Dr Michelle Bachelet, (left-wing revolutionary imprisoned by the military dictator Augusto Pinochet), two-time president of Chile (2006-2010, 2014-2018), first Executive Director of UN Women, took over as the Chair of the Board of Partnership for Maternal, New Born and Child Health (PMNCH) speaks to ICFJ Fellow Biraj Swain on the occasion of 71st World Health Assembly.
Full Disclosure: This interview was done on May 24, 2018, in Geneva. Biraj Swain’s trip to Geneva was sponsored by ICFJ Washington DC.
Dr Bachelet, tell us about your epic journey from being a trained doctor to being imprisoned and exiled and then coming back to win the general elections in Chile and becoming the President, not once, but twice. What message do you have for our generation of doctors?
So, I am a trained paediatrician. I come from a family where we were not medical doctors but socially and politically very conscious people. I grew up in that environment. I loved being a doctor, a paediatrician. But every time I solved a health problem such as cold or diarrhoea, I would feel like I was missing something. Those poor children probably did not have access to something such as life chances, clean water, sanitation, nutritious food. So, since I was in jail because of my political ideas…jail is public, I was actually held in a secret location (where you disappear from the public eye or are disappeared for life), incarcerated by the military dictator, I had time to think.
How long were you in Jail?
It was not much, about three weeks. Then I was expelled from the country. But in jail, I got time to think, introspect. Once out of the country, you analyse more. My Hippocratic oath kept coming back to me. The principle of “Do No Harm” meant, I needed to treat, but not just leave it at treatment.
Do not do harm is something very important. It is also the responsibility of the political leadership not to do any harm. You always have to make decisions that will not harm people. You can always have special interest regarding something. But try to do no harm. Try to find the best solution. So, after graduating I specialised in Paediatrics, I started to feel that something was missing. So, then I decided to go into public health. If you see paediatrician training has a lot of public health too. And public health led me to public service.
So you thought Paediatrics was too specialised and you wanted to understand the big picture with public policy and public health?
Yes! Yes!
So that’s when you transitioned?
Yes! I was already political in school. School was in the ‘70s. But my public health-public service transition was in the 90s, when I came back to Chile from exile.
I did not plan on being a minister, neither a president. My only concern was to be able to help people, the society. You see, life is very strange! I like relationship with people especially the children. I feel nurtured when I am with people. So, I decided if I am going to go into politics I am not going to lose the direct relationship with people. For me, it is important because I care about them. Particularly, in the situation we live in, the violation of human rights, and so on. I felt it was important to work towards it.
So what message can I send to young doctors? I studied medicine because I wanted to fight for equality, for access to health. People who need health must have access to health. I wanted to support that as a doctor, individually and also collectively. If you think about it, you will find so many disparities, obstacles, inequalities that impact health. And young doctors need to care about that too.
So you are saying not only public health is important but you need to keep eyes on the moving target of inequality, since they are all inter-connected? So, are you saying doctors in this age of super specialisation miss that, they work in silos?
We all know that public health is much more than that. It is not only about the absence of sickness, about missing diseases. It is not only about bacteria or virus, it is also about social determinants. On one hand, you need to ensure health is important. But also, you need basics such as water, food, shelter, sanitation, roads. You cannot ask the ministry of health for all that, but we need to promote them at a social level, we need to ensure them. Vaccines won’t solve them. We need to look at health in a broader way.
I had a human rights approach, life-cycle approach to health. Especially, since I came from a country, where conditions had been such that there were rampant human rights violations.
I am not asking doctors to think of all that, but I am asking for inter-sectoral coordination. The planning, programming and advocacy need to take care of these. We need to be aware of determinants both at a technical and political level and address them at both levels.
So you have led the UN Women and you have said rightly that health is too important to be left just to the doctors and it is about social determinants, public policy, political economy. You have been someone who championed public health as an important feminist agenda. What are your key messages for children and women? Why do you think global health is a feminist agenda?
I think it is clear that women’s health is pivotal to child health and adolescent health too and we need to prioritise them and address them together. I think, if you see women are at the centre of many issues. When a woman has a salary, she uses 95 per cent of it in the household. Men usually spend it on other things. So, women are very important in terms of family and recognising that is important.
