Senator Bill Frist, MD:

“We’re at a specialty-coffee-washing station in Rwanda, Kigali,- just outside of Kigali, Rwanda. Why is it important? It is because of economic development. In a country that is mainly plagued by poverty, what you see behind me, the employment of over 200 women, women who double their income by working at this specialty-coffee-washing station will now have that opportunity to put their kids in school, to put a roof over their head, to empower their family to earn an income in the future that indeed can capture their dreams and translate their hopes and dreams into a reality.”

John Podesta:

“Rwanda has a “Rwanda 2020 Plan” to try to really make sure that growth is widespread and that it affects everyone. And you saw a real spirit of entrepreneurship here today. We saw women sorting coffee earning about 50% more than they were earning in their livelihood. Before that we saw a young Rwanda entrepreneur who had built that coffee-washing station. The focus in on specialty coffee. Rwanda has always produced a lot of coffee, but now they’re producing for the high-end, and that’s a team effort, but just there’s just a lot of spirit and optimism about the capacity to get this country really moving again. And get the kids in school. Get the people working. And get some income into people’s pockets.

Senator Frist is sending in daily posts from ONE’s recent trip to Rwanda. Below is the post he wrote about Sunday.

SAINT JOHN THE BAPTIST-CATHEDRAL

The drive to Saint John the Baptist-Cathedral in Ruhengeri is about two hours. It is a windy, but beautiful, road. Rwanda is known as the Land of a Thousand Hills, and this journey explains why. The hills are green, and the trees are even a darker green, separated by roughly plowed hillsides; every inch of land is used. It’s lush. The worn, dusty brown walking paths switch back like big “Z’s” painted on the sides of steep, steep hills, climbing to the sky. Every mile seems more picturesque than the previous.

Bishop John gave the service. He recognized all of the visitors and preached about self-sufficiency, entrepreneurship, and service. He is an icon, not just here, but around the world. He has followers throughout the United States that adhere to his more traditional Anglican message. He probably has a church in your area. He is close friends with President Kagame. Our delegation loved the singing, the play put on by the young children on the Book of Job, and the sermon which seemed to be directed right at us. Bishop John came to dinner later that night with us as well. He is a holy man. And of his many abilities, the most unique is his uncanny gift to identify from the pulpit men and women who he thinks, that if give the opportunity, could significantly help Rwanda’s future. The people he has introduced to Rwanda and gotten to know well is impressive. Think Joe Ritchie and Rick Warren.

When he came back to Rwanda from Uganda in 1997 (remember that the genocide was just 3 years earlier), he came home to 400,000 orphans. At the church Bishop John established Sonrise School for orphans, with money mainly from the U.S. He published a book, The Bishop of Rwanda just last year; it’s a great read. If the Bishop meets people at his church who are wiling to invest in Rwanda, he calls his good friend President Kagame, and the three have lunch together and another new business comes to town or a new water project is undertaken. The Bishop serves not only the soul of Rwanda, but he is also the eyes and ears for economic development to lift the people out of poverty.

TOURISM

In the afternoon we traveled to the new, up-scale Sabyinyo Silverback Lodge to meet with the leaders of the tourism industry of Rwanda. The lodge itself is owned by a Rwandese community trust that focuses on not only the growing tourism sector but also on land and water conservation and socioeconomic development, The U.S. government has contributed $40,000 to construct the lodge and another $159,000 to the surrounding community. Why? Because this has become a centerpiece that is attracting tourists who spend money, and this development is becoming a source of employment and education for the entire region. Tourism is the cornerstone of development.

Rosette Rugamba is an old friend who hosted Karyn and me on our last trip to Rwanda; she oversees tourism in Rwanda. She is articulate and friendly and represents Rwanda with grace and charm and infectious enthusiasm.

The story of tourism is remarkable. It started with a vision and a strategy. A Tourism program in Rwanda did not begin until 2003. President Kagame declared that tourism would be the national industry of Rwanda. It would focus on the country’s most unique and precious natural resource: the primates, specifically the gorillas, the mountain gorillas, in the Virunga Mountains. In 1999, the first paid trip to see the gorillas took place, and in that year, there were a total of twenty tourists recorded to see the gorillas. Apparently a New York Times reporter happened to be one of the first to go on a gorilla trek and after his story, the single tour operator was flooded with requests for information. But there were no lodges or hotels to house the visitors. In 2004 the first lodge was built so people could stay near the gorilla launching point – the now famed Gorilla’s Nest. What was missing was the basic infrastructure to support the dream. Now, gorilla trekking is a huge industry, costing $500 per person for a trek and a one hour visit with the gorillas. Unfortunately, there is still a dearth of lodges.

A Dubai investment company announced just last month that it is investing huge amounts into upgrading the gorilla facilities and local lodges. It will bring world class facilities to the Virunga Mountains, Kibu and Akagera Park where Karyn and I once were with the President for a strategy planning retreat with his cabinet. The gorilla tourism caters to a high-end market, and this new investment will accelerate the growth.

