An Imperfect Offering: Humanitarian Action for the Twenty-First Century
By James Orbinski
Hardcover, 448 pages
Walker & Company
List price: $27.00
I was having a coffee with Austen Davis, a smart, happy man and the general director of Médecins Sans Frontières, or Doctors Without Borders, in Holland. It was the year 2000, and I had just returned from the Sudan, where I had met with the foreign minister to protest government bombings of MSF feeding centres in the south of the country. Austen and I were at an outdoor café beside the main door to the MSF office in Amsterdam. The office is in a refurbished old prison complex, its former courtyard converted to an open-air "paradiso" with cafés, newsstands and a good number of public art installations. A neoclassical archway leads to the courtyard and to the entrance of MSF. On one of its pillars is a plaque with a glass tear, commemorating the Jews of Holland who were lost during the Holocaust. Overhead, engraved on the arch, is the phrase: "Homo sapiens non urinat in ventum" — Man should not piss into the wind. The MSF office belongs here.
"Tears and piss. Is that all we have?" I asked Austen.
"Maybe. But we can refuse to simply cry. I say scream as loud as you can and piss as often as you can. Who knows, maybe the wind will shift!"
That's my man, I thought. The pissing phrase was once graffiti scratched onto the wall of the old prison. During the refurbishment, someone made sure it was transcribed into the arch. Or so the story goes.
Stories, we all have stories. Nature does not tell stories, we do. We find ourselves in them, make ourselves in them, choose ourselves in them. If we are the stories we tell ourselves, we had better choose them well. This book is a series of stories. I ask again and again, "How am I to be, how are we to be in relation to the suffering of others?" It is a question that has preoccupied me for much of my life. This book is a personal narrative about the political journey I have taken over the last twenty years as a humanitarian doctor, as a citizen and as a man. I have witnessed famine, epidemics of preventable diseases, war and its crimes, and genocide. I have witnessed politics fail and I have witnessed the struggle to be fully human when it does. I have witnessed an endless catalogue of terrors, and in them I saw myself, knowing that I might be merely a spectator to these, that I might suffer these, collaborate with these or inflict them on others. It is not a dispassionate story. I do not pretend to be outside of the events and circumstances I describe. I have lived and live in them, between them and through them. For me, these moments have been bigger than the smallness of time itself. They are personal moments, political moments or moments when there is no difference. Nor is this a sentimental story that meets victims with pity and paternalism or worthy of aid only so long as they are not a source of fear. It is about a way of seeing that requires humility, so that one can recognize the sameness of self in the other. It is about the mutuality that can exist between us, if we so choose.
It was my first act as a humanitarian doctor. And there wasn't anything medical about it. It was October 1992. I had been assigned as MSF's medical coordinator to Baidoa, Somalia, a city that had become known around the world as the "City of Death." There, and throughout the country, MSF had set up feeding centres, clinics and hospitals to give assistance to people suffering from starvation and a civil war that was becoming more brutal by the day. By the time the United Nations and various non-governmental organizations flooded in, hundreds of thousands were already dead. I landed in an American military C-130 Hercules on the airstrip just outside of town. An hour later, I was stunned into silence at a feeding centre, looking out over some three thousand people, an island of human hunger in the desert.
They sat in rows on the hard soil, emaciated and waiting. They were mostly silent, mostly beyond exhaustion. The wind was hot against my face. I couldn't help breathing in the fine dust it carried. I watched one woman with her infant in her lap. With a small stick, she was drawing something in the dust. She dropped the stick and poked her child. He didn't cry, and he didn't wake. Maybe he was asleep, or maybe he was comatose — I couldn't tell. She picked up the stick and continued drawing. As I watched her, my knees weakened. I sat on a crate of medical supplies.
In a corner of the feeding centre was a single white tent that had been designated the medical tent. Beside it were three others designated as the morgue. They were full — bodies piled as small imperfect pyramids, each at least three feet high. From the corner of my eye, I saw a movement on top of one of the piles. I turned away. I didn't want to know what it could mean. I looked to see if the wind was strong enough to cause a tent flap to move, or a piece of cardboard to fly though the air. It was.