Women and children are disproportionally affected by many inequalities and poverty. For example, in Latin America, I am sure in Asia and Africa too, women are vulnerable to many structural inequalities. A disease like HIV-AIDS has disproportionately affected them.
Women are treated as marginalised minorities when it comes to addressing their issues in public policy and programmes. It is very strange because women are not a minority, in my country they are 52 per cent, in the world they are 50 per cent. But we put them as minorities. But I know they have become very important in global health. Everyday thousands of women die because of complications in childbirth and pregnancy. And addressing women’s health is also about education, empowerment, life choices, options, and representation in public policy and public life.
India also has a high maternal mortality rate, as you have said sanitation is important and it is needed. Sepsis is one of the leading causes of maternal mortality.
Other than maternal mortality, every year we also have 10 million women with physical and mental disabilities. Cervical cancer is also rising, so are non-communicable diseases (NCDs). It is also about problems that can be solved. In my country, in our government, we started human papillomavirus (HPV) vaccinations. There are many acute and chronic diseases that can be prevented such as HPV through the vaccine and we need to address that. We have issues like child marriages or early pregnancy. We need to take care of that too.
It goes back to social determinants again. We know when a girl goes to school, it is kind of a vaccination against child marriages, HIV-AIDS and so on. The girl child knows she has more options, her parents know they have more options.
As a matter of fact, in India when women came into Panchayats (the local government) there were one million of them who got elected and came into them. You know what happened then? They became role models. More girls started going to schools and importantly their parents wanted them to go to schools. So girls and their families were not thinking about marriage but started thinking about other options like education, employment, public service.
When women rights are respected, we can reduce maternal mortality, infant mortality, address early child development, which is most crucial for our future.
Do you know the population of children in India in the early childhood cohort? It is 216 million in the age group of 0-6 years as per the 2011 census. Dr Bachelet, you have just been inaugurated as the chair of the Board of PMNCH. Tell us more about the PMNCH.
So this is a global partnership comprising of the civil society, governments, UN bodies, inter-ministerial bodies, the private sector, academia. Its goals are six-fold: Focus on early child development, youth-adolescent and maternal health, access to health with quality, equity and dignity, sexual and reproductive health rights (SRHR), and empowerment of women and the girl child.
In my country, the access to contraception is an issue especially in the northern states which are steeped in patriarchy. I understand, India is hosting the next PMNCH meet in December 2018 and you would be there alongwith the entire PMNCH leadership? Any message for my country?
I have been to India in April for the curtain-raiser event, an information sharing programme. I met some key leaders and decision-makers too.
In December, many world leaders will be there. When I met the Indian leaders, I said, the partnership has over a 1,000 members already and in the last meeting 1,000 of them attended. One of the Indian officials quipped, it is just like an Indian wedding. Bragging a thousand numbers in a billion plus country is not impressive!
Indian officials asked if I had suggestions, ideas for India. I said, I had lots of ideas working in the Health Ministry in Chile, in Latin America, but I also understand the scale is very different. We are talking about 1.3 billion people in case of India. So I will be humble and share, what we have done in Chile and done successfully or the experiences from Latin America, even the experiences from UN Women’s global work. But it is for the Indian leadership to take what they feel most apt from this, considering their scale.
Let’s talk about the challenge of retaining doctors in the public sector. The WHO recommended average is a 1.8 per 1000 population, in India, it is 0.6 per 1000 population. We have one-third of the recommended limit. First, we have a massive shortage of skilled personnel in the health system, and then, after training with tax-payers’ money, they do not stay in the public health system. Do you have a similar problem in Chile and do you have thoughts on how to retain doctors in the public health system?
It is a problem in most of the developing countries. Because usually, the public sector doctors’ salary are way less than the salaries for doctors in the private sector. Add to that, their training takes a really long time, 6-7 years.
In Chile, we incentivised rural posting of doctors by encouraging graduates with preferential admission in specialisations like Paediatrics, ObGyn etc, if they served in rural areas. The longer they served in remote rural locations, the more credits they got for admission in specialised programmes.
