Dr. Natasha “Anu” Anandaraja: Applying Global Lessons and Resourcing Women for a Better World
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Dr. Anu Anandaraja is the brave doctor and systems thinker who listens to women, and then advocates tirelessly to help them succeed. As a young daughter of immigrant doctors living in rural New Zealand she was inexplicably called to Africa - she became a pediatrician but felt called not to to be in community rather than hospitals, working alongside people -after genuinely listening and working in the same places for many years, she shifted her career to be responsive to the needs of women in communities around the world. In this discussion she helps us seamlessly see the connections between women living in Malawi and New York City. It is this vision of leaving no one behind that encapsulates her work with Women Together Global.
Dr. Anu Anandaraja is a pediatrician, a public health practitioner and the Founder and Executive Director of Women Together Global which operates in Malawi, the United States, New Zealand and Mozambique. She serves as a Co-founder and Advocacy Director for Equity Now at Mount Sinai.
Credits
Octavia's Cure is a production of Just Equity for Health.
This episode was hosted and executive produced by Dr. Stella Safo.
Creative direction and production by Amanda Misiti.
Post-production by Simon Cowart.
Digital content by Devon Johnson.
For more information, visit octaviascure.com.
Octavia's Cure is inspired by, but is not affiliated with or endorsed by the Octavia Butler estate.
Cover art and video intro art inspired by Nettrice Gaskins.
Transcript
Stella Safo, MD MPH (00:00)
Welcome to Octavia's Cure, a conversation series where we do something that can feel radical in this moment. We imagine a better health care and a bubble and a better public health system. We imagine a healthcare system that sees every person, every community, every corner of this globe as worthy of care and investment. And we root ourselves in hope, because hope paired with action is how change gets made. Hi, I'm Dr. Stella Safo. I'm your host and a primary care doctor and
Public health practitioner. And today we are going to be talking about global health. I'm very excited. My guest is Dr. Anu Anandaraja, a pediatrician, a public health practitioner, and the founder of Women Together, an organization doing extraordinary work at the intersection of health, gender, and community power around the world. She spent her career reminding us that what happens in the farthest corners of our world is never actually really that far from home, that global health is local health.
And that the systems we build abroad reflect the values we hold right here.
So, welcome to Octavia's Cure Anu.
Anu (01:18)
Thank you so much, Stella.
Stella Safo, MD MPH (01:21)
I want to start off by asking you about your journey because you have such a unique and fascinating journey. Tell us about kind of how you got to this point of doing global health and tell us about some of the ways that your work in public health and healthcare got you to this particular point.
Anu (01:38)
Yeah, sure.
So I started, there's so many, as you said, my career has been a very windy path. And so when I think about to where it began, there's a number of points where I could say, this is where it started, or this was the catalyst for it. Where it actually began was in small town New Zealand. So I grew up the daughter of immigrants in Sri Lankan immigrants in New Zealand in a small rural town. And...
There was in no way did I have any idea or any intention to become a doctor, but I knew I wanted to work in Africa for some reason. Just as a very, very young child, I had this sense that there was home or something waiting for me there. And I was obsessed and it wasn't a cultural influence or a media influence that reached small town New Zealand. And so I really had to go out of my way to find.
information and input and something to base my vision on. at that time it was, you know, it was wildlife documentary series, but this is where I got my vision of Africa as a continent from. And I kind of stored that away and started planning my escape from rural New Zealand to be able to put myself in Africa. at that time I was like, I'm going to be a naturalist, I'm going to be a journalist, I'm going to be a teacher.
My parents were both doctors, so they were quite certain that I was going to be a doctor. And by the time I was a teenager, they had convinced me that the best way to get myself to Africa was to become a doctor. So I went to medical school and I was really fascinated by biology writ large, but I wasn't that fascinated by medicine. But for me, it was this way to get to a place. And as I went through medical school and learned about health and learned about public health, I became
more more fascinated with people and lives and the way lives were lived and the way that our environments shaped us. And during medical school, I did a number of international volunteer opportunities, mostly in India, because those were connections that were available to me. And through that became very interested in community-based and rural health. So really started practicing at a community level and learning about
what
it really took
to create health in areas that were completely underserved in terms of medical technology and medical infrastructure, and where families were
Stella Safo, MD MPH (04:02)
Right.
