later, and the Veterans Affairs Department adopted Lincoln’s formulation as its motto. Yet as a string of VA scandals have come to light exposing shoddy patient care and bureaucratic malfeasance, it’s fair to ask, what happened to that mission?

Like all government-sponsored health care, VA is largely run by political appointees and bureaucrats, rather than professionals with specialized training in health care administration and management. The government approach to fixing a problem is usually to add a new regulation or yet another policy, when sometimes the cleaner solution would be to de-regulate and simplify.

Unfortunately, VA has suffered from this practice, resulting in an increase in middle managers and regulations that drive up costs, stifle innovation and make the system less responsive to the veterans it aims to serve.

The obstacles to timely care have been apparent to those working in the VA system for years. Indeed, I have experienced firsthand the challenges in that system; I served as a VA staff surgeon in Nashville, Tennessee, an experience that informed my approach to veterans’ issues when I later served in the Senate. I realize that VA simply must do better.

The patient scheduling scandal that arose in Phoenix this spring was simply the last straw. What made the revelations most appalling was the falsification of wait time records to ensure bonuses to administrators. That story suggests VA has lost sight of its true mission of service to veterans and their families.

In response, Congress wisely passed bipartisan legislation in July to bring greater accountability, transparency and patient choice to VA. Additionally, a new VA secretary, Robert McDonald, was appointed, with hopes that his fresh approach would lead the department in a new direction and institute some real change. Those were positive steps.

But those steps are only the beginning. The department has a long way to go both to restore the trust of our veterans and transform the current system into one that can deliver the timely, quality health care our veterans deserve.

So what next? The VA reform bill that passed earlier this year established a commission that will make independent recommendations that are due in early 2016. While this a worthy idea, we cannot continue to tell our veterans they will just have to wait.

It is essential that new ideas and fresh proposals, from outside VA and from all perspectives, be brought to the table for consideration. And we needed that to happen yesterday. Therefore, I am pleased to announce the formation of the Fixing Veterans Health Care policy taskforce, of which I will serve as one of five co-chairs.

My co-chairs on this taskforce, sponsored by the veterans advocacy organization Concerned Veterans for America, are Jim Marshall, a former Georgia congressman and Army Ranger, and two distinguished health care policy leaders — Dr. Mike Kussman, who served as the VA under secretary for health from 2007 to 2009, and Avik Roy, a health care scholar with the Manhattan Institute.

The goal of the taskforce is simple: Isolate existing challenges to veterans’ health care, identify systemic solutions, and propose concrete reforms to improve care delivery for our nation’s veterans. We will consult with the foremost health care management experts, former and current VA employees, members of Congress, and — most importantly — veterans and their families.

Through the submission portal on our taskforce website, we are actively seeking stories from veterans to get the most accurate story about what is going horribly, or well, in the VA system. We will then release a set of concrete recommendations in December that we hope will serve as the basis of reform legislation in the 114th Congress.

This taskforce will seek to think outside the box, challenge assumptions, and ask hard questions regarding the best possible way to deliver timely, efficient and effective care to our veterans. It seeks both short-term changes as well as systemic reform. And most importantly, the welfare of the veteran will be at the center of the coordinated patient care model we hope to recommend.

With politics, someone always disagrees, and we anticipate pushback from those who benefit from the status quo. But the status quo is unacceptable, and something has to change. It is on issues like these that we must employ bipartisan efforts and meet in the middle.

VA has changed before and they can do it again, which is why this taskforce is immensely important. Join us as we help the VA achieve the quality product our veterans deserve and we know they can deliver.

This article originally ran online:

New Horizons for Touch!

If you follow me on Twitter or Facebook, you have probably seen Touch mentioned several times. He’s a new friend of mine with a fascinating story, and today is a very big day for him!

A few months ago, the Old Friends Senior Dog Sanctuary in Mount Juliet contacted me about their annual fundraising auction on Oct. 10 at the Omni Nashville. They invited several individuals to contribute dog statues, and I was intrigued.

The sanctuary houses and places older and disabled dogs who otherwise would be euthanized. Michael and Zina Goodin, who founded the sanctuary, believe older dogs make particularly calm and loving companions, and they are committed to finding homes for as many as they can.

These older dogs have touched many lives in their time. The old adage about man’s best friend means something! I started researching the role dogs play in healing and communication, and I’ve been fascinated by what I’ve learned. (I wrote about therapy dogs at Vanderbilt in this Sunday’s Tennessean.)

I worked with Tracy Roberts, an education specialist and therapy dog certifier from Virginia, and Charlie Buckley, a Mississippi landscape artist, to create Touch, a dachshund statue.

Touch visited a girls’ camp in Mississippi to start his journey; we visited Sam Houston Elementary School at this beginning of the school year to get some help and guidance from the students there; and many more have contributed along the way.

He wears a particularly special collar—a collar passed down from two hard working therapy dogs who taught empathy and compassion. A dog’s work is to be both a sponge and a rock: sometimes solid to hold on to, and sometimes absorbing all the sadness and fears in the world.

Touch has been exposed to so many wise and loving people since his birth and he’s learned a lot! He’s up for the challenge.

Today he starts the process of moving on: the online portion of the fundraising auction begins today!

After the online portion of the auction closes on October 6, Touch and other dogs will be auctioned off on October 10 at a fundraiser for the Old Friends Senior Dog Sanctuary. Until then, you can keep up with Touch and his adventures through his Facebook page. He loves hearing from other dogs about how they help their people and their communities.


Opportunity to Act for Maternal and Child Health

I just welcomed my second grandson, and the dichotomy between the health care we enjoy and the realities in the developing world is never more stark than when I visited the proud new parents and their precious little one in the hospital—everyone  healthy and well.

The biggest killer of women between 15 and 19 in many developing countries is pregnancy and childbirth complications. Enabling women and couples to determine the number of pregnancies and their timing is critical.

Contraception is a pro-life cause.

I believe equipping women to use voluntary methods for preventing pregnancy not including abortion, that are harmonious with their values and beliefs, can make a dramatic  improvement in that number and have lasting benefits for the women, the children, and their communities.

Empowering women to plan and space their pregnancies increases their survival and that of their children by 50%. It means they can nourish and raise their babies. It means they can heal after childbirth and contribute to their families and their communities.

Letting women space their own pregnancies means they can stay in school longer. Did you know up to one in four girls in Sub-Saharan Africa drops out of school because of an unintended pregnancy?

These are important issues—critical ones! Will you join me to discuss maternal and child health?

On September 24, I’ll be giving the keynote address at a conference in Nashville looking at these very issues. I’ll be joined by speakers from the Bill & Melinda Gates Foundation, Lwala Community Alliance, Live Beyond, World Vision, Compassion International, Food for the Hungry, Hope Through Healing Hands, and Living Hope.

We need your voice!

For more information & to register.


An Ebola Turning Point: An Early Diagnosis?

Read my earlier Ebola primer and a look at what we know about how the virus behaves.

As the Ebola situation in West Africa progresses, we are dealing with increasingly complex medical and cultural challenges. I addressed some of the cultural issues in a Morning Consult column last month, and highlighted the importance of identifying infected patients:

The only solution is prevention, which relies on containment and isolation. The sick must be rapidly identified and contained. Their contacts must be followed for 21 days so they can be rapidly isolated, should they develop symptoms. Their care must be delivered in a hazmat suit. If the patient dies, and [50%] do, the body must be properly disposed of because a recently deceased Ebola victim is actively shedding the virus from his skin.

But thus far, identification has not been straightforward. In its earliest stages, Ebola looks like other diseases: malaria, typhoid fever, cholera. It’s clear that these patients are sick, but it’s not clear that they are infected with Ebola virus. During the incubation period, the infected individual may not show any symptoms at all.

Currently, public health workers try to work backwards from a very sick patient. Who lives with them? Who is in their community? Where have they traveled? Who may they have had contact with over the past month? Find those individuals. Follow their health for the next month. If anyone gets sick, the process starts over.

An early, precise diagnosis would be a game changer for this process.

  1. We could separate infected from uninfected patients immediately—before they are contagious. Even in locations without sophisticated quarantine facilities, physical separation of Ebola patients from others would cut down on cross contamination within clinics and communities, and better protect one of the hardest hit groups: health workers.
  2. We could dramatically decrease the virus’s geographic spread. Incubation takes 2 to 10 days, and usually that means the person is positive but not yet symptomatic. We believe that a patient isn’t contagious until the fever starts, but a rapid diagnostic test could identify a carrier before symptoms appear, and before they travel and risk spreading the virus.
  3. We could focus on post-exposure drug development. Identifying carriers before they feel ill would let us treat them early. Some drugs have already shown great efficacy if they are given immediately. Zmab is a drug designed as a prophylactic. It’s shown to be 100% effective in primates if given within 24 hrs of exposure and 50% in 48 hours. Other similar treatments could be extremely effective if we know who to give them to.
  4. Health care workers that have been exposed to Ebola can be quarantined for up to 21 days, and often they have not been infected. In an area with a severe shortage of trained medical personnel, the loss of any workers is disastrous. An early diagnostic test would let those medical professionals continue to safely treat their patients if they have not been infected.

The situation in West Africa is complex for so many reasons, and a rapid diagnostic test would not be an ultimate solution, but it could be the tipping point we need to stem the tide of new cases.

Join me to Discuss Palliative Care: We know we need it, but how will the system pay for it?

UPDATED: If you missed the event, the entire webinar broken down by speaker is archived online.

On September 10, 1 pm EDT, I and some friends will be speaking at a live, free webinar sponsored by the National Institute for Health Care Management (NIHCM) on palliative care. We certainly need it, but how will the system pay for it? I’ve outlined some of my thoughts below, but we need your voice too! Please join me!

Palliative care is one of the fastest growing specialties in American medicine today. This growth is driven not only by our aging population but also by the cultural and financial shift in medicine from fee-for-service to value-based care. However, when we talk about value-based care in the palliative care setting what we really have is a chicken-and-egg problem.

Value-based care is traditionally thought of as pay for outcomes. A hospital reduces hospital re-admissions, or a primary care physician achieves blood pressure goals on 80% of his patients and their reimbursement is higher. However, the important question is, How do you even achieve those goals in the first place? And in the palliative care setting—chronically ill patients who are not going to get “better”—What is an improved outcome?

The answer to the first question is a “medical team” model. Keeping patients well, especially the chronically ill, is all about care coordination. In the primary care setting, this means a team may have a physician, a nurse practitioner, a social worker, a registered nurse, a dietician, a psychologist and others all working together to meet the needs of a patient. A patient is not a single illness.  Each patient is a person with a family and possibly a job living in a community and dealing with many life stressors of which their illness is only one. You have to address the whole patient with all of their non-medical issues to reach success on their health outcomes.

In a palliative care setting, taking a medical team approach is even more imperative. The goal in palliative care is improved quality of life, which means better symptom management, reduced episodes of acute illness and overall better patient well-being. For chronically ill patients, coordinated care is the only way to achieve this.

If value-based care in the palliative setting means coordinated care, and the outcomes achieved can be cost saving, why isn’t everyone moving to this model? The reason is always the same: current reimbursement models do not support it. We bill for procedures, not outcomes, and even the shift to paying for outcomes is physician-centered. Chaplains and social workers are imperative, but they do not generate revenue under the current model.

We want the outcomes palliative care can offer. We want the cost-savings palliative care can generate. But to do that the payment model has to change, which requires proving to payers that the a medical team approach works, and finding people brave enough to venture into the palliative space when payment is not guaranteed.

The good news is healthcare systems and providers are changing. In Oregon and Colorado Medicaid reimburses for end of life discussions. Palliative care companies and programs within hospitals are springing up around the country. But the system is in transition and we need a more cohesive solution.


Why the VA Should Look Toward Proven Health Care Solutions

By Bill Frist and Tom Daschle

While it is not a secret that the Veteran’s Affairs hospital system has had inefficiencies for many years, the recent spotlight on veterans’ long wait times for basic medical attention has made headlines for good reason.

Long wait times are dangerous and extremely costly, resulting in unnecessary emergency room use, advancement of medical illness, and possibly even death, when early intervention would have been life and cost saving. In short, we are failing our veterans.

The confirmation of former Procter & Gamble chairman Robert McDonald to lead the VA is a step in the right direction. The bureaucratic entanglement from which the VA has suffered will potentially benefit from a leader with private industry experience. The bipartisan legislation recently enacted by Congress is another key step and will help ensure the VA has critical additional resources to eventually hire more personnel and open new facilities. But we still need more.

Delivering high-quality care for veterans will mean going beyond our national status quo, because inefficiency and waste are unfortunately part of the fabric of U.S. health care. Just consider appointment timing.

Nationwide, a patient faces an average of an 18-day wait for a doctor’s appointment. If the need for care is acute, that delay of preventative care means that a problem that could have been prevented yesterday is today out of control.

