A Discussion with Rabia Mathai, Senior Regional Representative for Asia and the Pacific, Catholic Medical Missions Board (CMMB)

September 20, 2011

Background: Rabia Mathai participated in the January, 2011 BRAC/Berkley Center/WFDD consultation on South and Central Asia, in Dhaka, Bangladesh, and this exchange was initially in that regional context. The discussion, however, extended beyond to a wide range of other issues, notably HIV and AIDS and maternal and child health. Dr. Mathai reflects on the pioneering role of faith-inspired organizations on these topics and on efforts to bring those efforts more into the limelight. She describes her recent work in Papua New Guinea, Vietnam, and the Philippines, noting the special difficulties of mobilizing financing in countries that fall in the category of middle income nations.

You are based in Bangalore, India, as the CMMB regional representative. What are the main challenges you have faced? What new programs have you been able to launch?

I have been with CMMB as their regional representative for nearly two years now, and will be winding up fairly soon. I have worked especially in Papua New Guinea (PNG), but also Vietnam and the Philippines, exploring ways to get new programs started.

The work on PNG has been especially intense, and I have been there several times. CMMB has been involved in PNG since 2000, working with the National Health Secretariat on prevention of mother to child transmission programs (PMTCT). Although those programs were initially successful, community involvement, and especially support from partners, was minimal, both due to the high level of domestic violence in the country, as well as the existing cultural norms and the stigma. As a result, we realized that we had to involve men, as well as HIV positive mentor mothers, for mothers newly diagnosed with HIV/AIDS and others, and to find other ways to encourage men to take action. In July 2010, we mobilized a team of ten, with members from government, NGOs, churches, and UNICEF, and went to Zambia. Working with UNICEF, we were able to put our experience, especially with men taking action, on the PMTCT agendas. Just last week we succeeded in getting a commitment for two million kina (about $1 million) from AusAID, to get the program started.

Why so much focus on PNG?

CMMB, as the faith-based leader in international healthcare, builds capacities, and is active in many different parts of the world, including programs in Africa, Latin America, Asia, Pacific, and I have been fortunate to have led programming efforts on all these continents. Now, as I am assigned to this region, my focus is on Asia-Pacific.

The Catholic health system in PNG is very strong—about 27 percent of the population is Catholic. PNG is a logical place to focus. The numbers on maternal and child mortality and HIV/AIDS are very high, the highest in the Pacific region. There are so many capacity building needs. So PNG has become the top priority in the Pacific. There are also possibilities for action with new Global Fund mechanisms, though PNG has the disadvantage that it is considered a middle income country. Despite this, so many programs in the various sectors depend on donor support.

PNG does have huge a petroleum project—Exxon Mobil and partners have a $15 billion liquefied natural gas (LNG) project. But nothing will be seen for years and meanwhile the country is an extreme case of absolute poverty. In 2010, PNG was declared a middle income country; that meant it was removed from USAID's child survival solicitation in 2010. The real situation is that the rich are getting richer, and the poor are getting poorer. In PNG the maternal mortality is 733, second only to Afghanistan. In Port Moresby, the capital city, hotel rates range from $450 to $600, and house rents for three bedroom apartments in a gated community are $2,500 per week. Food in supermarkets or restaurants is very expensive, and so is domestic air travel. There is hectic construction activity in the city. Plane-loads from Australia, Singapore, the Philippines are full of expatriate men and women. Plane fares are exorbitant, due to Air Niugini's monopoly.

Close to the project site in the Highlands, there are tribal wars associated with land settlements for this project. These areas are a no-no for UN personnel—and if there is a dire need for them to visit, the UN employs armed guards at $1,200 per day, per official. Tribal 'landlords' who might not have hitherto handled money, come to Port Moresby with their bundles, stay in hotels with young girlfriends and make merry, till the money is finished. Many of them come to the National Catholic Secretariat VCT clinics to get their girlfriends tested for HIV. Sister Tarcisia, the National Director told me that in the beginning she used to think that these are responsible fathers, getting their adolescent daughters tested.

More generally, it is a real problem in the Asia Pacific region, that there are countries with huge poverty, and public health problems, but they are considered middle income countries so it is very difficult to mobilize international funding. Vietnam, the Philippines, and India are in the same position.

What are the programs you have focused on in the Philippines?

The Philippines has lots of people who are extremely competent and well educated, and it is very much a Catholic country. So it has been easy for us to work there. But finding money is very tough, again because it is a middle income country. Then, after I first went there, in December 2009, it was just before the January 2010 Haiti earthquake, and for six to eight months after that no one talked about anything but Haiti. Only recently have we been able to launch some programs, with CMMB seed funds.

What about Vietnam? What are the actual and potential programs there?

