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THE INTERVIEW: Dr James Orbinski's war

In his path from a practice in small-town Orangeville, Ontario, to his acceptance of the Nobel Peace Prize on behalf of Doctors Without Borders (Médecins sans frontières) in 1999, Dr James Orbinski (pictured above, on the left) saw more suffering and misery than just about anybody on the planet. He was there in war-torn Somalia, in famine-stricken Sudan, in Afghanistan under Taliban rule, in Kosovo during the Serbian war, in Zaire's refugee camps during the civil war, in Rwanda during the genocide. He's dodged bullets and negotiated with rebel army leaders. He survived in spite of suffering post-traumatic stress disorder and contracting pneumonia from his chain-smoking, and he rose to international president of Doctors Without Borders.

Born in England and raised in Montreal before he became a doctor around the world, Dr Orbinski now teaches global health and politics at the University of Toronto and remains active in international humanitarian activism with his own organization, Dignitas, which focuses on HIV prevention and treatment in the developing world.

This year has seen has the publication of Dr Orbinski's engaging memoir, An Imperfect Offering: Humanitarian Action in the Twenty-First Century, and the release of an excellent new Canadian documentary about him, titled Triage: Dr. James Orbinski's Humanitarian Dilemma.

I spoke to Dr Orbinski about the film, his book and his life.

In Triage, you return to some of the places where you witnessed genocide and murder, in Rwanda and Somalia. What did it feel like to go back?

Well, I’ve been back and forth to Rwanda many times since the genocide, and I have been back and forth working in Africa many, many times over the last 18 years now. That was for Somalia my first return, but I did almost return a number of years ago when I was international president of MSF (Médecins sans frontières). We had two people who had been shot and I was literally on my way and the issue resolved and it wasn’t necessary for me to go to the country, so I went somewhere else. I have been back and forth many times in various situations, but even still going back was a difficult experience.

If you hadn’t become a doctor, what do you think you might have ended up doing?

I had actually applied and was accepted to a PhD program in international relations at the University of Ottawa. I was very interested in international issues and international affairs. It was a strong interest even as a young man. Obviously I found a way of melding, or bringing medicine to bear for those interests, and now I teach at the University of Toronto, cross-appointed to political science and medicine, to focus on global health.

Medical humanitarian work is often about political advocacy and raising awareness as well as medical care. But in a place like Somalia, the political situation has refused to improve.

As human beings, war is part of what we do. It is not a new phenomenon. And sadly it is likely to remain part of the range of options that we choose in terms of how we behave. So in a way to expect that NGOs will somehow erase the scourge of war is unrealistic and I think that for humanitarian organizations like MSF that focus on the direct relief of suffering of victims in war, that their action is highly effective when it is allowed to do what the organization wants to do. And those are political choices. War has rules and it has laws. One of the rules is victims of war have a right to humanitarian assistance. And that the belligerents in war have a duty to respect international humanitarian law, to use force proportionately, to use force in a manner that discriminates between combatants and noncombatants, and to obey the laws of war in the sense that they will not commit war crimes against humanity. As long as those rules of war are respected, then humanitarian organizations can be very effective in what it is they are trying to do, which is the direct relief of suffering.

You have seen lots of violations of those laws you just named.

War is part of what we do, but I would also say we decide politically what are the rules of war, and we change them. For example, in the mid-90s, largely driven by civil society organizations, NGOs, the convention that banned the use of land mines was agreed to, and that has had a profound impact on the number of civilians who are affected by land mines, in the same way that largely NGOs pushed for the creation of the International Criminal Court in the late 90s. that court now has legal international status, and people who engage in war crimes -- or allegedly engage in war crimes -- can be brought to the International Criminal Court where they will stand trial. Those are two examples of the rules getting better to actually reduce the amount of suffering that exists for victims in war, and to hold those who are responsible for violations of the laws of war responsible for those infractions.

Do you ever find it difficult to be optimistic about things like the International Criminal Court, given that it has not always been respected, such as in the case of Saddam Hussein never coming in front of the court?

I think there were very specific political choices made around the illegal and unjust invasion of Iraq, including the way in which the leader of that country, Saddam Hussein, would be dealt with post-war. That was an American-led invasion and an American-driven political process that quite frankly I profoundly disagree with at all levels. But others around the world who have allegedly engaged in war crimes have been brought before the International Criminal Court, so it's not a failure.

I don't mean to say it is. But do you find it difficult to be optimistic when even some of the biggest successes are not universally accepted?