These problems are not novel. We have seen advances in health care technology making sense of these issues. Companies offering online appointment scheduling, patient adherence apps, telemedicine, and more are already easing the strain such that some Americans can get the care they need when they need it. In these models, we have seen tools for strengthening and modernizing our health care infrastructure being polished, tested, and refined by real-world patient use. The VA could be an easy adaptor given the VA electronic medical record system was one of the first in the country and continues to be the largest integrated system. We are encouraged that the bipartisan legislation enacted by Congress takes this practical approach and sets up a task force to look at existing solutions that can be deployed at the VA.

The message is that Veterans need health care now, which means the VA needs infrastructural improvements yesterday. There is no valor in reinventing the wheel when solutions already exist. Veterans, and frankly all Americans, cannot afford the delay. Models that can be implemented quickly and efficiently already exist. We should, and we must, avail ourselves of those opportunities. These options are ready for adoption and will help ensure our veterans are able to quickly access the care they deserve.

Tom Daschle is a former Senate majority leader and a senior policy adviser at DLA Piper. Bill Frist is a former Senate majority leader and a cardiothoracic transplant surgeon.

This article originally ran in Roll Call on August 19, 2014:

Ebola: Contagious vs Infectious

Read my earlier Ebola primer.

As the CDC treats the nation’s first two Ebola cases there are a lot of questions and concerns about the disease in America—Could it become an epidemic here? How contagious is it? How is it caught?

Although my medical specialty is cardiothoracic surgery, I have spent a good deal of time working on global health issues in Africa and elsewhere, and I have been in close contact with the CDC over the past week. I thought it might be useful to highlight some of the features of Ebola that make it more—and less—dangerous.

As a viral disease, Ebola follows a fairly predictable timeline.

Incubation: the time between when a person is exposed to the virus, and when symptoms start. In Ebola, that incubation period can be between 2 and about 21 days. During that time, the patient does not feel sick and research suggests that they are not contagious. (see doi:  10.1016/j.phrp.2011.04.001) There’s been concern about infected travelers spreading Ebola to other parts of the world after traveling from West Africa. That is certainly possible with a long incubation period.

Onset of Symptoms: However, once an infected person starts to feel sick, they are quickly seriously ill. There is sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, impaired kidney and liver function.

Unlike a cold, when you could be spreading the virus and not really feel that unwell, Ebola patients know that they are sick. This is actually a good thing, because sick patients are easy to identify, isolate, and treat. Other diseases still need to be ruled out—malaria, typhoid fever, cholera—but it’s clear that the patient has a severe illness.

Transmission: Here is perhaps the scariest part. How do you get it? How did Dr. Brantly get it? How is the virus spreading between people?

Some diseases are infectious, but not contagious. Lyme Disease or Rocky Mountain Spotted Fever are transmitted from ticks to humans but cannot be spread from human to human.

Contagious diseases can be spread from person to person, but not all equally well. Chicken pox, small pox, and measles, for example, are airborne spread—meaning the virus spreads very well with each exhale. These diseases are highly contagious.

Ebola, on the other hand, is only spread through direct contact with the bodily fluids of infected patients—blood, semen, sweat, urine and other secretions. And then, that fluid needs an easy entry into the body: a shared needle, an open cut, an exposed mucous membrane. It could possibly be spread through a cough or a sneeze, but that would require a fairly large drop of mucous to be coughed into another person’s face and get into their mouth or nose or eye.

For healthcare workers in West Africa, this could be possible. With limited supplies, perhaps there is a tear in a glove, or there aren’t enough goggles to go around, or bedding is reused because there isn’t an adequate way to clean it.

If patients are being cared for at home—either because they are too far away from a medical facility, or there’s some cultural distrust of foreign aid workers—caregivers in close physical contact with sick loved ones would have no medical or cleaning supplies. There are also vast cultural issues that influence the virus’ spread, and I’ll touch on those soon.

But with supplies, knowledge, and fully-equipped medical centers, these circumstances would be much less likely to happen. For these reasons, the Centers for Disease Control (CDC) is not concerned about an outbreak in the United States.

The situation is certainly serious—and will continue to be very serious in West Africa. But although we don’t know everything about how this virus behaves and changes, we do have quite a bit of useful knowledge about how to keep it contained, and how to keep our healthcare workers at home and abroad safe.

Ebola Primer and Liberia

As I hope you’ve heard, there is an outbreak of the Ebola virus in Western Africa right now, particularly in Liberia. Two American aid workers, Dr. Kent Brantly with Samaritan’s Purse and Nancy Writebol, a volunteer working with the faith group Service in Mission, were recently infected.

I’ve been discussing the situation with the Centers for Disease Control, and I wanted to write a little bit about the transmission and natural history of the virus.

Ebola is a type of viral hemorrhagic fever (VHF). Four families of viruses cause VHFs, and Ebola is from the family Filoviredae. Dengue fever, Yellow fever, Crimean Congo fever, Hantavirus and Lassa fever are other types of VHFs you may have heard of.

Humans are not a natural vector for the Ebola virus, so outbreaks occur after a human comes in contact with an infected animal such as a monkey, pigs or especially bats. Human-to-human spread then occurs through contact with bodily fluids such as urine, secretions, blood, stool or contaminated medical equipment.

Ebola is not technically contracted by respiratory contact with an infected individual, but aresolization of secretions—for example, a coughing patient—can cause spread of the virus. Therefore, barrier precautions like gloves and gowns as well as airborne precautions like masks and goggles (to prevent absorption through the cornea of respiratory droplets) are necessary to prevent transmission. For healthcare workers, infection is almost exclusively the result of a tear or other weakness in their protective barriers.

VHF viruses are dangerous because they are highly contagious, have a high rate of infectivity with low doses of exposure and high rates of complications and death. Therefore, it is important to recognize the signs and symptoms to quickly isolate potentially infected individuals. First, the individual’s travel history is important if not already in an endemic area. Second the timing is helpful to raise suspicion. The incubation period is a few days to weeks. The illness begins with fever and muscle soreness, low blood pressure, red eyes and a rash (specifically, petechial hemorrhages).  The constellation of these symptoms with potential exposure is enough to warrant immediate quarantine.

The virus then attacks blood vessels all over the body and increases vessel permeability resulting in fluid loss and bleeding. The fluid and blood loss causes shock and disorders of the clotting system resulting in hemorrhage from mucous membranes as well as in internal organs such as the gastrointestinal tract and lungs. While there are experimental drugs under research and being used in Liberia today, the only known available treatment at this time is supportive care.  Supportive care includes fluids, blood products, blood pressure and respiratory support and possibly comfort measures.

The key to survival of Ebola is immediate and sufficient isolation of infected individuals and treatment with aggressive supportive care in an intensive care setting. Once patients have stabilized they are no longer infectious and can be taken out of quarantine. The virus is so rapidly fatal that naturally occurring outbreaks can be contained if patients are quickly isolated and effective barrier and airborne precautions implemented.

There are some experimental drugs for Ebola, but none have completed clinical trials and some have only been tested in lab animals. Many are arguing that the most advanced of these treatments be made available to the sick, even though they haven’t been fully tested yet. One such serum was administered to Ms. Writebol. Dr. Brantly has had a blood transfusion from a boy who survived the virus, in hopes that some antibodies to the virus may be transferred.

Much of the outbreak problem in West Africa can be attributed to lack of knowledge about the virus to recognize and immediately quarantine the sick, as well as the cramped facilities where the healthcare workers were operating. West Africa has never seen Ebola before, and most healthcare facilities are not properly equipped to handling the kind of quarantine needed.

The Centers for Disease Control is currently working to send in personnel and supply support to help contain the virus. Dr. Friedan, the director of the CDC, has little fear of spread to the U.S. due to quarantine posts at all points of entry. He also predicts it may take up to six months to completely contain the virus in Liberia, but he’s confident of eventual success.

Join me in praying for all of the infected individuals and the healthcare workers on the ground and abroad that are making efforts to help contain the outbreak.

What’s next?



Healthy Timing and Spacing of Pregnancies: My Conversation with Melinda Gates

Yesterday morning, I had the privilege of sitting down with Melinda Gates, Scott Hamilton, Jenny Eaton Dyer, and a room full of caring people to talk about Hope Through Healing Hands’ Faith-Based Coalition for Healthy Mothers & Children Worldwide.

Chatting with both Melinda and Scott is always such a pleasure—especially about such an important issue as this!


Maternal and child health is a huge problem and the numbers can seem horribly daunting:

  • The biggest killer of women between 15 and 19 in many developing countries is pregnancy and childbirth complications.
  • One in every 39 child-bearing women in sub-Saharan Africa dies in childbirth.
  • Up to one in four girls in Sub-Saharan Africa drops out of school because of an unintended pregnancy.

But the exciting thing is, we know the answer! Empowering women to plan and space their pregnancies, dramatically increases their survival, and that of their children by 50%.

Women in the developing world want the power to choose. Melinda talked of her experiences visiting with women all over the world, and hearing them ask for more information and more resources. They want to understand their own fertility and their natural options; they want access to contraceptives.

Letting women space their own pregnancies means they can stay in school longer. It means they can nourish and raise their babies. It means they can heal after childbirth and contribute to their families and their communities.

Empowered women tend to have fewer babies, because their children survive. Couples make difference decisions when they can count on their children living. And these women have a long term plan: their daughters are twice as likely to be educated if the mother was able to complete her own education.

Do you know what else goes down when women have the information they need to time and space their pregnancies? Abortion rates plummet. Dramatically.

Even in the face of cultural norms that push women to have as many babies as possible, these women see how much is at stake. They see vastly better lives for themselves, their families, and their communities.

By 2020, helping the 120 million women who want help planning their pregnancies will result in: Over 50 million fewer abortions ; Nearly 3 million fewer babies dying in their first year of life; and 200,000 fewer women and girls dying in pregnancy and childbirth.

Healthy timing and spacing of pregnancies is a pro-life, pro-family message.


But this isn’t just a great theory. We closed yesterday with a few challenges, and I’d like to extend them to you as well.

  1. Go to and sign up for our newsletter. Keep in touch, and stay plugged in.
  2. Write your Congressmen. In Tennessee, we live in a state where we do have two moderate-pragmatic Republicans who want to, and do lead on global health issues. But in this political climate, knowing they have your support so that they can offer strong leadership on these issues is so helpful. Send them an email!
  3. Talk about this issue in your social groups, in church, with your friends. Where we’re born is not up to us; we could have been born into these statistics. Jena Lee Nardella of Blood:Water Mission is a partner with HTHH on this, and she put it so well yesterday. This must be personal.

If you want to read more about our conversation and the effort, check out:

The Tennessean article that ran yesterday, including video from the conversation.
The Christian Post covered our conversation, and got some great quotes from our faith partners at Brentwood Baptist Church and Blood:Water Mission
The Time article that Jenny Dyer and I wrote a few months ago.
HTHH’s Toolkit with more information and resources



Retrospective on Rwanda

I’ve been home from Rwanda and Kenya only a few days and I’m already on another flight, heading back to Aspen, this time for the Aspen Ideas Festival Spotlight: Health, co-sponsored by the Robert Wood Johnson Foundation.

It’s on flights that I have time to reflect on a few takeaways, drawn from the myriad impressions and experiences I gathered in Rwanda. I tell everyone that journeys to Africa are life-changing and indeed this one was for me, and hopefully those who joined me.