Then we also went the other way to ensure doctors in primary and secondary care centres by sending medical graduates to these places so there is a steady stream of general practitioners and healthcare in primary and secondary health centres, as we trained a battery of specialists.
I also feel, we need to provide for the doctors’ living and working conditions, especially when they are young, have children and families, and are posted in remote rural locations. So providing accommodation, campus living was also introduced.
Other than doctors, health workers deserve a lot of attention. They are doing the heavy-lifting of healthcare delivery and most of them are women.
I have actually heard you say this and it has resonated with many feminist economists, that healthcare delivery is on the shoulders of an army of unpaid and underpaid women health workers and we need to address that too.
What about patients’ rights, Dr Bachelet? Transparency International did a study some two years ago in the Asia-Pacific region and in India, police and doctors were the most distrusted professionals. Interestingly, media still has a lot of credibility and currency of trust (though I do not necessarily agree). Your thoughts?
When I was in the Health Ministry in Chile, we brought legislations, engaged with doctors’ forum to ensure patients’ information’s confidentiality is maintained, especially in cases of HIV-AIDS and other stigmatising medical conditions. We also insisted on information sharing with patients before any treatment or procedure is undertaken so the patients knew what was happening to their bodies. Some doctors, and their forum resisted saying patients would not respect them, but we insisted on informed consent for patients.
But we also feel, we need to address the health workers’ safety, their dignity and working and living conditions too.
Let’s shift track a bit. The symbolism of Dr Tedros, first Ethiopian-African Director General of WHO, you as first Executive Director of UN Women, is immense. Do you actually think that the global power is shifting from the Global North to the Global South? If yes, what do you think we are doing with that power?
I think this is an old battle. Now cooperation and coordination are much more necessary. Besides, there is inequality between countries and within countries too. Our problems are much more global and inter-connected and no one is immune to them. The developing countries from the Global South are definitely exercising more power, but that is mostly in the political arena and in UN resolutions. For example, there are ethics issues too, countries from the Global South want regulation in case of formula milk and want promotion of breastfeeding.
I understand the role of Big Pharmaceuticals and access to medicine is also a fault-line amongst the Global South and Global North. The Indian delegation, led by Health Minister JP Nadda has done some heavy-lifting on Access to Medicine with reference to fair pricing. Your thoughts?
Well, honestly, we all need to work together. We need the private sector too, to deliver the global health agenda. We understand new medicines, new compositions cost enormous resources and years of research and development and private sector puts that kind of money. We need that. We also need the public sector to expand reach and strengthen. We need good cooperation and regulatory framework.
We need innovations too. And sometimes they come from small entrepreneurial people like, the other day we saw a young Indian who has developed a wristband for parents to monitor the temperature of their new-born and prevent hypothermia. We saw an innovator from Africa who has developed a mechanism to prevent excessive bleeding amongst mothers after childbirth. All these are important.
There is also the IAP, the Independent Accountability Panel set-up by the Director General of WHO and this year’s theme is the private sector. Then there is FENSA, the Framework for Engagement with Non-State Actors, which is important and underlines cooperation and communication.
I have heard you say we should not let FENSA become the new fence. I think it is important and a very smart statement and underlines the need for engagement and cooperation.
So this is a very interesting time for early child development and lots of initiatives have been underway, from the launch of the Care and Nurturing Framework to India hosting the next PMNCH Summit. In India, the cohort of early childhood is a massive number.
Tell us your thoughts on the current state of play in Early Child Development, ECD. What has changed from your days to current days? Tell us what shaped your childhood too. What happened in your early childhood that made you the inspiration that you are?
I think I had a very nurturing family, and had a very happy childhood. We were not rich, I came from middle-income family and my parents were public servants. I had a very caring childhood. The care and nurture we heard the other day at the launch, I received that at home.
Both my parents worked in the public sector, my father was in the military, actually, air-force and my mother worked at the university.
Your father was in the military? And your father’s boss imprisoned and exiled you.