Anu (04:02)
living in poverty and really at the interface of survival, at the edge of survival.
Stella Safo, MD MPH (04:08)
Yeah.
Anu (04:10)
And so my experience in India convinced me that I wanted to do medicine, but I could never see myself working in a hospital. I wanted to be out in the open with communities, working with people.
And so there was an inflection point actually at the end of med school when I thought, I really want to be, do I need to be a doctor to do this work? Maybe there's another path into dealing with health. But at that point, you know, the way my life took me, I got some sage advice from some sage people who said, just finish this journey, just do it.
Stella Safo, MD MPH (04:43)
Yeah, you were too far in.
Anu (04:45)
I was too far in and I just, one of the things I really discovered is that I loved working with children.
Stella Safo, MD MPH (04:50)
Hm.
Anu (04:51)
And so
I decided to do a pediatric residency and I came to New York. So I'd been in New Zealand up to that time, finished my medical career and started my pediatric residency at Mount Sinai here in New York City. And then as I came out of that pediatric residency, during that residency, I did as much as I could kind of in the international and global health sphere. And then as I exited, I was right at a point where Mount Sinai was setting up a global health education system, a centralized.
Global Health Education Program, and I was recruited into that to set that up. And so, you know, my pediatrics and my global health really came together at that point. And finally, about a year into that program, I finally realized my dream of touching down in Kenya and starting to
Stella Safo, MD MPH (05:33)
Yeah.
Anu (05:33)
explore what did health mean in the setting that I had dreamed about for so long. And over several years, I found myself the director of the
the Africa portfolio of partnerships that we managed for Mount Sinai. So I was working in Uganda and Tanzania and Kenya, and then for a long time in Mozambique, and then finally in Malawi. And that's where I really started to put my own vision for what health would mean
together.
Stella Safo, MD MPH (06:00)
And I cannot wait to talk about that because what you've built there is incredible. I want you to take us global in this global health conversation
Anu (06:06)
Yeah.
Stella Safo, MD MPH (06:07)
because a lot of people who are listening may not really be thinking about what's happening in global health outside of the walls of the US, for example, right? There's a lot happening here to keep us occupied. Help us set the scene. You know, people are hearing about things like huntavirus on this on the cruise ship, Ebola happening in in parts of sub-Saharan Africa. You know, what's what what
might people who are not tracking global health, what should they be aware about in terms of the current state and what's happening kind of on the ground?
Anu (06:36)
Yeah.
So for me, it's kind of hard for me to imagine health outside of global health, right? What I see as a doctor in New York City is such a tiny and exclusive experience of life, including our experience of health and healthcare seeking and healthcare systems. What
Stella Safo, MD MPH (06:56)
Mm-hmm.
Anu (06:57)
I see in the majority of places where I've worked and where I do work is an incredible scarcity of resources.
And here in New York City, we see a scarcity of resources, but it's demographically defined. There's a scarcity
Stella Safo, MD MPH (07:08)
Mm-hmm.
Anu (07:08)
for some and not for others. And what I
Stella Safo, MD MPH (07:10)
Mm-hmm.
Anu (07:11)
see in most of the places where I've worked, which are more resource-limited, low-income settings, is that the majority of folks are not able to access a standard of healthcare that we would think is just basic. The woman that I work with, for instance, in rural Malawi, and this would be 70 % of the population, live like this.
live in communities where there's very limited electricity, there's no running water, they're getting water from wells and boreholes, they are relying on firewood or charcoal for their main source of fuel, they're doing all of their cooking over fire. So all of that in itself contributes to a very profound health impact, right?
And then on top of that, their healthcare resources are very limited. So the women that I work with are largely walking an hour to three hours to get to their local healthcare provider. They're walking with their sick child or themselves being unwell. They're walking two or three hours to get to their local healthcare provider. They get to their healthcare provider and that provider can't actually do any diagnostic testing, can't do x-rays, can't...
run labs for them. So they're doing a clinical diagnosis, which is not always a bad thing. There's much that can be done by taking a good history and doing a good examination of a patient. But those kind of more advanced diagnostic tests
Stella Safo, MD MPH (08:30)
Mm-hmm.