  • Partners in Health—that unique Boston-based nonprofit global health organization—is uniquely positioned in Rwanda to develop research-based health service models that can be applied around the world. In fact, we in the States have much to learn from these. It’s well on its way to doing innovative, PROVEN programs of science-based health delivery; creating disciplined training programs; and even taking aggressive cancer therapy to the rural poor in a way that is economical and effective.
  • Paul Farmer should get the Nobel Prize. He has demonstrated in Haiti and Rwanda and around the world that health care can be brought to the people who need it. He has shown the world that therapy once regarded as too expensive to buy and deliver—like HIV treatment—can be effectively and inexpensively administered to the poor and rural. And now he is addressing cancer treatment in rural Rwanda.
  • Gorilla health is like human health. My work with the gorilla health began at the National Zoo in Washington. Some mornings I would scrub in at 6 am over in Rock Creek Park to take care of a sick gorilla before opening the Senate as Majority Leader. My interest in gorilla health continues, and that is why I introduced our group at the base of the Virunga Mountains to the vets with the Mountain Gorilla Veterinary Project, on whose board I served for years. The upland gorilla, whose march toward extinction was reversed by Dian Fossey, has grown in number from 750 to 880 just over the years I have been involved. Animal conservation working hand in hand with animal health makes a difference. As an aside, I want to raise a red flag to the rapidly growing problem throughout Africa of elephants being massacred for ivory.
  • ONE health is a concept and a movement I hope others come to understand. It gives name to my conviction of focusing time and energies on human health, animal health, and environmental health. Health and healing applies to all—in Rwanda to the land around us, the farmers, the cows and buffalo, all interacting integrally with each other, as so clearly manifested at the base of the Virunga Mountains. Living side by side with mutual respect for each is the only answer. Gorillas are extremely susceptible to human-borne illness. Crowding brings buffalo in close contact with the gorillas, contaminating waterholes and leading to disease and death. Too many people still rely on bush meat for food, killing gorilla and monkeys. Gorillas are also threatened by hunters trying to trap antelopes for holidays and celebrations, unintentionally ensnaring baby gorillas. Health for one is health for all.
  • The HRH program in Kigali blew me away. It will work and I predict become the model of the future where governments are not corrupt. It is built around partnerships. Twenty-six US universities partner with USAID, the source of $33 million, to deliver and improve health services in Rwanda. The process through which the money flows goes like this: the American taxpayer gives his money to USAID who channels the money to government of Rwanda led by Paul Kagame who channels the money through the highly respected Minister of Health Dr. Agnes Binagwaho. Dr. Binagwaho distributes the money to the sites; 86 health professionals on the ground lead large programs to improve health service delivery. An orthopedic surgeon from the Brigham in Boston or a hospital administrator from Yale may then come to introduce systems to the Rwandan hospitals and district pharmaceutical distribution center. Over an eight year period, the goal is to train Rwandan workers with the skills and knowledge to build and sustain their own programs over years to come. It is working and it is a wise and smart use of the taxpayers’ dollars.
  • Paul Kagame is the man for the times. He has courageously taken a country that in 1994 was deeply divided by genocide, which claimed the lives of 20% of the population, and deeply divided by artificial colonial convictions, and though strong leadership has reconciled the people, formally achieving forgiveness in the immediate aftermath of neighbor-killing-neighbor, and establishing and maintaining remarkable peace. At the same time his belief in markets and investment has led to 20 years of annualized growth of 8% and is greatly expanding the middle class. His leadership is dramatic. He leads from above but implementation begins at the village level. When the president says thatched grass roofs lead to poor health and suggests replacement, it is each neighborhood that comes together every Friday over a two year period to assist in replacing the grass roofs with metal ones. When it is identified that wearing no shoes, the African custom, allows parasites to enter the body leading to disability and death, a proclamation from above to wear shoes was implemented at the community level almost immediately. The New York Times and New Yorker don’t like him, but I think he is an amazing man who has saved his country of 11 million people.
  • Journeys to Africa by Americans are a good thing. Our group of 10, half of whom had not been to Africa, bonded and shared our own perspectives in a close, personal, and intimate way. Africa touches one’s heart. It inspires. It cause one to dream. It changes your life.
  • Health care is improving fast in Rwanda. Vaccinations far surpass those in the US. Childhood mortality has been cut by 2/3. The basic district health clinics are accessible to all and they place a heavy emphasis on family planning, healthy pregnancies, and early childhood health and nutrition. Maternal, newborn, and child health are the foundations of strong communities. The fledgling national health insurance system is solid and growing fast and has been received well. The system gets by with MRIs and CT scanners. It has only one urologist in the country and five pathologists. Heart surgery is rarely done. But all that will change as the economy improves. The new cancer center at Butero, established at the district hospital as a brainchild of Paul Farmer and the Ministry of Health, will greatly expand cancer therapy the county, heretofore lost in all of the attention on infectious or communicable diseases like HIV, malaria, and tuberculosis.
  • On my return journey, I stopped in Nairobi, Kenya. Crime in Nairobi is high—street crime and home invasions with burglary and carjacking. Al-Shabaab, the al-Qaeda-affiliated Somali terrorist group, is increasingly threatening the city. Tourists are not coming and hotel census is down. Corruption rules the government and police, it seems. But commerce continues and I spent a day in a wonderful market and had top notch service at the Tribe Hotel, where Jonathan, my son, introduced me to the wonderful family who has developed it.

Bipartisanship saves lives

(The Hill, June 24, 2014)

By former Sens. Tom Daschle (D-S.D.) and Bill Frist (R-Tenn.)

When parents in America think about their children turning five, sending them off to kindergarten for the first time can be stressful. But if you live in the developing world, your biggest worry is whether your children will even live to see their fifth birthday.

But that is changing, and this year six million fewer children will die before their 5th birthday than in 1990. To put that in perspective, that’s 2 million more children than are even in kindergarten in America today. Driving that change is an unparalleled reduction in deaths and sickness from pneumonia, diarrhea, measles, HIV/AIDS, malaria, polio and neglected tropical diseases.

This is a global sea change, and if it surprises you, you are not alone. Relatively few Americans are aware of this remarkable story, much less the role the United States and many other global actors played in making it happen.
Americans can be proud that these unprecedented advances would not have happened without our involvement as the largest single donor to global health and working in historic collaboration with the other governments, multilateral institutions, local entities, NGOs, civic groups, faith and business communities, universities and philanthropies.

As the majority and minority leaders of the Senate in 2003 when the President’s Emergency Plan for AIDS Relief, or PEPFAR, was created, we know firsthand how pivotal the U.S. role was in one of the biggest pieces of the global health puzzle.

Through PEPFAR – which President George W. Bush initiated with vision and strength, and President Obama has worked hard to continue – the U.S. led the international community by providing tens of billions of dollars to stop the spread of HIV, giving appropriate care to the millions ravaged by AIDS and keeping them alive with anti-retroviral and other interventions.

PEPFAR is one of the crowning examples of how American resolve and leadership can bring about an enormous impact with a relatively small portion of our national budget. It shows that Democrats and Republicans can actually agree on historic health initiatives, not only on HIV/AIDS, but also in tackling malaria, vaccines, clean water and other smart and effective interventions. That same collaboration of compassion can continue to save millions of lives in the future.

The improved child survival rates are so startling they are hard to believe at first glance. According to a 2013 UNICEF report, the global mortality rate of children under five years old dropped by 47 percent, from 90 deaths per 1,000 live births in 1990 to 48 per 1,000 in 2012. In some regions, the decline in under-five mortality was even steeper– as high as 65 percent in both the East Asia and Pacific and the Latin America and Caribbean regions.

A large portion of the progress came in much of the last decade, not coincidentally after the historic international commitment to the Millennium Development Goals. UNICEF estimates that, as compared to 12 years ago, today 700,000 fewer children die of pneumonia, and 600,000 fewer children die of measles.

Not only did deaths decline, so did sicknesses. Polio cases have decreased by more than 99 percent since 1988, when the disease was endemic in 125 countries. Today, polio is in only three countries. That is nearly all-out eradication of a dreaded malady that it seemed would never go away.

Encouraged as we all should be about the successes so far, there remain 6.6 million children under five who will not reach their fifth birthdays this year, dying mainly from preventable diseases. That is just not acceptable. Without a similar commitment by the U.S. and other international partners in the foreseeable future, we risk squandering the gains of the last 25 years and missing the opportunity to go even further in the next 25. We must keep driving the momentum that got global health to this point.

Some worry the commitment could wane, as Congress has struggled of late to achieve bipartisan consensus on much of anything and, according to a recent Pew Research Center study, a majority of Americans prefer to limit our international engagement to take care of problems at home.

Based on our experience with PEPFAR and other global health initiatives, we are convinced members of Congress from both sides of the aisle remain united around the small, but smart, investments in global health that have historically yielded extraordinary results.

And this week, businesses, NGO, faith, civic and philanthropic leaders are increasing their own investments, coming together to affirm their commitments of more than $2 billion of private resources to invest in ensuring children survive and thrive beyond their fifth birthday.

The world knows what works to increase child survival rates, and we can do this. But doing it will require continue bipartisan cooperation and the energetic grassroots efforts that made the last 25 years of progress possible.

Daschle served South Dakota in the U.S. Senate from 1987 to 2005 and was the Majority Leader from 2001 to 2003. Frist served Tennessee in the U.S. Senate from 1995 to 2007 and was Majority Leader from 2003 to 2007.

Read more:

Watching Global Health Diplomacy in Action: A Week in Rwanda

(Morning Consult, June 23, 2014)

One week ago I had dinner in an open air restaurant overlooking Kigali, Rwanda. It was a beautiful night, and the almost-full moon illuminated Kigali and the land of a thousand hills.

As we were leaving, one of our hosts approached me. A formal and reserved woman, she quietly told me that at the end of her medical school education—about 1999—she almost walked away from the career she’d been building. All of her patients were dying of AIDS; the virus seemed unstoppable. There was nothing she could do to help them. There was no hope.

In despair, she told her Canadian advisor that she was ready to quit medicine. He encouraged her to keep working. “There are therapies to treat this virus in the world. They are young, they are very expensive, but there is reason for hope and optimism,” he told her. “These patients who have led you to despair have a treatment. And someday, if we all work hard, that treatment will be here.”

She had tears in her eyes when she looked up.

“And then,” she said, “you came.”

The “you” was the United States President’s Emergency Plan for AIDS Relief—PEPFAR. PEPFAR initially committed $15 billion starting in 2003 to fight the global HIV/AIDS pandemic. Rwanda was one of the original focus countries.

The United States and PEPFAR turned around a country that had been destroyed, indeed a continent that was being destroyed, by your generosity and your commitment, she said. Drugs that were out of reach, all of the sudden were being distributed to patients.

PEPFAR changed this woman’s life personally too. She stayed in medicine. She became active in public health issues. Today Anita Asiimwe, MD, MPH, is the Minister of State in Charge of Public Health and Primary Care.

I wiped away tears at the earnestness with which Dr. Asiimwe spoke. I looked at Dr. Paul Farmer, who led last week’s Rwanda trip with me, and he was emotional too.

I’ve long believed that health and medicine are the most powerful currency for peace and healing. Public policy matters. The United States is generous and it really affects people’s lives, both patients and providers.

Dr. Asiimwe’s story set the stage for a humbling week.

Dr. Paul Farmer, representing Partners in Health (PIH) and Harvard Medical School, and I, representing Hope Through Healing Hands, led a small coalition to learn more about health care in Rwanda and the progress being made there in the past 20 years.

In 1994, twenty percent of the Rwandan population—about a million people—was murdered in a genocide against the Tutsis over a 100 day period. I have studied the origin of the genocide, visited the memorials, talked with the survivors, read the explanatory books and made multiple journeys to Rwanda ­—but it is still hard for me to fathom. We in the US stood idly by when this happened.

The genocide was rooted in a deep-seated post-colonial divide coupled with eugenic constructs of race grounded in the previous century. All social order was destroyed. HIV infection rates skyrocketed. Child survival plummeted. And health care delivery capacity was nonexistent.

But the people of this country came together and began to rebuild. Formalized programs of reconciliation were embedded in every village and in every place of worship. The government began to plan an equity-oriented national policy focused on people-centered development.

The results speak for themselves. Life expectancy has doubled since the mid-1990s. Premature mortality rates have fallen dramatically in recent years

In 1998 the government released a national development plan based on a comprehensive consultative process coupled with long-term visionary thinking called Vision 2020. The plan involves the principles of people-centered development and social cohesion. Central to the vision is health equity. The government understood that prosperity would not be possible without substantial investments in public health and health care delivery.

In the early 2000s, I visited President Kagame in Rwanda and observed over the course of the day the inclusive consultative process, which brought experts and stakeholders from around the country together to plan for the future. I was impressed, and remember thinking at the time that we in the US should be doing a lot more of this strategic sort of planning.

In 2003 the Rwandan constitution formalized the inalienable right to health. The Rwandan people made the commitment—in contrast to the violence which led to the 1994 genocide—to commit to, and invest in life.

Their work is bearing fruit.

Initially, PIH was a health care provider in the hospitals and health centers it started. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at three district hospitals and 41 health centers, with the help of 4,500 community health workers.

The Rwanda Human Resources for Health (HRH) Program was launched two years ago in collaboration with Harvard Medical School, USAID and other US government programs. About 70 to 100 clinicians, administrators, and planners from Harvard-affiliated hospitals work closely with the Rwandan Ministry of Health to develop the clinical service infrastructure and train healthcare providers.

These groups are laying groundwork that Rwanda is building on to establish its own mature health services. But that doesn’t mean the time for dreaming is over.

Paul Farmer’s next dream for Rwanda is to set up a major multidisciplinary research university in a rural area outside of Kigali. It’s part of his vision to move services, “out to where the people are.” It will train doctors, nurses, and community health workers; it will give broad practical instruction in the post-secondary space; it will give opportunity to people among the poorest regions of the country.

It’s a crazy idea, but—mark my words—you will see it alive in five years.

Farmer already has the Minister of Health and Rwanda’s President on board. He’s funded studies on long-term sustainability. He has initial planning money from two donors, and is working with Melinda Gates on development.

For having survived so much pain, Rwanda has proven itself extraordinarily resilient. Starting with PEPFAR’s HIV/AIDS relief and now the work being done by PIH Rwanda and others, investments in health truly are returning dividends in peace, growth, and healing.

It is global health diplomacy at its best.

Read more:

Notes from the Road: Mountain Gorillas

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and blogs from Monday, Tuesday, and Wednesday

Today we went to see some of Rwanda’s natural treasures: mountain gorillas.