By giving monetary value to the gorillas, all sorts of conservation occur. The park is now policed to stop the rampant poaching that, just until recently, characterized the region. No longer is bush meat harvested for the international black markets. The land is protected. The community benefits with economic growth. The gorilla permits generated about $7 million this year. In 2000 only 3,700 tourist totals visited Rwanda; by 2008, over 39,000 visited generating over $42 million (2007).

If you want to come see the primates, I recommend the tour company operated by John Kayihura or Joseph Birori. They are both top notch and have been at it since 1999. Both are friends.

MOUNTAIN GORILLLA VETERINARY PROJECT

People ask why I ever began this relationship with gorillas, both in the states and in Rwanda.

Since we didn’t have time to take a full day out for a trek to see the gorillas, we opted instead to visit the orphanage for gorillas at Kinigi, near Ruhengeri, which currently cares for four mountain gorilla and six Grauers gorillas. We went over to visit the orphan gorillas with the Mountain Gorilla Veterinary Project, on whose board I serve. I started taking care of the gorillas (lowland) at the National Zoo in the late 1990s and early 2000s in Washington. Lucy Spelman, the former director of the National Zoo, is in the states this week so we missed her, but we received an excellent briefing from a student veterinarian who introduced Cindy McCain , John Podesta, Judy Black, and John and Karen Kasich to 9 orphan gorillas. All the gorillas in the zoos are lowland gorillas; they are not the upland or mountain gorillas in the mountains in Rwanda and Congo. My work at the National Zoo began because of my surgical expertise in the heart. The transplants I do in humans are for cardiomyopathy; gorillas also can develop cardiomyopathy and suffer from premature death.

The mountain gorillas were popularized by the 1988 film “Gorillas in the Mist,” a story about the life of Dian Fossey, an American zoologist who dedicated her life to the protection and study of mountain gorillas, She began in 1967 and continued until her murder in 1985 at her research station in the Virunga Mountains. Then there were 250 gorillas (up from 250); today there are 750. Of the 750, about half are visited by tourists and the other half are kept totally separate with no visits by humans. This natural, “controlled” trial comparing the two groups will likely someday help us better understand the impact of human interaction with the primates (and the impact of such eco-tourism).

OneHealth is a new discipline that combines the health interests of animals, humans, and the land. I have been a strong advocate for this emerging field because of my initial experience with anthrax back in 2001. The biological organism which causes this disease, relatively common in the veterinary world of animals, was used to terrorize the nation, close down the offices for more than 50 senators for months, and kill innocent postal workers. Avian flu comes from birds, and HIV from animals. For naturally occurring and emerging new diseases, an understanding of the interaction between animal and human disease is imperative. The gorilla and the human have 98% the same genes! That is where my interest comes from.

DINNER: TRADE AND INVESTMENT

We loaded up our bus to go to the Bourbon Coffee shop/restaurant.owned by Arthur Karuletwa. The restaurant is built around coffee, and even though Rwandans don’t typically drink coffee, he has been able to capture the equivalent wave of Starbucks and he is doing fantastically.

It was my task to be “Oprah Winfrey” for the meeting, as the entire purpose was to hear from all the Rwandese what is working and what more is needed to make the “pie” of the economy grow larger (growing a respectable 7% since 1996). As I darted around the large table of 25 speakers, I posed follow-up questions of my own to make sure each person reflected their thoughts. We learned the particular success of specialty coffee: production, high-end tourism, construction services and food processing. We heard that President Kagame had emphasized the importance of a strong banking and financing community. Exports include coffee, tea, tin and coltan (tantalum). Imports are consumer goods, machinery and petroleum products.

In 1998 while on the Foreign Relations committee in the Senate, I was chairman of the African subcommittee. We worked hard on AGOA (The African Growth and Opportunity Act) which opened access to the U.S. markets. Using this Act, over $4 million in tungstem jewelry, baskets, apparel and semiprecious stones were exported. Key trading partners include China, Germany, and the United States; exports totaled more than $167 million. American Joe Richie is a member of the Presidential Advisory Committee, and he has both a formal and an informal network of friends focus on Rwanda, heart and soul. He is a generous man, and he has an even more caring daughter who joins him and his wife in Rwanda.

Dr Vincent Karega, state minster in charge of investment and export promotion, was our kickoff speaker/discussant. Bishop John Rucyahana of the Shyira District (serves 2 million and is the largest) is peripherally active in the banking community and as I said earlier doesn’t hesitate to teach economic prosperity from the pulpit.

My friend Michael Porter, who spoke at my development course I taught at Princeton last year, joined us. He was in town for the Presidential Advisory Committee, and he spoke to us about the comparative competitive strategy underway; he too has a daughter at Princeton, who is a favorite of mine.

So at the end of the day, our heads were swirling on these economic and growth issues. What is apparent is that there is a willingness and real interest in making the economic pie bigger with the hopes of combating poverty. To do this as a country, you begin with your strengths and build upon them. The Rwandan strengths at present are the tourism industry with gorillas as a focus and the coffee industry. Both are helping grow the economic pie to lift people out of poverty.

Off to bed. It was a full day. Some pretty remarkable stories.