Anu (08:30)
are not available to them. And then they're sent away with a prescription, which they then have to go to a pharmacy and hope that that medicine is on the shelf and hope that they can afford it. And in many cases, both of those things are not true. The medicine is not available and if it is, they cannot afford it. So then they're walking three hours back home with a sick child on their back.
with no actual health care having happened for them. And this will
Stella Safo, MD MPH (08:51)
Mm-hmm.
Anu (08:53)
happen many times a month. So we're talking about women who have incredible childcare responsibilities, incredible household responsibilities, are trying to earn an income, but are having to take this time out of their lives to do these incredible tracks to access
Stella Safo, MD MPH (09:05)
Yeah, because it can find
Anu (09:07)
health care and then not actually receive what they need at the end of it. And I could go on and on about what this means, but actually the majority of...
of families and individuals that I work with in low income countries are living like this. So this is the reality actually of our world. And unfortunately
Stella Safo, MD MPH (09:27)
Mm-hmm.
Anu (09:27)
here in New York City with all of the resources, presumptively all of the resources of the United States of America available to us, we still see people living in these healthcare deserts. Like we've heard about food deserts, but there's also healthcare deserts. There's these gaps where because of finances and politics,
and the structural violence of how we're living and the structures we've created for people who are marginalized. And the access to healthcare is not there. It's not
Stella Safo, MD MPH (09:55)
Mm.
Anu (09:56)
there. So you can spend, and I know we've all had this experience, you can spend hours on the phone or hours
Stella Safo, MD MPH (10:02)
Mm-hmm.
Anu (10:02)
in actual health seeking behavior, going from doctor to doctor to doctor to doctor or a healthcare facility to healthcare facility and not receive the care that you need or know that the care is there, but you can't reach it.
because of who
Stella Safo, MD MPH (10:14)
Mm-hmm.
Anu (10:14)
you are, because of your financial position, because of your level of socioeconomic power.
Stella Safo, MD MPH (10:21)
Mm-hmm.
Anu (10:22)
And so I would actually say the majority of the world's people are not living in an optimal healthcare access situation. So it's not just the women living in rural Africa and we've got this vision of, that's Africa. No, this is the majority of the world.
Stella Safo, MD MPH (10:34)
Mm-hmm.
I think what's powerful about that is that part of the reason why we wanted to talk to you today on Octavia's Cure is that we're thinking about imagining a better system. We're thinking about how to do it for all of us. And we're thinking about what already exists in terms of solutions. So as you're describing,
Anu (10:49)
Mm-hmm.
Stella Safo, MD MPH (10:50)
you know, just the level of resource limitation that we have in the world, and you've been working in this for years and solving in this for years, I feel like this is exactly the perspective that we need to bring in.
Where we say, what are some of the solutions that we've tried in places where we acknowledge that we, you know, have scarcity of medications, doctors, et cetera, that have worked? And how do we bring that maybe into our quote unquote abundance environments in in the US? Before we get to those those solutions though, I want to ask you about a real moment, I think, in global aid, you know, work that was a real low moment, which was the defunding of USAID and what that meant and why that actually matters.
In a way that isn't just separate from American life. Can you kind of draw that out for us about what it meant to you and how it actually impacts all of us?
Anu (11:41)
Yeah.
Stella Safo, MD MPH (11:41)
Yeah.
Anu (11:42)
So, you know, as someone who worked in kind of traditional models of development aid for decades and then stepped outside to try and create a model that was somewhat different, I had plenty of criticisms of USAID and the way that development as development aid as United States of America worked in the world. USAID was was an essential component of health care in many middle and low income countries around the
And by essential, mean it funded the majority of some countries health
Stella Safo, MD MPH (12:12)
Hmm.
Anu (12:13)
budget and through that funding provided the majority of the healthcare workforce. And so even though there were spaces where USAID development work wasted a huge amount of money and didn't land the resources at the level where they should have landed, the sudden withdrawal of that money without any real intelligent
or targeted approach to reducing wastage meant that suddenly healthcare resources just vanished from communities.
Stella Safo, MD MPH (12:45)
Yes, yeah.
Anu (12:46)
And I'm talking about imagining that you have a fully functional hospital one day and the next day 70 % of the staffing of that hospital is just not there.
Stella Safo, MD MPH (12:57)
Mm.
