'An Epidemic of Indifference in India's Biggest Problem'

Dr Unni Karunakara ended his three-year term as International President of MSF in October 2013 after having served the Nobel Peace Prize-winning organisation for almost two decades. During his tenure, MSF confronted many challenges to delivering healthcare in conflict zones, natural disasters, and to populations with inadequate access to healthcare in over 70 countries around the world. In 2012 alone, MSF medical teams worldwide provided over eight million outpatient consultations, helped deliver around 1,85,000 babies, conducted nearly 80,000 surgical procedures, and vaccinated almost 7,00,000 people against measles. Immediately after stepping down, he was on the saddle cycling the length of India and riding 5367 km, realizing a 25-year-long dream. Dr Karunakara travels around the world to deliver lectures on public health, including teaching at Columbia's Mailman School of Public Health. He has been recently selected as a senior fellow at Yale’s prestigious Jackson Institute for Global Affairs.

You were the first Asian and Indian to head the Medecins Sans Frontieres (Doctors without Borders). What was the experience like?                                 
Being Indian or Asian doesn’t matter much. In a humanitarian organization, what matters is how much you value its principles. Like the presidents before me, I worked as a doctor and have been in several positions in the movement. The job of the president is to be the face of the organization. This involves being chair of the International Board. The main function of the international board is to ensure that the programmes are run in a principled manner.

Did you have a smooth tenure as MSF President?
No, not at all. It is a large organization with 35,000 people working in almost 70 countries with representatives from 100 nationalities. When it comes to the policies and principles, there were always differences. So we as an organization pride ourselves on having a multiplicity of views. There are always discussions and debates. That does not mean in any decision we make we are unanimous. But there is always a strong sense of purpose.

Is it easy to carry out humanitarian assistance when a region is facing crisis?
There is a difficulty in the implementation of any humanitarian project. One has to be both principled and pragmatic. For example, in Myanmar, for the last twenty years, Rohingya Muslims have been consistently and systematically excluded from service given by the Myanmar government. They live in camp-like conditions. They are Burmese. But they do not have citizenship rights. We have been providing health care. Many of them who access it are Rohingyas. For a long time we have been concerned about their plight. We have not been able to raise the issue with the Burmese government because the regime is notoriously immune to any kind of outside pressure. Things have changed during the last two years. I am talking about twenty years prior to that. The reason why MSF has not been able to push internationally hard ahead, we also try to get global public opinion to talk about the issue. One of the reasons why we have not been able to do this is because the HIV AIDS programme looks after 30,000 patients there. We could be asked to leave the country. If that’s the case, what happens to these patients? So there is one thing being principled and wanting to give voice to people who have remained voiceless for long. But there are so many factors to be considered. In any implementation of humanitarian projects, some kind of compromise has to be made.

You were International President for three years (2010-13). Any difficult decisions?
One of the most difficult times I had with MSF was towards the end when we decided to leave Somalia. MSF has been providing assistance for 22 years in Somalia.

Do you regret the decision?
Leaving Somalia also meant leaving Somalians without any health care. We were the only organization providing humanitarian assistance.  We regret the decision. But we got to the point where we had no choice. So any decision you take can be seen from a different perspective. These are dilemma or moral issues. As a humanitarian organization can you leave 100,000 Somalis? Are their lives any less valuable? One of the reasons we left was that we got to a situation where it became impossible to keep our teams safe. In the last 22 years we had lost 16 people. So there is an implicit value judgment about the lives of volunteers versus the lives of Somalis.

Are there other instances where difficult decisions have to be taken?                   MSF opposes female genital mutilation. We would never carry it out at our facility. At the same time if the local nurse asks for sterile equipments to do female circumcision, then do you tell her that we cannot give her any equipment. Circumcision is going to happen anyway with unsterilized equipment leading to infection and potentially life-threatening situations. Then the choice you have is the policy where you are clearly against such practices. At the same if you can help someone do the circumcision, which is going happen anyway, then you have the responsibility to do it. These are the dilemmas doctors face on a daily basis.

What other moral dilemma do MSF doctors face?                                                                      
In Papua New Guinea, here is no war. But every conflict, whether at home, street, or community, is settled by violence. If you want to carry out a life saving surgery on a woman we need permission from a man from her family. We cannot give any service to a woman without the permission from a man – father, brother, husband or the son. So the dilemma is, women will die if you don’t perform the surgery and but if you do it without permission the next day people will be swarming the hospital. There are other dilemmas. For instance, the Sri Lankan government tells you to give assistance to only those living in the camps. Any communication about happenings has to be approved by the government. It goes against the principle of independence. At the same time there are people who need help. You are tested as an organization.    