-Sen. Bill Frist, MD

July 19, 2 pm
Nyandugu Coffee Washing Station

How in the world can you take an economy in which over 50% of the population is under the poverty level, is landlocked, ranks somewhere around 160th out of 180 countries on the “Developmental Scale,” and even think about “making extreme poverty history?” as we in ONE like to say.

Answer: Establish viable, sustainable economic growth based on the resources that you have. And the resources that Rwanda naturally have are agriculture (even though it is the most densely populated country in Africa) and tourism (they showcase the upland or mountain gorilla, the magnificent cousins to the lowland gorillas—those whom I used to take care of in the National Zoo –– but more on that in a couple of days).

First, the ONE delegation went to see a fantastic partnership at a “Coffee Washing Station,” owned by the Alfred Nkubili. Our U.S. government, namely USAID, has partnered with the owner and manager to establish a coffee bean washing station. This station purchases coffee beans (“cherries” actually) from farmers (many peasant farmers) and then they process the bean through a washing cycle that separates the beans by quality. These beans become the specialty coffee beans that are sold to Starbucks and specialty coffee shops across America.

To accommodate the burgeoning specialty coffee market, these washing stations hire about 200 women to separate and process the beans. At these facilities, these women’s salaries are double to what they could make elsewhere. And a doubling of their salary means they make enough to pay for school for four children, feed their family, and put a roof (even a metal roof!) over their head. That is economic growth!! The old foreign aid way was a handout – no longer. By facilitating the creation of these washing stations through partnerships with USAID (that’s the US government, and that is your dollar), we are elevating people out of poverty, growing their income and the country’s GDP! It’s pretty remarkable: that’s not “aid”; that’s sustainable economic development.

Just adjacent the massive coffee bean sorting machine, Tim Shilling, a project manager for USAID and member of the Texas A&M Agricultural Research Center, presented to us an enthusiastic talk in a beautiful hillside setting. We learned a lot about the coffee industry here. For instance, Rwanda has grown coffee for the past 100 years (although no one in Rwanda drinks coffee!) because it has ideal climactic growing conditions and genetics. All the coffee is grown by small land holders. Believe it or not, coffee contributes 50% of the GDP!

In 2002, USAID introduced the “central processing” concept and a higher quality of beans were collected. Out of this concept emerged the first “specialty coffee.”

The Rwandan private sector invested $15 million in such partnerships. And today over 30 American/European roasting companies are buying this specialty coffee (note that there were none in 2002—they started from zero).Specialty coffee earnings have grown from $1 million in 2001 to $135 million in 2008. Today there are 75 such washing stations in Rwanda, and there is demand for double that amount. The old Rwandan coffee would garner prices 10 to 15% below average market prices, but today it’s the same or higher than the average. Mr. Nkubili has grown his small business to include five Washing Stations, generating gross sales of $865,000. His business injects revenues of $550,000 to coffee growers selling their coffee cherries (2,000 tons).

Assistance by donors like USAID (that’s you and me, the American taxpayer) has helped coffee farmers move up the value chain due to the education in washing, or “central processing” as well as the marketing techniques that make coffee beans more attractive to high-end buyers. It’s value creation.

That is a “hand up” and not a “hand out.” I wish my colleagues in the U.S. Senate could be here to more fully appreciate how good of an investment this is. We at ONE have to figure out someway to get this story about development out to the American people. It’s real; it’s measurable; it’s sustainable; and it’s lasting.

As John Podesta and I walked back up the hill, we reminded each other that we have a lot of work back at home to do in terms of communicating the empowering story we heard today. On the journey goes.

-Sen. Bill Frist, M.D.

The first stop this morning was the Kigali Genocide Memorial Center. John Podesta and I laid a wreath at the mass grave site of the genocide victims. I had the opportunity to do this last year when I was in Rwanda with Samaritan’s Purse, Scott Hughett, and my wife, Karyn (who is at home now recuperating from back surgery). The site and the service in which we participated are a moving, memorial remembrance of the million people who died over those 100 days of genocide. (It is so hard to comprehend). Each member of our delegation laid a single rose alongside the wreath, one by one, as we each paid our respects. Beneath that wreath lay a mass grave, one of many at the site, containing the partial remains of over 5,000 individuals from the Kigali region.

It was remarkable that the memorial was designed to tell the story a mere four years after the genocide occurred, during a time when the horror and pain and raw feelings surely must have been still high. The result is a gripping, very tough, realistic portrait achieved through graphic, yet telling, photographs, video interviews, and displays.

We then had lunch at the famous Hôtel des Mille Collines, where so much of the 1994 history took place. On the patio we heard first-person testimonials from both a perpetrator, a man who had killed many, many of his fellow Rwandans, and a victim, whose vivid story left all of us in tears. She had watched her husband and children murdered, escaped amidst mass killing in her village (by people she knew), been captured and tortured with repeated sexual assaults by fifteen men, received massive lacerations and broken bones by machete, and yet, she survived. At the table, sitting a mere three feet apart were killer and victim/survivor. How does a country like this move forward? Rwanda is confronting the past openly, with discussion, truth, forgiveness and reconciliation. And they are looking to the future, a future full of hope. This is a lesson of human resilience, played out in our presence: on the patio of the Hôtel des Mille Collines.