Rwanda has a long history of gorilla conservation. Dian Fossey, author of Gorillas in the Mist, founded the Karisoke Research Center in Rwanda in 1967 and studied gorillas in the Virunga Volcanoes until her death in 1985.

We were hosted by Gorilla Doctors, a mountain gorilla veterinary project supported by the UC Davis Wildlife Health Center and dedicated to saving the mountain gorilla species one gorilla patient at a time. Gorilla Doctors serve the mountain gorillas throughout the Virunga Volcano Mountain Range that spans Uganda, Rwanda, and the Democratic Republic of Congo (DRC).

With Gorilla Doctor guides, we spent six rainy hours trekking through Volcanoes National Park looking for the Titus family of 10 gorillas—including one silverback and one 3 month old newborn. We finally caught up with them at about 9,000 feet.

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These incredible creatures are monogamous vegetarians. Each mother has 4-5 children during her lifetime, starting when she’s about eight years old. They can live to be 43 years.

At one point, the gorilla population here was down to 250 animals. When I visited in 2008, there were 750. Today, Gorilla Doctors estimates that there are 880 gorillas.

But gorillas are not quite the departure from human health that they may seem.

Dr. Jan Ramer, regional manager of the Mountain Gorilla Veterinary Project, explained that Gorilla Doctors approach their work from the “one health” perspective, a belief that the health of one species is inextricably linked to that of its entire ecosystem, including humans and other animal species.

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It’s easy to see how closely the species connect.

The number one killer of gorillas is trauma. On our walk we came across three rope and wire snares. Though meant for antelope, gorillas, especially infants and juveniles, sometimes get caught in these snares. Gorillas may lose limbs or digits to snares, or die as a result of infection or strangulation. Gorilla Doctors respond to reports of gorillas in snares and work to treat their wounds and release them.

The number two killer of gorillas is infectious diseases, and humans and gorillas are susceptible to the same diseases. In fact, the most common infection in gorillas is respiratory disease, which can range from a mild cold to severe pneumonia, in individuals or in whole groups. These diseases are often passed from human to gorilla.

I’ve worked with these animals before, even doing some gorilla surgery, but seeing them in their homes never gets old. Amazing creatures.


Notes from the Road: Building Infrastructure for Long Term Growth

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, Monday’s blog, and Tuesday’s notes.

This morning we met with patients and physicians at Centre Hospitalier Universitaire de Kigali (CHUK), the urban hospital equivalent. For the past few days we have explored Paul Farmer’s vision of taking health care to the people in rural areas, so often neglected around the world.  Today we looked at health care in the city.

CHUK is the primary teaching hospital, located in the heart of Kigali. With 25 departments—17 clinical and 8 administrative—CHUK provides training, clinical research, and technical support to Rwanda’s 39 district hospitals.

Again we were able to meet patients and hospital staff. I was particularly impressed with this three-year-old little firecracker. He fractured his hip falling out of tree, but that wasn’t keeping him down! I also had the honor of meeting this dedicated woman. She’s served as a nurse in all of CHUK’s departments over the past 11 years.


Over and over I’m impressed with how much Rwanda, with PIH and other groups, has accomplished.

For instance, Rwanda has one of the highest vaccination rates in the world—a status they have achieved through very hard work over the past eight years.

Vaccines for children here are a series of six individual vaccines that begin at birth over the first two years of life. In a country with about 11.5 million people—the majority of whom are very poor, a 94% vaccination rate has been achieved through national campaigns centered in communities. The vaccines are administered through community health centers in each of the villages. This is really, truly remarkable.

Breast and cervical cancer have been on the rise in Rwanda, so in 2010, a national campaign to vaccinate schoolgirls against HPV began that is gradually making it across the country through community health centers. The hospital at Butaro—where we were yesterday—is participating in research and the collection of data around this vaccine.

It works; it’s a great vaccine. For cervical cancer it’s very important. And Rwanda is taking a leadership role. As you can imagine, cancer is not treated well in the developing parts of the world. So it’s pretty remarkable that both a vaccine program and cancer care are coming together here.

Of course Rwanda’s remarkable progress is contrasted by the genocide that took place here 20 years ago.

This afternoon we visited the moving Kigali Genocide Memorial, where the history of genocide worldwide is powerfully presented. It was a return visit for me, but no less humbling.

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Last time I was here, a bipartisan group of Senators laid a memorial wreath. This time, I considered what Rwanda has accomplished in those 20 years:

  • a dedicated nurse spending 11 years caring for the sick;
  • Partners in Health Rwanda’s work over the past nine years;
  • a nationwide vaccine program against polio, tuberculosis, and measles, for the past eight years; and
  • the PIH Women’s and Girls Initiative training women for the past six years.

But these are only the beginning.

Maybe the most hopeful thing I saw today was the work of Human Resources for Health (HRH). We had the privilege of meeting physicians from this innovative Rwanda-U.S. joint partnership to strengthen the Rwandan health care system.

Harvard Medical School, USAID and other US government programs are funding about 70 to 100 clinicians and administrators and planners through the Rwandan Ministry of Health to develop the clinical service infrastructure.

These are inspiring mid-career physicians from Harvard-affiliated hospitals who are changing the world. Our tour was conducted by an American orthopedic surgeon who is dedicating a period of her life to serving the hospital and the training program of young Rwandan physicians.  They are all heroes.

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The program, funded by the American Taxpayer and in its second year of an eight year commitment, is a tremendously powerful and smart investment in the future.

What is needed in Rwanda—and globally!—is a long term plan. HRH is building up infrastructure which is so badly needed to lift up the health sector here. But equally importantly, their work will make health care in Rwanda sustainable and prepared for the future.

Notes from the Road: Cancer Care in Rural Africa

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and Monday’s blog

Who says you can’t treat patients suffering from cancer in the poorest, most rural parts of the world?

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I’m writing on my iPhone on a bumpy dirt road that I am told will be paved next year. It winds for two hours through gorgeous green mountains sculpted with terraced plots of land and scattered homes stepped up and down the hillside.

But 30 minutes ago I was on a mountain top in a cancer ward listening to the heart sounds of a 6-year-old boy with leukemia and examining the slowly disappearing lumps on the chest of a 20 year old man with non-Hodgkin’s lymphoma—both being treated with state of the art intravenous chemotherapy.


Butaro Hospital, based in Burera District, Northern Province, is a PIH-supported facility and home to the Cancer Center of Excellence, a cancer-referral site for all of Rwanda. The cancer ward was opened up in this rural district hospital two years ago. As we toured the wards, we saw children with leukemia, women with breast cancer and men with bowel cancer.

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Paul Farmer introduced to the world the fact that HIV treatment does not have to be expensive and that it can be successfully treated in the poorest parts of the world. No one believed him at first. But he proved them all wrong.

Now he is doing the same for cancer diagnosis and treatment. If it can be pulled off in rural, mountainous, and hard-to-reach Burera, it can be done anywhere.

One third of the patients come from the local district, a third come from outside the district, and a third from around the country and even neighboring countries.

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The hospital has only the essentials: a simple plain film x-ray machine, one ultrasound machine, and basic blood chemistries but nothing like blood cultures. There are no pathologists there—photographs or iPhone pictures can be sent to partner hospitals in Boston, Brigham and Women’s and Dana Farber Cancer Center, when needed.

But the staff is Rwandan and they have been trained in concert with Partners who place a heavy emphasis on fact-based science, research, and clinical training with certification. Pride among the staff bursts forth. People are living and have hope where they were dying in despair.

It’s truly an amazing thing to see.

Notes from the Road: Rwanda and Health Diplomacy in Action

KIGALI, RWANDA | Why are we in Rwanda? What makes it a unique place to learn about health policy, and health care delivery? What will we learn that can make us smarter as we address health issues back at home?
I thought through these questions on the flight to Rwanda, and I had plenty of time. It’s been a long series of flights—Aspen to Denver to Chicago to New York to Amsterdam to Kigali. But the real journey began today as we saw our first health facilities.

Today (Monday), the delegation piled into a Land Rover after breakfast for the 2.5 hour drive to our first stop: the Partners in Health (PIH) headquarters at Rwinkwavu. We toured the Rwinkwavu District Hospital & Health Center, which was funded in part by the Rwandan government, PIH, and Bill & Melinda Gates.

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Formally, I’m here as the Chairman of Hope Through Healing Hands, the global health nonprofit I founded. Having been both a surgeon and a public servant, I am convinced that health and medicine are the best currency for peace and healing worldwide. I started Hope Through Healing Hands to put that belief into action.

It’s a vision that is shared by Dr. Paul Farmer, PIH’s founder and director. Paul has been a friend and like-minded champion for global health for years. He has always had the vision to see things that others could not, the audacity to dream big, and the commitment, dedication, hard work to make his visions–whether a nursing school, hospital, outpatient clinic, or even an entire medical school–a reality. It’s an honor to tour Rwanda with him, and see the progress being made.

When I was last in Rwanda, in the summer of 2008, I was impressed to see how diligently international funds were used (in that case, PEPFAR funding focused on HIV, malaria, and tuberculosis care and prevention). I said then, I wish all Americans could join our delegation to see how wisely their contributions have been spent, and with accountability.

I have seen the same today in the Rwinkwavu District Hospital.

When Rwinkwavu District Hospital first opened, Paul planted several trees there on the property. Standing in their shade today, they are a visual reminder of the growth and progress that PIH—and Rwanda as a whole—has made.

With Paul Farmer under the trees he planted.

With Paul Farmer under the trees he planted.

The district hospital is in Southern Kayonza District, one of three that PIH serves. The 110-bed Rwinkwavu District Hospital and its eight health centers are in remote, rural area, and yet it is delivering care to the poor with both compassion and excellent science.

The highlight of my day was meeting the young researchers at Rwinkwavu who were learning how to conduct sophisticated clinical studies that are and will continue to be published in peer-reviewed journals. They are pushing medicine forward not only in their hospital, but globally as well!

Increasingly the hospitals in Rwanda are seeing surgical disease including cancer. For so many years, the African continent has concentrated on infectious diseases. Now that most of those are under control, the most dramatic emergence is of chronic disease of the heart and lung. In addition, there is a huge need for trauma treatment centers, which are generally nonexistent.

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After our hospital tour, we visited the PIH Women and Girl’s Initiative, a wonderful artisanal cooperative that had been started specifically for teenage girls, ages 12 to 18, an age group that has been neglected a bit in Rwandan society. The 20 young women that we met had dropped out of school for various reasons, but had banded together to start a cooperative and learn about small business. They manufacture purses, robes, aprons, gloves that are truly magnificent. (Yes, I bought an apron.)

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While the medicine being done compels the surgeon in me, from a global health perspective, the most exciting thing about PIH’s work in Rwanda is that it truly is being taken up by the Rwandan people.

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Initially, PIH was a health care provider in these hospitals and health centers. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at Rwinkwavu District Hospital and two other hospitals and 41 health centers, with the help of 4,500 community health workers.

At dinner I had the opportunity to sit beside Dr. Agnes Binagwaho, Rwanda’s Minister of Health. Dr. Binagwaho and I have met several times on my previous trips. She’s been championing public health in Africa since 1994. Tonight she, I, and David Vreeland, discussed the role of information technology in healthcare and the transformation it promises. Rwanda has made outstanding progress implementing health IT to support clinical decision making–a challenge we struggle with in the US as well.

This is the power of global health diplomacy—empowering a community to achieve health, healing, and peace, and seeing incredible gains for the entire global community.

Tomorrow we head North to another province, another hospital, and a cancer center of excellence. I’m excited to see what we learn there.

Off to Rwanda: Considering Child Nutrition

I was in Aspen earlier this week working on some of the challenges facing healthcare and the health industry in the US, but it’s time to switch gears.

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From my 2008 visit to Rwanda with the ONE Campaign.

Sunday, I leave for Rwanda to lead a one week group trip with my friend Dr. Paul Farmer to see some of the work being done by Partners in Health (PIH) in the country. I haven’t been in country since 2008, and I’m anxious to see the progress PIH and other groups are making in health.

Since the spring of 2005, Paul’s PIH organization has been in Rwanda working closely with the government and the Ministry of Health to reach the rural, underserved areas of the country. PIH began by focusing on HIV/AIDS work, but has now expanded to full healthcare offerings. Today, over 800,000 people are served by PIH’s 40 health facilities.

But the health challenges in Rwanda are still vast! Next week with PIH we’ll be considering many aspects of health in Rwanda, but one in particular that I’ll be looking at while I’m there is nutrition.

I firmly believe–and have seen firsthand!–that global health diplomacy works as a real and powerful currency of peace worldwide. And a healthy start to life–a mother enjoying a safe and healthy pregnancy leading to a safe birth and healthy infancy–is crucial to building a foundation that leads to stable communities and global peace.

Food insecurity and malnutrition account for more than half of the deaths of children under 5 in developing countries, and Rwanda has had its fare share of nutrition challenges. In 2005, 18% of children in the country were underweight.

