One Question, Thirty Years, 130 Countries

“My life has never been a planned one,” Unni Karunakara says when asked to look back on his career. With a laugh, the 62-year-old former president of Médecins Sans Frontières (MSF) describes his twenties as “rudderless”: after medical school, he worked at a pharmaceutical company, traded shares, broke off his radiology training, and even did a stint as a roadie for a rock band. 

What he eventually found was not a straightforward career but a question: Who gets care, who does not, and why? That question has followed him through 130 countries and 30 years of public health work – from the Ogaden Desert in Ethiopia to Geneva, the corridors of the United Nations and back to his home country, India. 

It has now brought him to Berlin on a Richard von Weizsäcker Fellowship, during which he is examining Germany’s role in global health, asking a hard question: how does a country that talks about global solidarity make decisions when those decisions cost something? 

“Medicine is about sickness, not about health.” 

Long before Unni Karunakara found his mission, it seems his mission was already pulling at him. As a young medical student in Manipal, he heard on the BBC World Service about French doctors working in the famine that was ravaging Ethiopia in 1984-85. “I was terribly impressed – intrepid doctors going where assistance was most needed. Inspired, I wrote MSF a letter offering my services as a volunteer. I never heard back.”

It took another ten years to get there. Along the way, his South African friends at medical college – who studied in India because apartheid denied them a place at home – made injustice something he heard about first-hand. “It sparked the idea that there are many ways of practising medicine and approaching health", Karunakara recalls.

A chance encounter with a British doctor during his radiology training gave him the vocabulary he had been missing: “The light bulb moment was: medicine is not health. Health is much more. Health and well-being had everything to do with socio-political and economic conditions."

At 32, Karunakara applied to Harvard for a master’s in public health. He lasted one day – “Nine out of ten students were physicians; it just didn’t feel right” – and transferred to Yale, where lawyers, engineers and literature graduates argued about health alongside medics. “It was the perfect bridge between the sciences and the social sciences.” 

“Power is always taken, not given.” 

Serendipity struck again when Karunakara chose South Africa for his public health internship. It was 1994, and Nelson Mandela had just become president. Watching apartheid end gave him “a certain understanding about power”, he says: “Power is there till one day you don't have it, right? Power is always taken, not given".

On his way back to New York, he had a stopover at Brussels Airport – “and I happened to start talking to this guy.” The guy was from MSF, and the conversation led to an offer. Karunakara had a year of studies left, loans to repay, and plans to become an academic. He took the offer anyway.

He handed in his Yale thesis early and joined MSF before his graduation ceremony. His first assignment: setting up a tuberculosis control programme in Ethiopia. Two months later, a parcel arrived by Cessna at the Jijiga airstrip, containing his graduation photos. His classmates had enlarged his photo to life-size, robed and hooded it and taken him to the commencement. “There was even a photograph of me receiving my degree from Prof Levin!”

“Health is nothing but politics writ large.”

Ethiopia led to Azerbaijan, Brazil, the Congo, Bangladesh – each posting a variation on the same lesson. In the Congo, patients were being treated for sleeping sickness with a toxic arsenic-based drug; the safer alternative had been discontinued for lack of profit and repurposed as a cosmetic hair-removal cream for Western markets. Karunakara recalls the episode with more than a hint of outrage.

"I want people everywhere to be treated the way I want to be treated,” he says. Echoing Rudolf Virchow, one of the founding fathers of public health, he continues: “Health is nothing but politics writ large. It is about challenging the status quo. In that sense we need to be activists, taking on economic and power interests that work against the health of the public."

Karunakara worked with MSF for more than two decades. In 2010, he was elected MSF’s International President. Working against political failure and structural inequity worldwide was tough, he says. "But pessimism is a luxury. Action is critical. Sitting at home is not an option.” 

“Just go, listen and understand.” 

After stepping down as MSF president, Karunakara returned to India, got on a bicycle and rode 6,000 kilometers from Srinagar to Kerala – back through a country he had been away from for nearly 20 years. “Cycling was a very democratic way to see how India had changed. When you cycle you can stop, you can talk to people. You’re not zipping down a highway”.

It is a habit of mind that runs through everything he does. He has little patience for public health delivered from above. “Change – indeed, development – cannot be imposed from outside”, he says. “It requires indigenous strategies, owned and implemented by communities and their governments. As public health professionals, make sure to take the time to observe, listen, reflect, and facilitate."

The fight against inequity has become more urgent in the face of today’s political shifts, he adds. "The principle of humanity, the absolute belief and conviction that all people deserve a life of respect and dignity: we never used to talk about that. Now, everywhere I go, I keep talking about it, because it is no longer a given."

Germany: a principled leader in global health? 

Thirty years after his first letter to MSF went unanswered, Karunakara is in Berlin as a Richard von Weizsäcker Fellow. The question that has followed him across 130 countries has not changed.

During his fellowship, he plans to meet policymakers, civil society leaders, and activists across the political spectrum. With the United States retreating and one-party state China at the other end of the geopolitical landscape, Germany has positioned itself as a principled leader in shaping global health.

How does it intend to live up to that? Karunakara is in Berlin, in part, to test that claim. Germany has moved to center global health discussions in Berlin through the annual World Health Summit: does that forum genuinely include global voices, or does it set priorities from the center outward? And how does Germany stand by its stated principles of equity and social justice when those principles cost money? “Germany says they are putting in more money. But the numbers don’t show it.”

The underlying question – who controls what, on whose terms, and who loses out – is the one he keeps ending up with. Whether he planned to or not.