Vietnam was a more difficult case to enter. The Catholic Church was not viewed there so favorably. Indeed CARITAS was closed down during the 1970s, and it was only two years ago that it got permission to reopen. It is very important in Vietnam that we work with multi-ethnic and multi-religious groups.

We have been able to work with the Catholic Archdiocese of Ho Chi Minh city, on a program focused on building Life Skills in adolescents and young adults, especially those who are vulnerable to HIV, drugs, and associated risk behaviors.

Have you worked in India during this period?

I have been deeply involved in CMMB’s India program over the past ten years, working both with the Catholic Bishops Conference, at national and strategic levels, and at the grass roots. We have also worked to build relationships with the national and state-level government. The Catholics are so strong in India in the health and education sectors, with over 5000 healthcare institutions (hospitals, clinics, orphan care, home based care, colleges to train medical, nursing, allied health professionals), that they used to operate more or less on a parallel track. But now they are recipients of Global Fund money and need to be more part of the overall strategy. CMMB has useful programs to train doctors and nurses. We have focused a lot on building capacity. We also partnered with two well-known medical colleges, especially after the tsunami. We found funding to restore primary health care in tsunami-affected areas, and also start a program in telemedicine for upgrading skills of private family physicians, and that is proving to be an excellent example. The government has now contracted the medical school to start a country-wide, national program. We also have worked to eliminate leprosy. There is still a lot of stigma and people affected, especially in the rural areas, where people affected rarely even come out to declare their disease-status. Early detection is especially important, and we have been able to mobilize program funds for this, and for reconstructive surgeries.

How did you come to this extraordinary international career? Can you start with your family? Where you were born?

I was born in Hyderabad in India, and came from an elite Muslim family of lawyers and diplomats, who have played important roles in pre- and post- independence India. My father was a justice of the High Court, trained in London, and an avid polo player. My mother was a painter of national repute. Therefore, coming from such a background, I cannot believe to this day, why and how I embarked into international public health work - living and working in Zambia, Mozambique, South Africa, Kenya, Mauritius, Jamaica, United States, Bangladesh, and India.

The beginning of my career may have roots in one of my mother’s large paintings in our dining room; we looked at it each and every day, at breakfast, lunch and dinner. That could have had a lasting impact. It had sayings on it that read:

The world is my country,
mankind are my brethren,
to do good is my religion.

I puzzled over it constantly. Looking back, it seems contradictory to the way I was actually brought up in my early years. Our situation at home was not unlike that of the Buddha, who, through all the early years of his life, did not even know there was suffering in the world. It was the same for us: we did not know. And we found out slowly, that there were children on any day who had not eaten, were sick, had no clothes, shoes, or did not go to school. But it was possible then for parents to close out the world. There was no television. Our parents could have us believe what they wanted us to believe and shelter us from many ills. I wonder now after 40 years of community development and public health work, how did I break out?

I started school from age 5, and because the best schools then were Catholic, I was sent to a convent school. My father had studied in England, and my family took holidays in Europe; in that sense, we were a very modern Muslim family. In the convent, it struck me forcibly that the nuns were so religious, and they did such good work. It seemed a very organized religion, something very close to a social movement. They did so many things for poor kids and women, gave them food, education, and gifts. They had many projects, and also a very good way of doing good.

Even with the sheltered life I led, when I was young I felt a lot of stress. Perhaps because I was bored by family life, I always had to be first, to win every medal. I was very young, just 18, when I went away to university in New Delhi. At that time, it was very unusual for a girl from such a protected family to go away. And in the first week there, I met Mathai, my future husband. He was from Kerala, from a well known family there, quite traditional. I was 20 when we were married. I had started a masters degree, which I did not finish then. And at that time I began to explore Christianity. Mathai was a staunch Mar Thomas follower, (they are very much like the Anglicans). He had something I would call a blind faith in God. But we were both very young: I was 20, he 23 when we married, and not set in our ways and beliefs. We both continued our studies, I completed my masters and was working for my doctorate, already then focusing on community development and maternal and child health.

We left India in 1969, when Mathai had a fellowship in France, a post doctorate. Our two boys were born soon afterwards. Back in India, I taught at a university, as an assistant professor. Then I joined CARE as the regional director for South India. As time went on I became more focused, and knew more, about maternal health and child nutrition. It became my central interest.

I resigned from CARE in 1978, and we went to Zambia, and embarked on our international journey through Africa and other continents. We were in Mozambique when Mathai died, in 1992. During this period I worked primarily with UNICEF.