Anu (12:57)
70
% of the pharmacy has been emptied of medicine. 70 % of the diagnostic tools that you need to do basic things like testing for cervical cancer, testing for HIV, are just not there. So in those
Stella Safo, MD MPH (13:08)
Mm.
Anu (13:09)
early days where USAID funding was so abruptly cut, the kind of situation that we saw in our communities is that pregnant women could no longer get their antiretrovirals, which
Stella Safo, MD MPH (13:22)
Mm-hmm.
Anu (13:23)
meant that
they were now at risk of passing HIV to their children.
Stella Safo, MD MPH (13:28)
Mm-hmm. Mm-hmm.
Anu (13:30)
So we are now talking about an intergenerational effect.
Stella Safo, MD MPH (13:33)
Mm-hmm.
Anu (13:34)
We're talking about not just, know, people are, you know, someone has an ear infection, they can't get antibiotics and it's gonna take a long time for that to clear up and maybe they get like a big infection in the air and they lose an eardrum and they lose some hearing, bad enough. But we're talking about, we are now passing diseases on generation to generation which are life
Stella Safo, MD MPH (13:52)
Yeah.
Anu (13:53)
threatening.
and which have an intergenerational traumatic impact and which severely impact a family's ability to survive. So
Stella Safo, MD MPH (14:01)
Mm-hmm. Mm-hmm.
Anu (14:03)
basically we're saying, and on top of that, we're also saying that what we've also done is we've reduced women's ability to plan their families, so contraception's no longer available. We've reduced women's ability to test for HIV, and we've reduced women's ability to, if they have HIV, to keep their families safe, right?
So what are
Stella Safo, MD MPH (14:23)
Mm-hmm.
Anu (14:23)
we doing? We're creating new generations of HIV infected
Stella Safo, MD MPH (14:27)
Okay, okay, no.
Anu (14:28)
people, family members, household members. These are people, right? So it wasn't just that something that was nice was lost. We're talking about the future of a whole generation. We're talking about the future of a whole country. We're talking about women's and children's lives that have been lost and will continue to be lost.
Simon (14:49)
We'll return to Octavia's cure after these messages from our sponsoring partners.
Stella Safo (14:55)
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Stella Safo (15:29)
Thank you for being a part of Octavia's Cure and coming with us on this journey. We love to remain in dialogue with you, so after you listen to the episode, please download our Carry the Cure cards and share about what Octavia's Cure is trying to achieve, which is a reimagined health and public health system for us all. Thank you.
Simon (15:49)
And now back to the podcast.
Stella Safo, MD MPH (15:54)
And I I love the example that you know, I could talk about HIV all day. I love the example of using HIV, and I want to use the infectious disease world to kind of bring it home. You know, people are so worried about Ebola. And when something like Ebola happens somewhere, and exactly as you've described, you don't have the workforce, the resources, the testing that you need, you can't contain that outbreak in that area. So if you want to make it about kind of your own reality, if you can't contain that outbreak in that area.
It is much more likely that it gets on a plane and is able to spread. And and you know, we I I hate talking in the language of like, you know, you don't have to care about those people, but care about yourself. And yet I think it is important that people understand the immediate consequence, right? The immediate consequence, exactly as you've said, of not treating and helping and taking care of our our global brothers and sisters is that the disease burden goes up, economic, you know, challenges go up in these countries.
the inability to be able to take care of their working populations. I mean, it's just the ramifications are huge. And health is central to all of it. So just thank you for laying that out so beautifully for us. Would you add anything else to what you were just saying? Because I had to jump in there and take that example a little bit farther. I loved it.
Anu (17:07)
No, I mean, I think it's really, that's a really important example, because unfortunately, we do respond to those things that we feel are an immediate threat. And if those people over there are dying of HIV, that's okay. Unfortunately, in some people's books, but yes, we, I mean, with this most recent Ebola outbreak, we should have been aware of that outbreak at the
Stella Safo, MD MPH (17:27)
Mm-hmm.
Anu (17:28)
end of last year.
Stella Safo, MD MPH (17:29)
Mm-hmm.
Anu (17:29)
So
one thing that I think the public don't understand in general is that when we withdrew USAID funding of health programs around the world, we lost our ability to surveil the globe for disease.
Stella Safo, MD MPH (17:42)
Mm-hmm.
