Where there is a wheel, there is a way

Dr Unni Krishnan Karunakara, former International President of Médecins Sans Frontières, who is on a cycle tour of India to raise awareness and funds, talks about the tour, his years with MSF and the many challenges of providing health care in conflict zones.

Dr Unni Karunakara, Soda village sarpanch Chhavi Rajawat and the economist Dr Jyotsna Puri cycling from the village to Pachewar in Rajasthan.

ON October 1, Dr Unni Krishnan Karunakara completed his three-year term as International President of the independent humanitarian organisation Médecins Sans Frontières—Doctors without Borders. He is the first Indian (in fact, the first non-white) president of this 42-year-old organisation. Before holding this post, he had been with MSF for 15 years, and on leaving MSF, he took up something that had been on his mind for years: a cycle tour down the length of India.

An avid cyclist, he had done a round trip from Delhi to Leh and Srinagar to Delhi in 1988 when he was 25. Now, as his 50thbirthday approaches, he is on a tour that has been named Unnicycles. It involves cycling 5,350 km across 10 States with 65 stops in between.Three thousandkilometres into his journey from Kashmir to Kerala, he spoke to Frontline at a small guest house at Vengurla port in Maharashtra’s Konkan district where he had halted for the night.

“A cycle journey across India to start conversations and to support Médecins Sans Frontières” is how your tour is described. What has it been like after 63 days on the road and what conversations have you started?

The initial motivation was very personal. It had nothing to do with MSF. In 1988, I had done some cycling and I had always wanted to cycle to Kanyakumari, but between studies and work I never got the time. But now that I am out of MSF and not planning to work for at least the next few months, I decided to do this. And once I decided to do it, I thought, why not raise awareness about MSF as well. So the idea is to spark conversations with the general public, medical students, and health-care providers on health, health care, and humanitarian action.

I’m not exactly going around telling people about MSF directly, but it is through the people I meet and their experiences that I talk about MSF. For instance, I met this man in Punjab. I was getting my cycle fixed in a cycle shop and we got talking. The people there are very concerned about cancer. And the other big problem, I realised, was drug abuse among young people. I have found that water and sanitation are also huge issues all across the country. So it is when people talk of such things that I bring in MSF. So, you see, I’m essentially using this time to meet people, to understand the issues.

Another example: I remember the plague in Surat and I remember that people said it was because of the huge piles of rubbish that never got cleared. I did not visit Surat at that time or even later but since it was on my route this time, I was keen to see for myself. I was apprehensive as I rode closer to Surat but what a surprise! The city was absolutely clean! I met the chief medical officer, and he explained how the city services are organised in such a way that garbage is no longer a health threat. So, you see, what I’m doing is very random. I want to approach this with a sense of humility. I have been out of the country for 20 years, so I’m asking questions.

So an average day would be…

I start around 6-30 a.m. and have breakfast by 9 a.m., by which time I would have usually done about 40 km. It is really hot from 1 to 3 p.m., so we take a break. Right now I am in the Konkan. It is exhausting, beautiful and a real struggle. I would say it is tougher than the Himalayas—the inclines are so steep, so sudden, very sharp and the roads are terrible, full of potholes. But what has been great is that I have met quite a few cyclists. I met this Japanese cyclist who is going around the world. He has been at it since 2009. This is his 55th country. Tomorrow, I will catch up with a team of 25 cyclists from the Youth Hostels Association of India who left Mumbai a day before me. We will cycle into Goa together.

Twenty-five years ago, when I was on another cycling tour, I met only two cycle tourists and they were both English. This time I’ve met so many more and so many Indians. So it is good to know that it is catching on.

Your trip must take a lot of planning. What is your logistic support like?

Actually, I just have a small team accompanying me in a van. They do my planning. This is generally done a day before or on the day itself. There are four bicycles in the van.

They are, of course, as a back-up, but mainly for the people who join me along the way [co-riders who will join for fund-raising will include the Canadian Olympic medallist Helen Upperton and the poet and author Jeet Thayil].

In Rajasthan, I had Chhavi Rajawat [India’s first woman sarpanch with an MBA degree], who biked with me for three days. We went to the Barefoot College in Tilonia. On the bike itself I carry a change of clothes, water and foodstuff.

MSF works in crisis-ridden areas. Can you talk about some of the situations you have seen and handled?

I have been with MSF since 1995. The job of the president is to represent the organisation and present its position to heads of state, to the media and occasionally to negotiate or advocate change. The Central African Republic is a completely forgotten country. It gets very little assistance. Every person there gets two or three infections of malaria every year. I tried to convince the then President to invest more time and his personal energy in improving the health situation, but it did not quite work. Then, as you probably know, we are not allowed to work in Syria but we do provide whatever assistance we can. [This has just changed and MSF now does work in Syria.]