Then I saw his eyes flutter. The wind caught his long shirt and ballooned it over his body. He lay among the dead, skin stretched taut over his exposed ribs and pelvic bones. One of his hands grasped at something, anything, whatever the wind might hold. I carried him to the medical tent. He weighed less than 70 pounds, and I thought him light as I tried to catch his arm from falling. I did this without thinking. I acted not as I thought I should but as I had no choice but to do.
All the beds inside the medical tent were taken, so I laid him on the ground. A helper put a blanket over him. She was irritated and told me impatiently that he had been moved to the morgue because there was not enough time or people to look after all of the patients, and in any case, he was going to die anyway. At that moment, I felt rage at the efficiency of placing the living among the dead. And I felt despair — for him, for myself. I could be him, dependent on the actions of a stranger for the hope of at least dignity in death.
His eyes opened and closed. He shivered under the blanket, and soon he was dead. This was the last violated remnant of a fuller life. I didn't even know his name, but I knew he had been someone's son, someone's friend and possibly someone's husband, someone's father. What choices led to civil war and famine, leaving hundreds of thousands of people like this man to suffer in this way, at this time, in the last decade of the twentieth century?
When I began working with MSF, I naively accepted the cloak of the apolitical doctor. I believed humanitarianism — with its principles of neutrality, impartiality and independence — to be outside of politics, in some ways even superior to it, and a way of avoiding its messy business. But I would come to see humanitarianism not as separate from politics but in relation to it, and as a challenge to political choices that too often kill or allow others to be killed.
In Somalia, I witnessed the carnage of the political anarchy that came with the end of the Cold War. Here aid was not only a lifeline to those who suffered. For warlords and profiteers, it was the most valuable commodity in the country. Aid was looted, and extortion and protection rackets became part of its delivery. Aid workers were kidnapped, beaten and sometimes killed. Even as our compounds came under attack by warlords and looters, we struggled to continue to work. Some called for a UN intervention to impose order, if only to allow humanitarian action to continue. Shortly after my arrival, Somalia would see a US-led and UN-mandated military intervention under a humanitarian flag. And within a few months the humanitarian intervention would use force in a clumsy effort at state craft. Between six and ten thousand Somalis were then beaten, tortured and killed by Italian, Belgian, Canadian and American "humanitarian" troops. UN forces knowingly shelled hospitals, and Somali public opinion turned against the UN mission. On October 5, 1993, over a thousand Somalis and eighteen U.S. Rangers were killed in Mogadishu. The image of a ranger being dragged naked and dead through the streets of the capital city changed the foreign policy of the world's only remaining superpower. In turn, that changed the politics of the United Nations and sealed the fate of Somalia. People were again abandoned into political anarchy, and the possibility and practice of humanitarianism there lay in tatters. I learned that even for the neutral and impartial humanitarian, politics matters, and matters a lot.
In Somalia I worked to apply medical knowledge to the treatment of patients, and to organize clinics, hospitals and feeding centres. But I am first a man, and I struggled to bring my whole person to bear for people like the man who had been on the pile of bodies. Humanitarianism is about more than medical efficiency or technical competence. In its first moment, in its sacred present, humanitarianism seeks to relieve the immediacy of suffering, and most especially of suffering alone.
In our choice to be with those who suffer, compassion leads not simply to pity but to solidarity. Through pity, we respond to the other as a kind of object, and can assume a kind of apolitical stance on the causes of and the conditions that create such suffering, as though these lie somehow outside the responsibility of politics, and as though charity and philanthropy are adequate responses. In being with the victim, one refuses to accept what is an unacceptable assault on the dignity of the other, and thus on the self. Humanitarianism involves an insistence that international humanitarian law be applied and a call to others to act as citizens to demand that governments respect basic human dignity. Solidarity implies a willingness to confront the causes and conditions of suffering that persist in destroying dignity, and to demand a minimum respect for human life. Solidarity also means recognizing the dignity and autonomy of others, and asserting the right of others to make choices about their own destiny. Humanitarianism is about the struggle to create the space to be fully human.