Anu (17:43)
And so there are, and I don't think people understand that for a long time, USAID's presence and the presence of this healthcare workforce that was well-trained and well-equipped has been monitoring
and surveilling and tracking and dealing with disease so that it doesn't spread across this globe. so it's not just Ebola is a big issue that we could talk forever about, but it really is kind of the huge and scary manifestation of other things that have been there for a very long time. For instance, multi-drug resistant tuberculosis, right?
Stella Safo, MD MPH (18:22)
Mm-hmm.
Anu (18:24)
We better believe that's here. That's coming here. So I used to work as a pediatric medical specialist for the Department of Health doing pediatric tuberculosis care.
Stella Safo, MD MPH (18:34)
Hm.
Anu (18:34)
And that was in the early 2000s. And we had a very tight surveillance system. And yet we were getting cases of multi-drug resistant tuberculosis coming into the United States of America.
Stella Safo, MD MPH (18:47)
Hmm. Hmm.
Anu (18:48)
And that was with a full shield outside.
existing outside the US in countries with a high prevalence of tuberculosis. We have now removed that shield entirely. So the cold face of this is now here. The cold face is in New York City. The cold face is in any major international hub. We used to have it out there, it is now here. And that one of the destroying USAID destroyed our ability to keep a shield out there and our withdrawal from international bodies like the WHO is just further putting us at risk. So it's pure foolishness.
And I think there's just a complete pure foolishness
Stella Safo, MD MPH (19:22)
Say it again. Pure foolishness.
Anu (19:26)
and it will come to get us, it will.
Stella Safo, MD MPH (19:28)
Yeah,
it absolutely will. I, you know, part of the the creation of Octavia's Cures from the legacy of Octavia Butler who saw into the future and showed
Anu (19:38)
Yeah.
Stella Safo, MD MPH (19:38)
us the stark future so that we could design and solve and improve upon it. And we want to do that here in the healthcare space. And so as much as the doom and gloom is important for people to understand, I want to take us into what you do so brilliantly, which is to design solutions and to design a way forward through this. Tell us about women together.
Tell us about why you particularly focus on women and describe for us some of the solutions that you've been able to build in East Africa and in other places with women together, that we can start to think about how do we bring some of those principles to areas within the US that are facing similar scarcity environments, often done by demographics or social class. I'd love to hear from you about how we imagine a better future.
Anu (20:23)
Yeah, thanks Stella. So the reason that I started or returned to women and created Women Together is because when I was working in the field, one of my main tasks was improving maternal and child health in the field. And so that meant setting up programs to improve maternal and child health, whether it was in Mozambique or Uganda or Kenya. And I was working a lot at community level, implementing solutions that
were health related solutions that had been designed in spaces other than those where we were implementing them. So for instance, following WHO mandates or policies, following the mandates and policies of think tanks that were based at Columbia University or Johns Hopkins, following the research driven mandates or the grant making mandates of organizations like the Gates Foundation, et cetera. And so there were well informed external bodies that were driving a global health agenda. And then
I would be one of those people who arrives in the field and is trying to implement a campaign to have every family use insecticide treated mosquito nets to prevent the spread of malaria, or trying to implement a plan to put in place a nutritional supplement to make sure that we're dealing with childhood malnutrition, or even putting in place a plan with a local Ministry of Health to train a community-based healthcare workforce to boost the access to healthcare.
In the many years of implementing programs at community level, what I saw is that we largely relied on women, community level women. We gathered women, we said, here's the plan. We need you to distribute these mosquito nets. We need you to promote this childhood nutritional supplement. We would love you to come and be trained as traditional midwives so we can do clean birthing kits in your community, et cetera, et cetera. A lot of the time, we were relying on those women who already were raising families, growing farms,
trying to earn income, doing all the work of their household and the community, we were giving them one more thing to do, right? And as women, they had that responsibility. Men often stood back and like agreed to all the terms of everything and then pointed to the women as the workforce that were gonna carry that out. And the women did a good job. And we saw that the needle on healthcare indicators shifting, lower maternal mortality, lower malaria deaths.
you know, better childhood nutrition, etc. We saw those needles moving, but not sustainably, because we weren't empowering the people who were meant to put those solutions in place to be able to actually sustainably support those solutions or to find their own solutions. And what I saw myself doing a lot was helping to put something in place, but knowing that at some point, the energy and the resources and the ability
Stella Safo, MD MPH (23:13)
Mm-hmm.