The greater meta-story is the confession, forgiveness, and reconciliation, not just of these two but of the thousands of Rwandans who just fourteen years ago had identical experiences. How could they forgive? How could they live together even today? If you ever think something seems impossible, reflect on the fact that just fourteen years after genocide, Rwanda has both killer and victim living side by side, together. It doesn’t seem possible but everywhere we go we see this reconciliation process well established and underway, opening up a fresh start for the future. Other Rwandans at the lunch stimulated an enlightening discussion. Rwanda is about reconciliation, not retaliation. Their experience is that repentance begins with confession and leads to reconciliation which leads to justice. They claimed it was important to remember the past, but not to fixate upon it. We learned so much. There are about 350,000 survivors of genocide today. As you can imagine, these survivors were deeply wounded by the experience, and they are still in need of assistance and care.

We also learned that the court system is pure Rwandan. It is a local innovation which launched to deal with the 120,000 suspects of genocide. Traditional courts were too slow and failed for four years; thus, the new court system was adopted. Today there remain 4,000 perpetrators to be tried. The goal of these courts is to seek justice and reconciliation. Perpetrators are punished, but if they confess to their victim’s family and community, they are given leniency.

The world abandoned Rwanda in 1994. The U.S. failed; we watched on the sidelines. We failed humanity. This failure pushed me to bring the genocide resolution against the government of Sudan with respect to Darfur to the floor of the Senate, as Majority Leader. I did so when the Administration and the State Department did not want to call it “genocide” (though six weeks later, the Administration did label it “genocide”). Yet, when Americans, like our delegation, come to Rwanda, the Rwandan people told us that they are left with the feeling that now “We are not alone.”

Rwanda’s “fresh start” is being accelerated by a remarkable president and a government who understand how good governance can facilitate private sector growth to fight poverty. For instance, coffee washing stations open up new worlds for those who had once lost hope. They say again and again that they don’t want “hand-outs,” they want “hand-ups.” They are doing whatever it takes to maximize economic growth: to expand business and foreign investment. They looking and moving ahead with remarkable speed instead of looking backward.

None of what I’ve written gives justice to the nature of the lunch with Rwandans, but I share it just to give you a feel of Rwanda today. In the words of Rwandan Senator Odette Nyiramilimo, M.D., “The past fourteen years have been a time of stabilization; the next ten years are a time of economic growth and opportunity.”

What a morning. A heavy weight was felt by all as we departed the famed hotel with unimaginable images in our minds.

-Sen. Bill Frist, M.D.

July 19 2008 8 a.m. Saturday

First for the questions that I am most frequently asked. What is ONE? And why are Tom Daschle and Bill Frist leading this delegation to Rwanda?

ONE is a grassroots organization with about 2 million members in the U.S whose purpose is to fight extreme poverty and preventable disease around the world. I’ve been working with ONE since Bono and I went to Uganda in 2001. ONE pushes for better policies and, where needed, more resources to support effective, anti-poverty programs. We lobby and put pressure on political leaders in our country to do more, but to do that well we know we must listen to those who are living in the developing world trying to transform their societies for the better. And there is no more appropriate place in the world to do that than Rwanda, a country that went through the most horrendous atrocities imaginable just 14 years ago, with a million people killed in genocide over a period of 100 days. Today is creating a future of hope and opportunity that will lift the country out of poverty and decimate preventable disease. They demonstrate good governance and investments in education and health, and they create an environment conducive to business and trade.

We have tremendous admiration for those people working on the ground to improve the lives of the world’s poorest, and it is our responsibility and obligation to spread their success stories and share their lessons learned.

As an anti-poverty organization, ONE often advocates for development assistance, HIV/AIDS policy, and clean water, but we also know that the lasting solution to poverty is economic growth, trade, investment.

Rwanda has laid out an incredibly ambitious vision for where it hopes to take the economy by 2020 in its Vision 2020; it’s an inspiring framework. Vision 2020 is Rwanda’s goal/plan to be a middle income country by the year 2020. They’ve said they want to be the “Singapore of Africa.”

My own goal of putting together this trip for our ONE delegation is to visually and graphically make the link of health and education to trade and investment. Although not always apparent (especially to the politicians in Washington!), these are connected spheres of activity. In a healthy country, they build upon and reinforce each other. Healthy, educated people produce more developed economies. Business and trade produce the tax revenue that a government can invest in public education and public health. But too often our development initiatives treat these as separate.

We begin today as ONE; the setting, challenges, and some solutions will be explored by our motley family of ONE.

Sen. Bill Frist, M.D.

July 18, 2008

We were up at 6 am and off to the airport. Things took just a bit longer to clear customs for our flight to Kigali, Rwanda, so we were delayed us just a bit. We left Mozambique after a full four and a half days, with many great memories. We are much more educated as to the challenges of the people of Mozambique, and we appreciate them teaching us about how we can be most useful. They don’t want fish; they want the opportunity to fish. And we can help make the setting more conducive to fishing – by help with clean water, roads, training community health workers (who can teach others and treat others), and capacity building.