But Rwanda’s government has made real progress in child nutrition since 2009. That year, a Presidential Initiative launched to address malnutrition. The country also joined forces with the US in the Feed the Future initiative.

A 2010 health survey showed that chronic malnutrition and stunting affect 44% of children under the age of 5 in Rwanda.

In September of last year, the Right Honorable Prime Minister, Dr. Pierre Damien Habumuremyi launched a 1,000 Days Campaign, focusing on food availability and a balanced diet for pregnant women through the first two years of life of their babies.

The first 1,000 days may seem like such a small window of opportunity for global change, but the data are clear that childhood undernutrition has long-lasting consequences.

WHO models estimate that over half of adults in the prime working age group–20-29 year olds in Rwanda–have been affected by childhood stunting. Many of these adults wear the visible badges of malnutrition: shorter height or lessened muscular development. And for just as many, malnutrition has exacted a mental toll as well, diminishing the cognitive function of the working age population.

Along with the rest of what we’ll see–including a bit of gorilla trekking and possibly gorilla surgery–I’m anxious to see what progress Rwanda’s 1,000 Days Campaign has made, and the returns realized on nutrition investment.

I’ll be sure to keep you updated.

Call to action on global nutrition

(The Hill, May 28, 2014)

The United States has shown courageous leadership over the last decade on global health. Earlier this year, Congress once again voted to protect the budget for those critical investments that we make to save lives, prevent the transmission of diseases and end preventable child deaths. During my time in Congress, we fought hard for life-saving global health programs. We were able to work together with both Democrat and Republican presidents to launch and implement historic health initiatives in priority areas such as HIV/AIDS, malaria, vaccines, and clean water. These programs have saved millions of lives, and proven that health is the best currency for peace.

But even as funding for global health soared, foundational programs promoting maternal and child nutrition were largely overlooked. Yet the need for greater leadership and investments in nutrition could not be more clear. Across the world today, 162 million children—1 in 4 children under 5 years of age—are physically and developmentally stunted, and 80 percent of those live in just 14 countries. The combination of physical limitations and reduced cognitive development directly linked to poor nutrition sentences these children to lives of unfulfilled potential, and it creates a severe drain on their communities and countries. A 2013 report from the UN Food and Agricultural Organization (FAO) estimates that the social and economic costs of malnutrition are unconscionably high, amounting to as much as $US3.5 trillion per year or $US500 per person globally.

Thanks to U.S. leadership on global health, child death rates have been cut in half over the last 20 years from 12 million to 6 million per year. With continued investments and unwavering leadership, child death rates could be cut in half again over the next decade. We must not save these children, only to abandon them in their most crucial developmental years.

Providing the right nutrients is fundamental to health, particularly during the first 1,000 days from a woman’s pregnancy to her child’s second birthday. In the 2012 Copenhagen Consensus report, an expert panel of economists concluded that every $1 invested in nutrition generates as much as $138 in better health and increased productivity. Yet despite the severe costs associated with malnutrition and the extraordinary returns on nutrition investments, the world spends less than 1 percent of development aid on life saving, basic nutrition solutions.

The tide is turning. In the 2014 budget, Congress provided a funding boost to the global nutrition account, signaling strong bipartisan support to combat malnutrition. President Obama has committed to developing a global nutrition strategy, and USAID Administrator Dr. Raj Shah, who has taken the lead on this initiative, just announced the completion of that strategy and the effort underway to develop a coordination plan across all agencies and programs that contribute to improved nutritional outcomes.

Moreover, in June 2013 at the Nutrition for Growth event in London, the U.S. joined other world leaders and signed a global agreement that will boost global prosperity, prevent millions of infant deaths, and unlock greater human potential by working in partnership with developing countries to tackle malnutrition. This commitment is reflected in the Global Nutrition for Growth Compact, which has been endorsed by over 90 stakeholders.
Governments from Scaling Up Nutrition (SUN) countries and their development partners are also taking nutrition seriously. A total of 50 countries have joined the SUN movement to date, committing to driving forward their national nutrition plans at scale.

These plans and commitments are encouraging, but we must sustain and build upon the momentum that has been created over the last year on global nutrition. The president and Congress must remain resolute in their support for strong global health and nutrition funding in the FY15 budget and in prioritizing nutrition as a critical pillar in our foreign assistance investments. They must work together to oversee the implementation of the new strategy, and to provide the increased resources that are necessary to reach the millions of children who continue to suffer needlessly from poor nutrition.

Investments in maternal and child nutrition build the foundation for the next generation to survive and thrive, and serve as a shining example of U.S. global leadership at its best.

Frist, an acclaimed heart transplant surgeon, served Tennessee in the U.S. Senate from 1995 to 2007. He was Senate Majority Leader from 2003 to 2007. He is chairman of Hope Through Healing Hands and Tennessee SCORE, a professor of surgery and author of six books. Learn more about his work at

This article originally ran in The Hill:

Happy Memorial Day

Maura C. Sullivan is a former U.S. Marine Corps Captain, Iraq War Veteran and graduate of Harvard Business School. She is a Commissioner, American Battle Monuments Commission– managing America’s overseas WWI & WWII cemeteries.  

Maura has demonstrated exemplary service to this country, continued commitment to public service, and an unusual breadth of experience. I’m proud to call her a friend.

She’s been in France this week welcoming American families who have traveled to spend Memorial Day honoring their loved ones who died abroad for the cause of freedom in World War II. She shared some of her thoughts with me, and I’m honored to share them with you.

I hope you’ll join me in thanking Maura, our other servicemen and women, and the Gold Star Families today.

Bill Frist

I’ve been afforded an incredible honor this year to spend Memorial Day with a Marine Corps “Gold Star” Family at Rhone American Cemetery in France, but I recently realized that many Americans aren’t familiar with the term, Gold Star Family, the honorific we bestow on families when one of their members has died while in uniformed service.

During World War I, families hung banners in their windows with a blue star for each service member.  If their service member was killed, they would replace the blue star with gold.  The tradition continued in WWII and beyond.  Today across America, more than 8,000 families of the Iraq and Afghanistan fallen bear this burden as do countless more from wars dating back to WWII. You can often recognize a Gold Star family member by the simple gold star lapel pin they proudly wear in memory of their loved one.

I am encouraged to see organizations like The American Battle Monuments Commission and The Franco-American Society honoring the sacrifice of our Gold Star Families and ensuring that the legacy of their service is passed down to future generations.  They join President Obama, who called upon the nation to honor Gold Star Families by issuing a Presidential Proclamation in 2010 declaring the last Sunday in September to be Gold Star Mothers’ and Families Day.  Additionally, The Marines’ Memorial  Club in San Francisco hosts an annual Gold Star Parents Honor and Remembrance  Weekend and the U.S. Army announced this past February that it will release three public service announcements over the next year to increase awareness of Department of Defense-issued Gold Star and next-of-kin lapel pins

Freedom is not free.  Many families paid dearly for it.  Let us cherish them this Memorial Day and hold them close to our hearts.  If you have the honor of meeting a Gold Star family member, thank them for their sacrifice and perhaps inquire about their loved one who died fulfilling the most fundamental and sacred obligation of our nation.


The Case For Global Health Diplomacy

(Health Affairs Blog, April 14, 2014)

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

The full text of this story is available for free at the Health Affairs Blog at


Contraception Is A Pro-Life Cause In Developing World

(Time Magazine, March 21, 2014)

By Bill Frist, M.D. and Jenny Eaton Dyer, Ph.D.

When it comes to the health of children and mothers worldwide, there are immense challenges yet many signs of hope.

Over 6.9 million children die every year in the developing world from preventable, treatable causes. While the loss of these children is a tragedy of epic proportions, the good news is that over the last six years, this number has been lowered by 35%. We know we can combat newborn mortality and enhance child survival. Simple, low-cost measures are being taken to ensure better health for these children around the world. Measures like oral rehydration therapy, bed nets to prevent malaria, and access to immunizations have accelerated the rate of reducing child mortality in developing nations.

With an increased focus on maternal, newborn, and child health over the past few years, the global community has seen real progress against daunting challenges. An underappreciated part of that story is healthy birth spacing and timing, or family planning, which has a profound effect on the survival and quality of life of both mothers and children. As Michael Gerson, former speechwriter for President George W. Bush and Washington Post columnist, puts it, “family planning is a pro-life cause.”

When we talk about voluntary family planning in the international context, what do we mean? The definition I use is enabling women and couples to determine the number of pregnancies and their timing, and equipping women to use voluntary methods for preventing pregnancy, not including abortion, that are harmonious with their values and beliefs.

It shocks Americans to learn that one in every 39 child-bearing women in sub-Saharan Africa die in childbirth. However, when a woman delays her first pregnancy until she is at least 18, her chances of surviving childbirth increase dramatically. If she can space her pregnancies — through fertility-awareness methods (sometimes called natural family planning) or modern contraceptive tools — to at least three years between births, she is more likely to survive and her children are more than twice as likely to survive infancy.

The Center for Strategic and International Studies (CSIS) hosted a delegation in February for congressional staff, foundation, and nonprofit leaders, including Jenny Eaton Dyer, to see the emerging success of family planning in Ethiopia. With the infrastructure of their path-breaking Health Extension Worker (HEW) program, training 38,000 women as health workers in just a few years, women in the most rural communities now have access to antenatal care and family planning. With a Health Post designated for every 5,000 people, women have access to tools for healthy timing and spacing of pregnancies without having to walk for miles to a higher level health facility. In less than a decade, since 2005, Ethiopia’s contraceptive prevalence rate has nearly doubled, from 15% to 29%.

Healthy timing and spacing of pregnancies, alongside an increase in births taking place in Health Centers with skilled care during delivery and post-partum care, offers a strikingly successful model to reduce maternal mortality and improve child survival.

In addition to expanding access to voluntary family planning information and services, Melinda Gates, co-chair of the Bill & Melinda Gates Foundation, has also focused on healthy timing and spacing of pregnancies as a critical factor for global health and development. Hope Through Healing Hands, with support from the Gates Foundation, is promoting awareness and advocacy among Americans to support maternal, newborn, and child health. We are highlighting the crucial role that voluntary family planning is playing in nations such as Ethiopia.

Healthy timing and spacing of pregnancies does more than save lives from health risks: it also allows girls to stay in school. In Ethiopia, where the average age of marriage is just 16 (with many girls married as young as age 11), girls are often forced to drop out of secondary school to begin families. If girls can delay their first pregnancy and stay in school, ideally until the university level, they will be better equipped to partner with their husbands to meet their children’s needs, in a more stable family economic environment.

And as First Lady Roman Tesfaye of Ethiopia stated, “When a mother can contribute to her own life and family, she contributes to the nation as a whole.” Moving beyond the national level, healthy timing and spacing of pregnancies is also a key to other global health goals, like combating hunger and improving the status of women and girls. Family planning is a key, often hidden, engine for additional global health achievements.
Family Planning 2020 is a global partnership of more than 20 governments working with civil society, multilateral organizations, the private sector and others. Created at a 2012 London summit, it represents a commitment to meet the needs of an additional 120 million women who want to delay or prevent pregnancy but lack access to information and tools.

With a focus on healthy timing and spacing of pregnancies, we can make major strides in just a few years. That’s great news for mothers, children, and our entire world.

Bill Frist is a former U.S. Senator from Tennessee. Jenny Eaton Dyer, Ph.D., is the executive director of Hope Through Healing Hands.

This article original ran in Time Magazine:

Building a Healthier America

Last week I joined the Partnership for a Healthier America (PHA)’s Building a Healthier Future Summit. It was a fun meeting with lots of good food and guest appearances by Sesame Street’s Abby Cadabby and Doug E. Fresh.

I’m a firm believer that we must make the healthy choice the easy choice to change behavior and improve health. I was happy to see that a lot of other people are working toward that as well.

If you want to scan the live comments, follow the #PHASummit hashtag, but here are just a few of my notes and thoughts from the event…

Michelle Obama spoke and I was happy to hear her encouraging home cooking as a solution to childhood obesity. It’s a message she says she’ll continue to champion after the end of this presidential term. Cooking at home and eating as a family promotes better nutrition and cost savings, Ms. Obama said.

PHA announced several new partners: Dannon, Del Monte, Kwik Trip, Sodexo, Nutri Ventures, Knowledge Universe, FirstBIKE, UnityPoint Health-Trinity, Eskenazi Health, Meridian and St. Luke’s Hospital all made commitments to making healthier choices more accessible and affordable for busy parents and families.

In particular:

Dannon committed to improving nutrient density and reducing sugar and fat in its yogurt products. Dannon will also invest in education and research focused on healthy eating habits.

Del Monte Foods committed to improving the nutrient density of what it sells through marketing and new product innovation. It also is donating more fruit and vegetable products to anti-hunger efforts.