Anu (23:14)
and the capacity to do that was going to run dry.
Stella Safo, MD MPH (23:17)
Mm, because life, because life would happen and these women would have to go and find the solutions and yes, makes sense. Mm-hmm.
Anu (23:22)
And the money would run out and the funding priority
would shift and the donor interest in it would shift. And all of those beautiful mosquito nets would end up being used as fishing nets or to cover crops to keep birds and insects off it. Because what was important was being able to feed my family at
Stella Safo, MD MPH (23:39)
Right.
Anu (23:40)
the end of the day. And this mosquito net wasn't doing it for me.
And I'm not knocking mosquito nets or malaria reduction absolutely necessary, but we didn't have a holistic view of what was happening and we weren't involving women. And because of that, we weren't getting sustainable solutions.
Stella Safo, MD MPH (23:52)
Uh-huh.
Anu (23:53)
And so when I left that kind of global health approach, I really wanted to look at what happens when we start with women. What happens
Stella Safo, MD MPH (24:02)
Hmm.
Anu (24:02)
when we sit down and say to women, what do you need? You know what's going on in your community. What is your vision for your family? What is your goal for your children?
Where do you want them to go? Why aren't they getting there? And what can we do about that? And then let's
Stella Safo, MD MPH (24:16)
Mm-hmm.
Anu (24:16)
put the money behind what you know is important. And let's build up your capacity and your ability and your health and your wellbeing so that you can carry that forward. Because women were the ones carrying everything forward in those communities. They were not being resourced themselves. And I can
Stella Safo, MD MPH (24:33)
Mm-hmm. Mm-hmm.
Anu (24:34)
say that about the communities I worked with there. And I can say that about the community that I work with in New York City.
The women are given the work, they are not given the resources. So I was like, okay, let's start with the women and resource them. And so the model that we built in Malawi was doing exactly that, sitting down, listening to women, understanding where they wanted to go, what they saw as the future for their children, and helping them to get there in the way that they defined. And what it
Stella Safo, MD MPH (24:57)
Mm.
Anu (24:58)
always started with was I need to be able to feed my kids and get them to school and I need money. I need money
Stella Safo, MD MPH (25:01)
Mm-hmm. Mm-hmm.
Anu (25:03)
to do that. So the first thing that we do is set women up in cooperative groups to do
to learn income generating skills and set up businesses together so they can have money in their hands. As soon as there's money in their hands, there's food in their kids' stomachs. The
Stella Safo, MD MPH (25:18)
Mm.
Anu (25:19)
kids are going to school and they can afford to get themselves to healthcare.
Stella Safo, MD MPH (25:22)
Hmm.
Anu (25:23)
And then the survival pressure is taken off them. And as soon as that survival pressure is taken off them and they have the ability to support their families, then they start thinking about layering on other things, right?
Stella Safo, MD MPH (25:33)
Mm-hmm.
Anu (25:34)
How about we deal with cervical cancer in our community? Too many of our women are dying of that. How about we get clean water into our community?
How about we do something about cholera in our community? How about we? And so it's about having women have an economic base to stand on from where they can build all those other things.
Stella Safo, MD MPH (25:53)
Mm-hmm.
Anu (25:54)
And so for me, it went from concentrating on health, but knowing that health can't stand by itself to concentrating on economic security and building up all the other determinants of health and health itself from that point.
Stella Safo, MD MPH (26:07)
Mm-hmm.
Mm-hmm. And it makes so much sense because if you're not able to take care of your basic needs, how can you do anything else? I remember sitting in a lecture with Paul Farmer years back and it was like a public health lecture. And he was talking about how he got in so much trouble when he was working with funding dollars. And he was he his funding dollars were meant to give HIV medications to individuals living with HIV. And he instead used those dollars to buy food. And he got in trouble because they were like, Well, the money is for
The HIV drugs. And he said, people won't take their HIV drugs if they're not able to feed themselves. And it really is exactly as you've described the order of need, right? If you can't handle, you know, the basic needs of yourself and your family and your community, you can't think about using your mosquito net the way it's supposed to be used because you might die today of starvation versus dying later of malaria. So I think that that
framing and that
flip is really fascinating that a doctor and a public health practitioner, you've ended up in this world of kind of economic collective sustainability work. And I think that that's really, really powerful. I am curious about how you think about the lessons of women together and what you're learning and what you're pulling through. How you take that and how you what's the kind of theme that we can consider.
under the kind of framing of Octavia's cure of help us think about the improvements for healthcare and public health, for the US and and beyond. But some
Anu (27:33)
Mm-hmm.