After Mathai’s death I came to the U.S., where my children were studying. I went back to my studies, at the University of Texas, completing a masters and doctorate in international public health. Then I worked for the American Red Cross. The American Red Cross seconded me to the Geneva-based International Federation of the Red Cross, where I was the regional health advisor for South Asia, which included India, Nepal, Bangladesh, Pakistan, Afghanistan, and Sri Lanka. Working within this region, gave me an incredible opportunity to learn/polish my regional language skills: Urdu, Tamil, Bengali, Hindi, Gujarati, Marathi, Malayalam etc. Then, in 2002, I joined CMMB.

Such a long and demanding career in international public health has come with its share of excitement, and being witness to brutality. To mention, but a few: I have had an encounter with 11 Taliban gunmen, have been in the midst of land-slides and earthquakes in the Himalayan ranges, and have lived for five years through the civil war in Mozambique, witnessing brutal attacks, setting villages ablaze, and butchering innocent men, women, and children.

How did you become involved in the HIV/AIDS issue during this period?

We were in Zambia during a critical period. It was in 1982 that the then-president of Zambia, Kenneth Kaunda, announced that his son had died of HIV/AIDS. In many respects I have been involved in HIV/AIDS ever since. But I was working on many other issues, which could be considered the broader context of HIV/AIDS. I was a consultant to UNICEF and to international food and nutrition programs. These were highly relevant to maternal and child health.

When I went back to school, from 1992 to1996, at the University of Texas, I specialized in reproductive and sexual health, starting really from HIV/AIDS. I was also involved in capacity issues.

During the five years I spent in Mozambique, I was with UNICEF, seconded to the Ministry of Health and Social Action as a technical advisor. It was a rather difficult period. The civil war was still going on, and the Mozambicans did not want to believe there were any problems like HIV/AIDS. Everything had to be converted into Marxist terms and structures, with a president, secretary, special protocol, and a hierarchy. But there were street children everywhere. One of priests, Denis Senuglane, played a central role in starting some of the first programs, initially within the Church, then national, focused on street children. The program was very successful and many of the children involved have done well; one, for example, is an excellent painter today. I was involved in founding a number of basically underground organizations working with children.

I became involved more systematically with HIV/AIDS while I was living and studying in Houston. There was a collaborative center there, engaged with WHO. Thus I started working at the international level, first for the Red Cross, where I was regional director for South Asia. They were remarkably well organized, present in 178 countries. It was possible to work with that network, and everything happened with the click of an email to the country president or director general. They could organize at the national provincial, and grassroots levels; they were really connected to the country’s nervous system. Everything was well connected.

I began to wonder then how it would be if similar approaches could apply to the systems I had seen and knew were already working, specifically with the faith-based entities that were everywhere. The priests and parishes were trusted.

With HIV/AIDS it was complicated. In those early years there was so much stigma around HIV/AIDS, much of it in the churches. But we found bishops and priests who were willing to work with us.

Then in early 2002, I began working for the Catholic Medical Mission Board (CMMB). It has been a wonderful experience. Next year, in 2012, CMMB will be completing 100 years of service, providing healthcare globally, to the needy and vulnerable, irrespective of caste, creed, religion, or national origin. CMMB’s programs have a three-pronged approach: it supplies medicines and medical supplies to in-country partners, mostly faith-based, in nearly 100 countries. CMMB also sends out medical and public health volunteers, all over the world, both immediate and long term. Then CMMB has programs with in-country partners, often including the National Catholic Bishops Conferences. I have been fortunate, in initiating several of these pioneering efforts: Choose to Care, Born to Live, Nurses Training for HIV and AIDS in many countries (including Nigeria, India, and China), Youth Life Skills Training for HIV and AIDS, AIDS Relief, community-based maternal and child health projects (e.g. La Salud Familiar), and so on.

Choose to Care, a collaborative program with the South African Catholic Bishops Conference, works in 144 parishes, in five countries, involving HIV prevention, hospice care, and community-based rehabilitation of orphans, in South Africa, Namibia, Botswana, Swaziland, and Lesotho. It was so successful that Father Bob Vitillo, then as now with Caritas, was contracted by CMMB to write about it. It was published as best practice, really the first such best practice example involving faith organizations for UNAIDS. I was also able to lead a project to prevent mother to child transmission in several countries: Born to Live. It too was very successful in Kenya, South Africa, Zambia, Nigeria, Swaziland, India, and Papua New Guinea. Many Choose to Care and Born to Live sites later became AIDS Relief treatment sites. Thus our CMMB programs came to cover many countries and areas.

When PEPFAR came, in 2003, CMMB became part of a faith-based consortium coordinated by CRS, and included other partners, such as IMA, the Futures Group, and the University of Maryland. We started programs in several countries, focused on AIDS treatment and prevention. Several foundations, local universities, and in-country partners also got involved. I am happy at what we have been able to do.