Yes, he was in the air force. Well, he was imprisoned too. He died in prison because of torture. What I mean to say is that at that time, public service was not well paid, but we were a happy family and we lived with what we had. I joked my milk bottle was the most precious thing on earth, most beautiful.
But we were also taught respect and had a lot of discussions, got wisdom at the dinner table.
My mother is still alive, she is 92, and she is still involved in a lot of social causes.
The time from conception to the first six years is very important. One child who is given love, and one who isn’t, you could see the difference. I am convinced the children are the most important investment and investment in ECD is the best buy in public finance. And this is not just because I love children but because they are our future.
Children also need stimulation so their connection with their mothers, their learning abilities improve. We know that on the one hand, if you have a nurturing environment, if the caretakers are loving, caring, know how to play with the children, babies learn since they are in the womb, and you feel it. On the other hand, kids who are subject to violence, malnutrition, and so on, they will not be able to achieve a proper connection, personality or growth.
Dr Bachelet, you designed a program in Chile called the Chile Crece Contigo, which is a continuing universal creche care for children in Chile. In India, right now, the labour movement is asking for a universal creche care and partners coming from the feminist movement are supporting the agenda. Also in India, the female work-force participation is going down and one of the reasons is the burden of care on women and it is very expensive to afford child-care. Tell us more about Chile Crece Contigo, it will resonate with the labour movement in India.
Well, before, we had a Chile Crece Contego, I felt I was very lucky. I am, of course, the mother of three children. I was lucky, I could afford child-care, as I went on to study, to grow professionally. But that is not the case with many mothers, who have to choose between income earning activities, professional growth, or stay-at-home child care and poverty. Then the burden of child care fell on the elder siblings too, which affected the education of elder siblings, trapping the family in poverty.
Once in government, I decided to expand nurseries and kindergartens, to focus on early childhood education, to make it affordable for those who can pay, and make it free for those families who couldn’t pay. So every child had access to nursery and kindergarten paid for by the state.
In my country, we have a massive public sector bank debt burden. Last year, in the Budget, Rs 2,110 billion were allocated to refinance the public sector banks without strengthening the safeguards, so new bad debt couldn’t be prevented. Many pro publica economists have calculated it would cost just Rs 500 billion to ensure quality creche care for every child in India.
The cost of recapitalising banks is four times the cost of universal creche care. Right now, some of us, are saying that to talk about bail-out packages to banks is not enough. Let us also talk about human investment costs, especially opportunity cost to childhood. Your thoughts?
Well, public sector banks are important and sometimes the only lending instruments. I am sure they need to be recapitalised too. But your point on human development is very important. I attended the World Bank Spring meetings earlier this year and the Bank has been emphasising on human development. In developed countries, 70 per cent of the GDP comes from human capital whereas, in developing countries, it is as less as 40 per cent only.
So investment in human development is crucial and child development is the best and most important investment in human development. It is the cornerstone, it is our collective future!
Newslaundry is a media critic platform. It is also consumed by budding and practising journalists. Do you have any thoughts on the current state of health and ECD journalism and your expectations from journalism per se?
I would like to see journalists who exercise their freedom of expression. Also, I expect that they will be very responsible and serious and try to do the best they can. In Chile, we have an ethics body for media practitioners. The ethics body insists on fact-checking, on giving all sides the chance to respond. But that is not the case many times.
Some peddle fake news, or report without fact-checking or giving the other side the time and opportunity to respond. And that is not fair.
There are too many countries where the media is concentrated with too few people. I remember once when a journalist wanted to write something, the editor gave the opposite narrative and ordered that is what the journalist needed to write and the investigation had to retrofit the pre-decided narrative.
Such practices are not useful because we need people to be empowered with information. It is okay if journalists have an adversarial relationship with the political power, but the people need to be informed with facts, not fiction. And journalism could do a lot more by focusing on that.
The people need hope.
Declaration: The interview has been edited slightly for brevity and grammar.
Acknowledgements: The author would like to acknowledge Ms Lori McDougall for facilitating the interview with Dr Michelle Bachelet.
Photo Credit: Azhar Hasan Abbas
The author/interviewer can be reached at biraj_swain@hotmail.com
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