It’s a long flight to Rwanda; check the map. The dot between Nampula, Mozambique, to the dot of Kigali, Rwanda, is 8 hours – as the single engine plane with a 30 knot headwind flies! “Are we there yet?” I kept hearing from the seats behind me. I have piloted single engine planes a lot in Africa – Uganda, Sudan, and Kenya. But never in Mozambique and Rwanda so I even had to fly a little bit today.

Mauro de Lorenzo, my “plus one” scholar/aide who assists me with the MCC, had kindly gotten a couple of rolls for each of us for our breakfast, but that was it for meals until after we landed. On board, the pilots had brought some sausage and Ritz crackers that we all split – I was looking for some cheese but we had run out on the last leg. Cokes (minus Carville this time) and water kept us hydrated, but not too much because there is no bathroom on the plane. There’s nothing better than getting a little hypoxic after a few hours of flying at 13,500 feet. There was a little turbulence for the final two hours, but overall, it was a beautiful day flying over a majestic countryside with the vivid colors enhanced by the African sunlight.

We did make one fuel stop in Tanzania for 30 minutes, and we stretched our legs. Then back up to Kigali. We finally arrived, and we were met at the plane by the ONE Campaign staffers, one from the U.S. and one from Germany. One of the Deputy Ministers (who is also a physician – yeah!!) met us at the airport to welcome us and off we went to the hotel. When I was last in Rwanda, the hotel was under different ownership, but it has now been upgraded and it’s very comfortable. We went to the lounge looking for food at 5:30pm. I still had cheese on my mind, but unfortunately the bar only had peanuts.

Mauro and I were met by Tyler Denton from ONE, and we discussed the next five days of the trip. It looked perfectly planned. We will begin with the genocide history tomorrow.

I had a private meeting that I will tell you about in a few days that ran for an hour, and then I went to dinner with Cindy McCain. The rest of the group will arrive from the States after dinner. Cindy is blogging as well, so I will let her tell her story, but let me just say, she is the only one of our group who was on the ground – right here – during the genocide. In the Senate, I tried to keep most of my humanitarian work private and as anonymous as possible; Cindy really has! I am sure the world will uncover over the months ahead.

Small world. At dinner, outdoors at an Indian restaurant, someone came up and introduced himself. A fellow Nashvillian, Chris Peak, is here for several months working with the NGO, Sisters of Rwanda, started by another Nashvillian. I will check their website (www.SistersofRwanda.org) as soon as I finish this. Chris was eating nearby at a table with about 10 other young volunteers working with NGOs here in Rwanda – all were from the U.S. People like Chris are why I am so optimistic about the world.

At about 9pm, everyone else arrived and we gathered for the first time as a group. Tom Daschle and I are leading the group. We are the co-Chairs for ONE Vote ’08.

Sit down before you read who all is in our new family for the next 4 days. We are ONE: John Podesta and Mike Huckabee, Susan McCue and Jack Oliver, Karen and John Kasich, David Lane, Judy Black, Tom Freston, Cindy, Tom, and me.

It’s midnight now so off to bed. But follow us on our journey. You will meet genocide affected families, gorillas, former guerillas, entrepreneurs, people with HIV, children with malaria, community health workers on the front line, and capitalists. We will visit a USAID farm site, see areas subjected to extreme poverty, attend church with Bishop John, visit an HIV clinic, and maybe even meet President Paul Kagame.

As I told the group tonight at the gathering, the next several days will be life changing. So the family has met and we are off and running.

-Sen. Bill Frist, MD

I woke up at 3:30am this morning, left my son Harrison in the hotel room, and headed for our 4:30am departure to Nampula, Mozambique. We flew in a Cessna Caravan of AIM AIR with Capt. Dan Spooner. Capt. Spooner had taken me in AIM AIR with Samaritan’s Purse about a year and a half ago to Darfur from Nairobi, Kenya and then into northern Uganda into the area of the Lord’s Resistance Army.

On the plane flying the length of Mozambique, we were able to capture the beautiful morning light with sun rising on a sharp horizon, red-orange turning bright orange and then a brilliant yellow. After about six hours of travel and one stop in Beira to refuel, we landed in Nampula city and were met by Mayor Castro Serafim who spent the day with us. He is articulate and is now running for reelection. He has been mayor of Nampula city for five years. We also had lunch with the Governor of the Nampula province, Felismino Ernesto Tocale. Interestingly enough, he was a former organic chemistry professor before entering politics.

We spent the afternoon with the Millennium Challenge Corporation (MCC). Accompanying me were Cassia Carvalho-Pacheco, Resident Country Director of the MCC in Mozambique, and Paulo Fumane, Executive Director MCA-Mozambique, who will be responsible for implementation of the Compact.

We visited four different sites which ran the spectrum of the clean water, sanitation, and land tenure aspects of the MCC Compact. Since the MCC compact has been signed but not yet implemented, we went to the areas where MCC will have an impact before the program had begun, where the planning stages had started. Implementation does not start until mid-September.

