What is social entrepreneurship? In essence, it’s about using the tools of entrepreneurship—opportunity, resourcefulness, innovation—to address stubborn social and environmental problems. A defining feature of social entrepreneurship is the concept of systemic change; that is, change that addresses the underlying social, political, and economic forces that conspire to exclude the poor and marginalised from the opportunities that many of us take for granted.
The global AIDS movement is perhaps the most powerful example of systemic change in our lifetimes. Although the discovery of combination therapy for HIV in 1995 turned AIDS from a death sentence into a manageable chronic disease, high drug prices and fragile, underfunded health systems in much of the global south meant that millions were denied access to lifesaving treatment.
A decade later, thanks to a global movement of grassroots AIDS activists and scientific advocates, the world looked different. Billions of dollars in new funding were committed for AIDS treatment. Market reforms reduced drug prices by over 90%. And, most importantly, a global consensus emerged that every person with HIV/AIDS had a right to treatment.
I recently had the opportunity to chat with Dr Joia Mukherjee, a long-time colleague, mentor, and co-conspirator of mine, about the legacy of the global AIDS movement, and what comes next in modern healthcare delivery.
Peter Drobac: Working to transform unjust systems is a defining feature of social entrepreneurship. You highlight the Global AIDS movement as an example of large-scale, systemic change. What lessons from the AIDS movement could help aspiring social entrepreneurs address other complex social problems?
Dr Joia Mukherjee: To me, the most important and unique aspect of this movement and its success is transnational solidarity. Making the problems of human beings universal rather than walled off as only meaningful from the lens of the national state. Many of our friends from wealthy countries stood side by side with those from impoverished countries and said, “we matter” “All of us.” We could, as a human species do that for many other things.
Public health and international development have traditionally been fairly utilitarian—do the most good for the most people with the resources available. How does a focus on equity and human rights challenge that convention?
I think where utilitarian frameworks have failed is in the last part of your statement, “with the resources available.” The problem is, the decision about what resources are available is not based on “reality,” it is based on a set of choices that the global community and individual countries make: the choice of waging war, the choice in pricing pharmaceutical products, the choice of promoting market solutions to social problems.
Therefore, the conversation starts with a “resources available” question that comes out of a very skewed function machine. When the focus is on human rights and health equity, the equation is reversed. We are mandated as human beings to assure basic rights and social protection and then we need to understand how much it will cost and how it will be financed.
When we asked the children […] what their main risk factor for AIDS was, they said, “poverty.”
What has been your most powerful learning experience?
To this day, I can honestly say that my most powerful learning experience was when I first worked as an AIDS educator in Uganda in 1994. I was working with children 11-14 and teaching them about AIDS transmission, prevention, etc. When we asked the children, after many hours of workshops, games, songs, and learning, what their main risk factor for AIDS was, they said, “poverty.” I was stunned. It transformed my life and moved me away from prevention to a comprehensive view of what is really needed to achieve health; economic and social rights like a job, housing, school, food, and health care that has both prevention and treatment. Poverty is such a crushing and unaddressed aspect of all health—from epidemics, to non-communicable diseases, to death in childbirth. This has always guided me.
I can think of few other academic health care leaders who spend as much time as you do in villages and communities with patients and front-line health workers. Why is this important to you?
Medicine, as taught in the US, is so technical. Health is not. By seeing the struggles of patients to feed their families and even get to clinic—through the mud, on a donkey, being carried on a litter—profoundly shapes how I think about delivery. It is why the book has such a strong focus on social medicine. As Chief Medical Officer of PIH, it is similarly important for me to see what challenges our staff face—whether it is a drug stock out or unimaginable lines in the emergency room. It motivates me to do better and do more; and reminds me that there are no simple fixes for social justice.
Universal Health Coverage (UHC) has become the top priority of World Health Organisation and many others. Is it really possible to achieve UHC? What would it take?
Strategy and money are both critical to the progressive achievement of UHC. Countries must commit more money for their people (and many have) but at the end of the day, for impoverished countries, even if political commitment is high, there is not enough money. We must globalize the notion of the financing for this basic human right. But developing a delivery strategy is also critical. Aid often fragments systems and results in enormous insufficiencies. Part of Rwanda’s success is vision and strategy, and coordination of donors and partners to adhere to a plan. Having just returned from Cuba I can also say that it is the best planned and most coordinated system I have ever seen—and the results speak to that in both countries.
What would you say is the distinction, if any, between Global Health and Global Health Delivery?
The focus on delivery is because I believe what defines the current state of global health in the world has been the increasing ability to deliver care; not just measure or describe, but to address vast inequalities in access to life saving medicines and services. Understanding why that gap is there and what can be done about it is a critical piece of the work.
Recently, you have stressed the importance of activism in creating social change. What causes are you focused on right now?
This is an interesting moment for women in the US and around the world. The #metoo movement and the attention on women’s issues, but also the backlash from nationalism and conservatism. It is difficult but also presents an opportunity to build solidarity between women rich and poor, black and white. Right now, we are focused at Partners In Health at trying to build that type of solidarity around childbirth and maternity issues. We know there are massive race and class disparities in birth outcomes for both mother and baby across the world. Can we get women who have the privilege of excellent health care to demand that high quality care for women is not privilege afforded to a few but a basic human right?
Also, AIDS isn’t over and in fact the gains are under threat. We have to assure more funding to end the epidemic. I will always be an AIDS activist.
Featured image credit: “Medicare for All Rally” by Molly Adams. CC BY 2.0 via Flikr.