Kwik Trip, a family-owned business that runs more than 400 convenience stores and other outlets in Wisconsin, Minnesota and Iowa, committed to improving healthier food access and implementing a new EATSmart program and other policies that promote healthy habits among consumers. Kwik Trip will also start a Healthy Concessions Program that allows organizations to purchase healthier items at discounted prices to use in their fundraising efforts.

FirstBIKE is committing to donate balance bikes to the YMCA and similar organizations in order to provide increased physical activity opportunities for children in early childcare environments.

Knowledge Universe is implementing specific standards that promote healthier behavior at its KinderCare, CCLC and Champions centers, focusing on limiting screen time, providing ample opportunities for physical activity, healthy food and beverage choices, accommodating mothers who wish to breastfeed and offering engagement and nutrition education for parents.

Nutri Ventures committed to use its multi-media entertainment to promote healthy lifestyles and nutritious foods to children across the country.

Sodexo committed to implement healthy dining programs in 95 percent of its food service accounts, expand healthier food choices in hospitals, offer more free breakfast meals in schools and increase the selection of healthier, more nutritious options in its vending and K-12 lunchroom programs.

Eskenazi Health, Meridian, St. Luke’s Hospital and UnityPoint Health – Trinity have joined nearly 400 hospitals in PHA’s Hospital Healthy Food Initiative in a commitment to offer more healthy options throughout their facilities over the next few years. These hospitals will implement PHA’s Hospital Healthy Food Initiative guidelines, which include improving the nutrition of patient meals as well as that of the food options in on-site cafeterias.

All of the companies set specific benchmarks for their commitments, and you can read those at the PHA website. Dannon, Del Monte and Kwik Trip and FirstBIKE, Knowledge University, Sodexo, Nutri Ventures, and the hospitals.

Investing in Healthy Mothers and Children Worldwide

Earlier this week, a project we’ve been working on for months finally came to fruition! Hope Through Healing Hands announced a partnership with the Bill & Melinda Gates Foundation to launch the Faith-Based Coalition for Healthy Mothers and Children Worldwide.

Since 2004, Hope Through Healing Hands has made investments to support infrastructure, sustainable health development, education, healthcare, and emergency relief in developing nations.

We’ve sponsored the placement of over 75 medical, nursing, and public health students as well as medical residents in underserved clinics around the globe to bolster health care support and provide training to community health workers. We have invested in the education of young health professionals to help stem the global health worker crisis.

HTHH’s newest initiative, with the help of the Bill & Melinda Gates Foundation, might be our biggest effort yet.

  • Every year, complications from pregnancy and childbirth claim the lives of nearly 287,000 women and permanently disable many more, mostly in developing countries.
  • Children born to women younger than 18 years have an excess mortality risk of about 40% and are more likely to be stunted and anemic than children born to women over 18 years of age.
  • 42 million unplanned pregnancies worldwide end in abortion. 67,000 women die because of abortion-related injuries and millions more suffer complications and long-term injuries.

Yet if 120 million women get access to information on the healthy timing and spacing of pregnancies, 200,000 fewer women and girls will die in childbirth by 2020 and 3 million fewer babies will die in their first year of life by 2020. Fifty million abortions will be avoided by 2020.

The impact will be incredible.

The savings is not only counted in lives of women, girls, and newborns. Every dollar spent in family planning in a developing nation saves the country $4 in needed government services and support down the road. Healthy women can better care for themselves, their families, and build their communities.

How do we do this? By educating women in developing countries about the safest ages for pregnancy (between 18 and 34). By offering women contraception options (NOT including abortion) to help them space their children 2-3 years apart so that mothers can fully heal, and babies can get more of what they need that crucial first year.

Our work at HTHH is to spread the word, to build a coalition of faith-leaders and conservatives to promote awareness and advocacy for maternal, newborn, and child health with a focus on healthy timing and spacing of pregnancies. We’ve got several great initiatives planned. The Faith-Based Coalition for Healthy Mothers and Children Worldwide will offer education and advocacy support. There are opportunities to join us on our website.

This is an opportunity to profoundly impact future generations, and I’m so thrilled Hope Through Healing Hands will be leading the charge on behalf of these little ones and their families!

The Cadillac Tax: Implications and a Potential Silver Lining?

(Forbes, February 26, 2014 )

Like much of the Affordable Care Act, the Cadillac tax—Obamacare’s solution to a tax subsidy created during World War II—offers a solution to an important problem, but is fraught with unintended consequences. Ideally, the tax would prompt employers to offer more cost-effective plans, with some shift of risk to employees along with mechanisms to help employees spend healthcare dollars wisely. For many reasons, that is not likely to be the reality.

The Cadillac Tax was designed to raise revenue for the ACA and it will. But we cannot continue to be the little Dutch boy with our finger in the dam. There is an opportunity here to allow the impact of the Cadillac tax to be positive and encourage real restructuring of healthcare spending.

Most economists thinking seriously about the depth of our deficit agree that the Employer Sponsored Insurance (ESI) tax subsidy is a significant part of the problem. ESI subsidies date back to the freeze on wage increases during World War II. To offset the freeze, the ESI allowed companies to use pre-tax dollars to pay for generous health benefits tax-free.

Of course that was nearly 70 years ago. Today, wages are free to rise, yet the ESI subsidy still costs $250 billion a year. What’s more, that cost only benefits about half of Americans: those with employer-sponsored health insurance.

Today, the ESI subsidy encourages overspending in health care by allowing money to be taken out of the normal wage tax structure and put into a safe haven if spent on health plans. The tax structure encourages the misappropriation of fund towards bloated health plans and is regressive.

The ability to funnel wages into health benefits is not just the purview of the wealthy. State and local government workers often find much of their compensation tied up in health benefits. Governments and many unions use the subsidy to compensate middle-income workers at a lower cost to the employer.

Rather than simply repealing the old tax structure, the Obamacare solution is an additional tax, a penalty imposed on “Cadillac” or very high cost health plans. It calls for a 40% excise tax on employer-sponsored plans spending more than $10,200 per employee (or $27,500 per family). This number includes employer and employee-paid premiums and employer contributions to Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs). There will purportedly be some adjustment for areas where healthcare is more expensive and for employees in high-risk jobs, but the regulations have not yet been promulgated.

The purpose of the Cadillac tax is threefold: to address cost of the ESI, to help finance the Affordable Care Act (ACA), and to reduce employer incentive to overspend on health plans and employee incentive to overuse services encouraged by these high-cost plans.

The Congressional Budget Office (CBO) originally projected the tax would raise $137 billion over the first decade starting in 2013. However, due to effective lobbying by pro-union groups and others, the tax is delayed until 2018 and CBO expects it to raise $80 billion between 2018-2023. Other experts estimate as much as $214 billion raised by 2023 based on indirect revenue from wage increases.[1] But beyond its role as a funding mechanism, the Cadillac tax could have significant unintended consequences for employees and the health system as a whole.

Based on the plan size defined by the tax, in 2018, about 16% of employer-sponsored plans will be affected. However, if healthcare spending continues to exceed inflation, a greater percentage of plans will qualify as “Cadillac plans”—spending more than $10,200 per employee or $27,500 per family— each year. The tax is tied to the Consumer Price Index (CPI) +1% for the first 2 years of implementation but then just the CPI. If healthcare spending continues to grow at approximately 6% per year (the historic average, though it has grown at a lower rate in recent years), the Cadillac tax will swallow 75% of employer-sponsored plans by 2029.

This should be a significant enough impact to change employer behavior, but will the change be positive or negative? I can see at least three major potential impacts of the incentive created to slim down “bloated” health plans.

First, employers will move toward reducing the cost of plans to avoid the tax, but not to curb overall health care spending. A 2013 survey by the International Foundation of Employee Benefit Plans[2] revealed that of the 879 single-employer plans they surveyed, 40% of employers responded that they were currently making changes in their insurance plans to avoid the tax and 16.8% stated they were seriously considering it.

The most obvious strategy for lowering employer contribution is to pass costs to employees, either as higher employee premiums, higher deductible plans, removing employer contribution to HSAs and FSAs, increasing co-pays and coinsurance, or just decreasing covered services. While these changes may avoid the tax, they will only decrease the healthcare costs of an employer’s work force if the employee then turns around and spends their healthcare dollars wisely. Alternatively, if employees just avoid healthcare they need due to cost, it could result in more expensive hospitalizations and sick days down the road.

Second, “high-cost” plans are not necessarily “benefit-rich” plans. Sicker populations, including the elderly and chronically ill, and populations with more women are simply more expensive to insure. Despite attempts to tailor their plans, employers will not be able to decrease their community rating if they have large numbers of older employers and women. Especially considering the ACA requires more comprehensive coverage for some areas like preventative and obstetrical care, creating a “bare bones” plan is actually antithetical to the rest of the ACA. To dodge this internal inconsistency, workers will likely find themselves in the exchanges. While these workers will still have a health insurance option, if it happens in great numbers it will affect the cost of premiums in the exchanges. In other words, the exchanges will take on the risk and cost of insuring older and sicker workers without the balance of the young-healthy population to share the cost.

Finally, given that state and local employers frequently use benefits to make up for lower salaries, the tax will likely affect your garbage man and your child’s teacher. This may result in increased salary, but will definitely result in decreased benefits, higher premiums, and more cost sharing. Due to the misalignment of inflation and the cost of healthcare—healthcare costs rise faster than inflation—a subtle whittling of plans each year to avoid the Cadillac tax will eventually lead to an underinsured work force. We are already hearing stories about people taking on higher deductible plans where the deductible exceeds their ability to pay. In other words, the Affordable Care Act will result in unaffordable plans and an underinsured workforce.

On the bright side, the Cadillac tax could have a positive impact on the pricing of healthcare if employers take into account the long-term effects of their immediate maneuvers to avoid the tax. Rather than scheming to avoid the tax at all costs, employers can accept some portion of increased tax while instituting cost-sharing mechanisms that use consumer shopping and market forces to drive down overall healthcare prices. For example, employers can employ strategies like referenced-based pricing and consolidation of services with specific providers to allow for lower contracted costs. Creative solutions like these will actually decrease the cost of care, not just move money around on the balance sheet.

We need to attack the cost of healthcare at its source: level of use and initial pricing of services. Simply adding another tax that will indeed raise money but will not change cost is just biding time. Employers have an opportunity here to be pioneers. While the Cadillac tax may change some with revised legislation, it is an idea that has stuck and it addresses a problem that needs solving. This is an opportunity for innovation and change in the private market that can truly impact healthcare behavior and habits.

This story originally ran in Forbes:


[1] B. Herring & L, Korin Lentz (2011) What Can We Expect from the “Cadillac Tax” in 2018 and Beyond?. Inquiry: Winter 2011/2012, Vol. 48, No. 4, pp. 322-337.

[2] International Foundation of Employee Benefit Plans. 2013 Employer-Sponsored Health Care: ACA’s Impact: Survey Results, available at

Connected Health and the Rise of the Patient Consumer

(Health Affairs, February 2014)

How to achieve better care at a lower cost? Two powerful new forces may hold the answer.

America’s health care delivery sector stands at a tipping point—a convergence of a growing, graying, and highly consumptive population with increasingly limited financial and human capital resources.

Policy makers naturally gravitate toward government to provide the framework for solutions to this worsening scenario in which demand outstrips available resources. I’ve spent about equal time in government and the private health sector, and I believe there are two other levers that are more likely to be effective.

The first lever is the rapid ascent of the newly empowered consumer, equipped for the first time with actionable knowledge that can affect his or her health. The second consists of magnificent advances in information technology (IT). The exponential growth and application of these technologies are revolutionizing, in a very short period of time, the automation, connectivity, decision support, and mining of health information and data, which together will radically transform and improve health care delivery.

These two forces are just beginning to come of age. Neither was a significant driver of health care value just three years ago. Today their potential is enormous. Together, the empowered consumer and rapidly advancing health IT will channel our chaotic, fragmented, and wasteful health care sector toward a more seamless, transparent, accountable, and efficient system. They will answer the underlying question of how we will get better care for less cost. They will be the primary keys for game-changing, value-driven reform, where provider compensation and payments are determined not by the type and number of specific services rendered but by the quality and outcomes of care provided.

The rest of this article is available for free courtesy of Health Affairs.



Tennessee at Crossroads: 2013-14 State of Education Report

When SCORE was launched in 2009, we identified a “once in a lifetime opportunity” for unprecedented growth in student achievement in Tennessee. In November, we have learned that the efforts of educators, policymakers, and other stakeholders have helped Tennessee become the fastest improving state in the nation – and 2nd overall behind the District of Columbia – in terms of student achievement according to the Nation’s Report Card.

It was a huge achievement for Tennessee. But it was only the beginning.

Tennessee is at a crossroad – a critical point – in its pursuit of a better public education system. Tennessee is still under the NAEP national average, and we can’t lose our sense of urgency.

At SCORE, we believe it is critically important for a non-partisan, non-governmental organization to examine our state’s progress, to identify promising practices as well as challenges, and to provide specific recommendations for how Tennessee can continue on the pathway of preparing all students for success in college and the workforce.