Nampula is one of the four northern provinces (like states) in Mozambique that is targeted by the MCC. All $507 million dollars will flow to these four provinces which constitute the poorest region in Mozambique. They are the least developed as a consequence of almost twenty years of devastating war. This war was fought in the countryside, and its victims were Mozambique’s subsistence farmers, millions of whom became refugees in neighboring countries in those years. New roads will link southern Tanzania to northern Mozambique which will open up commerce.

At each stop the routine was similar. Under a tree, in a field, in narrow alleyways, or just crowded together on a dirt road, we met local leaders and authority figures. And whenever I stopped to talk to residents, they were delighted to share something of their hopes and struggles with me. Whenever the Mayor introduced me, he told the people that I represented the MCC, and that America has come to help the Mozambique people live more productive lives…that America will help them realize their dreams.

I added that I, as a director of MCC, represented the American people and their friendship with the people of Mozambique. I told them that ordinary Americans – people just like them – are investing their taxpaying dollars in the future of Nampula so that they will have roads, clean water, and property rights that they deserve in order to earn a higher income and better take care of their own families. I emphasized that MCC is their program, not ours. Our goal was to fulfill their dreams and hopes and make them a reality. I stressed that the American people chose Mozambique because the country met the objective criteria that suggested that they would use the money well and wisely. American officials do not implement the Compact, Mozambican ones do. And it is up to the citizens of Mozambique to hold them accountable for doing so. The responsibility is theirs.

Everywhere we went the people said, “Thank you for coming, and thank you the American people.”

At the first site, we went to a small village that had maybe 100 dirt brick houses, about 30 kilometers from Nampula (Nampula is a city of 400,000 and the province has 4 million – it is the third largest city. HIV is about 12%. Poverty is almost 51%). Here we focused on property rights (or land tenure). The local surveyors had plotted out carefully 600 new lots, all squared off, but still empty. Certificates will be issued to formally give ownership to those who applied and paid a small fee. These deeds will constitute formal title. This concept is new. Ownership has been customary, and the cause of frequent dispute and discord in the community. The lack of legal title also robs these poor people of their most valuable asset: their land. As Mozambique’s financial institutions become more sophisticated, enterprising farmers should be able to use their title as collateral to get affordable loans to expand their business. This land tenure process is one of the 4 components of the compact.

We met under a beautiful tree, and 40 of the town families and representatives came out to meet us. They talked and interacted with me – one asked for energy, one asked for better roads. One asked for sanitation.

Then we visited a particularly blighted area of Nampula to see the seriousness of the sanitation problem in the city. The dusty streets were unpaved, of course, and I had to step around the gaping sewage holes literally collecting the sewage seeping out of adjacent homes. It is the perfect breeding ground for the mosquitoes that carry malaria.

We walked by a water pump and stopped. It was the only one within several kilometers. The people pointed to it: a nice concrete box with a hand pump. That said, it was put in by the government last year, but after a few months it broke down and now does not work. They pleaded with us to fix it, because the women now had to walk two hours each day to get water and that took them away from their children and families.

We traveled in car to another area, and we saw again a huge drainage ditch—a small canyon really– with stagnant water. This was the result of rain erosion caused by a complete lack of drainage engineers in Nampula. Runoff from a nearby hospital trickled in. Garbage lined the floor of the ravine, about 30 feet deep and 40 feet across, adjacent to the houses. Children played in the ditch. Apparently two hours before, a large group of neighborhood women had been gathering the filthy water there to use at home.

Lastly we went to a beautiful setting, about 20 kilometers from town, with tall trees still standing, untouched by the ravages of the civil war. There we met with people in a new development that asked for clean water. There was one standing pump that they wanted to demonstrate to us. When we went over an old woman was tying pieces of cord together so that she could lower her bucket directly down about 30 feet into the well. The hand pump was broken, and there were no parts to fix it. The community was embarrassed that their water pump that they had come out to demonstrate was broken, but the encounter dramatized the fragility of the infrastructure and the importance of sustainable economic development with a goal of self-sufficiency and not permanent dependence. Fortunately, the quality of the water, once the woman had hauled it up, was excellent.

We saw today the “before picture” of what MCC is all about. In September the implementation of the MCC Compact will start right here in Nampula. We leave today with a realistic picture of the needs and challenges. We’re also aware of the appreciation of the people of Mozambique have for the United States, but also the high expectations they have for us. We have to see to it that this investment achieves its intended effects. I look forward to coming back to these sites in a few years to check on the promises of progress.

-Sen. Bill Frist, MD

I woke up to a crystal blue sky in Maputo. I began the day performing a major lung operation for tuberculosis (pneumonectomy), and I ended the day discussing with the President of Mozambique the American people’s commitment to fighting extreme poverty in his country.

Maputo Central Hospital: Surgery

At 7:30am, we departed for Maputo Central Hospital, housed in a 100 year old building, but nonetheless a functional, governmental hospital with 1200 beds. All the doctors are governmental employees, and they make about $700USD per month. That being said, they are very prestigious figures in the community. In Mozambique, there are only 500 doctors for 20 million people, and there are very few specialists. In terms of equipment, there is one CT Scan, in Maputo, for 4 million people. By way of comparison, there are probably 32 in Nashville for about 1 million people.