During this period and through this work, it became increasingly obvious that faith-based programs were doing so much work, but were not recognized. To address this, CMMB commissioned a study to the Global Health Council, who did a six country study. Conceptually grounded in UNAIDS’ Global Strategy Framework on HIV/AIDS, that highlighted the roles of faith-based organizations in fighting HIV and AIDS. The main issue that emerged was the need to build capacity (especially for monitoring and evaluation, and documentation), but also the significance of the capacities that did exist, but were not well known. We concluded that there were not many things emerging that we did not know, but it was the first time such work in the six countries had been documented. The countries involved were Thailand, India, Haiti, South Africa, Uganda, and Kenya.

We were able to disseminate the results of this work widely, through WHO in Geneva and the International AIDS Society, among others. CMMB is part of the inter-agency staff team that focused on mother to child transmission, and on WHO and UNICEF pediatric groups, and many others. So, in the past eight to nine years, we have had good opportunities to document and to spread the message. We have also worked to build the capacity of the archbishops and bishops, to understand HIV and AIDS and tuberculosis, and to build South to South cooperation. For example, we made it possible for Cardinal Napier, from South Africa, to talk about Church’s role in fighting HIV and AIDS to 150 bishops in India, and that made a large impression. Similar events to strengthen South to South cooperation have been organized. Interestingly, working with Catholic hierarchies in Asia has been rather strenuous, because many tend to be pretty traditional, in comparison to my experience in working in Africa and Latin America, and the Caribbean.

Have you worked with the Community of Sant’Egidio in these areas? They have years of work on similar programs.

Yes, and they do excellent work, that has got better over the years. Because they were involved in Mozambique in the peace talks, they had unusually good relationships and were able to start on HIV/AIDS very early. They were able to bring in generic medications from India and to work with the governing institutions, to work freely when no one else was able to do so. At first, they tended to bring in very young doctors, but their programs are really very good. In many ways they have been the forerunners of many of the best programs today.

With your long experience and deep studies on maternal mortality, what is your sense of priority areas where action is needed, and where faith institutions can make a real difference?

There are technical issues, of course, and then there are cultural and societal norms, and traditions which are different in every region. But what we really need is to make the moral case. And almost everywhere the real central issue is the status of women. This is a broad, sweeping comment, but it is true. As an example, early marriages affect so much mortality. Even for educated people, as in India, people die because of attitudes. Many societies are steeped in traditions, in complicated ways. The decisions of in laws as to whether they will spend resources or seek medical help are life and death matters. The ways in which people rely on traditional birth attendants is also important. There has to be some kind of institutional delivery, not necessarily a hospital, but a place where there can be safe delivery. Traditional expectations of women, their labor, and their nutritional status, all come together. When children give birth to children, that is the worst, and a vicious cycle continues. Worldwide, pregnancy and its related complications, is the major cause of death for girls 15 to 19. This rate is often five times greater than that for-20 year-old girls.

Do you think religious leaders could make a big difference? Where and who?

I’ll have to think about that, but my answer is certainly yes. Religious leaders should emphasize that no religion propagates ideas that contribute to danger for mothers, but that their approaches are steeped in traditions, which need to change. In the context of our world that has now become a global village, the constitution of the powerful Elders’ Global Coalition is a real key to dynamic action. However, this august group of world leaders will need to be broadened, maybe through formation of satellite regional or country specific groups, to include other leaders, including religious, political, traditional, men, boys, even mothers and mother-in-laws who support such ideas. This will need to be proportional to the intensity of the problem in the various regions of the world, and through a study of who could influence whom, where, and when. The campaign: Girls, not Brides is laudable, especially considering that an estimated 10 million girls worldwide, are married off each year. This would translate into 100 million in a decade.

For example, in India, popular leaders like Sri Sri Ravi Shankar and Swami Agnivesh can make a difference. But they are often not willing to talk about one issue alone. They see an issue like HIV/AIDS or child marriage as part of a broader pattern that includes alcohol, domestic violence, and son preference. The issues of girls being ‘killed’ from illegal abortions and also the missing girls are linked, and they need to be attended to. Even for child marriage, though, the answers are not simple so the leaders are right: we need to address the issues as part of a package.

With today the largest generation of youth in human history, it is so important that we address all these problems. There are 3.3 million young girls with AIDS today, and the approach has to be broad, to include the other social issues that are important.

What are your plans for the future? Surely not retirement?

I will be leaving one home, to return to my other home - will be leaving India soon, and will return to the United States. I will also be leaving CMMB soon, at the end of a decade’s service. I am, though, looking for an institutional base and look forward to many exciting projects, some possibly through my own foundation.

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