The 2013-14 State of Education in Tennessee Report reflects months of research and more than 500 interviews with educators, students, policymakers, and other Tennesseans.

This year’s report is grounded in five key areas that we believe are crucial to Tennessee’s work to improve student achievement in the year ahead: Maintaining a commitment to rigorous standards and assessments; Strengthening schools through effective leadership; Expanding student access to great teaching; Investing in technology to enhance instruction; and Supporting students from kindergarten to career.

Under these headings are many specific recommendations. Here are just a few that I highlighted this morning.

  • Tennessee must stay the course on the continued implementation of the Common Core State Standards.
  • Because measuring student success with higher standards is a precursor to informing effective instruction, Tennessee must continue its commitment to implementing the PARCC assessments.
  • Principal preparation programs in our state should have rigorous selection processes and curriculum requirements that prioritize the skills that instructional leaders need.
  • Teacher support is crucial. It is imperative that teachers are provided with the tools and resources that will enable them to be experts in their profession.
  • School districts should create, as well as protect, time and opportunities throughout the academic year for high-quality professional learning that increases educator effectiveness and results for students.
  • It is critical that public policy implementation enables the state to attract and retain the best teachers.
  • It is important to use technology as a vehicle for quality instruction and for individualizing student learning.
  • We must increase and expand opportunities for high school students to participate in rigorous coursework including AP, International Baccalaureate, dual-credit, and dual-enrollment courses.

These are just a sampling of the points from the full study. I encourage you to visit SCORE’s website to read the full report.

We have great work ahead of us, Tennessee. But we’ve proven that the stakeholders in Tennessee education–the teachers, students, administrators, parents, and policy-makers–are committed to excellence and growth.

Digitize your own advanced-care plan

(The Hill, December 18, 2013)

End of life planning is so important. It’s a topic I’ve spoken on frequently. But it’s not just a plan that you need. Your family members must be able to find it when they need it. That’s why free, online tools like the ones My Directives offers are so valuable! It makes your wishes available any time, anywhere. 

The holidays are here, and with them time to gather with family and friends. This year, as we gather around the holiday table, I suspect that healthcare will be a common theme.

I challenge you, though, to move beyond the politics to discuss a topic that really matters: you, your voice, your thoughts. Who do you want empowered to speak for you during a medical crisis if you can’t? What kind of medical care would you want, or want to avoid? What are your hopes and fears if you were in an emergency situation?

While some of us might have thought about if we would want life-saving measures used, such as CPR or a ventilator, not nearly enough of us have shared those preferences with our loved ones, and even fewer have documented them in an advance medical directive.

Now, here’s the kicker. For the very few who have created a directive, can we — or better yet, our future doctors — access it immediately if needed?

While you might feel powerless to affect health reform, you can take charge of your own care by using this holiday season to discuss your thoughts and digitize them so your preferences are known. Make your voice heard. Don’t wait for an accident or illness to strike — there’s too much else to focus on, and your decisions need to be clear.

As a transplant surgeon, I saw critical health situations every day. I know firsthand the emotions that accompany the time spent in emergency rooms and intensive care wings. I’ve walked that road with hundreds of patients and their families.

Consider that at the end of life, nearly all patients will lose the ability to make their treatment preferences known — some in their last days, others for weeks or months on end. In the absence of advance care planning, patients are much more likely to receive medical interventions that can actually prolong or worsen their suffering and will certainly increase expense for their loved ones.

For example, cancer patients without advance care planning are seven times more likely to be placed on mechanical ventilation, and eight times more likely to have emergency CPR prior to death. On the other hand, nursing home patients who engage in such planning are less frequently hospitalized, report improved patient and family satisfaction, and experience 33 percent lower costs of care.

I imagine some of you are thinking, “Yes, this makes sense for my parents or grandparents.” I can assure you this is not a topic just for the elderly or sick; this is a topic for all of us. Talk of “death panels” during the healthcare debate was a distraction — and a dangerous one, at that. The truth is that we all need to take personal responsibility for our own end-of-life wishes.

If you won’t create your directive for yourself, do it to relieve a burden on your loved ones. I’ve talked with patients and families across the country about their end-of-life experiences. Families report that facing a decision about a loved one’s treatment near the end of life is one of the most stressful life events. However, for families whose loved ones have prepared a treatment plan, the experience is more peaceful. These families are able to take advantage of precious time together, rather than worry about and debate the right course of action.

There’s no better time than during the holidays to start the conversation with your loved ones., for instance, offers free digital advance medical directive forms online with instructions on completion and how to introduce the subject with family. The service helps ensure doctors can find your directive online during a crisis.

When a good advance directive is in place, providers can better do their jobs, and patients can be confident that their wishes will be part of the treatment process. Your doctors are medical experts, but only you are the expert on your hopes and preferences. An advance care plan relieves your family and physicians of the burden of having to guess your wishes.

These days, we’re hearing many voices in support of — or in opposition to — various parts of the healthcare law. But when it comes to one of the most important healthcare decisions you will ever make, the voice we really need to hear is yours.

Frist represented Tennessee in the U.S. Senate from 1995-2007 and was Senate majority leader from 2003-2007. He is a heart and lung transplant surgeon.

This story originally ran in The Hill:

End-of-life stories give us impetus to learn

(The Tennessean, December 1, 2013)

By Sen. Bill Frist, M.D. and Manoj Jain M.D.

Authors’ note: This is the final of six parts. We are honored and extremely grateful that so many shared their family stories with us. We have preserved the stories but have changed individuals’ names.

Over the past three months, as we have journeyed through the difficult topic of “end-of-life care,” we’ve had the privilege of hearing from many Tennesseans. You have shared stories of tender passings, tales of deep struggle, and accounts of sheer confusion and angst at the end of life of a loved one. The personal stories you’ve entrusted to us have renewed our passion and commitment to enable conversations in families, with doctors and in the community that will ensure loving and peaceful experiences at the end of life.

Milly described how this summer her husband suffered a massive stroke, which left him unable to feed himself and, even worse, unable to swallow food without aspirating. Milly and her husband had prepared for such a day because they had endured the painful death of her stepfather the previous summer: an experience in which he was left mute and paralyzed for months in the nursing home.

Include family in plan

Initially, Milly said, her children were alarmed and angered at the thought of forgoing more aggressive treatment in the hospital. While Milly and her husband had signed advanced directives together, they hadn’t shared their plans with the children. Thankfully, when they saw their father’s signature on the advance directive papers their anxiety was eased and they graciously accepted his wishes. Milly describes her husband’s last two weeks at home with hospice as “tough” but infinitely better than being in the hospital or the nursing home.

As with many families, it took a painful experience for Milly and her husband to realize the importance of planning for end of life. We encourage everyone to take the first step now, and not wait for a tragic experience to underscore the need for end-of-life preparation.

Once you’ve made your decisions, share your wishes with your loved ones. Knowing that the choice is yours relieves family of the burden of making difficult decisions.

Joe shared the medical journey of his wife, who was diagnosed with lung cancer and was told she had less than a year to live. She began chemotherapy and for four years enjoyed a good quality of life, able to care for herself and spend precious time with her family. When her tumor spread into her spinal cord, Joe’s wife wanted to continue chemotherapy and simultaneously begin hospice, yet hospice declined. Forced to choose, she ultimately returned home with hospice support and died surrounded by family.

Strings attached

Joe and his family experienced a sad reality in much of end-of-life care: Services are available, but they have strings attached. Hospice is a service offered to Medicare patients at no cost; yet, for patients to be eligible for hospice their life expectancy must be less than six months and they must no longer be taking any active treatments such as chemotherapy.

There is need for a sea change in end-of-life care, and models of palliative care are gaining ground in Tennessee. For example, Aspire Health aims to build a patient-centered comprehensive service that doesn’t demand a choice.

A final story: Grace’s parents’ health declined together over several months. While recovering from a heart attack, her father was diagnosed with rapidly progressing Lewy body dementia. Hospital social workers suggested a nursing home with physical therapy, but after family discussion and much prayer, Grace’s family decided to make the transition to hospice. Grace’s father died in his home surrounded by family.

‘See you soon’

Grace’s mother’s last words to her husband of almost 70 years were “I will see you soon.” She became ill the day of her husband’s funeral, was diagnosed with pneumonia and congestive heart failure, and died six weeks later.

For Grace, the tandem death of her parents seemed “surreal,” but the coordinated care from the primary care team, the hospice team and the home caregivers made it possible to endure those months and glean the best from them.

The experience was also made easier by her father’s meticulous preparations. He had carefully planned for the end of his life, even including a note reminding his family to “call the church sexton (during the funeral) so he’ll open the church so people can go to the bathroom.”

In sharing their stories, Milly, Joe and Grace have given all of us the impetus to learn from their experiences. Health care is complex. We are working within the medical community to increase the options for end-of-life care, but it is up to us all as individuals to initiate conversations about end-of-life wishes with our families.

If you’re still unsure where to begin, Alive Hospice, in Nashville, has launched The Gift Initiative this holiday season, encouraging all of us to give ourselves and our loved ones the ultimate gift of peace and preparation. Resources and free materials are available

For many, the Isaac Asimov quote holds true: “Life is pleasant. Death is peaceful. It is the transition that is troublesome.” But we believe that with thoughtful preparation, peace of mind is available to us all at the time of transition.

Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader. Manoj Jain is a Tennessee doctor who writes for The Washington Post.

Originally posted at:

Notes from the Road: Global South Summit 2013

NASHVILLE | At the Global South Summit last week, I moderated a panel on one of my favorite topics: transforming healthcare into health.

There is much discussion about how the current model of healthcare is “broken.” But the fact is, the system is producing exactly what it was designed to produce. The problem is that the current healthcare model was designed around brick and mortar buildings supporting the delivery of services and procedures. It is a sector with misaligned and misplaced incentives that leads to inefficiency and lowered productivity.

Calling it “broken” suggests that we need to return it to a previously working state. The truth is we need a radical redesign.

In tackling that question, I was joined by a panel of some of the top innovators in the country.

  • Jean Claude Saada, Chairman, Cambridge Holdings;
  • Dr. Clare Pomeroy, President and CEO, Lasker Foundation;
  • Dr. Jeffrey Balser, Vice Chancellor, Vanderbilt Medical Center;
  • Bill Gracey, President and CEO, Blue Cross/Blue Shield, Tennessee; and
  • Dr. Eric Bing, Director of Global Health, George W. Bush Institute, Southern Methodist University.

As Chairman and CEO of Cambridge Holdings in Dallas, Jean Claude Saada is launching a new strategic initiative to create “mindful living communities” and innovation hubs in major cities and research centers around the US and world: oneC1TY.

The idea, Saada said, came from speaking with his own grandmother. She lives in a small community surrounded by her friends and family. She walks to the market, to church, eats and cooks at home daily and grows her own produce. Her life and relationships are centered on a community within walking distance and includes everything she needs. The anecdote is backed by research into communities where people live the longest. Researchers found that they tended to have leaner diets and access to fresh food. They were active. They kept their minds active. They conversed more with family and friends and lived outdoors. Saada was inspired to deliberately build similar communities that enable healthy living.

Before Claire Pomeroy took her role as President and CEO of the Lasker Foundation, she served as Vice Chancellor and Dean of the UC Davis Health System. She knows that the mission—health—is often forgotten. When looking at the determinants of health, only 10% is actually health systems, she said. The rest is determined by behavior, genetics and social determinants. For example, the largest driver of children’s health is the educational status of mom!

Health outcomes just don’t improve unless you address the social determinants of health, and Pomeroy called for community partnerships to address the biggest needs, whether that’s violence, mental health, or dental care. We also have to address education, transportation and food deserts, she said. (Read a great article from the Washington Post on the food deserts in our country). The focus must shift and non-traditional partnerships must emerge. Pomeroy called for a culture change, a look at the big picture, and “health in all policies.”

I asked Jeff Balser at Vanderbilt Medical Center what role university medical centers should play in helping us move health and healthcare forward. He stressed the importance of research, and noted that it is changing as well. The system of doing research, publishing it and hoping it is impactful in 20 years is not the current case, he said. Now researchers could watch the discovery of a gene in their training lab actually guide drug design and make it to the market in a clinical trial within the time it takes to complete their PhD.

Big data, Balser said, is emerging both as a research resource and a care resource. For example, each case of diabetes is different with a different prognosis and outcome because the natural history of a diagnosis is patient specific. My mother’s diabetes is not my best friend’s diabetes, so offering them both the same treatment plan is not maximizing the impact of the health intervention.  Personalization of treatment based on not just genetics, but the social determinants of health can be a challenge but it is also an amazing opportunity.

Bill Gracey took on the questions of the financial and business model shifts as we change our thinking from “healthcare” to “health”. Bing echoed Pomeroy: To look at money, structure and lifestyle issues individually and not collaboratively is a road to nowhere. The health insurance industry, in an attempt to bring various aspects together, has invested several million dollars in wellness portals that incentivize wellness, Bing said. Not for having better health, he noted, but for doing the right things. Blue Cross Blue Shield has also focused on palliative care and chronic disease management as a space needing more integration but facing challenges in current payment models.