In the winter of 1993–94 I worked in Afghanistan while the Taliban were fighting for political power. The Soviets and the CIA had pulled out not long before, and Kabul and other cities were under siege. In January, 120,000 people walked some 250 kilometres from the capital city to the Pakistan border. They were turned back and had to take refuge in the mountains of the Khyber Pass. The morning after I arrived, I watched one woman who sat on a rock outside an MSF clinic tent. Three of her children huddled around her crying in the cold, and she held her dead infant in her arms. Her lips quivered as she looked at me. I didn't know whether she was cold, afraid or both. My translator, Abdullah, said to me, "Listen. Do you hear that?" I listened around me, and after a while I said, "I don't hear anything. Everyone is so quiet. There is nothing but silence." He paused before answering me. "Exactly."
People come to clinics and hospitals not to be heard but to be treated. And so often they wait in silence. It isn't simply that people speak a different language, or that I am the doctor and they the patients. Their silence is a practised and all but unbearable habit, one learned by suffering in their communities, in their families, in their bodies and with their children. For some, such suffering has been years in the making; for others, their suffering is compressed into the last few weeks of a war or a turmoil that forces a family to leave its home and go elsewhere — anywhere that might be safer. And yet for most — as for this mother in Afghanistan with her children huddled around her — the thought of giving up is inconceivable.
The silence of the people in the clinics, the whispered single syllables acknowledging that the doctor has found the source of their pain — these sounds and the empty spaces between mark where suffering is borne not by those who choose but by those who must endure what is imposed on them.
Simone Weil in her commentary on Homer's Iliad — a commentary written in the summer of 1940 after the fall of France to the Nazis — remarked that a "trembling" marks those who "now feel a nothingness in their own presence." It is a trembling, a quivering, of those who are reduced to a bare life that is no longer inherently sacred. It is into this silent place that the humanitarian acts, and in speaking from this place, the voice of outrage is raised. It is a voice that bears witness to the plight of the victim, and one that demands for the victim both assistance and protection, so that the silence does not go unheard. Speaking is the first political act. It is the first act of liberty, and it always implicitly involves another. In speaking, one recognizes, "I am and I am not alone."
At its best, politics is an imperfect human project. It is at its worst when we delude ourselves into thinking it can be perfect. In Rwanda in 1994, I was MSF's head of mission in Kigali, the country's capital city. It was a place with a very particular delusional politics, the criminal politics of genocide. It was a brutal, horrible time, a time of rational, systematic and state planned evil. More than a million people — virtually all Tutsis — were butchered in fourteen weeks. Bodies filled the streets of the capital, and the gutters alongside a hospital that we managed to keep open ran red with blood.
One night, after many long hours of surgery, a girl of about nine told me how she had escaped murder at the hands of the killing squads. The squads were part of an organized government plan to erase the existence of the Tutsi people from Rwanda. Through an interpreter, the little girl told me, "My mother hid me in the latrines. I saw through the hole. I watched them hit her with machetes. I watched my mother's arm fall into my father's blood on the floor, and I cried without noise in the toilet."
The genocide was life as we can choose to live it. For years before the genocide, the French government trained and armed the Rwandan soldiers. And all the way through the genocide, the French supplied them with arms, mercenaries and intelligence. MSF and other NGOs repeatedly called for UN intervention, but Belgium, France and the United States paralyzed the UN, and each knowingly pursued their foreign policies through genocide. The eventual un/French-led military intervention was too little too late, and barely more than a deception that allowed those who committed the genocide to escape into Zaire.
Many have described genocide and similar human cruelties as unspeakable. But they are as unspeakable as they are undoable. As human beings, we do genocide. Doctors cannot stop this crime. But the little girl in the latrine had no voice, and as doctors we had a responsibility to speak out against what we knew. And we did not speak into the wind. We spoke with a clear intent to rouse the outrage of public consciousness around the world, and to demand a UN intervention to stop this criminal politics.
