Dr. Joia Mukherjee, Medical Director of Partners in Health, on Haiti, why aid is often undemocratic, practical and low-tech AIDS treatment, socialism and passion

By Hazel Schaeffer

TMW: What stage is your relief work in Haiti?Dr. Mukherjee: We’ve been in Haiti since 1987 and we have a very large staff, 4,000, all Haitian people, and we operate 10 medical facilities in Haiti. One is a charity hospital and nine are public facilities. The medical care in the 11 facilities in Haiti . [is] the ongoing work that we do. [Those clinics]-all the way from primary healthcare, vaccinations, surgery-are now very inundated with people who have displaced from Port-au-Prince. The general work we do has been increasing and [as are] the types of things we have to do. There’s a lot more mental health need now, [and] there’s a lot more rehabilitation service and physical therapy because there are so many wounded people. We have a lot of need for ongoing orthopedic surgery. I don’t consider [the services] in those facilities that we already operate [as] relief work …

We do more standard relief work in Port-au-prince, which we had not been to before. Because almost half our staff is Haitian they’re all connected to Port-au-Prince. We’re providing direct medical care to people living in these camps of displaced people and then helping to provide care and also put together with the Haitian leadership a strategic vision for the general hospital which is the large academic general facility that is publicly funded. Even before the earthquake it was really woefully inadequately funded and that’s the main trauma and the main surgical center in Haiti. The two main areas of relief work is making sure that hospital stays running all the time and providing medical care and sort of the wrap around social services to people in the camps.

Now that media interest in Haiti has largely fallen off, is it difficult to maintain funding for your work?

So far not too bad and we’ve been really lucky with places like Macalester and the Macalester Haiti Relief Org and other solidarity groups that have sprung up that are keeping Haiti alive. Of course we had a big peak of fund raising weeks immediately after the earthquake, but we are still seeing a lot of interest and solidarity around Haiti, but I think what people need to understand is to really rebuild Haiti, and build it back much better than it was, is going to take decades of work.

What I am interested in, especially speaking to students, is we need a long-term movement in solidarity and support with Haiti because it can’t be dependent on a media snapshot. It has to be dependent on lots of people engaging on a weekly or monthly basis on what’s going on in Haiti. So last week for example, we had the Donors’ Conference where big governments all over the world pledged support for Haiti- and they pledged money around $ 4 billion. We need to make sure every penny of that money gets to Haiti and actually gets to the grassroots. That’s the kind of thing we can do as foreigners to help Haitians pay attention and watch that money and make sure it’s being distributed properly.

One thing I’ve really learned from aids movement is having a social strategy for action really is important. In the AIDS movement we see this: If The President’s Emergency Plan for AIDS Relief or the Global Fund Does something wrong about AIDS, the AIDS community [is] on top of it. They’re protesting they’re calling, they’re writing letters. Having a social strategy in a movement can be very effective even when the media attention is not on that movement. I think we need something very similar in Haiti, where people who care about Haiti say OK, what are our four goals in common? We can all do our separate thing, but [have] four goals in common . If this doesn’t come through we can put pressure. I think the international community can be engaged in that.

PiH was singled out to assist the Haitian Ministry of Health in Port-au-Prince’s main hospital. How has PiH developed its high status as a medical provider? How does its approach compare with other similar organizations?

Definitely accompaniment. When we are present with a government within a country, we’re not there to do it ourselves. We’re there to support and help, for example the director of the hospital . We bring in volunteers that are there to help work together with the Haitian staff. Our model has never been to be an American NGO but to say we’re here to support . and to improve the efforts that are already here.

The reason the administration of that hospital really wanted us in that role is they saw lots of groups come in put there tents to do their work and not really help the Haitian staff come back to work. Not really help the Haitian staff have the tools they need for surgery or nursing care and our model is very, very different.

PiH developed an AIDS treatment program in Haiti. How was it started, what was your involvement, and why is it being used as a model for other parts of the world?

We started treating AIDS because patients had AIDS, our own staff had AIDS, community health workers, etc. We decided we were going to make it really low tech, not really heavily on tests. Not because we didn’t think people deserved it, but because we wanted to make sure as many people got treated as possible especially in those first years.

I worked very closely with my Haitian colleagues … One of our original HIV patients that was treated in ’98 just died this year. She was on treatment for 12 years and she had 12 more years of life because of AIDS therapy and was able to get both of her kids through school and it really gave her a new life. Working with our Haitian colleagues we said, OK we’re going to make this as low tech as possible, start with the sickest patients first and apply a community based strategy of accompaniment. Each patient would have a person who would visit them daily, make sure they were taking their medicine, encourage them, give them emotional support. We trained these community health workers to also look for side effects of the medicine. The critique was, you can’t do this. AIDS treatments are too complicated, the side effects too bad, people will never take their medicine. We put that adherence or following up on the community member-who were doing this work as real members of the team and paid to do that work- and engaged them with the medical doctors.