You recently undertook a cycling tour across India. What did you learn?
The last time I undertook a cycling tour was 25 years ago. Clearly, things have changed in India. There has been a lot of progress if you may say so. There aren’t many people on bicycles. Now people are on scooters, few deaths for children below the age of five, decline in maternal mortality. So things have improved. At the same time some problems remain the same. People are not able to get health service at the bottom of the pyramid. It could be on account of geography, corruption, absence of doctors and nurses, poor infrastructure for them to live while migrant labourers and certain communities are excluded and live in chronic conditions. If you want to slice the cake certain castes are excluded and do not know what their rights are.

How do you see the health care system in India? 
There are real issues with access. For me, a good health system is the one that reaches people. One of the things I learnt working in different parts of the world is that people who need the most care are the ones who don’t or can’t come to the health centre because there are so  many factors – distance, lack of doctors, or medicine. And also they are not treated well at the health centre. So why should they come? So they go to quacks. So, the health care system is not doing well though it reaches middle class, but not the bottom of the pyramid of 1.3 billion plus country. If you are not able to get them service we are in a huge problem. Secondly, water and sanitation situation is in bad shape. Open defecation is another issue. Third is the garbage. As Indians we think we are clean people bathing twice and bathing in holy rivers. But we don’t think twice before dumping garbage before our doors. Cycling along the country I found people travelling in luxury and swanky cars but throwing out garbage. Gujarat is considered to be developed. Visit a city like Bahruch. It is so dirty.

So India badly needs a sanitation revolution?
Absolutely. If we address hygiene and sanitation issues we can address some of the key problems – malnutrition, water-borne disease… It has huge implication. It needs to be addressed on an urgent basis. The governments in J&K and Haryana are communicating about the importance of hygiene, sanitation and toilets, washing hands, etc. But you also realise 50 per cent of people do not have access to clean drinking water and toilets.

What about private clinics?
The quality here too is dismal. We cannot verify whether they are doctors or not. In a district like South Canara in Karnataka, where the living standards of the people are quite high compared to other parts, a group of women told me that they will get better service from government doctors who run private clinics than in hospitals.

So there is a deeper malaise.                                          
These are societal problems. We always point to the political class and dub them as corrupt. Somehow we aid and abet corruption. As a government doctor it is my duty to treat patients at government hospitals and not lure them to the private clinic. This is unethical. As part of my cycle tour I have been talking to medical students along the way. I have spoken at ten medical colleges and told students that as doctors their jobs do not end with writing a prescription. Doctors must ensure that people live healthier lives and they should be vocal about sanitation, pollution and hygiene issues. We don’t see many doctors as activists.

Do you see a bigger role for MSF in all this?
We are a humanitarian organisation. We treat patients. We don’t treat systems. We are not in India to help develop a new system. We help people living in a state of crisis. We help people to survive the crisis period. It is for the citizens and government come together to put a working system. MSF is a small organization. It cannot meet all the health challenges in India. We are a catalyst for change. We are treating kalazar in Bihar. We consider drug-resistant tuberculosis in India a humanitarian crisis. India has the largest burden of tuberculosis in the world. The treatment for TB is the same as it was fifty to sixty years ago. Basically, there is no new therapy or treatment. We cannot look up to big pharma giants because they do not work on diseases that affect the poor. There is no market and people have no money to pay.

So what is the way forward?                           
Better drugs. Affordable drugs.

MSF is has also worked in the conflict areas within India. What were the challenges like?
India is not Afghanistan. There are pockets of conflicts. They are low intensity and long drawn out chronic conflicts. We are working in Chhattisgarh where we provide health care. We reach remote places. MSF tells authorities and those in control of the region that they are neutral and are not involved in local politics. We can be misunderstood. Today in Myanmar, where Rohingyas live, MSF is targeted by the Buddhists. They think we are providing health care to Muslims. But that is not true. If you look at the records half of our patients are Buddhists.

You have spent two decades with MSF. How has it changed Dr Unni Karunakara?
The more you travel abroad the more you understand India better. I have travelled to the remotest parts of the world and seen how people are living in dire situations. You get a new perspective on human suffering and what people go through. So when I am back, I more sensitive to things here as well -- inequity and inequality. But the biggest problem in India is an epidemic of indifference. People don’t just care. There are so many Indias living together. We live next to each other. But our lives don’t intersect.