An Imperfect Offering is about finding a way to confront unjust human suffering in the world as it is. Today one of the greatest challenges facing humanitarianism is the blurring of boundaries between humanitarian assistance and the political objectives of military intervention. In the post–Cold War world, we have seen selective military humanitarian interventions in Somalia, East Timor, Kosovo, Haiti and Sierra Leone. But we have not seen the same actions taken in Angola, Chechnya, Nepal or North Korea. In these and many other countries, egregious violations of human rights and the laws of war have occurred or are occurring, causing profound and widespread human suffering.
I flew to New York City in the early morning of September 11, 2001. From my taxi on the way to a meeting at the United Nations, I watched the twin towers of the World Trade Center burn. As I volunteered at a triage site for victims, I knew that the world had changed. Terrorism and the United States–led Global War on Terror have replaced the Cold War as the overriding geopolitical context in which organized humanitarianism seeks to operate. The selectivity of intervention continues. In Darfur, Sudan, crimes against humanity, if not a slow-motion genocide, are taking place. Yet little more than political rhetoric has been offered for the people of Darfur, where more than 400,000 have died since 2003. Accusations of Western imperialism in Afghanistan and Iraq have made humanitarian practice even more difficult. In both countries, where enormous needs exist, humanitarianism is little more than a wolf in sheep's clothing as the United States and its allies use humanitarian assistance as a political tool to win hearts and minds in their military campaigns. In June 2004, five MSF aid workers were assassinated in Afghanistan. So unsafe are the conditions in both countries that MSF and many other organizations have been forced to withdraw or remain on the sidelines as millions suffer. In a post–9/11 context, the moral waters for a humanitarianism rooted in human dignity are muddied further by those same Western powers that use torture and so-called extraordinary renditions, who openly rewrite the laws of war, and who suspend an increasing number of civil liberties at home — all in the name of George Bush's "Age of Liberty," supposedly an age of freedom, democracy and human rights.
We must confront injustice and hold our own governments accountable for what is done in our name. Catherine Lu, a political philosopher at McGill University, has written that "justice is the hallmark of human society. . . . Like all virtues and vices, [it] is particular to humanity. While we may metaphorically use the language of justice to define acts of the gods, or fate or nature, in the end, it is only human beings who can be just or unjust. . . . Justice is an ideal which requires no superhuman efforts for its attainment, but cannot be effected without human will or effort, and these are most lacking when injustice is done."
The first act of justice is recognizing the victim. In January of 2000, I was in South Africa at an MSF AIDS clinic. In a public act of civil disobedience, MSF was about to illegally import HIV/AIDS drugs into South Africa. Why? AIDS is a fully treatable disease — as treatable as diabetes. Yet today, worldwide, 30 million people have died of the disease, 33 million live with HIV infection, and upwards of 100 million may be infected by 2020. And almost all those infected live in the developing world. In 1996, patented drugs were available in the Western world. But at a cost of more than $15,000 a year for one person (all figures in this book are in U.S. dollars), there wasn't a hope in hell that anyone in the developing world would get them.
At the clinic, I examined a twenty-year-old man. If he were virtually anywhere in the Western world, he would have been just starting his life. But in South Africa his life was nearly over. He weighed less than a hundred pounds. He was so weak that his mother and grandmother had to help him onto the examining table. As he sat gasping for air, he asked me some very simple questions: "Why do you come here with only kindness when what I need is medicine? Your kindness is good, but it will not help this AIDS. They have such medicine in your countries, why not here in South Africa for people like me?"
It was in hearing these kinds of questions that MSF began its Access to Essential Medicines Campaign. We began by gathering information and mobilizing a coalition of citizen groups from around the world. We publicly shamed pharmaceutical companies and governments that supported the privilege of profit over people's right to exist. We pooled our purchasing power and bought generic versions of drugs. And we brought the price for the treatment of AIDS down from over $15,000 for patented drugs to less than $200 for generic versions of the same drugs. From Seattle to Doha, we challenged, pushed and cajoled the World Trade Organization, the WHO, the UN and national governments. We have achieved many victories, and we have failed. And we have had imperfect outcomes, like Canada's Bill C-9 that in theory allows for export of generic drugs to the developing world but in reality is a bureaucratic quagmire. AIDS was the issue at the thin edge of the wedge. But other diseases — symptoms of a politics that has too long neglected millions of people — are at the other end of that wedge. How we approach diseases like African sleeping sickness, malaria and tuberculosis, for example, has been radically changed by the Access to Essential Medicines Campaign.