The strategy was one of very decentralized care and the health central level in the communities with a lot of participation from community members. I think it’s been a model for the world, one because we showed it could be done and two because we showed it could be done based on a Haitian staff, a local staff, doctors, nurses, etc. not on a foreign staff and three because we said you don’t have to be a big research institution with lots of lab tests to do it. So I think those three things made it feasible for people to try in places like Rwanda and Lesotho.

How are disaster relief and human right related and how are they different?

That’s been a big challenge for me as a kind of person who really believes in a basic human rights strategy. Fundamental to the human rights strategy is the notion that by virtue of the fact of being human you have basic rights and the way that comes across in any country is it’s also by virtue of being a citizen you have certain rights. In virtue of being a citizen rights would be given by the government, but a place like Haiti the government doesn’t have money to deliver even the right to vote. The international community becomes engaged in so that people have the right to vote because no poor government can pull of an election without a lot of help. Somehow with education and with healthcare we assume that the government whatever they can do fine, and the rest we can make people pay for. That’s not basic rights approach and so we’ve tried to support the public sector to deliver rights to health as a basic right free of charge. In disasters were used that model as well. We bring our local Haitian staff, but working at the behest of the government in areas of need to provide health care as a basic right.

The diffi
culty in disasters and particularly in poor countries is that there’s this general feeling that the governments can’t hand this stress, the government can’t handle this money and the money keeps being channeled to NGOs who mostly are American, have no grassroots presence and really are not accountable to the local population.

To have a real right you have to have a certain kind of accountability, [which], in our view is democracy. If you don’t like how something’s going, you vote the bums out. It’s frustrating for me to see that of every dollar of U.S. assistance that goes to Haiti after the earthquake only a penny or less goes to the Haitian government. That means that peoples ability to hold their government accountable is taken away form them. So what people in Haiti are writing as graffiti on the wall is “Down with thieving NGO’s” because they know that the money is not going to a system that has any accountability to them.
When you keep trying to take [aid] out of the hands of local people and local government, you lose accountability and it becomes more of charity model than a rights based model. We’d like to see more channeled through the government or coordinated through the government so that people will have a say in how that moneys being used.

Now that were on the U.S., do you have any thought on Obama’s health care legislation that was just enacted?

I find it sort of uncomfortably hypocritical to be talking about a basic right to health care where we don’t have that right in the U.S. I think the solution they came up with we have a little experience with it in Massachusetts this thing called Connector. It is basically assigning people to private insurance that they have to buy, some of which is a little subsidized … To make people buy into a system is not a rights based approach.

I think a public option would have saved it from silliness. People call that socialist, whether its socialist or not most of the civilized wealthy democracies in the world have socialized protection for health. England, France, Canada, Sweden, Norway, Denmark. We live in the richest society in the world and people don’t have a basic right to healthcare.

Even with this connector type situation we’re still going to have 25 million people uninsured. I think it’s embarrassing. I was not a big fan of the legislation. I appreciate Obama trying to take it on. The only good basic economic right we have in the United States is primary and secondary education and I think people take it for granted. I don’t think they realize that is also socialist. Most people send their kids to public school and pay for it with their tax money and thank god it’s not on their day-to-day list of priorities for their family. We should have the same for health care.

You’re and activist, physician and teacher. In your experience what is the potential or the actual interaction between these professions?

It’s funny, I don’t even think of the three of them as separate. That’s the interaction. The father of modern medicine is a guy named Rudolf Virchow. He said “physicians are the natural lawyers for the poor.” [It’s the idea] that you can’t practice medicine without looking at the social context. Virchow was urging us to be activists. Part of my role as a teacher is teaching medical students and undergraduates and young people that [if you care about] medicine, or education or the basic rights, you become an activist by nature.

If you’re really going to be a doctor and not just do the end of the line work, you have to address the issues around poverty and that makes you an activist. To me that just makes you a doctor. Maybe my teaching is trying to get more people aware of the interaction between what’s called academia, the social determinants of health, and health outcomes and the idea of health disparities. It is really a very classical medical training in the social context of health.

What message do you want college students to take from your experience in Haiti and elsewhere?

I’d say we need people to stay engaged. That social pressure will change the world. That all of you guys have enough of a voice to make that happen. People should find what they are passionate about and do that. If you want to be a write be a writer that looks at social change … There are so many ways to contribute to changing the world by just looking at whatever your passionate about and where disparities occur and how you raise your voice.

I think that there is a great potential in this generation of Americans to get us out of our sleepiness. I think for Haiti we need a movement, we need people to be concerned about Haiti for the long haul, for the next thirty years. I think we need to look at how we can all work together to a common goal that there will be a massive change in our life, that we won’t accept dire poverty. The movement is freedom from want, freedom from starvation, freedom from not having a roof over your head, freedom from basic pain and suffering from poverty. We could achieve that in our lifetime. That has been achieved in the United States. We have poor people, but we don’t have people dying of starvation. At the turn of the last century we did. We need to have collective action. That will take lots of forms and everyone can participate. It doesn’t have to be through medicine. There should be this basic challenge to accepting the notions that there are different standard to human dignity. I think your generation can do that.