Dr. Atilo Morais, a superb, thoracic surgeon training in cardiac surgery, gave us a tour through the hospital. He introduced us to his patients. Elias Novela, a 59 year old man, had a history of tuberculosis (TB). His symptoms included a shortness of breath, bloody coughing, and fevers. We reviewed his x-rays which presented a huge right lung mass, thought to be an empyema secondary to his TB. This man would die without surgery of his “bronchopleural fistula” that had developed because of the TB. About 2 million people die of TB every year in Mozambique (about 2.5 million die of HIV/AIDS, and 1 million die of Malaria).

I operated with Dr. Morais having been given full surgical privileges granted for the length of our stay. He spoke little English, and I speak no Portuguese – but luckily, cutting and sewing don’t require any talking!

I explored the patient through the bed of the 6th right rib. We removed the empyema cavity, careful not to spill the purulent material within the TB abscess. This is a big operation, but one common in Maputo because of the high incidence of tuberculosis infection. We removed the entire lung, suturing closed the bronchus, the pulmonary artery and vein. The patient as of right now is recovering well. He will remain on anti-TB therapy and should have a good long-term course. This is something very very rare in the US because out TB gets treated early.

Save the Children: Mozambique

I’m also here visiting with Mary Beth Powers and John Grabowski of Save the Children. Mary Beth leads Save the Children’s Survive to 5 Campaign, which I chair. More than 26,000 children die every day from easily treatable maladies. Almost half of these are newborns. About 6 million children could be saved every year through a concerted effort at vaccination, the use of cheap and readily available treatments for pneumonia, diarrhea, and malaria, ensuring mothers protect their children from malaria-bearing mosquitoes with bed nets, and improving nutrition.

Save the Children in Mozambique has focused our work on interior rural areas, where most Mozambicans live. This majority is extremely vulnerable to shocks such as floods, drought and crop diseases, as they are solely reliant on rain-fed agriculture. HIV/AIDS is dealing severe blows as well, fueled by the expansion of international trade corridors with neighboring countries. Save the Children’s work includes strengthening food security and combating child malnutrition, especially during the “hungry season,” as well as aggressively expanding HIV/AIDS programs to help stem what the government has termed a national emergency.

John Grabowski recently oversaw the merger of three Save the Children programs operating in Maputo: US, Ireland, and the UK. He explained the synergy that emerged from this commonsensical pooling of resources and strategy. Save the Children has moved strongly in the direction of outcomes measurement, moving in a results-driven direction.

African hospitals and clinics usually lack the equipment and laboratories necessary to save lives. That’s why technological innovations that can reduce the costs of medical technology for developing countries are so important. I’ve been joined here in Maputo by Dr. Rebecca Richards-Kortum, professor of bioengineering at Rice University in Houston, Texas. Dr. Rebecca is a national leader in designing effective, simple health technologies that are appropriate for the conditions in African clinics. She’s also a pioneer in looking for enterprise-based solutions for getting these technologies into the hands of the people who need them most. She demonstrated three fantastic devices that she and her students at Rice have been working on: a diagnostic lab-in-a-backpack, a low-cost imaging device to detect oral and cervical cancer, and a combined incubator and bilirubin phototherapy device for newborns (it costs less than $100 to build with locally-available materials, as opposed to about $2,000 for factory-made equipment).

You can learn more about Dr Rebecca’s pioneering work right here.

Iris Ministries Orphanage and Clinic: Samaritan’s Purse

In the afternoon, we drove about 35 minutes outside of Maputo, to Zimpeto to the Iris Ministries orphanage which houses over 425 children ranging from a few weeks old (they have 42 babies) to 20 years of age. Arco-Iris in Portuguese means “rainbow,” signifying God’s promises. This remarkable orphanage began simply by reaching out tot eh street children, providing them with clothes, food, shelter, and medicine. It has grown to where it now has a 700 person school, a pastor’s training center, and a large community clinic where I was able to see several patients over the course of the afternoon. We were greeted by a warm, prayerful crowd of about 200 people; many were students from the school. A young boy read a welcome message, and there were songs and dancing! Iris is supported by Samaritan’s Purse.

The first little boy was 24 months old. He had spontaneous tremors of his distal arms and legs; he is hyperreflexic. With normal facial features, the cranium seemed quite small. My diagnosis was severe brain injury probably suffered at birth. He really needs a CT, given the contours of his hea,d to evaluate his brain, and I will make the referral. But he probably will not receive it due to the lack of CT scans in the country.

The second patient was a 14 year old girl. She had a 6 month progressive history of difficulty swallowing and talking –a feeling of fullness in the throat. Chest x-ray shows a military pattern consistent with TB; barium swallow shows a mass high in the neck – the culprit. The remainder of exam was fine: intraoral, thyroid, neck nodes. I tested her for TB, and while waiting for results, she will be started on triple therapy to fight TB. Tentative diagnosis: TB mass of the neck (She should respond to the medicines I gave her).