There are incredible challenges to providing humanitarian aid in crisis areas… Afghanistan, Syria, the Congo, Myanmar... there is a big backlash against humanitarian organisations. Intimidation of our people shows an increasing trend, especially in Myanmar, Libya and Syria.

How do you manage to convince warring factions that MSF is neutral and is there to help whoever needs medical help? Do people accept this?

This comes with a lot of discussion and dialogue. Now, with everyone having access to the Net, they can even check on us there. It is not just our principles on paper, but the people’s perception of our principles. The moment you accept money from the United States government, you can imagine what the reaction would be to MSF in Afghanistan. So we do not accept money from the U.S. or France or from petroleum, pharma or mining companies. Most of our funding is from individuals. We have very strong ethical funding policies. Yes, there are a few Scandinavian countries which give us money, but we make sure that there are no strings attached.

Do you ever find yourself in situations where you go beyond being doctors, where you have to mediate between sides?

Ethiopia in the early 1980s. Part of being neutral is that you safeguard against humanitarian assistance being used for political purposes. The Ethiopian government was using famine and humanitarian assistance to forcibly displace families. We spoke out against it and we were kicked out of the country. Then, in Sudan, we came out with a report that highlighted human rights violations. We examined many women in our hospital who reported being raped. Rape has medical and psychological consequences, so we reported it but the report was construed as political. We were told we were doing human rights work! We said our doctors came across problems and issues that affected the patient’s health, we don’t point fingers. We just say that xyz number of women reported such a thing and we ask the government and international agencies to take action.

We have a double mandate: to take medical action and to bear witness to people who are marginalised and whose voices are not heard. So we lobby to get them heard. This extends to the debate on generic drugs as well.

Yes, it was an interesting debate you had on generic drugs with Dylan Mohan Gray [director of “Fire in the Blood”, a film on AIDS and generic drugs] on your Mumbai stopover.

We looked into why some people have access to drugs and why some don’t. The [intellectual] property regime, neglect of diseases, etc… these are the reasons why we launched an active campaign… to right the balance. The starting point for everything is always the patient for us.

One of the interesting things done by MSF in India is the work in Kashmir on stress and mental health.

Kashmir is a society living through a low-intensity conflict. The mental health system in Kashmir was not developed enough to assist the people. And seeking mental health care was taboo. It has taken a lot of work on our part. Today, the State does have a mental health programme. I am happy to say we had a part in that.

In your 18 years with MSF, there must have been certain faces that stood out, some stories that stayed with you or dangers that were faced. Can you talk about those?

Two of our Spanish colleagues were kidnapped in Kenya on October 13, 2011. They were released in Somalia in July 2013. It was the longest kidnapping in MSF history. The negotiations for their release took a lot of energy and time. I also remember a seven-year-old child in Angola. I thought he was three. He was so under-nourished, so terribly, chronically under-nourished, and was with all the cognitive and nutritional deficits that follow. There has been too much for me to isolate and remember just individuals—sleeping sickness epidemics in the Congo and Uganda, Ebola outbreaks….

Tuberculosis is of special interest. In 1995, I started in Ethiopia with a TB control programme. You know, HIV has a wide variety of drugs since lots of research & development goes into the disease. The challenge in HIV is to get the drugs to everybody. But in TB we are still working with antiquated drugs. India has the largest burden of the disease and there is so much work yet to be done.

You must be coming up against cultural and religious beliefs when you practise in so many places around the world.

Yes, it does happen. Papua New Guinea is not a country at war but it is incredibly violent. Domestic, communal, political, tribal disputes are all settled with violence. Doctors have difficulty in helping women because the tradition there is that a doctor can treat a woman only if a man from her family is around to give the go ahead. So, even if it is life-saving surgery, the doctors have to wait for a “yes” from a man. So we do have ethical dilemmas: our responsibility as doctors versus what is accepted/not accepted in a country. And that ethical dilemma extends to our doctors too: how would a Catholic doctor deal with a need for MTP [medical termination of pregnancy]?

As humanitarian workers, we provide help to whoever needs it. There have been instances where we have had a rebel leader in for treatment. We knew that when he recovered he would go back to killing people. We need to constantly find that balance between principles and pragmatism. Our ability to provide treatment in the Congo works well because the different groups know we are there just to provide health care.

It is the same in Afghanistan. The moment your impartiality or neutrality is suspect, then that’s it... the trust is gone.

What is your assessment of MSF and what, if at all, needs to be changed? You essentially respond to medical emergencies but medical aid is often a long-term prospect. Are you looking at developing models to facilitate caregiving?

There is a distinction between humanitarian work, which is treating patients, and development work, which is treating the system. To treat patients, you have to work with the system. In many countries we do both.

In some countries, there is no system to interact with. So we provide care till a system is set in place. The systems are for the countries to decide. In some places this takes time, like in Sudan where we have been functioning for 30 years. As medical workers, we work with people who are most vulnerable, and by providing care we hope to be a catalyst for change.