A Doctor in Kigali

It was July 3, 1994, one of the final days of the Rwandan Genocide. In the bullet-scarred King Faycal Hospital in Kigali, Rwanda, Dr. James Orbinski was amputating the leg of a 14-year-old land mine victim. The boy’s foot was hanging precariously from his calf, held together by threads of flesh laced with bone and a piece of shoe. Orbinski, the 33-year-old co-founder of Doctors Without Borders Canada, had performed many amputations during his six weeks in Rwanda – treating hundreds of victims inflicted with machete wounds, or injured by grenades and land mines – but this was his first time unaccompanied by another physician. Orbinski was afraid he might cut an artery, and kill the child. Medical instruments were scarce, and all the hospital’s surgical blades were broken. The only tool at his disposal was a hacksaw. In half-an-hour, Orbinski sawed off the boy’s leg above the knee; he then shaped and stitched the tissue. The nurse placed the severed limb in a bucket on the floor. The boy’s mother rushed through the operating doors and toward her son, screaming, “Mama-we! Mama-we y’ nola.” (“Mommy is here.”) She held him around the head. He whispered, “Mama-we, Mama-we.” The boy’s leg was gone, but he was alive. It was, says Orbinski, “an imperfect offering.”

Orbinski’s new book, An Imperfect Offering: Humanitarian Action in the Twenty-First Century, to be published April 22 by Doubleday Canada, traces the journey of a humanitarian doctor who has served in some of the world’s most dangerous conflict zones. Orbinski, 47, was international president of Médecins Sans Frontières (Doctors Without Borders/MSF) from 1998 to 2001, and he accepted the Nobel Peace Prize on the organization’s behalf in 1999. Over the past quarter-century, he has worked in places such as Somalia during the famine and civil war; in the refugee camps in Jalalabad, Afghanistan; and at the Kosovo Macedonia border during the NATO bombings in 1999. His book explores every facet of his work, from the deeply personal to the broadly political: How does a man persevere – and, furthermore, create meaning and invoke change – after witnessing the most violent, sadistic acts human beings can inflict on one another? What is the role of the humanitarian in the post–Cold War era, in which traditional rules of war have been swapped for anything-goes ethical nihilism? How could MSF confront politics and public apathy during crises so it had the space and resources to heal patients? The notion of imperfection permeates many of Orbinski’s answers. “The book’s title is inspired by the poem and song Anthem, by Leonard Cohen, and there’s a beautiful line where he says, ‘Forget your perfect offering. There is a crack in everything,’” says Orbinski, who earned a master’s degree in international relations from U of T in 1998. “When I read that poem, it struck me that that’s the essence of my experience over the last 20 years as a physician, as a putative humanitarian, as a person who has tried in various ways to influence the political processes that determine who gets what, when. It’s very much an imperfect process with equally imperfect outcomes, but it doesn’t obviate the absolute necessity of trying. You achieve something, and sometimes just enough to go on.”

“The story in the book of the young boy whose leg I amputated is a very good example of that. The boy survived. His mother obviously loves him and he is alive, and had I not amputated his leg he probably would have died within 24 hours of gangrene or sepsis. On the one hand it is absolutely ideal that he’s alive, and on the other hand it’s far from ideal that he is without a leg. But here we are.”

Orbinski was born in England in 1960, and his Irish-born parents immigrated to Canada with their four young children when Orbinski was seven. The family settled in the Montreal neighbourhood of Notre-Dame-de-Grâce, then home to many English-speaking immigrants and working poor. Orbinski recounts in his book how, at the age of nine, he learned “a different knowing of death” – that humans didn’t only die naturally, but at the hands of one another. He saw a television program on the Holocaust, with images of people lying dead at Auschwitz and of a woman with numbers tattooed on her forearm. The next day, Orbinski’s mother took him to the Jewish quarter of the city, as she did before the start of every school year, to buy him new shoes. A very kind old man with beautiful eyes helped him, and called him a good boy. He noticed the man had numbers tattooed on his arm. Orbinski woke up crying that night, after having nightmares of himself, family members and the old man taking off their new shoes for the Nazis.

As Orbinski became older, he knew he wanted to help relieve the suffering of others. He earned a psychology degree from Trent University, and was employed for two years as a youth worker at a juvenile detention centre in Calgary. He then entered McMaster University as a medical student and became immediately enthralled with the study of immunology. Orbinski speaks often about the idea of “living your question.” In his book, he describes his question as, “How am I to be, how are we to be in relation to the suffering of others?” In his gentle, thoughtful tone, he elaborates on this concept. “To enter into what draws you, what calls you, is to live your question…. I have always been fascinated with science, particularly with the methodology of science, and what this means in terms of action – what you can do with what you know. My questions have really come out of these loves and I’ve been drawn to what is classically defined as humanitarian medicine, humanitarian work.”