There is no greater or more gratifying profession than being a doctor.

Meeting with President Armando Guebuza
Hurriedly, I switched from casual clothes to more formal attire to go see the President of Mozambique. He was friendly, quick to smile and respond, sort of fellow. I introduced him to my son, Harrison, who is an investment banker in New York, and he paid a little extra attention for that reason.

I then told we had had the opportunity to see Maputo, Chimoio and Nampula, though they were quite a distance from one another (the coast line of Mozambique is twice as long as that of California).I told him that I have loved exploring the inside of his country and the insides of his people! (That was supposed to be a joke since just hours before I had my hands I the patients’ chest.)

I congratulated the President on his outstanding leadership in signing the MCC compact last year—12 months ago almost to the day. But, since then, Mozambique has fallen 6 months behind schedule given their 5 year clock to work on the projects that they have targeted (clean water, agriculture, and land tenure). The American people are holding them accountable for the $507 Million dollars; Congress will watch how well they implement this funding like a hawk.

Save the Children Reception

The Save the Children’s reception was held at the home of John Grabowski. I met with a number of doctors, including a cardiologist, who asked if Vanderbilt would send a team of cardiac surgeons, cardiologists, an intensivist, and a perfusionist to help upgrade the cardiac surgery program in Maputo. Since Vandy is already doing so much in Mozambique on global health with the Institute of Global Health run by Sten Vermund, we should give it a shot. We noted that 2/3 of the 27,000 people who will die over the next 24 hours could be saved with inexpensive technologies, if we could just get them out in time.

-Sen. Bill Frist, MD.

In Maputo, Mozambique, today, I met with senior officials to discuss the progress of the Millennium Challenge Corporation Compact (MCC) that Mozambique signed with the United States last summer.

This five-year, $507 million agreement focuses on the neglected northern part of the country where I will visit later this week. The Compact will bring clean water to tens of thousands of people for the first time—making them less vulnerable to disease and more economically productive. MCC’s grant will also allow Mozambique to build new roads that link poor communities with markets. A land tenure component will help ensure that property rights are respected. Finally, the Compact seeks to eradicate a coconut disease that threatens one of northern Mozambique’s most valuable crops.

Last year, President Bush appointed me to the Board of Directors of the MCC, which was created by Congress in 2003 when I was Majority Leader of the United States Senate to reduce global poverty through economic growth. The MCC represents a fundamentally different way of giving American development aid to the world’s most deserving nations.

In the past, most of our aid money was, frankly, wasted. That’s because we didn’t pay attention to the quality of the government or how well it treated its people. That caused many Americans to grow skeptical about foreign aid. The late Senator Jesse Helms used to refer to foreign aid as a “rat-hole” because of all the waste and corruption!

We learned something from those failures. MCC only awards aid to countries that are accountable, both to their own people, and to the American taxpayers who ultimately provide the grants. There is no point at all in wasting your taxpayer dollars in countries with bad governments. But in well-governed countries, American generosity can produce transformational change in the daily lives of poor people.

The MCC method compares countries using 17 independent measurements of good governance, investment in the well-being of their citizens, and the promotion of free enterprise. Only the best are eligible to compete for an MCC grant.

MCC has allocated nearly $7.5 billion in public investments abroad since its founding. And with a lean staff of 300 people, the agency is one of the most efficient I’ve seen in Washington.

Today I met with Aiuba Cuereneia, the Minister for Planning and Economic Development. He is one of the Mozambique’s rising young leaders, and the country’s President has entrusted him with managing this important relationship with the United States.

Minister Cuereneia led the team that designed the Compact. Now, as Chairman of the Board of the special agency Mozambique established to implement it, he is ultimately responsible for getting things done.

In fact, he already has his eye on the next five-year Compact. And he knows that Mozambique’s eligibility depends on maintaining the country’s positive policy performance in governance, social investment, and economic freedom. That kind of national “ownership” of an aid project—coupled with powerful incentives to perform—is what produces lasting results. In my opinion, it’s what makes MCC better than any other method of giving large-scale foreign aid.

I drove outside of the city to visit a successful public-private partnership model for water distribution that Mozambique intends to replicate using MCC funds. FIPAG, Mozambique’s public water agency, partnered with Aguas de Moçambique, a Portuguese-Mozambican joint venture to manage the distribution network. The standpipe they installed now pipes clean water into a poor neighborhood for the first time.

Many crucial public services in developing countries cannot be delivered by public agencies alone. The involvement of the private sector is required, just as it is in the United States. Too often, development efforts assume that the poor do not benefit from private sector activity. In fact, around the world, private sector growth has been the single most powerful agent of permanent poverty reduction. MCC’s approach prioritizes economic growth and seeks to maximize the private sector impact of Compacts.

The MCC model can even produce change before any money is spent. We’re finding that governments are undertaking important reforms in an effort to qualify for MCC assistance—or to keep policy performance on track in order to qualify for a second five-year MCC Compact, as Minister Cuereneia said Mozambique would like to do.

This “MCC effect”, as we call it, makes MCC the biggest bargain in foreign aid.

-Sen. Bill Frist, M.D.