Eric Bing brought a global perspective to the topic. After the genocide in Rwanda, communities had massive health needs and minimum resources. So they innovated. Each community nominated health workers that were in charge of going house to house to determine issues as basic as “Who is ill here?” and  “Who is pregnant here?” and “Do they have a toilet here?”  This information was relayed to doctors using cellular phones to aggregate data so resources could be organized. There was also significant task-shifting to mid-level providers and non-medical professionals to save costs.  While these interventions may seem simplistic, they were lifesaving.  Simple needs assessment and allocation of resources in the most efficient way seems like a no-brainer, but in an economy where we have so much, we tend to forget these principles.  But in the circumstances of a crisis, they are the only hope.  As the U.S. approaches the rising healthcare crisis, though not as acute, we should consider these types of simple solutions.

Bing agreed with a tenet I’ve long believed to be true: disease knows no boundaries and health care is a great way to do diplomacy. U.S. leadership in HIV has made a huge difference across the board, Bing said. It has made a difference in maternal health and clean water and other issues. The US commitment is steady right now, but he challenged that it could be more.

Notes from the Road: 2013 Health Care Investors Conference

NASHVILLE | Last Wednesday, (Nov 13) I had the privilege of joining Bass, Berry and Sims and Deloitte at the 2013 Health Care Investors Conference. I sat down with Brad Smith, CEO of Aspire Health; Andrew Lasher, CMO of Aspire Health; and Anna Gene O’Neal, CEO of Alive Hospice, to discuss some of challenges and opportunities in end-of-life care today, and how we believe a new partnership can help.

End-of-Life care is positioned strategically for both the individual and the nation. Transitioning from a volume-based system to a value-based system requires a new model. We don’t have enough money to provide everything to everyone. At the same time, palliative care is needed at an intimate and chaotic time in people’s lives. Most people are not spending the last few years they way they want to—they don’t die the way they want to die.

Something has to change. Fee-for-service payment models will not sustain palliative care or even hospice. There has to be a forward-thinking to deliver these services in way that cost effective for the companies providing care. No one has been able to do this sustainably in the pure for profit or non-profit sector. The question that Smith, O’Neal, Lasher and I discussed is, “Can we meet this need by marrying for- and non-profit organizations with similar missions and goals?”

Andrew Lasher pointed out that palliative care is both a new field of medicine and the very oldest. In the past, it was the only thing medicine had to offer. Now we are good at managing chronic illness. We are prolonging life, but not comfortably. We need more physicians with training to merge the treatment of chronic illness with a palliative frame work. Currently, our teaching programs are not doing this quickly enough.

I agree. We have lost the connection between the physical, medical patient and the emotional, spiritual individual. Palliative care is what my dad used to practice in the mid 1900s. He used a holistic view of the patient to offer treatment and comfort as coinciding services –not separate options. In the current model, treatment and comfort are addressed as a decision point resulting in diverging paths where they should be travel companions.

Alive Hospice is striving to do end-of-life better, said Anna Gene O’Neal. The average daily census at Alive Hospice is more than 480 patients. Alive is the only hospice with both adult and pediatric services. They are front runners in the field in both their concept and their forward thinking. They focus not only on shepherding patient through the end of life, but also caring for families in the bereavement phase.

Alive is also taking on the responsibility of community education. They launched The Gift Initiative this month, a program to encourage everyone to have end of life conversations with their families. “Are we challenging ourselves to define what we want at the end of life instead of letting a fragmented healthcare system do it?” O’Neal asked.

Lasher pointed out that the biggest difference between hospice and palliative care is not the disease, but the patient’s preferences. Is the patient treatment-focused or comfort-only-focused? Does the patient still want chemo or dialysis? If so, they can’t go to hospice, but they are still hospice eligible and need 24/7 responsiveness, comfort support and spiritual support. Aspire seeks to remove the difficult choice and provide patients with both options as an integrated treatment plan.

There are people across the country doing palliative care the way we are describing it, but they are doing it on a small scale. There are several models. Large healthcare systems have done it because it is the right thing to do. Inpatient hospitals have also developed it because it is needed. And then there are some palliative care MDs who have built a private practice. However, these are all small scale, and cannot bear the volume of patients who need these services.

Aspire wants to partner with other groups like Alive Hospice and build a comprehensive service, said Brad Smith. 80% of the markets across the country have a person—not a company—doing this.

In O’Neal’s experience, there are lots of patients that are hospice-eligible but not hospice-ready. They have less than six months to live, but are not ready to withhold medical treatments. From Aspire’s perspective, the right thing was clear: serving these patients so they can get medical continuity of care, quarterbacking their resources—all the specialists—and giving them palliative care without using hospice specifically. But the current payment model is not sufficient to support this ideal and there is not enough volume to show the payers this. Right now these patients are just “dust on the balance sheet,” she said.

Providing this bridge service is the right thing to do, but it is causing a monetary loss. This is where I see a huge opportunity to lobby payers and push payment reform to support these services. Aspire Health and Alive Hospice together bring expertise to the table that will create value and show the payers they can make money.

The biggest issue is figuring out how to contract with the payers, said Smith. There are lot of unknowns about enrolling patients, volume and triaging patients, making it difficult to make a value-based argument to a health plan.

Partnering with Alive has allowed us to start answering these questions so we can better liaise with payors. Physicians are excited about delivering care in a more scalable way. If we can get the payors on board, we have a new business venture.

What does this new model look like practically? Andrew Lasher described a 65-year-old patient with heart failure and very advanced emphysema who was short of breath and in pain. The patient had been admitted to the hospital seven times in the six months before enrolling at Aspire. His wife, his primary caretaker, chauffer, and breadwinner, was exhausted. In his condition, serious problems emerged with no warning.

Aspire’s first step was to arrange 24/7 support. He has IV diuretics at home, and a physician network on call. In the three months since enrolling, he’s had one hospital admission.

Keeping patients out of the hospital prevents delirium and infections and decreases the strain on caregivers. The patient says he feels better. This is different from home health, Lasher explains, because home health is limited in time and the scope of issues they can address. However, Aspire is a physician supervised network that can diagnose and treat new problems as well as provide ongoing care of existing ones.

The cost model here is different. It truly merges quality of care with cost savings in a very tangible way. Decreasing hospitalizations is clearly cheaper than home based care to the system. The issue is that if there is a fragmented set of payors you may save a hospital money, but not the home health care company.

Brad Smith explained for a patient at the very end of life—two to three months to live—costs can be about $50,000. But Aspire’s approach can reduce those costs by $10,000 to $20,000. It hasn’t been as hard to sell this to health plans – groups that cover all aspects of a patients care under one roof – because when the health plans run the data they realize their potential cost savings!

The risk of this model is that this has not been done before at this scale, but as the healthcare sector changes, the bearer of that risk is changing. Governments and payors used to bear the majority of the risk, but that is shifting to providers and patients—the very people who most benefit from this model. Realigning the payor system to pay for this increased quality and merge the savings of a prevented hospital stay to cover the cost of in home palliative care and care coordination will make this model profitable and do what we all know is best for patients simultaneously.

Bloomberg: The Real Price of Healthcare

Nov. 21 (Bloomberg) — Bloomberg View columnist Lanhee Chen is joined by former U.S. Senate majority leader William Frist, Mayo Clinic CEO John Noseworthy, Boston Consulting Group partner Michael Ringel, John Hopkins Medicine CEO Paul Rothman, Thompson Holdings CEO Tommy Thompson, and Walgreen CEO Gregory Wasson to discuss the state of healthcare in the United States. They speak at Bloomberg’s The Year Ahead: 2014 conference at the Art Institute of Chicago.

Original Post

Child’s first 5 years hold key to success

(The Tennessean, Nov 14)

As a surgeon, I understand the exigency of a window of opportunity. In cardiac transplant, procurement of a donor heart starts a strict four-hour window until that heart needs to be beating in the chest of the accepting patient — a patient who is almost always a plane ride away.

Neuroscience research has revealed a similarly crucial window of opportunity. Between birth and 5 years old, 90 percent of a child’s brain development occurs, and at a lightning-fast pace. Every sight, smell, sound and sensation makes an impact. Long before most children step foot into a classroom, neurons are building networks, cognition is exploding, language is developing, and the foundations are being laid for a lifetime of learning.

Outside of that five-year window, you lose opportunities you may never get back. Children who don’t develop sufficient language skills in those first years are up to six times more likely to experience reading problems in school. When children fall behind in reading, every other aspect of education suffers.

The good news is that taking advantage of this window of opportunity is much easier than transplant surgery.

Every interaction a child has with his or her environment is an opportunity for learning. In the first five years, daily activities — talking, singing, reading, playing — stimulate brain development and dramatically influence future health, learning and behavior.

This message may seem simple, but many children do not start school prepared.

A new initiative called Too Small to Fail, led byNext Generation and the Clinton Foundation, is working to make sure parents and caregivers get this message so they can make the most of the first five years of a child’s life and help the child succeed.

The initiative focuses on educating parents that the most impactful thing they can do for language development is the most obvious: talking to your kids.

Children build their vocabulary by listening to and interacting with their moms, dads, grandparents and caregivers. Just as a healthy diet and physical activity help toddlers grow, reading and talking to them helps their brains develop and builds language skills that form the foundation for learning the rest of their lives.

The more words a child hears from caring adults between birth and age 5, the better he or she will learn over a lifetime. However, these words need to be delivered in face-to-face interactions. Passive listening — watching videos or having the TV on in the background — does not show a positive association with language development.

In my home state of Tennessee and around the country, families are stretched thinner than ever. We are juggling multiple jobs that barely cover the cost of child care. We are single-parent homes facing issues as complicated as health care and as mundane as daily transportation and grocery shopping. It can seem like there’s never enough time — or money — to do all the things you would like for your children.

However, the exciting news of Too Small to Fail is that there is an opportunity for every parent and caregiver to make a real difference in the lives of their children without an act of congress or new government initiative. In fact, it costs no money at all.

When preparing dinner, shopping at the market or even folding laundry, identify shapes, colors and numbers. Ask your child questions about the buildings you pass on the way home. Which are tall and which are short? Make mealtime a time for discussion about what’s on their plate.

Talking and singing to children from the day they come home from the hospital helps develop language skills. Reading to your child for 15 minutes a day can make a tremendous difference in his or her future success. These may seem like small steps, but they add up quickly.

Recent research in brain science is really just reenforcing the importance of doing what we already know is good for our children. Our parental intuition is more astute than we think.

But life can be busy and sometimes we forget. That’s why Too Small to Fail is bringing together educators, business leaders, physicians, community organizations — everyone from me to Hillary Clinton. We all have a role to play in making sure parents and caregivers know the simple things they can do to get their children off to a great start.

This is one instance where talk may be cheap, but it will prove invaluable.

This article was originally featured at The Tennessean:

Tremendous Step Forward for Tennessee’s Children

Today the state of Tennessee has taken a tremendous step forward for our children and our future.  The Volunteer State has made more progress than any other state in the nation across 4th and 8th grade reading and math.

When I launched the State Collaborative on Reforming Education (SCORE) in 2009, we noted that “several factors are coming together to create a once-in-a-lifetime opportunity that could lead to unprecedented growth in student achievement within Tennessee.”  We outlined an ambitious plan for the state in our Roadmap to Success report that brought together key education stakeholders around four pillars of work – great teaching, high standards, strong leadership, and utilizing data to enhance learning.  And, we said we would monitor our progress by looking at key data, including 4th and 8th grade reading and math scores on the National Assessment of Educational Progress (NAEP) exam.

Today, NAEP released the 2013 Nation’s Report Card and the results are significant – Tennessee students grew more than students in any other state, making Tennessee the fastest improving state in the nation.  For example, in 4th grade reading, Tennessee jumped from 41st to 31st in the nation.  In 8th grade reading, we went from 41st to 34th.

There is certainly more work to be done, and we are ready for the challenge. But this growth means a big step toward a brighter future for our students and continued economic growth for our state.  It means that the goals we set for SCORE in 2009, while bold, are being achieved through steadfast, student-focused, and collaborative leadership.  It means Tennessee students are making dramatic academic improvements.

On behalf of SCORE, I must congratulate and thank our teachers, students, parents, business leaders, and elected officials – from Governor Bill Haslam to members of the Tennessee legislature – on a job well done.  Your passion and dedication are paying meaningful dividends.  Our hard work is paying off in what really matters – student success!


statement from SCORE

A great chart comparing net score increases and declines across the nation.

A graph of Tennessee’s progress from 2005-2013

Washington Post’s coverage of the NAEP scores

Tennessean’s coverage of NAEP scores

The Commercial Appeal’s coverage of the NAEP scores

New York Times coverage of the NAEP scores