Well, the title of my book is An Imperfect Offering. Nothing is perfect. Even what is imperfect only can come into existence by those who strive to create something better. The whole point of the book and the film is to invite the viewer or reader into a place where they can understand the importance of taking responsibility for the world in which they live and not simply giving up, and not simply saying everything is broken, there is no point to trying to fix it, and not simply retreating into some sort of utopian dream but actively engaging in the world and working, trying through concrete, realistic, practical initiatives to make it better.

That's an admirable philosophy, especially for some like you, who has seen all the things you have seen.

And I guess the question then would be how did he arrive at that position?

Right. How do you just decide to be an optimist? It seems like that sort of thing is simply built into how we think, or it's not.

It's actually a very simple rational choice. Frankly, I've seen the alternative. I've seen what happens if one doesn't work to make the situation better. I have seen genocide, I've seen famine, epidemics, AIDS, tuberculosis, cholera, meningitis, measles, that if one simply walked away from what is possible to do the results are self evident. Genocides happen, epidemics spread, people die of famine. In each of those circumstances, an alternative is possible. For me, I choose the alternative, which is to work practically in the focused and targeted way to improve the situation. It's a choice.

What’s your most salient memory from Rwanda?

The last chapter of the book is titled "Ummera." That is a Rwandan word that means "Find your courage and go on." It comes from a moment during the genocide when I was treating a woman who had been basically brutalized with a machete. She said to me, when I was overwhelmed by her situation and by the many hundreds of other patients on the street that day, she said to me, "Ummera. Find your courage and go on." That is my most significant memory and in essence the tenor of the book and the film, it's about making that choice.

The Canadian military commander Roméo Dallaire was also in Rwanda during the genocide, when you were there. His psychological problems since then have been well documented. Was that a worry for you and colleagues?

After the genocide I saw a counsellor. I had post-traumatic stress disorder, there is no question about that. But the question that is more important is what do you do with what you now know, and for me my choice was very clear, to continue working with MSF, and subsequently to continue engaging with the world. After the genocide I worked in Zaire, in Zambia, and then did a Master’s degree in international relations and was elected president of MSF and played my role there. And through the access to medicines campaign subsequently I was involved with starting a nonprofit drug company for neglected disease. I was a co-founder of Dignitas, I am on the board of War Child, a founding member of the board of the Stephen Lewis Foundation. All that demonstrates is what is important is what do you do with what you now know, and it is not simply a matter of the experience of my own dissonance with what I now know, its what I do with that is what matters. It is the same with General Dallaire. Certainly his own dissonance with what he now knew was difficult, there is no question, but again the more important question is what did he do with that. And in the first instance, like myself, he sought medical treatment. But that is not the end of it. He then engaged the world, and took what he knew in a view to improving the world, however imperfect the effort.

Did you ever imagine when you were younger that you’d someday be giving a Nobel Peace Prize lecture?

I had no possible idea.

What was going through your mind at the time?

I was very nervous, but I wanted to take the opportunity to speak out on behalf of the people of Chechnya at that time. That was a decision that we at MSF had made together, we wanted to use the moment as an opportunity to bear witness to the suffering of the people of Chechnya, and we did. That was the opening comment of the speech.

Did the Russian ambassador ever speak to you again after that?

He certainly squirmed in his seat.

What do you make of the Canadian mission in Afghanistan, which hasn't really succeeded in enabling humanitarian workers to work safely?

In my mind there's a very dangerous mixing of humanitarian, development, political and military objectives in Afghanistan, and the lack of clarity around the relationship of each of those objectives, one to the other, is part of the problem that now exists in Afghanistan. It's not a problem that is unique to Canada's involvement in Afghanistan -- there are 34 NATO members states active in Afghanistan. It is not clear to me what is the state security purpose in Afghanistan? What is the military goal of NATO’s involvement in Afghanistan? What are they trying to achieve? When that question is asked publicly one often hears a miasma of answers that confuse humanitarianism, development, diplomatic goals and military goals, and there is no clear answer to that question. The consequence is that there is confusion on the ground, there is a lack of humanitarian space. You are absolutely right that many, many humanitarian organizations find it impossible to work in Afghanistan. MSF for example had five people assassinated in Afghanistan in 2004. There are staggered stops and staggered starts to development programs, all of which is a function in my mind of the lack of a primary objective. Why are NATO member states at war in Afghanistan? What are they trying to achieve?