Stella Safo, MD MPH (27:34)
of those things that you would say come through for you that you're like, and this is what we need to be thinking about as we as we create the next iteration of healthcare delivery.
Anu (27:43)
So I think one of the major things that we talk about, and I'm sure you've spoken about this on this podcast already, is that last mile of health, right? The distance, and we kind of looping back to one of the initial things I said about women walking one, two, three hours with sick children to get to healthcare. So how do we bridge that last mile of health between the healthcare facility and the community? And a lot has been done at
on this, when we talk about last mile health, we talk about community health workers, we talk about building up resources in the community itself. So decentralizing healthcare away from hubs where care is available and bringing it to people. And one of the things that I saw when I was working in community health worker systems in Mozambique is that they can fall into the same structural dysfunction as a centralized health system if we're not careful.
in that they select for men and money. So, for instance, working in community health worker systems in Mozambique, we had set up a system where we partnered with the Ministry of Health and we required a five-month-long training program in residence.
where people had to leave and we took people from the communities, right? So there's different levels. You can take people from medical schools and medical institutions and train them as community health workers and place them in the community. Limitations because those people don't belong to the community. They don't know the community. They may not be trusted by the community and they don't want to live in the community. These are educated people who have been putting out in the middle of nowhere where they don't have a life. They can't put their kids in school. They are far from their families. They have no accountability or commitment to that community, right? So that's one they've.
Another and better way of doing this is taking people from the community and training them to deliver health care to the community. However, if you then you can then recreate a system of a leadism where the only people who are eligible to do that community health worker training from a community are those that speak English, are literate, can leave home for five months to train in a foreign place, right? And then go back to their communities and have to be respected in their communities.
So then you end up selecting for men. You end up selecting for men who already have power and status in the community. They're the ones who have been able to afford to go to school and learn English and be literate. So those men are the same men that all the opportunities come to in that community. They are the ones who are the relatives of the local chiefs. They're the ones who already have political favor. They get chosen, they get trained. So even though in Mozambique we said, you know, we want 50 % of this workforce to be women.
We'd made a system where women couldn't survive. And hello, echoes of this all over the world. We're taking women, we're designing a system, but we're not designing it for women. And then we're blaming and we're blaming and apologizing when women can't make it inside their system yet we haven't designed a system that they can be successful in. And we badly, sorely need them in that system.
So, you we started off with a 50-50 of, you know, trainees, men and women coming to train as community health workers. By the end of it, 5 % of it were women, right? And so what does that do? That means when those community health workers leave their community for five months, train, come back to their community, and it's all men, the women in the community can't access that healthcare. Yeah, that healthcare is right sitting there next to them in their community. They can't go to that man for a pap smear. They don't want to talk to him about their dysfunctional uterine bleeding.
They don't want to talk to him about contraception. And so we've recreated a patriarchal supremacist system that doesn't serve women. And so because it doesn't serve women, also doesn't serve children because of
Stella Safo, MD MPH (31:34)
Mm-hmm.
Anu (31:35)
the way that the social dynamics are. And so with that last mile health, it's not enough to say put the health care in the community. I'm coming back to why this matters for New York City too. It has to be designed.
Stella Safo, MD MPH (31:48)
Mm.
Anu (31:49)
for the community, meaning it has to be designed for the people who are health seeking in that community, meaning it must be designed well for women.
Stella Safo, MD MPH (31:57)
Hmm.
Anu (31:58)
And if we're putting any resources into a community and health, cannot be done without intense and deep research and information
Stella Safo, MD MPH (32:05)
Mm.
Anu (32:06)
gathering on how women are placed, what their needs are, what their specific barriers are, and how
Stella Safo, MD MPH (32:11)
Mm-hmm.
Anu (32:12)
they can contribute and how they would design a health system that would serve women.
Stella Safo, MD MPH (32:16)
Mm, mm.
Anu (32:17)
And
it cannot be based on the elite elements of education, economics, and social standing.