Orbinski’s humanitarian journey began in earnest at age 27, when he obtained a fellowship to research pediatric HIV/AIDS in Rwanda. For a year, he worked at hospitals and clinics and witnessed extreme poverty, malnutrition and the prevalence of diseases such as polio, which left many paralyzed and would have been easily contained within the Canadian medical system. He became engrossed with moral questions surrounding the unequal distribution of resources, and the economic and political forces that caused such severe inequities. After returning to McMaster, Orbinski heard that student Richard Heinzl (BSc 1986 UC), was creating a Canadian chapter of Médecins Sans Frontières – an international group that provides medical assistance to victims of war and other catastrophes. The organization practiced strict impartiality while assisting victims, providing aid based solely on need and irrespective of politics, race or religion. However, MSF differed from groups such as the Red Cross in that members spoke out against human rights violations to create public awareness of atrocities. Orbinski became a founding member of MSF Canada, and one of his first missions was to Baidoa, Somalia, in October 1992. Hundreds of thousands had already died in the famine induced by a civil war that had been raging for two years. More than half of the country’s eight million people were on the verge of starvation. In the midst of rampant violence, Orbinski and other MSF team members provided medical care at clinics and feeding centres in Baidoa and surrounding villages. They often treated up to 2,000 patients a day, while hundreds more waited outside clinics suffering from starvation and the diseases that accompany it.

One day in June, when violence was at an apex, Red Cross and MSF staff treated hundreds of people in the Red Cross hospital, on the grounds and lying along the road. Heavy shelling and mortar fire hailed from everywhere. Snipers, some with rocket-propelled grenades, were pervasive. The blood of the dead and wounded ran in the gutters. Orbinski and his team performed triage work, taping numbers to the patients’ foreheads. A “1” meant treat right away; a “2” meant treat within 24 hours. Those who had “3” were “irretrievable.” They were moved to a small hill, made as comfortable as possible with blankets, water and available morphine. This was where they died.

In his book, Orbinski writes that he “felt beaten by the waves of suffering, of killing, of screams, of silent stares, of terror, and waves of not just political indifference but malfeasance.” He had acted and spoken, while an entire world stood by without helping. He remained while the violence eddied more constrictively around the hospitals – until he was one of the last doctors left in Kigali. He made a choice. His choice was to stay and save what lives he could, to relieve what suffering he could – it was that simple, and that hard. He did not leave until the genocide ended.

Orbinski has returned to Rwanda numerous times since the genocide; his latest journey, in 1997, was captured in Triage: Dr. James Orbinski’s Humanitarian Dilemma. The documentary, directed by Patrick Reed, screened at the Sundance Film Festival in Utah this January. How did Orbinski cope during his time in Rwanda? How did he carry on? Orbinski speaks about his experiences collectively, about the role of the humanitarian. “There are moments in a particular story [in An Imperfect Offering] where I knew that my fear overwhelmed everything else, and there are other moments where the implications of not acting or speaking overwhelmed my fear.” Later, he adds, “What I’ve experienced is that I can’t know the future. I can’t know if anything that I do will change what happens tomorrow. I can’t know with certainty, but what I do know is if I do nothing, nothing will change.”

But it was the Rwandan Genocide, during which Orbinski served as MSF’s head of mission, that he has called both “my undoing” and “the most transformative moment in my life.” During the 100-day period from April to July 1994, one million men, women and children – including 85 per cent of all Tutsis in Rwanda – were murdered, and another half-million people (including moderate Hutus) were injured, by Hutu extremists. Orbinski entered Rwanda in mid-May, at a time when almost everyone else – from UN agencies, to aid organizations, to the U.S. Marines – had fled. (By early April, only MSF, the Red Cross, the UN peacekeeping force headed by Roméo Dallaire, and two UN humanitarian members remained in Kigali.) Orbinski split his time among the King Faycal Hospital, the UN compound, the Red Cross Hospital and a stadium filled with 12,000 people seeking refuge. When he arrived at the Faycal Hospital, 6,000 people occupied every recess of the building, from the stairwells to the closets. Orbinski and other MSF members worked 16- to 18-hour days while outside, killing squads continued to slaughter men, women and children. The MSF team treated waves of victims with machete wounds, gunshot wounds and shrapnel injuries. They cared for people who had chest injuries from being buried alive; women and girls who had been raped; and those maimed by grenades and land mines. They established an orphanage in Faycal Hospital for children whose parents had been killed. And still, more and more victims arrived.