In 2001, when my term as president of MSF was finished, I worked as chair of MSF's Neglected Diseases Working Group. We focused on why there was so little drug research for diseases that affect primarily poor people in the developing world. Returns on investment are simply not big enough for a global pharmaceutical industry entirely and rapaciously driven by profit, and governments have failed to ensure that the wealth created by patent monopolies is directed towards priority global health needs. Instead of waiting for others to act, MSF created the not-for-profit Drugs for Neglected Diseases initiative. Launched in July of 2003, it now has over seventeen drugs under development, and in March of 2007 it released its first drug, an antimalarial that targets the specific needs of people in the developing world. We acted not to assume responsibility for the problem but to practically demonstrate that effective change and just alternatives are possible.
The campaign acted as social movements have done for centuries. The campaigns for women's rights and labour rights, the movement against slavery, the environmental movement — all have refused to accept the unacceptable, and all have struggled to put human dignity at the centre of their political project. Ideas can be a profound force, more powerful than militaries or economies. Their power is rooted not in weapons or money but in people acting in concert.
In 2004 I travelled with James Fraser of MSF to Malawi. Malawi is a country devastated by AIDS but unable to treat the 14 percent of its population that is HIV-positive, because even with medicines that are now affordable, its health care system is more a fantasy than a reality. I visited the hospital in Zomba where 20 percent of people in the district are HIV-positive. It was a living hell, and just as in my first moment in Somalia in 1992, my knees weakened as I looked around. The hospital was overrun with desperately sick patients. A hundred and fifty people were crammed into a ward that had only thirty beds. Sick people were lying under the trees outside. Ninety percent of the sick were HIV-positive. It was not a hospital but a morgue. There was one nurse, Alice, and no doctor. I spoke with Alice, and she wept when I asked simple questions about how she had seen the disease spread. In a feeble effort to console her, I said, "There is always hope." She wiped away her tears and said, "Yes, Dr. James, there is hope, but it's a long way from here."
James Fraser and I decided at that moment to leave MSF and start a new organization, one that would actively help communities face the crisis on their own terms. We called it Dignitas International, and it is committed to community based care for people living with HIV in the developing world. Working with village health workers, doctors, nurses and officials from Malawi's Ministry of Health, and in alliance with a team of international researchers, we have developed a prevention and treatment program at the hospital and in the villages of Zimbabwe have ten thousand HIV-positive patients under our care and bring to them the best tools and treatment that medical science has to offer. And with Malawi's Ministry of Health working with us, there will be more who get treatment. Thousands want it, and they will get it. In creating a world of practical possibility, there is hope.
Today I am forty-seven, a husband, a father of two young boys, a doctor, a citizen, a sometimes humanitarian, and always, at the end of the day, a man. Over the last twenty years, I have struggled to understand how to respond to the suffering of others. I have come to know perhaps too well that only humans can be rationally cruel. Only humans can choose to sacrifice life in the name of some political end, and only humans can call such sacrifices into question. As a physician I am given virtually unhindered access to some of the most intimate experiences in people's lives, usually through suffering, but not always. I can see a person, a family or a community grow into health. I have witnessed the good of which we as human beings are capable: the good that calls a mother to feed her child, regardless of how unbearable her own suffering may be; the good of a mother and a grandmother who carry their sick boy to a clinic in South Africa. The good of those who refuse to remain silent as another is violated, and who act to right a wrong. It is the good we can be if we so choose.
Excerpted from An Imperfect Offering: Humanitarian Action for the Twenty-First Century by James Orbinski Copyright © 2008 by James Orbinski. Excerpted by permission of Walker & Company. All rights reserved.