Stella Safo, MD MPH (32:27)
That is a whole word. It really is. Because
Anu (32:29)
Yeah
Stella Safo, MD MPH (32:30)
it's it's, you know, we design these systems and they get their results and we're shocked by them, but the systems are designed to get the results that they get. And so let's think about who's at that design table and how we're designing it to really meet the needs of our desired end users, whether they be women, children, those who are from minoritized backgrounds, etc. I want to leave on a note of hope, and I want you to tell me what is giving you hope in this time, because you know.
I live in the world sometimes of nihilism and pessimism, but I try, I try to pass as someone who has hope. And so I want
to hear
Anu (33:01)
Hahaha!
Stella Safo, MD MPH (33:02)
from you, having seen the world, worked in all corners of the world, and you know, having faced these hard problems, but also bringing these solutions, what would you say is giving you hope in this time?
Anu (33:15)
You give me hope.
No, you honestly, you honestly give me hope. Woman who has so committed and dedicated and selfless. Like selfless not into the point that I don't care about myself, but just you don't see any other way forward except to take everyone with you. There's no future for
Stella Safo, MD MPH (33:33)
Mm, I should.
Anu (33:35)
you without everyone going together. And that gives me hope that there are people around who have that vision for the world that they won't go, they won't leave people behind.
So that gives me hope. What gives me hope is women rise, women rise. And so even at this time in the United States where we're looking at our rights slipping away, and I'm not even gonna say our rights slipping away, our rights actively being destroyed.
Stella Safo, MD MPH (34:02)
Say it. Mm-hmm.
Anu (34:04)
At this time when everything seems to go backwards here, when I spend time in Malawi with the women and the girls in the communities in Malawi, I'm like, no, the world's going forward. This world is going forward. Things are going backwards over there, but here in Malawi, when I'm standing there and there are women who are building their communities, building waterways, building health systems, building women led transport system, building schools, getting their girls through school.
when these women are talking about girls' rights and gender equity and
Stella Safo, MD MPH (34:37)
Mm-hmm.
Anu (34:38)
eliminating gender-based violence, when these women are saying, I want my daughter to be the next president of Malawi, I'm like, yeah, we're going. are corners of the world, there are spaces in this world where women are gathering strength, are recognizing
Stella Safo, MD MPH (34:52)
Mm.
Anu (34:54)
who they are, are owning their strength.
and are 100 % fully on board to take it to the next level in their own community, in their own country. And so, you know, maybe the United States, we're losing it. We're losing it. On so many levels, we're losing it. Let's put our energy where we can build. And so there are so many spaces in the world where there are so many communities of women in this world who are forging ahead. So let's put our strength there.
And there are so
Stella Safo, MD MPH (35:22)
Yeah.
Anu (35:23)
many pockets of that in the United States as well. it's
Stella Safo, MD MPH (35:25)
Mm-hmm.
Anu (35:26)
really, it's a shifting of perspective. It's okay. This empire is falling, but others are rising.
Stella Safo, MD MPH (35:32)
Amen. Amen. I really receive that final kind of word on hope because I think that you're right. We don't live necessarily in this small pocket only, right? There are places where we are seeing progress. and there are places here too where I think we're seeing exactly as you've said, some real movements forward. Thank you so, so much, Anu, for your wisdom, your work, your time. it is really
Just necessary to hear from someone like you who is bringing these solutions globally. So I'll close it, I'll close
Anu (36:05)
Thank you Stella.
Stella Safo, MD MPH (36:06)
us out on Octavia's Cure. we have this conversation and have had this conversation about global health and how global health is local. And I want us to all think about how we bring a little bit of the framing of women together and global health improvement into our own domestic and local lives. That is the work that we have to do here. That is the work of Octavia's Cure.
Thank you so much.
Stella Safo (36:31)
Octavia's Cure is a production of Just Equity for Health. This episode was hosted and executive produced by Dr. Stella Safo, with creative director and producer Amanda Massidi, post production and graphics by Simon Cowart, and digital content production by Devin Johnson. Learn more about our work at Octavia'scure.com. If you love Octavia's Cure, please subscribe wherever you get your podcast and leave a review so more listeners can find us. Thank you.
Stella Safo, MD MPH (37:08)
Awesome. Okay.