In human experience, language can enlighten but it can also entrap. One word can be so gravid with meaning that it could ignite the outrage of citizens, the deployment of troops, the legal obligation of action. Its absence, on the other hand, could promote the opposite reaction: the absence of deed. In 1994, as hundreds of thousands were slaughtered in Rwanda, the UN Security Council refused to invoke the word “genocide” – pressured largely by the Clinton administration, which did not want to use the word because it would legally obligate them to send troops to the country. (A year earlier, U.S. troops had intervened in Somalia’s civil war. Eighteen American soldiers were killed, and the images of two dead soldiers being dragged through the streets of Mogadishu were televised worldwide; Clinton did not want to become involved in another international peacekeeping operation.) Orbinski and MSF, however, called for the use of the word “genocide” by the United Nations; they called for a UN-mandated military intervention to stop the killing; and they spoke out to the media to illuminate the horror of the genocide. “Humanitarianism, at its root, is about the direct relief of suffering in terms of action, but it’s predicated on a basic respect for the dignity of the human being,” says Orbinski. “In practice war is not always waged according to the rules. So when the rules of war are broken – war crimes against humanity, and in the most extreme circumstance, genocide – it’s an obligation of the humanitarian to call into question the actions of those who are breaking those rules, and also to call to accountability the political decisions that are made. In Kigali, Rwanda, during the genocide, it was very clear that there was no humanitarian space. Genocide is the complete obverse of humanitarianism. There is, by definition, no respect for the dignity of others or of the intended victim. There’s no limit on the use of force. The intent is actually to eliminate the very existence of the other, and so the possibility of humanitarianism simply does not exist in that circumstance.”

“MSF insisted that there be a right political response to the genocide, and the international criminal court was created in response to that debate… However apparently dispiriting and apparently futile the world may seem, it’s anything but if we assume our responsibilities as citizens and as human beings, if we speak. [Political philosopher] Hannah Arendt said that the first political act is to speak and I think that she was absolutely right.”

In 2004, Orbinski and James Fraser, another doctor with MSF, travelled to the Zomba Central Hospital in Malawi, Africa. Ninety per cent of the patients were HIV-positive, and hundreds of critically ill men, women and children crowded the building: three to four patients were packed to a bed; others lay suffering on the floor and under the beds; and more still were gathered under trees on the hospital grounds. The medical staff consisted of one nurse. The hospital reflected the reality of the health-care system and the AIDS epidemic across much of Malawi and the developing world. (In Malawi, there are 12 million people – roughly the population of Ontario – but only 100 doctors. Fourteen per cent of the population is HIV-positive. In the Zomba region, 20 per cent are HIV-positive.) “It was just overwhelming. Overwhelming for me, but also, even more obviously, for that nurse,” says Orbinski. “And for both James Fraser and myself, it was just clear we had to do something about this.”

What Orbinski and Fraser did was leave MSF to create Dignitas International, an organization that develops community-based care and treatment programs for people who are HIV-positive and have AIDS. While the group does train doctors, it focuses mainly on training nurses, lab technicians and other health-care workers. “One of the big issues in Malawi and much of the developing world is the level of education in the general population and illiteracy, and so there are not a large number of people who are highly educated. But just because you’re not educated doesn’t mean you’re not smart,” says Orbinski, who doesn’t get paid for his role as co-founder and chair of Dignitas. “If you can develop a set of tools that are scientifically valid and allow for a person with a Grade 8 or Grade 9 education to actually deliver treatment, to do proper assessment and management, then you can empower those people and communities appropriately to actually control and contain an epidemic.”

Dignitas now has about 10,000 HIV-positive people under its medical care, almost 5,000 of whom are receiving AIDS treatment. The organization works with Malawi’s Ministry of Health officials and community groups and, in a few years, has trained hundreds of health-care workers, delivered AIDS education to more than 100,000 people in the Zomba district, built a lab and other medical facilities and provided social support to AIDS orphans and women’s groups. The organization is now establishing a network of research institutions – with the University of Toronto, University of Malawi, the BC Centre for Excellence in HIV/AIDS and others – so they can share their knowledge and let others take up the model. Orbinski focuses, through Dignitas, on community- based care and HIV/AIDS in his role as a research scientist at St. Michael’s Hospital. As a professor of political science at the University of Toronto, Orbinski is also working with U of T professors at the Department of Public Health Sciences to create a collaborative PhD program in global health. The program is slated to begin in September, and he will be teaching the core course.

Orbinski also has more personal productions underway. He and his wife, Rolie Srivastava – an environmental-sciences researcher whom he met after returning from a journey to Rwanda in 1996 – are expecting their third child in mid- April. The baby will join brothers Rohin, age four, and Taidgh, age three. And this afternoon, a very excited Orbinski is taking a very excited Rohin to his first skating lesson. Orbinski and Srivastava made up a cheer for him last night, and sang it to him again this morning. Orbinski breaks into song. “Rohin Orbinski, faster than a Jet Ski/If he was any taller, you’d think he was Wayne Gretzky.”

Did Orbinski always envision himself doing humanitarian work? He answers thoughtfully. “The question is this idea of fate, and of a kind of a determined future…. I don’t have that experience. I think if anything, one of the core ideas that I am trying to express through this writing and also through the film, is that it’s a choice. Every moment in your life is a choice, and we have a choice as to how we will see the world and how we will see ourselves in it, and therefore what we will do,” he says. He later adds, “What I do know is that I have tried to live my question, to really understand my question and struggled in the answers that emerged – however imperfect they may be.”