Who’s your humanitarian hero?

I personally don't think there is any such thing as a humanitarian hero. Humanitarianism in the way I have described it, at its most elemental, is about being a decent human being. I would shudder to think that that somehow is elevated to realm of heroism and therefore sits beyond realm of normal human conduct.

One of your predecessors as president of Doctors Without Borders is the group’s co-founder, Dr Bernard Kouchner. He’s since gone a very direction than you have. He moved into politics, acting as governor of Kosovo and now the French foreign minister, and he’s become the face of military humanitarian intervention.

Kouchner and MSF parted because of differences in opinion of what the organization is and could be. MSF maintains the view that humanitarianism is about the direct relief of suffering in war and responsibility of humanitarian workers to bear witness to that and to assist and push governments to assume their responsibilities to respect the rules of war. Kouchner took a much more politicized view, and talked about the droit d’ingérence, the right of states to intervene. He took a vision that created a mixing of humanitarian and political roles that makes it difficult to practise either effectively. As Minister of Foreign Affairs, it is a very particular role. It is not a humanitarian role.

Do you think you might follow Dr Kouchner’s example someday in the sense that he saw public office as the way he could best effect change?

I’ve made my choices thus far and I am very happy with those choices. I am a professor now at the University of Toronto, and at St Michael’s Hospital as a research scientist, and I am involved deeply in international health and global health issues. I am happy with what I am doing.

Is it difficult to convince Canadian physicians to volunteer for international medical aid?

There's always a need for more experienced healthcare professionals, not just doctors. The majority of people that work with MSF and even the Red Cross in a medical capacities are nurses. Organizations like MSF and Dignitas are constantly looking for skilled nurses, lab technicians, physicians and others. You are always looking for the best.

You mentioned earlier that humanitarian work is essentially being a good human being. Is it the duty of physicians, if they have the ability, to help in international humanitarian medical work?

There are number of issues. It is certainly my view that it is the duty of the physician to act and relieve suffering where he or she can, if it is present in your community. But the question is, where is your community? I think it's a choice. I don't think there is an inherent duty or ethical responsibility to work with a humanitarian organization that works overseas or in war zones. It's a choice.

These days in Canada, there’s a lot of talk about how we have a severe doctor shortage. After working in places like Somalia and Zaire, does the notion that Canada is so short on doctors that we have to recruit from those very places bother you?

It does. It really is an inaccurate description of reality. In Malawi, a country of 12 million people, there are 100 doctors for the entire country. Twelve million is roughly the population of Ontario. If we had 100 doctors in Ontario, you can well imagine what the healthcare system would be like. In Canada, the United States, continental Europe, Australia, New Zealand, the United Kingdom, between 24% and 28% of our medical practitioners are foreign trained medical graduates. Of that 24-28%, roughly 78% come from countries like Malawi. In Manchester, England, for example, there are more Malawian doctors working there than in the entire country of Malawi. In much of the developing world the single most significant healthcare issue today is the brain drain of human resources from the developing world to the north. We are poaching their human resources -- in my view unnecessarily so. The problem has been defined largely as a supply problem, a shortage of doctors. But that is inaccurate. The problem is also a demand problem. In my view it is completely unrealistic for a person to expect a doctor to take blood pressure and diagnose hypertension and treat hypertension, for example, when it's perfectly possible for a well trained nurse or nurse practitioner or physician assistant to delivery basic primary healthcare. In my view the challenge here is in the first instance to develop human resource policies for healthcare that actually meet the genuine needs of our society. And the second major issue within that is to reshape the conception of appropriate demand. In practical terms that means training nurse practitioners, physician assistants and nurses to delivery effective primary healthcare, and that is well within the realm of what they can do.

You have young children. It seems like it would now be much more difficult for you to justify working in a war zone and risking your life. That's a big consideration for a lot of doctors who are thinking of volunteering.

No question.

Do you think your war doctoring days are over?

My primary responsibility now is as a father. No one can replace me in that responsibility. While I have that responsibility, I have to be very careful that my other choices allow me to meet that responsibility.

Can you estimate how many people you’ve treated in your career?

A lot.


Photo: Steve Simon, courtesy of White Pine Pictures

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1 comment:

  1. roseAugust 21, 2012 at 8:05 AM

    It does. It really is an inaccurate description of reality. In Malawi, a country of 12 million people, there are 100 doctors for the entire country. Twelve million is roughly the population of Ontario.

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