“As Albert Camus wrote, the doctor’s role is as a witness–to witness authentically the reality of humanity, and to speak out against the horrors of political inaction. . . . The only crime equaling inhumanity is the crime of indifference, silence, and forgetting.”
In 1988, James Orbinski, then a medical student in his twenties, embarked on a year-long research trip to Rwanda, a trip that would change who he would be as a doctor and as a man. Investigating the conditions of pediatric AIDS in Rwanda, James confronted widespread pain and suffering, much of it preventable, much of it occasioned by political and economic corruption. Fuelled by the injustice of what he had seen in Rwanda, Orbinski helped establish the Canadian chapter of Médecins Sans Frontières (Doctors Without Borders/MSF). As a member of MSF he travelled to Peru during a cholera epidemic, to Somalia during the famine and civil war, and to Jalalabad, Afghanistan.
In April 1994, James answered a call from the MSF Amsterdam office. Rwandan government soldiers and armed militias of extremist Hutus had begun systematically to murder Tutsis. While other foreigners were evacuated from Rwanda, Orbinski agreed to serve as Chef de Mission for MSF in Kigali. As Rwanda descended into a hell of civil war and genocide, he and his team worked tirelessly, tending to thousands upon thousands of casualties. In fourteen weeks 800,000 men, women and children were exterminated. Half a million people were injured, and millions were displaced. The Rwandan genocide was Orbinski’s undoing. Confronted by indescribable cruelty, he struggled to regain his footing as a doctor, a humanitarian and a man. In the end he chose not to retreat from the world, but resumed his work with MSF, and was the organization’s president when it was awarded the Nobel Peace Prize in 1999.
An Imperfect Offering is a deeply personal, deeply political book. With unstinting candor, Orbinski explores the nature of humanitarian action in the twenty-first century, and asserts the fundamental imperative of seeing as human those whose political systems have most brutally failed. He insists that in responding to the suffering of others, we must never lose sight of the dignity of those being helped or deny them the right to act as agents in their own lives. He takes readers on a journey to some of the darkest places of our history but finds there unimaginable acts of courage and empathy. Here he is doctor as witness, recording voices that must be heard around the world; calling on others to meet their responsibility.
“Ummera, ummera–sha” is a Rwandan saying that loosely translated means ‘Courage, courage, my friend–find your courage and let it live.’ It was said to me by a patient at our hospital in Kigali. She was slightly older than middle aged and had been attacked with machetes, her entire body rationally and systematically mutilated. Her face had been so carefully disfigured that a pattern was obvious in the slashes. I could do little more for her at that moment than stop the bleeding with a few sutures. We were completely overwhelmed. She knew and I knew that there were so many others. She said to me in the clearest voice I have ever heard, “Allez, allez. Ummera, ummera-sha”–‘Go, go. Courage, courage, my friend–find your courage and let it live.’
—From An Imperfect Offering
From the Hardcover edition.
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Dr. James Orbinski is a past international President of Médecins sans Frontières (MSF). He is a Research Scientist and Associate Professor of Family and Community Medicine and Political Science at St. Michael’s Hospital and the University of Toronto. He is a founder of the Drugs for Neglected Diseases Initiative, a not-for-profit pharmaceutical research and development entity focused on the diseases of the South. He recently founded Dignitas, an organization focused on community based treatment, care and prevention of HIV in the developing world. Dr. Orbinski lectures internationally on humanitarianism and global health.
From the Hardcover edition.
STORIES ARE ALL WE HAVE
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."
From the Hardcover edition.
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Descripción Anchor Canada, 2009. Paperback. Estado de conservación: New. Never used!. Nº de ref. de la librería P110385660707